8.5 French peripheral intravenous access during air medical transport of the injured patient

Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient.Method: Retrospective chart review of patients identified by concurrent transport registry who received peripheral 8.5 F IV access during air medical transport for injury. The transport program consists of four remote-based BK-117 helicopters staffed by a nurse/paramedic crew. A peripheral 8.5 F IV access was obtained by protocol using guidewire technique over an existing peripheral IV. Crew education consisted of a combination of didactic and hands-on experience updated periodically on an ongoing basis.Results: From July 1991 through March 1995, 23 injured patients transported to a single Level I trauma center received a peripheral 8.5 F introducer. The patients averaged 30.9 years of age and were primarily male (78.3%) with blunt injuries (87%). Initial trauma score averaged 9.8; injury severity score averaged 24.6. All patients had at least one additional IV line; 21 of 23 patients were endotracheally intubated. Ground times averaged 19 minutes, flight time averaged 22.1 minutes, and in-flight fluids averaged 2239 ml or 101 ml per minute of flight. Complications associated with prehospital IV access did not occur.Conclusion: Peripheral 8.5 F access through a guidewire technique of an existing IV provides a rapid, simple approach to large-bore IV access in the injured patient transported by air.     

CT-guided transthoracic cutting needle biopsy of intrathoracic lesions: comparison between coaxial and single needle technique

Purpose

To evaluate the complication rates and diagnostic accuracy of two different CT-guided transthoracic cutting needle biopsy techniques: coaxial method and single needle method.

Methods

This study involved 198 consecutive subjects with 198 intrathoracic lesions. The first 98 consecutive subjects received a single needle cutting technique and the next 100 consecutive subjects received a coaxial technique. Both groups were compared in relation the diagnostic accuracy and complication rates.

Results

No significant difference was found between the two groups concerning patient characteristics, lesions and procedure variables. There was a borderline statistical difference in the incidence of pneumothorax at within 24-h post biopsy between patients in the single needle group (5%) and the coaxial group (13%) (P = 0.053). Little difference was found in the pneumothorax rate at immediately post biopsy between the two groups, which was 28% in the single needle group and 31% in the coaxial group. There was no significant difference in the hemoptysis rate between the two groups, which was 9.2% in the single needle group and 11% in the coaxial group. Both techniques yielded an overall diagnostic accuracy of 98% for malignant lesions with similar sensitivity (single needle: 96.9% vs. coaxial: 96.4%) and specificity (single needle: 100% vs. coaxial: 100%).

Conclusion

There is little difference in the pneumothorax rates and bleeding complications between patients who either received a single needle or a coaxial transthoracic cutting biopsy. Both techniques produce an overall diagnostic accuracy of 98% for malignant lesions.     

Evaluation of the rapid four-step cricothyrotomy technique: An interim report

Introduction: We described the rapid four-step cricothyrotomy technique (RFST), a new cricothyrotomy method specifically designed for the prehospital environment. In this article, we report our initial clinical experience and provide additional information regarding the technique itself.Method: This article is a prospective, consecutive case series. Each time Life Flight personnel used the RFST in the prehospital setting, they were asked to complete a brief questionnaire regarding their experiences with the technique. Data were collected between July 1995 and June 1997.Results: During the study period, 13 cricothyrotomies were performed using the RFST, all of which were successful. One report of significant bleeding occurred and was controlled with cricoid pressure. In 4 of the 13 patients, the skin and soft tissue were incised before performing the stab incision through the cricothyroid membrane. In nine cases the incision was enlarged before passing the tracheostomy tube. A second attempt was needed to successfully pass the tube in two patients. No difficulties were reported in maneuvering the hook, and the #20 scalpel blade was thought to be an appropriate size. All personnel with previous cricothyrotomy experience preferred the RFST to their previous cricothyrotomy approach.Conclusion: Our experience with the RFST has been very favorable. We recommend this technique to others for use in the prehospital environment. We also invite the reader to participate in ongoing evaluation comparing the RFST with standard cricothyrotomy techniques.     

CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules

OBJECTIVE: The purpose of our study was to determine the diagnostic accuracy and to analyze the factors influencing the diagnostic accuracy and incidences of pneumothorax and chest tube insertion rates for percutaneous CT-guided needle biopsy of small (< or = 20 mm) solitary pulmonary nodules. SUBJECTS AND METHODS: One hundred sixty-two patients with 162 small solitary pulmonary nodules underwent CT-guided transthoracic needle aspiration biopsy. The overall diagnostic accuracy, pneumothorax rate, and chest tube insertion rate were calculated. Factors influencing the diagnostic accuracy and pneumothorax rate were statistically evaluated. Influencing factors, diagnostic accuracies, pneumothorax rates, and chest tube insertion rates were statistically compared. RESULTS: Overall diagnostic accuracy, pneumothorax rate, and chest tube insertion rate were 77.2%, 28.4%, and 2.5%, respectively. Diagnostic accuracy was significantly affected by length of needle path and lesion size (p < 0.05). The pneumothorax rate was significantly affected by the percentage of predicted forced expiratory volume in 1 sec, the number of punctures, and the needle path length (p < 0.05). The chest tube insertion rate was significantly affected by the number of punctures (p < 0.05). For diagnostic accuracy, needle path lengths of 40 mm or less and lesion sizes greater than 10 mm were significantly more accurate than other factors (p < 0.05). For pneumothorax rates, a percentage of predicted forced expiratory volume in 1 sec of greater than 70%, a single puncture, and a needle path length of 40 mm or less were significantly lower than other factors (p < 0.05). CONCLUSION: CT-guided transthoracic needle aspiration biopsy is a useful diagnostic tool for small solitary pulmonary nodules smaller than 20 mm in diameter. The diagnostic accuracy is significantly improved for large (> 10 mm) lesion size and short (< or = 40 mm) needle path length.     

Risk factors for pneumothorax and bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung lesions.

PURPOSE: To evaluate risk factors for pneumothorax and bleeding after computed tomography (CT)-guided percutaneous coaxial cutting needle biopsy of lung lesions. MATERIALS AND METHODS: This study involved 117 consecutive patients with 117 intrapulmonary lesions. Statistical analysis of factors related to patient characteristics, lung lesions, and biopsy technique was performed to determine possible contribution to the occurrence of pneumothorax and bleeding. Interactions between related factors were considered to prevent colinearity. RESULTS: Pneumothorax occurred in 12% (14 of 117) of patients. Needle aspiration of two moderate asymptomatic pneumothoraces were performed; there was no chest tube insertion. Lesion depth (P =.0097), measured from the pleural puncture site to the edge of the intrapulmonary lesion along the needle path, was the single significant predictor of pneumothorax. The highest risk of pneumothorax occurred in subpleural lesions 2 cm or shorter in depth (this represented 33% of lung lesions but caused 71% of all pneumothoraces; OR = 7.1; 95% CI, 1.3-50.8). Bleeding presented as lung parenchyma hemorrhage and hemoptysis in 30 patients (26%). Hemoptysis occurred in four patients (3%). Univariate analysis identified lesion depth (P <.0001), lesion size (P <.015), and pathology type (P =.007) as risk factors for bleeding. Multivariate logistic regression analysis identified lesion depth as the most important risk factor, with the highest bleeding risk for lesions more than 2 cm deep (14% of lesions caused 46% of all bleeding; OR = 17.3; 95% CI, 3.3-121.4). CONCLUSIONS: In CT-guided coaxial cutting needle biopsy, lesion depth is the single predictor for risk of pneumothorax, which occurs at the highest rate in subpleural lesions. Increased risk of bleeding occurs in lesions deeper than 2 cm.     

CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan

PURPOSE: The aim of our study was to update the rate of severe complications following CT-guided needle biopsy in Japan via a mailed survey. MATERIALS AND METHODS: Postal questionnaires regarding CT-guided needle biopsy were sent out to multiple hospitals in Japan. The questions regarded: the total number and duration of CT-guided lung biopsies performed at each hospital, and the complication rates and numbers of pneumothorax, hemothorax, air embolism, tumor seeding, tension pneumothorax and other rare complications. Each severe complication was followed with additional questions. RESULTS: Data from 9783 biopsies was collected from 124 centers. Pneumothorax was the most common complication, and occurred in 2412 (35%) of 6881 cases. A total of 39 (35%) hospitals reported 74 (0.75%) cases with severe complications. There were six cases (0.061%) with air embolism, six cases (0.061%) with tumor seeding at the site of the biopsy route, 10 cases (0.10%) with tension pneumothorax, six cases (0.061%) with severe pulmonary hemorrhage or hemoptysis, nine cases (0.092%) with hemothorax, and 27 cases (0.26%) with others, including heart arrest, shock, and respiratory arrest. From a total of 62 patients with severe complications, 54 patients (0.55%) recovered without sequela, however one patient (0.01%) recovered with hemiplegia due to cerebral infarction, and the remaining seven patients (0.07%) died. CONCLUSIONS: This is the first national study documenting severe complications with respect to CT-guided needle biopsy in Japan. The complication rate in Japan is comparable to internationally published figures. We believe this data will improve both clinicians as well as patients understanding of the risk versus benefit of CT-guided needle biopsy, resulting better decisions.     

Complications After Transthoracic Needle Biopsy of Pulmonary Nodules: A Population-Level Retrospective Cohort Analysis

ObjectiveTo provide recent population-based estimates of transthoracic needle biopsy (TTNB) complications and risk factors associated with these complications.MethodsThis retrospective cohort analysis included adults from a nationally representative longitudinal insurance claims data set who underwent TTNB in 2017 or 2018. Complications that were evaluated included pneumothorax, hemorrhage, and air embolism. Separate logistic regression models estimated the association of pneumothorax or hemorrhage with the setting of care (ie, inpatient or outpatient) and selected baseline patient demographic and clinical characteristics including age, gender, history of chronic obstructive pulmonary disease, diagnosis of pleural effusion, tobacco use, use of oral anticoagulants and antiplatelet agents, prior lung cancer screening, previous bronchoscopy within 1 year, and Elixhauser comorbidity index.ResultsAmong 16,971 patients who underwent TTNB, 25.8% experienced a complication within 3 days of the procedure (pneumothorax 23.3%, hemorrhage 3.6%, and air embolism 0.02%). Among patients who experienced pneumothorax, 31.9% required chest tube drainage. Among patients undergoing an outpatient TTNB (n = 12,443), 6.9% were hospitalized within 7 days. Biopsy in an inpatient setting, chronic obstructive pulmonary disease diagnosis, and prior bronchoscopy were associated with higher rates of both pneumothorax and hemorrhage. Prior lung cancer screening was associated with an increased risk of pneumothorax, and prior use of oral anticoagulants or antiplatelets was associated with higher rates of hemorrhage.ConclusionThis contemporary population-based cohort study demonstrated that approximately one-quarter of patients undergoing TTNB experienced a complication. Pneumothorax was the most frequent complication, and hemorrhage and air embolism were rare. Among outpatients, complications from TTNB are an important cause of hospitalization.     

Will the presence of radiological signs of tension pneumothorax affect the clinical presentation of primary spontaneous pneumothorax?

Introduction

Patients with primary spontaneous pneumothorax (PSP) rarely presented with radiological signs of tension pneumothorax on their presenting chest X-ray. Even though, those patients may not develop the hemodynamic instability that is seen in tension pneumothorax. The aim of this study is to elaborate whether the presence of radiological signs of tension pneumothorax in patients with PSP will affect their clinical presentation.

