To develop, implement and evaluate an integrated care pathway for patients presenting with pneumothorax.

BACKGROUND AND PURPOSE: Pneumothorax is a common presentation to acute healthcare services in Ireland, however there is wide variation in management approaches between centres. There is robust evidence to demonstrate that ambulatory management of pneumothorax is feasible and safe. The purpose of this study was to evaluate whether the implementation of an integrated care pathway (ICP) for pneumothorax patients with a focus on ambulatory care would be economically beneficial for the healthcare system. METHODS: This study developed, implemented and evaluated an ICP for all patients presenting with pneumothorax, with a specific focus on ambulatory management for suitable patients. The ICP was designed to be utilised in the Irish healthcare setting, and was evaluated using a prospective multi-centre observational study, with a rigorous economic analysis at the centre of study design. MAIN FINDINGS: Implementation of the ICP resulted in a statistically significant reduction in inpatient length of stay of 2.84 days from 7.4 to 4.56 days (p = 0.001). The incremental per patient cost reduction of treating a patient according to the pneumothorax ICP was 2314 euro. There were no adverse events related to drain insertion at the study sites. CONCLUSIONS: This study demonstrates therefore that standardisation of care for pneumothorax patients with a focus on ambulatory management are economically beneficial for the publicly-funded healthcare service. It is envisaged that this work will be used to inform healthcare policy at a national level across Ireland.

Neumotórax espontáneo / Spontaneous pneumothorax

Introducción: El neumotórax espontáneo es la causa más frecuente de ingreso urgente en los servicios de cirugía torácica. Objetivo: Caracterizar a pacientes ingresados con diagnóstico de neumotórax espontáneo. Métodos: Se realizó un estudio descriptivo de 93 pacientes con diagnóstico clínico y radiológico de neumotórax espontáneo, se establecieron las variables del estudio y se utilizaron frecuencias absolutas y porcentajes. Para la asociación de las variables se empleó el estadígrafo ji cuadrado con un nivel de confiabilidad del 95 por ciento. Resultados: Predominó el neumotórax espontáneo primario (65,5 por ciento), el sexo masculino fue el más afectado (80,6 por ciento), con mayor frecuencia en el hemitórax derecho (72,2 por ciento) y el tabaquismo como antecedente (83,9 por ciento). La pleurostomía mínima fue el tratamiento definitivo en el 72 por ciento de los pacientes. La complicación más frecuente después de la pleurostomía, fue la fuga persistente de aire. El tratamiento quirúrgico con pleurodesis mecánica, ofreció un 100 por ciento de efectividad. La mortalidad quirúrgica fue nula. Conclusiones: El neumotórax espontáneo predomina en el sexo masculino en una proporción de 4,2:1, en pacientes menores de 40 años de edad. El antecedente patológico personal que más se asocia es la enfermedad pulmonar obstructiva crónica. El síntoma predominante es el dolor torácico. El neumotórax espontáneo primario fue más frecuente y el hemitórax derecho el más afectado. El tabaquismo está presente como antecedente en ambos tipos de neumotórax espontáneo. La modalidad de tratamiento más utilizada es la pleurostomía mínima(AU)

Introduction: Spontaneous pneumothorax is the most frequent cause of urgent admission to thoracic surgery services. Objective: To characterize patients admitted with a diagnosis of spontaneous pneumothorax. Methods: A descriptive study of 93 patients with a clinical and radiological diagnosis of spontaneous pneumothorax was carried out, the study variables were established and absolute frequencies and percentages were used. For the association of the variables, the chi square statistic was used with a confidence level of 95 percent. Results: Primary spontaneous pneumothorax predominated (65.5 percent), the male sex was the most affected (80.6 percent), with greater frequency in the right hemithorax (72.2 percent) and smoking as the antecedent (83.9 percent). Minimal pleurostomy was the definitive treatment in 72 percent of the patients. The most frequent complication after pleurostomy was persistent air leak. Surgical treatment with mechanical pleurodesis offered 100 percent effectiveness. There was not surgical mortality. Conclusions: Spontaneous pneumothorax predominated in males in a ratio of 4.2: 1, in patients under 40 years of age. The most associated personal pathological history was chronic obstructive pulmonary disease. The predominant symptom was chest pain. Primary spontaneous pneumothorax was more frequent and the right hemithorax the most affected. Smoking was present as a history in both types of spontaneous pneumothorax. The most widely used treatment modality was minimal pleurostomy(AU)

Safe chest tube placement in a patient with tension pneumothorax receiving rivaroxaban therapy for non-valvular atrial fibrillation.

