Search Results (31)

Refractory thoracic infections require targeted antimicrobial combinations, repeated drainage interventions and often staged surgical procedures of varying complexity grades. In necrotizing pneumonia cases, successful treatment is complete removal of destroyed non-functional parenchyma, pleural cavity debridement, and complete pathogen eradication based on culture-based sensitivity-driven antimicrobials. The latter proves challenging in pan-resistant microbial strains where both medical and surgical treatments demonstrate limited effectiveness. We describe a case of persistent thoracic sepsis due to pan-resistant Pseudomonas receiving sequentially thoracoscopic decortication, thoracotomy for lobectomy, and open thoracostomy as the last treatment option to prevent fatal sepsis in view of non-available antibiotics. The immediate source-control effect raised the question of the ideal timing for selecting an aggressive thoracoplastic procedure despite its deforming nature over any other treatment approach. Full article

Bronchopleural fistula is a rare but severe complication of lung resection, associated with significant morbidity and mortality, especially when an open-window thoracostomy is required. The clinical and surgical management is complex and becomes even more challenging in the presence of underlying conditions such as recurrent infections or malignancy. Postoperative management is equally demanding, as local compression may help prevent fistula recurrence but can compromise flap perfusion. A 65-year-old male with a history of right upper lobectomy and subsequent sublobar resection for lung adenocarcinoma presented with an 8 × 4 cm open-window thoracostomy complicated by chronic bronchopleural fistula and empyema. Extensive fibrosis of the surrounding tissues, including the ipsilateral latissimus dorsi muscle, limited the available reconstructive locoregional options. Reconstruction was performed using primary fistula closure reinforced with a contralateral free latissimus dorsi musculocutaneous flap and a fascia patch graft secured with cyanoacrylate-based bioadhesive. Postoperatively, continuous near-infrared spectroscopy monitoring enabled safe application of compressive bandage while minimizing the risk of flap perfusion compromise. Complete fistula closure was achieved. Apart from a surgical site abscess requiring debridement on postoperative day 7, no further complications occurred. At the 2-year follow-up, the patient remains free of fistula recurrence, wound dehiscence, or oncological relapse. We describe a novel approach for open-window thoracostomy closure combining a free musculocutaneous flap with a fascia patch graft reinforced by bioadhesive, together with postoperative perfusion monitoring using near-infrared spectroscopy. This strategy may help address both the reconstructive and postoperative challenges associated with complex bronchopleural fistulas. Full article

Background/Objectives: This study examined whether dynamic systemic inflammation- and nutrition-based scores measured at baseline (T0) and during follow-up (T1: days 7–10) are associated with treatment response and surgical requirement in first-episode primary spontaneous pneumothorax (PSP). Methods: A total of 216 consecutive patients with first-episode PSP, treated between January 2020 and December 2024, were retrospectively analyzed. All patients initially underwent tube thoracostomy. During follow-up, 117 patients recovered with drainage therapy, whereas 99 required VATS because of a prolonged air leak. The CAR, SIII, SIRI, PIII, NLR, PLR, and PNI, measured at T0 and T1, were analyzed. Δ-values (T1–T0 differences) were evaluated, and diagnostic performance was assessed using ROC curve analysis. Results: At T0, inflammation- and nutrition-based indices did not differ significantly between groups. In contrast, at T1, CAR, SIII, SIRI, PIII, NLR, and PLR values were significantly higher in the VATS group than in the drainage group (all p < 0.05). Over time, inflammatory indices increased markedly in the VATS group, whereas changes in the drainage group remained limited. PNI decreased significantly at T1 in both groups. ROC analysis demonstrated that CAR, SIII, and NLR showed moderate discriminative performance for identifying patients who required VATS (area under the curve ≈ 0.65). Conclusions: Dynamic assessment of systemic inflammation-based biomarkers provides clinically relevant insight for surgical risk stratification in first-episode PSP. While baseline measurements alone are insufficient, follow-up values and temporal changes—particularly in CAR, SIII, and NLR—may reflect progression toward a surgical phenotype and could serve as adjunctive, non-directive decision-support indicators in PSP management. Full article

