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PubMed1985

Bronchial laceration in a newborn with persistent posterior pneumomediastinum.

A large posterior pneumomediastinum that compromised the respiratory status and reaccumulated promptly after needle aspiration, aroused the suspicion of airway laceration. Tracheogram was consistent with laceration of the right bronchus. Evacuation of air with chest tube resulted in complete resolution of pneumomediastinum and healing of bronchial tear with no recurrence following removal of chest tube after seven days.

Bronchi↗
PubMed1995

Vascular erosion caused by a double-lumen central venous catheter during therapeutic plasma exchange.

BACKGROUND: The use of large-bore double-lumen dialysis catheters has simplified the procedure of therapeutic plasma exchange, but these catheters are associated with unusual and possibly life-threatening complications. CASE REPORT: A 46-year-old black man was admitted to the hospital with acute onset of paresthesia and weakness. A diagnosis of Guillain-Barré syndrome was made. Plasma exchange therapy was instituted by peripheral venous access. After three such exchanges, a double-lumen central venous catheter was placed via the left subclavian vein on hospital Day 7. The patient experienced a sudden onset of severe chest pain and dyspnea during the fourth plasma exchange. He became diaphoretic and hypotensive and experienced tachycardia. The apheresis procedure was stopped. Because of worsening respiratory distress, endotracheal intubation was performed. A chest x-ray revealed a large right pleural effusion. The central venous catheter was removed. A chest tube was placed, and a large amount of bloody fluid was drained. Several days later, the endotracheal and chest tubes were removed. CONCLUSION: An unusual complication of the use of a central venous catheter, erosion of the superior vena cava, occurred during therapeutic plasma exchange. Prompt recognition of this complication and appropriate therapy can be life-saving.

Blood Component Removal↗
PubMed2001

Boerhaave's syndrome: a pediatric case.

BACKGROUND: The term Boerhaave's syndrome refers to esophageal rupture after a sudden increase in intraluminal pressure. This syndrome is most common among alcoholic adult men. This case report is that of a pediatric patient with a similar pathologic process. STUDY: A 6-month-old Hispanic boy with acute lymphoblastic leukemia on chemotherapy arrested 3 weeks into his induction therapy. Diagnostic and therapeutic procedures revealed a hydropneumothorax, which was managed with chest tube drainage. The underlying etiology was revealed 10 days later when feeds were introduced and found exiting the chest tube. A contrast study confirmed esophageal perforation, which was surgically repaired. CONCLUSION: A nontraumatic hydropneumothorax should raise the possibility of Boerhaave's syndrome (spontaneous esophageal rupture), even in pediatric patients. Such a finding warrants a contrast study to facilitate early diagnosis.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1990

Immediate drainage is not required for all patients with complicated parapneumonic effusions.

We retrospectively investigated if the clinical course of complicated parapneumonic effusions was altered by treatment with immediate drainage plus antibiotics vs antibiotics alone. The two groups of patients had no significant differences in age, duration of symptoms prior to hospitalization, initial maximum temperature, WBC count, or characteristics of the pleural fluid. There were no differences in the duration of hospitalization, fever, elevated WBC count, intravenous antibiotic therapy, or the time for roentgenographic resolution of the effusions. There was one death in each group. The infection of the pleural space resolved in 13 of 16 patients treated with antibiotics alone. No recurrence of the infection of the pleural space occurred in these patients. Antibiotics alone were not sufficient in two cases which eventually required chest tube drainage. Therefore, not all complicated parapneumonic effusions require drainage. A prospective study is required to determine if chest tube drainage should be part of the initial management of complicated parapneumonic effusions.

Anti-Bacterial Agents↗
PubMed2006

Experimental assessment of the drainage capacity of small silastic chest drains.

Recently, flexible fluted small silicone drains have been used widely as chest drains after cardiac surgery. Despite the clinical advantages of using smaller silastic chest drains over conventional chest tubes, an experimental comparison of the drainage capacity between these two drain tubes has not yet been performed. The drainage capacity of 19F silicone drains and 28F conventional tubes was tested. In an in vitro study, both tubes were set in a water bath and drained at a pressure of 10 mm Hg. In an in vivo study, the drains were inserted into the hemithorax in 8 adult pigs. Blood was infused at 20 mL x min(-1) into both chest cavities and the tubes were drained at 15 cm H(2)O for 30 min. In the in vitro study, the drainage capacity of the conventional chest tube was 9-times higher than that of the smaller silicone drain (103.8 vs. 11.6 L x hr (-1)). However, in the in vivo study, there was no difference in drainage capacity between the two different tubes over time. This experiment demonstrated that the smaller silastic chest drain has sufficient drainage capacity, almost identical to the conventional chest tube, in the clinical setting.

