Thoracostomy Tube Placement Research Articles

Chest Tubes and Pleural Drainage: History and Current Status in Pleural Disease Management

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care.

Implementation of the 300-mL Rule for the Management of Traumatic Hemothorax.

Traumatic hemothorax (HTX) is often managed with tube thoracostomy (TT); however, TT carries a high complication rate. In 2017, a guideline was implemented at our Level I trauma center to observe traumatic HTX ≤300mL in hemodynamically stable patients. We hypothesized that this guideline would decrease TT placement without increasing observation failure rates. This was a single-center retrospective review of all adult patients admitted with a HTX on computed tomography (CT) before (2015-2016) and after (2018-2019) the guideline implementation. Exclusion criteria were TT placement prior to CT scan, absence of CT scan, death within 5 days of admission, and a concurrent pneumothorax (PTX) >20mm. HTX volume was calculated using CT scan images and Mergo's formula: V=d 2xL (V: volume; d: depth; L: length). The primary outcome was observation failure, defined as the need for TT, video-assisted thoracoscopic surgery, thoracotomy after repeat imaging or worsening of symptoms and pulmonary morbidity. A total of 357 patients met inclusion criteria, of whom 210 were admitted after guideline implementation. There were no significant differences in baseline demographics, comorbidities, or injury characteristics across both cohorts. The post-implementation cohort had a significant increase in observation rate (75% vs 59%) and a decrease in TT placement (42% vs 57%). Moreover, the post-implementation group had a statistically significant shorter hospital (6 vs 8 days) and ICU (2 vs 3 days) LOS. No significant differences in observation failure, pulmonary complications, 30-day readmission, or 30-day mortality were observed across both cohorts. The implementation of the 300mL guideline led to a decrease in TT placement without increasing observation failure or complication rates. Level III, Therapeutic/Care Management.

Recommended recumbency to avoid insertional complications during small-bore wire-guided thoracostomy tube placement in cats—a cadaver study

BackgroundSmall-bore wire-guided thoracostomy tubes (SBWGTT) are commonly used in cats to manage pleural disease and generally have a low complication rate. Our study aimed to explore the correlation between recumbency of cats, placement method, and the occurrence of insertional complications to identify risk factors during SBWGTT placement.In this experimental cadaveric study, SBWGTT placement using a modified Seldinger technique was conducted in 24 feline cadavers. Cats, euthanized for reasons unrelated to the study, were randomly assigned to pleural effusion (EFF; n = 12) and pneumothorax (PNEU; n = 12) groups. Each cadaver was intubated and ventilated with a peak inspiratory pressure (PIP) of 10 mmHg, and sterile saline or air was instilled into the thorax over a 5 mm thoracoscopic trocar in the fourth intercostal space (ICS). Instillation was stopped when the lateral thoracic wall to lung distance (TWLD) reached 10 to 12 mm, measured with ultrasound in the favorable position. Sternal recumbency was the favorable position for the EFF group, and lateral recumbency for the PNEU group. Following the placement of the first SBWGTT in each group, the cadavers were positioned unfavorably (lateral recumbency for EFF group, sternal recumbency for PNEU group), and a second drain was introduced contralaterally. A bilateral 8th ICS thoracotomy was then performed to visually assess intrathoracic structures and drain integrity.A binary logistic regression mixed model was conducted to determine interaction between the induced condition and body position.ResultsA total of 48 SBWGTTs were placed, with complications observed in 33.3% (8/24) of cases. Five of these were major complications consisting of lung lacerations. Complications were more common in the unfavorable position, accounting for 75% of cases, although this result was not statistically significant. The odds of complication rates were > 70% in the unfavorable position and decreased with an increase in TWLD (< 30%).ConclusionComplications associated with SBWGTT placement are influenced by recumbency, although the data did not reach statistical significance. Placing cats in lateral recumbency for pneumothorax treatment and sternal recumbency for pleural effusion treatment may reduce insertional complications.

Parasternal thoracotomy via sternocostal disarticulation: a novel surgical approach to the canine thorax.

