Pneumothorax in the critically ill patient

Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days.     

Concealed lung abscess in critically ill,mechanically ventilated patients

We describe 3 critically ill patients with pneumonia complicated by lung abscesses and contralateral pneumonia due to spill of purulent secretions into the healthy lung. Although the clinical picture of lung abscess often runs an indolent course, this was not observed in these critically ill patients, who all died from this complication. Diagnosis was delayed as chest X-ray underestimated lung pathology compared to computed tomography (CT) scan. Therefore percutaneous chest tube drainage and placement of a double-lumen endobronchial tube to protect the healthy lung were delayed and spill of purulent secretions into the contralateral lung occurred. These cases show the importance of rapid evaluation by CT scan of the chest in mechanically ventilated patients with slowly resolving infiltrates on chest X-ray.     

Lung penetration by thoracostomy tubes: imaging findings on CT

We have analyzed the radiographic and computed tomographic (CT) appearance of thoracostomy (chest) tubes inadvertently placed into the lungs. We have studied the clinical sequela of such malpositioning and discussed treatment options. Cases were collected from chest CT log book reports between January 1998 and January 31, 2005 which indicated or suggested intrapulmonary thoracostomy tube placement. CT scans were reviewed by the authors. The chest radiographs and medical records--including thoracic surgical reports--of those patients whose scans demonstrated intrapulmonary tube placement or indeterminate tube location were reviewed. Fifty patients, in whom 51 thoracostomy tubes were placed into the lungs, are included in this series. None of these tubes were described as intrapulmonary on reports of chest radiographs done before CT scanning. In 13 patients (26%), thoracostomy tube placements produced immediate improvement in pleural abnormalities. Dramatic increase or development of chest wall emphysema or pneumothorax was noted in 4 (8%) patients after tube placement. Twenty-five patients (50%) demonstrated either abrupt or gradual increase in pulmonary or pleural opacity on postplacement chest radiographs. Twenty-one (42%) had no apparent clinical complications. Thirteen (26%) had either prolonged air leaks or recurrent pneumothorax. Ten (20%) developed pneumonia. Retained hemothorax or empyema occurred in 8 (16%). Twelve patients (24%) required subsequent thoracic surgery. Intrapulmonary placement of thoracostomy tubes is probably more common than previously reported. This possibility should be considered when radiographs and CT scans are evaluated.     

Pneumothorax

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.     

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.     

Migration of the chest tube into the esophagus in a case of Boerhaave's syndrome

Boerhaave’s syndrome is the spontaneous transmural rupture of the esophagus. Patients can have a variety of manifestations. Boerhaave’s syndrome has to be considered in acutely ill patients with no other explanations for their illness. Computed tomography scan of the chest is emerging as a useful tool for the evaluation of these patients. Surgical repair is the standard of care. Adequate drainage of the pleural fluid is necessary to prevent pulmonary complications. Esophageal perforation should be considered whenever thoracostomy tube drainage assumes an enteric character. When inserting the chest tube for draining pleural fluid, the trochar should not be used because of potential injury to the already perforated esophagus. Posterior placement of the chest tube should be avoided because the tube may migrate into the perforated esophagus. Because of the high incidence of mortality, prompt suspicion, diagnosis, and management are warranted. A careful history, detailed review of the imaging, and a high index of suspicion are key for prompt diagnosis.     

High incidence and mortality of pneumothorax in critically Ill patients with COVID-19

BackgroundThe clinical characteristics of the patients with COVID-19 complicated by pneumothorax have not been clarified.ObjectivesTo determine the epidemiology and risks of pneumothorax in the critically ill patients with COVID-19.MethodsRetrospectively collecting and analysing medical records, laboratory findings, chest X-ray and CT images of 5 patients complicated by pneumothorax.ResultsThe incidence of pneumothorax was 10% (5/49) in patients with ARDS, 24% (5/21) in patients receiving mechanical ventilation, and 56% (5/9) in patients requiring invasive mechanical ventilation, with 80% (4/5) patients died. All the 5 patients were male and aged ranging from 54 to 79 years old. Pneumothorax was most likely to occur 2 weeks after the beginning of dyspnea and associated with reduction of neuromuscular blockers, recruitment maneuver, severe cough, changes of lung structure and function.ConclusionsPneumothorax is a frequent and fatal complication of critically ill patients with COVID-19.     

Management of acute pleural diseases in intensive care units

Pleural involvement is frequently seen among patients hospitalized in Intensive Care Units (ICU). In most cases, patients are hospitalized with or will develop scarce transsudative effusion secondary to cardiac failure or atelectasis. Other pleural issues in ICU concern pneumothorax in ventilated patients (barotrauma), empyema following nosocomial pneumonia or investigation procedures. More rarely hemo(pneumo)thorax or chylothorax will be diagnosed. As a rule, acute pleural pathologies rarely justify hospitalization in the ICU, depending on the etiologic mechanism or concomittant clinical signs of intolerance (respiratory insufficiency, collapsus, coma...). After tube thoracostomy, most patients will be managed in the respiratory ward to monitor the drainage, to begin etiologic diagnosis and to discuss a possible surgical intervention, usually a few weeks or months after the ICU.     

