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Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study
Ufuk Cobanoglu,Fuat Sayir,Salim Bilici,Mehmet Melek
Pediatric Reports , 2011, DOI: 10.4081/pr.2011.e29
Abstract: Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options. We excluded from the study cases with: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema.
Tube Thoracostomy: Complications and Its Management  [PDF]
Emeka B. Kesieme,Andrew Dongo,Ndubueze Ezemba,Eshiobo Irekpita,Nze Jebbin,Chinenye Kesieme
Pulmonary Medicine , 2012, DOI: 10.1155/2012/256878
Abstract: Background. Tube thoracostomy is widely used throughout the medical, surgical, and critical care specialities. It is generally used to drain pleural collections either as elective or emergency. Complications resulting from tube thoracostomy can occasionally be life threatening. Aim. To present an update on the complications and management of complications of tube thoracostomy. Methods. A review of the publications obtained from Medline search, medical libraries, and Google on tube thoracostomy and its complications was done. Results. Tube thoracostomy is a common surgical procedure which can be performed by either the blunt dissection technique or the trocar technique. Complication rates are increased by the trocar technique. These complications have been broadly classified as either technical or infective. Technical causes include tube malposition, blocked drain, chest drain dislodgement, reexpansion pulmonary edema, subcutaneous emphysema, nerve injuries, cardiac and vascular injuries, oesophageal injuries, residual/postextubation pneumothorax, fistulae, tumor recurrence at insertion site, herniation through the site of thoracostomy, chylothorax, and cardiac dysrhythmias. Infective complications include empyema and surgical site infection. Conclusion. Tube thoracostomy, though commonly performed is not without risk. Blunt dissection technique has lower risk of complications and is hence recommended. 1. Introduction Tube thoracostomy is the most commonly performed surgical procedure in thoracic surgery. As a life saving procedure, general surgeons, intensivists, emergency physicians, and respiratory physicians may at one time or the other be required to perform tube thoracostomy. The first documented description of a closed tube drainage system for the drainage of empyema was by Hewett in 1867 [1]. However during the Second World War, the experience gained in military and civilian hospitals contributed to the development of tube thoracostomy in chest trauma management, and, at the time of the Vietnam war, it has become the standard of care for management of chest trauma [2]. In 1992, Lilienthal reported the postoperative use of chest tube following lung resection for suppurative diseases of the lung [3]. Tube thoracostomy is an invasive procedure and complications can result due to inadequate knowledge of thoracic anatomy or inadequate training and experience. These complications can simply be classified as technical or infective. Trocar technique is by far associated with a higher rate of complication [4, 5]. 2. Methods A literature review on tube
Hazards of tube thoracostomy in patients on a ventilator
Kasra Shaikhrezai, Vipin Zamvar
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-39
Abstract: Tube thoracostomy is a common procedure to drain fluids and/or air from the pleural space via an ICD. The British Thoracic Society (BTS) has published a guideline [1] for ICD insertion which in many institutions has been deployed as a standard approach to tube thoracostomy in both practice and training programs. Recently there is an increasing concern regarding the training of doctors with regard to precise and methodological ICD insertion [2,3]. Harris et al [4] conducted a national survey among chest physicians in the UK recording their experiences regarding complications and serious harms following ICD insertion. The study revealed 67% of NHS trusts have experienced major complications of ICD insertion.A 51-year-old man with history of chronic obstructive pulmonary disease (COPD) and cigarette smoking presented with a shortness of breath, chronic pneumonia and empyema involving the right side of his chest. Soon after admission his condition deteriorated developing type-2 respiratory failure necessitating intubation and commencement of mechanical ventilation. Patient required positive end-expiratory pressure (PEEP) of 10 mmHg and 80% fraction of inspired oxygen (FiO2) to maintain the oxygen saturation of 91% with PCO2 (partial pressure of carbon dioxide) and PO2 (partial pressure of oxygen) of 7.1 and 8.2 kPa respectively. Following central line insertion a pneumothorax was noted on his chest radiograph. Under aseptic technique and blunt dissection a large bore ICD was inserted anterolaterally into the right chest preceded by the introduction of index finger and sweeping manoeuvre explained by the BTS guidelines [1]. It is imperative to appreciate that a diseased hyperventilated lung with a high PEEP is very prone to perforation by any instruments penetrating the chest wall and pleura. Shortly after tube thoracostomy the patient started to develop a large subcutaneous emphysema originating in the right moving towards the left side of the chest wall. Unfortunately
Tube thoracostomy in the management of pleural fluid collections
AME Nwofor, CN Ekwunife
Nigerian Journal of Clinical Practice , 2006,
Abstract: Objective: To determine the demographic pattern, indications and complications associated with tube thoracostomy in Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi. Patients and Methods: A 5-year review of case records of patients who underwent tube thoracostomy at NAUTH Nnewi between January 1999 and December 2003. Demographic data, clinical features, duration of drainage, complications and outcomes were analyzed. Results: A total of 65 cases were studied, male: female ratio was 2.4:1. Eighteen patients (27.7%) were below 10 years of age. Infective cases accounted for 63.1% (41) of the cases that had tube thoracostomy. Forty-one patients (63.1%) had tube drainage for 10 days or less. Complication rate was 41.5%(27), mostly mild, with dislodgement of the tube accounting for about half. Failure rate of 13.7% (9) was recorded for the procedure. A mortality of 6.2% (4) was recorded but there was no procedure related death. Seven patients (10.8%) required further surgery. Conclusion: Tube thoracostomy is a simple and efficacious procedure for the treatment of pleural space collections. The safety of the procedure can be improved upon by adequate training in the insertion procedure, while proper selection of cases will reduce failure rate and unnecessary morbidity. Early resort to thoracoscopic or open surgery when tube thoracostomy is considered inappropriate or has failed will improve the success rate in the overall management of pleural fluid collections.
Complicaciones de los tubos de tórax Complications of tube thoracostomy
Leonidas Tapias,Luis Felipe Tapias-Vargas,Leonidas Tapias-Vargas
Revista Colombiana de Cirugía , 2009,
Abstract: El drenaje del espacio pleural es una frecuente práctica clínica de valor diagnóstico y terapéutico. Las indicaciones más frecuentes de este procedimiento tienen que ver con situaciones en las que se producen depósitos de fluidos en esta cavidad, como aire, sangre, linfa, líquido pleural, pus y otros. Es importante conocer la técnica quirúrgica de inserción y las complicaciones más frecuentes derivadas de la colocación de los tubos de tórax. Realizamos una revisión de la literatura existente sobre el tema, enfatizando en estudios que evaluaran las tasas de complicaciones derivadas de las toracostomías cerradas con tubo. Encontramos que la gran mayoría de estudios sobre complicaciones de la colocación de los tubos de tórax son retrospectivos y en el contexto del trauma. Las complicaciones se han clasificado así: por inserción, posicionales e infecciosas. La tasa general de complicaciones se encuentra entre 3,4% y 36%. Las complicaciones por inserción ocurren en 0% a 7,9% de los casos, las posicionales en 2,4% a 33,3% y las infecciosas en 0,8% a 12%, con empiema en 1,1% a 2,7%. También, hay complicaciones anecdóticas reportadas. Las complicaciones producto de la colocación de un tubo de tórax en la cavidad pleural son frecuentes y en muchos casos clínicamente relevantes. El uso de la técnica de disección roma, la habilidad y el conocimiento, la identificación precoz y el manejo de las posibles complicaciones, pueden reducir la morbimortalidad de este procedimiento. Drainage of the thoracic cavity is a frequent clinical procedure performed for diagnostic and therapeutic purposes. Most common indications are related with conditions where air, blood, lymph, pleural fluid, pus, and other materials accumulate in the chest cavity. It is important to know the technique of tube thoracostomy and be familiar with the more frequent associated complications. We have performed a literature review with emphasis on the complications associated with the insertion of intrathoracic tubes. Most papers encountered in the literature are retrospective studies in the context of trauma. General complications rate vary from 3.4% to 36%. Complications derived from tube insertion occur in 0% to 7.9% of cases, those derived from the position of the tube occur in 2.4% to 33.3%, and septic complications in 0.8% to 12%, with empyema in 1.1% to 2.7%. Anedoctal complications are also reported. Complications derived from tube thoracostomy are frequent and in many cases clinically relevant. Blunt dissection technique, appropriate skill and knowledge, and the early identification and manage
Antibiotics are not needed during tube thoracostomy for spontaneous pneumothorax: an observational case study
Guven Olgac, Umit Aydogmus, Lutfiye Mulazimoglu, Cemal Kutlu
Journal of Cardiothoracic Surgery , 2006, DOI: 10.1186/1749-8090-1-43
Abstract: One-hundred and nineteen patients underwent tube thoracostomy for primary spontaneous pneumothorax. None of them received prophylactic antibiotic treatment. Eight patients with prolonged air leak undergoing either video assisted thoracoscopic surgery or thoracotomy were excluded.Of the remaining 111 (104 male and 7 female), 28 (25%) patients developed some induration around the entry site of chest tube that settled without further treatment. White blood cell count was high without any other evidence of infection in 12 (11%) patients and returned to its normal levels before discharge home in all. There was also some degree of fever not lasting for more than 48 hours in 8 (7%) patients. Bacterial cultures from suspected sites did not reveal any significant growth in these patients.Prophylactic antibiotic treatment seems avoidable during closed tube thoracostomy for primary spontaneous pneumothorax. This policy was not only cost-effective but also prevented our patients from detrimental properties of unnecessary antibiotic use, such as development of drug resistance and undesirable side effects.Primary spontaneous pneumothorax (PSP) usually occurs following rupture of a subpleural bleb or bulla located at apices of the lungs without an associated underlying pulmonary disease. It is most frequently seen in tall, smoker and young adults with a male to female ratio of 6:1 [1,2]. Evacuation of the pleural air with simple aspiration or closed tube thoracostomy (CTT) is the treatment of choice in most cases. More invasive surgical procedures such as bullectomy and/or pleurodesis with either pleurectomy or pleural abrasion are usually recommended in cases with recurrent disease and occasionally at the first episode in certain circumstances [1].Different opinions exist regarding the use of prophylactic antibiotics following insertion of a chest tube and only very few and rather old papers on this topic are listed in recent literature [3,4]. BTS (British Thoracic Society) guide
The Professional Medical Journal , 2010,
Abstract: Empyema as a complication of community acquired pneumonia (CAP) is relatively common occurrence in developing countries. Study Design: Prospective study. Period: 4 year Jan 2001- Dec 2004. Setting: Department of Pediatric surgery the Children’s hospital Lahore. Patients & Method: A total of 114 cases of empyema thoracic secondary to CAP were dealt with during this period, while in the sameduration a total of 1768 cases of pneumonia were treated at the Children’s hospital Lahore. Results: Majority of the patients with CAP (59.61%) were below one year of age whereas the patients who developed empyema, were mainly (45.67%) between 2 to 5 years of age. Patients above 5 years of age having CAP (31.70%) and having repeated attacks of respiratory tract infection were most susceptible to develop empyema. Staphylococcus aureus was the most common organism found (40.35%) in this series. Vaccination, poverty and gender did not significant affected the development of empyema among the patients of CAP. Antibiotic resistance had no role in the development of empyema. Ibuprofen may be a risk factor. All the patients were initially managed with tube thoracostomy and antibiotics. Forty-eight patients (42.10%) needed subsequently operative management. Three patients (2.63%) had fatal course in this series same as seen in patients of CAP (2%). Conclusions: Immunization against causative organism and modification of out patient treatment may affect the incidence of empyema in children and should be studied prospectively.
