Requiring Chest Tube Insertion Research Articles

Normal saline injection and rapid rollover; preventive effect on incidence of pneumothorax after CT-guided lung biopsy: a retrospective cohort study

BackgroundComputed tomography (CT)-guided lung biopsy is a widely used technique for the diagnosis of pulmonary lesions and with a high technical success rate and diagnostic accuracy. On the other hand, it is associated with a high risk of complications, especially pneumothorax. Various methods have been tried to reduce the incidence of pneumothorax, but no established method exists. The purpose of this study was to evaluate whether the combination of tract sealing with normal saline and rapid rollover can reduce the rate of pneumothorax and chest tube insertion after CT-guided lung biopsy.MethodsWe reviewed all CT-guided lung biopsies performed at a single institution between October 2016 and December 2021. Before August 2019, no specific additional techniques were employed to mitigate complications (Group 1). In contrast, after September 2019, normal saline for tract sealing was injected during needle removal, and if pneumothorax was observed during the intervention, the patient was rolled over into the puncture-site down position immediately after needle removal (Group 2). The rate of complications was compared between the two groups.Results130 patients in Group 1 and 173 in Group 2 were evaluated. There was no significant difference in pneumothorax rate between the two groups (30.0% vs. 23.1%, P = .177). A chest tube was inserted in 10 of 130 patients in Group 1 and only in 1 of 173 in Group 2 (P = .001). There were no complications associated with this combinational technique.ConclusionsThe combination of normal saline injection and rapid rollover significantly reduced the incidence of pneumothorax requiring chest tube insertion after CT-guided lung biopsy. Therefore, normal saline injection and rapid rollover can serve as a preventive method for severe pneumothorax in CT-guided lung biopsy.

Assessing risk factors for complications in computer tomography-guided lung biopsy: quantitative analysis for predicting pneumothorax.

Computer tomography (CT)-guided lung biopsy carries the risk of pneumothorax. A variety of other risk factors affect the occurrence of pneumothorax. Assess the incidence and risk factors associated with pneumothorax complications in CT-guided lung biopsy, and to conduct a quantitative analysis of the variables among the significant risk factors to identify more effective indicators for predicting pneumothorax complications. Retrospective logistic. Single center in China. From June 2017 to May 2021, consecutive patients who underwent CT-guided lung biopsy were identified from the medical record system. Binary logistic regression analysis was used to identify potential risk factors for pneumothorax. Receiver operating characteristic (ROC) curves were constructed for continuous variables to determine cutoff values that optimized sensitivity and specificity. The incidence and risk factors of pneumothorax in CT-guided lung biopsy. 132 patients. The incidence of pneumothorax was 28.9% (38/132), with 6.8% (9/132) of patients requiring chest tube insertion. Results indicated that smaller lesion size (OR 0.724; 95% CI 0.619-0.848; P=.0001), longer needle tract length (OR 1.320; 95% CI 1.145-1.521; P=.001), multiple passes through the pleura (OR 4.618; 95% CI 1.378-15.467; P=.013), and needle tract length/lesion diameter (L/D) ratio (OR 0.028; 95% CI 0.002-0.732; P=.007) were independent risk factors for pneumothorax. ROC curve analysis determined a cut-off value of 0.81 for the L/D ratio (sensitivity=89.5%, specificity=71.3%). The area under the ROC curve (AUC) values of maximum diameter, needle tract length, and L/D ratio for pneumothorax were 0.749, 0.812, and 0.850, respectively. The L/D ratio, multiple passes through the pleura, longer needle tract length, and smaller lesions were independent risk factors for pneumothorax. A L/D ratio of less than 0.81 may indicate a pneumothorax. It may be necessary to use the proper sealing procedure for this patient group. Due to its retrospective nature, there may be inherent selection bias.

A multicenter study on the epidemiology of complicated parapneumonic effusion in the era of currently available pneumococcal conjugate vaccines

BackgroundParapneumonic effusion (PPE) is a common complication of pneumonia. Streptococcus pneumoniae is the most common cause of bacterial pneumonia. A reduction in pneumonia hospitalizations has been observed since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). Despite this apparent benefit, an increase in the incidence of PPE was recorded in some countries following PCV7 implementation. As the 13-valent pneumococcal conjugate vaccine (PCV13) was expected to provide a wider protection against PPE, the aim of the present study was to evaluate the impact of PCV13 introduction on the epidemiology of complicated parapneumonic effusion (c-PPE) among children in the Athens greater area. MethodsAll cases of community-acquired pneumonia (CAP) with PPE requiring chest tube insertion (complicated PPE, c-PPE) hospitalized in the 3 public Children’s hospitals in Athens between 01/01/2004 and 31/12/2019 were included in the study. ResultsA total of 426 cases of c-PPE associated with pneumonia were recorded of which 198 were admitted during 2004–2010 (period A, prePCV13/PCV −7 introduction period) and 228 during 2011–2018 (period B, post - PCV13 period). A definite bacterial etiology was established in 44.4 % of all cases and of those 25.4 % were caused by S. pneumoniae. An increasing trend in c-PPE incidence was observed during period A; although, a significant decrease on c-PPE annual rates was observed during the period B (p = 0.011), a remarkable increase in serotype 3 cases was recorded. ConclusionA decreasing time trend in c-PPE cases among children was shown after the introduction of PCV13 in our area. However, serotype 3 is nowadays a common cause of PPE. Hence, continuous surveillance is imperative in order to follow c-PPE epidemiology over time.

