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Traumatic pneumothoraces remain a life-threatening problem that may be resolved quickly with timely diagnosis. Unfortunately, they are still not optimally managed. The most critically injured patients with hemodynamic instability require immediate diagnoses of potentially correctible conditions in the primary survey. Point-of-care ultrasonography (POCUS) performed by the responsible physician can be a tremendous adjunct to expediting diagnoses in the primary surgery and can typically be done in seconds rather than minutes. If more detailed sonographic examination is required, the second ary survey of the hemodynamically unstable patient is more appropriate. All involved in bedside care need to be conscious to efficiently integrate POCUS into resuscitation with the right intentions and goals to avoid sono-paralysis of the resuscitation sequence. Sono-paralysis has recently been described as critical situations wherein action is delayed through unnecessary imaging after a critical diagnosis has been made or unnecessary imaging details are sought despite an urgent diagnosis being made., Traumatic pneumothoraces remain a problem in contemporary Canadian trauma care, having been recognized as a preventable cause of post-traumatic death that is still not optimally managed. They are common in [...]

Purpose Over the last decade, the use of ultrasound as a technique to look for pneumothorax has rapidly evolved. This review aims to analyze and synthesize current knowledge on lung ultrasound targeted at the diagnosis of pneumothorax. The technique and its usefulness in different scenarios are explained, and its merits over conventional radiology are highlighted. Methods A systematic literature search (1995-2010) was performed, involving PubMed, to describe the more recent scientific evidence on the topic. Moreover, this review is also a synopsis of experts' opinion and personal clinical experience. Results and conclusions Ultrasound diagnosis of pneumothorax relies on the recognition of four sonographic artifact signs: the lung sliding, the B lines, the lung point, and the lung pulse. Combining these few signs, it is possible to accurately rule in or rule out pneumothorax at the bedside in several different clinical scenarios. Sensitivity of a lung ultrasound in the detection of pneumothorax is higher than that of conventional anterior-posterior chest radiography, and similar to that of computerized tomography. A major benefit of a lung ultrasound is that it can be used quickly to diagnose pneumothorax at the bedside in any critical situation, like cardiac arrest and hemodynamically unstable patients. Moreover, it can be used to detect radio-occult pneumothorax and to quantify the extension of the air layer. Advantages in terms of reduced complexity, feasibility at the bedside, and absence of exposure to ionizing radiation make lung ultrasound the method of choice in several common clinical situations., Author(s): Giovanni Volpicelli [sup.1] [sup.2] Author Affiliations: (1) grid.415081.9, 0000 0004 0493 6869, Department of Emergency Medicine, San Luigi Gonzaga University Hospital, , Turin, Italy (2) grid.415081.9, 0000 0004 0493 [...]

Background: Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. Methods: All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients&apos; thoracoabdominal CT scans and corresponding chest radiographs. Results: Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). Conclusion: Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma. Contexte: La radiographie pulmonaire anteroposterieure en position couchee constitue un moyen non sensible de detecter le pneumothorax (PTX) post-traumatique. La tomodensitometrie (TDM) detecte souvent un pneumothorax occulte (PTXO) non diagnostique par une radiographie pulmonaire. Toutes les publications anterieures decrivent l&apos;epidemiologie du PTXO chez les patients qui ont subi un polytraumatisme contondant. Nous voulions determiner la frequence du PTXO chez les patients victimes d&apos;un traumatisme perforant. Methodes: Tous les patients victimes d&apos;un traumatisme perforant admis au cours d&apos;une periode de 10 ans a l&apos;Hopital commemoratif Grady qui avaient un PTX ont ete identifies. Nous avons etudie les TDM thoracoabdominales des patients et les radiographies pulmonaires correspondantes. Resultats: Nous avons verifie les dossiers de 1121 (20 %) patients victimes d&apos;un PTX (mecanisme perforant). L&apos;imagerie par TDM etait disponible pour 146 (13 %) des patients. De ce total, 127 (87 %) avaient eu une radiographie pulmonaire en position debout. