Pulmonary Reexpansion Research Articles

Phrenic nerve infiltration: A good practice to combine pulmonary expansion and pain control in patients with high risk of prolonged air leak

ObjectiveProlonged air leak due to residual air space after lung resection is a main challenge. To date, few surgical options have been described to prevent this complication. The aim of this study is to investigate the safety and the efficacy of intraoperative phrenic nerve infiltration with long-acting anesthetics in producing transient hemidiaphragm paralysis in patients at high risk for prolonged air leak, thus improving pulmonary expansion after surgery and reducing air leaks, while controlling postoperative pain. MethodsBetween January 2021 and 2023, 65 consecutive patients at risk for prolonged air leak (defined in accordance with “2019 Society of Thoracic Surgery score criteria of prolonged air leak”) who underwent lung resection (lobectomy or anatomic segmentectomy) for malignancy were prospectively included in the study. They were randomly (1:2 ratio) assigned to receive (group A, 22 patients) intraoperative phrenic nerve infiltration with ropivacaine 10 mg/mL in the peri-neurotic fat on the pericardium or not to receive intraoperative phrenic nerve infiltration (group B, 43 patients). Five patients in group B were excluded because they did not undergo anatomic resection. Data on pulmonary reexpansion, prolonged air leaks, pain at 24 and 72 hours postsurgery, referred shoulder pain, length of hospital stay, and length of chest tube permanence were collected and compared. ResultsHemidiaphragm elevation (P = .006) and pulmonary expansion (P = .000) were significantly higher in group A. Patients in group A showed lower pain at 24 and 72 hours compared with group B (P = .004). Shoulder pain (0.001) and prolonged air leak (0.000) were higher in group B. Length of chest tube was longer in group B. No difference in hospital stay length was observed. ConclusionsThis is the first study to investigate 2 combined effects of phrenic nerve anesthetic infiltration (hemidiaphragm elevation and pain control), with potential enhancement of a patient's recovery after surgery. Intraoperative phrenic nerve infiltration in patients with a risk for prolonged air leak appears to be a safe and effective clinical practice to improve pulmonary expansion in this set of patients, reducing postoperative air leak. This result is associated with an additional improvement in pain control, especially for shoulder pain.

Reexpansion pulmonary edema after treatment of primary spontaneous pneumothorax.

A 24-year-old male patient, without further symptoms or comorbidities presented to the emergency room with acute dyspnea after heavy lifting two days before. On auscultation an attenuated vesicular breath was noticed on the right lung. In the initial chest radiograph a right-sided primary spontaneous pneumothorax with minor mediastinal shift was diagnosed. After insertion of a 12-French chest tube the patient's clinical condition deteriorated. The following chest radiograph and computed tomography of the thorax showed a reexpansion pulmonary edema in the right lung. The patient was admitted to the ICU and supportive treatment was initiated. Pulmonary reexpansion edema after drainage of a pneumothorax is a very rare complication with mortality rates reaching up to 20%. The exact pathophysiology remains unknown. Typical Symptoms include dyspnea, hypotension, and tachycardia. To minimize the risk of a pulmonary reexpansion edema, not more than 1200-1800 ml of air should be drained at once and the drainage should be stopped when the patient starts coughing.

Risk factors for pulmonary atelectasis in adults with tracheobronchial tuberculosis