Pneumothorax after CT-Guided Lung Biopsy: What Next?

Background Pneumothorax is the most common complication of computed tomography (CT)-guided lung biopsy. The asymptomatic rate ranges from 17.5 to 72%. The symptomatic rate requiring chest tube insertion is 6 to 18%. Aims This article studies the role of management of postbiopsy pneumothoraces by needle aspiration and pigtail catheter insertion. Methods This was a prospective observational study conducted over 2 years. Postbiopsy and prior to withdrawing the coaxial cannula a CT data set was obtained to detect and quantify pneumothoraces as mild, moderate, and severe. In all asymptomatic cases of mild pneumothorax simple observation was done. In all asymptomatic cases of moderate pneumothorax, immediate needle aspiration was performed. In all symptomatic cases, cases with severe pneumothorax, and cases with progressively enlarging pneumothorax small caliber 6 to 8F pigtail catheters were inserted. Results Ninety-one cases had mild pneumothorax, 42 had moderate pneumothorax, and 18 had severe pneumothorax. In the 91 patients of mild pneumothorax only 1 (1%) patient showed increase in size of pneumothorax on follow-up requiring catheter insertion. In the 42 cases of moderate pneumothorax, which were managed by simple aspiration of pneumothorax, 4 (9.5%) cases showed increase in size of pneumothorax on follow-up. A total 23 cases required pigtail catheter insertion in our study. These constituted 15.2% of pneumothorax cases. The mean duration of catheterization in our study was 3.74 ± 1.09 days. Conclusion Majority of pneumothoraces are benign and do not require any intervention, just observation. Manual aspiration is an effective way of treating moderate pneumothoraces with success rate of 90%, thereby reducing the number of cases requiring catheter insertion; however, close observation is required as few cases may progress to severe pneumothorax and require pigtail insertion. Only a small percentage of biopsy cases (6.4%) require catheter insertion which is a safe and effective treatment.

Does Gelfoam slurry embolization post-pulmonary biopsy reduce risk of pneumothorax? A prospective randomized control study

BackgroundCT-guided percutaneous transthoracic biopsy has become a widely accepted safe method in establishing the etiology of lung masses. Pneumothorax is the most commonly faced complication requiring further therapeutic intervention for treatment with chest tube drainage adding to the time of hospital stay.Aim of workWe aim to evaluate the effect of Gelfoam mixture biopsy tract embolization as a minimal added cost in reducing the overall rate of complications, the need of chest tube placement, and hospital stay.Patient and methodsA total of 138 transthoracic CT-guided lung biopsies were randomized to 70 track embolized patients and 68 control. The study protocol was approved from the National Cancer Institute ethical committee review board. Data were collected from the local PACS system and analyzed, reviewed and performed by one of three interventional radiologists. Patient records were analyzed for primary health risks, pre-procedural CT was analyzed for lesion-related risk factors, and intra-procedural CTs were analyzed for procedure-related risk factors. Outcome measures include incidence of pneumothorax, pneumothoraxes requiring chest tube insertion and hospital admission rates.ResultsMarked pneumothorax requiring chest tube insertion and hospital admission were significantly reduced in the embolized group as 7.1% compared to 19% in the non-embolized group with significant p value of 0.037. Hospital admissions reduced from 19% down to 4.3% in embolized cases with a significant p value of 0.007. On univariate regression analysis, embolization reduced chest tube placement odds by 68% (OR = 0.32, 95% CI 0.109–0.97, p = 0.044). The only significant procedural-related factor was needle pleural angle > 70° where it increased the risk of pneumothorax by 2.85 times and chest tube placement by 3.10 times. Gelfoam embolization significantly reduces the odds of post-procedural hospital admission by 81% (OR = 0.189, 95% CI 0.051–0.699, p = 0.012). In multivariate regression analysis, Gelfoam was significantly protective against chest tube insertion and prolonged hospital stay, by reducing the odds 74.3% (OR = 0.257, 95% CI 0.082–0.808, p = 0.020) and 86% (OR = 0.133, 95% CI 0.027–0.662, p = 0.014), respectively. Needle pleural angle more than 70° increased odds of chest tube insertion by 252%. Lesions that were in very low position related to the diaphragm and just behind ribs were less prone to chest tube insertion by 83% (OR = 0.164, 95% CI 0.035–0.779, p = 0.02), while those showing mediastinal invasion and central lung lesions had increased odds by 6.812 times (95% CI 1.452–31.958, p = 0.015) for longer hospital stays.ConclusionsGelfoam embolization post-CT-guided lung biopsy has proven to statistically reduce large pneumothoraces requiring chest tube insertion, longer hospital stay, and reduced unnecessary expenses.

