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.

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.

Hemoneumotórax espontaneo, una manifestación inusual de la endometriosis pleural / Spontaneous hemopneumothorax, an unusual manifestation of pleural endometriosis

El hemotórax y neumotórax es una condición usualmente relacionada con etiología traumática, infecciosa, inflamatoria o coagulopatía. La aparición espontanea en pacientes jóvenes precisa la búsqueda de etiologías diferenciales. La expresión clínica de la endometriosis pleural incluye neumotórax, hemotórax, hemoptisis y nódulos pulmonares. La radiografía de tórax, la tomografía computarizada, la resonancia magnética nuclear, la broncoscopia y la biopsia se constituyen como el pilar del diagnóstico. Presentamos un caso de un paciente joven con disnea y hemo-neumotórax espontaneo con diagnóstico de endometriosis pleural. (AU)

Hemothorax and pneumothorax is a condition usually related to traumatic, infectious, inflammatory or coagulopathy etiology. The spontaneous appearance in young patients requires the search for differential etiologies. The clinical expression of pleural endometriosis includes pneumothorax, hemothorax, hemoptysis, and pulmonary nodules. Chest X-ray, computed tomography, nuclear magnetic resonance, bronchoscopy and biopsy constitute the mainstay of diagnosis. We present a case of a young patient with dyspnea and spontaneous hemo-pneumothorax diagnosed with pleural endometriosis. (AU)

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.

Papel de la ecografía en la sala de emergencia en el diagnóstico del trauma de tórax / The Role of Sonography in the Emergency Room for the Diagnosis of Thoracic Trauma

Introducción: Dentro de la atención al lesionado con trauma torácico se cuenta con varios medios diagnósticos, entre ellos la evaluación por ecografía focalizada en trauma extendido a tórax, el cual ha mostrado una alta sensibilidad, aun realizado por médicos no radiólogos como cirujanos generales, emergencistas e intensivistas. Objetivo: Determinar la utilidad de la ecografía torácica extendida realizada por cirujanos en lesionados con traumatismo torácico. Métodos: Se realizó un estudio observacional, descriptivo de evaluación de pruebas diagnósticas con un diseño transversal, en 1052 pacientes ingresados en la sala de emergencia. Se les realizó la evaluación por ecografía torácica extendida en el Hospital Universitario "General Calixto García", durante el período comprendido entre enero de 2020 y febrero de 2021. Resultados: Fueron realizados en un periodo de 1 año un total de 1052 ultrasonidos torácicos, 221 casos fueron positivos, de ellos 81 neumotórax (7,7 por ciento) y 62 hemoneumotórax (5,9 por ciento) todos confirmados por tomografía de tórax. La edad promedio fue de 45,27 (18-97), el sexo masculino prevaleció con 772 casos (73,4 por ciento). Los mecanismos productores de trauma más frecuentes fueron: caída de altura 273 casos (26 por ciento) y trauma contuso 181 casos (17,2 por ciento). La ecografía torácica extendida obtuvo una sensibilidad de un 95,24 por ciento y una especificidad de 99,88 por ciento en el diagnóstico lesiones torácicas. Conclusiones: La ecografía torácica extendida demostró que en manos de los cirujanos generales es una herramienta confiable, segura, no invasiva, poco costosa, repetible, que permite diagnosticar rápidamente lesiones torácicas y tratarlas(AU)

Introduction: Within care for the injured patient with thoracic trauma there are several diagnostic means. For example, extended focused assessment with sonography for thoracic trauma has shown high sensitivity, even when performed by non-radiologists such as general surgeons, emergency specialists and intensivists. Objective: To determine the usefulness of extended thoracic sonography performed by surgeons on injured patients with thoracic trauma. Methods: An observational, descriptive and cross-sectional study of diagnostic tests assessment was carried out in 1052 patients admitted to the emergency room. They were assessed by extended thoracic sonography at General Calixto García University Hospital, during the period between January 2020 and February 2021. Results: A total of 1052 thoracic ultrasounds were performed in a period of one year, of which 221 cases were positive. Of them, 81 were pneumothorax (7.7 percent) and 62 were hemopneumothorax (5.9 percent), all confirmed by chest tomography. The average age was 45.27 (18-97). The male sex prevailed, with 772 cases (73.4 percent). The most frequent trauma-producing mechanisms were altitude fall, accounting for 273 cases (26 percent), and blunt trauma, accounting for 181 cases (17.2 percent). Extended thoracic ultrasound showed a sensitivity of 95.24 percent and a specificity of 99.88 percent in the diagnosis of thoracic injuries. Conclusions: Extended thoracic ultrasound showed that, in the hands of general surgeons, it is a reliable, safe, noninvasive, inexpensive and repeatable tool that allows rapid diagnosis and treatment of thoracic injuries(AU)

