Search Results (29)

Objectives: This study was aimed to identify risk factors for persistent air leak after chest tube placement for secondary spontaneous pneumothorax and to determine the optimal timing of treatment. Methods: We retrospectively analyzed 221 cases of secondary spontaneous pneumothorax in patients aged ≥50 years who were treated with chest tube drainage. Patients were categorized into the observation group or additionally treated group based on whether they received interventional treatment beyond chest tube drainage. Air leak resolution patterns were analyzed using hazard function analysis. Risk factors were evaluated using univariate and multivariate analyses. Results: Hazard function analysis revealed that the probability of air leak resolution decreased by approximately 50% within the first 5 days after the initiation of chest tube drainage, with only 33% of cases resolving by day 7. Beyond days 7–10, resolution probability stabilized at a minimal level. Multivariate analysis identified previous pneumothorax history (HR: 0.422, p = 0.007) and low geriatric nutritional risk index (GNRI) (HR: 2.521, p < 0.001) as significant independent risk factors for persistent air leak. Further analysis of early resolution (within 7 days) identified female sex (HR: 0.24, p = 0.003), absence of previous pneumothorax (HR: 0.21, p = 0.003), and higher GNRI values (HR: 1.04, p = 0.008) as positive predictors. Conclusions: Risk stratification based on pneumothorax history and nutritional status enables the optimization of the timing of intervention for persistent air leak. We recommend considering additional treatment between days 7 and 10 of chest tube drainage, with earlier intervention for high-risk patients. This approach may improve patient outcomes while avoiding unnecessarily prolonged conservative management. Full article

Introduction and case report: Angiosarcomas, rare soft tissue malignancies originating from endothelial cells, represent only 1–2% of all soft tissue sarcomas. Primary pleural angiosarcoma (PPA) is exceptionally rare, with only 43 reported cases since 1943. There are many diagnostic and therapeutic challenges due to the rarity of these tumors. We present the case of a 72-year-old man presenting with back pain, dyspnea and anemia. Conventional imaging revealed bilateral pleural effusion and a thickened parietal pleura, while contrast chest MR was able to identify pleural sites of contrast enhancement. Left chest tube placement evidenced a hemothorax, and the cytology result was negative. A thoracoscopic approach was chosen, allowing us to perform different parietal pleural biopsies. Radiological and pathological features led to the diagnosis of epithelioid PPA. Despite pleural drainage and blood transfusions, the patient died only 4 days after diagnosis. Objectives: To present a literature review, evaluating the disease epidemiology and the clinical, diagnostic and therapeutic features of PPA. Methods: We reviewed cases of PPA in the literature (1954–2024) by searching the PubMed database for the terms “pleural angiosarcoma” and “pleura + angiosarcoma”. Results: We found a total of 47 cases that were described between 1987 and 2024 with sufficient data to be included in our review. PPA was found to be a challenging diagnosis, found mostly in older Caucasian males. The cytology is mostly indeterminant, and an endoscopic approach is usually needed. Radical surgery is the most common treatment option, and chemotherapy and radiation therapy are also often used. However, the prognosis is poor. Conclusions: PPA is very rare, and complex cases such as this one showcase the importance of innovative approaches like MRI and emphasize the significance of multidisciplinary collaboration for optimal patient management. Bilateral spontaneous hemothorax, as seen in this case, is uncommon and poses additional challenges in disease management. Further research to advance the diagnostic capabilities and treatment efficacy is needed. Full article

Background: Endotracheal tube (ETT) placement is crucial for neonates with respiratory failure. Ultrasonography (US) has emerged as a valuable tool to detect ETT positioning, competing with traditional methods. Nurses, being front-line caregivers, can perform basic ultrasound examinations. This study aimed to assess whether a nurse inexperienced in US could identify the correct ETT position in neonates after a brief ultrasound training. Methods: This study included intubated neonates hospitalized in a NICU with a postmenstrual age of under 45 weeks. A NICU nurse, following a short ultrasound training, measured the distance of the ETT tip to the right pulmonary artery and aortic arch. Chest X-rays (CXRs) confirmed the ETT position. The neonates’ ages, genders, weights, and examination times were recorded. Results: This study involved 67 neonates, including 40 (59.7%) males, with 39 (58.2%) weighing below 1500 g. The median time for correct ETT placement confirmation by CXR was 12.6 min, while US-assisted ETT recognition took 6 min initially and 5.1 min at the end of the training, which was a significant difference. No major differences were found in US distance based on the neonate’s weight and age. Gender marginally influenced US distance (β = −0.089, p = 0.056). Conclusions: The NICU nurse responded well to ultrasound training, showing results comparable with CXR. Further studies with more patients and additional studied factors are needed to fully assess US’s reliability in determining ETT positioning. Full article

