Thoracostomy Site Research Articles

Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in Pediatric Patients.

Chest tube thoracostomy site selection is typically chosen through landmark identification of the fifth intercostal space (ICS). Using point-of-care ultrasound (POCUS), studies have shown this site to be potentially unsafe in many adults; however, no study has evaluated this in children. The primary aim of this study was to evaluate the safety of the fifth ICS for pediatric chest tube placement, with the secondary aim to identify patient factors that correlate with an unsafe fifth ICS. This was an observational study using POCUS to evaluate the safety of the fifth ICS for chest tube thoracostomy placement using a convenience sample of pediatric emergency department patients. Safety was defined as the absence of the diaphragm appearing within or above the fifth ICS during either tidal or maximal respiration. Univariate and multivariable analyses were used to identify patient factors that correlated with an unsafe fifth ICS. Among all patients, 10.3% (95% confidence interval [CI] 6.45-16.1) of diaphragm measurements crossed into or above the fifth ICS during tidal respiration and 27.2% (95% CI 19.0-37.3) during maximal respiration. The diaphragm crossed the fifth ICS more frequently on the right when compared with the left, with an overall rate of 45.0% (95% CI 36.1-54.3) of right diaphragms crossing during maximal respiration. In both univariate and multivariate analyses, a 1-kg/m 2 increase in body mass index was associated with an increase of 10% or more in the odds of crossing during both tidal and maximal respiration ( P = 0.003 or less). A significant number of pediatric patients have diaphragms that cross into or above the fifth ICS, suggesting that placement of a chest tube thoracostomy at this site would pose a significant complication risk. POCUS can quickly and accurately identify these unsafe sites, and we recommend it be used before pediatric chest tube thoracostomy.

Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection.

IntroductionTension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.MethodsA prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.Results29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.ConclusionIn this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.

Novel Approach to Ultrasound-Guided Thoracostomy.

Thoracostomy is often a required treatment in patients with thoracic trauma; however, performing a thoracostomy using traditional techniques can have complications. Ultrasound can be a beneficial tool for identifying the correct thoracostomy insertion site. We designed a randomized prospective study to assess if ultrasound guidance can improve thoracostomy site identification over traditional techniques. Emergency medicine residents were randomly assigned to use palpation or ultrasound to identify a safe insertion site for thoracostomy placement. The target population comprised of hemodynamically stable trauma patients who received an extended focused assessment with sonography for trauma (EFAST) and a chest computed tomography (CT) exam. The resident placed a radiopaque marker on the skin of the patient where a safe intercostal space was believed to be located, either by palpation or ultrasound. Clinical ultrasound faculty reviewed the CT to confirm marker placement relative to the diaphragm. A Fischer's exact test was used to analyze the groups. One hundred and forty-seven patients were enrolled in the study, 75 in the ultrasound group and 72 in the landmark group. This resulted in the placement of 271 total thoracostomy site markers, 142 by ultrasound and 129 by palpation and landmarks. The ultrasound group correctly identified thoracostomy insertion sites above the diaphragm in 97.2% (138/142) of patients, while the palpation group identified a safe insertion site in 88.4% (114/129) of patients (P=.0073). This study found that emergency medicine residents are more likely to identify a safe tube thoracostomy insertion site in trauma patients by using ultrasound, as compared to using landmarks and palpation.

