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PubMed1985

"Balanced" thoracic drainage is the method of choice to control intrathoracic pressure following repair of diaphragmatic hernia.

Respiratory failure from pulmonary hypoplasia continues to be the major cause of death in newborn infants with diaphragmatic hernia. Recent investigations have suggested that postnatally induced pulmonary injury can result from excessive positive or negative intrathoracic pressure and contribute to the respiratory deterioration. Therefore, the method of thoracic drainage on the side of the diaphragmatic hernia is critical in controlling and maintaining normal intrathoracic pressure in both intrathoracic spaces. No chest tube or an ipsilateral chest tube connected to water seal, can result in either excessive negative or positive intrathoracic pressure and, therefore, both methods should be avoided. Recently, we employed a "balanced" intrathoracic drainage system which maintains the ipsilateral intrathoracic pressure within the normal physiologic range of +2 to -8 cm H2O regardless of the degree of pulmonary hypoplasia, presence of an ipsilateral pulmonary air leak, straining by the infant, or mechanical ventilation. This system is simple, requires no suction apparatus, and is easily assembled with equipment readily available within the hospital. This technique has been utilized in 18 newborn infants with diaphragmatic hernia and pulmonary hypoplasia. There have been no complications which specifically could be related to the balanced drainage system.

Drainage↗
PubMed1998

A comparison of demand-valve and bag-valve ventilations in a swine pneumothorax model.

OBJECTIVE: Two means of delivering artificial ventilation readily available to out-of-hospital personnel are the bag-valve (BV) and the O2-powered demand-valve (OPDV). However, use of the OPDV has been limited because of concerns that it may worsen an underlying pneumothorax. This study compared the changes in size of pneumothorax in swine ventilated with the 2 devices. METHODS: Three swine were anesthetized, intubated, and instrumented with a femoral arterial line and a pediatric Swan-Ganz catheter. A chest tube was placed, the chest was opened, and the lung parenchyma was visualized. The lung was disrupted by a single stab with a #10 scalpel; the chest was then sealed; and a pneumothorax was created by injecting 30 mL of air through the chest tube. The animals were ventilated by 12 emergency medical technicians using either BV or OPDV. After 10 minutes of ventilation, the pneumothorax volume was measured. RESULTS: When comparing final pneumothorax volumes after 10 minutes of ventilation with the 2 devices, there was no significant difference (mean +/- SD = 40.8 +/- 28.2 mL vs 52.3 +/- 23.1 mL, p = 0.286). CONCLUSION: There is no difference in final pneumothorax volumes after OPDV or BV ventilation.

Animals↗
PubMed2006

Current technique for resection of mediastinal goiter.

We have developed a combined surgical technique involving traction sutures, the harmonic scalpel, and laryngeal nerve monitoring for the removal of mediastinal goiters. This technique is safe, expeditious, and effective; it minimizes the risk of blood loss or nerve injury; and it obviates the need for sternotomy. During a 4-year period, we performed this operation on 21 patients. We observed only two complications: one patient developed postoperative seroma 1 week after surgery and another experienced vocal fold paralysis after intentional sacrifice of the recurrent laryngeal nerve, which was encompassed by cancer. No other recurrent laryngeal nerve was injured. Operative blood loss was negligible, no systemic infection or permanent hypoparathyroidism was observed, and no patient required a chest tube or chest incision. Almost all patients were discharged home on postoperative day 1.

Aged↗
PubMed2002

Suction vs water seal after pulmonary resection: a randomized prospective study.

STUDY OBJECTIVE: To evaluate whether suction or water seal is superior in the management of chest tubes after pulmonary resection. DESIGN: A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or - 20 cm H(2)O suction. SETTING: University hospital. PATIENTS: Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded. RESULTS: There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean +/- SEM, 1.50 +/- 0.32 days vs 3.27 +/- 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 +/- 0.35 days in the water seal group and 5.47 +/- 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively). CONCLUSION: Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.

Aged↗
PubMed2000

Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter.

