Bronchoscopic Valve Management of Persistent Air‐Leaks in Mechanically Ventilated Patients

Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes.

Persistent air leak (PAL) may complicate the course of secondary spontaneous pneumothoraces, and presents a particular challenge in patients who are deemed unfit for any form of surgical intervention. Although autologous blood patch pleurodesis (ABPP) has been used by thoracic surgeons for decades to manage PAL following pulmonary surgery, its role in the management of spontaneous pneumothoraces remains less well defined. The aim of this prospective observational study was to assess the feasibility of ABPP in this setting. Thirty-eight consecutive patients who had secondary spontaneous pneumothoraces with confirmed PAL and who were deemed unfit for surgery were recruited. The most common underlying causes were post-TB bronchiectasis (n=22) and COPD (n=12). A total of 80-120 ml of the patient's own unheparinised blood was injected via a 50 ml bladder syringe into the pleural cavity via an intercostal drain (ICD). The ICD was clamped for one hour, followed by chest radiography and if the air leak ceased, the ICD was removed. ABPP could be repeated once within 48 hours if PAL was still present, and was deemed successful if the ICD could be removed within 72 hours of the final procedure. ABPP was successful in 31 (81.6%) subjects and 15 (39.5%) required two procedures. The duration of PAL prior to ABPP was 15 (+/-5) days and the mean time to removal of the ICD was 1.6 days after the final procedure. The ICD could be removed within 24 hours in 17 (44.7%) subjects. Only one procedure related complication (haemoptysis) was observed. ABPP appears to be feasible, safe and an inexpensive intervention for PAL in poor surgical candidates with spontaneous pneumothoraces.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

BackgroundThe TIME2 Trial[1], a randomised clinical trial comparing indwelling pleural catheter (IPC) with talc pleurodesis for malignant pleural effusion, included a prospective economic analysis. S78 Table 1.Estimates of income using...

Transient Diaphragmatic Paralysis by Continuous Para-Phrenic Infusion of Bupivacaine: A Novel Technique for the Management of Residual Spaces

Pneumothorax after a pneumonectomy is a rare but potentially fatal condition due to markedly reduced pulmonary reserve. Preventing recurrence is crucial in this population. When surgery is required, intraoperative ventilation is particularly challenging. Options include conventional strategies such as high-frequency jet ventilation or endobronchial blockade, or extracorporeal membrane oxygenation (ECMO) when apnea tolerance is limited. We report the case of a 79-year-old male with a history of a left pneumonectomy for lung cancer, chronic obstructive pulmonary disease, and pulmonary emphysema who presented with sudden-onset, right-sided chest pain. Chest radiography revealed a right-sided pneumothorax, which was managed with chest tube drainage. A chest CT demonstrated a large bulla in the middle lobe. The pneumothorax recurred a few days later, requiring the reinsertion of an 18-Fr chest drain. The patient was evaluated by the thoracic surgery team but was deemed high risk, and chemical pleurodesis with talc slurry was performed through the chest drain to prevent recurrence. Two days after discharge, the pneumothorax recurred. Following recurrent episodes despite drainage and talc pleurodesis, the case was discussed in a multidisciplinary team involving pulmonology, thoracic surgery, and intensive care. Given his age, frailty, comorbidities, and severely reduced pulmonary reserve, conventional ventilation strategies were considered unsafe, and ECMO was selected to permit definitive surgical treatment. He underwent venovenous femoro-jugular ECMO cannulation, followed by uniportal video-assisted thoracic surgery with wedge resection of the middle-lobe bulla and combined chemical pleurodesis with talc and mechanical pleurodesis by pleural abrasion, without complications. He was extubated on the day of surgery and decannulated the following day. Postoperative Doppler ultrasonography revealed deep venous thrombosis of both cannulated vessels, and anticoagulation with low-molecular-weight heparin was initiated. The patient was discharged on postoperative day 12, with a switch to the direct oral anticoagulant edoxaban. No recurrence was observed at the five-month follow-up. Recurrent pneumothorax in a post-pneumonectomy patient represents a high-risk scenario in which conventional ventilation may not safely permit surgery. ECMO-assisted surgery offers a viable option for definitive management in patients with prohibitive pulmonary function.

Rebuttal From Dr Lee

The suggestion that spontaneous pneumothorax (SP) may result from diffuse porosity rather than discrete anatomic abnormality challenges the practice of targeted bullectomy. We assessed whether underlying pulmonary abnormalities are correlated or could be predicted from the mode of presentation, with potential implications for treatment. We analyzed 192 consecutive video-assisted thoracoscopic surgery resections for SP (139 primary, 53 secondary) in 171 patients (115 male, age 36, range, 16 to 81). Presentation was categorized as: recurrent never drained (RND), recurrent drained, persistent air leak (PAL). Resected lung pathology was categorized as: no bleb/bulla, ruptured bleb/bulla, unruptured bleb/bulla. No correlation between presentation and resected lung pathology was observed for primary (P=0.608) or secondary SP (P=0.597). A similar proportion of patients in each pathologic group presented with PAL or RND; ruptured bleb/bulla or no bleb/bulla was equally noted in PAL and RND group. There is lack of association between resected lung pathology and mode of presentation. This suggests that discrete anatomic abnormalities may not be responsible for the air leak leading to pneumothorax. In conjunction with favorable reported outcomes from medical thoracoscopy and talc pleurodesis alone, these findings challenge the current practice of routine video-assisted thoracoscopic surgery lung resection in these patients.

Spontaneous pneumothorax – How long should we keep a chest drain?