Unusual case of spontaneous hemopneumothorax in a Tunisian pulmonology department: a case report.

Spontaneous hemopneumothorax is a rare encountered entity in clinical practice. It can be life threatening, so a prompt diagnosis and therapeutic intervention are required. We report a case of a right spontaneous hemopneumothorax in a 31-year-old man, complicated with hemorrhagic shock. Conservative therapy with only thoracic drainage with close monitoring of outflow and hemodynamic parameters was performed. In front of hemodynamic instability, an emergency video-assisted thoracoscopic surgery was performed. An apical bulla adhering to the parietal pleura has been identified as the source of the bleeding. The resection of the bullae and electrocauterization of the bleeding adhesion were effectuated. The hemostasis was easily achieved. The actual experience suggests that video-assisted thoracoscopic surgery should be performed as soon as possible after the diagnosis of spontaneous hemopneumothorax. Indeed, conservative therapy with chest drainage should only be performed as bridge to recovery for the stabilization before the video-assisted thoracoscopic surgery.

Hemopneumothorax - An Unexpected Cath Lab Diagnosis.

A 57-year-old woman presented with chest pain. Electrocardiography (ECG) revealed an inferior ST-segment elevation myocardial infarction. Thrombolysis was initiated and repeat ECG showed reduction of ST elevation. The patient reported ongoing pain and developed hypotension. Fluoroscopy of the chest demonstrated gross tracheal deviation and collapse of the left lung. This case highlights the importance of maintaining a broad differential diagnosis and of harnessing the various skills within a multidisciplinary team.

Spontaneous hemopneumothorax with a ruptured aneurysm in the second intercostal artery: report of a case.

Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected. Contrast-enhanced computed tomography showed a ruptured aneurysm near the left pulmonary apex. Emergency angiography further revealed the ruptured aneurysm in the second intercostal artery. Transcatheter angiographic embolization (TAE) was performed, which resulted in hemostasis. On hospitalization day 2, the hematoma was removed via video-assisted thoracic surgery. A bulla was also identified in the lower lobe and removed. She was discharged from the hospital on a postoperative day 6 without complications. Thus, TAE might be effective to control bleeding during the initial treatment of SHP due to a ruptured aneurysm.

Hemopneumothorax detection through the process of artificial evolution - a feasibility study.

BACKGROUND: Tension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax. METHODS: Acoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline. RESULTS: The in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise. CONCLUSIONS: We present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.

The Use of Chest Seals in Treating Sucking Chest Wounds: A Comparison of Existing Evidence and Guideline Recommendations.

INTRODUCTION: Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax. METHODS: The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines. RESULTS/DISCUSSION: Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals. CONCLUSION: Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax.

INTRODUCTION: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32-40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. METHODS: Prospective RCT comparing 14Fr PCs to 28-32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1-5 (1 = tolerable experience, 5 = worst experience). Unpaired Student's t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05. RESULTS: Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375-1087; for PCs vs. 400 ml; IR, 240-700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, "I can tolerate it"; IR, 1-2) than CT patients (median, 3, "It was a bad experience"; IR, 3-4, P = 0.001). CONCLUSION: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28-32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434.

Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest.

INTRODUCTION: There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

Spontaneous hemopneumothorax in a patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness that was first documented in China in December 2019 and shortly after declared a pandemic on March 11, 2020. The pathophysiology of the virus is still not completely understood and remains under investigation. Consequently, new symptomatic manifestations and complications of the disease continue to be discovered. Here we present the case of a spontaneous hemopneumothorax resulting in hemorrhagic shock in an adult male with PCR confirmed COVID-19.

[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.