Drenaje pleural neonatal artesanal para neumotórax / Handmade neonatal pleural drainage for pneumothorax

Señor editor: La incidencia de neumotórax en neonatos oscila entre 1-2% en recién nacidos a término y alrededor del 6% en prematuros. Se presentan con mayor frecuencia en pacientes con patología pulmonar previa (neumonía, síndrome de aspiración meconial) y en aquellos que requieren tratamiento con presión positiva continua o ventilación mecánica.

Mr. Editor: The incidence of pneumothorax in neonates ranges from 1-2% in term neonates and about 6% in preterm infants. They occur more frequently in patients with previous pulmonary pathology (pneumonia, meconium aspiration syndrome) and in those who require treatment with continuous positive pressure or mechanical ventilation

Drenaje percutáneo con catéter del neumotórax en pacientes con COVID­19 / Percutaneous catheter drainage of pneumothorax in patients with COVID-19

Introducción. La transmisión del SARS-CoV-2 principalmente se da por gotas y contacto cercano con las per-sonas infectadas, pero los aerosoles parecen ser también una fuente de infección. El neumotórax espontáneo o secundario puede presentarse en pacientes con COVID-19, ayudado por patologías de base como la enfermedad pulmonar obstructiva crónica. Es necesario garantizar procedimientos seguros para los pacientes y buscar todas las medidas posibles para la protección del personal de la salud, por eso el drenaje de neumotórax con catéter pleural en lugar de sonda de toracostomía puede ser una de ellas.El objetivo de este estudio es presentar a los cirujanos una alternativa a la toracostomía tradicional, mediante la utilización de catéteres de menor diámetro, para la resolución de la ocupación pleural.Aspectos Técnicos. Se presenta el protocolo para inserción segura de un catéter pleural para el drenaje de neumotórax, mediante un sistema completamente cerrado, y se dan recomendaciones sobre el uso de filtros virales y solución viricida en el sistema de drenaje pleural conectado al catéter. Conclusión. El estado de pandemia por COVID-19 y el riesgo que representa para los profesionales de la salud la exposición a fuentes de transmisión durante procedimientos generadores de aerosoles, hace que se deban extremar las medidas para evitar el contagio.

Introduction. The transmission of SARS-CoV-2 mainly occurs by drops and close contact with infected people, but aerosols also seem to be a source of infection. Spontaneous or secondary pneumothorax can occur in patients with COVID-19, helped by underlying pathologies such as chronic obstructive pulmonary disease. It is necessary to guarantee safe procedures for patients and to seek all possible measures for the protection of health personnel, so drainage of pneumothorax with a pleural catheter instead of a thoracostomy tube may be one of those. The objective of this study is to present surgeons with an alternative to traditional thoracostomy, using smaller diameter catheters, to resolve pleural occupancy.Technical aspects. The protocol for the safe insertion of a pleural catheter for pneumothorax drainage is presented, using a completely closed system, and recommendations are given on the use of viral filters and viricidal solution in the pleural drainage system connected to the catheter.Conclusions. The state of the COVID-19 pandemic and the risk that exposure to sources of transmission sources during aerosol-generating procedures represents for health professionals means that extreme measures must be taken to avoid contagion.

Preventive Effect of Tolvaptan on Pleural Effusion after Cardiac Valvular Surgery / 日本心臓血管外科学会雑誌