The number of patients treated with direct oral anticoagulants is increasing worldwide. Although bleeding complications associated with direct oral anticoagulants are lower than those associated with vitamin K antagonists, the increased number of patients treated with these anticoagulants suggests that a higher absolute number of patients are at risk. Tube thoracostomy is an invasive procedure with a high risk of bleeding. To date, among direct oral anticoagulants, only dabigatran has a well-studied antidote to reverse its effects during emergency procedure or surgery. This report describes a case in which emergency placement of a tube thoracostomy, in a patient with type 2 respiratory failure due to left tension pneumothorax and receiving the anticoagulant rivaroxaban, in the pharmacokinetics phase with greater anticoagulant effect, did not result in bleeding greater than that typically encountered during such interventions. The procedure ended successfully with no acute complications.

Mycobacterium abscessus subsp. abscessus empyema complicated with subcutaneous abscess.

There have been no case reports of thoracic subcutaneous abscess after surgery for Mycobacterium abscessus complex associated empyema. We herein report a case of Mycobacterium abscessus subsp. abscessus (M. abscessus subsp. abscessus) induced subcutaneous abscesses following surgical treatment for concurrent M. abscessus subsp. abscessus -associated empyema and pneumothorax. A 75-year-old woman had M. abscessus subsp. abscessus -associated empyema and pneumothorax. She underwent surgical treatment of decortication and fistulectomy and suffered from M. abscessus subsp. abscessus -associated subcutaneous abscesses after thoracentesis/drainage. A multidisciplinary approach combined with surgical care, thermal therapy, and multidrug chemotherapy contributed to a successful result. An early multidisciplinary approach is believed to be important in cases of M. abscessus subsp. abscessus -associated empyema and subcutaneous abscess.

Early Autologous Blood-Patch Pleurodesis versus Conservative Management for Treatment of Secondary Spontaneous Pneumothorax.

BACKGROUND: Autologous blood-patch pleurodesis has been effectively utilized as a treatment option for the condition of secondary spontaneous pneumothorax (SSP). Moreover, it can be used with persistent air leak, with or without residual air space. However, there have been no robust reports for the optimal timing for autologous blood-patch pleurodesis. The aim of this study is to compare early autologous blood-patch pleurodesis with conservative management of SSP. METHODS: We conducted a randomized controlled study at the Menoufia University Hospital. A total of 47 patients with SSP were randomly allocated into two groups: group A (23 patients) received intrapleural instillation of 50 mL autologous blood 3 days after insertion of chest drain and group B (24 patients) managed conservatively. The duration required for air leak to seal, chest drainage duration, length of hospital stay, and the incidence of complications were compared and statistically analyzed. RESULTS: The duration of air leak, duration to drain removal, and length of hospital stay were all significantly shorter in group A than in group B. CONCLUSION: Early intrapleural instillation of autologous blood is successful in sealing air leak in patients with SSP with persistent air leak, who are not fit or not willing to undergo surgery. It is superior to conservative treatment or late instillation of autologous blood, even if their lungs are not fully expanded.

Bilateral tension pneumothorax after acupuncture.

Acupuncture is an ancient complementary medicine which is currently used worldwide. Many serious adverse events have been reported which include a spectrum of mild-to-fatal complications. However, the level of awareness with regard to complications is still low both to physicians and patients. We report a 63-year-old who presented with acute shortness of breath 2 hours after having had acupuncture. On examination, there was absent breath sound heard on the left lung and slightly reduced breath sound on the right lung. She had type 1 respiratory failure. Urgent chest radiograph confirmed bilateral pneumothorax which was more severe on the left with tension pneumothorax and mediastinal shift. Chest tubes were inserted bilaterally after failed needle aspiration attempts. Subsequently, the pneumothoraces resolved, and she was discharged well. The bilateral pneumothoraces caused by acupuncture were curable but could have been potentially fatal if diagnosis was delayed. This case report adds to the limited current literature on the complications of acupuncture leading to bilateral pneumothoraces.

Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT-Guided Needle Biopsy.

PURPOSE: To investigate whether an autologous intraparenchymal blood patch (IPB) reduces the rate of pneumothorax-related complications associated with computed tomography (CT)-guided lung biopsies. MATERIALS AND METHODS: This study included 834 patients: 482 who received an IPB and 352 who did not. Retrospective review was performed of all CT-guided lung biopsies performed at a single institution between August 2006 and September 2013. Patients were excluded if no aerated lung was crossed. The rate of pneumothorax, any associated intervention (eg, catheter placement, aspiration), chest tube placement, and chest tube replacement requiring hospital admission were compared by linear and multiple regression analysis. RESULTS: Patients who received an IPB had a significantly lower rate of pneumothorax (145 of 482 [30%] vs 154 of 352 [44%]; P < .0001), pneumothorax-related intervention (eg, catheter aspiration, pleural blood patch, chest tube placement; 43 of 482 [8.9%] vs 85 of 352 [24.1%]; P < .0001), and chest tube placement along with other determinants requiring hospital admission (18 of 482 [3.7%] vs 27 of 352 [7.7%]; P < .0001). No complications related to the IPB were noted in the study group. CONCLUSIONS: Autologous IPB placement is associated with a decreased rate of pneumothorax and associated interventions, including chest tube placement and hospital admission, after CT-guided lung biopsies, with no evidence of any adverse effects. These results suggest that an IPB is safe and effective and should be considered when aerated lung is traversed while performing a CT-guided lung biopsy.

17 Cases of Acupuncture Related Pneumothorax and Factors Influencing Pneumothorax.

OBJECTIVES: Acupuncture is increasing in popularity as a complementary and alternative medicine. Pneumothorax is the most common and potentially serious adverse effect after acupuncture. This complication can cause fatality in the absence of rapid treatment. Here, we analyze the clinical presentation and discuss prevention of post-acupuncture pneumothorax and an approach to reducing this complication. METHODS: Patients presenting with post-acupuncture pneumothorax in our hospital center during 2011-2015 were retrospectively analyzed. Body mass index (BMI), patient's pre-acupuncture chief complaint and disease, and the characteristics associated with pneumothorax were assessed. The diagnosis of pneumothorax was based on clinical presentation and chest radiography. Conservative treatment or thoracostomy was performed. RESULTS: Seventeen patients (15 women and 2 men) with a mean age of 42 years (range: 18-73 years) were included; three were underweight (BMI < 18.5kg/m2), 11 patients had a healthy weight (BMI= 18.5-22.95kg/m2), one was overweight (BMI = 23- 24.95kg/m2), and two were obese (BMI ≥ 25 kg/m2). All but one case of bilateral pneumothorax had unilateral pneumothorax (right side: 6; left side: 10). Chest pain or dyspnea, or both. were the initial symptoms in all patients. Twelve patients underwent immediate thoracostomy. The patient with bilateral pneumothorax underwent right-side thoracostomy, and subsequently left-side thoracostomy, due to progression of the left-side pneumothorax. Five patients were successfully managed conservatively. All patients had an excellent outcome; all were asymptomatic and exhibited a normal chest X-ray at follow-up. CONCLUSION: Acupuncturists must be aware that delayed diagnosis and management of pneumothorax are life-threatening, and when symptoms of possible pneumothorax arise, patients should be advised to undergo an appropriate evaluation and intervention, particularly so in those with abnormal BMI.

Dependent Lung Tension Pneumothorax During 1-Lung Ventilation: Treatment by Transmediastinal Thoracentesis.

Contralateral tension pneumothorax during 1-lung ventilation is rare but life threatening. We report the case of a patient who developed tension pneumothorax of the dependent lung during 1-lung ventilation while the surgeon was anastomosing the bronchi after sleeve lobectomy. Ventilation was not possible in either the dependent or nondependent lung, leading to severe desaturation and cardiac arrest. While the surgeons were administering direct cardiac compression, we suspected tension pneumothorax. As soon as the surgeons pierced the mediastinal pleura, adequate circulation was restored. Immediate diagnosis and treatment is important for this complication.