Objective: To investigate the risk factors for pulmonary atelectasis in adults with tracheobronchial tuberculosis(TBTB). Methods: Clinical data of adult patients (≥18 years old) with TBTB from February 2018 to December 2021 in Public Health Clinical Center of Chengdu were retrospectively analyzed. A total of 258 patients were included, with a male to female ratio of 1∶1.43. The median age was 31(24, 48) years. Clinical data including clinical characteristics, previous misdiagnoses/missed diagnoses before admission, pulmonary atelectasis, the time from symptom onset to atelectasis and bronchoscopy, bronchoscopy and interventional treatment were collected according to the inclusion and exclusion criteria. Patients were divided into two groups according to whether they had pulmonary atelectasis. Differences between the two groups were compared. Binary logistic regression was used to analyze the risk factors for pulmonary atelectasis. Results: The prevalence of pulmonary atelectasis was 14.7%, which was most common in the left upper lobe (26.3%). The median time from symptom onset to atelectasis was 130.50(29.75,358.50)d, and the median time from atelectasis to bronchoscopy was 5(3,7)d. The median age, the proportion of misdiagnosis of TBTB before admission, and the time from symptom onset to bronchoscopy in the atelectasis group were higher than those without atelectasis, and the proportion of receiving bronchoscopy examination and interventional therapy previously, and the proportion of pulmonary cavities were lower than those without atelectasis (all P<0.05). The proportions of cicatrices stricture type and lumen occlusion type in the atelectasis group were higher than those without atelectasis, while the proportions of inflammatory infiltration type and ulceration necrosis type were lower than those without atelectasis (all P<0.05). Older age (OR=1.036, 95%CI: 1.012-1.061), previous misdiagnosis(OR=2.759, 95%CI: 1.100-6.922), longer time from symptom onset to bronchoscopy examination (OR=1.002, 95%CI: 1.000-1.005) and cicatrices stricture type (OR=2.989, 95%CI: 1.279-6.985) were independent risk factors for pulmonary atelectasis in adults with TBTB (all P<0.05). Of the patients with atelectasis who underwent bronchoscopy interventional therapy, 86.7% had lung reexpansion or partial reexpansion. Conclusions: The prevalence of pulmonary atelectasis is 14.7% in adult patients with TBTB. The most common site of atelectasis is left upper lobe. The TBTB type of lumen occlusion is complicated by pulmonary atelectasis in 100% of cases. Being older, misdiagnosed as other diseases, longer time from onset of symptoms to bronchoscopy examination, and being the cicatrices stricture type are factors for developing pulmonary atelectasis. Early diagnosis and treatment are needed to reduce the incidence of pulmonary atelectasis and increase the rate of pulmonary reexpansion.

Evaluation of (Wet) and (Dry) Mediastinal Chest Drainage in Minimally Invasive and Conventional Cardiac Surgery.

Drainage of fluid and evacuation of air from the pericardial and pleural spaces after cardiothoracic surgery is necessary to prevent effusion, tamponade, and pneumothorax, and also to detect hemorrhage. For this purpose, negative-pressure drains are placed in the mediastinum and pleural cavities. We compared the efficacy and safety of two systems wet and dry drainage for the management and monitoring of negative pressure and anti-reflux valve safety systems, to promote healing of the pleural and pericardial cavities. Two devices for mediastinal chest drainage [Venice PAS (Wet) and Rome PAS (Dry); both Eurosets SRL, Medolla, Italy] were evaluated in terms of safety, efficacy and clinical outcomes in a cohort of 60 patients who underwent elective cardiac surgery procedures. The patients were divided into a minimally invasive cardiac surgery (MICS) group [n=30; mitral valve surgery (MVS) by right anterolateral mini-thoracotomy] and a conventional cardiac surgery (CCS) group [n=30; coronary arterial bypass grafting (CABG) in full sternotomy] at a single institution (Anthea Hospital GVM Care & Research, Bari, Italy). Negative pressure was managed with a target value of -20 cmH2O measured in the chest tube and was related to the device: deviation of ± 1 cmH2O for the Venice PAS (Wet) and 0 cmH2O for the Rome PAS (Dry) in the MICS group; deviation of 1 ± 0.8 cmH2O for the Venice PAS (Wet) and 0.8±0.2 cmH2O for the Rome PAS (Dry) in the CCS group. A constant volumetric air leak meter (VALM) value and the absence of air-leak bubbling were correlated with the absence of air in the pleural cavity and complete pulmonary re-expansion to restore normal respiratory dynamics in the MICS group for both models of chest drainage. The maximum total pericardial blood drained was 1104 ± 302 ml with Venice PAS (Wet) and 1530 ± 230 with Rome PAS (Dry) in the CCS group. There were no reports of cardiac tamponade in either group. The two mediastinal chest drainage devices [Venice PAS (Wet) and Rome PAS (Dry)] in this study were effective, accurate for measuring the applied negative pressure, and safe in their application after cardiac surgery procedures via minimally invasive and conventional approaches for blood and liquid drainage, prevention of cardiac tamponade, and restoration of normal respiratory dynamics after surgical pneumothorax. Both systems are equipped with anti-reflux valves to prevent air and blood from entering the drainage, and no adverse events were reported.