Background: Pneumothorax (PTX) develops in 1–2% of neonates, leading to significant morbidity and mortality and requiring providers to be comfortable with management. Our objective was to evaluate whether radiographic measurements of PTX size can be used to predict the need for procedural intervention in neonates in order to help guide the need for the availability of specific personnel. Methods: With the help of a data analyst, 62 patients diagnosed with neonatal PTX between March 2016 and October 2024 were identified. Most babies (46) were born in 2023–2024 when our new electronic health record could more easily identify these infants. PTX size was evaluated using radiographs by calculating the ratio of the widest transverse measurement of the PTX on both anteroposterior (AP) and, when available, lateral decubitus (DECUB) divided by the widest transverse measurement of the hemithorax above the diaphragm. Clinical data were collected, and statistical analysis was performed using need for intervention (thoracentesis (TC), chest tube (CT), or both). Results: We found that a larger PTX size ratio, measured in the AP (p < 0.0001) or DECUB view (p < 0.008), was highly associated with need for intervention in this cohort of infants with PTX. Only 33% of PTXs required intervention. Also, 13/14 (93%) cases who underwent TC ultimately required a CT. PTX was more prevalent in males in general, but sex was not associated with needing intervention. The average gestational age (GA) of the cohort was 36 5/7 weeks, with only 12% being < 34 weeks GA. Univariate analysis indicated that lower GA and birth weight were risk factors for intervention. There was a trend (p = 0.075, by Fisher’s exact test) suggesting that infants with both respiratory distress syndrome (RDS) and PTX may be more likely (60%) to require intervention (no RDS, 29% intervention). Finally, a receiver operator characteristic curve was derived from the AP ratio based on the yes/no intervention which resulted in an area under the curve statistic of 0.902 and the optimal AP ratio cutoff of 0.184. Conclusions: The ratio of the transverse measurement of the PTX/hemithorax size from radiographs was highly predictive for need for intervention in a cohort of primarily term infants with PTX. Smaller and lower GA infants were at a higher risk for requiring procedural intervention. Nearly all infants who had TC also needed a CT. These findings could inform clinical strategies for managing neonatal PTXs, especially in identifying appropriate needed personnel availability if a TC occurs. Full article

Background/Objectives: Accurate and prompt tube thoracostomy (TT) placement within the safety zone while avoiding diaphragmatic injury remains challenging, particularly in trauma patients with distorted thoracic anatomy. This study evaluated the accuracy and safety of landmark-based TT techniques, including a novel mid-sternum method. Methods: In this retrospective study, chest computed tomography scans of 245 adult trauma patients who presented to a Level I trauma center in Korea between February and June 2022 were analyzed. TT insertion routes using the mid-sternum, nipple, and mid-arm point methods were compared against the conventional fifth intercostal space (ICS) method. Results: Of the 245 enrolled patients, the median age was 55.0 years (interquartile range, 42.0–64.0), and 186 (75.9%) were male. On the right side, routes avoiding the diaphragm were observed in 82.0% (fifth ICS), 92.7% (mid-sternum), 55.5% (nipple), and 90.2% (mid-arm point) of patients. The mid-sternum method showed a significantly higher avoidance rate than the fifth ICS method (p < 0.001), with 91.1% sensitivity and 77.4% specificity for identifying TT routes within the safety zone. On the left side, routes avoiding the diaphragm were observed in 97.6% (fifth ICS), 98.8% (mid-sternum), 86.9% (nipple), and 95.1% (mid-arm point) of patients, with no significant difference between the fifth ICS and mid-sternum methods (p = 0.375). The mid-sternum method showed 90.4% sensitivity and 85.2% specificity for routes within the safety zone. Conclusions: The mid-sternum method demonstrated high anatomical safety and performance comparable to or superior to the conventional fifth ICS method, particularly in minimizing the risk of diaphragmatic injury. It may offer a practical and safe alternative for TT placement in trauma care. Full article

Background: Achalasia is a primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis, which increases the risk of aspiration during anesthesia. Peroral endoscopic myotomy (POEM) is a minimally invasive therapeutic approach requiring tailored anesthetic management. This study aimed to evaluate perioperative anesthesia management during POEM, focusing on ventilation parameters, intraoperative hemodynamics, laboratory changes, and the incidence and severity of postoperative complications. Methods: A retrospective analysis was conducted on 51 patients who underwent POEM between June 2016 and April 2025. Demographic features, anesthesia techniques, intraoperative physiologic parameters, hematologic profiles, and postoperative complications were evaluated. Standard preoperative fasting protocols were implemented. Rapid sequence induction (RSI) with propofol and rocuronium was followed by endotracheal intubation. Desflurane was used for maintenance anesthesia, with ventilation settings adjusted to limit end-tidal carbon dioxide (ETCO₂) elevation. Results: The median age of patients was 48 years, with a slight female (52.9%) predominance. Most patients were American Society of Anesthesiologists (ASA) II (64.7%) or ASA III (35.3%) scores and had comorbid hypertension (31.4%) or diabetes (11.8%). The median anesthesia duration was 180 min, and the peak inspiratory pressure remained stable at 25 mmHg. Oxygen saturation (SpO₂) improved during the procedure, while ETCO₂ increased from baseline to 49 mmHg by the end. Blood pressure declined transiently but recovered intraoperatively. Hematologic analysis showed significant increases in white blood cell (WBC) and neutrophils and mild decreases in hemoglobin, hematocrit, and platelets. Early postoperative complications included subcutaneous emphysema (19.6%), minor bleeding (9.8%), and pneumoperitoneum (7.84%). Two patients required tube thoracostomy due to pneumothorax, but no patient developed a complication requiring surgical exploration. During a median follow-up of 546 days, no mortality was reported. Long-term complications were infrequent, with gastroesophageal reflux disease (GERD) (3.92%) and esophagitis (1.96%) being the most notable. Conclusions: POEM can be performed safely with appropriate anesthetic management. Despite significant physiologic changes during carbon dioxide (CO₂) insufflation, no life-threatening complications occurred, and the majority of adverse events were minor and self-limiting. Close intraoperative monitoring and interdisciplinary coordination contribute to favorable perioperative outcomes. Full article