Background and Objectives: Video-assisted thoracoscopic surgery (VATS) is associated with less postoperative pain than traditional open thoracotomy. However, trocar and chest tube placement may damage the intercostal nerves, causing significant discomfort. An ultrasound-guided serratus anterior plane block (SAPB) is a promising mode of pain management; this reduces the need for opioids and the associated side-effects. This study evaluated whether SAPB, compared to intravenous analgesia alone, reduces opioid consumption after thoracoscopic lung wedge resection. Materials and Methods: In total, 22 patients undergoing VATS lung wedge resections were randomized into two groups (SAPB and control): both received intravenous patient-controlled analgesia (PCA), and one group received additional SAPB. The primary outcome was the cumulative intravenous fentanyl consumption at 8 h postoperatively. The visual analog scale (VAS) pain scores and the incidence of postoperative complications were assessed over 48 h post surgery. Results: Fentanyl consumption by 8 h post surgery was significantly lower in the SAPB group than in the control group (183 ± 107 μg vs. 347 ± 202 μg, p = 0.035). Although the VAS scores decreased with time in both groups, the differences were not statistically significant. The SAPB group required fewer opioids by 48 h. No significant between-group differences were observed in postoperative complications, including nausea and vomiting. Conclusions: SAPB effectively reduced opioid consumption after VATS lung wedge resection. SABP may serve as a valuable component of multimodal pain management. Full article

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. Full article

Background: Despite the implementation of enhanced recovery programs, the reported average postoperative length of stay after robotic lobectomy remains as 4 days. In this prospective study, we present the outcomes of early discharge (on day 2) with telehealth home monitoring device after robotic lobectomy for lung cancer in selected patients. Methods: All patients with a caregiver were discharged on postoperative day 2 (POD 2) with a telemonitoring device provided they met the specific discharge criteria. Inclusion criteria: <75 years old, stage I-II NSCLC, with caregiver, ECOG 0–2, scheduled for lobectomy, logistic proximity to hospital (<60 km); intra-postoperative exclusion criteria: conversion to open surgery, early complications needing hospital monitoring or redo-operation, difficult pain management, <92 HbO2% saturation on room air or need for O2 supplementation, altered vital or laboratory parameters. Teleconsultations were scheduled as follows: the first one in afternoon of POD2, two on POD3, then once a day until chest tube removal. After discharge, patients recorded their vital signs at least four times a day using the device, which allowed two surgeons to monitor them via a mobile application. In the event of sudden changes in vital signs or the occurrence of adverse events, patients had access to a direct phone line and a dedicated re-hospitalization pathway. The primary outcome was safety, assessed by the occurrence of post-discharge complications or readmissions, as well as feasibility. Secondary outcomes: comparison of safety profile with a matched control group in which the standard of care and the evaluation of resource optimization were maintained and economic evaluation. Results: Between July 2022 and February 2024, 48 patients were enrolled in the present study. Six patients (12.5%) dropped out due to unsatisfied discharge criteria on POD2. Exclusion causes were: significant air leaks (n:2) requiring monitoring and the use of suction device, uncontrolled pain (n:2), atrial fibrillation, and occurrence of cerebral ischemia (n:1 each). The adherence rate to vital signs monitoring by patients was 100%. A mean number of four measurements per day was performed by each patient. During telehealth home monitoring, a total of 71/2163 (1.4%) vital sign measurements violated the established acceptable threshold in 22 (52%) patients. All critical violations were managed at home. During the surveillance period (defined as the time from POD 2 to the day of chest tube removal), a persistent air leak was recorded in one patient requiring readmission to the hospital (on POD 13) and re-intervention with placement of a second thoracic drainage due to unsatisfactory lung expansion. No other postoperative complication occurred nor was there any readmission needed. Compared to the control group, the discharge gain was 2.5 days, with an economic benefit of 528 €/day (55.440 € on the total enrolled population). Conclusions: Our results confirm that the adoption of telehealth home monitoring is feasible and allows a safe discharge on postoperative day two after robotic surgery for stage I-II NSCLC in selected patients. A potential economic benefit (141 days of hospitalizations avoided) for the healthcare system could result from the adoption of this protocol. Full article