Does needle gauge affect complication rates of computed tomography-guided lung biopsy?

It has been thought a larger bore biopsy needle may yield a better sample for molecular testing, but this could potentially expose the patient to higher pneumothorax rates. This study aims to determine if a larger bore biopsy system results in more complications. A total of 193 patients who underwent computed tomography (CT)-guided lung biopsy in a single tertiary center from 2013-2021 were evaluated retrospectively. Patients were divided into two groups, patients who underwent lung biopsy using the 17/18-gauge (18G) biopsy system and the 19/20-gauge (20G) biopsy system. Data recorded included biopsy needle gauge, nodule location and size, plug use, positioning, the length of the intraparenchymal tract, number of biopsy passes, pneumothorax, chest tube insertion, and admission. The mean age was 64.1±12.4 years. The median diameter of the lung nodules was 1.95 cm, and the median depth of the intraparenchymal needle tract was 2.7 cm. Pneumothorax was identified during the procedure by CT fluoroscopy or on post-procedural chest X-ray (CXR). The overall rate of pneumothorax among all patients was 35.2%, and 10.9% of the study population (i.e., 30.1% of patients with pneumothorax) required chest tube insertion. The rate of pneumothorax or chest tube insertion was not significantly different between patients who underwent lung biopsy using 17/18G or 19/20G biopsy system. Patients who developed pneumothorax were older, with smaller-sized pulmonary nodules and longer length of the intraparenchymal tract. The pathologic sensitivity of the 18G gun was higher than that of the 20G gun (93% sensitivity, 100% specificity vs. 79.5% sensitivity, 100% specificity). In the multivariate logistic regression fitted model, the length of the intraparenchymal tract was the only factor predictive of post-procedural pneumothorax and chest tube insertion. An intraparenchymal needle tract length of greater than 2 cm was identified to have the best threshold to predict pneumothorax [sensitivity: 73.5%; false positive rate: 57.6%; area under the curve: 66.27%]. Findings suggest similar rates of pneumothorax and chest tube insertion using small 19/20G vs. 17/18G biopsy systems. The 18G system was more sensitive compared to the 20G system in determining pathologic results. Increasing length of lung parenchyma needle tract and smaller lung nodules appear to be risk factors for pneumothorax. Physicians should plan on intraparenchymal tracts that are less than 2 cm to decrease the chance of pneumothorax.

DIAGNOSTIC ACCURACY AND COMPLICATIONS OF PERCUTANEOUS CT-GUIDED NEEDLE BIOPSY OF LUNG NODULES IN 161 PATIENTS

Objective: Transthoracic needle biopsy is a diagnostic method that has proven its reliability in lung nodules and is frequently applied in daily practice. The diagnostic accuracy of biopsies performed with computed tomography navigation is quite high, even if the lesion sizes are smaller than 1 cm. We aimed to evaluate the diagnostic accuracy and complications of the computed tomography-guided percutaneous transthoracic needle biopsy procedure performed in our center.
 Material and Methods: Patients who underwent computed tomography guided percutaneous transthoracic pulmonary nodule biopsy procedure between January 2017 and January 2020 were included in the study. The size and anatomic location of lesions, the distance between the pleura and the lesion, the angle of the needle with the pleura, the procedure time, the number of pathologic samples taken per patient, the total radiation dose, complications, and the pathological results of the lesions were analyzed from the patients’ computed tomography images and patients’ records.
 Results: Among the 161 patients admitted for the transthoracic percutaneous needle biopsy procedure, 135 were male (mean age 64.3±11.1 years) and 26 were females (mean age 61.3±15.4 years). The pathological evaluation of 32 patients were reported as non-diagnostic. The diagnostic accuracy of computed tomography guided transthoracic biopsy was calculated as 80.1%. Major complications occurred in 10 patients (6.2%), and minor complications occurred in 60 patients (37.2%). The rate of procedure requiring chest tube insertion was 4.9%. The mean effective radiation dose of the patients per procedure was calculated as 5.26±3.25 mSv.
 Conclusion: Computed tomography guided transthoracic biopsy procedure are a method with a high diagnostic accuracy rate, low rate of complications and can be preferred in all appropriate pulmonary nodules.

Necessity of performing a routine chest radiograph following the insertion of tunnelled Hickman catheter under imaging guidance: A single centre experience.

A chest radiograph has traditionally been performed following the insertion of a tunnelled Hickman catheter to immediately exclude rare but potentially serious complications such as pneumothorax and haemothorax and confirm appropriate positioning of the catheter tip. The value of completing the routine chest radiograph has been questioned when fluoroscopic image may be easily obtained in the angiography suite for the same purpose, and the rate of iatrogenic pneumothorax remains extremely low in the Medical literature. We describe our experience of performing Hickman catheter insertion under ultrasound and fluoroscopic guidance and whether routinely performing the chest radiograph is justifiable. A single centre retrospective review was performed of patients who received a tunnelled Hickman catheter and underwent postprocedural chest radiograph in the Interventional Radiology Department during a fifteen-year period from August 2007 to April 2021. Patient demographics and complications were documented. Delayed iatrogenic pneumothorax was diagnosed in one asymptomatic patient (0.06%) on a chest radiograph out of 1735 patients, and they required chest tube insertion. Other complications included two cases of right common carotid artery puncture, one case of right internal jugular vein dissection and one case of left internal jugular perforation. Two patients required a repeat procedure within 24 h due to superior migration of the Hickman catheter on chest radiograph. Given the extremely low rate of iatrogenic pneumothorax, chest radiograph following the insertion of a tunnelled Hickman catheter under ultrasound and fluoroscopic guidance may be an unnecessary investigation unless the patient is symptomatic, or there is sufficient clinical concern.