HERNIATION OF AN EMPHYSEMATOUS PULMONARY BULLA INTO THE INTERCOSTAL SPACE

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Herniation of the lung into the thoracic wall is a rare presentation. It is defined as the protrusion of the lung tissue covered with pleura into the thoracic wall. Given the rarity of the presentation, only a limited number of cases have been reported in literature. Here, we present a case of bullous lung herniation in a patient with COPD on immunosuppressant medication without the involvement of thoracic surgical intervention. CASE PRESENTATION: A 74-year-old gentleman was admitted for 2 weeks of dyspnea and intermittent productive cough. He had a past medical history of COPD, pulmonary fibrosis, and RA (treated with Rituxan, Azathioprine, and Prednisone). Prior to hospitalization, he was treated with a 5-day course of Azithromycin and 20 mg of Prednisone. His symptoms progressed despite therapy. On admission, he denied chest pain, hemoptysis,night sweats, fever, weight loss, or recent trauma. On physical examination, his blood pressure was 160/79, oxygen saturation of 93% on 3 liters nasal cannula (not on baseline oxygen). Laboratory was significant for WBC elevation of 15.6, PT of 20.1, INR of 2.0, sputum culture was positive for gram positive cocci and rods. On imaging, chest CT scan showed emphysematous and bullous changes of the lung parenchyma with a 2.9 cm thick walled bulla in the right lung that was herniating between his 6th and 7th rib. Additionally, a subtle, nondisplaced fracture of the 7th rib was also noted. He was treated with prednisone 5 mg and his RA medications were held. Pulmonology was consulted, and strict control of his cough was recommended in order to prevent a pneumothorax secondary to increased pulmonary pressure, especially given his rib fracture. Surgery was not indicated. The patient’s status improved with DuoNeb, mucolytics, spirometry, lidocaine patches, tramadol and acapella valve use. The patient was discharged home. He followed with pulmonology as an outpatient for monitoring. DISCUSSION: Lung herniation into the thoracic space can be congenital or acquired through medical or surgical therapy. Herniation of an emphysematous bullae is a rather rare presentation of this phenomenon. However, increased intrathoracic pressure secondary to a coughing fit, coupled with emphysematous lung in COPD patients can cause herniation through the intercostal space given the presence of a weak site in the muscular or sub connective tissue. Most cases present in the upper lobes of the lungs, which represents another novel presentation in our patient with his herniation being between the 6th and 7th intercostal space. CONCLUSIONS: Herniation of emphysematous bullae is a very rare condition and complication, very few cases have been reported. The clinical presentation is nonspecific, and the use of chest X-ray does not always identify the herniation. In most of the reported cases, the diagnosis can be confirmed with a chest tomography. Reference #1: Okur E, Tezel C, Baysungur V, Halezeroglu S. Extrathoracic herniation of a lung bulla through a tube thoracostomy site. Interact Cardiovasc Thorac Surg. 2008;7(6):1210–1. Reference #2: Van Berkel V, Kuo E, Meyers BF. Pneumothorax, bullous disease, and emphysema. Surg Clin North Am 2010;90:935–53. Reference #3: Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. Chest Surg Clin N Am. 2003;13(4):631–49 DISCLOSURES: No relevant relationships by Armida Lefranc, source=Web Response No relevant relationships by Tony Makdisi, source=Web Response No relevant relationships by Aniket Pandya, source=Web Response

Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection.

Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

379 Novel Approach to Ultrasound Guided Thoracostomy (NoGUT)

Traditional landmark thoracostomy technique has a known complication rate of 30%. While early data suggests that ultrasound can be a beneficial tool for identifying the correct thoracostomy tube insertions site, clinical studies are limited. We designed a pilot prospective randomized study to assess if ultrasound guidance can improve thoracostomy site identification over traditional landmark technique. 43 emergency medicine residents were randomly assigned to use either palpation or ultrasound to identify a safe insertion site for chest thoracostomy placement. We defined “safe” as above the diaphragm. The study was performed on a convenience sample reflecting a heterogenous mix of emergency department patients. The target patient population was comprised of hemodynamically stable trauma patients who received extended focused assessment with sonography in trauma (eFAST) and a chest computed tomography (CT) exam. The resident was instructed to place a small radiopaque marker on the skin of the patient where he/she believed was a safe intercostal space. Clinical ultrasound faculty then reviewed the chest CT to confirm radiopaque marker placement in relationship to the diaphragm. Fischer exact test was used to analyze the differences between the two groups. 97 patients were enrolled in the study resulting in the placement of 91 thoracostomy site markers by ultrasound and 89 by palpation. The average weight was 84kg with a BMI of 29kg/m2 (BSA 2.02) and these were comparable in both groups. The ultrasound group correctly identified thoracostomy tube insertions site above the diaphragm in 97.8% (89/91) of patients while landmark group identified a safe insertion site 89.9% (80/89) (p=0.0316). The ability to accurately locate a safe intercostal space for chest thoracostomy insertion was improved under ultrasound guidance. This technique is an excellent adjunct for novice providers and for patients with difficult landmarks or abnormal anatomy. Further studies are warranted to determine if this method can decrease complications with chest thoracostomy insertion.

