[Analysis of Influencing Factors of Complications for CT-guided 
Percutaneous Lung Biopsy].

BACKGROUND: Computed tomography guided percutaneous lung biopsy (CT-PLB) is a widely used method for the diagnosis of lung lesions. However, it is invasive, and the most common complications are pneumothorax and pulmonary hemorrhage, which can be life-threatening in severe cases. Therefore, the aim of this study is to analyze the independent risk factors affecting the occurrence of different complications of CT-PLB, so as to reduce the incidence of complications. METHODS: The 605 patients with complete clinical data who underwent CT-PLB in our hospital from May 2018 to December 2019 were retrospectively analyzed. According to the location of the lesions, they were divided into subpleural group and non-subpleural group. The patients were divided into pneumothorax group, pulmonary hemorrhage group, pneumothorax with pulmonary hemorrhage group and non-pneumothorax/pulmonary hemorrhage group according to the complications. The risk factors affecting the incidence of different complications and the independent risk factors of each complication were analyzed. RESULTS: The incidence of pneumothorax was 34.1%, the incidence of pulmonary hemorrhage was 28.1%, and the incidence of pneumothorax complicated with pulmonary hemorrhage was 10.8% (63 cases). The independent risk factor affecting the incidence of subpleural pneumothorax was lesion size (P=0.002). The independent risk factors affecting the occurrence of pneumothorax in the non-subpleural group were plain scan CT value (P=0.035), length of needle through lung tissue (P=0.003), and thickness of needle through chest wall (P=0.020). Independent risk factors affecting the occurrence of pulmonary hemorrhage in the non-subpleural group were length of needle through lung tissue (P<0.001), △CT value of needle travel area (P=0.001), lesion size (P=0.034) and body position (P=0.014). The independent risk factors affecting the co-occurrence of pneumothorax and pulmonary hemorrhage were the length of needle through lung tissue (P<0.001) and the △CT value of needle travel area (P<0.001). CONCLUSIONS: CT-PLB is a safe and effective diagnostic method, which of high diagnostic value for lung lesions. Selecting the appropriate puncture program can reduce complications such as pneumothorax and pulmonary hemorrhage, and improve diagnosis and treatment efficiency.

Pneumothorax during manned chamber operations: A summary of reported cases.

In-chamber pneumothorax has complicated medically remote professional diving operations, submarine escape training, management of decompression illness, and hospital-based provision of hyperbaric oxygen therapy. Attempts to avoid thoracotomy by combination of high oxygen partial pressure breathing (the concept of inherent unsaturation) and greatly slowed rates of chamber decompression proved successful on several occasions. When this delicate balance designed to prevent the intrapleural gas volume from expanding faster than it contracts proved futile, chest drains were inserted. The presence of pneumothorax was misdiagnosed or missed altogether with disturbing frequency, resulting in wide-ranging clinical consequences. One patient succumbed before the chamber had been fully decompressed. Another was able to ambulate unaided from the chamber before being diagnosed and managed conventionally. In between these two extremes, patients experienced varying degrees of clinical compromise, from respiratory distress to cardiopulmonary arrest, with successful resuscitation. Pneumothorax associated with manned chamber operations is commonly considered to develop while the patient is under pressure and manifests during ascent. However, published reports suggest that many were pre-existing prior to chamber entry. Risk factors included pulmonary barotrauma-induced cerebral arterial gas embolism, cardiopulmonary resuscitation, and medical or surgical procedures usually involving the lung. This latter category is of heightened importance to hyperbaric operations as an iatrogenically induced pneumothorax may take as long as 24 hours to be detected, perhaps long after a patient has been cleared for chamber exposure.

[Catamenial pneumothorax with persistent air leak].