Pneumothorax during upper airway stimulation: Does experience make a difference?

ObjectivesUpper airway stimulation is a treatment option for select patients with obstructive sleep apnea. Pneumothorax may occur with UAS implantation during placement of the respiratory sensor. This study aims to evaluate the incidence of pneumothorax during UAS device placement. We hypothesize that sleep surgeons with high implantation volumes experience lower rates of pneumothorax compared to the general population of surgeons. MethodsWe also aim to describe management of pneumothorax when it does occur. The incidence of pneumothorax during UAS implantation among the general population of surgeons was assessed using the TriNetX Research Network. Additionally, a select group of Otolaryngologist sleep surgeons with a high UAS implantation volume were surveyed regarding experiences with UAS related pneumothoraces. Results8 pneumothoraces occurred among 3823 UAS procedures in the surveyed otolaryngologist sleep surgeon population. 4 required chest tube insertion. Among the general population cohort, 42 of 1233 patients developed pneumothorax after UAS implantation. The rates of pneumothorax between the otolaryngologist sleep surgeon cohort and general population of surgeons cohort were 0.21 % and 3.4 % respectively (p < 0.00001). ConclusionPneumothorax rarely occurs during UAS implantation. Surgeons with higher implantation volumes showed a lower incidence of pneumothorax. Pneumothorax management is dependent on patient stability, perioperative setting, and degree of injury. The use of needle decompression, chest tube placement, and suture placement also vary with clinical scenario.

Percutaneous Image-Guided Biopsy for a Comprehensive Hybridization Capture-Based Next-Generation Sequencing in Primary Lung Cancer: Safety, Efficacy, and Predictors of Outcome

IntroductionTo evaluate factors associated with successful comprehensive genomic sequencing of image-guided percutaneous needle biopsies in patients with lung cancer using a broad hybrid capture-based next-generation sequencing assay (CHCA). MethodsWe conducted a single-institution retrospective review of image-guided percutaneous transthoracic needle biopsies from January 2018 to December 2019. Samples with confirmed diagnosis of primary lung cancer and for which CHCA had been attempted were identified. Pathologic, clinical data and results of the CHCA were reviewed. Covariates associated with CHCA success were tested for using Fisher’s exact test or Wilcoxon ranked sum test. Logistic regression was used to identify factors independently associated with likelihood of CHCA success. ResultsCHCA was requested for 479 samples and was successful for 433 (91%), with a median coverage depth of 659X. Factors independently associated with lower likelihood of CHCA success included small tumor size (OR = 0.26 [95% confidence interval (CI): 0.11–0.62, p = 0.002]), intraoperative inadequacy on cytologic assessment (OR = 0.18 [95% CI: 0.06–0.63, p = 0.005]), small caliber needles (≥20-gauge) (OR = 0.22 [95% CI: 0.10–0.45, p < 0.001]), and presence of lung parenchymal abnormalities (OR = 0.12 [95% CI: 0.05–0.25, p < 0.001]). Pneumothorax requiring chest tube insertion occurred in 6% of the procedures. No grade IV complications or procedure-related deaths were reported. ConclusionsPercutaneous image-guided transthoracic needle biopsy is safe and has 91% success rate for CHCA in primary lung cancer. Intraoperative inadequacy, small caliber needle, presence of parenchymal abnormalities, and small tumor size (≤1 cm) are independently associated with likelihood of failure.

QUALITY IMPROVEMENT INITIATIVE TO REDUCE THE RATES OF CHEST TUBE FAILURE IN MANAGEMENT OF IATROGENIC PNEUMOTHORAX FOLLOWING CT-GUIDED LUNG BIOPSY