Ultrasound-guided thoracostomy site identification in healthy volunteers

BackgroundTraditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance.Methods33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces.ResultsThe participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003].ConclusionsThe ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

Gastropleural fistula in a case of tubercular empyema thoracis

A 40-year-old gentleman presented to our institution with complaints of persistent discharge of ingested food particles via left-sided open window thoracostomy site for last 3 days. Open window thoracostomy was done outside for chronic tubercular empyema thoracis, which was not responding to tube thoracostomy and anti-tubercular medications. Contrast-enhanced computerized tomographic scan (CECT) of the thorax and abdomen revealed fistulous communication between the stomach and left-sided pleural cavity. Endoscopy of the upper gastrointestinal tract showed normal esophagus with internal opening at the fundus of stomach. We deferred any major surgical intervention in view of infected thoracostomy site, anticipated difficulty in primary repair, and poor nutritional status of the patient. Patient responded to low pressure suction through thoracostomy site, nutritional support, and anti-tubercular medication via feeding jejunostomy. This case highlights the fact that gastropleural fistula—a rare surgical entity may occur with different possible etiopathogenesis and probably in our case it has developed due to either inadvertent placement of suture through the gastric wall or iatrogenic perforation during open window thoracostomy.

Late presentation of congenital diaphragmatic hernia: A diagnostic dilemma

Congenital diaphragmatic hernias are commonly symptomatic within 24 hours after birth, but late presentation is not uncommon. Late presentation of congenital diaphragmatic hernia poses diagnostic difficulties as clinical picture are vague, and more commonly presented with non-specific gastrointestinal and respiratory symptoms. Due to the vague and non-specific clinical presentation, clinician faces a diagnostic dilemma resulting in delay in diagnosis and many a times an inappropriate management. This article reports 2 cases of late-presenting congenital diaphragmatic hernia (over the period of 6 months from September 2014 to February 2015) in National Institute of Disease of Chest and Hospital (NIDCH). In first case, she was diagnosed as right-sided tubercular pleural effusion and was treated with CAT-1 anti-tubercular therapy for 6 months without any clinical improvement. Later CT scan of chest was done and diagnosed as a case of congenital diaphragmatic hernia. The second case was diagnosed as a left-sided hydropneumothorax and treated with left tube thoracostomy. During removal of the intercostal chest tube, some fatty tissue was pulled out of the thoracostomy site. In NIDCH, she was diagnosed as a case of diaphragmatic hernia by barium follow-through. Both cases were diagnosed as Bochdalek hernia during the repair of the hernia defect via thoracotomy.

Periorbital Subcutaneous Emphysema

Forty years old male was admitted with fever, cough and breathlessness since five days. Examination revealed signs of pleural effusion on left side of chest. Chest X-Ray showed left sided pleural effusion and left middle zone consolidation. Pleural fluid analysis suggested empyema. Patient was managed with intravenous antibiotics and left-sided inter-costal tube drainage. A day after thoracostomy patient developed swelling around eyes and thoracostomy site. Diffuse crepts were palpable around eyes, left side of chest and neck (Figure 1). CT confirmed the diagnosis of subcutaneous emphysema around eyes and chest wall. Swelling disappeared with conservative management within next three days (Figure 2). Periorbital emphysema is mostly due to disruption in the integrity of orbital boundaries because of trauma and subsequent orbital and sinus fractures. Less frequently follows dental surgeries. As a result of continuity of facial planes it can rarely occur as a result of spread from neck and chest subcutaneous tissue.