Background : Post-operative fluid management after cardiac valvular surgery is very important. In our institute, carperitide 0.0125 γ was started during surgery and oral furosemide 20-40 mg/day and spironolactone 25 mg/day were started at post-operative day (POD) 1 as the standard therapy. Tolvaptan, vasopressin V2 receptor antagonist, was started when fluid retention such as pleural effusion occurred. With this strategy, the frequency of pleural drainage was more than 40%. Therefore we changed our standard therapy in February 2018. In this new standard therapy, carperitide (0.0125 γ) was started and maintained until oral intake became possible and tolvaptan 7.5 mg was started with furosemide 20 mg and spironolactone 25 mg as oral medicine usually at POD 1. In this study, whether tolvaptan prevents pleural effusion or not after cardiac surgery was examined. Subjects and Methods : Sixty-four patients were operated during February 2017 and December 2018 were included in this study. Thirty-two patients operated in the period until January 2018 served as control group and were compared with 32 patients for whom tolvaptan was started on POD 1 (tolvaptan group). Results : There was no significant difference between two groups for background, operative procedure, operation time, cardiopulmonary bypass time, aortic cross clamp time and fluid balance during procedure. Tolvaptan was given to all patients in the tolvaptan group and in 22% of patients in the control group. Oral furosemide dose (tolvaptan group 21±5 mg/day, control group 31±20 mg/day, p＝0.0112), and the frequency of patients with intravenous furosemide administration (tolvaptan group 9%, control group 44%, p＝0.0038) were significantly less in tolvaptan group. In the tolvaptan group, intravenous furosemide administrated only once in all patients, whereas the frequency of intravenous furosemide administration was 1-32 times, average 6.6 times in control group. Tolvaptan was stopped within 1 week because of too much urination in two patients and the elevation of liver enzyme in two patients without any adverse effects. Post-operative urination volume until POD 5 did not differ. In both groups, body weight increased at POD 1 and 2 and returned to pre-operative weight at POD 3. Pleural effusion was significantly less in the tolvaptan group at POD 3 (tolvaptan group : none 66%, small amount 22%, moderate amount 3%, drain tube inserted 9%, control group : none 16%, small amount 34%, moderate amount 13%, drain tube inserted 38%, p＝0.0003), at POD 7 (tolvaptan group : none 72%, small amount 28%, vs., control group : none 47%, small amount 19%, moderate amount 22%, drain tube inserted 13%, p＝0.0041) and at discharge (tolvaptan group : none 94%, small amount 6%, vs., control group : none 69%, small amount 22%, moderate amount 9%, p＝0.0301). The frequency of pleural drainage was also less in the tolvaptan group (tolvaptan group 9.4%, control group 44%, p＝0.0038). Conclusion : After cardiac valvular surgery, tolvaptan started at POD 1 is very effective to reduce the frequency of pleural effusion and pleural drainage, and careful checking for too much urination and the elevation of liver enzymes is mandatory.

Diagnóstico y tratamiento del derrame pleural paraneumónico / Diagnosis and treatment of parapneumonic pleural effusion

El derrame paraneumónico ocurre como complicación de una neumonía y en nuestro medio corresponde al 2% de las hospitalizaciones de causa respiratoria. Se debe sospechar en pacientes con neumonía presentan evolución desfavorable y debe confirmarse por exámenes de imágenes. El estudio y drenaje del líquido pleural es fundamental para un manejo adecuado y evolución satisfactoria, por lo que la toracocentesis y la instalación de drenaje pleural no deben retrasarse. El tratamiento debe ser hospitalizado, con antibióticos endovenosos y en la mayoría de los casos la evolución es satisfactoria y sin secuelas para el paciente.

Paraneumonic effusion occurs as a complication of pneumonia and in our case corresponds to 2% of respiratory hospitalizations. It should be suspected in patients with pneumonia presenting unfavorable evolution and must be confirmed by imaging tests. The study and drainage of pleural fluid is essential for adequate management and satisfactory evolution, so that thoracentesis and pleural drainage installation should not be delayed. The treatment should be hospitalized with intravenous antibiotics and in most cases the evolution is satisfactory and without sequelae for the patient.

Hemotórax: etiología, diagnóstico, tratamiento y complicaciones / Hemothorax: etiology, diagnosis, treatment and complications

Resumen La sospecha de hemotórax inicia con una historia clínica adecuada, particularmente, el padecimiento actual, por ejemplo, casos con trauma torácico. El paso inicial de la evaluación es diferenciar los derrames pleurales hemorrágicos de los verdaderos hemotórax. Confirmar el diagnóstico de manera temprana es fundamental, dado que, conforme progresan las fases de organización del coágulo, se van desarrollando adherencias entre la superficie del parénquima pulmonar y la pleura parietal, aspecto que dificulta evacuarlo mediante drenaje pleural convencional. La radiografía de tórax continúa siendo el estudio complementario inicial, sin embargo, es importante realizar estudios adicionales que permitan orientar la decisión terapéutica; la elección del análisis paraclínico puede justificarse con base en la experiencia y disponibilidad de recursos en el centro de atención. La instalación del tratamiento primario es crucial e inicia con el drenaje de la cavidad torácica vía sonda pleural en la mayoría de los casos; el uso de fibrinolíticos se considera de segunda línea y particularmente en hemotórax coagulado o casos que tienen riesgos significativos de complicaciones al someterse a un procedimiento quirúrgico mayor (Por ejemplo. decorticación). Las complicaciones se pueden disminuir al sistematizar el enfoque diagnóstico-terapéutico.