A case of tension pneumothorax during hyperbaric oxygen therapy in an earthquake survivor with crush injury complicated by ARDS (adult respiratory distress syndrome).

Pneumothorax (PTX) is rarely reported in patients receiving hyperbaric oxygen (HBO2) therapy. Patients with air-trapping lesions in the lungs and those with a history of spontaneous PTX, lung disease, mechanical ventilation or chest trauma are at an increased risk for PTX during HBO2 therapy. A 28-year-old male earthquake survivor was referred to our center for multiple wounds 21 days after being rescued from the debris. He had been intubated and put on mechanical ventilation for three days because of adult respiratory distress syndrome (ARDS). At initial presentation, he was conscious, well-oriented and hemodynamically stable. The initial six HBO2 treatments were uneventful. On the seventh HBO2 treatment, the patient lost consciousness and developed cardiopulmonary arrest near the end of decompression. The HBO2 specialist accompanying the patient inside the chamber immediately initiated CPR. A diagnosis of tension PTX was made. After the patient was removed from the chamber, a chest tube was inserted, which improved the symptoms. Although rare, tension PTX can occur during HBO2 therapy. Early diagnosis and intervention are crucial for saving a patient's life. Increased vigilance is required during treatment of patients with risk factors for PTX.

Pneumothorax as a complication of combination antiangiogenic therapy in children and young adults with refractory/recurrent solid tumors.

PURPOSE: Antiangiogenic agents show significant antitumor activity against various tumor types. In a study evaluating the combination of sorafenib, bevacizumab, and low-dose cyclophosphamide in children with solid tumors, an unexpectedly high incidence of pneumothorax was observed. We evaluated patient characteristics and risk factors for the development of pneumothorax in patients receiving this therapy. PATIENTS AND METHODS: Demographics, clinical course, and radiographic data of 44 patients treated with sorafenib, bevacizumab and cyclophosphamide were reviewed. Risk factors associated with the development of pneumothorax were analyzed. RESULTS: Pneumothorax likely related to study therapy developed in 11 of 44 (25%) patients of whom 33 had pulmonary abnormalities. Median age of patients was 14.7 years (range, 1.08-24.5). Histologies associated with pneumothorax included rhabdoid tumor, synovial sarcoma, osteosarcoma, Ewing sarcoma, Wilms tumor, and renal cell carcinoma. Cavitation of pulmonary nodules in response to therapy was associated with pneumothorax development (P<0.001). Median time from start of therapy to development of pneumothorax was 5.7 weeks (range, 2.4-31). CONCLUSION: The development of cavitary pulmonary nodules in response to therapy is a risk factor for pneumothorax. As pneumothorax is a potentially life-threatening complication of antiangiogenic therapy in children with solid tumors, its risk needs to be evaluated when considering this therapy.

Surgical treatment of catamenial pneumothorax: Report of three cases.

Catamenial pneumothorax (CP) is a rare entity of spontaneous, recurring pneumothorax in females. Although it has been known to be associated with thoracic endometriosis, varying clinical course and the lack of consistent intraoperative findings have led to conflicting etiological theories. We herein discuss the etiology, clinical course, and surgical treatment of three patients with CP. Three females (aged 40 years, 28 years, and 34 years) had recurrent right-sided spontaneous pneumothoraces that coincided with their menses. They had undergone video-assisted thoracoscopic surgery (VATS) previously. Blueberry spots in the right diaphragm were detected in all three cases. Two patients had recurrence, postoperatively. The other patient, who received luteinizing hormone-releasing hormone analog therapy for an abdominal endometriosis in the perioperative period and postoperative chemical pleurodesis to prevent recurrence, has been free of recurrence for 15 months, postoperatively. However, pelvic endometriosis was detected in this patient only. Therefore, CP should be suspected in ovulating females with spontaneous pneumothorax, even in the absence of any symptoms associated with pelvic endometriosis. In addition, while performing VATS, careful inspection of the diaphragmatic surface is important. In complicated cases, hormonal suppression therapy and chemical pleurodesis might also be helpful adjunct modalities.

[Bilateral pneumothorax following acupuncture]. / Bilateraler Pneumothorax nach Akupunktur.

