Thoracostomy Tube Removal Research Articles

Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter?

BackgroundSurgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention. MethodsWe performed a single center retrospective (2018–2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal. ResultsFrom 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal. ConclusionThis study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.

Timing of ultra-portable ultrasound (UPUS) Examinations in detecting clinically concerning recurrent pneumothorax

BackgroundRecurrent pneumothorax (rPTX) is a common complication following thoracostomy tube (TT) removal in chest trauma patients. While chest X-ray (CXR) is most commonly used to detect a rPTX, bedside ultraportable ultrasound (UPUS) is a feasible, low cost, and radiation free alternative. No consensus exists with regards to the optimal timing of diagnostic imaging to assess for rPTX post-TT removal. Accordingly, we sought to identify an ideal UPUS timing to detect a rPTX MethodsWe conducted a single center prospective study of adult (≥18years) patients admitted with a chest trauma. UPUS examinations were performed using the Butterfly iQ+™ ultrasound. Three intercostal spaces (ICS) were evaluated (2nd through 4th). Post-TT UPUS examinations were performed at different timepoints following tube removal (1–6 h). A rPTX on UPUS was defined as the absence of lung-sliding in one or more intercostal spaces, and was considered a clinically concerning rPTX if lung-sliding was absent in ≥2 ICS. UPUS findings were compared to CXR. ResultsNinety-two patients (97 hemi-thoraces) were included in the analysis. A total of 58 patients had a post-TT removal rPTX of which 11 were either clinically concerning or expanding. Comparing UPUS findings to CXR, the 3-hour post-TT removal ultrasound examinations were associated with the highest sensitivity. By hour 4, no rPTX showed expansion in size. Three patients required an intervention for a clinically concerning rPTX, all of whom were detected on UPUS 3-hour post-TT removal. ConclusionBedside UPUS performed at 3-hour post-TT removal has the highest sensitivity in detecting clinically concerning rPTX. Size of rPTX appears to stabilize by hour 4. In the absence of clinical symptoms, repeat imaging or observation of non-significant rPTX beyond 4 h may not provide added clinical benefit. Level of EvidenceLevel II, Diagnostic Tests or Criteria

Severe acute alcoholic pancreatitis complicated by distributive shock, abdominal compartment syndrome, and black pleural effusion

Severe acute pancreatitis (SAP) is a life-threatening medical emergency that can lead to multi-system organ failure and mortality. Here, we highlight a case of SAP complicated by a black pleural effusion (BPE), distributive shock, and acute abdominal compartment syndrome (ACS) requiring emergent decompressive laparotomy. BPE fluid analysis was consistent with previously reported exudative effusions from a pancreatic pseudocyst, though the computed tomography (CT) of abdomen and pelvis did not show definitive evidence of a pseudocyst. In addition, black fluid was also discovered during decompressive laparotomy for ACS. It is possible that the severely elevated intra-abdominal pressure contributed to a temporary translocation/transudation of this fluid from the abdominal cavity into the pleural space, as no re-accumulation of the BPE was observed on a follow-up CT after thoracostomy tube removal.

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center.

Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous. Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate. The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality. VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection

ObjectivesThe need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. MethodsPatients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. ResultsA total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. ConclusionsReserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Efficacy of thoracic ultrasonography in thoracostomy tube removal

Efficacy of thoracic ultrasonography in thoracostomy tube removal

The Time Course of Recurrent Pneumothorax Development after Thoracostomy Tube Removal in Trauma Patients: An Ultra-Portable Ultrasound Study (UPUS Trial)

The Time Course of Recurrent Pneumothorax Development after Thoracostomy Tube Removal in Trauma Patients: An Ultra-Portable Ultrasound Study (UPUS Trial)

Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients

IntroductionA chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX. Materials and MethodsA practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed. ResultsEighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed. ConclusionBedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Tube thoracostomy for trauma at Counties Manukau District Health Board, Aotearoa New Zealand.

Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety. A 30-month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded. One hundred and forty-three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P= 0.015). Non-accidental injuries were more likely to need TT (P= 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P< 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P< 0.0001). Post-procedural monitoring recommendations were documented in 1% insertions and 11% removals. The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety.

Thoracostomy Tube Removal in Pediatric Trauma: Film or No Film?