Abstract Initial approach of cases with suspected hemothorax begins with a complete clinical history (eg. recent thoracic trauma). The first step is to differentiate hemorrhagic pleural effusion of true hemothorax; then, prompt diagnosis is essential. We must keep in mind, as time progresses, the clot firmly adheres to the lung and pleural surface making it difficult to treat; therefore, any delay in this process diminishes the opportunity to evacuate the hemothorax through conventional thoracostomy with chest tube insertion and pleural drainage. Chest X-ray still the initial study, however, complementary tests should be performed in order to guide therapeutic decisions. The choice must be justified on local availability and experience. Undoubtedly, primary evacuation is mandatory; fibrinolytics are reserved as second-line treatment, also can be considered in coagulated hemothorax or patients who are at a high risk of surgical complications. In order to diminish any morbidity it is advisable to perform a systematic diagnostic and therapeutic approach.

Drenagem pleural / Drainage of pleural fluids

A drenagem pleural é procedimento cirúrgico largamente utilizado na prática médica diária, que permite o restabelecimento das pressões negativas no espaço pleural. Apesar de ser considerado ato relativamente simples, poderá levar à graves complicações devido a falta de cuidados que precisam ser respeitados. Procuramos ressaltar alguns aspectos que, se não respeitados no seu conjunto, acabam determinando o insucesso dos procedimentos de drenagem de tórax.

Drainage of pleural fluids, which allows for the reestablishment of negative pressures in the pleural space, is widely employed in routine medical practice. Despite being considered a relatively simple act, it may lead to severe complications if adequate care is not taken. We will highlight some aspects which, if not well tended to, will result in unsuccessful outcome of chest drainage procedures.

Rapid diagnosis of pleural effusion due to tuberculosis by polymerase chain reaction (PCR)

Polymerase chain reaction was used to detect DNA sequence belonging to IS 6110, specific agent for M.tuberculosis, directly in pleural fluids of 48 patients suspected to be due to tuberculosis and 13 patients suspected to be due to lung cancer selected by clinical, biochemical and cytological data. Excepted 2 samples showed to have inhibition factors to the activity of tag polymerase, 33 of 48 samples were found PCR positive, giving a sensitivity of 72%. All 13 pleural fluids taken from patients with pleural effusion due to cancer were PCR negative. The results: PCR of pleural fluid can be a useful method for rapid diagnosis of pleural effusion due to tuberculosis, which is difficult to differentiate with those due to cancer.

Incidência de empiema pleural no trauma isolado do tórax com e sem uso da antibioticoterapia / Incidence of empyema in isolated chest trauma with and without antibiotic therapy

OBJETIVO: O objetivo do presente estudo foi avaliar a incidência de empiema pós-drenagem pleural fechada, nos pacientes com lesão isolada do tórax, com e sem uso da antibioticoterapia associada. MÉTODO: Utilizando o modelo estatístico de acompanhamento de coortes, os autores analisaram 167 pacientes acometidos por lesão traumática do tórax. Dois grupos foram selecionados para o estudo. O grupo controle incluiu 104 (62,3 por cento) pacientes sem uso da antibioticoterapia e, no grupo experimental, 63 (37,7 por cento) pacientes receberam a cefalotina sódica no pós-operatório (500mg IV - 6/6h). RESULTADOS: Entre os pacientes estudados, 12 (7,2 por cento) apresentavam trauma fechado; 98 (58,7 por cento), ferimento por arma branca; 41 (24,6 por cento) ferida por projétil de arma de fogo e 16 (9,5 por cento) lesões por outros agentes vulnerantes. Entre os pacientes do grupo controle o tempo médio de permanência hospitalar foi de 5,7±3,2 dias e, no grupo com antibiótico, 5,7±2,9 dias. Os resultados mostraram que oito (4,7 por cento) pacientes evoluíram com quadro de empiema pleural, sendo sete (6,7 por cento) casos no grupo controle e apenas um (1,5 por cento) no grupo experimental (p=0,26). O hemotórax coagulado foi a complicação não infecciosa mais freqüente, incidindo em 21 (12,5 por cento) pacientes. CONCLUSÃO: No presente estudo, os resultados mostram que o uso da antibioticoterapia não se mostrou eficaz em diminuir a incidência de empiema pleural nos pacientes submetidos à drenagem pleural pós-traumática.