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Iatrogenic pneumothorax following Interventional Radiology (IR) CT-guided transthoracic lung biopsy is a frequent complication with reported rates between 12-45% of which 2-15% will require thoracostomy tube placement. Recently, smaller tube sizes have been made commercially available, but it is unclear if these tubes are as efficacious and safe as larger chest tubes in the management of iatrogenic pneumothorax following lung biopsy. A previous quality assessment project at our institution demonstrated higher failure rates in chest tubes of less than 10 French (Fr). Our objective was to reduce the incidence of chest tube failure when managing iatrogenic pneumothorax after CT-guided lung biopsy via IR. METHODS: After demonstrating a failure rate in smaller bore chest tubes, we met with our interventional radiology colleagues and decided to place 10 Fr chest tubes or larger after iatrogenic pneumothorax following CT-guided lung nodule biopsies. As with our previous quality assessment project, we then retrospectively completed a chart review from January 2018 to March 2021 on all IR CT-guided lung nodules biopsied and identified cases of iatrogenic pneumothorax requiring chest tube placement and those with chest tube failure. We again defined chest tube failure as expanding pneumothorax requiring additional chest tube insertion or tension pneumothorax. RESULTS: In the pre-intervention group, there were a total of 7 chest tubes of less than 10 Fr and 5 chest tube failures in the 78 cases that required chest tube insertion (9% & 6% respectively). In the post-intervention group, no catheters smaller than 10 Fr were placed and there were no chest tube failures in the 54 cases that required chest tube insertion (0%); 6 (11%) individuals had a 10 Fr, 7 (13%) had a 12 Fr, and the remaining 41 (76%) had a 14 Fr chest tube inserted. The absence of chest tubes smaller than 10 Fr in the post-intervention group was statistically significant (p=0.02). There were no failures in the post-intervention group compared to 6% in the pre-intervention group (p=0.06). CONCLUSIONS: This analysis suggests a reduction in complication rates with the use of chest tubes 10 Fr or larger in management of iatrogenic pneumothorax from CT guided lung biopsy. This quality improvement project has demonstrated a significant change in practice habits with a trend toward reduced failure rates. A larger analysis will be needed to examine the statistical significance of reduced complications after intervention. CLINICAL IMPLICATIONS: This study demonstrated a change in practice habits toward larger sized chest tubes in the management of iatrogenic pneumothorax from CT-guided lung nodule biopsy. A larger analysis will be needed to demonstrate optimal chest tube size. DISCLOSURES: No relevant relationships by hassan Al-Balas, source=Web Response No relevant relationships by Stephen Bujarski, source=Web Response No relevant relationships by Sunjay Devarajan, source=Web Response No relevant relationships by James Ramey, source=Web Response No relevant relationships by Sarah Tuthill, source=Web Response

THE LEAKY LUNG: A CASE OF COVID-19 PNEUMONIA COMPLICATED BY LUNG ABSCESS, BRONCHOPLEURAL FISTULA, AND PNEUMOTHORAX

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung abscesses develop when necrosis of lung tissue caused by underlying infections form cavitary spaces of the lung parenchyma. A bronchopleural fistula (BPF) is a complication of cavitary lesions where a sinus tract forms between the bronchus and pleural space. We present the first reported case of a patient with severe COVID-19 who developed a lung abscess with a BPF and spontaneous pneumothorax requiring video-assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 60-year-old male with a history of hypertension and dyslipidemia presented to the hospital with shortness of breath after a recent diagnosis of COVID-19. The patient was hypoxic on room air and his chest x-ray (CXR) revealed bilateral infiltrates. The patient was admitted to the medical floors and treated with methylprednisolone, Remdesivir, piperacillin/tazobactam and DVT prophylaxis doses of enoxaparin. Methylprednisolone was increased to higher doses over the next few days in response to worsening inflammatory markers and hypoxia, as high as 125mg IV 4 times a day and was subsequently tapered to 160mg IV daily in divided doses for 30 days. On day 40, a new cavitary lesion of the right middle lobe (RML) was seen on CXR, and blood cultures grew methicillin sensitive staphylococcus aureus (MSSA) for which linezolid, meropenem and micafungin were started. On day 42, the patient developed a right sided pneumothorax which required chest tube insertion. On day 47 the patient developed respiratory distress and worsening pneumothorax, the pleural drainage system demonstrated continuous air leak and the patient was subsequently intubated due to worsening respiratory failure. VATS was performed which revealed a RML abscess; the procedure was converted to open thoracotomy with RML wedge resection. Histopathological analysis showed organizing pneumonia, interstitial fibrosis, alveolar damage and a BPF. Cultures taken from the abscess grew MSSA. On day 49, the patient became hypotensive and required the initiation of vasopressors. In the following days he developed a new air leak noted on the pleural drainage system. He remained in the ICU for several days and did not exhibit clinical improvement, thus his family transitioned him to comfort measures and he passed away soon after. DISCUSSION: High dose corticosteroids are used to treat severe COVID-19 with the goal of preventing cytokine storm and subsequent ARDS. Immunosuppression is a complication of prolonged treatment with high dose corticosteroids and may result in bacterial superinfection. Lung abscesses are typically treated conservatively with broad spectrum antibiotics. In cases such as those with BPF and pneumothorax, treatment with surgical intervention may be required. CONCLUSIONS: While corticosteroids have been used widely in the treatment of COVID-19, clinicians should be cautious in the consequences of prolonged utilization and should monitor for related complications. REFERENCE #1: Kuhajda, I., Zarogoulidis, K., Tsirgogianni, K., Tsavlis, D., Kioumis, I., Kosmidis, C., . . . Kuhajda, D. (2015, August). Lung abscess-etiology, diagnostic and treatment options. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543327/ REFERENCE #2: Salik, I. (2020, August 27). Bronchopleural fistula. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK534765/ DISCLOSURES: No relevant relationships by Arslan Chaudhry, source=Web Response No relevant relationships by Rajapriya Manickam, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Sherif Roman, source=Web Response No relevant relationships by Anish Samuel, source=Web Response

Complications and Risk Factors of Patients Undergoing Computed Tomography-Guided Core Needle Lung Biopsy: A Single-Center Experience.