Methods

Retrospective study of all cases of PSP over a period from January 2007 to December 2014. The cases were divided into two groups; tension group includes cases who have radiological signs of tension pneumothorax and non-tension group who do not have those signs. The main outcome was a comparison of the hemodynamic status of both groups.

Results

A total of 151 cases of PSP were included in the study. Radiologic signs of tension pneumothorax were identified in 13 cases of the sample. Only one case of the tension group developed hemodynamic instability in the form of desaturation to below 92% with no statistical difference between the two groups in maintaining the hemodynamic status.

Conclusion

In spite that PSP can be presented with radiological signs of tension pneumothorax, those patients usually maintained their hemodynamic stability. Tension pneumothorax rarely presented as consequence of PSP.

     

1162例严重胸部创伤的院前急救分析

目的：总结严重胸部创伤院前救治经验，提高院前救治水平。方法收集2009年1月～2014年12月经院前“120”现场救治后转入我院的严重胸部创伤（ AIS）≥3分患者病例资料1162例，其中男性827例，女性335例；年龄13～98岁，平均（45．3±10．8）岁。分析胸部损伤情况，院前、院内救治方法和救治结果等。结果1162例中，院前平均急救反应时间（46．52±17．33）min，平均急救时间（16．73±7．32） min。清除呼吸道异物31例，气管插管机械通气42例，紧急气管切开23例，张力性气胸减压25例，呼吸机正压通气纠正反常呼吸运动43例，纱垫填塞或包扎胸壁开放性伤口151例，呼吸心跳停止者现场进行徒手心肺复苏16例，胸部伤情未进行特殊处理者735例。本组死亡29例。结论院前快速准确判断，熟练正确急救为严重胸部创伤院内进一步救治创造机会和争取时间。     

CT-guided lung biopsy: incidence of pneumothorax after instillation of NaCl into the biopsy track

This study was conducted to evaluate whether instillation of NaCl 0.9% solution into the biopsy track reduces the incidence of pneumothoraces after CT-guided lung biopsy. A total of 140 consecutive patients with pulmonary lesions were included in this prospective study. All patients were alternatingly assigned to one of two groups: group A in whom the puncture access was sealed by instillation of NaCl 0.9% solution during extraction of the guide needle (n = 70) or group B for whom no sealing was performed (n = 70). CT-guided biopsy was performed with a 18-G coaxial system. Localization of lesion (pleural, peripheral, central), lesion size, needle-pleural angle, rate of pneumothorax and alveolar hemorrhage were evaluated. In group A, the incidence of pneumothorax was lower compared to group B (8%, 6/70 patients vs. 34%, 24/70 patients; P < 0.001). All pneumothoraces occurred directly post punctionem after extraction of the guide needle. One patient in group A and eight patients in group B developed large pneumothoraces requiring chest tube placement (P = 0.01). The frequency of pneumothorax was independent of other variables. After CT-guided biopsy, instillation of NaCl 0.9% solution into the puncture access during extraction of the needle significantly reduces the incidence of pneumothorax.     

Effect of needle tract bleeding on occurrence of pneumothorax after transthoracic needle biopsy