Background: The British Thoracic Society recommended tube thoracostomy plus intra-pleural fibrinolytics to treat empyema in children in 2005. However, numerous comparative studies have suggested Video-Assisted Thoracoscopic Surgery (VATS) as a first line of treatment for pediatric empyema due to its superior outcomes, including shorter length of hospital stay (LOS). This meta-analysis aimed to compare the following: (1) the LOS for VATS versus fibrinolytics to treat empyema in children; (2) secondary post-operative outcomes (fever, O₂ support, time taken for chest tube removal, analgesia, complications, failure, and abnormal chest X-ray at follow-up). Methods: The study was conducted according to PRISMA guidelines. A systematic search of PubMed, Cochrane, Web of Science, and Scopus was conducted according to PRISMA guidelines. Two independent investigators identified relevant studies, excluding case reports, opinion articles, and gray literature publications. A meta-analysis of randomized controlled trials (RCTs) was performed using RevMan 5.4, with data expressed as mean ± standard deviation (SD). Results: Of 1374 abstracts screened, 104 full-text articles were analyzed, and 6 RCTs (345 patients) were included in the meta-analysis. Patients undergoing VATS had significantly shorter LOS compared to those receiving fibrinolytics (9.1 ± 1.8 vs. 11.5 ± 2.5 days, p = 0.05). VATS patients also experienced shorter postoperative fever duration (4.2 ± 0.8 vs. 6.9 ± 4.6 days, p = 0.007) and earlier chest tube removal (5.0 ± 2.6 vs. 9.5 ± 3.3 days, p = 0.01). No significant differences were found between the two groups for other secondary outcomes. Conclusions: Children with empyema appear to benefit from VATS compared to tube thoracostomy plus fibrinolytics, with improved outcomes. Further RCTs are needed to corroborate these results. Full article

A 6-month-old neutered male Belgian Malinois dog living in a kennel was presented to a veterinary emergency service for the management of severe respiratory distress that had developed within the past 24 h. Thoracic radiographs performed by a referring veterinarian showed abnormalities identified as a pneumothorax. Upon admission to the emergency service, the striking anomalies turned out to be a large intrathoracic air-filled cavity and countless smaller ones causing mechanical compression of the adjacent pulmonary parenchyma and mimicking tension pneumothorax. Emergency management included thoracocentesis followed by placement of a thoracostomy tube. The dog exhibited rapid clinical improvement and recovered completely within a few days, without requiring surgical intervention. Serial follow-up radiographs showed progressive and complete resolution of all lesions. Based on the complete resolution without resection, the main lesion—initially interpreted as a giant pulmonary bulla—was ultimately considered consistent with an acquired pneumatocele. To the authors’ knowledge, this is the first report in veterinary medicine of a vanishing lung syndrome presentation in a dog. Full article

Background: Tube thoracostomy, utilized through conventional methodologies in the context of pleural disorders such as pleural effusion and pneumothorax, constitutes one of the primary therapeutic interventions. Nonetheless, it is imperative to recognize that invasive procedures, including tube thoracostomy, are classified as aerosol-generating activities during the management of pleural conditions in patients afflicted with COVID-19, thus raising substantial concerns regarding the potential exposure of healthcare personnel to the virus. The objective of this investigation was to assess the SARS-CoV-2 viral load by detecting viral RNA in pleural drainage specimens from patients who underwent tube thoracostomy due to either pleural effusion or pneumothorax. Methods: In this single-center prospective cross-sectional analysis, a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) assay was employed to conduct swab tests for the qualitative identification of nucleic acid from SARS-CoV-2 in pleural fluids acquired during tube thoracostomy between August 2021 and December 2021. Results: All pleural drainage specimens from 21 patients who tested positive for COVID-19 via nasopharyngeal PCR, of which 14 underwent tube thoracostomy due to pneumothorax, 4 due to both pneumothorax and pleural effusion, and 3 due to pleural effusion, were found to be negative for SARS-CoV-2 RNA. Moreover, individuals exhibiting pleural effusion were admitted to the intensive care unit with a notably higher incidence, yet demonstrated significantly more radiological anomalies in patients diagnosed with pneumothorax. Conclusions: The current findings, inclusive of the results from this study, do not furnish scientific evidence to support the notion that SARS-CoV-2 is transmitted via aerosolization during tube thoracostomy, and it remains uncertain whether the virus can be adequately contained within pleural fluids. Full article

