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A self-retaining chest drainage tube together with a special introducing trocar and cannula is described. The tube has been designed to overcome the disadvantages of existing conventional chest drainage tubes.
OBJECTIVE: We sought to determine the current practice habits among clinicians treating spontaneous pneumothorax and bronchopleural fistula. METHODS: Practice habits were determined by a randomized postal survey of 3,000 American College of Chest Physicians members. Group comparisons are performed by chi2 analysis with p<0.05 being significant. RESULTS: Four hundred nine respondents (13.6%) included 176 practicing pulmonologists (43.0%), 67 academic pulmonologists (16.4%), 102 thoracic surgeons (25.0%), and 64 others (15.6%). More than 50% of respondents treat a first small primary spontaneous pneumothorax (PSP) by simple observation, a first small secondary spontaneous pneumothorax (SSP) by chest tube, persistent air leak in both PSP and SSP with chest tube+video-assisted thoracoscopy, and use a 20 to 24F chest tube in mechanically ventilated ARDS-related tension pneumothorax. First recurrences of PSP and SSP were treated by a variety of interventions that included simple observation (PSP=14%, SSP=4%), chest tube (22%/17%), chest tube+sclerosis (20%/16%), chest tube+video-assisted thoracoscopy (36%/48%), and chest tube+thoracotomy (5%/12%). The most popular sclerosing agents are doxycycline (48%), talc slurry (24%), and talc poudrage (19%). More than 75% of physicians intervened in a persistent air leak between 5 and 10 days. Chest tubes are initially placed to suction by 48% of respondents in PSP and removed >24 h after air leak ceases in 79%. Chest tube clamping prior to removal is employed by 67% of respondents. Significant differences exist between thoracic surgeons and pulmonologists with surgeons placing more chest tubes for first-time PSP and performing chest tube+video-assisted thoracoscopy for first recurrences of PSP more often than pulmonologists. Thoracic surgeons seldom use sclerosis in spontaneous pneumothorax compared to pulmonologists. CONCLUSIONS: Marked practice variation exists in clinicians' approaches to the management of spontaneous pneumothorax and bronchopleural fistulas that is partially explained by differences between pulmonologists and thoracic surgeons. A national consensus statement is needed to guide randomized studies in pneumothorax management.
BACKGROUND: The optimal method for removal of chest tubes has not been determined and opinion remains divided. The purpose of this study was to determine the difference between two algorithms for the removal of chest tubes: one with continuous negative intrathoracic pressure (suction group) and the other with a trial of water seal (water-seal group). STUDY DESIGN: This study was a prospective randomized trial of 80 trauma patients requiring tube thoracostomies. RESULTS: Both methods of chest tube removal had similar incidences of recurrent pneumothorax (2.5 percent). The suction group had a shorter total chest tube time (72.2 hours versus 92.5 hours, p = 0.013) and shorter time required to remove the chest tube following air leak resolution (25.2 hours versus 35.6 hours, p = 0.034). Additionally, there were more patients requiring prolonged (greater than 36 hours) removal times in the water-seal group (p = 0.009). CONCLUSIONS: Both suction and water-seal methods for chest tube removal are effective and have similar incidences of recurrent pneumothorax. The use of the suction algorithm significantly decreased both chest tube duration and the time taken for chest tube removal. In patients hospitalized for isolated pneumo- or hemothorax, the use of the suction algorithm potentially could lead to shorter length of stay.
STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.
Pneumothorax in the ED most often will be primary and spontaneous in a young person who may be treated with either chest tube, mini-chest tube, or aspiration of pneumothorax according to local preference. The other large group of pneumothoraces will be spontaneous but secondary to a disease process, procedure, or drug abuse. The treatment of these must be individualized because conservative measures may not work and the underlying process may require attention as well. Although gaining in popularity, the use of devices or procedures other than formal chest tubes is still not general practice. The major complication of pneumothorax is tension pneumothorax, which is rapidly fatal and must be excluded immediately in all patients regardless of the etiology. Treatment of this complication must be carried out without delay for further diagnostic studies by venting the chest. The significance of pleural effusion depends on its volume and composition. If the cause is not known with certainty or if the patient is dyspneic, thoracentesis should be performed. The fluid is sent for numerous tests including specific gravity, pH, glucose, LDH, and protein. On this basis it is determined as either transudate, which tends to be associated with more benign disorders, or exudate, which is seen with infection, malignancy, and numerous other processes. In all cases the underlying disease requires therapy but only certain exudates require aggressive treatment primarily. Many parapneumonic effusions and all empyemas are exudates that require tube thoracostomy.
