Successful application of airway pressure release ventilation in a child with severe acute respiratory distress syndrome induced by trauma: a case report.

BACKGROUND: Trauma has been identified as one of the risk factors for acute respiratory distress syndrome. Respiratory support can be further complicated by comorbidities of trauma such as primary or secondary lung injury. Conventional ventilation strategies may not be suitable for all trauma-related acute respiratory distress syndrome. Airway pressure release ventilation has emerged as a potential rescue method for patients with acute respiratory distress syndrome and hypoxemia refractory to conventional mechanical ventilation. However, there is a lack of research on the use of airway pressure release ventilation in children with trauma-related acute respiratory distress syndrome. We report a case of airway pressure release ventilation applied to a child with falling injury, severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax. We hope this case report presents a potential option for trauma-related acute respiratory distress syndrome and serves as a basis for future research. CASE PRESENTATION: A 15-year-old female with falling injury who developed severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax was admitted to the surgical intensive care unit. She presented refractory hypoxemia despite the treatment of conventional ventilation with deep analgesia, sedation, and muscular relaxation. Lung recruitment was ineffective and prone positioning was contraindicated. Her oxygenation significantly improved after the use of airway pressure release ventilation. She was eventually extubated after 12 days of admission and discharged after 42 days of hospitalization. CONCLUSION: Airway pressure release ventilation may be considered early in the management of trauma patients with severe acute respiratory distress syndrome when prone position ventilation cannot be performed and refractory hypoxemia persists despite conventional ventilation and lung recruitment maneuvers.

Thoracic endometriosis presenting as hemopneumothorax.

Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be "catamenial" happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor.

BACKGROUND: Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI. METHODS: We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients. RESULTS: BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001). CONCLUSION: SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI. SUMMARY: Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.

[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.

Pneumothorax-associated fibroblastic lesion in combination with localized pleural angiomatosis: A possible cause of juvenile spontaneous hemopneumothorax.

Spontaneous hemopneumothorax is an uncommon but potentially life-threatening condition, with a potential for a rapid ventilatory collapse and a large collection of hidden blood loss into the pleural cavity. Here, we report the first case in the literature on pneumothorax-associated fibroblastic lesion in combination with localized pleural angiomatosis in a 19-year-old Caucasian male, resulting in massive spontaneous hemopneumothorax and hypovolemic shock. Our findings support a causal link between this condition and pneumothorax. The possible superimposed hemothorax is explainable by the pleural involvement of large angiomatous vessels, prone to rupture.

Primary spontaneous haemopneumothorax: an overlooked emergency.

Primary spontaneous haemopneumothorax (PSHP) is a rare condition. Potentially grave consequences do occur as a result of a failure to reach the diagnosis early. We report a case of a 17-year-old male who presented with a picture of PSHP but was later also found to have a component of haemothorax. He underwent thoracoscopy which was converted to thoracotomy. A torn vascular adhesion was the source of bleeding which was clipped and haemostasis was achieved.

Spontaneous haemopneumothorax.

An 18-year-old man presented with a 2 day history of breathlessness and left-sided chest pain, with no preceding trauma. He had no medical history of note, and had never smoked. He was in hypovolaemic shock, with Hb of 8.1 g/dl, and received fluid resuscitation. Chest x-ray (CXR) revealed left-sided hydropneumothorax, with the effusion of blood-consistency on CT thorax. Tube thoracostomy drained 1.7 litres of blood immediately. He remained haemodynamically stable after 4 units of blood transfusion on the first day with post-transfusion Hb 11 g/dl. Following cardiothoracic surgeon advice, tube was removed on day 5 draining total of 3.5 litres, with good response clinically and radiologically. Patient was well when followed up at 1 week after hospital discharge, with no recurrence and complete re-expansion of left lung on CXR.

[Lung adenocarcinoma originated from bulla wall accompanying spontaneous hemopneumothorax; report of a case].

A 68-year-old male was referred to our hospital for treatment of left hemopneumothorax. Chest X-ray film and chest computed tomography scans showed emphysematous bulla at the apical portion of the left lung, pleural effusion and atelectasis of the lingular segment and lower lobe of the left lung. He underwent bullectomy and decortication. On the 9 post operative days, the patient was discharged without complication. Pathological diagnosis was lung adenocarcinoma originated from bulla wall. We must recognize that cystic lung disease is a high risk factor of the lung cancer.