Extrathoracic herniation of a lung bulla through a tube thoracostomy site

We report a case of lung bulla herniation occurring two years after a tube thoracostomy application due to pneumothorax. A new bulla can develop or a pre-existing bulla can herniate through a weak part of thoracic wall, a tube thoracostomy site as in our case. Diagnostic and radiological features of this uncommon case are described.

Indications for Transcatheter Arterial Embolization in Persistent Hemothorax caused by Blunt Trauma

To confirm the usefulness of contrast-enhanced computed tomography (CECT) and the efficacy of transcatheter arterial embolization (TAE) in patients, who undergo tube thoracostomy for hemothorax secondary to blunt chest trauma. CECT was performed at admission in patients, who suffered blunt chest trauma but did not require an emergent thoracotomy. Pulmonary injuries with intrapulmonary hematomas or traumatic pneumatoceles or both on computed tomography images were diagnosed as pulmonary lacerations (PL). The size of the pulmonary injuries with the PL was measured as percent volume (volume of the PL/volume of the lung). Rib fracture displacement was measured on computed tomography images and expressed as parallel and transverse displacement of the fractured ribs (PD and TD, respectively). Patients with an injury to a thoracic great vessel (e.g., aortic injury) were excluded. CECT of the chest was performed on 154 of 976 consecutive patients with blunt torso trauma. Thirty-four patients have PL without a great vessel injury. Tube thoracostomy was performed at 38 sites in 29 patients. After the initial bloody drainage, the mean drainage during the first hour was 81.2 mL/h +/- 137 mL/h. The mean percent volume of the PL was 29.0% +/- 15.4%. The mean PD was 12.2 mm +/- 10.4 mm. The PD and the TD correlated with the hourly drainage (p = 0.001, p < 0.001, respectively). No correlation was found between the percent volume of PL and hourly drainage (p = 0.11). Of the 38 thoracostomy sites, 6 had a blood loss of > or =200 mL/h. Contrast extravasation on CECT was observed in five of these six sites, and angiography was performed. All five sites had contrast extravasation from an intercostal artery, and TAE was successfully performed. Intercostal arterial bleeding should be suspected in patients with persistent hemothorax > or =200 mL/h and large displacement of a fractured rib. In such cases, CECT should be performed and TAE is indicated if contrast extravasation is observed.

Study of pigtail catheters for tube thoracostomy

Background: To study the efficacy and complications of percutaneous small bore pigtail catheters for tube thoracostomy. Methods: 50 cases of pleural effusion requiring drainage were enrolled in the study. Pigtail catheters of the size 9 to 12 F were used. Results: The procedure was successful in 46/50 (92%) cases. Fibrinolytic therapy and pleurodesis was successful through these tubes. Complications included blockade in 4 (8%), small pneumothorax in 10 (20%) and chest pain at tube thoracostomy site requiring analgesics in 30 (60%). Conclusion: Small bore pigtail catheters are safe, comfortable, cost effective and have few complications especially in loculated pleural effusions.

Tissue Remodeling in a Bioartifical Fibromuscular Patch Following Transplantation in a Human

Tissue engineering applications might help to overcome currently encountered limitations in reconstructive surgery in many surgical subspecialties (1). Recently we reported the successful reconstruction of a tracheobronchial defect in a patient using a bioartificial airway patch (2). Here we describe the remodeling of the transplanted bioartificial tissue. In a 58-year-old male, a bioartificial fibromuscular patch was implanted into a 1.5 × 1.5 cm large tracheobronchial anastomosis defect (onset 4 weeks postoperatively) as previously described in detail (2). Briefly, the patient had undergone right carinal pneumectomy for relapsing non–small-cell lung cancer following operation and radiation (60 Gy) 4 years earlier. The defect had caused pleural empyema and pyosepticemia which were treated by thoracostomy and medically. At time of patch implantation, an omentum major transposition and right subscapular myoplasty combined with a thoracoplasty were performed. The patch had been generated within 5 weeks from a 3 × 4 cm skin biopsy that was obtained at the thoracostomy site. Autologous muscle cells (MC) and fibroblasts (Fb) were isolated enzymatically from the biopsy and cultured for 2 weeks (37°C, HAM-F12/MEM culture media; volume ratio 50:50). An acellular 24 × 36 mm collagen network (derived from a porcine jejunal segment) served as carrier matrix. Autologous Fb and MC in a cell ratio of 95:5 were seeded for 3 weeks on the matrix (37°C, HAM-F12/MEM culture media; volume ratio 50:50). Patch integrity was controlled by fibroscopies 1, 3, 6, and 12 weeks following implantation. We detected patch matrix reorganization resulting in increased mechanical stability and a defect area decrease from 12 × 9 mm to 9 × 5 mm. A transtracheal patch biopsy performed 12 weeks after implantation documented a harmonic cellular distribution pattern with a surprisingly altered patch composition representing 80% MC and 20% Fb (Fig. 1).FIGURE 1.: Cellular patch composition. Overall cell number doubled within 3 months. Fb represented the cellular majority during tissue culture before implantation (in vitro). Three months after implantation tissue remodeling resulted in a dominant MC fraction.Numerous clinical and experimental studies surveyed bioartificial implants for a wide range of clinical applications, including tracheal reconstruction (1). As yet, the venture to generate a bioartificial tracheal substitute did not provide a convincing graft (3) and currently autologous repair tissues (i.e., pericardial patches) represent dependable alternatives for limited tracheal reconstruction that result in scar tissue formation and contraction of the airway defect (4). In our presented case, we repaired a limited defect in the tracheobronchial system with a tissue engineered autologous tracheal patch. Analogous to clinical experiences with autologous pericardial patches, we detected a decrease of defect size over time. In contrast to previous findings, patch biopsy revealed a profound change of tissue composition within the first 3 months following implantation: the MC:Fb cell ratio had reversed in favor of MC. This unexpected increase of smooth muscle cells in the patch matrix cannot be explained by cicatrization. The underlying mechanism, however, remains unknown and cannot be explained by our data. Either the privileged ingrowth of patient MC or a survival benefit of implanted MC could explain these findings. In the light of previous unexpected (sometimes fatal) clinical experiences with bioartificial grafts (5), further studies are needed to address questions regarding the healing behavior and mechanisms of bioartificial implants. Thorsten Walles Christian Biancosino Patrick Zardo Paolo Macchiarini Department of Thoracic and Vascular Surgery Heidehaus Hospital Hannover, Germany Jens Gottlieb Department of Pulmonology Medical School Hannover Hannover, Germany Heike Mertsching Fraunhofer Institute for Interfacial Engineering and Biotechnology Stuttgart, Germany

First human transplantation of a bioengineered airway tissue

First human transplantation of a bioengineered airway tissue

Foley catheter tamponade of intercostal hemorrhage in preterm infants

Foley catheter tamponade of intercostal hemorrhage in preterm infants

Thrombotic, infectious, and procedural complications of the jugular bulb catheter in the intensive care unit.