Catamenial pneumothorax is a spontaneous recurrent pneumothorax that occurs in women of reproductive age and in temporal relationship with the menses. It usually occurs within 24 hours before or 72 hours after the start of the menstrual cycle; however, multiple variations have been described in terms of the temporal relationship. To date, it is considered a rare condition; this may be justified by the limited available knowledge on this disease leading to misdiagnosis. Often, making a diagnosis of catamenial pneumothorax is complicated; it mainly depends on the medical history; also, it may be a surgical or histopathological diagnosis. Management strategies for catamenial pneumothorax may include combinations of hormonal therapy, pleurodesis, lung parenchyma resection, and diaphragm resection/repair. The aim of reporting this atypical case of catamenial pneumothorax is to highlight the relevance of having the adequate knowledge on this entity so it does not go unnoticed despite its apparent low incidence.

Endobronchial silicone spigot in prolonged air leaks: Nationwide study on outcomes and risk factors for treatment failure.

BACKGROUND: The endobronchial silicone spigot, also known as the endobronchial Watanabe spigot, is used in bronchoscopic interventions to manage prolonged pulmonary air leakage. However, the outcomes of this procedure have not been thoroughly investigated. METHODS: Using a Japanese national inpatient database from April 2014 to March 2022, we assessed the clinical characteristics and outcomes of all eligible patients who received the endobronchial spigot. We also investigated risk factors associated with treatment failure. Treatment failure was defined as in-hospital death or the need for surgery after bronchial occlusion. RESULTS: We analyzed data of 1095 patients who underwent bronchial occlusion using the endobronchial spigot. Among them, 252 patients (23.0%) died during hospitalization, and 403 patients (36.8%) experienced treatment failure. Factors associated with treatment failure included age between 85 and 94 years (odds ratio [OR] 1.83; 95% confidence intervals [CI], 1.04-3.21); male sex (OR 2.43; 95% CI, 1.44-4.11); low Barthel index score; comorbidities of interstitial pneumonia (OR 1.71; 95% CI, 1.18-2.48); antibiotics treatment (OR 1.45; 95% CI, 1.02-2.07); steroids treatment (OR 1.59; 95% CI, 1.07-2.36); and surgery prior to bronchial occlusion (OR 2.08; 95% CI, 1.29-3.35). In contrast, pleurodesis after bronchial occlusion (OR 0.49; 95% CI, 0.32-0.75), and admission to high-volume hospitals were inversely associated with treatment failure (OR 0.58; 95% CI, 0.37-0.90). CONCLUSIONS: The endobronchial Watanabe spigot could be a nonsurgical treatment option for patients with prolonged pulmonary air leaks. Our findings will help identify patients who may benefit from such bronchial interventions.

Nasogastric tube placement perforating the nasopharynx causing mediastinal passage and feeding into the pleural space.

A mid-60s female with known primary progressive multiple sclerosis was admitted to our hospital with aspiration pneumonia. Due to reduced consciousness, a nasogastric (NG) tube was inserted for feeding. A chest x-ray (CXR) report from a thoracic radiologist confirmed an atypical tip position due to a hiatus hernia but concluded it was almost certainly within the stomach. However, after deteriorating on feed commencement, a CT scan of the chest confirmed the tube had perforated the nasopharynx and run parallel to the oesophagus through the mediastinum into the right pleural space. The patient subsequently developed an empyema and pneumothorax, requiring multiple therapeutic interventions and a prolonged hospital stay. This case demonstrates how the routine insertion of an NG tube can lead to serious complications. Additionally, position check CXRs can be difficult to interpret, so the decision to use the tube must be made cautiously by the clinical team.

Methods of measurement for pneumothorax in pediatric patients: a systematic review.

Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.

Current situation of management of spontaneous pneumothorax in Japan: A cross-sectional cohort study.

