ObjectivesOccult pneumothorax is increasingly diagnosed in trauma patients due to widespread use of computed tomography (CT), yet its optimal management remains controversial. This study aimed to identify clinical and radiological predictors of deterioration requiring tube thoracostomy and to develop a predictive model to guide management decisions.MethodsIn this retrospective single-centre study, 166 patients with blunt trauma-associated occult pneumothorax were analyzed. Clinical and radiological variables—including subcutaneous emphysema, haemothorax volume, pneumothorax size, mechanical ventilation, and rib fractures—were evaluated for association with delayed tube thoracostomy. A weighted multivariable logistic regression model addressed class imbalance, and model performance was assessed using receiver operating characteristic (ROC) analysis.ResultsOf 166 patients, 17 (10.2%) required delayed tube thoracostomy. Subcutaneous emphysema (odds ratio [OR] 20.10, P = .001) and mechanical ventilation (OR 17.30, P = .002) were the strongest independent predictors of deterioration. Haemothorax volume also showed a significant association (OR 1.06, P = .045). Other factors, including pneumothorax size, rib fractures, age, and sex, were not predictive. The predictive model demonstrated excellent discrimination (area under the curve [AUC] = 0.97), suggesting potential for clinical risk stratification.ConclusionsPhysiological indicators such as subcutaneous emphysema and mechanical ventilation are superior to anatomical parameters in predicting deterioration among patients with occult pneumothorax. Our findings support a selective management strategy and highlight the utility of predictive modelling to guide tube thoracostomy decisions. Prospective multicentre studies are warranted to validate these results.

Emergency Department Accuracy of Point-of-Care Ultrasound in Identifying Clinically Significant Pneumothorax in High-Severity Trauma Patients.

Background: Achalasia is a primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis, which increases the risk of aspiration during anesthesia. Peroral endoscopic myotomy (POEM) is a minimally invasive therapeutic approach requiring tailored anesthetic management. This study aimed to evaluate perioperative anesthesia management during POEM, focusing on ventilation parameters, intraoperative hemodynamics, laboratory changes, and the incidence and severity of postoperative complications. Methods: A retrospective analysis was conducted on 51 patients who underwent POEM between June 2016 and April 2025. Demographic features, anesthesia techniques, intraoperative physiologic parameters, hematologic profiles, and postoperative complications were evaluated. Standard preoperative fasting protocols were implemented. Rapid sequence induction (RSI) with propofol and rocuronium was followed by endotracheal intubation. Desflurane was used for maintenance anesthesia, with ventilation settings adjusted to limit end-tidal carbon dioxide (ETCO2) elevation. Results: The median age of patients was 48 years, with a slight female (52.9%) predominance. Most patients were American Society of Anesthesiologists (ASA) II (64.7%) or ASA III (35.3%) scores and had comorbid hypertension (31.4%) or diabetes (11.8%). The median anesthesia duration was 180 min, and the peak inspiratory pressure remained stable at 25 mmHg. Oxygen saturation (SpO2) improved during the procedure, while ETCO2 increased from baseline to 49 mmHg by the end. Blood pressure declined transiently but recovered intraoperatively. Hematologic analysis showed significant increases in white blood cell (WBC) and neutrophils and mild decreases in hemoglobin, hematocrit, and platelets. Early postoperative complications included subcutaneous emphysema (19.6%), minor bleeding (9.8%), and pneumoperitoneum (7.84%). Two patients required tube thoracostomy due to pneumothorax, but no patient developed a complication requiring surgical exploration. During a median follow-up of 546 days, no mortality was reported. Long-term complications were infrequent, with gastroesophageal reflux disease (GERD) (3.92%) and esophagitis (1.96%) being the most notable. Conclusions: POEM can be performed safely with appropriate anesthetic management. Despite significant physiologic changes during carbon dioxide (CO2) insufflation, no life-threatening complications occurred, and the majority of adverse events were minor and self-limiting. Close intraoperative monitoring and interdisciplinary coordination contribute to favorable perioperative outcomes.

Computed tomography-detected hemothorax after blunt chest trauma: Does everyone need an intervention? A retrospective analysis.

