Successful Sealing of Post-COVID-19 Bronchopleural Fistula with Computed Tomography Scan-Guided Percutaneous Cyanoacrylate Glue Injection: A Case Series.

Bronchopleural fistula (BPF), a sinus tract between the bronchial system and the pleural space, is associated with COVID-19 and can lead to pneumothorax, which increases the mortality rate. Due to the analytical status of COVID-19 patients, sealing the BPF necessitates the least minimal invasive treatment. Herein, we demonstrated a technique of sealing post-COVID-19 BPF with direct injection of cyanoacrylate glue under the guidance of a computed tomography scan. Following glue injection, the BPF was completely sealed in all four patients. In conclusion, in COVID-19 patients with small and distal BPF, percutaneous glue injection is recommended for BPF closure.

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation.The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases.In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis.With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward.In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising.In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness.In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. (AU)

Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital.

BACKGROUND: Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. AIMS: To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessment of complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. METHODS: Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. RESULTS: One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. CONCLUSION: Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects.

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation. The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases. In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis. With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward. In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising. In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness. In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. In neuromuscular patients, ultrasound is a good predictor of impaired lung function. Currently, in Neuromuscular Disease Units, TU is an indispensable tool. Ultrasound study of the intercostal musculature is also effective in the study of respiratory function, and is widely used in Respiratory Rehabilitation. In Intermediate Care Units, thoracic ultrasound is indispensable for patient management. In these units there are ultrasound protocols for the management of patients with acute dyspnoea that have proven to be very effective.

The clinical features and prognosis of fungal pleural infection: A case series and literature review.

Fungal pleural infections are infrequent and insidious, for which there are neither large clinical studies nor targeted guidelines to provide standardized treatment options. We reported 4 cases of fungal pleural infection and reviewed the cases of fungal pleural infections in previous studies to provide a basis for the diagnosis and treatment of fungal pleural infections. There were 2 females and 2 males with a mean age of 58.5 years in our data. The average time from onset to diagnosis was 30.25 days. Risk factors most frequently included pulmonary diseases (n = 4) and malignancy (n = 1). Two patients underwent pleural biopsy through a thoracoscope, and no pathogens were detected. Pleural fluid culture was positive in 2 out of 3 cases. The diagnoses were "possible" (n = 1), "probable" (n = 1), and "proven" (n = 2). All patients received systemic antifungal therapy, and 3 received combined thoracic drainage. The outcomes were cured (n = 1), improved (n = 2) and lost to follow-up (n = 1). We reviewed 12 cases of fungal pleural infection in previous studies. The diagnosis was confirmed via culture in 7 cases and via biopsy in 8 cases. The pathogen was Aspergillus in 7 cases. After a combination of systemic antifungal (n = 12) and local treatment (n = 11), 10 patients improved and 2 patients died. Diagnosis of fungal pleural infection should incorporate risk factors, clinical presentation and fungal evidence, with pleural fluid culture being an important and feasible mean of confirming the diagnosis; and treatment should be based on systemic antifungal therapy supplemented by topical therapy.

A Retrospective Cohort Study Evaluating the Safety and Efficacy of Sequential versus Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection.

Methods: We conducted a retrospective review of patients with pleural infection requiring intrapleural therapy at two tertiary referral centres. Results: We included 84 (62.2%) and 51 (37.8%) patients who received sequential and concurrent intrapleural therapy, respectively. Patient demographics and clinical characteristics, including age, RAPID score, and percentage of pleural opacity on radiographs before intrapleural therapy, were similar in both groups. Treatment failure rates (defined by either in-hospital mortality, surgical intervention, or 30-day readmission for pleural infection) were 9.5% and 5.9% with sequential and concurrent intrapleural therapy, respectively (p = 0.534). This translates to a treatment success rate of 90.5% and 94.1% for sequential and concurrent intrapleural therapy, respectively. There was no significant difference in the decrease in percentage of pleural effusion size on chest radiographs (15.1% [IQR 6-35.7] versus 26.6% [IQR 9.9-38.7], p = 0.143) between sequential and concurrent therapy, respectively. There were also no significant differences in the rate of pleural bleeding (4.8% versus 9.8%, p = 0.298) and chest pain (13.1% versus 9.8%, p = 0.566) between sequential and concurrent therapy, respectively. Conclusion: Our study adds to the growing literature on the safety and efficacy of concurrent intrapleural therapy in pleural infection.