To describe the technique and outcomes of a modified paramedian thoracic approach in dogs involving a parasternal thoracotomy via rib disarticulation at the sternocostal joint. 93 client-owned dogs. Medical records of dogs that underwent parasternal thoracotomy at a private practice between the years 2015 and 2021 were reviewed. Signalment, weight, clinical presentation, surgical details, complications, and short-term outcomes were recorded. Cox proportional hazards regression models were utilized to analyze the impact of covariates on hazard events. Kaplan-Meier curves were employed to evaluate survival functions for select variables. Parasternal thoracotomy via sternocostal disarticulation was performed in 93 dogs. Eighty-eight dogs (94.6%) survived the procedure. Eighty-three dogs (89.2%) survived to discharge from the hospital. Age, weight, postoperative time to eating, postoperative ambulation, and surgical or anesthetic duration were not significantly associated with survival to discharge. Thoracostomy tube duration significantly decreased the likelihood for survival to discharge; for each additional hour of thoracostomy tube placement, the odds of survival to discharge diminished by 5.7% (hazard ratio, 0.94; 95% CI, 0.912 to 0.976). Parasternal thoracotomy via rib disarticulation at the sternocostal joints may be a viable alternative to median sternotomy that does not require specialized equipment for bilateral hemithoracic visualization. Postoperative complications and short-term outcomes are comparable to those reported for the traditional median sternotomy approach. Prolonged thoracostomy tube duration may impact survival to discharge.

Improvements in Efficiency and Resident Satisfaction Following the Implementation of a Central Supply Closet

Introduction: In the 1970’s, the idea of burnout began and was defined as emotional exhaustion, depersonalization, and low sense of personal accomplishment (1). Recently, there has been a push by graduate medical education to counter resident burnout, as demonstrated by resident wellness initiatives becoming a requirement for residency programs in the United States (2). At our institution, a source of burnout was the time it took to gather supplies for critical bedside procedures, which was addressed by instituting a central supply closet. Methods: A checklist was made of the supplies needed for four common bedside procedures: central venous access, arterial line placement, thoracostomy tube placement, and incision and drainage. 9 surgery residents were individually timed to locate the equipment required for each individual procedure with the supply closet and without. A survey was used to evaluate resident satisfaction in the number of locations to search, timeliness, and ability to provide quality patient care before and after the supply closet. This survey was done on a scale of 1 to 5, with 1 being very dissatisfied, and 5 being very satisfied. Paired t-tests were used for data analysis; p&lt;0.05 was considered statistically significant. Results: For central line supplies, the average times were 542 seconds (s) without the closet, and 211s with the closet (p=0.0041), arterial line supplies took 570s without and 178s with (p=0.0114), thoracostomy tube supplies took 590s without, and 213s with (p=0.0017), and incision and drainage supplies took 518s without, and 239s with the closet (p=0.0066). Average resident satisfaction for the number of locations to search for supplies went from 1.5 to 4.8 with the closet, length of time to gather supplies went from 1.3 to 4.9 with the closet, and ability to provide quality patient care went from 1.4 to 4.8 (all p&lt;0.0001). Conclusions: The implementation of a supply closet with easy access to supplies allowed for improved speed in completing bedside procedures, leading to expedited patient care, improved resident satisfaction and well-being, and decreasing a source of surgery resident burnout.

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.

Thoracic cavity irrigation prevents retained hemothorax and decreases surgical intervention in trauma patients.

Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( β = -1.58; 95% CI, -2.52 to -0.75). Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. Therapeutic/Care Management; Level III.

Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures

BackgroundTraumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures. MethodsThis is a single-center retrospective review (2015–2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC. ResultsA total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS. ConclusionVC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.

Tube Thoracostomy Complications inPatients With ARDS Requiring ECMO: Worse inCOVID-19 Patients?

