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PubMed2006

Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews.

OBJECTIVE: To evaluate the effectiveness and potential complications of simple thoracostomy, as first described by Deakin, as a method for prehospital treatment of traumatic pneumothorax. METHODS: Prospective observational study of all severe trauma patients rescued by our Regional Helicopter Emergency Medical Service and treated with on-scene simple thoracostomy, over a period of 25 months, from June 1, 2002 to June 30, 2004. RESULTS: Fifty-five consecutive severely injured patients with suspected pneumothorax and an average Revised Trauma Score of 9.6+/-2.7 underwent field simple thoracostomy. Oxygen saturation significantly improved after the procedure (from 86.4+/-10.2% to 98.5%+/-4.7%, P<0.05). No difference exists in the severity of thoracic lesions between patients with systolic arterial pressure and oxygen saturation below and above or equal to 90. A pneumothorax or a haemopneumothorax was found in 91.5% of the cases and a haemothorax in 5.1%. No cases of major bleeding, lung laceration or pleural infection were recorded. No cases of recurrent tension pneumothorax were observed. Forty (72.7%) patients survived to hospital discharge. CONCLUSIONS: Prehospital treatment of traumatic pneumothorax by simple thoracostomy without chest tube insertion is a safe and effective technique.

Adolescent↗
PubMed2006

Video-based ergonomic analysis to evaluate thoracostomy tube placement techniques.

BACKGROUND: Thoracostomy for relief of pneumo- or hemothorax may be performed emergently at the bedside, in the emergency department or trauma area, often in nonideal circumstances. We hypothesized that ergonomic analysis of thoracostomy techniques can identify areas for potential improvement in patient and operator safety. METHODS: Interviews with Subject Matter Experts (SME) provided steps in the task of thoracostomy; 44 thoracostomies (emergent and elective) were video-recorded and reviewed by SMEs. Ergonomic analyses evaluated surgical performance techniques using video clips. RESULTS: Risks to the patient and operator included instrument-tray positioning and instrument content. Analyses of video records revealed that despite SME-survey consensus, operators inconsistently followed recommended techniques. CONCLUSIONS: Discrepancies between SME-recommended and observed practice are prevalent, with simple ergonomic problems impeding performance, and creating risks for patients and operators. Video-based ergonomic analysis is a rich source for identifying task performance problems and potential solutions.

Chest Tubes↗
PubMed2006

Outcome of pediatric empyema thoracis managed by tube thoracostomy.

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

Adolescent↗
PubMed2006

Antibiotics are not needed during tube thoracostomy for spontaneous pneumothorax: an observational case study.

BACKGROUND: Usefulness of prophylactic antibiotics following tube thoracostomy remains controversial in the literature. In this study, we aimed to investigate the consequences of closed tube thoracostomy for primary spontaneous pneumothorax without the use of antibiotics. METHODS: One-hundred and nineteen patients underwent tube thoracostomy for primary spontaneous pneumothorax. None of them received prophylactic antibiotic treatment. Eight patients with prolonged air leak undergoing either video assisted thoracoscopic surgery or thoracotomy were excluded. RESULTS: Of the remaining 111 (104 male and 7 female), 28 (25%) patients developed some induration around the entry site of chest tube that settled without further treatment. White blood cell count was high without any other evidence of infection in 12 (11%) patients and returned to its normal levels before discharge home in all. There was also some degree of fever not lasting for more than 48 hours in 8 (7%) patients. Bacterial cultures from suspected sites did not reveal any significant growth in these patients. CONCLUSION: Prophylactic antibiotic treatment seems avoidable during closed tube thoracostomy for primary spontaneous pneumothorax. This policy was not only cost-effective but also prevented our patients from detrimental properties of unnecessary antibiotic use, such as development of drug resistance and undesirable side effects.

Adolescent↗
PubMed1993

Delayed perforation of the esophagus by a closed thoracostomy tube.

We report on a previously undocumented complication of a trocar-free thoracostomy tube--delayed perforation of a normal esophagus. The complication presented clinically with fever and copious enteric drainage four days after thoracostomy tube insertion. Diagnosis was established by a contrast study of the esophagus. Retrospectively, the postinsertion chest radiograph showed the offending thoracostomy tube tip impinging on the posterior mediastinum, displacing an indwelling nasogastric tube. Early recognition and repositioning of the thoracostomy tube is the key in preventing this rare but serious complication.