A novel and safe technique in closed tube thoracostomy
Koray Dural, Gultekin Gulbahar, Bulent Kocer, Unal Sakinci
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-21
Abstract: The study involved 180 patients who required TT application for any etiology within one year. The patients were divided into two groups as Group A, who had undergone classical surgical technique (n = 90) and Group B, who had undergone a combination of surgery and trocar techniques (n = 90). The groups were compared for TM, the effect of TM on the drain removal, and other insertion related complications.In Group A, 23 patients had TM, 4 of whom developed associated ineffective drainage, while the patients in Group B had no insertion related complications (p = 0.001). The mean drain removal time of the patients with TM was 5 ± 2.25 days. In the patients who did not develop TM, it was 3.39 ± 1.18 days (p = 0.001).The modified combination technique is a reliable method in preventing TM and its potential complications.TT is a standard and generally reliable method in the management of pathologies responsible for accumulation in the pleural space [1]. The two most commonly used methods in the thoracic surgery clinics are surgery and trocar technique. Because the incidence rate of pulmonary parenchyma and intrathoracic organ injury is increased by trocar technique procedures, it is now used in very few centers. This study aimed to investigate the effects of combined modified technique that involves surgery and trocar technique on tube malposition (TM) and other potential complications.This randomized, prospective study involved 180 patients who required TT for various etiologies between 2006 and 2007. The detection of the type of method to be used for the allocated patients were determined by using the prepared bloc randomization lists before the study. After receiving the statement of patient consent from all patients, the patients were evaluated in two groups as those who were applied surgical technique (Group A) and those who were applied combined modified technique (Group B). The presence of severe pleural adhesion was considered a contraindication for modified techniq
Complications of Tube Thoracostomy using Advanced Trauma Life Support Technique in Chest Trauma
PE Iribhogbe, O Uwuigbe
West African Journal of Medicine , 2011,
Abstract: Background: Tube thoracostomy (TT) is central in the management of chest trauma sufficing in over 80% of cases. As a result the procedure is commonly performed in most emergency departments. Objective: The aim of this study was to assess the efficacy and complications of TT using Advanced Trauma Life Support (ATLS) technique in chest trauma. Methods: This prospective study was done at the Trauma Unit of the University of Benin Teaching Hospital in Nigeria. All patients with chest trauma who needed tube thoracostomy between February 2006 and February 2009 were studied. Data recorded for each patient included injury, mechanism of injury, lasgow Coma score, revised trauma score, and indications for tube thoracostomy. Chest radiographs were obtained preinsertion, post insertion and post extubation for all the cases. Patients were monitored for tube thoracostomy complications. Results: Of 9415 trauma patients seen during the period 105 patients had tube thoracostomy but only 70 (56 male, 14 female) had adequate data for analysis. Seventy-four tubes were passed in the 70 patients with unilateral tubes in 66 (94.3%) and bilateral tubes in 4 (5.7%). Blunt chest trauma occurred in 32 (45.7%) and penetrating chest trauma in 38 (54.3%) of the patients. Simple haemothorax and haemopneumothorax were the commonest indications for tube thoracostomy. Complications recorded include four cases of kinked tubes, four of superficial wound infection and 10 cases of residual haemothorax. Conclusion: Tube thoracostomy in the Emergency Department using advanced trauma life support principles is effective in chest trauma and associated with few complications.
Empyema Thoracis
Ala Eldin H. Ahmed and Tariq E. Yacoub
Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine , 2012, DOI: 10.4137/CCRPM.S5066
Abstract: Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia. Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality. Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases. Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH . 7.20 whereas complicated PPE are exudates with glucose level ,2.2 mmol/l and pH , 7.20. Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema. They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area. A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure. There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS. It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.
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