Animals↗
PubMed2001

Blunt chest trauma with deep pulmonary laceration.

BACKGROUND: Deep pulmonary laceration (DPL) is rare and its survival rate is low. The present study focused on the prognostic factors of DPL. METHODS: The present study concerned 17 DPL patients treated in Tokai University Hospital between 1988 and 1998. The prognostic factors of DPL were compared with systolic blood pressure (SBP), PaO2, and the volume of intrathoracic blood loss. Characteristic findings of initial chest roentgenograms of DPL were investigated. RESULTS: Eleven patients were saved and 6 patients died. An SBP of less than 80 mm Hg on arrival at the hospital and a blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival were poor prognostic factors. Hypoxemia on arrival was not a poor prognostic factor. Chest roentgenograms showed macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side. Selective bronchial occlusion with a Univent prevented suffocation by intrabronchial blood. CONCLUSIONS: Two poor prognostic factors of DPL are SBP less than 80 mm Hg on arrival and blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival.

Accidents, Traffic↗
PubMed1984

Empyema occurring in the multiply traumatized patient.

During an 11-month period 31 cases of nosocomial empyema were identified in 29 of 741 multiply traumatized patients who remained in our unit for more than 3 days. Nosocomial empyema was defined as purulent culture-positive material drained from the pleural space after five days' hospitalization. All patients had fever and leukocytosis. Possible risk factors included previous aspiration in five patients but none developing pneumonia, prior respiratory tract infection in nine but none with the same pathogen as their empyema, prior antibiotic use in over 50% of the patients, and severe head or chest injury in two thirds of the patients. Thirty-eight pathogens were recovered: S. aureus, 14; beta-streptococci, three; Pseudomonas, six; Klebsiella, two; Enterobacter, two; E. coli, two; other Gram-negative bacilli, six; and anaerobes, three. Fourteen infections were polymicrobic and bacteremia occurred in 42% of the patients. Of these 29 patients, 27 had chest tubes inserted for fluid in the pleural cavity before development of empyema; nine for hemo- or pneumothorax secondary to chest trauma, 11 for pneumothorax while on ventilators, and seven for unexplained sterile pleural effusion. If empyema complicated a prior hemothorax it was usually caused by Staphylococcus aureus and occurred about 10 days after draining blood from the pleural cavity. If empyema was a complication of pneumothorax or serothorax it was usually due to Gram-negative organisms colonizing the upper respiratory tract and occurred within 4 days of draining the fluid. Sixteen per cent of all patients who had chest tubes placed for fluid in their pleural cavity subsequently developed empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2004

Intrapleural instillation of rituximab for the treatment of malignant pleural effusions in NHL.

A patient with CD20(+) leukaemic lymphoplasmacytic Non-Hodgkin's lymphoma (NHL) presented with bilateral malignant pleural effusions. Systemic chemotherapy, repeated percutaneous drainage and bilateral continous chest tube drainage were unable to control the effusions. Rituximab was instilled in a dose-escalating manner via the chest tubes into both pleural spaces, within two weeks the effusions resolved, and the patient has stayed free of symptoms for eight months ongoing. Rituximab may be a promising novel treatment option for malignant effusions in CD20(+) NHL.

Antibodies, Monoclonal↗
PubMed1995

[Use of intravenous hyperalimentation catheter to drainage prolonged postoperative pleural effusion after harvesting the internal thoracic artery].

Increased chest drainage, a higher incidence of pleural effusions in the postoperative period, and more chest tube drainage was found after harvesting the internal thoracic artery (ITA). Patients with these complications required thoracocentesis, or prolonged chest tube drainage. But these methods may be painful and make a limitation to activity of daily life (ADL) in these patients. We therefore sought an effective procedure for these patients, and applied pleural placement of intravenous hyperalimentation catheter. This technique could drain the effusion completely, conveniently and painlessly without a limitation to ADL. Pneumothorax, infections and other complications occurred in no patients. We concluded that this method might be useful in these patients with prolonged post operative pleural effusion after harvesting the ITA who have failed other modes of therapy.

Aged↗
PubMed1994

[Purulent pleurisy in the child].

