Risk factors of pneumothorax in computed tomography guided lung nodule marking using autologous blood: a retrospective study.

BACKGROUND: To investigate the risk factors of pneumothorax of using computed tomography (CT) guidance to inject autologous blood to locate isolated lung nodules. METHODS: In the First Hospital of Putian City, 92 cases of single small pulmonary nodules were retrospectively analyzed between November 2019 and March 2023. Before each surgery, autologous blood was injected, and the complications of each case, such as pneumothorax and pulmonary hemorrhage, were recorded. Patient sex, age, position at positioning, and nodule type, size, location, and distance from the visceral pleura were considered. Similarly, the thickness of the chest wall, the depth and duration of the needle-lung contact, the length of the positioning procedure, and complications connected to the patient's positioning were noted. Logistics single-factor and multi-factor variable analyses were used to identify the risk factors for pneumothorax. The multi-factor logistics analysis was incorporated into the final nomogram prediction model for modeling, and a nomogram was established. RESULTS: Logistics analysis suggested that the nodule size and the contact depth between the needle and lung tissue were independent risk factors for pneumothorax. CONCLUSION: The factors associated with pneumothorax after localization are smaller nodules and deeper contact between the needle and lung tissue.

The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

INTRODUCTION: COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. METHODS: This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. RESULTS: During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. CONCLUSION: Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis.

BACKGROUND: Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL. METHODS: We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression. RESULTS: We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia. CONCLUSION: Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data.

Recurrent spontaneous pneumothorax in an NF1 patient with a novel causative variant: broadening genotype-phenotype correlations.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease with complete penetrance, most commonly known to affect the skin and eyes. Although lung involvement in the form of cysts and bullae occurs in up to 20% of adults, the seemingly intuitive association of NF1 and spontaneous pneumothorax is not widely recognised among clinicians. Here, we report the second case of recurring spontaneous pneumothorax in the context of NF1 with a confirmed molecular diagnosis. In both cases, the NF1 variants featured a premature stop codon in the C-terminal protein domain. Interestingly, our patient had mild skin symptoms, suggesting that spontaneous pneumothorax may not be correlated with cutaneous disease severity. More genotype-phenotype correlation studies are needed for NF1 in general and for its link to spontaneous pneumothorax in particular.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

BACKGROUND: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications.

Objective: There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients. Methods: In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR. Results: EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group. Conclusion: Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

A three month old infant with severe respiratory distress.

This case report discusses the diagnostic challenge of congenital lobar emphysema (CLE) in a three-month old infant with severe respiratory distress. The infant was initially misdiagnosed and managed as a case of pneumothorax. This case highlights the importance of CT scans as a diagnostic tool for early diagnosis and lifesaving management of CLE. It also signifies the need for adequate funds and infrastructure in the health care system especially in rural areas of developing countries like Pakistan.

Aerostasis to limit air leak following extended pleurectomy-decortication.

Extended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air leak remains a major postoperative challenge, lengthening hospital stay and increasing morbidity. In this video report, we present a stepwise approach for visceral decortication and introduce the concept of aerostasis by construction of an artificial neopleura. Our results suggest that improved aerostasis results in shortened air leak duration.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

OBJECTIVES: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made. SHAREABLE ABSTRACT: This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

Air leak syndrome in animals: definition and pathogenesis.

Air leak syndrome (ALS) is described in human medicine as a constellation of clinical disorders including pneumomediastinum, pneumopericardium, pulmonary interstitial emphysema, pneumothorax, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema. The pathogenesis of ALS depends on the anatomy of the mediastinum and its associations with thoracic, abdominal and cervical connective tissues, as well as a physical phenomenon referred to as the Macklin effect. Various animal species develop diverse combinations of these lesions, although ALS has not been recognized in animals. However, this term aids pathologists in addressing this disease compilation. The aim of this retrospective study is to illustrate examples of ALS in animals by arbitrarily selecting 13 cases in dogs, cats, pinnipeds, sea otters and harbour porpoises. ALS can be classified into three groups based on aetiology: iatrogenic, secondary or spontaneous. Iatrogenic ALS was diagnosed in two cats with tracheal laceration following endotracheal intubation. Secondary ALS was identified in two dogs, one with acute respiratory distress syndrome and the other due to grass awn migration. Secondary ALS in pinnipeds was diagnosed following severe pulmonary parasitism, uraemic pneumonia and oesophageal perforation. The other marine mammals developed ALS following trauma. Spontaneous ALS was also diagnosed in one cat and one dog without any apparent predisposing causes.

