A retrospective multi-institutional survey of characteristics of surgically treated spontaneous hemopneumothorax patients.

OBJECTIVE: The Japan Society for Pneumothorax and Cystic Lung Disease conducted a nationwide retrospective survey to identify correlations between the timing of surgical intervention and the incidence of transfusion, and to examine the factors contributing to the need for transfusion among clinical features in surgically treated spontaneous hemopneumothorax (SHP) patients. METHODS: We analyzed the characteristics and perioperative results of patients with SHP who underwent thoracoscopy or thoracotomy between April 2009 and March 2019. RESULTS: From 17 institutions, 171 cases were enrolled in this study. Receiver-operating characteristic curve analyses for the incidence of transfusion and waiting time before the operation revealed an area under the curve of 0.54 (95% confidence interval [CI] 0.44-0.64). Therefore, we did not compare the clinical features using a cutoff value of waiting time before the operation. More than 80% of the patients underwent surgical treatment within 24 h from admission. Multivariate analysis revealed that the total volume of hemorrhage was the only significant factor contributing to the incidence of transfusion (p = 0.00011, odds ratio: 0.03, 95% CI 0.0051-0.18). Moreover, multivariate analyses revealed that the waiting time before the operation was a contributing factor for prolonged total hospitalization (p < 0.0001, estimated regression coefficient: 0.036, 95% CI 0.027-0.045). CONCLUSION: In SHP patients, a reduction in the waiting time before the operation significantly contributed to not the avoidance of transfusion but a reduction in total hospitalization time. In addition, transfusion was performed depending on the volume of blood loss.

[Contralateral Pneumothorax after Surgery for Idiopathic Hemopneumothorax;Report of a Case].

A 17-year-old man came to the hospital complaining of right back pain. He had a history of an emergency operation for a left idiopathic hemopneumothorax. A chest X-ray revealed right lung collapse and suggested pleural adhesion at the apex of the right lung. He was diagnosed with right spontaneous pneumothorax and the surgical treatment was performed, because pleural adhesion may cause the hemothorax. During surgery, several pleural adhesion bands were found in the thoracic cavity between the right lung apex and chest wall. Spontaneous pneumothorax with a pleural adhesion at the apex is considered to be the indication for surgery because of the risk of hemothorax.

Spontaneous hemopneumothorax after laparoscopy: a case report and literature review.

BACKGROUND: Spontaneous hemopneumothorax (SHP) is defined as the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax. This rare clinical disorder may be life-threatening. CASE PRESENTATION: A 71-year-old woman presented with a 1-month history of recurrent bloody stool, and electronic colonoscopy suggested a rectal mass. Laparoscopic radical resection of rectal cancer was performed. Two days later, she developed chest tightness, shortness of breath, and slight pain in the left chest. Emergency chest radiography revealed mild left pneumothorax and pleural effusion. SHP was suspected and a thoracic drain was inserted. However, the patient developed hemorrhagic shock 3 hours after drainage. She underwent emergency video-assisted thoracic surgery (VATS), which revealed left lung tip rupture with bleeding and adhesive band fracture at the top of the left thoracic cavity. The ruptured lung tissue was removed and electrocoagulation at the adhesion band was performed for hemostasis. The patient was discharged on postoperative day 11. At the time of this writing, she had developed no SHP recurrence or any other complications. CONCLUSIONS: This case shows that conservative treatment may have serious consequences in patients with SHP. Thus, chest X-ray examination and VATS should be performed in patients with SHP.

Hemopneumothorax After Trigger Point Injection for Fibromyalgia.

CONTEXT: Trigger point injections (TPIs) and acupuncture are common procedures in management of chronic back pain and usually are considered safe. Needling into cervical and thoracic regions can be associated with life-threatening complications. OBJECTIVE: The team intended to make practitioners aware of the potential for hemopneumothorax after TPI. DESIGN: The research team describes a case of hemopneumothorax after TPI. SETTING: The case study took place in the Department of Emergency Medicine at the Ankara University School of Medicine (Ankara, Turkey). PARTICIPANT: The participant was a 45-y-old woman, who had been admitted to the emergency department at the School of Medicine with dyspnea and dizziness after TPI for fibromyalgia. RESULTS: Computerized tomography of the thorax showed a significant hemopneumothorax at the right hemithorax and a collapsed right lung, markedly in the right, lower lobe. The hemopneumothorax was successfully treated with chest-tube and video-assisted thoracoscopic surgery. CONCLUSIONS: Health care professionals need to be aware of hemopneumothorax when performing TPI on the chest wall.