BACKGROUND: Previous studies have shown that a chronic indwelling pleural catheter (PC) safely and effectively relieved dyspnea, maintained quality of life, and reduced hospitalization in patients with malignant pleural effusions. Outpatient management of malignant pleural effusion with a PC may reduce length of stay and early (7-day) charges compared with inpatient management with chest tube and sclerosis. METHODS: A retrospective review of consecutive PC patients (n = 100; 60 outpatient, 40 inpatient) were treated from July 1, 1994 to September 2, 1998 and compared with 68 consecutive inpatients treated with chest tube and sclerosis between January 1, 1994 and December 31, 1997. Hospital charges were obtained from date of insertion (day 0) through day 7. RESULTS: Demographics were similar in both groups. Pretreatment cytology was positive in 126 of 168 patients (75%), negative in 21 (12.5%), and unknown in 21 (12.5%). Primary histology included lung (n = 61, 36%), breast (n = 39, 23%), lymphoma (n = 12, 7%), or other (n = 56, 34%). Median survival was 3.4 months and did not differ significantly between treatment groups. Overall median length of stay was 7.0 days for inpatient chest tube and inpatient PC versus 0.0 days for outpatient Pleurx. No mortality occurred related to the PC. Eighty-one percent (81/100) of PC patients had no complications. One or more complications occurred in 19 patients (19%). Patients treated with outpatient PC (n = 60) had early (7-day) mean charges of $3,391 +/- $1,753 compared with inpatient PC (n = 40, $11,188 +/- $7,964) or inpatient chest tube (n = 68, $7,830 +/- $4,497, SD) (p < 0.001). CONCLUSIONS: Outpatient PC may be used effectively and safely to treat malignant pleural effusions. Hospitalization is not required in selected patients. Early (7-day) charges for malignant pleural effusion are reduced in outpatient PC patients compared with inpatient PC patients or chest tube plus sclerosis patients.

Aged↗
PubMed1994

Localized tension pneumothorax in patients with adult respiratory distress syndrome.

Tension pneumothorax as a complication of ventilatory support may cause severe cardiac problems. The diagnosis may be difficult. Risk factors predisposing to the misdiagnosis of this condition include atypical location of the pneumothorax. Three patients with adult respiratory distress syndrome who had atypical, localized tension pneumothorax are described. Each had an ipsilateral functioning chest tube in place at the time. Placement of chest tubes into the localized pneumothoraces resulted in immediate improvement in hemodynamic status in two patients, but the third patient died before the chest tube could be placed. A diagnosis of tension pneumothorax should be considered in any patient on a ventilator whose hemodynamic status deteriorates in the presence of high airway pressures. In patients with adult respiratory distress syndrome the pneumothorax can remain localized because the heavy, noncompliant lungs cannot collapse enough for air to dissect diffusely through the pleural space; pleural adhesions may also contribute to this phenomenon.

Adult↗
PubMed2002

Surgical versus non-surgical management of pleural empyema.