BACKGROUND: Limited epidemiological information is available on spontaneous pneumothorax. To address this gap, the Japan Society for Pneumothorax and Cystic Lung Disease (JSPCLD) conducted a nationwide retrospective survey to investigate the current epidemiology of spontaneous pneumothorax in Japan. METHODS: In this study, we conducted a retrospective cross-sectional cohort study to demonstrate the clinical features of spontaneous pneumothorax in one year from April 2019 to March 2020, compare patient characteristics and treatment outcomes between primary (PSP) and secondary spontaneous pneumothorax (SSP), and investigate the risk factors associated with in-hospital mortality among patients with SSP. RESULTS: A total of 1784 patients from 28 institutions were enrolled in the study, with PSP observed in 956 cases (53.6%) and SSP in 817 cases (45.8%). The age distribution showed a biphasic peak caused by the different peaks between PSP and SSP. In-hospital mortality occurred in 42 cases (2.4%) among all patients, with 0 cases (0%) in PSP and 42 cases (5.1%) in SSP. Multivariable analyses revealed that interstitial pneumonia as an underlying disease (odds ratio: 2.4700, 95% confidence interval: 1.1100 to 5.4800, p = 0.0269), performance status≧3 (odds ratio: 7.3900, 95% confidence interval: 3.1900 to 17.2000, p < 0.0001), and lower value of serum albumin on admission (odds ratio: 0.4060, 95% confidence interval: 0.2140 to 0.7690, p = 0.0057) were significantly associated with in-hospital mortality among patients with SSP. CONCLUSIONS: SSP patients with poor baseline conditions are at a higher risk for in-hospital mortality. It is crucial to provide close and meticulous management for SSP patients with compromised conditions.

[Diagnosis and management of idiopathic spontaneous pneumothorax in adolescents]. / Mise au point diagnostique et prise en charge du pneumothorax spontané idiopathique de l'adolescent.

INTRODUCTION: Due to the absence of consensual definition and agreed-upon pediatric treatment, pneumothorax (PNO) in children and adolescents often remains difficult to properly apprehend. STATE OF THE ART: While initial diagnostic suspicion is clinical, confirmation necessitates chest imaging, and lung ultrasound has become increasingly prevalent, often at the expense of chest radiography. The goal of treatment is twofold, on the one hand to a fully re-expand the lungs, and on the other hand to forestall PNO recurrence. Depending on PNO severity and clinical tolerance, it may be advisable to envision conservative management, oxygen supplementation, needle exsufflation, or chest tube drainage. PERSPECTIVES: In order to harmonize clinical practices, guidelines for the precise definition and graduated management of PNO in children and adolescents are highly advisable. CONCLUSIONS: Idiopathic spontaneous PNO frequently occurs in teenage populations, and its likewise frequent recurrence is not satisfactorily predicted by chest CT findings. It is of paramount importance that patients be fully informed of the risk of recurrence.

Pneumothorax in a term newborn.

With the advent of surfactant and gentle ventilation, the incidence of neonatal pneumothorax has decreased over the last two decades. Pneumothorax associated with respiratory distress syndrome is more common in preterm infants, but term infants often present with isolated pneumothorax. The use of CPAP or non-invasive respiratory support in the delivery room for a term infant with respiratory distress increases transpulmonary pressures and increases the risk of pneumothorax. Prompt diagnosis with a high index of suspicion, quick evaluation by transillumination, chest X-ray or lung ultrasound is critical. Management includes observation, needle thoracocentesis and if necessary, chest tube placement. This manuscript reviews the incidence, pathogenesis, diagnosis and management of a term infant with isolated pneumothorax, summarizing the combination of established knowledge with new understanding, including data on diagnostic modes such as ultrasound, reviewing preventative measures, and therapeutic interventions such as needle thoracocentesis and a comparison of pigtail vs. straight chest tubes.

Endometriosis first presenting in pleural fluid cytology.

Most patients with thoracic endometriosis present with catamenial pneumothorax, a rare condition in which recurrent episodes occur within 72 h before or after the start of menstruation. We report a case of thoracic endometriosis presenting with recurrent bloody pleural effusions without pneumothorax diagnosed on pleural fluid cytology. We describe the cytomorphology and immunoprofile of thoracic endometriosis and discuss the differential diagnoses, including neoplastic processes. We also highlight the importance of communication with clinicians for timeliness of diagnosis and treatment, especially when thoracic endometriosis is not suspected.

Efficacy and safety of intraoperative partial spray of 50% glucose for patients with spontaneous pneumothorax.