Acupuncture, a subsection of traditional Chinese medicine, plays an important role as an alternative healing method. Even though there is little proof of its efficacy, acupuncture is becoming more and more popular in the Western world, especially because it is considered almost free of side effects. However, severe complications may occur and have previously been described.We will present a patient who suffered from bilateral pneumothoraces after acupuncture into the paravertebral area. This complication was not considered as a differential diagnosis thus even worsening the patient's life-threatening condition.

Efficacy of arginine supplementation for the treatment of air leakage.

BACKGROUND: Recently, the role of the amino acid arginine in wound healing has been emphasized. We studied whether postoperative enteral arginine supplementation can contribute to the resolution of prolonged air leakage after lung resections. METHODS: 42 patients undergoing lung resection at our institutions from 2009 to 2012 were enrolled in this study. In these patients, continuous air leakage in the expiratory phase was identified on the day of surgery and on the following day. The patients were divided into 2 groups; the first group included 21 patients consuming 3 packs of an arginine supplement beverage daily postoperatively, and the second group (control) included 21 patients who did not consume any additional supplements. The durations of air leakage and chest tube drainage were compared between the two groups. RESULTS: The mean durations of air leakage and chest tube drainage were shorter in the arginine supplementation group (4.4 vs. 6.7 days, p = 0.010; 6.5 vs. 8.3 days, p = 0.042, respectively). CONCLUSION: Postoperative enteral arginine supplementation may contribute to stopping air leaks after lung surgery.

The acupunctured lung.

We discuss a 72-year-old woman admitted with acute shortness of breath and severe sharp chest pain several hours after receiving acupuncture therapy. She was subsequently diagnosed as having an iatrogenic pneumothorax secondary to acupuncture. We discuss the complications of acupuncture and why patients should be informed of the risks of such procedures.

Awake video-thoracoscopic surgery for intractable pneumothorax in pregnancy by using a single portal plus puncture.

A 31-year old female patient in the ninth week of pregnancy complained of chest pain and dyspnoea. The patient had experienced an episode of spontaneous pneumothorax on the left side at the age of 20 and had undergone chest tube drainage. Her medical history was unremarkable and she had no history of smoking. She had no family history of pulmonary disease. Thoracic radiography showed a pneumothorax on the right side. The patient underwent chest tube drainage in the thoracic space. When surgical intervention for continuous air leakage was unavoidable, we selected video-assisted thoracic surgery under local and epidural anaesthesia in consideration of her general condition. We conclude that awake surgical intervention is applicable in selected patients with pneumothorax in pregnancy and is particularly useful in those in whom general anaesthesia is best avoided.

[Chest pains in emergency admission. Diagnostics and treatment]. / Brustschmerzen in der Notaufnahme. Diagnostik und Behandlung.

Thoracic pain is a common symptom in the emergency medicine setting and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered many of which are associated with a high mortality. Management of this situation is complicated by the fact that rapid and unexpectedly occurring and rapidly progressing deterioration are not uncommon in patients who initially did not appear to be seriously ill. Also for some underlying pathologies the physical examination can have an inconspicuous or"false negative" result and atypical presentations can give rise to false interpretations. The clinical and technical diagnostic methods, the implementation and interpretation including possible sources of error and limitations will be described in detail.

Management of residual pleural space and air leaks after major pulmonary resection.

Postoperative air leaks associated with residual pleural space is a well known complication contributing to prolong hospitalization. Many techniques have been proposed for the treatment of this complication. Between 1999 and 2009, 39 patients with air leaks associated with residual pleural space (>3 cm at chest X-ray) persisting over three days after major lung resection were enrolled in this study. All patients were treated with combined pneumoperitoneum and autologus blood patch. Pneumoperitoneum is obtained by the injection of 30 ml/kg of air under the diaphragm, using a Verres needle through the periumbilical area. The blood patch is obtained by instillating 100 ml of autologus blood through the chest tubes. No patients experienced complications related to the procedure. Obliteration of pleural space was obtained in all the patients at a maximum of 96 h postoperatively. Air leaks stopped in all the cases at a maximum of 144 h from surgery. Chest tube was removed 24 h after the air leakage disappearance. Our 10-year experience supports the early, combined use of pneumoperitoneum and blood patch whenever pleural space and air leaks present after major pulmonary resection. This approach may be recommended because of its easiness, safety, effectiveness, and the low costs.