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PubMed1988

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy.

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.

Adult↗
PubMed1996

Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema: a multicenter trial.

To test the efficacy of intrapleural fibrinolytic therapy in patients with loculated pleural effusions, we conducted an open, prospective, and multicenter trial among five hospitals in Mexico. We enrolled patients with hemothorax or empyema, clotted and/or loculated, that was not resolved through conventional pleural drainage with chest tube and antibiotics in patients with empyema. All patients received repeated doses of 250,000 IU of streptokinase through chest tube. Effectiveness criteria were before and after intrapleural streptokinase (IPSK) drainage, and poststreptokinase radiographic and respiratory function test improvement. Forty-eight patients were studied; there were 30 patients with empyemas, 14 with hemothorax, and 4 patients with malignant pleural effusions without lung trapping. Successful fibrinolysis was obtained in 44 patients, with complete resolution of the pleural collection and adequate radiologic and spirometric improvement. In three of four patients with multiloculated malignant hemothorax with high-yielding pleural drainage, IPSK allowed successful lysis of loci and an adequate pleurodesis was achieved. Only four patients required surgical treatment. The overall success rate in our series was 92%, similar to previous reports. The results in this first prospective and multicentric trial suggest that intrapleural fibrinolysis is an effective and safe adjunctive treatment in patients with heterogeneous pleural coagulated and loculated collections to restore the pulmonary function assessed by respiratory function tests and can obviate surgery in most cases.

Adolescent↗
PubMed1993

Pneumothorax in AIDS patients: operative management.

Acquired immunodeficiency syndrome (AIDS) is a devastating disease. Pneumocystis carinii pneumonia (PCP) is a major clinical manifestation of AIDS. A 2-year experience with eight operations for PCP-associated pneumothorax in seven AIDS patients was reviewed. Initial treatment was tube thoracostomy in all cases. Operation was performed because of inability to expand the lung and/or persistent air-leak. Time from insertion of the initial chest tube to operation was 9-66 days (mean, 33 days). Pulmonary air leaks were closed with surgical staples and/or sutures. Chest tubes were removed 3-16 days after surgery (mean, 8.5 days). There were no cases of postoperative respiratory insufficiency and there were no deaths. Patients were discharged from the hospital 6-18 days after surgery (mean, 13 days). The postoperative hospital stay was substantially shorter than the preoperative period of nonoperative therapy (13 vs. 33 days). Follow-up is complete in six of the seven patients. Three patients died of AIDS 4-8 months after surgery (mean, 6 months). Three patients are alive 7-14 months after operation (mean, 11 months). Operative management of PCP-associated pneumothorax is effective and can be performed with low morbidity and mortality. We conclude that surgery should be considered as an early option in AIDS patients with PCP-associated pneumothorax.

AIDS-Related Opportunistic Infections↗
PubMed1997

Palliative iodized talc pleurodesis with instillation via tube thoracostomy.

Pleural effusions are a severe complication of advanced malignant disease. Palliative treatment strategies should be simple and effective. We investigated iodized talc pleurodesis through tube thoracostomy for this purpose. A total of 43 patients received a suspension of 5 g talc with 3 g thymol iodine via chest tube. The procedure was well tolerated without major complications in all cases. Unfortunately, 4 patients died of disease within the 1st month after treatment, so that only 39 patients were evaluable for treatment outcome. Follow-up ranged from 1 to 14 months. The success rate after 3 months was 92.5%. In conclusion, iodized talc pleurodesis is an excellent tool in the palliative management of malignant pleural effusions. Administration via chest tube is sufficient for treatment success.

Adult↗
PubMed2005

Accidentally created tension pneumothorax in patient with primary spontaneous pneumothorax--confirmation of the experimental studies, putting into question the classical explanation.

BACKGROUND: The widespread explanation of patophysiology of tension pneumothorax is that compression to the mediastinum by the progressively accumulating intrapleural air causes torsion at the atrio-caval junction, impaired filling of the right heart and circulatory arrest as potentially life-threatening complication. Some experimental studies on animals put into question such an explanation, suggesting that respiratory arrest due to hypoxia of the respiratory center, not a circulatory arrest, represents dominant life threatening feature. CASE REPORT: we present a patient with spontaneous pneumothorax in whom tension pneumothorax occurred accidentally, i.e., in whom air was insufflated under great pressure from the aspirating system into the pleural cavity, immediately after insertion of a chest tube. As the situation was recognized immediately, urgent reanimation was undertaken--endotracheal intubation, ventilation through the balloon, reconnection of the chest tube to another aspirating system. Lung reexpansion was achieved and the patient was discharged after an uneventful course. In this patient, it was possible to register the sequence of events before, during and after the incident. Dominant clinical finding during resuscitation of this apnoic, cyanotic and unconscious patient was respiratory arrest in presence of evident maintenance of peripheral circulation, that supports results of experimental studies. Dominant findings in experiments with creation of tension pneumothorax was that, although pressures rose throughout the right side of the circulation, no developing pressure gradient was found on this side of the circulation; furthermore, respiratory arrest preceded cardiac arrest in these animals. Hypoxia of the respiratory center, caused by the increasing portion of pulmonary blood flow being shunted through nonventilated or hypoventilated lung, was suggested as primary cause of death of experimental animals. The same factor seems to be a cause of respiratory arrest in our patient. CONCLUSION: respiratory arrest, preceding circulatory arrest, seems to be the principal life threatening condition in patients with progressive tension pneumothorax.