A variety of published techniques for the production of concentrated fibrinogen from units of screened single-donor human plasma have led to increasing clinical use of fibrin glue in the United States. We have adapted a method of applying this material with a disposable plastic sprayer. In 20 consecutively treated patients, fibrin glue was sprayed on the anterior mediastinum before closure of the median sternotomy incision. A control group of 20 patients undergoing the identical cardiac operations (13 coronary artery bypass grafting procedures [CABG], 4 valve replacements [including 1 reoperative procedure], and 3 combined valve replacements and CABG) by the same surgeon within a one-year period was chosen for comparison of chest tube outputs. Specifically, chest tube outputs were as follows for treated and untreated patients, respectively: at 12 hours, 461 +/- 40 ml (mean +/- 1 standard error of the mean versus 731 +/- 80 ml; at 24 hours, 714 +/- 73 ml versus 1,016 +/- 109 ml; and at 48 hours, 863 +/- 93 ml versus 1,187 +/- 137 ml. The differences between control and spray chest tube output are statistically significant by unpaired t test (p less than 0.05) at both 12 and 24 hours. Thus, this method can reduce perioperative hemorrhage from the anterior mediastinum after cardiac operations.
BACKGROUND: Little is known about the incidence of and associated management outcomes of occult hemothorax in blunt trauma patients. The increased use of computed thoracic tomography for the evaluation of the multiply injured blunt trauma patient has led to an increase in the identification of these hemothoraces and management dilemmas. METHODS: A retrospective review of blunt trauma patients with occult hemothoraces was performed. Patients were divided into 2 groups: chest tube versus no chest tube. Outcomes and complications for the 2 groups were defined. Data included demographics, Injury Severity Score, length of stay, need for mechanical ventilation and thoracic consult, pneumonia, and empyema. The size of the occult hemothorax was measured on the computed thoracic tomography. RESULTS: Eighty-eight patients (21.4%) had a total of 107 occult hemothoraces. Patients in the chest tube group were more likely to have a higher Injury Severity Score and an associated occult pneumothorax and to have smaller hemothoraces. CONCLUSIONS: Occult pneumothoraces occur in a significant proportion of the multiply injured blunt trauma population. Small, isolated, occult hemothoraces can be managed safely in the stable patient.
PURPOSE: The necessity of a postoperative chest tube for the treatment of pneumothorax after a radical nephrectomy is controversial. MATERIALS AND METHODS: A five-year retrospective study was performed on 91 patients, having undergone a radical nephrectomy. We examined the existence and length of a pleural rent, presence of a postoperative thoracostomy tube, postoperative pneumothorax, postoperative pneumonia, postoperative atelectasis, pain scores, hemoglobin saturation, and length of hospital stay with univariate and multivariate analysis. RESULTS: Incidence of a pleural rent occurred in 29 (36%) of open radical nephrectomy cases; 4 of the 29 cases had a postoperative thoracostomy tube. There was no significant difference in hemoglobin saturation levels between cases that had no pleural rent, a pleural rent without a thoracostomy tube, and a pleural rent with a postoperative thoracostomy tube. A pleural rent without a postoperative chest tube had significantly lower rates of pain score, atelectasis, pneumonia, pleural effusion, and length of hospital stay compared to individuals with a postoperative chest tube. Patients with a chest tube had a significantly higher incidence of pain, atelectasis, pneumonia, effusion, and length of hospital stay. CONCLUSION: Iatrogenic pleural rents treated without a postoperative chest tube show a significant decrease in postoperative complications of pneumonia and atelectasis, pain score and length of hospital stay. These patients show no significant increases in postoperative complications; therefore, it appears that postoperative chest tube placement after a pleural injury occurs is of no advantage.
