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BACKGROUND: Needle thoracostomy is a potentially life-saving intervention for tension pneumothorax but may be overused, potentially leading to unnecessary morbidity.
OBJECTIVE: To review prehospital needle thoracostomy indications, effectiveness, and adverse outcomes.
METHODS: A retrospective cohort study was conducted based on registry data for a United States Midwestern Level I trauma center for a 7.5-year period (January 2015 to May 2022). Included were patients who received prehospital needle thoracostomy and trauma activation before hospital arrival. The primary outcomes were correct indications and improvement in vital signs. Secondary outcomes were the need for chest tubes, correct needle placement, complications, and survival.
RESULTS: A total of n = 67 patients were reviewed, of which n = 63 (94%) received a prehospital thoracostomy. Of the 63 prehospital thoracostomies, 54 (86%) survived to arrival. Of these 54, 44 (n = 81%) had documented reduced/absent breath sounds, 15 (28%) hypotension, and 19 (35%) with difficulty breathing/ventilating. Only four patients met all three prehospital trauma life support criteria: hypotension, difficulty ventilating, and absent breath sounds. There were no significant changes in prehospital vitals before and after receiving needle thoracostomy. In patients receiving imaging (n = 54), there was evidence of 15 (28%) lung lacerations, 6 (11%) of which had a pneumothorax and 3 (5%) near misses of important structures. Review of needle catheters visible on computer tomography imaging found 11 outside the chest and 1 in the abdominal cavity.
CONCLUSIONS: The study presents evidence of potential needle thoracostomy overuse and morbidity. Adherence to specific guidelines for needle decompression is needed.

Air embolism is a rare cause of ischaemic stroke. It is known that air can enter the cerebral arterial circulation from pulmonary venous circulation through a bronchovenous fistula, or in cases of pulmonary barotrauma in deep-sea diving. We describe a case of spontaneous cerebral air embolism against a background of advanced interstitial lung disease (ILD). To our knowledge, this case demonstrates a mechanism of stroke in ILD patients that has not been previously described.
CONCLUSIONS: This case demonstrates a mechanism of stroke in patients with severe interstitial lung disease (ILD) that has not been previously described, and we suggest that in cases of advanced ILD, clinicians should consider this as a possible mechanism of stroke. The management of these patients should include transferring them to hyperbaric facilities to prevent further air emboli.

BACKGROUND: Pneumothorax may occur as a complication of cardiopulmonary resuscitation (CPR) and could pose a potentially life-threatening condition. In this study we sought to investigate the incidence of pneumothorax following CPR for out-of-hospital cardiac arrest (OHCA), identify possible risk factors, and elucidate its association with outcomes.
METHODS: This study was a retrospective data analysis of patients hospitalized following CPR for OHCA. We included cases from 1st March 2014 to 31st December 2021 which were attended by teams of the physician staffed ambulance based at the University Medical Centre Graz, Austria. Chest imaging after CPR was reviewed to assess whether pneumothorax was present or not. Logistic regression analysis was performed to identify factors for the development of pneumothorax relevant and to assess its association with outcomes [survival to hospital discharge and cerebral performance category (CPC)].
RESULTS: Pneumothorax following CPR was found in 26 out of 237 included cases (11.0%). History of obstructive lung disease was significantly associated with presence of pneumothorax after CPR. This subgroup of patients (n = 61) showed a pneumothorax rate of 23.0%. Pneumothorax was not identified as a relevant factor to predict survival to hospital discharge or favourable neurological outcome (CPC1 + 2).
CONCLUSIONS: Pneumothorax may be present in greater than one in ten patients hospitalized after CPR for OHCA. Pre-existent obstructive pulmonary disease seems to be a relevant risk factor for development of post-CPR pneumothorax.
RESULTS: gov ID: NCT06182007 (retrospectively registered).
BACKGROUND: NCT06182007 (retrospectively registered).