Introduction: Independent lung ventilation (ILV) with double lumen endotracheal tube (DLt) or endobroncial blockade has a known role in managing pneumothorax or by isolating the diseased lung. We report a case in which ILV was used along with a bronchial blocker for treatment of severe persistent pneumothorax (PtX). case report: We report a 66-year-old female admitted with septic shock and respiratory failure from right lobar pneumonia who developed a rightsided pneumothorax. Despite the placement of two chest tubes, the patient had persistent acidosis and air leak. she required independent lung ventilation with a double lumen endotracheal tube and a bronchial blocker. this isolated the right lower lobe airleak and provided lung protective concordant positive pressure ventilation to the right middle and upper lobes. conclusion: Persistent air leaks in an intubated patient can be challenging. Our case highlights the concept of anatomical lung separation. With this clinicians can to allow provide isolation of the diseased lung, while using other subsegments to maintain adequate gas exchange. Muna Beg1, Pantea Mahtosh1, Sudhir Rajan1, Hekmat Nasiri1, Vincent Liu1,2 Affiliations: 1Kaiser Permanente Santa Clara Medical Center, Homestead Campus, 3rd floor, Department 384, 710 Lawrence Expressway, Santa Clara, CA 95051, USA; 2Kaiser Permanente Division of Research 2000 Broadway Oakland, CA 94612, USA. Corresponding Author: Muna Beg, MD, 1-562-481-4328, Kaiser Permanente Santa Clara Medical Center, Graduate Medical Education Department, Homestead Campus, 3rd floor, Department 384, 710 Lawrence Expressway, Santa Clara, CA 95051, USA; E-mail: Muna.a.beg@kp.org Received: 26 May 2015 Accepted: 02 June 2015 Published: 03 September 2015

Management of Recurrent Malignant Pleural Effusions: An Ever-Recurring Issue?

ABSTRACTBACKGROUND:Traumatic pneumothorax is one of the most common findings encountered after chest trauma and often forces clinicians to quickly decide between tube thoracostomy and observation. Although large pneumothoraces (LP), most often defined radiologically as a pleural gap greater than 2 cm, are routinely managed with chest tube drainage, the management of minimal pneumothoraces (MP) is still a matter of debate.METHODS:In this study, we analyzed 193 consecutive penetrating thoracic trauma patients managed in our center over a five-year period (2020–2025). Patients were classified into minimal pneumothorax and large pneumothorax groups based on computed tomography (CT) findings. Clinical and radiological parameters, Injury Severity Score (ISS), complications, and hospital stay were recorded, and their associations with chest tube placement were assessed.RESULTS:Among the 193 patients, 112 (58%) were in the MP group and 81 (42%) in the LP group. The median age was comparable between groups (30.5 years [interquartile range, IQR: 22.8-39.3] vs. 28 years [IQR: 23-39], p=0.797). Gender distribution was also similar, with males accounting for 93.3% in the MP group and 93.8% in the LP group (p=1.000). Pneumothorax size strongly influenced treatment (p<0.001): chest tube thoracostomy was performed in 95.1% of LP vs. 9.8% of MP cases. Conservative observation was successful in 90.2% of MP patients. LP patients had significantly longer hospital stays (8.29 vs. 4.56 days, p<0.001), higher ICU admission rates (27.2% vs. 5.4%, p<0.001), and higher ISS (21.33 vs. 13.68, p<0.001). Complications were more frequent in LP (24.7% vs. 0.9%, p<0.001), with hemothorax, persistent air leak, and pleural effusion being the most common. Most hemothorax cases were attributed to the initial penetrating trauma, while only a small minority were tube-related. Among patients with LP (>2 cm), four were managed conservatively due to their stable clinical condition, and no mortality occurred in this subgroup. Mortality occurred exclusively in the chest tube group (18/88, 20.5%), with no deaths among observed patients overall (p<0.001). In subgroup analysis, gunshot wounds were associated with a higher need for chest tube even in MP (20.7% vs. 6.0%, p=0.033).CONCLUSION:Our findings indicate that careful observation is a safe option in patients with minimal pneumothoraces, while large pneumothoraces generally necessitate invasive treatment and are associated with worse outcomes. Our results are consistent with previous reports in the international literature.

The Removal of Chest Tubes Despite an Air Leak or a Pneumothorax

Primary spontaneous pneumothorax is a pathology mainly affecting healthy young patients. Clinical guidelines do not specify the type of pleurodesis that should be conducted, due to the lack of comparative studies on the different techniques. The aim of this study was to compare talc poudrage and pleural abrasion in the treatment of spontaneous pneumothorax. A retrospective comparative study was performed, including 787 patients with primary spontaneous pneumothorax. The 787 patients were classified into two groups: Group A (pleural abrasion) n = 399 and Group B (talc pleurodesis) n = 388. The variables studied were recurrence, surgical time, morbidity and in-hospital length of stay. Statistical analysis was done by an unpaired t-test and Fisher's exact test (SSPS 18.0). Statistically significant differences were observed in the variables: surgical time (A: 46 ± 12.3; B: 37 ± 11.8 min; P < 0.001); length of stay (A: 4.7 ± 2.5; B: 4.3 ± 1.8 days; P = 0.01); apical air camera (A: 25; B: 4; P < 0.001); pleural effusion (A: 6; B: 0; P = 0.05). Talc poudrage shows shorter surgical times and length of stay, and lower re-intervention rates. Morbidity is lower in patients with talc poudrage. Statistically significant differences were not observed in recurrence, persistent air leaks, atelectasis and haemothorax.

IntroductionMalignant pleural effusions (MPE) cause disabling symptoms often relieved by thoracentesis. Indwelling pleural catheter (IPC) insertion and talc pleurodesis (TP) are equally effective treatments1 yet; current BTS guidelines suggest talc...