An assessment of the thrombotic, infectious, and technical complications of continuous jugular bulb catheter monitoring in the intensive care unit (ICU) was made. Over a 1-year period, 44 patients suffering from traumatic brain injury, subarachnoid hemorrhage, or stroke received jugular bulb catheter monitoring in the ICU. They were followed for catheter insertion complications and the development of bacteremia. In 20 patients chosen randomly, an ultrasonographic evaluation was performed after removal of the catheter for an assessment of internal jugular vein thrombosis. Of the 44 patients, 1 became bacteremic; the source was identified as a thoracostomy site. Among the complications related to the 44 catheter insertions, there were 2 instances of carotid artery puncture (4.5%), 1 misplaced catheter (thoracic placement), and 1 clinically insignificant hematoma. Of the 20 patients investigated with ultrasonography, 8 (40%) had nonobstructive, subclinical internal jugular vein thrombi after jugular bulb catheter monitoring (95% confidence interval, 19-61%). The median monitoring duration was 3 days (range, 1-6 d). No clinical factor was identified to be associated with thrombus formation. We conclude the following: 1) the risk of bacteremia related to the jugular bulb catheter was negligible; 2) complications related to catheter insertion were rare and clinically insignificant; and 3) the incidence of subclinical internal jugular vein thrombosis after jugular bulb catheter monitoring is considerable. Although it is worthy to note this complication, no patient with a thrombus became symptomatic in the present series. The risk-benefit assessment of this monitoring technique must include consideration of subclinical thrombosis.

Thoracostomy

Tube thoracostomy in the Emergency Department is an integral part of trauma and care and treatment of nontraumatic intrapleural collections. An understanding of pleuropulmonary anatomy, physiology, and pathophysiology forms the basis for appropriate and safe application of this procedure. Rapid diagnosis and treatment of intrapleural collections in the trauma patient is essential when one considers the grave prognosis of untreated tension pneumothorax or massive hemothorax. Prior knowledge of possible procedural complications with particular attention to thoracostomy site, sterile technique, and careful blunt dissection makes chest tube placement straightforward and safe. Most post-procedural complications can be avoided through a thorough understanding of the collection system and careful monitoring of the patient.

Effectiveness of chest tube evacuation ofpneumothorax in neonates

This is a retrospective review of the effectiveness of 149 chest tubes placed in attempts to evacuate 91 pneumothoraces among 57 infants. Forty-four percent of initial evacuation attempts were ineffective; 42% of total chest tubes throughout the clinical courses were ineffective. The largest number of these ineffective chest tubes lay posterior in the pleural cavity. Fifty-six percent of posterior tubes were ineffective whereas only 4% of anterior tubes were ineffective. Other causes for failure included tubes which had perforated the lung, diaphragm, or mediastinum or were lying subcutaneously. On some occasions, chest tubes were mistakenly used to evacuate intrathoracic air which was actually a pulmonary pseudocyst or pneumomediastinum. Two thoracostomy sites were chosen: the superior and lateral. Eighty-five percent of chest tubes inserted through the superior approach lay anteriorly in the pleural cavity whereas only 47% of the laterally inserted tubes lay anteriorly. Superior thoracostomy tubes were significantly more effective than lateral tubes because of their more frequent anterior location. There were also fewer complications with superior thoracostomy tubes. Whereas only 10% of superiorly inserted tubes encroached upon the mediastinum, 32% of lateral tubes did so. To be effective, chest tubes should be placed anteriorly in the pleural space; this location is more often achieved via the superior thoracostomy approach.

A Method of Early Irrigation of the Contaminated Postpneumonectomy Space

A modified balanced drainage system was used with other measures in a patient with an obstructing pulmonary carcinoma, infection, and necrosis. Management included right pneumonectomy, perioperative systemic antibiotics, protection of the remaining lung, and a modified balanced drainage system that allowed early irrigation of the postpneumonectomy space. On the tenth postoperative day, irrigations were discontinued, the right chest was filled with an antibiotic solution, and the thoracostomy tubes were removed. The mediastinum remained in a satisfactory position, and the patient recovered without evidence of empyema. He died of a cerebral metastasis five and a half months postoperatively. This method combines principles that have been used for many years. A balanced drainage-irrigation system permits early irrigation of the contaminated postpneumonectomy space while the mediastinum is still mobile. Prolonged hospitalization and formal closure of the thoracostomy sites can be avoided.