We present the case of a male patient in his late 80s who presented with a fall with symptoms and signs of community-acquired pneumonia. Chest X-ray showed the suspicion of a left-sided pneumothorax. A CT of the chest subsequently ruled out the presence of a pneumothorax on the left side. The pseudo-pneumothorax on the chest X-ray was secondary to a skinfold. This case highlights how well a skinfold can mimic pneumothorax. Careful clinical and radiological examination with bedside lung ultrasound and/or CT of the chest can help differentiate true pneumothorax from pseudo-pneumothorax, provided the patient is hemodynamically stable. Our case highlights the importance of clinical examination, various imaging modalities, and confirmation of a diagnosis before proceeding to interventional procedures in the context of limited clinical suspicion of the differential.

OBJECTIVE: Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease occurring primarily in women. Pneumothorax and chylothorax are common pleural complications in LAM. We aim to explore various options in the surgical management of pleural disease in LAM.
METHODS: A retrospective chart review of all patients at the Center for LAM and Rare Lung Diseases at Columbia University was performed, and date, type and indication for surgical procedure were collected. All patients with any cystic lung disease seen between January 1, 2000 and March 1, 2023 were included in the database.
RESULTS: The charts for 326 patients with possible LAM were reviewed, including 213 with confirmed LAM and 113 females with cystic lung disease consistent suspected to be LAM were reviewed. 40.5% underwent surgical procedures at our institution or at referring hospitals. 15.6% of patients underwent surgical lung biopsies. 16.6% had a history of pneumothoraces, of which 79.6% underwent chemical and/or mechanical pleurodesis, 14.8% required pleurectomy, and 7.4% were discharged with tunneled indwelling pleural catheters (IPC). 5.6% of confirmed LAM patients have history of chylothorax, with thoracic duct ligation, thoracic duct embolization, pleurodesis, and pleurodesis with long-term tunneled IPC placement all used as treatment strategies.
CONCLUSIONS: Here we demonstrate the significant burden of pleural disease in patients with LAM. It is imperative that thoracic surgeons understand the high incidence of pneumothorax in this patient population. Tunneled IPCs are underutilized but provide long term options for chylous management with long term mechanical pleurodesis and a decrease in hospital length of stay.

BACKGROUND: Spontaneous pneumothorax in COVID-19 occurs infrequently but in up to 15% of patients dependent on mechanical ventilation (MV). Pneumothorax-related deaths account for 1% of all COVID-19-related deaths.
OBJECTIVE: To determine factors associated with pneumothorax in COVID-19 patients and the effect of pneumothorax on early survival.
METHODS: This was a retrospective study of 4799 COVID-19-positive hospitalized patients. The groups were homogenized using propensity score matching (PSM) in two groups comprising 67 COVID-19 patients each. The prevalence of pneumothorax was determined. Multiple logistic regression was used to determine factors associated with pneumothorax. P value < 0.05 was taken as significant.
RESULTS: The prevalence of pneumothorax in COVID-19 patients was 1.6%. Lung disease, comorbidities, and oxygen support, which were significantly different between the two groups before PSM, were homogenized after PSM. In a univariate analysis, symptom duration (P ˂ 0.001), neutrophilia (P ˂ 0.001), lymphopenia (P ˂ 0.001), neutrophil-lymphocyte ratio (P = 0.003), ferritin levels (P = 0.012), D-dimer levels (P = 0.011), MV support (P ˂ 0.001), antibiotherapy (P ˂ 0.001), length of hospital stay (P = 0.009), and death (P = 0.002) differed significantly between the groups. Pneumothorax had a significant negative effect on survival (32.8% vs. 59.7%, P = 0.01). In a multivariate regression model, factors associated with pneumothorax were duration of symptoms (Adjusted Odds ratio (AOR) 1.68; 95% Confidence Interval (CI): 1.26-2.25; P = 0.001), mechanical ventilation (AOR 23.92; 95% CI: 4.12-138.72; P = <0.001), dual antibiotics (AOR 8.28; 95% CI: 1.56-43.86; P = 0.013), neutrophilia (AOR: 1.08; 95% CI: 1.02-1.14; P = 0.011), and lymphopenia (AOR: 0.92; 95% CI: 0.86-0.90; P = 0.022).
CONCLUSIONS: The presence of pneumothorax was associated with poor survival in COVID-19 patients. Patients with a prolonged time from symptom onset to treatment and those dependent on mechanical ventilation in intensive care were in the high risk group for the development of pneumothorax.