ObjectivesTo determine the risk factors and complications of transthoracic computed tomography (CT)-guided core needle lung biopsy.MethodsThis is a retrospective study of 124 patients who underwent CT-guided core lung biopsy in King Khalid University Hospital (KKUH), Riyadh. This retrospective study was conducted between January 2016 and January 2020. Patient data were collected using a standardized data form that was entered into an Excel sheet in accordance with the variables. The Statistical Package for the Social Sciences software (SPSS, version 24.0 [SPSS Inc., Chicago, IL, USA]) was used to compute for the risk of complications after CT-guided core lung biopsy and perform all statistical comparisons, and the results were reported.ResultsThe overall complication rate due to CT-guided core needle biopsy was 34.7% (43) (P<0.001) of the total sample. Of the total complications, 69.76% (n = 30) had pneumothorax, 20.94% (n = 9) had hemorrhage, 6.98% (n = 3) had both pneumothorax and hemorrhage, and 2.32% (n = 1) had both air embolism and pneumothorax. Of all patients who developed pneumothorax, 20% (n = 6) required chest tube insertion. Patients with secondary chronic obstructive pulmonary disease (COPD) had a complication rate of 80% among the whole sample. Lung lesions less than 3 cm had a complication rate of 48.8% (P<0.034). The needle size showed a higher rate of complications between 20 and 18 gauge with 47.4% (n = 9) and 32.4% (n = 34), respectively.ConclusionsWe conclude that CT-guided lung biopsy is a well-established low-risk procedure that is less invasive. However, it still carries a risk of complications with some risk factors, such as small lung lesion size and secondary COPD.

Pleural complications in patients with coronavirus disease 2019 (COVID-19): how to safely apply and follow-up with a chest tube during the pandemic?

OBJECTIVES Severe acute respiratory syndrome coronavirus 2, a novel coronavirus, affects mainly the pulmonary parenchyma and produces significant morbidity and mortality. During the pandemic, several complications have been shown to be associated with coronavirus disease 2019 (COVID-19). Our goal was to present a series of patients with COVID-19 who underwent chest tube placements due to the development of pleural complications and to make suggestions for the insertion and follow-up management of the chest tube.METHODSWe retrospectively collected and analysed data on patients with laboratory-confirmed COVID-19 in our hospital between 11 March and 15 May 2020. Patients from this patient group who developed pleural complications requiring chest tube insertion were included in the study.RESULTSA total of 542 patients who were suspected of having COVID-19 were hospitalized. The presence of severe acute respiratory syndrome coronavirus 2 was confirmed with laboratory tests in 342 patients between 11 March and 15 May 2020 in our centre. A chest tube was used in 13 (3.8%) of these patients. A high-efficiency particulate air filter mounted double-bottle technique was used to prevent viral transmission.CONCLUSIONSIn patients with COVID-19, the chest tube can be applied in cases with disease or treatment-related pleural complications. Our case series comprised a small group of patients, which is one of its limitations. Still, our main goal was to present our experience with patients with pleural complications and describe a new drainage technique to prevent viral transmission during chest tube application and follow-up.

Learning curve predictors for minimally invasive mitral valve surgery; how far should the rabbit hole go?

To analyze predictors that influence the learning curve of minimally invasive mitral valve surgery (MIMVS). Patients who underwent MIMVS between March 2010 to March 2015 were retrospectively analyzed. Predictive factors that influence the learning curve were analyzed. One hundred and five patients were included in the analysis. Cardiopulmonary bypass (CPB) time in minutes was 158.72 ± 40.98 and the aortic cross-clamp (ACC) time in minutes was 114.48 ± 27.29. There were three operative mortalities, one stroke and five >2+ mitral regurgitation. ACC time in minutes was higher in the low logistic Euroscore II (LES) group (LES < 5% = 118.42 ± 27.94) versus (LES ≥ 5 = 88.66 ± 22.26), P < .05 while creatinine clearance in μmol/L was higher in the LES < 5% group (LES < 5% = 84.32 ± 33.7) versus (LES ≥ 5% = 41.66 ± 17.14), (P < .05). One patient from each group required chest tube insertion for pleural effusion P < .05. The cumulative sum analysis (CUSUM) for the first 25 patients had CPB and ACC times that reached the upper limits. Between 25 to 64 patients the curve remained stable while with the introduction of reoperations and complex surgical procedures the CUSUM reached the upper limits. The learning curve is affected by many factors but this should not desist surgeons from approaching this technique. The introduction of high-risk patients in clinical practice should be carefully measured based on surgeon experience.

Long-term outcome following microwave ablation of early-stage non-small cell lung cancer.