OBJECTIVES: The management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax. PATIENTS AND METHODS: We conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group). RESULT: The GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p < 0.01). None of them presented dehydration-related symptoms. CONCLUSIONS: The use of intraoperative glucose intrapleural spray is effective and safe in terms of preventing recurrences and postoperative complications.

Clinical characteristics of pneumothorax and pneumomediastinum in mechanical ventilated patients with coronavirus disease 2019: a case series.

BACKGROUND: Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM. METHODS: We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation. RESULTS: During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH2O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0-3.8]). CONCLUSION: Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies.

Talc slurry pleurodesis in patients with secondary intractable pneumothorax: A phase 2 study.

BACKGROUND: Secondary pneumothorax, which occurs most commonly in the elderly, is caused by underlying diseases. Cardiac dysfunction and other organ inefficiencies may render surgical repair impossible. Such non-operative and poor-risk cases are targets for pleurodesis, which involves the instillation of chemicals or irritants to the thoracic cavity through injection, bronchoscopic bronchial occlusion, or other procedures. Sterile graded talc has been used for pleurodesis mainly in Europe and the United States; however, only a few studies and case series investigating this topic have been published. This study evaluates the efficacy and safety of talc slurry pleurodesis. METHODS: Patients with inoperable secondary intractable pneumothorax, who were not candidates for surgical repair, were recruited. Four grams of sterilized talc was suspended in 50 mL of physiological saline and injected through a tube into the pleural cavity. Additional 50 mL of saline was subsequently injected through the same channel to clean the residual saline in the injection tube. Another additional talc instillation was allowed to control persistent air leakage. The primary endpoint was the proportion of drainage tube removal within 30 days after talc pleurodesis. RESULTS: Thirty-one patients were included in this study. In 23 out of 28 patients, the drainage tube could be removed within 30 days of talc instillation (82.1 %, 95 % CI = 63.1-93.9), exceeding the threshold of 36.0 % (p < 0.0001). The most common event was pain (11/28 patients, 39.3 %). CONCLUSIONS: Talc slurry pleurodesis is effective for intractable secondary pneumothorax, with minor side effects.

Spontaneous pneumothorax in a dog with a history of successfully treated heartworm disease: A case report.

OBJECTIVE: To describe a dog presented with spontaneous pneumothorax secondary to chronic pulmonary changes associated with a history of resolved canine heartworm disease. CASE OR SERIES SUMMARY: A 7-year-old 25.2kg female spayed German Shepherd mix was presented for management of spontaneous pneumothorax. The dog had a history of heartworm disease that underwent therapy prior to adoption, and the dog was heartworm antigen negative (SNAP 4Dx) during hospitalization for the pneumothorax. An exploratory thoracotomy was performed due to an unresolving pneumothorax requiring multiple thoracocenteses. Perioperatively, the lungs did not expand with positive pressure ventilation and diffuse, multifocal to coalescing areas of darkened tissue that were grossly consistent with necrosis and/or hemorrhage were noted. The dog was euthanized intraoperatively due to an assumed poor prognosis. Histopathologic examination findings were consistent with chronic reactive changes related to previous heartworm infection. No neoplastic or infectious etiologies were identified. NEW OR UNIQUE INFORMATION PROVIDED: Spontaneous pneumothorax is a known complication of active heartworm infection. However, this case represents the first report of spontaneous pneumothorax secondary to chronic pulmonary changes caused by resolved heartworm infection.

Conservative and operative management of spontaneous pneumothorax in children and adolescents: Are we abusing of CT?