Animals↗
PubMed1998

Talc pleurodesis in recurrent pleural effusions.

BACKGROUND AND AIMS: The treatment of recurrent malignant pleural effusions is known to be difficult and varies from observation in asymptomatic patients to pleurectomy with varying results. This prospective study presents the efficacy and the limits of iodized talc pleurodesis in patients with malignant and non-malignant recurrent pleural effusions. METHODS: In a prospective trial talc pleurodesis was performed in 50 patients with recurrent pleural effusions (malignant effusions: n=36, non-malignant effusions: n=14). After insertion of a chest tube and complete re-expansion of the lung, 5 mg of talc and 3 mg of thymol iodine were installed with 0.5 ml of 1% xylocaine/kg body weight and 30 ml 0.9% saline solution. The chest tube was removed after an average time of 4 days and chest radiographs were performed 1 month after instillation to evaluate the efficacy of pleurodesis. RESULTS: Successful therapy was achieved in 31 of 33 patients (94%) with malignant effusions within a follow-up period of 7 months. Three patients died within 1 month after therapy due to progressive malignant disease. The treatment was successful in all cases of non-malignant effusions and complications did not occur in either group. CONCLUSIONS: These results indicate that pleurodesis with iodized talcum slurry is a simple and inexpensive method with high efficacy in controlling malignant and non-malignant pleural effusions.

Chest Tubes↗
PubMed1990

Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient.

Bronchopleural fistulas are associated with high morbidity and mortality and are particularly challenging in the ventilated patient. Familiarity with both basic and more technical medical management techniques may lessen morbidity and improve survival. Prompt recognition of BPFs and appropriate placement of a chest tube with an adequate suction device are crucial to prevent potential tension pneumothorax and to drain an infected pleural space. The chest tube may be used therapeutically to decrease BPF air leak and to promote fistula repair. Appropriate conventional ventilator manipulations aimed at decreasing fistula air leak and maintaining adequate oxygenation and ventilation may fail and necessitate a trial of HFV. Definitive therapy by the bronchoscopic application of a sealing agent to occlude the fistula site can be used, particularly in the poor surgical candidate.

Bronchial Fistula↗
PubMed1982

Use of Denver shunt in recurrent hepatic hydrothorax.

A 49-year-old woman with alcoholic cirrhosis was hospitalized for severe respiratory distress. A moderate amount of ascites was noted on physical examination, and the right hemithorax was completely opacified on the chest x-ray film. Thoracentesis was performed, and a follow-up chest x-ray film showed marked reduction of pleural effusion. Two days later the patient again was in respiratory distress, and a chest tube was inserted. On the tenth hospital day, a peritoneovenous (Denver) shunt was inserted and the chest tube was removed. Follow-up chest x-ray films showed almost complete resolution of pleural effusion, and the patient has remained free of symptoms. When hepatic hydrothorax does not respond to conventional therapy, we believe aggressive treatment with a Denver shunt may be successful. To our knowledge this procedure has been performed successfully in only one other patient. Further study is needed to assess its value as a possible alternative method of treatment.

Female↗
PubMed2003

Recurrent pleural effusion complicating liver cirrhosis.

BACKGROUND: Pleural effusion (PE) is a rare complication of advanced liver cirrhosis, which may lead to an operation when uncontrolled. The purpose of this study was to evaluate the modality of the occurrence of pleural effusion and to describe its surgical management. METHODS: We studied 21 patients who were referred to the department of thoracic surgery because of massive and recurrent PE caused by liver cirrhosis. The PE was a transudate in 16 patients and an exudate in 5. Talc pleurodesis was attempted in all patients. The patients were divided into two groups. Video assisted thoracoscopy was performed in 13 patients in whom the clinical condition permitted general anesthesia; the pleural cavity was entirely explored before pleurodesis (group 1). Chest tube drainage alone was performed in 8 patients who were unable to undergo general anesthesia; talc pleurodesis was performed through the chest tube in these patients (group 2). RESULTS: In group 1 the PE was right-sided in 8 patients, left-sided in 3, and bilateral in 2. Diaphragmatic defects were observed in 2 patients, and a fluid leak oozing from the diaphragm was observed in 1 patient. Ten patients were considered cured and were without recurrence. Two patients underwent late recurrence before dying from their liver cirrhosis. Only 1 patient had an early recurrence that was cured by complementary talc slurry. In group 2 all patients presented with a right PE; of these, 3 patients died from septic shock caused by pleural infection. Three patients underwent early recurrence but were cured after repeat talc slurry. One patient had a midterm recurrence. One patient had an early recurrence treated by intrahepatic porto-systemic shunt with partial improvement. CONCLUSIONS: Passage of ascites through diaphragmatic defects appears to be the main cause of PE complicating cirrhosis. Patients may benefit from talc pleurodesis. Video assisted thoracoscopy pleurodesis is the technique of choice with consistent results. Repeated talc injection through the drain may prove useful for patients in poor clinical status.