Pleural effusions in critically ill patients

Pleural effusions (PEs) are common in critically ill patients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients. Their impact on the pathophysiology of acute respiratory failure remains unknown. They are usually small and uncomplicated transudates that are easily overlooked on a supine portable chest X-ray and do not require drainage or infectious exudates that always require thoracocentesis. The diagnosis of PEs in critically ill patients has been revolutionized with the advent of chest ultrasound allowing easy bedside quantification of pleural fluid and making thoracocentesis a safe procedure especially in high-risk patients on mechanical ventilation. CT provides a much more accurate evaluation of the size and location of PEs and is extremely helpful in the guidance of catheters into loculated fluid collections. Hemothorax in critically ill patients is usually related to trauma or surgical interventions and requires early drainage and possibly surgical exploration.     

肺萎陷与气胸鉴别方法初探

目的探讨鉴别肺萎陷与气胸的方法。方法5名肺癌患者,其中合并气胸3例。合并右胸腔积液1例,合并以积液为主右液气胸1例。合并胸腔积液患者先行闭式胸腔引流术加负压抽完胸液后,影像学检查尚见气胸,进行闭式胸腔引流抽气却未见气体抽出,合并气胸者进行闭式胸腔引流抽气亦未见气体抽出。所有患者在CT引导下,将含有10ml气体的注射器穿刺进入胸腔,见气体吸人胸腔。结果考虑5例患者存在肺萎陷。结论肺萎陷与气胸的鉴别方法：胸部影像学示气胸,行闭式胸腔引流术抽气未见气体抽出,可在CT引导下将含有10ml气体的注射器穿刺进入胸腔,见气体吸入胸腔者,考虑存在肺萎陷。     

Sequential treatment of a simple pneumothorax

In a prospective investigation of isolated simple pneumothorax, the treatment of 35 patients with a total of 37 pneumothoraces was studied. A standardized sequential treatment approach was followed for evacuation of the pneumothorax and maintenance of lung reexpansion. The protocol involved catheter placement using a Seldinger technique, aspirations, and documentation of reexpansion by chest radiography and observation. Reaccumulation of air was treated with Heimlich valve attachment to the catheter at intrapleural pressure and further observation. Continued air leak following Heimlich valve attachment was treated with chest catheter suction using a Pleurovac at -20 cm H2O pressure. Chest tube thoracostomy was performed for continued failure of reexpansion. In 22 of the 37 pneumothoraces (59%) simple catheter aspiration maintained lung reexpansion without complications. In the remaining 15 pneumothoraces (41%), seven (47%) responded to Heimlich valve attachment, and three (20%) maintained expansion with chest catheter suction. Chest tube thoracotomy was required to maintain expansion in 33% (five) of those who failed catheter suction (14% of all pneumothoraces studied). Patients treated successfully with simple catheter aspiration were sent home. Patients requiring a Heimlich valve, chest catheter suction, or chest tube thoracostomy were hospitalized. Use of these catheter techniques resulted in lower cost and was associated with shorter hospitalizations than in chest tube thoracostomy. Our study suggests that sequential treatment of simple pneumothorax should be considered as a cost-effective and therapeutically successful alternative to immediate chest thoracostomy in selected cases.     

Pleural controversy: optimal chest tube size for drainage

In recent years, a higher and higher percentage of patients with pleural effusions or pneumothorax are being treated with small-bore (10-14 F) chest tubes rather than large-bore (>20 F). However, there are very few randomized controlled studies comparing the efficacy and complication rates with the small- and large-bore catheters. Moreover, the randomized trials that are available have flaws in their design. The advantages of the small-bore catheters are that they are easier to insert and there is less pain with their insertion while they are in place. The placement of the small-bore catheters is probably more optimal when placement is done with ultrasound guidance. Small-bore chest tubes are recommended when pleurodesis is performed. The success of the small-bore indwelling tunnelled catheters that are left in place for weeks documents that the small-bore tubes do not commonly become obstructed with fibrin. Patients with complicated parapneumonic effusions are probably best managed with small-bore catheters even when the pleural fluid is purulent. Patients with haemothorax are best managed with large-bore catheters because of blood clots and the high volume of pleural fluid. Most patients with pneumothorax can be managed with aspiration or small-bore chest tubes. If these fail, a large-bore chest tube may be necessary. Patients on mechanical ventilation with barotrauma induced pneumothoraces are best managed with large-bore chest tubes.     