Evaluation of uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculous empyema

Objective: To examine the safety and efficacy of the uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculosis empyema. Methods: From January 2018 to December 2020, 122 cases of tuberculous empyema treated by decortication in Department of Surgery, Wuhan Pulmonary Hospital were retrospectively analyzed, including 100 males and 22 females, aged(M(IQR)) 29.5(28.0) years (range: 13 to 70 years). According to the surgical approach and drug resistance, patients with drug-resistant tuberculosis who underwent uniportal video-assisted thoracoscopic decortication were included in group A (n=22), and those who underwent thoracotomy decortication were included in group B (n=28). Drug-sensitive patients who underwent uniportal video-assisted thoracoscopic decortication were included in group C (n=72). There was no statistical difference in the baseline data of the three groups (P>0.05). The operation, early postoperative recovery, and prognosis-related indicators were compared among three groups by Kruskal-Wallis test and χ2 test by Mann-Whitney U test and Bonferroni method between groups A and B, groups A and C. Results: The intraoperative blood loss of group A, group B, and group C was 200(475) ml, 300(200) ml, and 225(300) ml, respectively. There was no significant difference in intraoperative hemorrhage (H=2.74, P=0.254) and treatment outcome (χ2=4.76, P=0.575) among the three groups. Compared with group B, the operation time of group A (302.5(187.5) minutes vs. 200.0(60.0) minutes, U=171.0, P=0.007) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0 (2.2) months, U=146.5, P=0.032) were longer, and the postoperative drainage duration (9.5(7.8) days vs. 13.0(10.0) days, U=410.0, P=0.044), and the postoperative hospitalization time (12.0(7.8) days vs. 14.5(4.8) days, U=462.2, P=0.020) were shorter. There was no significant difference in complications between group A and group B (63.6%(14/22) vs. 71.4%(20/28), χ2=0.34, P=0.558). Compared with group C, the postoperative drainage duration of group A (9.5(7.8) days vs. 7.0(4.0) days, U=543.5, P=0.031), the postoperative hospitalization time (12.0(7.8) days vs. 9.0(4.0) days, U=533.0, P=0.031) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0(2.0) months, U=961.5, P=0.001) were longer. The operation time (302.5(187.5) minutes vs. 242.5(188.8) minutes, U=670.5, P=0.278), and complications (63.6%(14/22) vs. 40.3%(29/72), χ2=3.70, P=0.054) were not different between group A and group C. Conclusions: For drug-resistant tuberculous empyema, the uniportal video-assisted thoracoscopic decortication can achieve the same good therapeutic effect as drug-sensitive tuberculous empyema, and it is as safe as thoracotomy. At the same time, it has the advantage of minimally invasive and can accelerate the early postoperative recovery of patients.

Clinical outcomes of vinorelbine loading CalliSpheres beads in the treatment of previously treated advanced lung cancer with progressive refractory obstructive atelectasis.

Background: Drug-eluting beads bronchial arterial chemoembolization (DEB-BACE) has been used in the treatment of locally advanced lung cancer and has the potential to improve outcomes and reduce recurrence. However, DEB-BACE shows a poor therapeutic effect in advanced lung cancer after failure of multiple therapies. This study assessed the effect of DEB-BACE in the treatment of progressive lung cancer with refractory obstructive atelectasis. Methods: Progressive advanced lung cancer patients with refractory obstructive atelectasis were voluntarily enrolled in this study after failure of multiple conventional therapies. Baseline information, DEB-BACE treatment process, and changes in clinical symptoms were recorded. The primary endpoints were the objective response rate (ORR) and improvement rate of dyspnea. The secondary endpoints were time-to-progression (TTP), overall survival (OS), and rate of pulmonary re-expansion. Treatment-related adverse events and serious adverse events were analyzed to assess the safety of DEB-BACE. The Cox regression model was performed to analyze the possible factors impacting prognosis of DEB-BACE. Results: DEB-BACE was successfully performed with CalliSpheres beads loaded with vinorelbine in the 20 enrolled patients. ORR and disease control rate were 80% and 85%, respectively, at the first follow-up (43.4 ± 15.26days). The improvement rate of dyspnea was 85% and 80% at 1week and 1month (p < 0.0001, p < 0.0001), respectively. TTP was 41.25 ± 14.43days and 89.55 ± 61.7days before and after DEB-BACE, respectively; DEB-BACE delayed the progression of advanced lung cancer (p < 0.0001). OS was 238.03 ± 33.74days (95% confidence interval: 171.9-304.16). The rate of pulmonary re-expansion was 80% at the first follow-up. The reasons for poor prognosis were tumor necrosis, longer disease duration, and pulmonary atelectasis duration (p = 0.012, p = 0.038, p = 0.029). Massive hemoptysis was observed in two cases, and one patient died of asphyxia caused by hemoptysis. Moderate hemoptysis occurred in one case. All three adverse events were considered as the result of the tumor cavity after DEB-BACE. Conclusion: DEB-BACE loaded with vinorelbine is a feasible option for progressive advanced lung cancer with obstructive atelectasis after failure of other treatments.