Simultaneous occurrence of ipsilateral primary spontaneous hemopneumothorax and contralateral pneumothorax in an adolescent.

Primary spontaneous hemopneumothorax is a rare disorder but can be life-threatening secondary to massive bleeding. The authors encountered an uncommon case of left primary spontaneous hemopneumothorax and simultaneous right pneumothorax. After initial bilateral tube thoracostomies, successful 1-stage bilateral video-assisted thoracic surgery (VATS) was performed before the condition deteriorated or complications occurred. Active oozing from a ruptured vascularized bulla was identified at the apex of the left upper lobe. One-stage bilateral VATS appears to be a reasonable method of surgical intervention, but in patients under life-threatening clinical conditions, it may still be difficult to use this strategy, and a staged operation may be considered.

Hemoneumotórax espontáneo / Spontaneous pneumothorax

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Traumatismos torácicos graves. Revisión de 39 casos / Severe thoracic trauma: review of 39 cases

Objetivo Estudiar la incidencia y las lesiones torácicas en una serie de niños politraumatizados. Comparar la contractilidad cardíaca de los pacientes con troponina T elevada con la de los que tenían un electrocardiograma (ECG) patológico. Analizar el valor de la tomografía computarizada (TC) como primera exploración en los pacientes con sospecha de traumatismo torácico. Material y métodos Se realizó un estudio retrospectivo durante cinco años de pacientes con una injury severity score igual o superior a 25. Se definieron como traumatismo torácico la contusión pulmonar, el hemoneumotórax, la lesión de grandes vasos, la contusión cardíaca o la fractura costal. Se describieron las lesiones encontradas. En todos se realizó un ECG y una determinación de troponina T. Se practicó un ecocardiograma a los que ésta superaba las 0,035 U/l, excepto en dos por falta de disponibilidad de la técnica, y a los que mostraban un ECG alterado. Se realizó una TC torácica a los pacientes inconscientes o en los que la exploración clínica sugería la existencia de traumatismo torácico, y a todos ellos una radiografía de tórax en las siguientes 24 h. Resultados Se registraron 39 casos de 209 politraumatizados. La lesión más frecuente fue la contusión pulmonar. A 10 pacientes con concentraciones de troponinas elevadas se les practicó un ecocardiograma, y éste fue patológico en 8. Los 6 pacientes con el ECG alterado tenían un aumento de las troponinas y el ecocardiograma patológico. Se practicaron 81 TC torácicas, de las que resultaron patológicas 36. En tres ocasiones se observaron lesiones en la radiografía simple en pacientes en los que no se había valorado la necesidad de realizar una TC. Conclusiones La lesión más frecuente es la contusión pulmonar. En el 80 % de los casos en los que se realizó un ecocardiograma a los pacientes con troponinas elevadas, resultó patológico. La TC realizada a los pacientes con sospecha de traumatismo torácico tiene una elevada rentabilidad

Objective To study the incidence and types of severe thoracic trauma in a cohort of pediatric polytrauma patients, compare cardiac contractility between patients with elevated troponin T levels and those with abnormal electrocardiogram (EKG) findings, and to analyze the value of thoracic computed tomography (CT) scan as a first investigation in patients with suspected thoracic trauma. Material and methods We performed a 5-year retrospective study in a cohort of trauma patients with an injury severity score of >= 25. Thoracic trauma included pulmonary contusion, hemopneumothorax, large-vessel injury, myocardial contusion, and rib fracture. In all patients, EKG and determination of troponin T were performed at admission. Echocardiogram was performed in patients with troponin T levels > 0.035 U/L (except in two patients, because the technique was not available) and abnormal EKG findings. A thoracic CT scan was performed in unconscious patients or when thoracic trauma was clinically suspected, as well as a simple thorax X-ray in the following 24 hours. Results Among 209 multiple-trauma patients, thoracic injuries where detected in 39 patients. The most frequent injury was pulmonary contusion. Echocardiogram was performed in 10 patients with high troponin levels, with abnormal findings in eight patients. The six patients with EKG alterations also had high troponin levels and pathological findings on echocardiogram. Thoracic CT scan was performed in 81 patients, with abnormal findings in 36 patients. Thoracic lesions were observed in simple X-ray in three patients who had not undergone CT scan. Conclusions The most frequent thoracic trauma was pulmonary contusion. The results of echocardiogram were abnormal in 80 % of the patients with high troponin levels who underwent this examination. Thoracic CT scan was highly useful in suspected thoracic trauma

Video-assisted thoracic surgery for spontaneous haemopneumothorax.