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care. Full article

Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials. Full article

Infective pleural effusions are mainly represented by parapneumonic effusions and empyema. These conditions are a spectrum of pleural diseases that are commonly encountered and carry significant mortality and morbidity rates reaching upwards of 50%. The causative etiology is usually an underlying bacterial pneumonia with the subsequent seeding of the infectious culprit and inflammatory agents to the pleural space leading to an inflammatory response and fibrin deposition. Radiographical evaluation through a CT scan or ultrasound yields high specificity and sensitivity, with features such as septations or pleural thickening indicating worse outcomes. Although microbiological yields from pleural studies are around 56% only, fluid analysis assists in both diagnosis and prognosis by evaluating pH, glucose, and other biomarkers such as lactate dehydrogenase. Management centers around antibiotic therapy for 2–6 weeks and the drainage of the infected pleural space when the effusion is complicated through tube thoracostomies or surgical intervention. Intrapleural enzymatic therapy, used to increase drainage, significantly decreases treatment failure rates, length of hospital stay, and surgical referrals but carries a risk of pleural hemorrhage. This comprehensive review article aims to define and delineate the progression of parapneumonic effusions and empyema as well as discuss pathophysiology, diagnostic, and treatment modalities with aims of broadening the generalist’s understanding of such complex disease by reviewing the most recent and relevant high-quality evidence. Full article

Evidence on the optimal antibiotic strategy for empyema is lacking. Our database study aimed to evaluate the effectiveness of empirical anti-pseudomonal antibiotics in patients with empyema. We utilised a Japanese real-world data database, focusing on patients aged ≥40 diagnosed with empyema, who underwent thoracostomy and received intravenous antibiotics either upon admission or the following day. Patients administered intravenous vasopressors were excluded. We compared thoracic surgery and death within 90 days after admission between patients treated with empirical anti-pseudomonal and non-anti-pseudomonal antibiotics. Cause-specific hazard ratios for thoracic surgery and death were estimated using Cox proportional hazards models, with adjustment for clinically important confounders. Subgroup analyses entailed the same procedures for patients exhibiting at least one risk factor for multidrug-resistant organisms. Between March 2014 and March 2023, 855 patients with empyema meeting the inclusion criteria were enrolled. Among them, 271 (31.7%) patients received anti-pseudomonal antibiotics. The Cox proportional hazards models indicated that compared to empirical non-anti-pseudomonal antibiotics, empirical anti-pseudomonal antibiotics were associated with higher HRs for thoracic surgery and death within 90 days, respectively. Thus, regardless of the risks of multidrug-resistant organisms, empirical anti-pseudomonal antibiotics did not extend the time to thoracic surgery or death within 90 days. Full article

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications. Full article

Backgrounds: Our goal is to evaluate the correct management of broncho-pleural fistula (BPF) after lobectomy for lung cancer. Methods: We retrospectively reviewed our 25-years’ experience and reported our strategies and our diagnostic algorithm for the management of post-lobectomy broncho-pleural fistula. Results: Five thousand one hundred and fifty (5150) patients underwent lobectomy for lung cancer in the period between 1998 and 2023. A total of 44 (0.85%) out of 5150 developed post-operative BPF. In 11 cases, BPF was solved by non-invasive treatment. In nine cases, direct surgical repair of the bronchial stump allowed BPF resolution. In 14 cases, a completion intervention was performed. In six cases, we performed open window thoracostomy (OWT) after lobectomy; in two cases, the BPF was closed by percutaneous injection of an n-butyl cyanoacrylate glue mixture. In two cases, no surgical procedure was performed because of the clinical status of the patient at the time of fistula developing. Thirty-day and ninety-day mortality from fistula onset was, respectively, 18.2% (eight patients) and 22.7% (ten patients). Thirty-day and ninety-day mortality after completion pneumonectomy (12 patients) was, respectively, 8.3% (one patient) and 16.6% (two patients). Conclusions: The correct management of BPF depends on various factors: timing of onset, size of the fistula, anatomic localization, and the general condition of the patient. In the case of failure of various initial therapeutic approaches, completion intervention or OWT could be considered. Full article