Infecciones pleurales

Pleural infection is an invasion of the pleural membranes and the space between them by different microorganisms either directly or indirectly. Of note among them are parapneumonic infection and tuberculosis, given their frequency and specific treatments. The imaging test of choice at present is a chest ultrasound, both for the diagnosis and for guiding the thoracentesis, detecting local complications, and providing follow-up. A biochemical and microbiological analysis of the pleural fluid are necessary for confirming the infection, identifying complications, and guiding treatment. Delays in starting antibiotic treatment are related to high morbidity and mortality. Therefore, treatment will be started empirically in most cases. If the pleural effusion is complicated, performing invasive techniques in the pleural cavity should be evaluated. These techniques include the placement of pleural drainage, instillation of fibrinolytic drugs and viscosity-reducing drugs in the pleural space, and surgical treatment if there are septi in the pleural space, an absence of pulmonary re-expansion, or uncontrolled complications of previous treatment. A delay in providing these treatments also increases the disease's morbidity and mortality.

Effectiveness and Safety of Prolonged Needle Decompression Procedures in Tension Pneumothorax Patients with COVID-19

Introduction: Coronavirus disease-19 (COVID-19) has become a pandemic that is still ongoing today. This is a new challenge for health workers in handling emergency cases. Several COVID-19 patients arrived at the hospital with severe respiratory problems. Meanwhile, other pathological conditions causing respiratory failure must also be considered, such as pneumothorax. Objective: This study aimed to examine the effective emergency procedures to treat COVID-19 cases with tension pneumothorax. Case report: A 45-year-old male patient arrived with a referral letter from a pulmonologist with a diagnosis of simple pneumothorax and pneumonia. The patient also presented a positive SARS COV-2 PCR test result. The patient complained about a worsening of shortness of breath. A symptom of dry cough for 14 days was also reported. Chest radiograph examination subsequently indicated right tension pneumothorax. In the emergency ward, needle decompression procedure connected to the vial containing sterile intravenous fluids was performed. Re-examination of the chest x-ray demonstrated right pulmonary re-expansion. The patient was monitored and after four days, needle decompression was removed and no chest tube was inserted because complete resolution of the lungs had occurred. Discussion: This case illustrates that tension pneumothorax causes worsening of the patient's condition with COVID-19 diagnosis. In another case of tension pneumothorax in a COVID-19 patient, needle decompression of the 2nd intercostal space and the mid-clavicular line was performed as initial treatment followed by chest tube insertion as definitive treatment. However, in this case, chest tube approach was not carried out because the patient had demonstrated clinical and radiological improvement and a worsening condition had not occurred. Conclusion: Prolonged needle decompression connected to a vial containing sterile intravenous fluids as deep as 2 cm from the water surface is an effective procedure in the management of tension pneumothorax even without the installation of a chest tube.

Management of malignant pleural effusion. A retrospective study comparing efficiency and outcomes of VATS talcum pleurodesis, insertion of tunneled pleural catheter (PleurX®), and a combination of both

Abstract Objective The management of malignant pleural effusion is a common problem in thoracic surgery. Patients are often polymorbid and are usually referred at a terminal stage of their oncological disease. Our objective was to compare the efficiency and outcomes after different treatment strategies of malignant pleural effusion. Methods We retrospectively reviewed the charts of a total of 416 patients treated during the period of 2010 to 2020 who underwent thoracoscopic pleurodesis with or without implantation of tunneled pleural catheter (TPC) as well as patients who underwent the implantation of TPC alone. Primary outcome was postoperative survival and secondary outcome was length of stay (LOS). In addition, we documented the recurrence of ipsilateral pleural effusion and the need for reintervention as well as the pulmonary reexpansion of the lung on postoperative chest x-ray. Inclusion criteria were malignant pleural effusion and documented follow-up until time of death. Exclusion criteria were treatment for mesothelioma, pneumothorax and emphysema. Results A total of 199 patients were included for analysis. Median LOS of patients treated with implantation of TPC alone in analgosedation (n = 28) was 1 day (range:1-4 days). Median LOS of patients who received video-assisted talcum pleurodesis (n = 65) without implantation of a TPC was 6 days (range 1-38 days). Median LOS of patients who received VATS talcum pleurodesis and TPC (n = 106) was 3 days (range 1-34 day). The difference in LOS was statistically significant (p &amp;lt; 0.05). Median overall survival was 108 days (range 3-3001 days). There was no statistically significant difference in survival between the different treatment groups (p = 0.47). Conclusion The primary goal when treating patients with malignant pleural effusion is relief of dyspnea and/or pain and to keep the duration of the inpatient treatment to a minimum. In patients with a considerable surgical risk due to comorbidities and their underlying oncological disease and who don’t require the sampling of histological material, a conservative treatment option with implantation of a TPC can be sufficient. The additional insertion of a TPC not only reduces the length of stay, but also has a positive effect on the efficacy of the pleurodesis in terms of less recurrence. We therefore recommend the routine use of TPC when performing VATS talcum pleurodesis in patients with malignant pleural effusion.