The incidence and management outcomes of COVID-19 patients with acute respiratory distress syndrome (ARDS) on veno-venous extracorporeal membrane oxygenation (V-V ECMO) requiring chest tubes are not well-described. This study sought to explore differences in tube thoracostomy rates and subsequent complications between patients with and without COVID-19 ARDS on V-V ECMO. This study is a single institution, retrospective cohort study of patients with COVID-19 ARDS requiring V-V ECMO. The control cohort consisted of patients who required V-V ECMO for ARDS-related diagnoses from January 2018 to January 2021. The primary outcome was any complication following initial tube thoracostomy placement. Study approval was obtained from the Brooke Army Medical Center Institutional Review Board (C.2017.152d). Twenty-five COVID-19 patients and 38 controls were included. Demographic parameters did not differ between the groups. The incidence of pneumothorax was not significantly different between the two groups (44% COVID-19 vs. 22% control, OR 2.8, 95% CI 0.95-7.9, P = 0.09). Patients with COVID-19 were as likely to receive tube thoracostomy as controls (36% vs. 24%, OR 1.8, 95% CI 0.55-5.7). Complications, however, were more likely to occur in the COVID-19 group (89% vs. 33%, OR 16, 95% CI, 1.6-201, P = 0.0498). Tube thoracostomy placement in COVID-19 patients with ARDS requiring V-V ECMO is common, as are complications following initial placement. Clinicians should anticipate the need for re-intervention in this patient population. Small-bore (14Fr and smaller) pigtail catheters appeared to be safe and efficacious in this setting, but further study on tube thoracostomy management in ECMO patients is needed.

Successful Medical Management of Bilateral Pneumothorax Due to Nasogastric Tube Misplacement in a Cat.

A 7 yr old female spayed domestic shorthair was evaluated for suspected lily ingestion and acute vomiting. The cat had vomited suspected lily plant material before presentation, and a nasogastric tube (NGT) was placed to continue to administer activated charcoal. The NGT was passed with sedation and limited restraint. To confirm placement, a single lateral radiograph was taken, which showed that the tube was in the trachea, bronchus, through the pulmonary parenchyma, and extending into the region of the craniodorsal retroperitoneal space. The tube was subsequently removed, resulting in a tension pneumothorax. Bilateral thoracostomy tubes were placed and attached to continuous suction. The pneumothorax resolved after 2 days, the thoracostomy tubes were removed, and the cat was discharged on day 3 after admission. To the authors' knowledge, this is the first described pneumothorax complication with successful medical management secondary to routine nasogastric tube placement in a cat. This case report underscores the importance of preparedness for thoracostomy tube placement before removal of any NGT that has been confirmed to be placed through the pulmonary parenchyma.

Bronchoscopic Lung Volume Reduction: Highlighting the Patient Selection Process

Patients with advanced emphysema frequently experience severe dyspnea that is inadequately treated with medical therapy alone. Over the past 4 years, we have seen increased usage of bronchoscopic lung volume reduction (BLVR) with endobronchial valves. Success of the procedure is dependent on patient selection because it is not necessarily appropriate for all patients with severe emphysema. (Table 1) The purpose of this review is to highlight the selection process at a single institution. We also discuss the influence of this process on outcomes. Between March 1, 2019, and October 12, 2021, 2402 patients were referred to a dedicated chronic obstructive pulmonary disease clinic at Mayo Clinic – Rochester, whereas 161 patients were subsequently referred for multidisciplinary BLVR review. Of those patients, 53 (32.9%) were selected to receive valves and 35 (21.7%) ultimately underwent the procedure. The main reasons for exclusion included an incompatible quantitative computed tomography analysis (n=37, 34.3%), presence of pulmonary nodule or active malignancy (n=14, 13.0%), or need for completion of pulmonary rehabilitation (n=9, 8.3%). Full or partial (>70%) target lobe collapse was observed in 58.6% of patients who received valves. Those with collapse experienced statistically significant improvements in spirometric measures. Twelve patients experienced a pneumothorax (34.3%), with 10 patients requiring thoracostomy tube placement and prolonged hospitalization (median, 11 days; range, 4-39 days). Nineteen patients required a secondary procedure within the first year. The study highlights how a multidisciplinary approach to the BLVR selection process enables individualization of a complex procedure and enhances the exclusion of inappropriate candidates.