Introduction: Total laryngectomy is used to cure advanced larynx cancer in many patients. The removal of the larynx requires the rehabilitation of the patient’s ability to communicate, and one common method is to place a tracheoesophageal voice prosthesis (TEP) as a secondary procedure after the patient has completed cancer treatment. The traditional technique utilizes a rigid esophagoscope for access, but this can prove difficult in many patients who have kyphosis, scarring of the neck, or trismus. We describe a technique to allow TEP placement in these challenging patients that does not utilize rigid esophagoscopy to access the tracheoesophageal puncture site. Methods: For more than 15 years, the senior authors of this study have used this technique in patients in whom traditional methods of TEP with rigid esophagoscope were unsuccessful or not attempted due to the anticipated high probability of failure. The ease of this technique has prompted its use for all patients undergoing secondary TEP placement in their practice. The technique is described in detail in the Methods section below. Results: The described method has been successfully utilized to place TEPs in many patients with challenging anatomy. There have been no failed placements, including a patient with severe trismus who was able to have a TEP placed by placing the chest tube and flexible endoscope transnasally. Further, because of precise visualization and ease of the technique, there have been no observed complications of injury to the pharyngoesophageal lumen or creation of a false passage. Conclusion: The use of a chest tube and flexible scope allows for the protection of the pharyngoesophageal lumen, precise visualization and placement of the puncture, and avoidance of a false tracheoesophageal passage, all while minimizing the need for extension of the patient’s neck. This has proven ideal for patients suffering the consequences of cancer treatment such as cervical scarring, fibrosis, kyphosis, and trismus. Full article

Objectives: To evaluate the effectiveness of track embolization using gelatin sponge torpedo in reducing the incidence of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy. Methods: A retrospective single-center analysis of percutaneous computed tomography (CT)-guided transthoracic lung biopsies was performed between 2017 and 2022. After excluding the patients who received an ultrasound-guided biopsy, combined lung biopsy with ablation, fiducial placement, unsuccessful procedure due to uncooperative patient, and age under 18 years, 884 patients’ clinical information was collected (667 without track embolization and 217 with track embolization). The incidence of early and late pneumothorax and chest tube placement were compared between the two groups. Propensity score matching (PSM) was applied to minimize selection bias. Univariable and multivariable analyses were performed to determine risk factors for pneumothorax. Results: After PSM, the baseline differences and all factors that could affect the incidence of pneumothorax were balanced between the track embolization group (217 patients) and the non-track embolization group (217 patients). The incidence rates of early pneumothorax (13.4% vs. 24.0% p = 0.005), late pneumothorax (11.0% vs. 18.0% p = 0.021), and chest tube placement (0.9% vs. 4.6% p = 0.036) were significantly decreased in the track embolization group. However, the success rate of tissue diagnosis yield and length of hospital stay were not significantly different between the two groups. In multivariate analysis, the risk of pneumothorax increased as the fissure was passed (OR = 3.719, p = 0.027). Conclusions: Using track embolization with a gelatin sponge torpedo significantly decreased the incidence of pneumothorax and chest tube placement following percutaneous CT-guided lung biopsy. Full article