We studied 122 cases of empyema in children. The mean age was 3 years. We found malnutrition in 33% of the patients. 60% of them had large pleural effusion and 56% associated pneumonia. Staphylococcus aureus (51%) and Streptococcus pneumoniae (18%) were the most frequently isolated bacterias in pleural fluid. The mortality rate was 6.5%. 53% of the children had closed chest tube drainage. There were minor abnormalities in pulmonary function tests. The best treatment of empyema in children is closed chest tube drainage and an antimicrobial therapy with antistaphylococcus antibiotic.

Adolescent↗
PubMed1992

Steroid use is associated with pneumonia in pediatric chest trauma.

A review of pediatric trauma focused on pediatric chest injuries was performed at a trauma center specializing in neurologic trauma. Eighty of 342 (23%) pediatric trauma patients admitted to the center had chest injuries. Age, gender, mechanism of injury, magnitude of injury, incidence of pulmonary infection, chest tube usage, endotracheal intubation, steroid or antibiotic usage, morbidity, and mortality data were reviewed. Sixteen of 78 children (20%) with chest injuries developed pulmonary infections and were compared with the noninfected group. Patients with pneumonia had a higher morbidity with significantly longer mean hospital stay (43.0 vs. 12.7 days; p = 0.001), duration of intubation (8.4 vs. 1.5 days; p = 0.001), and total days with chest tubes, (2.2 vs. 1.4 days; p = 0.02). Pneumonia was significantly associated with longer mean duration of steroid usage (6.4 vs. 0.8 days; p = 0.0001). Duration of steroid administration for the treatment of concomitant brain injury was a significant independent risk factor for the occurrence of pneumonia.

Adolescent↗
PubMed2007

What is the role of chest X-ray in the initial assessment of stable trauma patients?

BACKGROUND: The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness. METHODS: A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period. RESULTS: Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT. CONCLUSION: In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.

Adult↗
PubMed2000

Pulmonary lymphangioleiomyomatosis in a 29-year-old woman with bilateral spontaneous pneumothorax: case report.

Pulmonary lymphangioleiomyomatosis is a rare, progressive and fatal interstitial lung disease that affects women of child-bearing age. It is characterized by the nonneoplastic proliferation of atypical smooth muscle cells around lymphatics, venules, and bronchioles. Patients with pulmonary lymphangioleiomyomatosis most commonly present with exertional dyspnea and a cough. Pneumothorax is almost always found on the initial chest radiograph. We report a case of a 29-year-old woman who presented with abrupt right chest pain and progressive dyspnea. Physical examination in the emergency department was significantly diminished breath sounds over the right lung, and a chest X-ray revealed a right-sided pneumothorax. She required a chest tube for complete lung re-expansion. On the sixth day of admission, left-sided pneumothorax occurred and another chest tube was inserted. She underwent high-resolution computed tomography of the thorax with the findings of numerous cysts evenly distributed throughout the parenchyma of both lungs. Bilateral thoracotomy with lung biopsies and pleurodesis were performed and the surgical findings confirmed the presence of multiple, small, pink-colored cystic lesions on the surfaces of both lungs. Pathological examination showed the characteristic findings of pulmonary lymphangioleiomyomatosis.

Adult↗
PubMed1999

Prospective randomized trial of thoracostomy removal algorithms.

INTRODUCTION: The preferred chest tube (CT) removal algorithm has not yet been established. The purpose of this study was to determine which technique, water seal or suction, allowed for shorter CT duration. In addition, the recurrent pneumothorax (PTX) rate, the need for CT reinsertion, and the total number of chest x-ray films (CXR) were determined. METHODS: Prospective randomized trial of 205 trauma patients, older than 15 years of age, requiring tube thoracostomy for blunt and penetrating trauma. Patients requiring mechanical ventilation more than 24 hours were excluded from the study. Informed consent was obtained from all patients. Chest tubes were randomized for removal when output was less than 150 mL/24 hours, CXR revealed no significant PTX, and no air leak was present. Patients in the water seal group were disconnected from low wall suction and a CXR was obtained 6 to 8 hours later. Chest tubes in the no water seal group were disconnected from wall suction and pulled immediately. All tubes were removed by using standard protocol with patients at maximal inspiratory effort. A follow-up CXR was obtained after removal. RESULTS: Of the 205 patients, 93 patients (45 %) were randomized to the water seal group and 112 patients (54%) to the no water seal group. Four patients in the water seal group developed a PTX before CT removal and were considered treatment failures. After CT removal, repeat PTX was seen in 13 patients in the water seal group and in 9 patients in the no water seal group. However, seven patients in the no water seal group required CT reinsertion compared with one in the water seal group (p<0.05). Average number of CXR in the water seal group was 6.5 compared with 5.5 radiographs in the no water seal group. There was no difference in chest tube duration or hospital length of stay between groups for either all patients or only those patients with isolated chest injuries. Patients who required another CT had a hospital length of stay twice that of patients who did not. CONCLUSIONS: It is possible that patients in the no water seal group did not have sufficient time for a possible PTX to evolve, which resulted in a larger and more significant PTX requiring another CT. Although there was no difference in chest tube duration between the no water seal and water seal groups, a short trial of water seal appears to allow occult air leaks to become clinically apparent and reduces the need for another CT.