This study aimed to evaluate the long-term outcome of microwave ablation (MWA) of early-stage non-small cell lung cancer (NSCLC), including response to treatment and survival. This retrospective study was conducted on consecutive patients who underwent computed tomography-guided MWA of early-stage NSCLC (no evidence of nodal or distant metastasis) from November 2010 to December 2014 at our institution. Data were collected from systematic review of patient charts and imaging. Procedural complications, response to treatment and survival were assessed. 34 early-stage (T1a-T3N0M0) NSCLCs in 30 patients were treated with a total of 41 MWA sessions. There were no intraprocedural or 30-day post-procedural deaths. The most common complication was pneumothorax, encountered in 24 (59%) microwave ablation sessions, six (15%) of which required chest tube insertion. Over a median computed tomography follow-up period of 39months (range 3-89), 24 (71%) NSCLCs demonstrated local control, while 10 (29%) demonstrated local progression. Nodal/distant progression was more common than local progression, with 15 of the 30 patients (50%) having nodal or distant metastases at follow-up. Patient survival status was followed up over a median period of 56.5months (range 10-107). Median overall survival and 5-year overall survival were 56.5months (95% confidence interval, 26-not reached) and 46.7% (95% confidence interval, 31.8-68.4), respectively. MWA is safe and effective at achieving local control of early-stage NSCLC and may prolong patient survival. Nodal or distant metastases were the dominant manifestations of disease progression at long-term follow-up.

Sa1313 ANALYSIS OF SAFETY AND EFFICACY OF PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: A SINGLE-CENTER EXPERIENCE WITH MID-TERM FOLLOW-UP

Peroral endoscopic myotomy (POEM) has been introduced as a new effective therapeutic option for achalasia. This abstract illustrates our experience with POEM in a large single-center series of achalasia patients with mid-term follow-up. A retrospective review was conducted that included all consecutive patients with achalasia who underwent POEM between January 2016 to December 2018 in a tertiary care center. The primary outcome was clinical response, defined as an Eckardt score lower than 3. Secondary outcomes were procedure-related adverse events (graded according to the ASGE lexicon's severity grading system) and incidence of postoperative gastroesophageal reflux disease. A total of 206 patients (mean age 40.6 years, 94 males) underwent POEM for the treatment of achalasia (35 type I, 137 type II, 34 unspecified). Of these, 40 (19.4%) had received previous treatment for achalasia before POEM, including 27 pneumatic dilation, 8 prior POEM, 3 Heller myotomy, 1 botulinum toxin injection and 1 temporary esophageal stenting. Technical success was achieved in all patients. Posterior myotomy was performed in 70.9% of patients. Adverse events occurred in 20 (9.7%) patients. There were 9 inadverted mucosotomies, 5 pneumonia, 3 cardiac arrhythmia, 2 symptomatic pneumothorax requiring needle decompression, 1 pleural effusion requiring chest tube insertion. Fifteen adverse events were grade as mild, 5 moderate, and none severe. Among 185 patients with median follow-up period of 24 months (IQR 12.0-29.3), clinical success was achieved in 87.0% of patients, and Eckardt scores improved from pre-operative 6.4±1.9 to post-operative 1.4±1.6 (P <0.001). There were no significant differences in the success rate among the achalasia subtypes (P =0.947). Postoperative upper endoscopy revealed esophagitis in 19.5% of patients (5 LA grade A, 12 LA grade B), while 11.9% of patients had post-operative symptoms suggestive of gastroesophageal reflux (GerdQ >7). The present large series add to the evidence that POEM is a safe and effective treatment for achalasia patients, resulting in mid-term symptom relieved in nearly 90% of patients without severe adverse events.

A RARE CASE OF DISSEMINATED ADENOVIRUS CAUSING SEPTIC SHOCK WITH MYCOPLASMA COINFECTION SUCCESSFULLY TREATED WITH CIDOFOVIR