Clinical Variables and Radiomics Features for Predicting Pneumothorax in Patients Undergoing CT-guided Transthoracic Core Needle Biopsy.

Purpose To develop a prediction model combining both clinical and CT texture analysis radiomics features for predicting pneumothorax complications in patients undergoing CT-guided core needle biopsy. Materials and Methods A total of 424 patients (mean age, 65.6 years ± 12.7 [SD]; 232 male, 192 female) who underwent CT-guided core needle biopsy between January 2021 and October 2022 were retrospectively included as the training data set. Clinical and procedure-related characteristics were documented. Texture analysis radiomics features were extracted from the subpleural lung parenchyma traversed by needle. Moderate pneumothorax was defined as a postprocedure air rim of 2 cm or greater. The prediction model was developed using logistic regression with backward elimination, presented by linear fusion of the selected features weighted by their coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC). Validation was conducted in an external cohort (n = 45; mean age, 58.2 years ± 12.7; 19 male, 26 female) from a different hospital. Results Moderate pneumothorax occurred in 12.0% (51 of 424) of the training cohort and 8.9% (four of 45) of the external test cohort. Patients with emphysema (P < .001) or a longer needle path length (P = .01) exhibited a higher incidence of moderate pneumothorax in the training cohort. Texture analysis features, including gray-level co-occurrence matrix cluster shade (P < .001), gray-level run-length matrix low gray-level run emphasis (P = .049), gray-level run-length matrix run entropy (P = .003), gray-level size-zone matrix gray-level variance (P < .001), and neighboring gray-tone difference matrix complexity (P < .001), showed higher values in patients with moderate pneumothorax. The combined clinical-radiomics model demonstrated satisfactory performance in both the training (AUC 0.78, accuracy = 71.9%) and external test cohorts (AUC 0.86, accuracy 73.3%). Conclusion The model integrating both clinical and radiomics features offered practical diagnostic performance and accuracy for predicting moderate pneumothorax in patients undergoing CT-guided core needle biopsy. Keywords: Biopsy/Needle Aspiration, Thorax, CT, Pneumothorax, Core Needle Biopsy, Texture Analysis, Radiomics, CT Supplemental material is available for this article. © RSNA, 2024.

Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

Utility of artificial intelligence for detection of pneumothorax on chest radiopgraphs done after transthoracic percutaneous transthoracic biopsy guided by computed tomography.

OBJETIVE: To assess the ability of an artificial intelligence software to detect pneumothorax in chest radiographs done after percutaneous transthoracic biopsy. MATERIAL AND METHODS: We included retrospectively in our study adult patients who underwent CT-guided percutaneous transthoracic biopsies from lung, pleural or mediastinal lesions from June 2019 to June 2020, and who had a follow-up chest radiograph after the procedure. These chest radiographs were read to search the presence of pneumothorax independently by an expert thoracic radiologist and a radiodiagnosis resident, whose unified lecture was defined as the gold standard, and the result of each radiograph after interpretation by the artificial intelligence software was documented for posterior comparison with the gold standard. RESULTS: A total of 284 chest radiographs were included in the study and the incidence of pneumothorax was 14.4%. There were no discrepancies between the two readers' interpretation of any of the postbiopsy chest radiographs. The artificial intelligence software was able to detect 41/41 of the present pneumothorax, implying a sensitivity of 100% and a negative predictive value of 100%, with a specificity of 79.4% and a positive predictive value of 45%. The accuracy was 82.4%, indicating that there is a high probability that an individual will be adequately classified by the software. It has also been documented that the presence of Port-a-cath is the cause of 8 of the 50 of false positives by the software. CONCLUSIONS: The software has detected 100% of cases of pneumothorax in the postbiopsy chest radiographs. A potential use of this software could be as a prioritisation tool, allowing radiologists not to read immediately (or even not to read) chest radiographs classified as non-pathological by the software, with the confidence that there are no pathological cases.

An 88-Year-Old Woman With Pneumothorax and Black Pleural Effusion.

CASE PRESENTATION: An 88-year-old woman was admitted to our hospital with the sudden onset of dyspnea after eating. The patient had undergone nephrectomy for a left renal tumor 24 years previously. The patient had been prescribed ferrous citrate for iron-deficiency anemia. She complained of appetite loss a few days before admission but had no abdominal pain. CT scan showed no abnormalities in the lungs but a mass in the liver.