Intraoperative pulmonary re-expansion edema complicating pulmonary decortication for tuberculous pleural effusion

Pulmonary re-expansion edema (PRE) was first described by Carlston in 1958. To the knowledge, only one case has been described following pleuropulmonary decortication. The authors present the case of a 19-year-old patient who underwent pleuropulmonary decortication and who presented an PRE intraoperatively. Early diagnosis and the rapidity of treatment allowed a favourable evolution. Therefore, the prognosis of intraoperative PRE depends on the rapidity and efficiency of medical management.

Analysis of the therapeutic effect and prognosis in 86 cases of rib fractures and atelectasis

BackgroundThe aim of the present study was to explore the therapeutic effect and prognosis in patients with rib fractures and atelectasis after thoracic trauma in order to provide a basis for clinical decision-making in primary hospitals.MethodsA retrospective study was conducted on 86 patients admitted to our hospital between January 2016 and May 2020 with rib fractures and atelectasis after thoracic trauma. On the basis of the chest computed tomography scans taken at the time of discharge, the patients were divided into two groups: the reexpansion group and the non-reexpansion group. The two groups were compared with respect to the changes observed in the patients’ levels of blood oxygen saturation (SpO2) and pulmonary function, the presence of secondary pulmonary or thoracic infection, the time of chest tube drainage, the length of hospitalization, the cost of hospitalization, and the patients’ level of satisfaction with their quality of life 3 months after discharge.ResultsIn the reexpansion group, there were significant differences in the levels of SpO2 and pulmonary function measured before and after pulmonary reexpansion (P < 0.05). Compared with the non-reexpansion group, the patients in the reexpansion group had a lower incidence of secondary pulmonary and thoracic infection and a higher level of satisfaction with their quality of life after discharge; these differences were statistically significant (P < 0.05). There was no statistical significance between the two groups with respect to the time of chest tube drainage or the length of hospitalization (P > 0.05). However, the cost of hospitalization was significantly higher in the reexpansion group than in the non-reexpansion group (P < 0.05).ConclusionsThe patients in the pulmonary reexpansion group had a lower incidence of complications and a better prognosis than the patients in the non-reexpansion group.

Effect of different oxygen concentrations developing pulmonary atelectasis of neonates during anesthesia: a randomized controlled trial

Objectives: This study sought to evaluate the effect of different oxygen concentrations on the development of pulmonary atelectasis in neonates during anesthesia with mechanical ventilation using ultrasound. Methods: Sixty-three neonates undergoing laparotomies were randomly divided into three groups. A: FiO2 = 30%, B: FiO2 = 40%, C: FiO2 = 50%. Ultrasound was performed to guide pulmonary resuscitation maneuvers after tracheal intubation and before tracheal extubation and performed at the end of surgery in each group to evaluate lung consolidation. The following parameters were assessed: (1) primary observation index: pulmonary consolidation score; (2) secondary observation index: area of pulmonary atelectasis, changes in oxygenation index, pulmonary atelectasis, and the incidence of hypoxemia; (3) pulmonary complications at 72 hours postoperatively. Results: There was a significant difference in pulmonary consolidation scores between the 30% and 50% groups (p &lt; 0.001) and the 40% and 50% groups (p &lt; 0.01); the difference between the 30% and 40% groups was not significant (p &gt; 0.05). The incidence of pulmonary atelectasis was 82.54%. Pulmonary atelectasis occurred in the posterior (81%) and in the right posteriolateral positions (51%). There was a significant change in the oxygenation index before and after pulmonary ultrasound-guided re-expansion before recruitment (T1) compared to after preoperative recruitment (T2) (p &lt; 0.001) and before postoperative recruitment (T3) compared to after postoperative recruitment (T4) (p &lt; 0.001). 6 children in the 30% oxygen concentration group developed mild hypoxemia and 2 children developed moderate hypoxemia; while no hypoxemia occurred in the remaining two groups. No pulmonary complications occurred at 72 hours postoperatively. Conclusions: 40% FiO2 may be the oxygen concentration that neither causes significant pulmonary atelectasis nor hypoxemia during the maintenance of mechanical ventilation during neonatal anesthesia. However, there may also be lower lung consolidation scores and no hypoxemia between 30% oxygen concentration and 40% we have not studied it. Pulmonary atelectasis is present in most anesthetized patients and occurs mainly in gravity-dependent areas, more on the right than on the left side. Pulmonary ultrasound-guided pulmonary recruitment maneuvers can significantly improve neonatal pulmonary gas exchange function.