[Birt-Hogg-Dubé Syndrome Incidentally Found at Surgery for Idiopathic Hemopneumothorax;Report of a Case].

We suspected Birt-Hogg-Dubé syndrome (BHDS) from intraoperative findings of emergency operation for idiopathic hemopneumothorax. A 34-year-old man was delivered to our center due to sudden chest pain and dyspnea. Under the diagnosis of hemopneumothorax, emergency operation was performed. During surgery, multiple thin wall lung cysts of 2 to 5 mm in size were observed on the surface of all lung lobes. BHDS was suspected, but the surgery was limited to hemostasis and resection of pulmonary cyst since the diagnosis had not been established. Postoperative chest computed tomography (CT) revealed irregular shaped pulmonary cyst on the interlobar, mediastinal and diaphragm surface. Genetic analysis showed deletion in the folliculin gene confirming the diagnosis of BHDS.

Larger-Caliber Alternative Devices for Decompression of Tension Hemopneumothorax in the Setting of Hemorrhagic Shock.

BACKGROUND: The 14-gauge (14G) angiocatheter (AC) has an unacceptably high failure rate in treatment of tension pneumothorax (tPTX). Little is known regarding the interplay among hemorrhage, hemothorax (HTX), and tPTX. We hypothesized that increased hemorrhage predisposes tension physiology and that needle decompression fails more often with increased HTX. METHODS: This is a planned secondary analysis of data from our recent comparison of 14G AC with 10-gauge (10G) AC, modified 14G Veress needle, and 3mm laparoscopic trocar conducted in a positive pressure ventilation tension hemopneumothorax model using anesthetized swine. Susceptibility to tension physiology was extrapolated from volume of carbon dioxide (CO2) instilled and time required to induce 50% reduction in cardiac output. Failures to rescue and recover were compared between the 10% and 20% estimated blood volume (EBV) HTX groups and across devices. RESULTS: A total of 196 tension hemopneumothorax events were evaluated. No differences were noted in the volume of CO2 instilled nor time to tension physiology. HTX with 10% EBV had fewer failures compared with 20% HTX (7% versus 23%; p = .002). For larger-caliber devices, there was no difference between HTX groups, whereas smaller-caliber devices had more failures and longer time to rescue with increased HTX volume as well as increased variability in times to rescue in both HTX volume groups. CONCLUSION: Increased HTX volume did not predispose tension physiology; however, smaller-caliber devices were associated with more failures and longer times to rescue in 20% HTX as compared with 10% HTX. Use of larger devices for decompression has benefit and further study with more profound hemorrhage and HTX and spontaneous breathing models is warranted.

[Clinical Assessment of Spontaneous Hemopneumothorax].

We experienced 25 cases of spontaneous hemopneumothorax, in which 9 were defined as occult cases on chest X-ray at the time of visit. All 9 cases visited our hospital within 12 hours after the onset. Of these, 5 were done chest computed tomography (CT) and 3 could be diagnosed as hemopneumothorax. Emergency surgery were necessary in 4 of 9. Chest CT and careful observation is thought to be essential in case of suspiciously combined hemothorax in pneumothorax cases.

[Re-expansion Pulmonary Edema after Surgery for Spontaneous Tension Hemopneumothorax;Report of a Case].

A 23-year-old man was admitted to our hospital because of chest pain and dyspnea. X-ray and computed tomography showed left tension hemopneumothorax. After the emergent surgery, re-expansion pulmonary edema (RPE) occurred. Non-invasive positive pressure ventilation (NPPV) was applied to control RPE and RPE was successfully recovered. NPPV may be useful in managing RPE.

Bigger is better: Comparison of alternative devices for tension hemopneumothorax and pulseless electrical activity in a Yorkshire swine model.

BACKGROUND: Tension pneumothorax is a cause of potentially preventable death in prehospital and battlefield settings and 14-gauge angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive-pressure ventilation swine model. METHODS: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating carbon dioxide insufflation via transdiaphragmatic trocar, and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10-gauge angiocatheter (10G AC), modified Veress-type needle (mVN), and 3-mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded. RESULTS: One hundred ninety-five t-H/PTX and 88 PEA events were conducted in 25 swine. Laparoscopic trocar and 10G AC were more successful and had faster median time to rescue for t-H/PTX compared with 14G AC, whereas mVN performed comparably. Following PEA, 14G AC and mVN succeeded at rescue only 50% and 57% of the time, whereas 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted. CONCLUSIONS: While mVN performed comparably to 14G AC, both have unacceptable failure rates. Ten-gauge AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.