PURPOSE: Occasionally bleeding along the needle trajectory is observed at post-biopsy computed tomographic sections. This study was designed to evaluate the possible effect of needle tract bleeding on the occurrence of pneumothorax and on requirement of chest tube insertion. MATERIALS AND METHODS: Two hundred eighty-four needle biopsies performed in 275 patients in whom the needle traversed the aerated lung parenchyma were retrospectively reviewed. Bleeding along the needle tract, occurrence of pneumothorax and need for chest tube insertion, type and size of the needle, size of the lesion, length of the lung traversed by the needle, presence or absence of emphysema were noted. Effect of these factors on the rate of pneumothorax and needle-tract bleeding was evaluated. The data were analyzed by chi2 test. RESULTS: Pneumothorax developed in 100 (35%) out of 284 procedures requiring chest tube placement in 16 (16%). Variables that were significantly associated with an increased risk of pneumothorax were depth of the lesion (P < 0.001) and severity of emphysema (P < 0.05). There was bleeding along the needle tract in 18.6% (n = 53) of the procedures. Pneumothorax occurred in 18 (33.9%) out of 53 procedures in which tract-bleeding was observed and in 82 (35.4%) out of 231 procedures in which tract-bleeding was not seen. The difference between the two groups was not significant (P > 0.05). However, analysis of the relation between length of lung traversed by the needle, tract-bleeding and pneumothorax rate indicated that tract-bleeding had a preventive effect on development of pneumothorax (P < 0.001). Occurrence of tract bleeding also had preventive effect on pneumothorax in the presence of emphysema (P < 0.05). The only variable which had effect on occurrence of tract-bleeding was the length of the lung traversed by needle (p < 0.001). Requirement for chest tube insertion was smaller in the tract-bleeding group than non-tract bleeding group, 11% (2/18) to 17% (14/82), respectively. But this difference was not significant statistically (P > 0.05). CONCLUSION: Bleeding in the needle tract has a preventive effect on the occurrence of the pneumothorax in deep-seated lesions and in the presence of emphysema, although it does not affect the overall rate of pneumothorax.     

Correlation of the RTS (Revised Trauma Score) and RAPS (Rapid Acute Physiology Score) in rotor-wing prehospital care

INTRODUCTION: The Rapid Acute Physiology Score (RAPS) has been applied to patients transported by air, but not correlated with commonly used prehospital indices. The authors desired to determine the correlation between RAPS and Revised Trauma Score (RTS). Correlations between RAPS and RTS in patients with non-trauma ills were also investigated. METHODS: Eight-hundred forty-four consecutive patients transported by helicopter were retrospectively evaluated. Demographics, origin of transport, nature of illness, RTS and RAPS were recorded. RTS vs. RAPS scores were graphed using sunflower technique and correlation was calculated using Spearman Rank-Order Correlation Coefficients (SCC). Alpha was set at < or = .05. RESULTS: Sunflower plots revealed wide ranges of RAPS at like RTS values in less severely ill or injured patients. SCC analysis revealed statistically significant (p < .05) correlations for all patients and for subgroups of prehospital trauma, prehospital medical, interfacility trauma and interfacility medical patients. Degrees of correlation varied between groups, with agreement being strongest in prehospital trauma and weakest in interfacility trauma patients. CONCLUSIONS: We conclude that RTS and RAPS scores exhibit significant correlation in a variety of patient populations. The wide range of RAPS seen at like RTS values suggests that RAPS may be a more sensitive indicator of physiologic status in patients transported by air.     

Factors influencing pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture contributing factors?

PURPOSE: To study factors that may influence pneumothorax and chest tube placement rate, especially needle dwell time and pleural puncture angle. MATERIALS AND METHODS: In 159 patients, 160 coaxial computed tomography (CT)-guided lung biopsies were performed. Dwell time, the time between pleural puncture and needle removal, was calculated. The smallest angle of the needle with the pleura ("needle-pleural angle") was measured. These and other variables were correlated with pneumothorax and chest tube rates. RESULTS: One hundred fifty biopsies were included. There were 58 (39%) pneumothoraces (14 noted only at CT), with eight (5%) biopsies resulting in chest tube placement. Longer dwell times (mean, 29 minutes; range, 12-66 minutes) did not correlate with pneumothoraces (P =.81). Smaller needle-pleural angles (< 80 degrees) [corrected], decreased forced expiratory volume in 1 second to vital capacity ratio (<50%), lateral pleural puncture, and lesions along fissures were associated with higher [corrected] pneumothorax rates (P <.05). Emphysema along the needle path, pulmonary function tests showing ventilatory obstruction, and lesions along fissures predisposed patients to chest tube placement (P <.05). Pleural thickening and prior surgery were associated with lower pneumothorax rates (P <.05). CONCLUSION: Longer dwell times do not correlate with pneumothorax and should not influence the decision to obtain more biopsy samples. A shallow pleural puncture angle may increase the pneumothorax rate.     