Adult↗
PubMed1991

Use of purified streptokinase in empyema and hemothorax.

Enzymatic debridement of the pleural cavity for retained hemothorax or empyema is a frequently overlooked option. Thirteen of fourteen patients (93%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with purified streptokinase injections. The average increase in chest tube output following streptokinase injections was 158%. No significant adverse reactions occurred. One patient required thoracotomy when streptokinase therapy failed. Two others had successful resolution of their pleural collections but required thoracotomy for other indications. There were two deaths (14%), which were unrelated to the use of streptokinase or residual empyema. Intrapleural streptokinase is a safe, effective means of removing retained proteinaceous collections in the pleural space. It is a useful adjunct to chest tube drainage and may obviate the need for more invasive procedures.

Adult↗
PubMed2002

Evaluation of a teaching laboratory using a cadaver model for tube thoracostomy(1).

A prior study evaluated the efficacy of a dog laboratory to teach residents chest tube thoracostomy. This study evaluated a similarly structured program using human cadavers. A prospective repeat measure study of chest tube thoracostomy placement training was performed in a university laboratory setting using human cadavers. Ten Emergency Medicine residents were given a written pretest, followed by training. Resident attempts were then timed. The following day, a repeat test was administered. Three weeks later, a third written post-test was conducted. The written test scores improved for every participant. Mean times for procedure completion improved from 86 sec to 34 sec during the first session, and remained stable over 4 attempts from 30 sec to 32 sec during the second session. This approach to teaching clinical procedures should be considered for Emergency Medicine residency programs and for continuing education courses that emphasize procedural skills.

Cadaver↗
PubMed2000

Analgesia for pediatric thoracostomy tube removal.

Eutectic mixture of local anesthetics (EMLA; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient's pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhemoglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA group (P < 0.01). We conclude that EMLA is safe and useful for blunting the pain of CTR.

Adolescent↗
PubMed1998

Aprotinin versus epsilon-aminocaproic acid for aortic surgery using deep hypothermic circulatory arrest.

OBJECTIVE: To compare the relative efficacy of aprotinin and epsilon-aminocaproic acid (EACA) in decreasing blood loss and transfusion requirements after aortic surgery involving deep hypothermic circulatory arrest (DHCA). DESIGN: A retrospective chart review. SETTING: A university medical center. PARTICIPANTS: Forty-nine patients who had undergone thoracic aortic surgery with the use of circulatory arrest. INTERVENTIONS: Charts were examined for variables believed to influence postoperative blood loss, including the use of medications, and for the amount of postoperative chest tube drainage and perioperative transfusion. MEASUREMENTS AND MAIN RESULTS: Median chest tube output (CTO) at 6 and 12 hours postoperatively was nearly identical in patients treated with aprotinin or EACA (660 and 1,015 v 700 and 950 mL for aprotinin and EACA at 6 and 12 hours, respectively), as were total perioperative blood transfusions. Complications were not significantly different between groups with the exception of a trend toward increased incidence of renal failure in the group receiving EACA. CONCLUSION: Aprotinin and EACA appear to be equally efficacious in reducing perioperative blood loss and transfusion requirements in patients undergoing aortic surgery involving DHCA. Questions of safety remain about the use of EACA in this setting that could not be addressed by this small retrospective study. A prospective, placebo-controlled study is warranted to confirm the absolute efficacy of these agents and to better define safety issues.

Adult↗
PubMed1988

[Post-pneumonectomy pyothorax with and without broncho-pleural fistula].

This study reports the experience of the medical centre of Villiers Saint-Denis, where about 40 cases of pyothorax with or without broncho-pleural fistula were seen between 1975 and 1981. The authors describe their method to drain and wash the pleural cavity. They use a single chest tube with an irrigation system in simple empyema and two chest tubes with an irrigation system when they must close a broncho-pleural fistula. With this method, the infection was eradicated in 90% of the cases, and the broncho-pleural fistula closed within about 4 months in 80% of the cases. This method is compared with other methods used to treat pyothorax.