Tuberculous Bronchopleural Fistula: A Rare and Life-Threatening Disease.

Tuberculous bronchopleural fistula (BPF) is a rare and potentially life-threatening complication of pulmonary tuberculosis, in which abnormal connections form between the bronchial tree and the pleural space. These abnormal connections allow air and secretions to pass from the lungs into the pleural space, causing a range of symptoms from benign cough to acute tension pneumothorax. The management of tuberculous BPF requires an individualized approach based on the patient's condition and response to treatment. Anti-tuberculosis therapy is essential for controlling the active tuberculosis infections. Intercostal drainage and suction are also commonly used to drain air and fluid from the pleural space, providing relief from the symptoms. For some patients, more invasive surgeries, such as decortication, thoracoplasty or pleuropneumonectomy are required to definitively close the fistula when medical management alone is insufficient. Herein, we describe a rare case of tuberculous BPF in a young adult female, who was treated with anti-tuberculosis medications and open thoracotomy.

COVID-19-Related Pleural Diseases.

Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.

The Global Burden of Pleural Diseases.

Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.

Bronchoscopic interventions for bronchopleural fistulas.

Bronchopleural fistula is a potentially fatal disease most often caused after pneumonectomy. Concomitant problems such as pulmonary infection and respiratory failure are typically the main contributors to patient mortality because of the improper contact between the bronchial and pleural cavity. Therefore, bronchopleural fistulas need immediate treatment, which requires the accurate location and timely closure of the fistula. Currently, bronchoscopic interventions, because of their flexibility and versatility, are reliable alternative therapies in patients for whom surgical intervention is unsuitable. Possible interventions include bronchoscopic placement of blocking agents, atrial septal defect (ASD)/ventricular septal defect (VSD) occluders, airway stents, endobronchial valves (EBVs) and endobronchial Watanabe spigots (EWSs). Recent developments in mesenchymal stem cells (MSCs) transplantation technology and three-dimensional (3D) printed stents have also contributed to the treatment of bronchopleural fistula, but more research is needed to investigate the long-term benefits. This review focuses on the effectiveness of various bronchoscopic measures for the treatment of bronchopleural fistula and the directions for future development.

Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Pleural infection represents a significant clinical challenge worldwide. Although prompt drainage of pleural fluid is thought to play a key role in pleural infection management, the optimal size of intrapleural catheter has yet to be defined. OBJECTIVES: The aim of this systematic review and meta-analysis was to summarize data on efficacy and complications of small-bore drain (SBD), defined as ≤14F, in comparison to large-bore drain (LBD) in patients with pleural infection. METHOD: We searched MEDLINE and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed selected full text to identify studies according to predefined eligibility criteria. Summary estimates were derived using the random-effects model. RESULTS: Twelve original studies were included for qualitative analysis and 7 of these for quantitative analysis. The surgical referral rate of SBD and LBD were, respectively, 0.16 (95% confidence interval [CI], 0.12-0.21) and 0.20 (95% CI, 0.10-0.32), the pooled mortality were 0.12 (95% CI, 0.05-0.21) and 0.20 (95% CI, 0.10-0.32), and the length of hospital stay was 24 days in both groups. Data on complications suggest similar proportions of tube dislodgement. Intensity of pain was evaluated in one study only, reporting higher scores for LBD. CONCLUSIONS: This systematic review and meta-analysis provide the first synthesis of data on performance of SBD and LBD in management of pleural infection, and, overall, clinical outcomes and complications did not substantially differ, although the limited number of studies and the absence of dedicated randomized trials does limit the reliability of results.