BACKGROUND: No age-specific pediatric guidelines exist for the management of spontaneous pneumothorax (SP) in children and adolescents. Treatment remains heterogeneous and center dependent. The role of computed tomography (CT) has yet to be defined. AIMS: Review the management of SP in children and adolescents, with emphasis on conservative management and role of CT. METHODS: Retrospective analysis of 61 consecutive patients with SP at single tertiary center. Clinical, radiological, surgical data, follow-up, and outcomes were revised. RESULTS: First-line management was conservative for 32 (53%) patients and operative for 29 (47%). Asymptomatic/paucisymptomatic patients managed conservatively experienced less first-line treatment failure. Furthermore, the patients needing at least a chest drain or surgery during the follow-up were significantly lower in the conservative group. Conservative and operative patients showed no significant differences regarding ipsilateral recurrences or contralateral occurrences. Of the 61 overall CTs performed, 14 (23%) had an impact on management. Forty-three (70%) patients had at least a CT, in 22 (51%) the CT was positive for blebs. For 10 of these patients (45%) the presence of blebs had an impact on management. Patients with and without blebs showed no differences regarding ipsilateral recurrence, contralateral occurrences, or the need for at least a chest drain or surgery during the follow-up. CONCLUSIONS: First-line conservative management had a significantly shorter hospitalization and better outcome, with a similar incidence of recurrences. The presence of blebs at CT does not predict the risk of recurrence. The CT scan should be reserved for a small number of selected patients who have post-VATS refractory or recurrent pneumothorax.

Clinical features of pneumothorax associated with COVID-19: A retrospective analysis of two centres.

BACKGROUND: Pneumothorax is a known sequela of coronavirus disease 2019 (COVID-19). However, the clinical features of pneumothorax associated with COVID-19 have not been fully elucidated. METHODS: Patients who developed pneumothorax within 6 months of being diagnosed with COVID-19 were retrospectively analysed at two institutions. We investigated the background factors, COVID-19 severity and treatment, timing of pneumothorax onset, treatment modalities, treatment duration, and prognosis of these patients. RESULTS: A total of 21 patients were diagnosed with pneumothorax within 6 months of COVID-19 diagnosis. The combined incidence rate of pneumothorax at two institutions was 0.89 %. The mean age of these patients was 72.5 years, and they were predominantly male (90.5 %), with a history of smoking (76.1 %). The most frequent comorbidity was hypertension, followed by type 2 diabetes mellitus, COPD, and malignancy. Approximately 76 % of the patients had moderate or severe disease requiring oxygenation. Moreover, 90.5 % of these patients were taking antiviral drugs; 52.4 %, immunosuppressant agents (baricitinib/tocilizumab); and 66.7 % were on dexamethasone. The median time to the onset of pneumothorax was 15.0 days, and 86 % of cases occurred within 1 month of COVID-19 diagnosis. Bilateral pneumothorax and pneumomediastinum were noted in one patient each. Chest drainage was performed in 71.4 % of the patients. The mean treatment duration for pneumothorax was 14.1 days, and the 30-day mortality rate was 28.6 %. CONCLUSION: Pneumothorax associated with COVID-19 was more common in patients with moderate or severe disease requiring oxygenation, and occurred within 1 month of COVID-19 diagnosis. Pneumothorax associated with COVID-19 is a serious complication with a high mortality rate and clinicians should pay attention to it.

DraiNet: AI-driven decision support in pneumothorax and pleural effusion management.

OBJECTIVE: This study presents DraiNet, a deep learning model developed to detect pneumothorax and pleural effusion in pediatric patients and aid in assessing the necessity for tube thoracostomy. The primary goal is to utilize DraiNet as a decision support tool to enhance clinical decision-making in the management of these conditions. METHODS: DraiNet was trained on a diverse dataset of pediatric CT scans, carefully annotated by experienced surgeons. The model incorporated advanced object detection techniques and underwent evaluation using standard metrics, such as mean Average Precision (mAP), to assess its performance. RESULTS: DraiNet achieved an impressive mAP score of 0.964, demonstrating high accuracy in detecting and precisely localizing abnormalities associated with pneumothorax and pleural effusion. The model's precision and recall further confirmed its ability to effectively predict positive cases. CONCLUSION: The integration of DraiNet as an AI-driven decision support system marks a significant advancement in pediatric healthcare. By combining deep learning algorithms with clinical expertise, DraiNet provides a valuable tool for non-surgical teams and emergency room doctors, aiding them in making informed decisions about surgical interventions. With its remarkable mAP score of 0.964, DraiNet has the potential to enhance patient outcomes and optimize the management of critical conditions, including pneumothorax and pleural effusion.