PURPOSE: The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children. METHODS: The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies. RESULTS: Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P =.003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P =.055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement. CONCLUSIONS: Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.
BACKGROUND: Pleurodesis for end-of-life care has been used in adults for decades, but little is known about the usefulness of this technique in improving the quality of care for pediatric patients. OBJECTIVE: To assess whether intractable pleural effusions in pediatric oncology patients at end of life could be sufficiently relieved by pleurodesis. MATERIAL AND METHODS: Eleven pleurodeses were performed with doxycycline in seven pediatric cancer patients (age 3-21 years) with intractable pleural effusions at the end of life. Five patients had unilateral pleurodeses and two had a unilateral followed by bilateral pleurodeses. RESULTS: Respiratory rates decreased in all seven patients (P = 0.016) and aeration improved significantly after chest tube placement (P = 0.033). The chest tubes were placed a median of 1 day before pleurodesis. Eight of nine chest tubes (89%) were removed before discharge at a median of 3 days after pleurodesis. Pain secondary to the pleurodesis lasted 1 day or less. Improvement in the respiratory rate remained after pleurodesis and chest tube removal (P = 0.031). Five of seven patients (70%) were able to leave the hospital to return home. The five patients discharged lived 10 to 49 days (median 19 days) after discharge. CONCLUSION: Pediatric oncology patients with intractable effusions at end of life can have respiratory benefit from pleurodeses and, as a result, are more likely to return home for terminal care.
The practice of using conventional mediastinal chest tubes (MCTs) connected to a closed collection device is commonplace in cardiovascular surgery care settings. The MCT collection device requires a closed system to maintain a negative intrathoracic pressure with the goal of preventing inadvertent trapping of air and blood within the mediastinal space. Despite the proposed integrity of the closed system, there is no guarantee that the suction's negative pressure will prevent cardiac tamponade. In addition, it has been postulated that the required negative intrathoracic suction may potentiate mediastinal tissue damage. This clinical paper will describe the use of multi-lumen MCTs open to atmosphere following surgical repair for congenital heart defects. It is postulated that open MCTs may potentially reduce the risks of cardiac tamponade and mediastinal tissue damage. Through case presentation, the mechanics of open MCTs, nursing care, and possible complications will be delineated.
OBJECTIVES: Despite continued improvement in medical therapy, pediatric empyema remains a challenging problem for the surgeon. Multiple treatment options are available; however, the optimal therapeutic management has not been elucidated. The aim of this study is to assess different treatment options in the management of postpneumonic pediatric empyemas. METHODS: A retrospective review was performed of pediatric patients admitted to Dicle University School of Medicine Thoracic and Cardiovascular Surgery Department between 1990 and 2002, with the diagnosis of empyema. Data tabulated included patient demographics, presentation, treatment and outcome. RESULTS: There were 515 children (289 boys and 226 girls) with a mean age of 4.7 ranging from 18 days to 15 years. Empyema was secondary to pneumonia in all children. The most common radiologic finding was pleural effusion in 285 patients (55.32%). Staphylococcus aureus was the most frequently encountered organism and found in 105 patients (20.38%). Pleural fluid cultures were negative in 195 patients (37.86%). In addition to antibiotic therapy, initial treatment included serial thoracenthesis (n = 29), chest tube drainage alone (n = 214), chest tube drainage with intrapleural fibrinolytic therapy (n = 72), chest tube drainage with primary operation (n = 191), and primary operation without chest tube drainage (n = 9). Overall response rate with fibrinolytic treatment (complete and partial response) was obtained in 58 patients. In addition to decortication pulmonary resections were performed in 12 patients. Overall mortality rate was 1.55%. There was no operative mortality. Postoperative morbidity included wound infection in 21, delayed expansion in 8, and atelectasis in 35 patients. CONCLUSIONS: Multiple therapeutic options are available for the management of pediatric empyema. Depending on stages, every option has a role in the treatment of postpneumonic pediatric empyema. In the absence of bronchopleural fistula, intrapleural fibrinolytic treatment should be tried in all patients with multiloculations in stage II empyema. In the absence of pneumonia, decortication for empyema is a safe approach with low mortality and morbidity rates.