[Analysis of Influencing Factors of Complications for CT-guided 
Percutaneous Lung Biopsy].

BACKGROUND: Computed tomography guided percutaneous lung biopsy (CT-PLB) is a widely used method for the diagnosis of lung lesions. However, it is invasive, and the most common complications are pneumothorax and pulmonary hemorrhage, which can be life-threatening in severe cases. Therefore, the aim of this study is to analyze the independent risk factors affecting the occurrence of different complications of CT-PLB, so as to reduce the incidence of complications. METHODS: The 605 patients with complete clinical data who underwent CT-PLB in our hospital from May 2018 to December 2019 were retrospectively analyzed. According to the location of the lesions, they were divided into subpleural group and non-subpleural group. The patients were divided into pneumothorax group, pulmonary hemorrhage group, pneumothorax with pulmonary hemorrhage group and non-pneumothorax/pulmonary hemorrhage group according to the complications. The risk factors affecting the incidence of different complications and the independent risk factors of each complication were analyzed. RESULTS: The incidence of pneumothorax was 34.1%, the incidence of pulmonary hemorrhage was 28.1%, and the incidence of pneumothorax complicated with pulmonary hemorrhage was 10.8% (63 cases). The independent risk factor affecting the incidence of subpleural pneumothorax was lesion size (P=0.002). The independent risk factors affecting the occurrence of pneumothorax in the non-subpleural group were plain scan CT value (P=0.035), length of needle through lung tissue (P=0.003), and thickness of needle through chest wall (P=0.020). Independent risk factors affecting the occurrence of pulmonary hemorrhage in the non-subpleural group were length of needle through lung tissue (P<0.001), △CT value of needle travel area (P=0.001), lesion size (P=0.034) and body position (P=0.014). The independent risk factors affecting the co-occurrence of pneumothorax and pulmonary hemorrhage were the length of needle through lung tissue (P<0.001) and the △CT value of needle travel area (P<0.001). CONCLUSIONS: CT-PLB is a safe and effective diagnostic method, which of high diagnostic value for lung lesions. Selecting the appropriate puncture program can reduce complications such as pneumothorax and pulmonary hemorrhage, and improve diagnosis and treatment efficiency.

Endobronchial valves for emphysema and persistent air-leak: 10-year experience in an Asian country.

BACKGROUND: Endobronchial valve (EBV) therapy, a validated method for bronchoscopic lung volume reduction (BLVR) in severe emphysema, has been explored for persistent air-leak (PAL) management. However, its effectiveness and safety in the Asian population require further real-world evaluation. In this study, we assessed the outcomes of treatment with EBV within this demographic. METHODS: We conducted a retrospective analysis of medical records from 11 Korean centers. For the emphysema cohort, inclusion criteria were patients diagnosed with emphysema who underwent bronchoscopy intended for BLVR. We assessed these patients for clinical outcomes of chronic obstructive pulmonary disease. All patients with PAL who underwent treatment with EBV were included. We identified the underlying causes of PAL and evaluated clinical outcomes after the procedure. RESULTS: The severe emphysema cohort comprised 192 patients with an average age of 70.3 years, and 95.8% of them were men. Ultimately, 137 underwent treatment with EBV. Three months after the procedure, the BLVR group demonstrated a significant improvement in forced expiratory volume in 1 s (+160 mL vs. +30 mL; P = 0.009). Radiographic evidence of lung volume reduction 6 months after BLVR was significantly associated with improved survival (adjusted hazard ratio 0.020; 95% confidence interval 0.038-0.650; P = 0.010). Although pneumothorax was more common in the BLVR group (18.9% vs. 3.8%; P = 0.018), death was higher in the no-BLVR group (38.5% vs. 54.5%, P = 0.001), whereas other adverse events were comparable between the groups. Within the subset of 18 patients with PAL, the predominant causes of air-leak included spontaneous secondary pneumothorax (44.0%), parapneumonic effusion/empyema (22.2%), and post-lung resection surgery (16.7%). Following the treatment, the majority (77.8%) successfully had their chest tubes removed. Post-procedural complications were minimal, with two incidences of hemoptysis and one of empyema, all of which were effectively managed. CONCLUSIONS: Treatment with EBV provides substantial clinical benefits in the management of emphysema and PAL in the Asian population, suggesting a favorable outcome for this therapeutic approach.