Recurrent thoracic air leak syndrome in patients affected by pulmonary graft-versus-host disease: Surgical strategies and outcome.

Thoracic air leak syndrome (TALS) is a complication related to chronic pulmonary graft-versus-host disease (pGvHD) that affects approximately 0.83%-3.08% patients after allogenic hematopoietic stem cell transplant. Such complication is defined as the occurrence of any form of air leak in the thorax, including spontaneous pneumomediastinum or pneumopericardium, subcutaneous emphysema, interstitial emphysema and pneumothorax and has a negative impact on post-transplant survival. The aim of the present study is to describe a single-center experience in the surgical management of recurrent TALS in adolescents and young adults and its outcome. We retrospectively reviewed the clinical notes of patients with previous allogenic hematopoietic stem cell transplant who underwent surgical procedures for recurrent TALS from January 2016 until March 2021. We analyzed clinical data, number of episodes of thoracic air leak, surgical procedures and relative outcome. In the examined period, four patients, aged 16-25 years, underwent surgical procedures for TALS, including thoracostomy tube placement, thoracoscopic pleurodesis and thoracotomy. All the patients had been diagnosed with pGvHD before the onset of TALS, with a mean time lapse of 276 days (range 42-513). These patients experienced on average 4.5 air leak episodes (range 3-6). All the patients experienced at least two episodes before surgery. One patient underwent emergency tube thoracostomy only, three patients underwent thoracoscopic pleurodesis and two patients underwent thoracotomy. After surgery, patients were free from air leak symptoms for a mean time of 176 days (range 25-477). Pulmonary function progressively deteriorated, and all the patients eventually died because of respiratory failure after a mean time of 483 days (range 127-1045) after the first episode of air leak. Surgery provides temporary relief to symptoms related to TALS but has limited effects on the underlying pathophysiologic process. The development of TALS in a sign of progressive pulmonary function worsening and is associated with high risk of respiratory failure and mortality.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

Endobronchial Valves for Management of Persistent Air Leaks in Patients With Chronic Lung Disease

BackgroundPersistent air leak (PAL) is a challenging problem in patients with spontaneous pneumothorax and chronic lung disease who are poor surgical candidates. Conventional management consists of long-term thoracostomy tube placement; however, in some cases, patients are unable to leave the hospital because of the need for continuous negative pressure. We investigated the application of endobronchial valves (EBVs) in the management of patients with air leak for whom surgical intervention was contraindicated. MethodsEBVs were placed in patients with PALs arising from nonoperative causes. Successful outcomes were defined as the ability to remove the thoracostomy tube from suction, resolution of air leak, and removal of chest tube. ResultsSeventeen patients with PAL requiring negative pressure suction were treated with EBVs. The overall complete successful outcome rate was 82.4%. There was a statistically significant reduction in length of stay after valve placement in the success group compared with the failure group (8.9 days vs 61.7 days; P = .0097). ConclusionsEBVs are a valid option for patients who are not surgical candidates and have failed to respond to conventional management of PAL. This experimental use of EBVs leads to high success rates and shorter length of stay when it is successful.

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians

ObjectiveTo describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy. MethodsRetrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy. ResultsIn total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy. ConclusionPrehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

Viral Detection Is Associated With Severe Disease in Children With Suspected Community-Acquired Pneumonia.