Routine chest X-ray (CXR) post intrathoracic drain removal in cardiac surgical patients is common practice to identify the presence of a pneumothorax following drain removal. Such pneumothoraces occur infrequently and rarely require intervention. We investigated the utility of routine CXR post drain removal and hypothesised that the practice is unnecessary and a possible area for significant cost saving. We conducted a single-centre, retrospective study of 390 patients who underwent cardiac surgery over a one-year period. Routine CXR post drain removal was reviewed for the presence of a pneumothorax. Rates of intervention post routine CXR were analysed to assess for clinical benefit obtained from this practice. Potential cost savings were calculated by the cost of a mobile CXR and by considering the radiographer\'s time. There were 15 pneumothoraces detected on routine CXR post drain removal. All pneumothoraces detected on routine post drain removal CXR were defined as small. No patients had a clinically significant pneumothorax requiring re-insertion of a chest drain. The potential cost saved by omitting routine CXR post drain removal was estimated to be approximately A$7750 per year. This study did not detect any clinically significant pneumothoraces requiring intervention. It also suggests that routine CXR post drain removal does not provide any clinical benefit and indicates that current practice should be reviewed.

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (uVATS) is becoming popular for major lung resections, even for more complex procedures. The technique initially described for minor procedures seems more difficult to reproduce and has a longer learning curve. This review aims to describe the evolution from multiportal to uVATS and to explore its feasibility and reproducibility by identifying its drawbacks and limitations.
METHODS: Research from PubMed was obtained with the terms [uniportal] AND [surgery] OR [single-port] AND [thoracic surgery] OR [VATS]. Papers concerning pediatric cases and non-English papers were excluded. Individual case reports were also excluded.
CONCLUSIONS: uVATS seems to be widely adopted and performed for minor procedures. The applicability of uVATS for different indications is discussed, even though practically all thoracic surgical interventions can be performed through a single incision.
CONCLUSIONS: The transition from conventional three-port VATS to uVATS is described in this paper. An increasing number of thoracic surgeons worldwide have adopted this approach, even for major complex anatomical lung resections. Regarding the performance of minor thoracic interventions, we believe this technique is easily reproducible with a short learning curve because the instruments do not cross each other, and intraoperative movements remain intuitive. It is therefore a feasible, safe, and efficacious technique. For these reasons, we believe uVATS should be offered to all patients undergoing minor thoracoscopic procedures.

Background: Pneumothorax (PNX) represents a common clinical condition in emergency departments (EDs), requiring prompt recognition and treatment. The role of transthoracic ultrasounds (TUSs) in the diagnosis of PNX is still debated. We aimed to prospectively evaluate the accuracy of TUSs in the detection of spontaneous PNX in EDs. Methods: A total of 637 consecutive adult patients who presented to the EDs of four Italian hospitals complaining of acutely onset chest pain and dyspnoea were included in the study. Exclusion criteria were previous traumatic events, cardiogenic causes of pain/dyspnoea and suspected tension PNX. The absence of \"lung sliding\" (B-mode) and the \"bar-code\" sign (M-mode) were considered indicative of PNX in a TUS. Accuracy, sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated using a chest CT scan as reference. Results: Spontaneous PNX occurred in 93 patients: of those, 83 (89.2%) were correctly identified by TUSs. However, 306 patients with suspected PNX at TUS were not confirmed by chest CTs. The diagnostic accuracy of both the absence of \"lung sliding\" and \"bar-code\" sign during TUS was 50.4% (95% CI: 46.4-54.3), sensitivity was 89.2% (95% CI: 81.1-94.7), specificity was 43.8% (95% CI: 39.5-48.0), the PPV was 21.3% (95% CI: 19.7-23.1) and the NPV was 96.0% (95% CI: 92.9-97.7). Conclusions: TUS showed high sensitivity but low specificity in the identification of PNX in EDs. Relying exclusively on TUSs results for patients\' management in ED settings is neither suitable nor recommendable. TUS examination can be useful to strengthen the clinical suspicion of PNX, but its results should be confirmed by a chest X-ray or CT scan.