BACKGROUND: The aim of this study was to evaluate the incidence of pleural empiema associated with tube thoracostomy on patients with isolated chest injury, with or without the use of associated antibiotic therapy. METHOD: Using cohorts accompaniment statistical model, the authors analysed 167 patients with blunt or penetrating chest trauma. Two groups were selected for this study. Control group included 104 (62.3 percent) patients without antibiotic therapy; the experimental group, 63 (37.7 percent) patients, received cefalotin postopertively (500mg IV; every 6 hours). RESULTS: Twelve (7.2 percent) presented blunt trauma; 98 (58,7 percent) were stabbed, 41(24.6 percent) were wounded by fire arms; 16 (9.5 percent) injuries were associated with other type of accidents. The average length of stay for the control group in was 5.7±3.2 days, and for the antibiotic group was 5.7±2.9 days. The results showed that eight patients evolved with the pleural empyema, being seven cases from the control group, and only one from the experimental group (p=0.02). Clotted hemotorax was the most frequent non infectious complication occurring on 21 (12.5 percent) patients. CONCLUSIONS: The use of antibiotics were not effective on lowering the incidence of pleural empyema on patients that submitted to post-traumatic pleural drainage.

Edema pulmonar de reexpansão tratado com ventilação não invasiva: relato de caso / Reexpansion pulmonary edema treated with non-invasive ventilation: case report

The authors report a case of Reexpansion Pulmonary Edema (RPE) seen at Hospital de Pronto Socorro de Porto Alegre 3 hours after drainage of spontaneous pneumothorax. The patient presented a unilateral pneumothorax with one-week duration. After pleural drainage respiratory failure occured being managed at the Intensive Care Unit with non-invasive positive pressure ventilation through facial mask. The patient had favorable outcome and was discharged asymtomatic after 72 hours.

Trauma torácico: fatores de risco de complicações pleuropulmonares pós-drenagem pleural fechada / Thoracic trauma: a risk analysis of pulmonary complications following closed tube thoracostomy

O objetivo do presente estudo foi avaliar a importância dos fatores de risco na gênese das complicações pleuropulmonares, pós-drenagem pleural fechada. Analisou-se, prospectivamente, no período de janeiro de 1998 a junho de 1999, um total de 167 pacientes submetidos à drenagem pleural fechada, sendo estratificados emdois grupos selecionados para um estudo de acompanhamento de coortes. Ao grupo controle, de 104 pacientes,não foi administrada antibioticoterapia e, no grupo experimental, de 63 pacientes, a cefalotina foi a droga utilizada. A idade no grupo-controle variou entre 13 e 53 anos (26,8±8,9) e no grupo experimental entre 15 e 57(24,9±7,9), predominando o sexo masculino (95,2%), nos dois grupos estudados. O trauma aberto incidiu em92,8% dos pacientes, com predominância para as feridas por arma branca em 58,7%, contra 24,6% de feridas por projétil de arma de fogo. As complicações pleuropulmonares estiveram presentes em 35 pacientes (33,78%) do grupo controle, ao passo que, no grupo experimental, apenas 18 (28,6%) evoluíram com este tipo de complicação. Não ocorreram óbitos em ambas as séries estudadas. Nas análises estatísticas, o modelo bivariado mostrou que o tipo de trauma e o tempo de drenagem pleural foram as variáveis que mais importância tiveram como fatores preditivos de complicações. Na análise de regressão logística multivariada, as variáveis tempo de internação, trauma fechado e volume de sangue drenado maior do que 500ml, quando associadas, influenciaram de maneira positiva a ocorrência de complicações.