CT-guided biopsy of pulmonary nodules: is pulmonary hemorrhage a complication or an advantage?

PURPOSE

We aimed to assess the correlation between pulmonary hemorrhage and pneumothorax in computed tomography (CT)-guided transthoracic fine needle aspiration (TTFNA), particularly its possible value as protection against the development of pneumotorax.

MATERIALS AND METHODS

We reviewed the CT images of 538 patients (364 males and 174 females, mean age 70 years, range 36–90 years) who underwent CT-guided TTFNA of pulmonary nodules between January 2008 and September 2013. The following CT findings were assessed: pulmonary hemorrhage (type 1, along the needle track; type 2, perilesional; low-grade, ≤6 mm; high-grade, >6 mm), pneumothorax, distance between the target nodule and the pleural surface, and emphysema.

RESULTS

Pneumothorax occurred in 154 cases (28.6%) and pulmonary hemorrhage occurred in 144 cases (26.8%). The incidence of pneumothorax was lower in patients showing type 1 and high-grade pulmonary hemorrhage pattern. The incidence of pneumothorax in biopsies ≥30 mm from pleural surface was 26% (12/46) in cases showing this pattern, while it was 71.4% (30/42) when this pattern was not seen. Similarly, the incidence of pneumothorax in biopsies <30 mm from the pleural surface was 0% (0/28) in cases showing this hemorrhage pattern, while it was 19% (76/394) when this pattern was not seen.

CONCLUSION

Pulmonary hemorrhage during TTFNA is a frequent event that protects against pneumothorax. A bleeding greater than 6 mm along the needle track is associated with lower incidence of pneumothorax, especially in biopsies deeper than 3 cm.Computed tomography (CT)-guided transthoracic fine needle aspiration (TTFNA) biopsy is currently considered a reliable diagnostic technique to assess malignancy of pulmonary nodules and masses (1–4). CT-guided TTFNA is an invasive technique with low incidence of severe complications and contraindications (1).Pneumothorax is the most common complication occurring in the range of 8%–64% (with a risk of tension pneumothorax in about 7% of cases) (1–7). The risk of pneumothorax increases in the presence of obstructive lung disease and small target lesion. Furthermore, the risk of pneumothorax is directly related to the distance of the lesion from the pleural surface, number of pleural needle passages, fissures crossing, patient’s age, and operator experience (8). Pulmonary hemorrhage is the second most frequent complication of TTFNA. Pulmonary hemorrhage is rarely the cause of death and it may be associated with hemoptysis in 4%–5% of patients, even as a postprocedure complication (9). According to recent studies, the incidence of pulmonary hemorrhage ranges 15%–26%, depending on the distance of the pulmonary nodule from the pleural surface (10). Higher incidence of pulmonary hemorrhage is related to central or cavitated lesion, presence of bronchiectasis, and larger needles (11–13).The aim of this study was to assess the correlation between pulmonary hemorrhage and pneumothorax in CT-guided TTFNA.     