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: We present a rare case of refractory septic shock secondary to disseminated adenovirus co-infected with Mycoplasma that was successfully treated with cidofovir. CASE PRESENTATION: A healthy 7-year-old male presented with fever and cough of 10 days. He was diagnosed with Mycoplasma pneumoniae (Mp) based on cold agglutinin screen and was given azithromycin. With no improvement in symptoms after two days, chest x-ray revealed left lower lobe pneumonia, Biofire showed adenovirus (ADV) with negative Mp, and urinalysis showed 2+ protein and 3+ blood. He was admitted to the hospital, given ceftriaxone, and started on oxygen via nasal cannula for hypoxia. He rapidly deteriorated, developed left-sided pleural effusion requiring chest tube insertion, and had more difficult oxygenation; so he was transferred to the Pediatric Intensive Care Unit. Within 24 hours, he developed respiratory failure and pressor-dependent shock requiring veno-venous extracorporeal membrane oxygenation (ECMO). Antibiotics were escalated. With progression of disease, the decision was made to initiate cidofovir therapy (5mg/kg once) that day despite known proteinuria and renal insufficiency. He developed renal failure requiring initiation of continuous renal replacement therapy (CRRT) the day after ECMO started. An Mp titer was sent showing positive IgG and elevated IgM (4933 U/mL), so azithromycin was restarted. He was also started on steroids for concern for adrenal insufficiency. Initial ADV viral load was >2million copies. After 5 days a second ADV PCR was obtained showing 942 copies, so a second cidofovir dose (1mg/kg once) was given. He was able to be decannulated on day 7 to a conventional ventilator. Two weeks later, he had an undetectable viral load and was on room air. Renal support was weaned off completely with eventual recovery of function to baseline. DISCUSSION: ADV is ubiquitous, with some genotypes causing outbreaks of life-threatening viral pneumonia even in immunocompetent adults. Reports of severe ADV pneumonia are much less common in immunocompetent children: disseminated disease occurs in less than 2% and is very rare in those older than 3 years (two published reports in adults and children above the age of 3). It is possible that Mp served as an immune modulator for ADV to cause such severe disease. CONCLUSIONS: To our knowledge, this is the first co-infection with ADV and Mp described in critically ill children; Mp has been described as coinfection for measles and pertussis. A study of the ELSO registry from 1998-2009 showed that only 38% of children on ECMO for ADV infection survived to discharge, and that survival was less common among those requiring dialysis (17%); however, this patient had good acute outcomes with the use of cidofovir. Reference #1: Munoz FM, Piedra PA, Demmler GJ. Disseminated adenovirus disease in immunocompromised and immunocompetent children. Clin Infect Dis. 1998;27(5):1194-200. Reference #2: Jeong E, Maslyanskaya S, Coupey SM. Disseminated adenovirus disease presenting as septic shock in an immunocompetent pubertal girl. Infect Dis Clin Pract 2018;26: e25–e27. Reference #3: Prodhan P, Bhutta AT, Gossett JM, Stroud MH, Rycus PT, Bratton SL, Fiser RT. Extracorporeal Membrane Oxygenation Support Among Children with Adenovirus Infection: A Review of the Extracorporeal Life Support Organization Registry ASAIO Journal 2014; 60:49–56. DISCLOSURES: No relevant relationships by Ashley Choe, source=Web Response No relevant relationships by William Dalzell, source=Web Response No relevant relationships by Kathryn Kocher, source=Web Response No relevant relationships by Bianca Rad, source=Web Response

Initial Experience in CT-Guided Percutaneous Transthoracic Needle Biopsy of Lung Lesions Performed by a Pulmonologist.

In the diagnosis of lung lesions, computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) has a high diagnostic yield and a low complication rate. The procedure is usually performed by interventional radiologists, but the diagnostic yield and safety of CT-guided PTNB when performed by pulmonologists have not been evaluated. A retrospective study of 239 patients who underwent CT-guided PTNB at Yeungnam University Hospital between March 2017 and April 2018 was conducted. A pulmonologist performed the procedure using a co-axial technique with a 20-gauge needle. Then diagnostic yield and safety were assessed. The overall sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of malignancy were 96.1% (171/178), 100% (46/46), 100% (171/171), and 86.8% (46/53), respectively. The diagnostic accuracy was 96.9% (217/224) and the overall complication rate was 33.1% (82/248). Pneumothorax, hemoptysis, and hemothorax occurred in 27.0% (67/248), 5.2% (13/248), and 0.8% (2/248) of the patients, respectively. Univariate analyses revealed that pneumothorax requiring chest tube insertion was a significant risk factor (odds ratio, 25.0; p < 0.001) for diagnostic failure. CT-guided PTNB is a safe procedure with a high diagnostic accuracy, even when performed by an inexperienced pulmonologist. The results were similar to those achieved by interventional radiologists as reported in previously published studies.

Uniportal VATS Coil-Assisted Resections for GGOs.

Backgrounds Although uniportal video-assisted thoracic surgery (VATS) theoretically allows the direct palpation of any zone of the lung through a small incision, sometimes it can be difficult to localize pure ground-glass opacities anyway. The aim of this study is to evaluate the usefulness and safety of preoperative computed tomography (CT)-guided microcoil localization of GGO nodules in patients undergoing uniportal VATS lung resection. Methods The clinical data and CT images of 30 consecutive patients (30 pulmonary nodules) who underwent preoperative CT-guided coil localization and subsequent uniportal VATS resection, from January 2017 to October 2018, were reviewed. Results All the CT-localization procedures have been performed with success (30/30) and the mean procedure time was 35±15 minutes. The mean size of the nodules was 15,53±6,72 mm, and the mean distance of the nodules from the pleural surface was 19,08±12,08 mm. Eleven nodules (36,7%) were pure ground-glass opacities and 19 (63,3%) were mixed ground-glass with a solid component of 50% or more. In 5 cases, the localization procedure was complicated by asymptomatic pneumothoraxes and in 1 case the pneumothorax required chest tube insertion. In any case a conversion to thoracotomy was avoided because all nodules were identified and resected through uniportal VATS. Conclusions Preoperative CT-guided coil localization seems to be a feasible, safe, and accurate procedure. It makes uniportal VATS an easy approach even for resecting small, deep, and impalpable nodules.