Tension pneumoperitoneum associated with a pleural-peritoneal shunt.

The differential diagnosis of pneumoperitoneum is broad. We report a case of tension pneumoperitoneum in a patient on mechanical ventilation with initially unrecognized pneumothorax who had an indwelling pleural-peritoneal shunt. The patient developed ventilatory and hemodynamic collapse as air was diverted from the pleural space into the peritoneal cavity. Subsequent abdominal exploration revealed the source of the intra-abdominal air. Placement of a chest thoracostomy tube and removal of the pleural-peritoneal catheter resulted in significant clinical improvement. We suggest that it is important to recognize that pleural-peritoneal catheters may cause tension pneumoperitoneum without obvious concurrent pneumothorax.     

Pneumothorax in the ICU: patient outcomes and prognostic factors

STUDY OBJECTIVE: To identify the prognostic factors for pneumothorax in patients in the ICU. DESIGN: Retrospective cohort study. SETTING: ICU at a university-based teaching hospital. PATIENTS AND METHODS: Sixty patients developed pneumothoraces in the ICU during a period of 36 months. Medical records relating to patients' age, sex, underlying diseases, associated medical conditions, reasons for admission, acute physiology and chronic health evaluation (APACHE) II scores, procedures performed before the development of pneumothorax, occurrences of tension pneumothorax, duration of chest tube placement, chest tube removal, duration of ICU stay, and patient outcomes all were analyzed. A multivariate logistic regression model was applied with variables that were significantly associated with survival in the univariate analysis. The probabilities of chest tube removal were calculated using the Kaplan-Meier method. RESULTS: Thirty-five patients (58%) had procedure-related pneumothoraces. The procedure that most commonly caused pneumothoraces was thoracentesis (n = 19; 54%), followed by central vein/pulmonary artery catheterization (n = 14; 40%) and bronchoscopy/transbronchial lung biopsy (n = 8; 23%). A multivariate logistic regression analysis also showed that pneumothorax due to barotrauma (p = 0.001), tension pneumothorax (p = 0.0023), and concurrent septic shock (p = 0.0476) were significantly and independently associated with death. The log-rank test revealed that the success rate of chest tube removal was higher in patients with procedure-related pneumothoraces (p = 0.0055). CONCLUSIONS: Patients with procedure-related pneumothoraces had better outcomes. Patients with pneumothoraces occurring in the ICU due to barotrauma, or a complicating tension pneumothoraces, carry a higher risk of mortality.     

Clinical application of a digital thoracic drainage system for objectifying and quantifying air leak versus the traditional vacuum system: a retrospective observational study

BackgroundDigital thoracic drainage systems have recently been introduced and widely used in clinical practices in developed countries. These systems can monitor intrathoracic pressure changes and air leaks in real time, and also allow for objective and quantitative analyses, which aid in managing patients with a prolonged persistent air leak into the pleural space. We investigated the feasibility and effectiveness of such a new device versus the traditional vacuum system for treating patients with pneumothorax.MethodsClosed thoracostomy drainage was carried out on 100 adult patients with primary or secondary pneumothorax between January 2017 and December 2018. All the patients were aged ≥18 years and treated with a chest tube at a single medical center by the same cardiothoracic surgeons and intensivists. Patients who underwent closed thoracostomy drainage using an indwelling 24-French chest tube were divided into 2 groups immediately before closed thoracostomy: the digital thoracic drainage group (digital group, n=50) and the traditional analogue thoracic drainage group (analogue group, n=50). The detailed information about demographic data, treatment outcome, duration of indwelling catheterization., hospital days, cost-effectiveness and patient satisfaction was evaluated. We also evaluated whether digitally recorded intrapleural pressure changes and air leaks would predict chest tube removal timing and outcome.ResultsThe baseline parameters of the 2 groups were comparable with no significant differences in sex, age, weight or body mass index. The mean hospital day was shorter in the digital group than in the analogue group (17.96±12.23 vs. 18.32±16.64, P=0.902), and there was no statistically significant difference in the hospital length of stay between the 2 groups. Air leaks through the chest tube and duration of chest tube indwelling hours showed no significant statistical differences between the digital and analogue groups (213.47±219.80 vs. 261.94±184.47, P=0.235 and 223.44±218.75 vs 275.29±186.06, P=0.205, respectively). Total drainage amount and ambulation time per day were significantly higher in the digital group than in the analogue group [209.62±139.63 vs. 162.48±80.42 (P=0.042) and 6.42±3.62 vs.3.94±1.74 (P<0.001), respectively]. Hours of full expansion were significantly shorter and sleep disturbance caused by the noise of chest tube drainage was less in the digital group than in the analogue group [25.64±14.55 vs. 46.52±25.53 (P<0.001) and 2.38±1.03 vs. 5.70±2.87 (P<0.001), respectively].ConclusionsTo date, there is no definite consensus and guidelines on the standardized digital suction system in pneumothorax. This study proposed the guidelines for the application of digital thoracic drainage systems in pneumothorax and also suggested that digital thoracic drainage systems might be a valuable tool to determine chest tube removal timing and reducing the length of hospital stay in patients with pneumothorax.     