Thoracic trauma occurs in approximately 25% of all traumas, and one third of these patients will present with a pneumothorax, hemothorax, or a combination of the two. Hemodynamically abnormal patients require expeditious tube thoracostomy drainage, while the decision to intervene on a hemodynamically normal patient is guided by radiographic imaging. Ultrasonography, chest x-ray, and computed tomography (CT) scans are the most common imaging modalities for traumatic thoracic pathologies. A pneumothorax greater than 20% of the thoracic volume on chest x-ray or greater than 35 mm on CT, measured radially from the chest wall to the lung parenchyma, should be treated with tube thoracostomy. Pneumothoraces smaller than this may be observed; approximately 10% of these will fail observation and require tube thoracostomy treatment. Hemothorax size may be measured using the Mergo formula on a chest CT scan. It is recommended that a hemothorax larger than 300 mL should be drained. Irrigation with warm sterile saline upon placement of a thoracostomy tube has been shown to decrease the rate of secondary interventions, such as additional tube thoracostomies, or surgical intervention. Antibiotic administration prior to tube thoracostomy is recommended. This review article discusses the diagnosis, management, and complications of pneumothoraces and hemothoraces and their treatment.

Background of study; Diffuse parenchymal lung diseases (DPLDs) are complex conditions that often require histological confirmation for accurate diagnosis. While video-assisted thoracoscopic surgery (VATS) is the gold standard, transbronchial lung biopsy (TBLB) offers a less invasive alternative. This study evaluates the diagnostic yield and complications of TBLB in DPLD patients at Sir Ganga Ram Hospital. Objective; To evaluate the outcome of Transbronchial lung biopsy in parenchymal lung diseases in department of tertiary care hospital. Methods; This prospective study included 48 patients with HRCT features of DPLD who underwent TBLB at Sir Ganga Ram Hospital from January to December 2019. Biopsies were taken from middle or lower lobe segments using a 6 mm channel Fujinon therapeutic bronchoscope under sedation and analgesia. Patients with significant comorbidities or bleeding risk were excluded. Histological samples were sent for analysis. Results; Of 48 enrolled patients (mean age 53 ± 12 years; 28 males, 20 females), the most common HRCT finding was bilateral ground glass opacities (30.2%). Adequate histological samples were obtained in 90% of cases. The most frequent diagnoses were nonspecific interstitial pneumonitis (27.3%), usual interstitial pneumonia (24.2%), and sarcoidosis/hypersensitivity pneumonitis (18.2% each). Pneumothorax occurred in 8 patients; 6 resolved conservatively, while 2 required tube thoracostomy. Conclusion: TBLB is a safe, effective diagnostic option for DPLD, offering good yield with fewer risks, especially in resource-limited settings. Advances in technique may further enhance its accuracy.

A supplementary technique for localized pneumothorax requiring tube thoracostomy: scopy

A supplementary technique for localized pneumothorax requiring tube thoracostomy: scopy

Objectives: This study aims to evaluate the clinical outcomes of trauma patients with minimal pneumothorax, with a specific focus on those with rib fractures. The primary objective is to assess whether a minimum 48-hour observation period is adequate to prevent complications such as recurrent pneumothorax or prolonged air leaks, and to examine the role of early intervention. Methods: A retrospective study was performed on 185 trauma patients diagnosed with minimal pneumothorax over a five-year period. Among these, 83 patients had rib fractures, while 102 did not. Clinical outcomes, including time to tube thoracostomy and the necessity of surgical intervention, were analyzed. Data were compared using chi-square tests, logistic regression models, and Kaplan-Meier survival analysis to determine time-to-intervention trends. Results: Of the 185 patients, 159 were male and 26 were female, ranging from 19 to 85 years old. Tube thoracostomy was required in 9 patients with rib fractures after an average of 19 hours, while 5 patients without rib fractures required tube thoracostomy after an average of 17 hours. Surgical intervention was necessary for 4 patients due to recurrent pneumothorax or prolonged air leaks, all of whom had rib fractures. Conclusions: Patients with rib fractures are at increased risk for complications and should be closely monitored for at least 48 hours to detect and manage complications early. Early intervention, particularly tube thoracostomy, may prevent more serious outcomes in patients with rib fractures.