Adult↗
PubMed1994

Pain management in Canadian level 3 neonatal intensive care units.

OBJECTIVE: To determine current practices in neonatal intensive care units (NICUs) of managing postoperative pain, pain associated with nonsurgical procedures and disease-related pain. DESIGN: Retrospective, self-administered descriptive mail survey. SETTING: Level 3 NICUs in Canada. PARTICIPANTS: The head nurses of the 30 Canadian level 3 NICUs in February 1992; 26 (87%) responded. MAIN OUTCOME MEASURES: Five-point Likert scale of Always (in 100% of cases), Often (in 75% to 99%), Usually (in 25% to 74%), Rarely (in 1% to 24%) and Never (in 0%). Selected items were validated through a chart review. RESULTS: Opioids were used postoperatively always or often in 93% (13/14), 88% (15/17) and 65% (11/17) of the NICUs that cared for neonates having undergone cardiac, major and minor surgery respectively. Most of the NICUs did not use paralysis or sedation alone for postoperative pain management. Local anesthesia was used always or often for emergent chest tube placement in 16% (4/25) of the NICUs, for elective chest tube placement in 48% (12/25) and for lumbar puncture in 12% (3/24). An analgesic was rarely or never used for insertion of a tracheal tube in emergent situations in 88% (23/26) of the NICUs and in elective situations in 84% (21/25); the corresponding figures for sedative use were 85% (22/26) and 73% (19/26). Only 22% (5/23) used opioids regularly in cases of nonsurgically managed necrotizing enterocolitis. Physicians alone determined the rate of opioid weaning in 54% (13/24) of the NICUs. Opioids were usually described as being weaned as tolerated. CONCLUSIONS: Analgesic use for the management of postoperative pain in neonates having undergone cardiac and major surgery is frequent but continues to be infrequent in the postoperative care of patients having undergone minor surgery in some NICUs. Procedural and disease-related pain is frequently untreated or undertreated. Guidelines for establishing a protocol to manage pain in NICUs are given.

Analgesics↗
PubMed1998

[Postoperative chylothorax treated with fibrin glue and absorbent mesh: a case report].

A 66-year-old man was treated by graft replacement for a thoracic aortic aneurysm. Chylothorax occurred on postoperative day 2. In spite of cessation of oral intake and IVH management, chest tube drainage did not decrease, the patient became malnourished. A chest X-ray and CT scan revealed the massive pleural effusion. Reoperation assisted with a thoracoscopy was carried out for chylothorax on postoperative day 27. Because we were unable to find the thoracic duct and the leakage point, the fibrin glue and absorbent mesh was applied to parietal and mediastinal pleura. Four days after reoperation, the chest tube was removed. This method is useful for this type of a chylothorax and lymphorrhea.

Absorption↗
PubMed1999

Site of pleural drain insertion and early postoperative pulmonary function following coronary artery bypass grafting with internal mammary artery.

STUDY OBJECTIVES: Coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA) impairs postoperative pulmonary function. We studied the changes in pulmonary function and subjective pain relative to the site of chest tube insertion. DESIGN: Thirty patients undergoing CABG surgery using the LIMA were randomized into two groups. Group A (n = 15) received a left chest tube inserted from the midline (subxyphoid). Group B (n = 15) had a tube placed in the sixth intercostal space at the anterior axillary line. All of the patients underwent bedside pulmonary function testing preoperatively and on postoperative days (PODs) 1, 3, and 5. Pain sensation was quantified by a standardized score (1 to 10). RESULTS: A significant impairment of pulmonary function parameters was observed in both groups until POD 5. For group A, the decline in percent predicted (+/-SD) in the vital capacity (VC) from before surgery to POD 5 was, respectively, 92.3+/-30.6% to 56.9+/-12.6% (p < 0.001). For group B, the decline in the VC was from 88.0+/-18.2% to 55.5+/-14.8% (p < 0.001). The FEV1 declined concomitantly in group A from 86.2+/-18.2% to 50.8+/-12.1%, and in group B from 83.5+/-16.4% to 53.9+/-12.5% (p < 0.001). On POD 1, a significantly lower decrease in the VC was measured in group A than in group B, respectively: 45.3+/-15.5% vs 28.6+/-8.7% (p < 0.001). A significantly lower decrease in the FEV1 was also seen in group A than in group B, respectively: 36.9+/-12.9% vs 28.0+/-10.6% (p < 0.05). Pain experienced during deep inspiration was also significantly less in group A than in group B, respectively: 1.2+/-1.1 vs 2.5+/-0.9 (p < 0.01). CONCLUSIONS: Subxyphoid insertion of the pleural drain leads to a significantly lower impairment of pulmonary function and less subjective pain than insertion at the intercostal position. The drainage of the left pleural space is equally effective with both techniques.

Aged↗