This paper presents a combined optical coherence tomography (OCT) imaging/machine learning (ML) technique for real-time analysis of lung tissue morphology to determine the presence and level of invasiveness of idiopathic lung fibrosis (ILF). This is an important clinical problem as misdiagnosis is common, resulting in patient exposure to costly and invasive procedures and substantial use of healthcare resources. Therefore, biopsy is needed to confirm or rule out radiological findings. Videoscopic-assisted thoracoscopic wedge biopsy (VATS) under general anesthesia is typically necessary to obtain enough tissue to make an accurate diagnosis. This kind of biopsy involves the placement of several tubes through the chest wall, one of which is used to cut off a piece of lung to send for evaluation. The removed tissue is examined histopathologically by microscopy to confirm the presence and the pattern of fibrosis. However, VATS pulmonary biopsy can have multiple side effects, including inflammation, tissue morbidity, and severe bleeding, which further degrade the quality of life for the patient. Furthermore, the results are not immediately available, requiring tissue processing and analysis. Here, we report an initial attempt of using ML-assisted polarization sensitive OCT (PS-OCT) imaging for lung fibrosis assessment. This approach has been preliminarily tested on a rat model of lung fibrosis. Our preliminary results show that ML-assisted PS-OCT imaging can detect the presence of ILF with an average of 77% accuracy and 89% specificity. Full article

The advent of computed tomography (CT)-guided transthoracic needle biopsy has significantly advanced the diagnosis of lung lesions, offering a minimally invasive approach to obtaining tissue samples. However, the technique is not without risks, including pneumothorax and hemorrhage, and it demands high precision to ensure diagnostic accuracy while minimizing complications. This study introduces the Laser Angle Guide Assembly (LAGA), a novel device designed to enhance the accuracy and safety of CT-guided lung biopsies. We retrospectively analyzed 322 CT-guided lung biopsy cases performed with LAGA at a single center over seven years, aiming to evaluate its effectiveness in improving diagnostic yield and reducing procedural risks. The study achieved a diagnostic success rate of 94.3%, with a significant reduction in the need for multiple needle passes, demonstrating a majority of biopsies successfully completed with a single pass. The incidence of pneumothorax stood at 11.1%, which is markedly lower than the reported averages, and only 0.3% of cases necessitated chest tube placement, underscoring the safety benefits of the LAGA system. These findings underscore the potential of LAGA to revolutionize CT-guided lung biopsies by enhancing procedural precision and safety, making it a valuable addition to the diagnostic arsenal against pulmonary lesions. Full article

Objectives: The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial drain). Methods: Data on patients who underwent either uniportal or biportal VATS upper lobectomies with lymphadenectomy were prospectively collected in three European centers. The uniportal VATS group with a 28 Fr standard chest tube (U-VATS standard) was compared with the uniportal VATS group with a 28 Fr smart drain (U-VATS smart), and U-VATS smart was also compared with biportal VATS with a 28 Fr smart drain inserted in the VIII intercostal space (Bi-VATS smart). Results: When comparing the U-VATS standard group with the U-VATS smart, a higher fluid output was recorded in the U-VATS smart (p: 0.004) in the III post-operative day (p.o.) and overall (p: 0.027), with a lower 90-day re-admission in the U-VATS smart (p: 0.04). The Bi-VATS smart group compared to U-VATS smart showed a higher fluid output in the I p.o. (p < 0.001), with no difference in total fluid amount or hospitalization. The Bi-VATS smart recorded a lower incidence (p < 0.001) of residual pleural space or effusion (p: 0.004) at chest X-rays prior to drain removal but a higher level of pain and chronic intercostal neuralgia (p: 0.03). Conclusions: Chest tube insertion through the same incision space in uniportal VATS seems to be safe and effective. Smart drains can improve the fluid output in uniportal VATS, as if the drainage were inserted in a lower space (i.e., biportal VATS), but with less discomfort. Full article

Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH. Full article

Background: A feeding tube (FT) is routinely placed in critically ill patients, and its correct placement is confirmed with a chest X-ray (CXR), which is considered the gold standard. This study evaluated the diagnostic accuracy of ultrasonography (USG) in verifying FT placement compared to a CXR in an intensive care unit (ICU). Method: This was a prospective single-blind study conducted on patients admitted to the ICU of a tertiary hospital in Malaysia. The FT placements were verified through a fogging test and USG at the neck and subxiphoid points. The results of confirmation of FT placement through USG were compared with those obtained using CXRs. Results: A total of 80 patients were included in this study. The FT positions were accurately confirmed by overall USG assessments in 71 patients. The percentage of FT placements correctly identified by neck USG was 97.5%, while the percentage of those identified by epigastric USG was 75%. The corresponding patients’ CXRs confirmed correct FT placement in 76 patients. The overall USG assessment had a sensitivity of 92.11% and specificity of 75%, a positive predictive value of 98.59%, and a negative predictive value of 33.33%. The USG findings also showed a significant association between FT size and BMI. FTs with a size of 14Fr were better visualized (p = 0.008), and negative USG findings had a significantly higher BMI (p < 0.001). Conclusion: USG is a simple, safe, and reliable bedside assessment that offers relatively high sensitivity in confirming correct FT placement in critically ill patients. Full article

Background: Emergency department (ED) overcrowding is a public health crisis that affects patient care quality. Space management in the ED can affect patient flow dynamics and clinical practice. We proposed a novel design of the “emergency procedure zone” (EPZ). The purpose of the EPZ was to provide an isolated area for clinical practice and procedure teaching, to ensure a secure area with adequate equipment and monitors, and safeguard patient privacy and safety. This study aimed to analyze the impact of the EPZ on procedural practice and patient flow dynamics. Methods: This study was conducted at the ED of a tertiary teaching hospital in Taiwan. Data were collected from 1 March 2019 to 31 August 2020 (pre-EPZ period) and from 1 November 2020 to 30 April 2022 (post-EPZ period). Statistical analyses were performed using IBM SPSS Statistics software. This study focused on the number of procedures and length of stay in the emergency department (LOS-ED). Variables were analyzed using the chi-square test and Mann–Whitney U test. Statistical significance was defined as p < 0.05. Results: There were 137,141 (pre-EPZ period) and 118,386 (post-EPZ period) ED visits recorded during this period. The post-EPZ period showed a significant increase in central venous catheter insertion, chest tube or pigtail placement, arthrocentesis, lumbar puncture, and incision and drainage procedures (p < 0.001). For patients who were directly discharged from the ED, the post-EPZ period also had a higher percentage of ultrasound studies performed in the ED and a shorter LOS-ED for patients who were directly discharged from the ED (p < 0.001). Conclusions: The establishment of an EPZ in the ED has a positive impact on procedural efficiency. The EPZ improved diagnosis and disposition efficiency, shortened the length of stay, and provided benefits such as improved management, patient privacy, and teaching opportunities. Full article

Background: The aim of this multicenter retrospective study and literature review was to review management and outcomes of neonatal esophageal perforation (NEP). Methods: Protocol data were collected from four European Centers on gestational age, factors surrounding feeding tube insertion, management and outcomes. Results: The 5-year study period (2014–2018) identified eight neonates with median gestational age of 26 + 4 weeks (23 + 4–39) and median birth weight 636 g (511–3500). All patients had NEP from enterogastric tube insertions, with the perforation occurring at median 1st day of life (range 0–25). Seven/eight patients were ventilated (two/seven-high frequency oscillation). NEP became apparent on first tube placement (n = 1), first change (n = 5), and after multiple changes (n = 2). Site of perforation was known in six (distal n = 3, proximal n = 2 and middle n = 1). Diagnosis was established by respiratory distress (n = 4), respiratory distress and sepsis (n = 2) and post-insertion chest X-ray (n = 2). Management in all patients included antibiotics and parenteral nutrition with two/eight receiving steroids and ranitidine, one/eight steroids only and one/eight ranitidine only. One neonate had a gastrostomy inserted, while in another an enterogastric tube was orally successfully re-inserted. Two neonates developed pleural effusion and/or mediastinal abscess requiring chest tube. Three neonates had significant morbidities (related to prematurity) and there was one death 10 days post-perforation (related to prematurity complications). Conclusions: NEP during NGT insertion is rare even in premature infants after evaluating data from four tertiary centers and reviewing the literature. In this small cohort, conservative management seems to be safe. A larger sample size will be necessary to answer questions on efficacy of antibiotics, antacids and NGT re-insertion time frame in NEP. Full article