BACKGROUND: Despite continued improvement in medical therapy, empyema remains a challenging problem for the surgeon. Multiple treatment options are available; however, the optimal therapeutic management has not been elucidated. METHODS: A retrospective review was performed of all adult patients admitted to Denver Health Medical Center between January 1, 1993, and December 31, 1998, with the diagnosis of empyema. Data tabulated included patient demographics, presentation, chest computed tomography (CT) findings, treatment, and outcome. RESULTS: Empyema was diagnosed in 58 patients, 45 cases of which were multiloculated at the time of presentation. Empyema was secondary to pneumonia is 41 patients and posttraumatic in 15. In addition to antibiotic therapy, initial treatment included chest tube drainage alone (n = 6), chest tube drainage with primary operation (n = 19), and chest tube drainage with intrapleural fibrinolytic therapy (n = 33). In 15 patients (45%), fibrinolytic therapy failed. Initial chest CT revealed a pleural peel in 5 patients treated with fibrinolytics and all failed. Multiloculation, however, was not a factor in failure of fibrinolysis. Moreover, chest CT missed the presence of a pleural peel in 17 of 31 patients documented to have a significant peel at the time of thoracotomy. CONCLUSION: Multiple therapeutic options are available for the management of empyema. Multiloculation is not a contraindication to an initial trial of chest tube drainage or fibrinolytic therapy. In contrast, CT evidence of a pleural peel uniformly predicted failure of nonoperative treatment.
Spontaneous pneumothorax (SP) continues to be a frequent management problem. The lack of universally accepted management guidelines and a myriad of treatment options contribute to the current heterogeneous approach to SP. Forthcoming guidelines may improve management. Meantime, simple observation in stable patients with a primary spontaneous pneumothorax (PSP) is reasonable, and encouraging smoking cessation is paramount. More aggressive management of a patient with a secondary spontaneous pneumothorax (SSP) is advisable and should include at least chest tube drainage with chest tube size selection key. Careful assessment of recurrence risk and early corrective intervention for patients with a persistent air leak will improve care of both PSP and SSP patients. If chest tube-directed pleurodesis is chosen for recurrence prevention, talc is the most successful agent available. However, no more than 5 g of talc should be utilized, given the potential increased risk for acute respiratory failure at higher doses, and patients should be advised of alternatives such as doxycycline. No overwhelming clinical outcome advantages for a thoracoscopic over a limited thoracotomy approach to SP management has been reported in any randomized controlled trial. Institutional experience with and the availability of thoracoscopy or limited thoracotomy should dictate the operative approach to SP recurrence prevention and air leak correction until further study clarifies the choice.
BACKGROUND: Persistent air leak after operation on the lung is one of the most common problems encountered by thoracic surgeons. We present 6 patients who underwent pleurodesis with autologous blood for persistent air leak after operation. METHODS: Between June 1993 and January 1998, pleurodesis with autologous blood was performed in 6 patients who had air leak of more than 10 days' duration after operation for non-small cell lung cancer. A sample of peripheral blood was taken from the patient's arm and immediately introduced into the chest tube with no additives. The chest tube was left unclamped and off suction, connected to the waterseal drainage, and kept 60 cm above the patient's chest. The next day, the waterseal and chest roentgenogram were reviewed before the chest tube was removed. RESULTS: A persistent air leak with a mean duration of 16.7 days was observed after the initial operation. Fifty to 250 mL of blood was introduced one time into the chest tube. No patient experienced pain, respiratory difficulty, fever, or episodes of coughing during the procedure. After 24 hours, no air leak was detected in the waterseal drainage in any patient. CONCLUSIONS: On the basis of these preliminary findings, we believe pleurodesis with autologous blood is a safe and effective method for treating persistent air leak after a thoracic surgical procedure.