Improvement in Lung Insufflation in Spontaneously Breathing Tracheostomized Patients by Using a New Pulmonary Expansion Device: A Pilot Study

Abstract Lung expansion techniques (LETs) are a key component of pulmonary rehabilitation. Nevertheless, these can be limited in tracheostomized patients because of the infraglottic position of tracheostomy cannulas. We propose a novel pulmonary expansion device (PED) that allows deep inspiration with a postinspiratory pause for a few seconds by means of a unidirectional valve and an occlusion/flow release cap. It is equipped with a relief valve that opens at 60 cm H2O in cases in which this threshold is attained. We aimed to evaluate the impact on lung volume and pressure in spontaneously breathing tracheostomized patients subjected to LETs. A single-arm pilot interventional study was conducted in an adult intensive care unit (ICU), including spontaneously breathing tracheostomized patients. 80 treatments were performed on 10 patients with tracheostomies with PED over a period of 3 months. The maximal inspiratory volume (MIV) was significantly increased by using PED (MIV-PED) at both day 1 (725 (600–820) mL versus 1550 (1250–1700) mL, P &amp;lt; 0.001) and day 3 (870 (750–950) mL versus 1662 (1550–1900) mL, P &amp;lt; 0.001). Inspiratory pause pressure (PIP-PED) did not significantly change from day 1 to day 3 (18 (14–20) cm H2O versus 14 (12–22) cm H2O, P = 0.36). The use of the PED in tracheostomy patients acted as an artificial glottis by performing a novel pulmonary re-expansion maneuver, and increased volumes and intrapulmonary pressure with prolongation of maximum inspiration were achieved.

Effect of the expiratory positive airway pressure on dynamic hyperinflation and exercise capacity in patients with COPD: a meta-analysis

Expiratory positive airway pressure (EPAP) is widely applicable, either as a strategy for pulmonary reexpansion, elimination of pulmonary secretion or to reduce hyperinflation. However, there is no consensus in the literature about the real benefits of EPAP in reducing dynamic hyperinflation (DH) and increasing exercise tolerance in subjects with chronic obstructive pulmonary disease (COPD). To systematically review the effects of EPAP application during the submaximal stress test on DH and exercise capacity in patients with COPD. This meta-analysis was performed from a systematic search in the PubMed, EMBASE, PeDRO, and Cochrane databases, as well as a manual search. Studies that evaluated the effect of positive expiratory pressure on DH, exercise capacity, sensation of dyspnea, respiratory rate, peripheral oxygen saturation, sense of effort in lower limbs, and heart rate were included. GRADE was used to determine the quality of evidence for each outcome. Of the 2,227 localized studies, seven studies were included. The results show that EPAP did not change DH and reduced exercise tolerance in the constant load test. EPAP caused a reduction in respiratory rate after exercise (− 2.33 bpm; 95% CI: − 4.56 to − 0.10) (very low evidence) when using a pressure level of 5 cmH2O. The other outcomes analyzed were not significantly altered by the use of EPAP. Our study demonstrates that the use of EPAP does not prevent the onset of DH and may reduce lower limb exercise capacity in patients with COPD. However, larger and higher-quality studies are needed to clarify the potential benefit of EPAP in this population.