Thoracic ultrasonography for the pulmonary specialist

Thoracic ultrasonography is a noninvasive and readily available imaging modality that has important applications in pulmonary medicine outside of the ICU. It allows the clinician to diagnose a variety of thoracic disorders at the point of care. Ultrasonography is useful in imaging lung consolidation, pleural-based masses and effusions, pneumothorax, and diaphragmatic dysfunction. It can identify complex or loculated effusions and be useful in planning treatment. Identifying intrathoracic mass lesions can guide sampling by aspiration and biopsy. This article summarizes thoracic ultrasonography applications for the pulmonary specialist, related procedural codes, and reimbursement. The major concepts are illustrated with cases. These case summaries are enhanced with online supplemental videos and chest radiograph, chest CT scan, and ultrasound correlation.     

The role of thoracic ultrasonography for evaluation of patients with decompensated chronic heart failure

OBJECTIVES: This study examined the usefulness of thoracic ultrasonography for evaluation of fluid accumulation in patients with decompensated chronic heart failure (CHF) in comparison with physical signs, upright posteroanterior chest X-ray and echocardiography. BACKGROUND: Decompensated CHF is frequently accompanied by pleural effusion, suggesting that pleural effusion is a useful marker for confirming the diagnosis of the uncontrolled stage of CHF. Thoracic ultrasonography seems to be adequate for this purpose. METHODS: Patients with uncontrolled CHF and an interpretable physical examination, chest X-ray, ultrasonogram for the heart and thorax and thoracic X-ray computed tomographic (CT) scan were enrolled in the study (n = 60). Patients free from thoracic and cardiovascular diseases served as a control (n = 22). Thoracic CT scan was used as the gold standard for the presence or absence of pleural effusion. Variables used to predict body fluid accumulation included the following: pulmonary rales, jugular venous distension or peripheral edema, roentgenographic evidence of pulmonary edema or pleural fluid, pericardial or pleural effusion on ultrasonographic study. RESULTS: The reported incidence of pleural effusion detected by thoracic ultrasonography was high (91%). The incidence of physical signs and roentgenographic signs of body fluid accumulation, however, was modest (56%) to low (33%). The best clinical variable for identifying patients with decompensated CHF was the detection of pleural fluid by thoracic ultrasonography (91% predictive accuracy). This variable also had high interobserver agreement (95% overall agreement, kappa = 0.70). There was only 41% to 65% predictive accuracy of other clinical variables, with 72% to 95% agreement (kappa = 0.400-0.848). CONCLUSIONS: Thoracic ultrasonography is a simple, sensitive and accurate method for the evaluation of body fluid accumulation in patients with decompensated CHF. This technique can be used to assist in making the diagnosis of decompensated CHF if other causes of pleural effusion have been clinically ruled out.     

胸片阴性自发性气胸的胸部CT诊断

目的60胸部CT对正位胸片未见气胸患者的气胸诊断。方法应用CT对26例患者进行常规扫描。结果所有患者均经CT检查证实为局限性气胸,气体位于前胸部,后背部,胸骨后或纵隔旁。结论胸片阴性的气胸患者,临床表现多种多样,CT是诊断该病的最佳方法。     

Re-expansion pulmonary oedema: revisited

A case of re-expansion pulmonary oedema (RPO) following chest tube insertion for left spontaneous pneumothorax is reported. There were no severe symptoms and routine chest radiograph done four hours after tube thoracostomy showed features of pulmonary oedema in the re-expanded left lung. RPO is an uncommon complication of rapid pleural drainage of air or fluid with potentially serious cardiopulmonary manifestations but appears to run a benign course if there is no prior systemic hypoxaemia and if pneumothorax is drained without suction. Chest radiograph should be done routinely within four hours after chest tube insertion for early detection of RPO.     

Tube thoracostomy complicates unrecognized diaphragmatic rupture.

A case of traumatic diaphragmatic rupture is reported in which herniated stomach mimicked a tension pneumothorax. Tube thoracostomy by trocar caused insertion of the pleural drain into the intrathoracic stomach. CT scan of the thorax after oral administration of contrast material revealed the correct diagnosis. After removal of the drain and retraction of the stomach into the abdomen the gastric perforation and diaphragmatic defect could be closed by suture. The further course of the patient was uneventful. This case report underlines the importance of differential diagnosis of symptoms in a case with a history of blunt chest trauma and shows the risks of unnecessary use of a trocar.