BackgroundUse of routine chest x-rays (CXR) following thoracostomy tube (TT) removal is highly variable and its utility is debated. We hypothesize that routine post-pull chest x-ray (PP-CXR) findings following TT removal in pediatric trauma would not guide the decision for TT reinsertion. MethodsPatients ≤ 18 y who were not mechanically ventilated and undergoing final TT removal for a traumatic hemothorax (HTX) and/or pneumothorax (PTX) at a level I pediatric trauma center from 2010 to 2020 were retrospectively reviewed. The outcomes of interest were rate of PP-CXR and TT reinsertion rate following PP-CXR. Clinical predictors for worsened findings on PP-CXR were also assessed. ResultsFifty-nine patients were included. A CXR after TT removal was performed in 57 patients (97%), with 28% demonstrating worsened CXR findings compared to the prior film. Except for higher ISS (p = 0.033), there were no demographic or clinical predictors for worsened CXR findings. However, they were more likely to have additional films following the TT removal (p = 0.008) than those with stable or improved PP-CXR findings. One (1.8%) asymptomatic child with worsened PP-CXR findings had TT reinsertion based purely on their worsened PP-CXR findings. ConclusionsThe vast majority of PP-CXR did not guide TT reinsertion after pediatric thoracic trauma. Treatment algorithms may aid to reduce variability and potentially unnecessary routine films.

Retrospective evaluation of fluid production at the time of thoracostomy tube removal following elective and emergency surgery in dogs (2010-2017): 185 cases.

To report the rate of fluid production at the time of removal of thoracostomy tubes placed intraoperatively and to determine the association of this rate with specific patient factors, surgical factors, or clinical diagnosis. The secondary objective was to determine whether identification of pleural effusion within 2weeks of thoracostomy tube removal was associated with the same variables. Retrospective study. University teaching hospital. One hundred eighty-five client-owned dogs with thoracostomy tubes placed intraoperatively between January 2010 and March 2017. None. Thoracostomy tubes were removed at a median fluid production of 0.09mL/kg/h (range, 0-7.0m L/kg/h). Median fluid production at the time of thoracostomy tube removal was significantly higher in dogs with preoperative pleural effusion compared to dogs without preoperative pleural effusion (0.21 vs 0.05mL/kg/h; P=0.0001) and in dogs that had a median sternotomy compared to dogs that had a lateral thoracotomy (0.14 vs 0.09mL/kg/h; P=0.04). Of the 169 dogs available for follow-up, 12 (7.1%) had pleural effusion within 2weeks of removal of the thoracostomy tube. Detection of pleural effusion during the follow-up period was significantly associated with the presence of preoperative pleural effusion (P=0.0019) and the diagnosis (P=0.01). A greater proportion of dogs with a lung lobe torsion (4/9, 44.4%) and idiopathic chylothorax (2/7, 28.5%) had pleural effusion within 2weeks compared to other diagnoses. Reintervention was performed in 4.7% of dogs. Thoracostomy tubes were removed at pleural fluid production rates that frequently exceeded current veterinary guidelines. However, the fluid production rate at the time of thoracostomy tube removal was not associated with the detection of pleural effusion within 2weeks of thoracostomy tube removal, and the overall need for reintervention following thoracostomy tube removal was low (4.7%).

Recurrent pneumothorax following chest tube removal in thoracic stab wounds: a comparative study between end inspiratory versus end expiratory removal techniques at a major trauma centre in South Africa.

Tube thoracostomy (TT) insertion is a commonly performed procedure in trauma that is standardised, but the optimal removal technique based on the timing in relation to the respiratory cycle remains controversial. A prospective study was undertaken at a major trauma centre in South Africa over a 4-year period from January 2010 to December 2013, and included all patients with pneumothorax secondary to thoracic stab wounds. TTs were removed by either end of inspiration technique (EIT) or end of expiration (EET) technique and the rate of recurrent pneumothorax (RPTX) following removal was compared. We hypothesized that there is no difference in the rate of RPTX between the end inspiratory (EI) and end expiratory (EE) removal technique. A total 347 patients were included. Of the 184 TTs removed by EIT, there were 17 (9%) RPTXs. Of the 163 with EET, there were 11 RPTXs (7%), (9% versus 7%, chi-squared, P = 0.395). Of the total 28 (9%) patients with RPTXs following removal of chest tubes, two (7%) required reinsertion of chest tube (0.5% (1/184) in EIT and 0.6% (1/163) in EET, P = 0.747). Timing of TT removal in relation to the respiratory cycle does not appear to influence the incidence of RPTX in patients with thoracic stab wounds. Technique of removal may well be a more important consideration and more attention must be focused on refining the optimal technique.

Managing tube thoracostomy with thoracic ultrasound: results from a randomized pilot study.

Tube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT. Prospective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation. Sixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications. The use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.