Small (</=2-cm) subpleural pulmonary lesions: short- versus long-needle-path CT-guided Biopsy--comparison of diagnostic yields and complications

PURPOSE: To retrospectively compare the diagnostic yield and complications associated with the use of short versus long needle paths for computed tomography (CT)-guided biopsy of small subpleural lung lesions. MATERIALS AND METHODS: The study was approved by the institutional review board, and the requirement for informed patient consent was waived. The medical and imaging records of patients who underwent CT-guided biopsy of subpleural pulmonary nodules measuring up to 2 cm in diameter were reviewed. The study included 176 patients (79 men, 97 women; age range, 18-84 years) who were divided into two groups: In group A, a direct approach in which the needle traversed a short lung segment was used. In group B, an indirect approach involving the use of a longer needle path was used. Diagnostic yield, accuracy, and pneumothorax and chest tube placement rates were compared between the two groups. Two-tailed t tests and Pearson chi(2) tests were used to analyze continuous and categorized variables, respectively. RESULTS: Group A comprised 48 patients; and group B, 128 patients. The mean needle path length was 0.4 cm in group A and 5.6 cm in group B. The short-path approach necessitated more needle punctures (mean, 2.9 vs 1.8 with long-path approach, P < .001) through the pleura. The diagnostic yield in group A was significantly lower than that in group B (71% vs 94%, P < .001), particularly in patients with small (0-1-cm) nodules (40% in group A vs 94% in group B, P < .001). The frequency of postbiopsy pneumothorax was identical (69%) in the two groups. However, more group B than group A patients required chest tube placement for treatment of pneumothorax (38% vs 17%, P = .006). CONCLUSION: Use of long-needle-path biopsy of subpleural lesions resulted in a higher diagnostic yield, especially for small nodules. However, compared with the short-needle-path technique, this approach was associated with a higher frequency of chest tube placement for pneumothorax.     

CT-Guided Core Needle Biopsy of Pleural Lesions: Evaluating Diagnostic Yield and Associated Complications

ObjectiveThe purpose of this study was to retrospectively evaluate the diagnostic accuracy and complications of CT-guided core needle biopsy (CT-guided CNB) of pleural lesion and the possible effects of influencing factors.ResultsDiagnostic accuracy, sensitivity, specificity, PPV, and NPV were 89.2%, 86.1%, 100%, 100%, and 67.8%, respectively. The influencing factors had no significant effect in altering diagnostic accuracy. As far as complications were concerned, occurrence of pneumothorax was observed in 14 (16%) out of 88 patients. Multivariate analysis revealed lesion size/pleural thickening as a significant risk factor (odds ratio [OR]: 8.744, p = 0.005) for occurrence of pneumothorax. Moreover, presence of pleural effusion was noted as a significant protective factor (OR: 0.171, p = 0.037) for pneumothorax.ConclusionCT-guided CNB of pleural lesion is a safe procedure with high diagnostic yield and low risk of significant complications.     

Efficacy of an opposite position aspiration on resolution of pneumothorax following CT-guided lung biopsy

Objective:

To evaluate the efficacy of aspiration in an opposite position to deal with pneumothorax after CT-guided lung biopsy.

Methods:

A retrospective study was developed involving 210 patients with pneumothorax who had undergone CT-guided percutaneous core biopsies from January 2012 to March 2014 for various pulmonary lesions. Asymptomatic patients with minimal pneumothorax were treated conservatively. Simple manual aspiration was performed for symptomatic patients with minimal pneumothorax and for all patients with moderate to large pneumothorax. An opposite position aspiration was performed when simple manual aspiration failed. The efficacy of simple manual aspiration and the opposite position aspiration was observed.

Results:

Among 210 patients with pneumothorax, 128 (61.0%) asymptomatic patients with minimal pneumothorax were treated conservatively. The remaining 82 were treated with attempted simple manual aspiration. Out of these 82 patients, simple manual aspiration was successful in 58 (70.7%, 58/82) cases. The complete and partial regression rates were 17.2% (10/58) and 82.8% (48/58), respectively. In the other 24 patients (29.3%, 24/82), simple aspiration technique was ineffective. An opposite position (from prone to supine or vice versa) was applied, and a new biopsy puncture site was chosen for reaspiration. This procedure was successful in 22 patients but not in 2 patients who had to have a chest tube insertion. The complete and partial regression rates were 25.0% (6/24) and 66.7% (16/24), respectively. Applying the new method, the total effective rate of aspiration improved significantly from 70.7% (58/82) to 97.6% (80/82).