Adult↗
PubMed1997

Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital.

STUDY OBJECTIVE: To evaluate all tube thoracostomies (TTs) done by pulmonary/critical care fellows and attending physicians in the Medical University of South Carolina's health-care system documenting patient demographics, indication for placement, size and characteristics of the tube, and associated problems. DESIGN: Prospective. SETTING: University health-care system, including a university hospital, a Veterans Affairs hospital, and a county hospital. PATIENTS: All adult patients requiring consultation by a member of the pulmonary/critical care staff for a tube thoracostomy. RESULTS: One hundred twenty-six tube thoracostomies were performed over a 24-month period in 91 patients. The most common initial indication for a TT was pneumothorax (69/103, 67%). Overall mortality in the patient population was 35% (32/91). Early problems (< 24 hours following placement) occurred in 3% (4/126); late problems (> 24 h after placement) occurred in 8% (10/126). Problems occurred in 36% (4/11) of small-bore tube placements vs 9% (10/115) of standard TT placements (p=0.02). CONCLUSIONS: Tube thoracostomy can be safely performed by pulmonologists with relatively few associated problems.

Adolescent↗
PubMed2005

[Evaluation of open window thoracostomy for chronic tuberculous empyema with broncho-pleural fistula; a retrospective analysis of 33 cases].

We report here our 13-year experience treating chronic tuberculous empyema by open window thoracostomy. The subjects were 33 patients (28 males and 5 females) with a median age of 70 (range: 56-83) years who underwent surgery between January 1990 and December 2002. Patients with a history of pulmonary resection or thoracoplasty were excluded. All patients complained of cough and purulent sputum related to the presence of bronchopleural fistula. Previous illnesses included pulmonary tuberculosis (n = 20) and tuberculous pleurisy (n = 14) treated by artificial pneumothorax (n = 1) or chemotherapy (n = 22). Median duration from the initial episode of tuberculosis to surgery was 44 (range: 1-60) years. Mycobacterium tuberculosis (n = 9), Aspergillus fumigatus (n = 6), methicillin-resistant Staphylococcus aureus (MRSA) [n = 5], and Pseudomonas aeruginosa (n = 5) were representative microorganisms isolated from empyema. Preoperative mean %VC was 48 (range: 31-74)%. Mean follow-up was 34 (range: 1-131) months. Seven patients died of empyema-related disease within 6 months postoperatively. Nine patients underwent curative surgery to close the thoracostomy, including extrapleural pneumonectomy (n = 5), muscular transposition with thoracoplasty (n = 3), and lobectomy with muscular transposition and thoracoplasty (n = 1). In 17 patients, the thoracostomy was left open throughout the observation period because of severe impairment of pulmonary function. In elderly patients with severely impairment of pulmonary function, open window thoracostomy does not control empyema well and has a high rate of mortality.

Aged↗
PubMed2005

[Chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae treated by open window thoracostomy followed by thoracoplasty and latissimus dorsi muscle transposition].

We describe a case of chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae successfully treated by open window thoracostomy followed by thoracoplasty and transposition of the latissimus dorsi muscle. A 69-year old man with a history of artificial pneumothorax for pulmonary tuberculosis was referred to our hospital with fever and purulent bloody sputum. He was diagnosed as having right chronic tuberculous empyema with bronchopleural fistulae. Immediate tube thoracostomy markedly relieved symptoms except for low-grade fever. Sputum and empyema cavity cultures were repeatedly positive for MRSA. Open window thoracostomy (5th to 7th ribs resection) was performed to control the infection. The empyema cavity was cleaned with no residual calcified pleura. His condition gradually improved and he underwent thoracoplasty and transposition of the latissimus dorsi muscle 22 months after the initial surgery. He was discharged 25 days postoperatively in good condition. Seventeen months after the curative surgery, he remains well with no evidence of recurrence. A two-stage operation, open window thoracostomy to control infection followed by thoracoplasty and transposition of the latissimus dorsi muscle, is useful in cases of chronic tuberculous MRSA empyema with bronchopleural fistulae.

Aged↗
PubMed1987

Clagett open-window thoracostomy in patients with empyema who had and had not undergone pneumonectomy.