To evaluate the role of virus detection on disease severity among children presenting to the emergency department (ED) with suspected community-acquired pneumonia (CAP). We performed a single-center prospective study of children presenting to a pediatric ED with signs and symptoms of a lower respiratory tract infection and who had a chest radiograph performed for suspected CAP. We included patients who had virus testing, with results classified as negative for virus, human rhinovirus, respiratory syncytial virus (RSV), influenza, and other viruses. We evaluated the association between virus detection and disease severity using a 4-tiered measure of disease severity based on clinical outcomes, ranging from mild ( discharged from the ED) to severe (receipt of positive-pressure ventilation, vasopressors, thoracostomy tube placement, or extracorporeal membrane oxygenation, intensive care unit admission, diagnosis of severe sepsis or septic shock, or death) in models adjusted for age, procalcitonin, C-reactive protein, radiologist interpretation of the chest radiograph, presence of wheeze, fever, and provision of antibiotics. Five hundred seventy-three patients were enrolled in the parent study, of whom viruses were detected in 344 (60%), including 159 (28%) human rhinovirus, 114 (20%) RSV, and 34 (6%) with influenza. In multivariable models, viral infections were associated with increasing disease severity, with the greatest effect noted with RSV (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.30-4.81) followed by rhinovirus (aOR, 2.18; 95% CI, 1.27-3.76). Viral detection was not associated with increased severity among patients with radiographic pneumonia (n = 223; OR, 1.82; 95% CI, 0.87-3.87) but was associated with severity among patients without radiographic pneumonia (n = 141; OR, 2.51; 95% CI, 1.40-4.59). The detection of a virus in the nasopharynx was associated with more severe disease compared with no virus; this finding persisted after adjustment for age, biomarkers, and radiographic findings. Viral testing may assist with risk stratification of patients with lower respiratory tract infections.

Ventricular penetration with a rigid drainage catheter as a procedural complication caused by space‐occupying intrathoracic mass with significant cardiac displacement in a dog

AbstractA 3‐year‐old, female, entire labrador retriever was presented as an emergency referral for suspected iatrogenic cardiac trauma during thoracostomy tube placement for perceived pyothorax. The patient initially presented for non‐specific lethargy and anorexia and upon investigations was found to have a mass on the external thoracic wall and what appeared to be a large‐volume pleural effusion. During thoracostomy drain placement, fresh, clotting blood was aspirated through the drain. The patient was haemodynamically stable on arrival at the referral centre with a normal electrocardiogram. Imaging revealed penetration of the left ventricular free wall and septum and significant displacement of the heart due to a large intrathoracic space‐occupying mass. Cytology of the mass was suggestive of soft tissue sarcoma. The patient was euthanased.

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax.

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients. We conducted a retrospective institutional review board-approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement. A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58-97), specificity of 100% (95% CI 99-100), positive predictive value of 81% (95% CI 54%-95%), and negative predictive value of 100% (95% CI 99%-100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%-78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US. Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.

Complications and outcome of traumatic diaphragmatic hernia repair without post-operative chest drain: Retrospective study in 90 cats.

Diaphragmatic herniorraphy is the treatment of choice for traumatic diaphragmatic hernia (TDH). Several methods have been described for the removal of residual air and fluid during and after surgery, such as the insertion of chest drains, intercostal thoracentesis, and transdiaphragmatic thoracentesis. However, there are no indications regarding the most useful technique and the impact that choice of technique could have in the immediate postoperative period. To evaluate the development of complications and outcomes associated with the use of intraoperative transdiaphragmatic thoracentesis in cats undergoing diaphragmatic herniorrhaphy for TDH. Medical records of cats treated for acute and chronic TDH between 2010 and 2019 were reviewed. Cats were included if intraoperative pneumothorax was treated with transdiaphragmatic thoracentesis, without the use of intercostal chest drain. Outcome, intra- and post-operative complications were recorded. Intraoperative and postoperative complication rates were 3.3% and 12.4%, respectively. Development of postoperative pneumothorax was associated with the presence of comorbidities (p = 0.046). The overall survival rate was 93.3%. Long-term survival had a significant association with the presence of comorbidities (p = 0.045), if the procedure was performed as an emergency (p = 0.041) or in older cats (p = 0.011). Intraoperative transdiaphragmatic thoracentesis could be considered an effective method for the removal of residual air after surgery for TDH, because it ensures a good outcome for the patient, with low development of complications, especially for uncomplicated cases. The presence of comorbidities, the need to perform a surgical procedure in emergency, and the age of the patient can be considered factors influencing the development of complications. Critical patient selection, based on assessment of potential risk factors for complications is warranted to understand which patient will benefit from thoracostomy tube placement.

A novel simulation model for tube thoracostomy.

Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine. This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues. The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt. We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.