Emergency video-assisted thoracoscopic surgery for haemopneumothorax and diaphragm repair after stabbing, performed through pre-existing wounds.

Video of video-assisted thoracoscopic surgery (VATS) on a 16-year old who had been stabbed. The knife penetrated the diaphragm, lung and intercostal pedicle causing a haemopneumothorax. A chest drain was inserted by the trauma team. VATS was performed entirely through the stab and chest drain pre-existing wounds without extension.

Penetrating chest injuries caused by swordfish sword used as a weapon.

We report 5 cases of penetrating chest wounds caused by weapons made from swordfish swords, involving breakage of the sword that later appeared as a thoracic foreign body. The patients had been assaulted 2 days to 17 years earlier. Three of them had a chronic infected wound, one had a penetrating thoracic wound with hemopneumothorax, and one had a foreign body. Computed tomography showed a foreign body in the lung in 4 cases, with aortic penetration in one. The foreign body was removed via thoracotomy in all 4 patients, with aorta repair in one who presented later with a pseudoaneurysm.

Traumatic Diaphragmatic Hernia: Diagnostic Dilemma.

Traumatic rupture of the diaphragm is an uncommon condition. The prevalence of diaphragmatic rupture among blunt trauma victim ranges from 0.8 to 8%. The etiologic factors are blunt trauma (for example, in motor vehicle accidents) and penetrating trauma. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intra-abdominal and thoracic injuries. We present a case which was misdiagnosed as a case of left sided hemopneumothorax and treated with tube thoracotomy in other center.

Traumatic pulmonary pseudocyst due to thoracic trauma.

Traumatic pulmonary pseudocyst is uncommon and usually regresses spontaneously with conservative treatment. In rare cases, surgical intervention may be necessary. A pseudocyst may be treated surgically to prevent potential complications if the patient undergoes a thoracotomy for another reason. We present a patient with hemopneumothorax and traumatic pulmonary pseudocyst after a motor vehicle accident, who was operated on electively due to massive air leak.

[Reexpansion Pulmonary Edema during Emergency Surgery in a Patient with Spontaneous Hemopneumothorax].

A 43-year-old male patient with spontaneous hemopneumothorax of the right lung underwent emergency video-assisted thoracoscopic surgery for drainage, hemostasis and bullae resection. Fifteen minutes after reexpansion of the right lung, we found bubbly sputum coming out from the right tracheal tube and cloudy shadow in the right field of his chest X-ray. The occurrence of reexpansion pulmonary edema (RPE) was considered. Subsequent mechanical ventilation with PEEP and administration of steroid and diuretic was done as his treatment. His respiratory state was stabiized in the next two days. As the lung collapse following spontaneous hemopneumothorax often becomes more severe, we should pay attention to the occurrence of RPE after expansion of affected side lung. And, if it occurred, appropriate and prompt treatment as above should be done because of its high mortality.

Assessment of spontaneous hemopneumothorax: Indications for surgery.

BACKGROUND: Although spontaneous hemopneumothorax is rare, emergency surgery may be necessary if massive bleeding is present. METHODS: We examined therapeutic strategies and outcomes as well as background factors in 16 patients with spontaneous hemopneumothorax treated at our hospital between April 2002 and August 2013. RESULTS: Emergency surgery was performed in 3 patients, all of whom were hemodynamically unstable. Elective surgery was performed in 7 patients, all of whom showed continuous bleeding from a pleural cavity drain. The surgery consisted of intrapleural hematoma removal, hemostasis, and bullectomy; 3-port thoracoscopy was used in all of the surgical cases. Six patients, none of whom showed continuous bleeding, recovered with conservative therapy. Comparing the conservative therapy and surgery groups revealed the mean continuous bleeding volume and total blood loss to be significantly greater in the latter, but no significant difference was noted between the two groups in terms of the initial bleeding volume following tube thoracostomy. None of the cases required a blood transfusion. CONCLUSIONS: Spontaneous hemopneumothorax is not necessarily an indication for surgery, and even when the initial volume of blood drained through the chest tube is large, some patients can still be treated conservatively with careful monitoring of vital signs and continuous bleeding volumes. However, it is important not to miss the optimal timing of surgery in order to avoid administering unnecessary blood transfusions to young patients.