BACKGROUND: Pleural empyema is a collection of pus between the lungs and the chest wall. Approximately 50% of cases complicate pneumonia. There are a variety of treatment options ranging from intravenous antibiotics alone to open thoracotomy and debridement, depending in part on the stage of the empyema and the severity. The condition changes with time, becoming loculated and more difficult to drain. There is much debate about the most appropriate therapy particularly with the advent of new treatments such as fibrinolytic enzymes (e.g. streptokinase, urokinase) and video-assisted thoracoscopic surgery (VATS). OBJECTIVES: To determine which is more effective for the management of empyema: surgical (e.g. thoracoscopy, thoracotomy) or non-surgical techniques (e.g. thoracocentesis, chest tube drainage) and to establish whether there is an optimum time for intervention. SEARCH STRATEGY: The Cochrane Controlled Trials Register and DARE database were searched in addition to the Cochrane Acute Respiratory Infections Group's own register of trials. A specialised topic search with no language restrictions was used to search MEDLINE and EMBASE using Silverplatter. Bibliographies and the reference lists of identified studies and review articles were handsearched. Personal communication with authors and experts in the field is ongoing. SELECTION CRITERIA: Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded. DATA COLLECTION AND ANALYSIS: Trial quality was assessed using Jadad criteria as recommended by the ARI group (Jadad 1996). The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed length of time chest tubes were required, pain, hospital stay and any complications. MAIN RESULTS: Only one small randomised study was identified which met the inclusion criteria. It was conducted in a university thoracic surgery department. There were some methodological quality considerations which cast some doubt on validity ( patient selection, unclear allocation concealment and outcome assessor blinding) and it scored 'B' overall (Jadad score 3). The main results of the study were that when compared with chest tube drainage combined with streptokinase, the video-assisted thoracoscopic surgery (VATS) group had a significantly higher primary treatment success and spent less time in hospital. Each group suffered one mortality. REVIEWER'S CONCLUSIONS: It would appear that for large, loculated pleural empyemas VATS is superior to chest tube drainage with streptokinase in terms of duration of chest tubes and hospital stay. However there are questions about validity and the study is also too small to draw conclusions. There are risks of complications (associated with all treatments) which may not apparent with small numbers. VATS is performed under general anaesthetic and one lung ventilation. Fibrinolytics are also associated with side effects. Further larger multicentre studies need to be conducted.

Chest Tubes↗
PubMed2003

Patient positioning after fine needle lung biopsy-effect on pneumothorax rate.

PURPOSE: To evaluate the efficacy of precautionary positioning in preventing the development of pneumothorax and reducing the rate of chest tube placement after fluoroscopy-guided transthoracic needle biopsy (TTNB). MATERIAL AND METHODS: One hundred and seven patients who underwent TTNB were randomly assigned to one of two postbiopsy treatment groups: patients were placed with (precautionary positioning group) and without (non-precautionary positioning group) recumbent puncture site either down (n = 59 and 48, respectively) for at least 30 min. RESULTS: The overall pneumothorax rate was 8.4% (n = 9). Four of the 9 patients needed chest tube insertion. Pneumothorax rate was 8.33% (4/48) and 8.47% (5/59) in the precaution and non-precaution groups, respectively. Rate of chest tube insertion was 6.25% (n = 3) and 1.85% (n = 1) in the precaution and non-precaution groups, respectively. There was no statistically significant difference in the rate of pneumothorax and chest tube insertion between the two groups. CONCLUSION: Precautionary positioning after TTNB does not reduce the incidence of postbiopsy pneumothorax and rate of chest tube insertion.

Adolescent↗
PubMed2004

Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema.

BACKGROUND: The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay. METHODS: A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant. RESULTS: Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the "nonsurgery groups" (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the "surgery groups" (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery. CONCLUSIONS: Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.

Child↗
PubMed2006

Chest radiographs after removal of chest drains in neonates: clinical benefit or common practice?

BACKGROUND: Chest drain insertion is a common procedure in neonatal care. Routine radiography after removal of chest drains increases radiation exposure, handling and cost, but there are few data proving clinical benefit. OBJECTIVES: To review current practice and determine the yield of routinely obtained chest radiographs (CXR). METHODS: A retrospective chart review of all infants undergoing removal of chest tubes in a single tertiary neonatal unit in New Zealand between January 1998 and July 2004 was performed. RESULTS: In total, 119 infants were identified, from the database, to have a chest drainage performed. In 19 cases, the procedure was needle aspiration or the drain was removed outside of our unit, hence these were excluded. The remaining 100 patients with 110 episodes of chest drain removal after 174 chest tube insertions were analysed. In asymptomatic infants, routine radiography showed some reaccumulation of air in nine of 35 cases of pneumothorax or of fluid in two of the five cases of pleural effusion, but chest tube reinsertion was not required. In the 12 clinically symptomatic infants, chest tubes were reinserted in five cases (four reaccumulations of pneumothorax and one pleural effusion), and one infant had symptomatic right upper lobe collapse. In the remaining infants, there were no abnormalities on CXR accounting for deterioration. CONCLUSIONS: Given the low yield for routine radiography after chest drain removal, we suggest that close observation is likely to detect clinically relevant recurrence of pneumothorax.