Adult↗
PubMed2003

Radiation therapy in the treatment of Gorham disease.

An adolescent male with Noonan syndrome presented with a nonhealing fracture of the proximal right humerus. Over a 7-month period there was progressive loss of bone in this region, resulting in a flail arm at 9 months. Radiographic review was consistent with Gorham disease. In addition, there was significant bleeding in the soft tissues and pain. Radiation was delivered. Seven years passed, until the patient re-presented with right hemithorax near collapse secondary to chylothorax. A chest tube was placed with temporary relief, but significant effusion remained. Radiation was again administered, and by the end of therapy the chest tube was removed. The effusion has not recollected at last follow-up, which is now 6 months. The use of radiation in the treatment of Gorham disease has been demonstrated to have excellent palliative ability.

Chylothorax↗
PubMed1995

The blood saving potential of vortex versus roller pump with and without aprotinin.

To evaluate the potential of centrifugal blood pumps for saving blood, 120 patients scheduled for elective coronary artery bypass grafting were entered into a prospective randomized trial. A standard roller pump (group I) was compared with a centrifugal blood pump (group II) and roller pump plus aprotinin (group III). There was no significant difference between groups I and II with respect to free haemoglobin, lactic dehydrogenase, serum bilirubin, platelet surface glycoprotein IIb-IIIa and granule membrane protein 140, chest-tube drainage, use of blood products, length of stay in intensive care, time on ventilator and postoperative mortality. Aprotinin reduced chest-tube drainage and use of blood products significantly. Three cases of graft occlusions were noted in group III. Centrifugal blood pumps offer no advantage in routine heart surgery over conventional roller pumps. Aprotinin reduces blood loss, but does not influence GP IIb-IIIa and GMP 140 expression on blood platelets.

Blood Component Transfusion↗
PubMed2004

[Flail chest due to blunt trauma: clinical features and factors affecting prognosis].

BACKGROUND: We evaluated the clinical features of patients with flail chest, together with treatment results, and the factors affecting prognosis. METHODS: The study included 34 patients (27 males, 7 females; mean age 41 years; range 15-61 years) who underwent treatment for flail chest. A retrospective analysis was made regarding the etiology, injury to the chest wall, pulmonary contusion, hemothorax and pneumothorax requiring chest tube, associated injuries, injury severity score (ISS), the presence of shock on admission, the amount of blood transfusions within the first 24 hours, treatment, and the results. RESULTS: The most common cause of flail chest was traffic accidents (79.4%). Shock was detected in 41.2% and pulmonary contusions in 55.9%. Ventilatory support was required in 70.6%. The mean ISS was 36; mortality occurred in 32.4%. In seven patients without associated injuries and who did not receive ventilatory support, the mean ISS was 22.8 and all survived. However, in 18 patients with associated organ injuries, the mean ISS was 43.6, with mortality being 50% (p<0.05). Factors responsible for prolonged ventilatory support, pneumonia, and septic deaths included ISS above 31, associated fractures and injuries, blood transfusions, the need for chest tube, age equal to or above 50 years, and the presence of bilateral flail chest. The incidences of pneumonia and mortality were significantly less in patients treated with internal fixation (p<0.05). CONCLUSION: Our data show that careful fluid management and effective pain control, stabilization of the chest wall, immediate ventilatory support and early weaning from ventilation are the mainstays of treatment.

Accidents, Traffic↗
PubMed1981

Pneumothorax: a therapeutic update.

The traditional treatment of pneumothorax has been with a chest tube and hospitalization. A series of 35 patients with 41 pneumothoraces treated on an outpatient basis is presented here. A no. 12 chest tube connected to a Heimlich valve led to successful treatment in 88 percent of the cases. Failure of treatment requiring hospitalization occurred in 12 percent of cases and was due only to persistent air leaks. No complications occurred.

Adolescent↗