Patients with empyema not responding to simple chest-tube drainage and antibiotic therapy have been managed by a "Clagett"-type procedure that consists of open-window thoracostomy, antibiotic irrigation and closure of the window. The results of such treatment were reviewed. Of the 103 patients with empyema treated between 1967 and 1983, 41 underwent open-window thoracostomy. Twenty-eight (group 1) had empyema after pneumonectomy, 13 (group 2) did not; however, 9 of the 13 in group 2 had undergone lobectomy. The mean follow-up was 46 months for group 1 and 42 months for group 2. When surgical closure of the open-window thoracostomy was attempted, the success rate in group 1 was 85% for those without concomitant bronchopleural fistula, but only 36% in patients with a fistula. In group 2 the respective success rates were 50% and 57%. Unsuccessful closure resulted in chronic fistulas in four patients in each of the two groups. Six deaths in group 1 and two in group 2 were related to the original disease, but one was an operative death. These results demonstrate both the effectiveness and limitations of open-window thoracostomy in the management of these difficult cases.

Aged↗
PubMed1986

Tube thoracostomy and trauma--antibiotics or not?

Controversy persists regarding the use of antibiotics in association with t tube thoracostomy for trauma patients. We conducted a prospective randomized study of patients requiring tube thoracostomy for pneumo- and/or hemothorax complicating blunt or penetrating thoracic trauma in an attempt to assess the efficacy of prophylactic antibiotic therapy. Fifty-eight patients were included in the study. The control group (Group I) included 28 patients who received no antibiotic therapy: the experimental group (Group II) included 30 patients who received cefoxitin (1.0 gm IV q 6 h) commencing before tube thoracostomy and terminating 12 hours after its removal. The incidence of infectious complications (pneumonia and/or empyema) was recorded. Among the patients not receiving antibiotics, eight of 28 (29%) developed infectious chest complications. Of the patients receiving antibiotics, there was one infectious complication (3%). This difference is statistically significant (p = 0.0227). Cultures demonstrated significant conversion from negative to positive both within each group and between groups. The organism most commonly recovered was S. aureus. Our findings strongly suggest that patients requiring tube thoracostomy for trauma, whether blunt or penetrating, should receive the benefit of systemic prophylactic antibiotic therapy.

Adolescent↗
PubMed1981

Medially deployed thoracostomy tubes: cause of aortic obstruction in newborns.

It was observed that severe aortic displacement, narrowing, and obstruction can occur when thoracostomy tubes abut the mediastinum. To further investigate this previously undescribed phenomenon, aortography was performed with intraluminal pressure measurements in newborn puppies and aortograms obtained in two infant cadavers. In the puppies, when the tube tip pressed against the descending thoracic aorta, aortic pressure below that site decreased and aortic arch pressure rose. When the tube tip pressed against the ascending aorta, pressures in the aortic arch and abdominal aorta decreased. Aortography in the puppies and infant cadavers demonstrated aortic displacement, narrowing, and obstruction when the thoracostomy tubes abutted the mediastinum. The clinical consequences of malpositioned thoracostomy tubes were observed in two premature infants. When the posteromedially deployed tubes were partially withdrawn, systolic arterial pressures, which had been exceptionally low, suddenly and significantly increased distal to the tube tip. Medially deployed thoracostomy tubes may represent a potential hazard to the newborn infant.

Animals↗
PubMed1983

CT and radiographic assessment of tube thoracostomy.

Conventional chest radiography and computed tomography (CT) were used to evaluate tube thoracostomy drainage of pleural empyema in 26 selected patients. Frontal radiographs alone were inadequate in the evaluation of thoracostomy tube placement, as only one of 21 malpositioned tubes was identified; however, when lateral radiographs were also obtained, eight of nine malpositioned tubes were identified. Suboptimal drainage due to malpositioning was demonstrated best by CT in all 21 cases. Prolongation of hospitalization, serious complications, and death correlated with failure of early tube thoracostomy drainage as demonstrated by CT. Routine frontal and lateral chest radiographs are recommended for all patients after thoracostomy tube placement for empyema. For selected patients with empyema, early use of CT to guide tube repositioning or thoracotomy may reduce morbidity and mortality and decrease hospital costs.

Drainage↗
PubMed1978

Tube thoracostomy.