Particularités de la prise en charge de l’hémoptysie massive d’origine hydatique

Massive hemoptysis is a rare but serious presentation of pulmonary hydatid cysts. The literature reporting this clinical phenomenon is limited to sporadic cases. We undertook a retrospective study considering patients who had undergone lung surgery because of hydatid cyst from January 2000 o December 2015 and examined features associated with massive hemoptysis. Among 270 patients operated on for lung hydatidosis, 13 (4.8%) had experienced massive hemoptysis. This sub group had an average age of 24±12 years (13-60 years) and a sex ratio of 0.85. Preoperative embolization was attempted in 5 patients but failed in all cases. All patients with massive hemoptysis were operated on emergency. The origin of bleeding was determined and controlled in all cases (from a vein or an artery from the pulmonary circulation). Pulmonary re-expansion was satisfactory after obliteration of the residual cavity and no pulmonary resection was necessary. The postoperative course was uneventful in 11 patients. Prolonged air-leak beyond 7 days was noted in two patients but settled subsequently with simple follow-up. Average postoperative follow-up was 32 months (8-63 months). One patient (who had hydatid vomit with massive hemoptysis) developed controlateral hydatid recurrence that was also successfully operated on. No recurrence of hemoptysis was noted during the follow-up period for all patients. Massive haemoptysis secondary to pulmonary hydatidosis may be life-threatening. Surgery of hydatid cysts associated with direct vascular control of eroded vessels is sufficient to control hemoptysis.

SPONTANEOUS PNEUMOTHORAX DURING PREGNANCY: A RARE CHALLENGE

TYPE: Abstract Publication TOPIC: Disorders of the Pleura PURPOSE: Primary spontaneous pneumothorax (PSP) during pregnancy is a rare condition with serious risks to the mother and the fetus, so rapid recognition and treatment are essential. Since few cases has been described, symptoms of dyspnea and chest pain can be easily misdiagnosed. The aim is to describe a case of a pregnant patient with PSP, managed with chest tube drainage. METHODS: A 30-year-old woman on 28th gestational week (gravida 1/ parity 0), non-smoker, presented at urgency department with sudden pleuritic chest pain and dyspnea. No history of respiratory pathology or trauma. On physical examination, hemodynamically stable, no fever, tachypneic with oxygen saturation 97% on ambient air. Pulmonary auscultation with decreased vesicular murmur on the left hemithorax. No analytic alterations. No fetal distress. The chest radiography showed findings of large left pneumothorax, without mediastinum deviation. A chest drain was placed with reduction of pneumothorax. Given the absence of pulmonary re-expansion, suction treatment was made. RESULTS: The patient had progressive recovering and was hospital discharged asymptomatic. A caesarean section was performed on 39th gestational week, under epidural anesthesia, without complications. The patient maintains a pulmonology follow-up, without new episodes of pneumothorax. CONCLUSIONS: PSP during pregnancy should be part of chest pain and dyspnea differential diagnosis and promptly recognized to prevent severe complications. CLINICAL IMPLICATIONS: Given the symptomatic large pneumothorax, a chest tube was placed. Since the high risk of recurrence during delivery, it is recommended elective assisted delivery with forceps or ventouse extraction to lessen maternal efforts, despite some authors consider the caesarean section a safe option. DISCLOSURE: No significant relationships. KEYWORDS: pneumothorax, pregnancy

An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a canine model

Background/objectiveThoracic injuries commonly occur after blunt or penetrating trauma, leading to a blowing wound. For thoracic damage control in emergency, we evaluated a novel chest wound treatment device manufactured using expandable material with a one-way valve, and compared it with closed thoracic drainage for first-line treatment of traumatic pneumothorax in a canine model. MethodsTwenty beagle dogs (10 males and 10 females) were randomly and equally divided into two groups. After arteriovenous catheterization, an open pneumothorax model was established in the beagle dog using a minimally invasive procedure. The experimental group was treated using our test device, while the control group was treated by closed thoracic drainage. Animal survival, oxygen saturation (SO2), oxygen pressure (PO2), and changes in chest radiograph with reference to open pneumothorax before and after intervention were recorded at 30, 60, and 120 min. ResultsAfter a 24-h experimental period, all animals survived. The control group recovered more quickly than the experimental group at 30 min post-trauma. However, the indices were close to normal 120 min after the test device was inserted. During the puncture, chest-wall hemorrhage was stopped by using the device, whereas the control group experienced continual errhysis. The lung had almost re-expanded at the end of the experiment in both groups. The effect of pulmonary re-expansion in the control group was better than that in the experimental group at 120 min. ConclusionThe novel expandable one-way valve device is a safe and useful tool for the treatment of open chest trauma in emergency based on our animal experiment.

Acute effects of three pulmonary reexpansion modalities on thoracoabdominal motion of healthy subjects: Randomized crossover study.