Conclusion:

The opposite position aspiration can be safe, effective and minimally invasive treatment for CT-guided lung biopsy-induced pneumothorax thus reducing the use of chest tube significantly.

Advances in knowledge:

(1) Opposite position aspiration can elevate the success rate of aspiration significantly (from 70.7% to 97.6% in our study); (2) this procedure is a safe, effective and minimally invasive treatment for pneumothorax caused by biopsy; and (3) opposite position aspiration is a useful technique to reduce the use of chest tube, which has clinical significance.CT-guided transthoracic needle biopsy is an established and safe technique for the diagnosis of lung lesions. Pneumothorax is the most frequent complication of this technique.^1–4 Chest tube placement is associated with higher levels of pain and anxiety, and opioid pre-medication and local anaesthesia is required.⁵ The infection risk and in-patient stay increased significantly. Numerous modifications to the technique have been evaluated in an attempt to manage biopsy-induced pneumothorax and to reduce the number of cases that require chest tube placement. The purpose of this study was to evaluate the efficacy of changing the posture and/or puncture site in the treatment of pneumothorax following CT-guided lung biopsies.     

Risk factors for complications of CT-guided lung biopsies

Purpose

This study assessed the risk factors for pneumothorax and intrapulmonary haemorrhage after computed tomography (CT)-guided lung biopsies.

Materials and methods

CT-guided lung biopsies performed between January 2007 and July 2008 were retrospectively evaluated to select the study cohort. Whenever possible, emphysema was quantified by using dedicated software. Features related to the patient, the lesion and the needle and its intrapulmonary path were recorded, along with the pathology findings and operators?? experience. The occurrence of pneumothorax and parenchymal haemorrhage was recorded. Univariate and multivariate statistical analyses were performed to assess the association between risk factors and complications. P values <0.05 were considered significant.

Results

In 157/222 of the procedures considered, complications were associated with small lesion size and length of the intrapulmonary needle path. Transfissural course and type of needle were associated with pneumothorax using univariate analysis, whereas transfissural course was associated with intrapulmonary haemorrhage using both univariate and multivariate analysis. Emphysema, nodule type, patient position, access site and needle diameter were not significant. Fine-needle aspirates and operator experience were significantly correlated with inadequate biopsy samples.

Conclusions

The size of the lesion and the length of the intrapulmonary trajectory are risk factors for pneumothorax and parenchymal haemorrhage. The transfissural course of the needles is frequently related to pneumothorax and intrapulmonary haemorrhage, and the type of the needle is related to pneumothorax.     

A retrospective analysis of the intubations performed during 5 years of helicopter emergency medical service in Amsterdam

INTRODUCTION: Different skilled personnel perform prehospital airway management, by far one of the most challenging skills with major consequences upon failure. SETTING: The setting for this study was the helicopter emergency medical service at the Vrije Universiteit Medical Center, Amsterdam, the Netherlands. METHODS: We conducted a retrospective analysis of all medical charts of intubated trauma patients in the period from May 1995 to May 2000. We focused on intubation reasons and conditions. RESULTS: In 43 of 653 patients (7%) the process of intubation was recorded as being difficult, leading to 5 failed intubations (11.6%). In 432 of 653 trauma victims (66%), general anaesthesia was required before intubation. Forty (9%) of these patients died, most soon after arrival in the hospital. The clinical condition of 221 (34%) patients was so poor that they did not require additional drugs for intubation; 73% of those patients died, with two-thirds dying at the accident site. CONCLUSION: The rate of difficult intubation in this analysis is low (7%). The overall airway failure (11.6%) is the same as seen in the literature when sedation and relaxation are used. An adult trauma victim with a Revised Trauma Score of 0 has a very poor prognosis of survival.