Objectives This study aims to evaluate the clinical outcomes of trauma patients with minimal pneumothorax, with a specific focus on those with rib fractures. The primary objective is to assess whether a minimum 48-hour observation period is adequate to prevent complications such as recurrent pneumothorax or prolonged air leaks, and to examine the role of early intervention. Methods A retrospective study was performed on 185 trauma patients diagnosed with minimal pneumothorax over a five-year period. Among these, 83 patients had rib fractures, while 102 did not. Clinical outcomes, including time to tube thoracostomy and the necessity of surgical intervention, were analyzed. Data were compared using chi-square tests, logistic regression models, and Kaplan-Meier survival analysis to determine time-to-intervention trends. Results Of the 185 patients, 159 were male and 26 were female, ranging from 19 to 85 years old. Tube thoracostomy was required in 9 patients with rib fractures after an average of 19 hours, while 5 patients without rib fractures required tube thoracostomy after an average of 17 hours. Surgical intervention was necessary for 4 patients due to recurrent pneumothorax or prolonged air leaks, all of whom had rib fractures. Conclusions Patients with rib fractures are at increased risk for complications and should be closely monitored for at least 48 hours to detect and manage complications early. Early intervention, particularly tube thoracostomy, may prevent more serious outcomes in patients with rib fractures.

This study aimed to develop and assess the performance of an artificial intelligence(AI)-driven decision support system, XRAInet, in accurately identifying pediatric patients with pleural effusion or pneumothorax and determining whether tube thoracostomy intervention is warranted. In this diagnostic accuracy study, we retrospectively analyzed a data set containing 510 X-ray images from 170 pediatric patients admitted between 2005 and 2022. Patients were categorized into two groups: Tube (requiring tube thoracostomy) and Conservative (managed conservatively). XRAInet, a deep learning-based algorithm, was trained using this data set. We evaluated its performance using various metrics, including mean Average Precision (mAP), recall, precision, and F1 score. XRAInet, achieved a mAP score of 0.918. This result underscores its ability to accurately identify and localize regions necessitating tube thoracostomy for pediatric patients with pneumothorax and pleural effusion. In an independent testing data set, the model exhibited a sensitivity of 64.00% and specificity of 96.15%. In conclusion, XRAInet presents a promising solution for improving the detection and decision-making process for cases of pneumothorax and pleural effusion in pediatric patients using X-ray images. These findings contribute to the expanding field of AI-driven medical imaging, with potential applications for enhancing patient outcomes. Future research endeavors should explore hybrid models, enhance interpretability, address data quality issues, and align with regulatory requirements to ensure the safe and effective deployment of XRAInet in healthcare settings.

Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. Therapeutic/Care Management; Level IV.

Amaç: Bu çalışma, primer hiperhidrozis (aşırı terleme) tanısı konan hastalarda tek port sempatektomi (uniportal sempatektomi) ameliyatının etkinliğini değerlendirmeyi amaçlamaktadır. Gereç ve Yöntemler: 2019-2023 yılları arasında Kayseri Şehir Hastanesi’nde primer hiperhidrozis tanısı alan 58 hastaya tek port sempatektomi operasyonu yapılmıştır. Hastaların sonuçları değerlendirilmiştir. Bulgular: Hastalarımızın, %57’si el terlemesi şikayeti ile başvuran hastalardan oluşmaktadır. Bu hastaların postoperatif komplikasyonlar incelendiğinde %24’ünde refleks terleme görülmüştür. Hastaların %12’sinde ise tüp torakostomi ihtiyacı gözlenmiştir. Hastalarımıza uyguladığımız yaşam kalitesi anketiyle memnuniyet değerlendirilmiş olup buna göre hastaların %86’sı genel olarak memnun kalmıştır. Sonuç: Tek port sempatektomi, primer hiperhidrozisli hastalarda etkili bir tedavi yöntemi olabilir. Bu yöntem, her iki sempatik zincire aynı anda müdahale etme olanağı sunar. Ayrıca postoperatif dönemde ağrı, kozmetik ve maliyet açısından avantajlar sağlamaktadır

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

Pleural disorders in novel coronavirus disease 2019 (COVID-19), responsible for the deaths of more than 6.7 million people worldwide, are relatively uncommon and underappreciated findings. The severity of the pleural disease in these patients correlates with the treatment outcome and overall prognosis. We aim to review our experience with treatment modalities and prognosis in 45 patients with COVID-19, who were treated at our Clinic between April 2020 and October 2021. We conducted a retrospective, single-center, cross-sectional study. Demographic data, the type of thoracosurgical intervention(s), and treatment outcome for 45 patients included in this study were recorded for every patient. We analyzed the type and number of treatment modalities according to the pleural disorder, and the outcome of the treatment. Pneumothorax was the most common COVID-19-related pleural disorder, followed by the pleural effusion. Tube thoracostomy was the mainstay of treatment, performed in 84.4% of patients with unilateral pleural complications. In total, 20% of our patients were on mechanical ventilation, and all of them had a fatal outcome. We found statistical significance in comparison to the percentage of fatal outcomes between patients treated with and without mechanical ventilation (p=0.000). COVID-19-related pleural disorders are prognostic markers of disease progression. Mechanically ventilated patients who require tube thoracostomy have an unfavorable prognosis.