BackgroundChest physiotherapy can be an alternative to increase lung volumes through pulmonary expansion therapies, but there is still inconsistency in the literature in order to determine which device can promote a greater volume increase at the expense of a better ventilatory pattern. Therefore, the aim of this study was to evaluate and compare the chest wall kinematics of healthy subjects submitted to the use of three different devices for pulmonary reexpansion.MethodsChest wall compartmental and operational volumes, breathing pattern and thoracoabdominal asynchrony were evaluated in 12 healthy individuals through optoelectronic plethysmography during quiet breathing, pulmonary reexpansion and recovery. Three different devices (volume-oriented incentive spirometer–IS-v; positive expiratory pressure–PEP; and incentive spirometer volume and pressure oriented–IS-vp) were administered in a random order with at least 48h between the devices.ResultsA greater volume variation in the chest wall and its compartments was observed when the IS-vp was used in comparison with the other devices (p<0.05). Furthermore, the IS-vp mobilizes a greater amount of volume accompanied by greater synchronism between the compartments when compared to IS-v (p <0.05).ConclusionThe IS-vp may be able to increase total and compartmental chest wall volumes, as well as improve synchrony among compartments when compared to IS-v and PEP devices, thus constituting an important tool for treating patients with restrictive ventilatory pattern.

Comparison of three lung recruitment maneuvers in the treatment of severe extra-pulmonary acute respiratory distress syndrome

Objective To investigate the efficacy and side effects of three recruitment maneuvers (RM) for severe extra-pulmonary acute respiratory distress syndrome (ARDS). Methods A total of sixty-three extra-pulmonary ARDS patients were enrolled and randomly divided into three groups, which were treated with sustained inflation (SI), increment of positive end-expiratory pressure (IP) and pressure control ventilation (PCV) respectively.The oxygenation index (PaO2/FiO2) before and after lung recruitment was recorded in patients with complete lung recruitment, and the cause of discontinuation of lung recruitment was recorded in patients with incomplete lung recruitment.Positive end-expiratory pressure (PEEP) was recorded in patients who completed lung recruitment with the latter two methods when they reached the maximum degree of lung recruitment.The mortality rate of 14 d in 3 groups was recorded, and the clinical characteristics and prognosis differences were compared before and after each group. Results With PaO2/FiO2 as the standard, all the three methods of pulmonary reexpansion could make the lungs obviously reexpanse.The PaO2/FiO2 of each group before, 5 minutes after and 1 hour after reexpansion were respectively as below (SI group: 70.4±14.8 mmHg, 306.8±97.5 mmHg, 229.6±116.2 mmHg; IP group: 74.9±13.6 mmHg, 328.0±95.5 mmHg, 252.8±111.0 mmHg; PCV group: 67.8±14.9 mmHg, 304.2±82.2 mmHg, 223.7±83.6 mmHg.P 0.05). PEEP of IP group is higher than that of PCV group at the time of maximum RM (20.3±2.5 cmH2O vs.18.5±1.8 cmH2O, P 0.05). Conclusion The effects of three methods of lung recruitment on severe pulmonary exogenous ARDS patients were similar, but there was no significant difference in prognosis.Adverse reactions of SI method leads to the greatest probability of discontinuation of lung recruitment, and that of the PCV method is the smallest.Under the same effect of lung recruitment, IP method needs higher PEEP than PCV method.In practice, PCV method should be preferred. Key words: Acute respiratory distress syndrome; Recruitment maneuvers; Sustained inflation; Increment PEEP; Pressure control ventilation

Evaluation of pulmonary reexpansion in a porcine model of bronchial foreign body.

This study was designed to establish a porcine model of reversible obstruction of endobronchial foreign body (FB) and to assess the natural pulmonary reexpansion process using radiology and histopathology after removal of the bronchial FB. A metal stent was placed in the right lower lobe bronchial lumen of 15 pigs by bronchoscopy and removed after 2 weeks of stent retention. Animals were divided into two groups (group I and II), based on when they were sacrificed (week 2 or week 4) after stent removal. Pigs underwent computerized tomography scan to document pulmonary radiological changes. The lungs were harvested for electron microscopy examination, and the expression of pulmonary surfactant-associated protein A (SPA) was determined by immunohistochemistry. Thirteen (86.7%) animals successfully responded to the intervention. Atelectasis was formed by stent implantation within 2 weeks. The ratio of the residual atelectasis area was smaller in group II compared to that in group I (P < 0.01). The histological manifestations of experimental lungs were significantly improved in group II. Moreover, the expression of SPA in group II was higher compared to that in group I (P < 0.01). We have established a model of reversible bronchial FB obstruction in pigs that is both feasible and appropriate for evaluating the long-term process of pulmonary reexpansion after removal of FB. Bronchial metal FB retention for a period of 2 weeks could form atelectasis, and a natural pulmonary recovery process related to atelectasis takes approximately 4 weeks after removal of metal FB.