69-YEAR-OLD MALE WITH ENTRAPPED CHEST TUBE: COMPLICATION OF CPR

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cardiopulmonary resuscitation (CPR) is a lifesaving intervention routinely performed in medical institutions. However, it is associated with multiple complications including rib fractures requiring thoracostomy tube (TT) insertion. Additionally, there is a paucity of evidence identifying complications of CPR with a TT present. Here we describe a case of a patient who had their TT break due to CPR. CASE PRESENTATION: A 69-year-old male presented as a level two trauma status post motor vehicle collision. His initial injury severity score was 29 with injuries including: left-sided rib fractures with flail segment of ribs 1-6, left hemopneumothorax, comminuted fracture of the left scapular body and spine, left clavicle fracture with emphysema and hematoma. The patient was admitted to the surgical intensive care unit with management including a thoracotomy for rib plating and evacuation of the hematoma. Preoperative imaging is shown in Figure 1. The patient underwent left posterolateral thoracotomy with open reduction and internal fixation of left ribs 3-7 with evacuation of subcutaneous hematoma and left hemothorax. A 28 French TT was placed in the left posterior apical position, and a curved 28 French TT was placed in the left posterior inferior position. A postoperative chest x-ray confirmed lung re-expansion (Figure 2). On post-operative day 1, the patient became hypoxic, hypotensive, and bradycardic leading to cardiac arrest. Advanced cardiac life support was initiated including CPR and epinephrine for eight minutes until return of spontaneous circulation was achieved. A chest x-ray post arrest was taken showing the rib plating was intact. On post-operative day 2, removal of the TT was attempted. The distal portion of the left TT broke and remained within the thoracic cavity. A computed tomography of the chest (Figure 3) showed the broken portion of the tube. On post-operative day 3, the patient underwent left mini thoracotomy, removal of the retained TT under ultrasound guidance, and replacement of the apical TT. The distal end of the curved chest tube was found to be entrapped within the anterior rib fractures that resulted from CPR and successfully removed. The rest of the patient’s admission was unremarkable and he was discharged to a rehabilitation facility. DISCUSSION: To our knowledge this is one of the first cases to describe entrapment of a TT as a result of CPR. Additionally, this is one of the few cases to describe the use of a thoracotomy for removal of an entrapped tube. Thoracotomy has been reported as a management strategy in a similar case in which a nasogastric tube became entrapped intratracheally following lobectomy. There remains a paucity of data on the true incidence of abnormal positioning of tubes and the role of thoracotomy in the management of these patients. CONCLUSIONS: We present the case of a broken entrapped TT and successful removal via thoracotomy. Reference #1: Hoke RS, Chamberlain D. (2004). Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63(3):327-38. Reference #2: Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. (2009). Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emergency Medicine, 28;19(1):23. DISCLOSURES: No relevant relationships by Jordan Debbrecht, source=Web Response No relevant relationships by Katherine Foerster, source=Web Response no disclosure on file for Brian Gilbert; No relevant relationships by Michael Nguyen, source=Web Response no disclosure on file for George Philip; No relevant relationships by William Waswick, source=Web Response

Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis

BackgroundFollowing placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective. MethodsWe performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. ResultsDecision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations. ConclusionIn trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.

Clamping trials prior to thoracostomy tube removal and the need for subsequent invasive pleural drainage

BackgroundThere is little evidence supporting or refuting clamping trials, a period of clamping thoracostomy tubes prior to removal. We sought to evaluate whether clamping trials reduce the need for subsequent pleural drainage procedures. MethodsWe conducted a retrospective cohort study of trauma patients who underwent tube thoracostomy during 2009–2015. We compared patients who underwent clamping trials to those who did not, adjusting for confounders. The primary outcome was subsequent ipsilateral pleural drainage within 30 days. ResultsWe evaluated 214 clamping trial and 285 control patients. Only two of 214 patients failed their clamping trial and none developed a tension pneumothorax [0.0% (95% CI 0.0–1.7%)]. Clamping trials were associated with fewer pleural drainage procedures [13 (6%) vs. 33 (12%); adjusted OR 0.41 (95% CI 0.20–0.84)]. ConclusionsA clamping trial prior to thoracostomy tube removal seems to be safe and was associated with less likelihood of a subsequent pleural drainage procedure.

Management of a difficult infectional disease: Descending necrotizing mediastinitis.