Chest Tubes↗
PubMed1999

The utility of daily therapeutic thoracentesis for the treatment of early empyema.

STUDY OBJECTIVES: To determine if therapeutic thoracentesis is as effective as early chest tube placement or no drainage procedure in the treatment of early empyema in rabbits. DESIGN AND INTERVENTIONS: An empyema, as evidenced by gross pleural pus and a decreased pleural fluid pH and glucose level, was induced in 49 rabbits. The rabbits were divided into three groups: 16 underwent daily therapeutic thoracentesis starting at 48 h, 14 underwent chest tube placement at 48 h, and 19 served as controls. RESULTS: The mortality rate in the therapeutic thoracentesis group (0/16) did not differ significantly from that in the chest tube group (3/14) or that in the control group (6/19). At autopsy at 10 days, the gross empyema score in the therapeutic thoracentesis group (2.1 +/- 0.3) was significantly lower (p < 0.05) than that in the chest tube group (2. 8 +/- 0.3) or the control group (3.5 +/- 0.2). The mean pleural peel score of 5.8 +/- 1.1 in the therapeutic thoracentesis group was significantly less (p < 0.05) than the score for the nonintervention control group (13.4 +/- 1.6). CONCLUSIONS: From this study, we conclude that therapeutic thoracentesis is at least as effective as early chest tube placement for the treatment of early empyema using our rabbit model of empyema.

Animals↗
PubMed2005

Usefulness of the British Thoracic Society and the American College of Chest Physicians guidelines in predicting pleural drainage of non-purulent parapneumonic effusions.

AIM: To assess the value of the British Thoracic Society (BTS) and the American College of Chest Physicians (ACCP) guidelines to predict which patients with non-purulent parapneumonic effusions (PPE) warrant chest tube drainage. METHODS: A retrospective chart review was performed on all patients who underwent thoracentesis because of a PPE over a 10-year period at a Spanish medical center. Classification of PPE as complicated (CPPE) or uncomplicated (UPPE) was based on the clinician's decision to insert a chest tube to resolve the effusion. Empyema was defined as pus in the pleural space. Data collected included patient demographics, size of the effusion, and microbiological and pleural fluid chemistries that might influence the physician's decision to place a chest tube. RESULTS: Of the 240 patients with PPE who entered the study, 85 had UPPE, 67 had CPPE, and 88 had empyema. Individual pleural fluid parameters, namely a pH<7.20, a glucose<40 mg/dL or <60 mg/dL, a LDH>1000 U/L or a positive culture had a relatively high specificity (from 78% for LDH to 94% for glucose<40 mg/dL), but low to moderate sensitivity (from 25% for culture to 73% for LDH) in predicting the need for chest tube placement in non-purulent PPE. While pleural fluid cultures performed poorly in discriminating UPPE from CPPE (likelihood ratio positive 1.7), effusion's size performed the best (likelihood ratio positive 5.7). BTS and ACCP guidelines yielded measures of sensitivity (98% and 97%, respectively), and negative likelihood ratio (0.03 and 0.05, respectively) for identifying a CPPE. CONCLUSIONS: Both guidelines have similar accuracy and perform satisfactorily in distinguishing CPPE from UPPE, albeit at an admissible cost of needlessly increasing chest tube drainage.

Adult↗
PubMed1994

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.

BACKGROUND: A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions. METHODS: The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day. RESULTS: The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days). CONCLUSIONS: The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

Adult↗
PubMed2004

[Evaluation of postoperative pain relief after video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax].