The objective of this study was to analyse the risk factors for the development of thoracic infections after tube thoracostomy. Although technically simple, this procedure, 1 to 25 percent of the patients develop some type ofintra or post-operative complications. A total of 167 patients, submitted to emergency tube thoracostomy, wereadmitted and stratified into two groups selected by randomic sampling to a cohorts accompanying study. Onehundred and four patients, without antibiotic therapy, were considered as been the control group; and, 63 patientsusing cefalotin in post-operative as the experimental group. The mean age of the patients in the control group was26.8±8.9 years (range, 13 - 53), and 24.9±7.9 years (range, 15 - 57) for experimental group, predominating themale sex (95.2%) in both studied groups. The penetrating chest trauma was present in 92.8% of the patients, with a higher incidence of stab wounds (58.7%) in contrast to gunshot wounds (24.6%). Thoracic complications werepresent in 35 patients (33.7%) of the control group, whereas, in the experimental group, only 18 patients (28.6%) developed this kind of complication. In the statistic significance analysis, the bivariate model indicated that the variable trauma type and the duration of pleural space drainage were the most relevant ones as predictive factors for infections complications. In the multivariate logistic regression, the variables blunt chest trauma, length ofhospital stay and drainage blood volume higher than 500 ml, when associated, influenciated positively on the occurrence of these complications.

Quilotórax pós-traumático: experiência no pós-operatório de cirurgia cardiotorácica / Traumatic Chylothorax. Experience in the Postoperative Period of Cardiovascular Surgery

PURPOSE--To report the accumulated experience in the treatment of patients with postoperative chylothorax (CHT) recovery utilizing pleural drainage associated to alipoidic diet and/or intravenous nutrition. METHODS--The aim of this work is to analyse the management of 11 patients (8 males; 11 months to 70 years old) with post-operative CHT. The previous pathologies were: congenital heart disease in 7; coronary insufficiency in 2; pulmonary tumor in 1 and mediastinal tumor in 1. The diagnosis was made up to 2nd postoperative week in 6, up to 4th week in 3 and later in 2 patients. The volume through the drain ranged from 200 to 3200ml/24h (median 636ml/24h). The laboratory diagnosis was made by lipidic presence in pleural effusion. In all patients the clinical management was made by hipo or alipoidic diet. RESULTS--In 7 the response was good with a decrease of drainage progressively. In 4, it was necessary the introduction of intravenous nutrition by the insufficient response and maintenance of drainage. The reoperation was not used and lymph fistula closed in a period until 10 days in 1 patient; until 20 days in 6 and after this in 4. CONCLUSION--In conclusion, the post-operative CHT may be treated by thoracic drainage and alipoidic diet and/or intravenous nutrition with fistula closure in all patients and without need of reoperation

Objetivo - Relatar a experiência acumulada no tratamento de pacientes portadores de quilotórax (QT) pós-operatório com o uso de drenagem pleural associada à dieta alipídica e/ou nutrição parental. Métodos - Foram analisados 11 pacientes (8 do sexo masculino, com idade variando de 11 meses a 70 anos) com QT pós-operatório. As patologias eram: cardiopatias congênitas em 7; insuficiência coronária em 2; tamoração pulmonar em 1 e mediastinal em 1. O diagnóstico foi feito até a 2ª semana de pós-operatório em 6, até a 4ª semana em 3 e mais tardiamente em 2. Todos os pacientes foram submetidos à punção e/ou drenagem torácica e o volume drenado variou de 200 a 3200ml/24h (média de 636ml/24h). O diagnóstico laboratorial foi feito pela presença de lipídios no líquido pleural. Em todos os pacientes, o tratamento clínico constou de dieta hipo ou alipídica. Resultados - Em 7 pacientes houve uma diminuição da drenagem mas em 4 foi necessária a introdução de nutrição parenteral, visto que a diminuição da drenagem não ocorreu. A reoperação não foi realizada em qualquer um destes pacientes e houve fechamento da fístulan um período de 10 dias em 1 paciente, até 20 dias embe em mais de 20 dias em 4. Conclusão - O QT pós-operatório pode ser tratado por drenagem torácica e dieta alipídica e/ou nutrição parenteral com fechamento da fístula em todos os pacientes, sem necessidade de reoperação