BACKGROUND AND OBJECTIVE: The aim of this study was to review the treatment options for spontaneous haemopneumothorax (SHP) by video-assisted thoracoscopic surgery (VATS). METHODS: Records from 16 patients (14 male, age 16-38 years, mean age 26.1 years) with prominent SHP (blood loss over 400 cc in the first 24 h) undergoing VATS from July 1994 to December 2005 and treated by one thoracic surgeon in four medical centres or community hospitals of North and Mid-Taiwan were reviewed retrospectively. RESULTS: Thirteen patients (81.3%) were identified to have a prominent bleeding source intraoperatively. Torn engorged vessels from the parietal pleura to adjacent bullae were found in nine patients, and bleeders adjacent or over the parietal part of the adhered pleura were found in the other four. Ruptured bullae/blebs or air leakage were found in 14 (87.5%). All underwent removal of intrapleural blood clot, control of bleeders and their bullae/blebs were resected through three-port VATS (n = 13, 81.2%) or mini-thoracotomy and VATS (n = 3, because of unstable vital signs or conversion because of dense adhesion). Mechanical or chemical pleurodesis was carried out in all patients. The mean operative time was 53.8 +/- 21.7 min. There was no postoperative mortality. However, recurrent bleeding requiring reoperation occurred in one patient, and one other patient had a prolonged air leakage (>7 days) postoperatively and recovered spontaneously. The mean duration of chest tube drainage was 3.8 days and the median follow-up period was 3.2 years. CONCLUSION: SHP complicated by severe bleeding is a surgical emergency. VATS is a reasonable treatment for patients with SHP.

Spontaneous hemopneumothorax in children: case report and review of literature.

Spontaneous hemopneumothorax is rare, occurs in young adolescents, and can be life threatening secondary to massive bleeding. An adolescent with spontaneous hemopneumothorax and shock managed by tube thorascostomy is described here. We compared our case with published data of spontaneous hemopneumothorax in the pediatric age group. Spontaneous hemopneumothorax involves the accumulation of air and blood in the pleural space in the absence of trauma or other obvious causes. Spontaneous hemopneumothorax is usually seen in adolescents, more common in males than females. The common clinical features of spontaneous hemopneumothorax include dyspnoea and chest pain, and 30% present with hypovolemic shock. The bleeding can result from a torn adhesion between the parietal and visceral pleurae, from a rupture of vascularized bullae, or from torn congenital aberrant vessels. Over the last 6 decades, the treatment has progressed from the thoracotomy to minimally invasive techniques such as video assisted thoracoscopic surgery, with great reduction in mortality and recurrence rates. Although a rare entity, diagnosis of spontaneous hemopneumothorax must be considered in young adolescents presenting with spontaneous onset of chest pain and dyspnoea with radiograph findings of hydropneumothorax and/or signs of shock.

[Polytrauma with severe lung contusion. Early use of extracorporeal membrane oxygenation]. / Polytrauma mit schwerem Lungenparenchymschaden. Frühzeitiger Einsatz der extrakorporalen Membranoxygenierung.

Extracorporeal membrane oxygenation (ECMO) is a technique for sustaining body oxygenation in case of respiratory failure. Since ECMO technology has undergone improvements resulting in better hemo-compatibility and reduced side effects, venovenous ECMO is a mostly accepted treatment of adult respiratory distress syndrome (ARDS). One should discuss the early initiation of ECMO therapy for post-traumatic respiratory failure. We report about a 23-year-old male and a 15-year-old female patient, who suffered polytrauma and received early treatment with ECMO because of severe lung contusion.

Hemopneumotórax espontâneo / Spontaneous hemopneumothorax

Hemopneumotórax espontâneo é uma ocorrência incomum, sendo que o sangramento volumoso é considerado uma complicação ainda mais rara do pneumotórax espontâneo. Os autores descrevem o caso de um paciente que apresentou dor torácica aguda e dispnéia, com radiografia de tórax mostrando pneumotórax e derrame pleural. Durante a drenagem pleural tubular, ocorreu sangramento importante (1200mL). Foi submetido à toracotomia, na qual foi encontrado um vaso aberrante. O pós-operatório transcorreu sem incidentes.