BACKGROUND: We have investigated correlation between postoperative pain and chest tube insertion after video-assisted thoracoscopic surgery (VATS) for patients with spontaneous pneumothorax, and have evaluated preemptive analgesia by intercostal nerve block (ICB) using bupivacaine. METHODS: Thirty patients received VATS for spontaneous hemi-pneumothorax. There were two groups of the patients; Group CT received chest tube before the operation, and the Group NCT received no chest tube. Both groups received general anesthesia combined with ICB by 0.25% bupivacaine at the surgical region before operation. Postoperative pain was assessed using visual analogue scale (VAS scale: 0-10) and the need for additional supplemental analgesics before the operation, and at 6 and 24 hours after the operation, and at 3, 7, 14, and 30 days after the operation. RESULTS: Visual analogue scale in Group NCT before the operation, and at 24 hours, 3, 7, 14, and 30 days after the operation was significantly lower than that of Group CT. Analgesic requirements were significantly lower in the Group NCT than in the Group CT. CONCLUSIONS: We should avoid the insertion of a chest tube before the operation as much as possible. Furthermore early operation and intercostal nerve blockade before the operation were useful to prevent postoperative pain and its shift to chronic post thoracostomy pain.

Adolescent↗
PubMed1998

The value of routine posttracheostomy chest radiography.

OBJECTIVE: This study proposes to evaluate the efficacy of routine posttracheostomy chest radiography. DESIGN: A retrospective chart review provided the framework of this study. SETTING: The study took place at a university teaching hospital-level one trauma center. PATIENTS: The study included 293 patients undergoing elective tracheostomy between 1989 and 1993. MEASUREMENTS AND RESULTS: Data extracted from the charts included indication for tracheostomy, immediate preoperative and postoperative chest radiograph reports, management changes made secondarily to radiographic findings, including chest tube placement, institution of chest physiotherapy, and need for tracheal tube reposition. Complications were defined as findings not noted on the preoperative radiographs; these were pneumothorax, tube malposition, atelectasis, or clinical information resulting in management changes. All patients received postoperative chest radiographs in the trauma ICU. Statistical analysis of our data was carried out using the chi2 test. Patients with chest tubes in place at the time of surgery were the only group who were excluded so as not to confuse whether pneumothorax developed postoperatively. Of the initial 293 patients, 25 patients were excluded on the basis of having a chest tube. The remaining 268 charts were analyzed; 220 (82%) patients underwent tracheostomy for ventilator-dependent respiratory failure, 31 (12%) due to multiple facial fractures, 6 (2.1%) secondary to penetrating neck wounds, and 11 (4%) as a result of refractory vocal cord edema. One (0.3%) patient was found to have a postoperative 10% apical pneumothorax. Eight (2.4%) patients were found to have postoperative subsegmental atelectasis. There were no significant (p>0.05) management changes implemented as a result of these findings. No new infiltrates, effusions, or malpositioned tubes were noted. Deletion of routine posttracheostomy radiographs would save $52.39 per patient (cost) or $15,350 for 293 patients and $35,453 in total patient charges. CONCLUSIONS: Abnormalities revealed by routine chest radiography after tracheostomy did not appear to alter patient management frequently enough to warrant the costs. A randomized, prospective study should be performed to analyze the safety of abandoning this practice.

Humans↗
PubMed2003

Intracostal sutures decrease the pain of thoracotomy.

BACKGROUND: General thoracic surgeons spend much time dealing and treating patients' pain after thoracotomy. METHODS: Two hundred eighty consecutive patients underwent elective thoracotomy for pulmonary resection. Patients with a history of chronic pain were excluded. One general thoracic surgeon performed all procedures. All patients had a functioning preoperative epidural, a skin incision the width of their latissimus dorsi muscle which was cut, sparing of the serratus anterior muscle, undercutting of the rib, preemptive analgesia of the intercostal nerve before rib spreading, and similar number of chest tubes and postoperative pain management. The first 140 patients had their chests closed with pericostal sutures (stitches placed on top of the fifth rib and on top of the seventh rib), and the next 140 patients had their chest closed with intracostal sutures (stitches placed on top of the fifth rib and through the small holes drilled in the bed of the sixth rib). Pain was objectified by a numeric pain score and by the McGill pain questionnaire at 2 weeks, and 1, 2, and 3 months postoperatively. RESULTS: There were 140 patients in each group, and the groups were matched for age, gender, race, types of pulmonary resections, number of chest tubes, number of broken ribs, length of chest tube duration, and length of hospital stay (p > 0.05 for all). The mean pain score for the pericostal group (P group) at 2 weeks, 1 month, 2 months, and 3 months postoperatively was 5.5, 3.8, 2.3, and 1.6, respectively. For the intracostal group it was 3.3, 1.7, 1.1, and 0.6, respectively (p = 0.004, p = 0.0001, p < 0.0001, and p < 0.0001, respectively). Descriptors of pain in the P group were more likely to be, hot/burning, shooting or stabbing (p < 0.003). CONCLUSIONS: Intracostal sutures seem to be less painful than pericostal sutures at 2 weeks, 1 month, 2 months, and 3 months after thoracotomy. The pain is less likely to be described as burning or shooting.