Every primary care physician should be familiar with three methods of draining fluid or air from the pleural cavity. These methods are: (1) the insertion of a needle or Intracath catheter into the pleural space; (2) a tube thoracostomy using a Trocar catheter; and (3) a tube thoracostomy using a large intercostal tube. Complete anesthesia can be obtained with lidocaine, remembering that the intercostal nerve runs on the undersurface of the rib above. The Intracath catheter for removal of air is inserted in the second interspace anteriorally. The tube thoracostomy, using the Trocar catheter, is best done through the fourth interspace in the anterior axillary line but can be done wherever the exploratory needle shows the major fluid and air collection to be. The tube thoracostomy, using a large intercostal tube, is best done through the fourth intercostal space at the anterior axillary line. The intercostal catheter or tube should be fixed to the chest wall with sutures and then led to an underwater seal for collection of the contents of the pleural cavity.

Anesthesia, Local↗
PubMed1989

Empyema thoracis in patients undergoing emergent closed tube thoracostomy for thoracic trauma.

The vast majority of thoracic trauma victims require only observation or tube thoracostomy for definitive treatment of their thoracic injury. Although tube thoracostomy is generally considered a limited intervention, 2 to 25 percent of patients who undergo this procedure develop infectious complications. To determine the incidence and risk factors for the development of empyema thoracis after tube thoracostomy, a retrospective study was undertaken. We found that the development of empyema thoracis was increased in patients whose pleural space was incompletely drained and whose thoracic catheters were in place for a prolonged period.

Adolescent↗
PubMed1999

Advantages of surgical closure of patent ductus arteriosus without tube thoracostomy.

Between June 1994 and June 1995, 30 patients aged 6 months to 21 years (mean age, 6.38 years) underwent surgical closure of patent ductus arteriosus without tube thoracostomy. Comparison of surgical results with the results of 143 previous consecutive cases of patent ductus arteriosus performed with the conventional technique using chest tube thoracostomy revealed a statistically significant difference in postoperative temperature, need for narcotics, hospital stay and certain complications such as pneumothorax. There was no mortality and late results were excellent. It is concluded that patent ductus arteriosus closure without tube thoracostomy is feasible and can be safe, more comfortable and more cost effective than the standard procedure.

Adolescent↗
PubMed2002

A thoracostomy tube guideline improves management efficiency in trauma patients.

BACKGROUND: Thoracostomy tube (TT) placement constitutes primary treatment for traumatic hemopneumothorax. Practice patterns vary widely, and criteria for management and removal remain poorly defined. In this cohort study, we examined the impact of implementation of a practice guideline (PG) on improving management efficiency of thoracostomy tube. METHODS: We developed a PG aimed at standardizing the management of TTs in critically ill patients admitted to a Level I trauma center. During the 9-month period before (Pre-PG) and 3 months after (Post-PG) implementation, practice parameters including prophylactic antibiotics, duration of TT therapy, preremoval chest radiographs with associated charges, and complications were evaluated. Differences between groups were assessed by Mann-Whitney rank sum and chi(2) with Yates correction. RESULTS: There were 61 patients, 14 in the Pre-PG group and 47 in the Post-PG group. The groups were matched in age and Injury Severity Scores. The Post-PG cohort averaged 3 fewer days of TT therapy. After implementation of the PG, 21 patients did not have preremoval chest radiography, representing a $3000 reduction in radiology fees. Complication rates (retained pneumothorax, hemothorax, and empyema) were not different between the two groups. CONCLUSION: Implementation of a thoracostomy tube practice guideline was associated with improved management efficiency in trauma patients.

Adolescent↗
PubMed2004

Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia--a multi-center trial.

OBJECTIVE: To determine whether presumptive antibiotics reduce the risk of empyema or pneumonia following tube thoracostomy for traumatic hemopneumothorax. METHODS: A prospective, randomized, double-blind trial was performed comparing the use of cefazolin for duration of tube thoracostomy placement (Group A) versus 24 hours (Group B) versus placebo (Group C). RESULTS: A total of 224 patients received 229 tube thoracostomies. Logistic regression analysis revealed that duration of tube placement and thoracic acute injury score were predictive of empyema (p <0.05). Empyema tended to occur more frequently in patients with penetrating injuries (p=0.09). chi analysis showed pneumonia occurred significantly more frequently in blunt than penetrating injuries (p <0.05). Presumptive antibiotic use did not significantly effect the incidence of empyema or pneumonia, although no empyemas occurred in Group A. CONCLUSIONS: The incidence of empyema was low and the use of presumptive antibiotics did not appear to reduce the risk of empyema or pneumonia.

Adolescent↗