Descending Necrotizing Mediastinitis (DNM) is the fatal form of mediastinitis and mostly develops as a complication of peritonsillar abscesses or dental-odontogenic infections. The aim of this study is to evaluate clinical and surgical feature of the patients with DNM who were managed in our clinic. We retrospectively evaluated 13 consecutive patients with the diagnosis of DNM between February 2005 and February 2018. All of them had the typical physical appearance, history and radiological findings. Ten (77%) patients were male, 3 (23%) patients were female with a median age of 48.2 (18-76 years). All patients underwent Cervico-Mediastinal Drainage (CMD) with debridement of the necrotic and infected tissues. Other supplimantary surgical procedures were tube thoracostomy (n = 8), VATS mediastinal drainage (n = 4), tracheostomy (n = 2) and thoracatomy (n = 1). The median time to diagnosis of DNM, tube drainage (inserted after CMD) removal time, tube thoracostomy removal time, lenght of hospital stay were 1.8 (range 1-4) days, 13.6 (range 10-20), 12.6 days (range 10-27) and 21.5 days (range 15-30), respectively. Appropriate and potent antibiotics were used according to the fever-CRP response with the consultation on infectious disease specialist. Two patients were lost due to fulminant sepsis (n = 1) and massive cervical haemorrhage (n = 1). Overall mortality rate was 15%. Complications were recorded in 6 patients (46%). The critical point in the management of DNM is the correct diagnosis, rapid surgical intervention with antibiotherapy and close follow-up for possible complications. We concluded that the combination of minimally invasive management as VATS-tube thoracostomy with CMD is the most appropriate surgical interventions.

Trauma patients are safe to fly 72 hours after tube thoracostomy removal.

Current recommendations for safe air travel following traumatic pneumothorax are 2 to 3 weeks after radiographic resolution. These recommendations are based on several small observational studies and expert consensus, which cite a theoretical risk of recurrence and hypoxia because of decreased oxygen tension at altitude. We sought to systematically study the timing of chest drain removal after traumatic pneumothorax and risk of recurrence in relation to air travel. A retrospective cohort study of consecutively admitted patients who sustained a traumatic chest injury treated with tube thoracostomy over a 5-year period was undertaken. Adult patients with a postremoval expiratory chest x-ray demonstrating absence of pneumothorax and at least a 24-hour observation period before flight were eligible for study. All patients were transferred to a participating medical center for continued care. In-flight medical monitoring was available for all patients. Baseline patient characteristics, interval period from drain removal to flight, in-flight medical records, and incidence of radiographic or clinical recurrence of pneumothorax at the destination facility were recorded. Seventy-three patients who met the inclusion criteria were studied. All were male with a median age of 24 years (interquartile range [IQR], 22-26 years), injury severity score of 30 (IQR, 24-38), and chest abbreviated injury scale value of 3 (IQR, 2-4). The majority of patients sustained a penetrating injury (74%). The median duration of tube thoracostomy was 4 days (IQR, 3-6 days). The median period between thoracostomy tube removal and flight was 2.5 days (IQR, 1.5-4 days). Twenty-nine patients (40%) remained mechanically ventilated during transport. There were no reported in-flight medical emergencies for the entire cohort. There were no reported postflight radiographic or clinical recurrences during the subsequent 30 days. After a 72-hour period of observation, air travel after tube thoracostomy removal appears safe for both mechanically ventilated and nonventilated patients. Therapeutic, level IV.

Randomized controlled trial of chest tube removal aided by a party balloon.

Background Recurrent pneumothorax is one of the most common complications after thoracostomy tube removal. The purpose of this study was to assess the optimal method of thoracostomy tube removal by comparing party balloon-assisted Valsalva and classic Valsalva techniques. Methods Trauma patients with indications for tube thoracostomy from 2014 to 2015 were recruited. Exclusion criteria were age < 15- or > 64-years-old, history of chronic lung disease, Glasgow Coma Scale < 13, latex allergy, or tracheostomy. Participants were randomly allocated by randomized block design into 4 groups using different Valsalva maneuvers: group A: classic inspired, group B: classic expired, group C: balloon-inspired; and group D: balloon-expired. The primary and secondary outcomes were recurrent pneumothorax and respiratory complications. Results Forty-eight tube thoracostomies were randomized for analysis; 4 patients had bilateral tube thoracostomies. The mean patient age was 38.1 ± 19.9 years. The incidence of recurrent pneumothorax confirmed by chest radiography was 15.4% in group A, 16.8% in group B, and none in groups C and D ( p = 0.31). When group A combined with group B was compared with groups C and D, the incidence was 16% vs. 0%, respectively ( p = 0.11). The thoracostomy tube reinsertion rate in all 4 groups was 0%, 8.33%, 0%, and 0%, respectively, which was not significant ( p = 0.38). Conclusions Performing the Valsalva maneuver correctly during full inspiration may be the method of choice for removing thoracostomy tubes. Using a party balloon forces the patient perform the Valsalva maneuver adequately and is simpler to explain.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

ObjectiveThoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients. MethodsMethods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey. ResultsThere was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated. DiscussionThis project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.