We prospectively analyzed the surgical results in chronic organizing empyema thoracis utilizing a video-assisted thoracoscopic technique, particularly in debilitated patients. From January 1999 to September 2000, ten patients with stage III empyema thoracis underwent video-assisted thoracoscopic surgery for decortication (VATD). The mean age of the patients was 53.2 years, and they included one female and nine male patients. Four patients were regarded as not suitable for open thoracotomy. After the procedure, all patients had one infusion tube and two 32-F chest tubes inserted, the former for irrigation with saline solution and the latter for drainage. The mean operation time was 178 min. There was no mortality. The mean time to remove the infusion tube was 3.3 days. The mean time to remove the first chest tube was 7.1 days and the second chest tube 9.7 days. The mean hospitalization time after the operation was 14.9 days. The mean follow-up was 14.9 months. A restoration of lung function was ascertained in nine patients, with a 17.6% mean increase in forced vital capacity. There was no recurrence of empyema during the follow-up. Nevertheless, a reaccumulation of pleural effusion occurred in one patient 1 month after the procedure, which thus necessitated further treatment. VATD is considered to be a feasible surgical modality for the treatment of stage III empyema thoracis in selected patients.
OBJECTIVE: To assess the degree of correlation and agreement between cardiac output by thermodilution and bioimpedance using the BoMed NCCOM3-R7 monitor in postaortocoronary bypass patients. DESIGN: Prospective, randomized sampling. SETTING: Military teaching hospital intensive care unit. PATIENTS: Fifty patients undergoing coronary artery bypass surgery with thermodilution pulmonary artery catheters in place. Simultaneous determination of cardiac output by thermodilution and thoracic bioimpedance was performed. Readings were taken between 8 and 24 hrs after surgery. Forty patients were intubated; 19 patients had left-sided tube thoracotomy in addition to two mediastinal tubes, and 19 patients were obese. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall degree of correlation between the two measures was fair (r2 = .24). The bias and precision measurements were inaccurate as well (-0.33 +/- 3.14). Patients with normal body habitus or who were not receiving mechanical ventilation showed the best correlation (r2 = .40 and r2 = .45, respectively). Only 62% (31/50) of all patients had simultaneous measurements fall within 20% of each other, and there were no clinical features that made identification of those patients possible. CONCLUSIONS: Use of the BoMed NCCOM3-R7 bioimpedance monitor as a replacement for thermodilution-derived cardiac output cannot be recommended in postaortocoronary bypass patients. The distortions of patients' normal anatomy and physiology, coupled with the presence of endotracheal tubes and mechanical ventilation, mediastinal tubes and chest tubes, result in only fair correlation, significant bias, and poor precision between the two measures of cardiac output.
The goal of this study was to evaluate the efficacy of simple aspiration of air from the pleural space to prevent increased pneumothorax and avoid chest tube placement in cases of pneumothorax following interventional radiological procedures performed under computed tomography fluoroscopic guidance with the transthoracic percutaneous approach. While still on the scanner table, 102 cases underwent percutaneous manual aspiration of a moderate or large pneumothorax that had developed during mediastinal, lung, and transthoracic liver biopsies and ablations of lung and hepatic tumors (independent of symptoms). Air was aspirated from the pleural space by an 18- or 20-gauge intravenous catheter attached to a three-way stopcock and 20- or 50-mL syringe. We evaluated the management of each such case during and after manual aspiration. In 87 of the 102 patients (85.3%), the pneumothorax had resolved completely on follow-up chest radiographs without chest tube placement, but chest tube placement was required in 15 patients. Requirement of chest tube insertion significantly increased in parallel with the increased volume of aspirated air. When receiver-operating characteristic curves were applied retrospectively, the optimal cutoff level of aspirated air on which to base a decision to abandon manual aspiration alone and resort to chest tube placement was 670 mL. Percutaneous manual aspiration of the pneumothorax performed immediately after the procedure might prevent progressive pneumothorax and eliminate the need for chest tube placement. However, when the amount of aspirated air is large (such as more than 670 mL), chest tube placement should be considered.