ObjectiveTo evaluate a novel technique for diaphragmatic full-thickness resection (DFTR) using a vascular stapler to perform cytoreductive surgeries in patients with advanced ovarian cancer. Study DesignSingle-center retrospective analysis of consecutive patients with advanced-stage ovarian cancer undergoing stapled diaphragmatic full-thickness resections (S-DFTRs) as part of cytoreductive surgeries between January 2018 and June 2022, according to the IDEAL recommendations. ResultsFifteen patients underwent cytoreductive surgeries with S-DFTRs. The median operative time was 300 (114–547) minutes. Cytoreduction was considered complete in all cases. All S-DFTRs were performed on the right diaphragm. Concomitant left diaphragmatic peritoneal stripping was performed in 5 cases (33.3%) and was associated with a conventional DFTR in 1 case (6.7%). Prophylactic intraoperative tube thoracostomy was never required. Four patients (26.7%) were admitted to the intensive care unit. Pleural effusion was observed in 9 patients (60.0%), and 4 (26.7%) required a postoperative pigtail catheter thoracostomy. Three patients (20.0%) required catheter placement on the right hemithorax (ipsilaterally to the S-DFTR) and 2 patients (13.3%) required catheters on the left hemithorax (contralaterally to the S-DFTR). Pneumothorax requiring tube thoracostomy was observed in 1 case (6.7%) on the left hemithorax (contralaterally to the S-DFTR). Pulmonary embolism and pneumonia were both observed once (6.7%). The median hospitalization length was 14 (5–36) days. During the follow-up, 6 patients (40.0%) had a recurrence, but none involved the pleura or the diaphragm. According to the IDEAL classification, this study could be ranked as stage 2a (development). ConclusionsThis technique appears to be a fast and safe method for performing diaphragmatic cytoreductive surgeries and could reduce postoperative complications.

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

Background: Over 5 million central venous catheters (CVCs) are placed annually. Pneumothorax and catheter malpositioning are common adverse events (AE) that requires attention. This study aims to evaluate local practices of mechanical complication frequency, type, and subsequent intervention(s) related to mechanical AE with an emphasis on catheter malpositioning. Methods: This is a retrospective review of CVC placements in a tertiary hospital setting from 1/2013 to 12/2013. Pneumothorax and CVC positioning were evaluated on post-insertion chest x-ray (CXR). Malposition was defined as unintended placement of the catheter in a vessel other than the intended superior vena cava on CXR. Catheter reposition was defined as radiographic evidence of a new catheter with removal of the old catheter less than 24hrs after initial placement. Data points analyzed included pneumothorax and thoracostomy rate, CVC malposition frequency, catheter reposition rate, catheter duration, and incidence of complications such as catheter associated venous thrombosis. Result: Among 2045 eligible CVC insertions, pneumothoraces occurred in 14 (0.7%; 95%CI 0.38, 1.17) and malpositions were identified in 275 (13.4%; 95% CI 12.3, 15.3). The proportion of pneumothoraces that required tube thoracostomy was 57%. The proportion of CVCs with malposition that were removed or replaced within 24h was 32.7%. "Malpositioned" catheters that were left in place by the clinical team (n = 185) had an average catheter duration of 8.2 days (95% CI 7.2, 9.3) versus 7.2 days (95% CI 6.17, 8.23) for catheters that were replaced after initial malposition (p = 0.14, t test). The incidence of venous thrombosis in repositioned "malpositioned" catheters was 7.8% versus 4.9% for "malpositioned" catheters that were left in place. Conclusions: Clinically significant catheter malposition and pneumothorax after CVC insertion are low. In this study, replaced and non-replaced "malpositioned" catheters had similar catheter duration and rates of complications, challenging the current dogma of CVC malposition practice.

PNEUMATOCELE FORMATION FOLLOWING COVID-19 PNEUMONIA: A CASE REPORT

Reduced survival in patients requiring chest tubes with COVID-19 acute respiratory distress syndrome