Aged↗
PubMed1984

Empyema in children: clinical course and long-term follow-up.

Sixteen patients, aged 1 month to 15 years, were studied to determine the clinical course and long-term outcome of empyema in previously healthy children. The pathogens responsible were Haemophilus influenzae type b (seven patients), Staphylococcus aureus (five patients), Streptococcus pneumoniae (three patients), and viridans group Streptococcus (one patient). All patients had loculated fluid showing on chest roentgenographs. Chest tube drainage yielded 20 to 1,495 mL (mean 293 mL) during the first three days, accounting for 83% of total drainage. Chest tubes were removed after three to 17 days (mean ten days). Only slight roentgenographic improvement showed during chest tube drainage. Three patients required an open thoracotomy because of an unsatisfactory clinical response. Hospitalization ranged from eight to 77 days (mean 25 days). All patients had residual pleural thickening shown on chest roentgenographs taken at discharge. Thirteen patients were seen 5 to 140 months (mean 66 months) after discharge. Findings from physical examination were normal in 12 of the 13 patients. Pulmonary function tests in ten of the 13 patients revealed (mean percent predicted +/- 1 SD): vital capacity 92 +/- 12, residual volume 85 +/- 31, total lung capacity 92 +/- 13, peak flow rate 96 +/- 17, forced expiratory volume in 1 second 90 +/- 13, and maximal mid-expiratory flow rate 93 +/- 25. In all but one patient, findings on chest roentgenograms were normal or showed slight pleural thickening. Children with loculated empyema can be treated successfully with antibiotics and chest tube drainage. Few patients require open drainage, and further surgery is rarely required. The long-term outcome is excellent.

Adolescent↗
PubMed1999

Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema.

STUDY OBJECTIVES: To determine the predicting factors for outcome of tube thoracostomy in patients with complicated parapneumonic effusion (CPE) or empyema. DESIGN AND SETTINGS: Retrospective chart review over a 55-month period at a tertiary referred medical center. PATIENTS AND MEASUREMENTS: The medical charts of patients with empyema or CPE were reviewed. Data including age, gender, clinical symptoms, important underlying diseases, leukocyte count, duration of preadmission symptoms, interval from first procedure to second procedure, the time from first procedure to discharge (recovery time), the amount of effusion drained, administration of intrapleural streptokinase, chest tube size and position, loculation of pleural effusion, and characteristics and culture results of pleural effusion were recorded and compared between groups of patients with successful and failed outcome of tube thoracostomy drainage. RESULTS: One hundred twenty-one patients were selected for study. One hundred of these patients had received tube thoracostomy drainage with 53 successful outcomes and 47 failed outcomes of chest tube drainage. Nineteen patients received decortication directly, and the other two received antibiotics alone. Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. Multiple logistic regression analysis demonstrated that loculation and pleural effusion leukocyte count < or = 6,400/uL were the only independent predicting factors related to failure of tube thoracostomy drainage. CONCLUSIONS: Loculation and pleural effusion leukocyte count < or = 6,400/microL were independent predicting factors of poor outcome of tube thoracostomy drainage. These results suggest that if the initial attempt at chest tube drainage fails, early surgical intervention should be considered in good surgical candidates with loculated empyema or pleural effusion with leukocyte count < or = 6,400/microL.

Aged↗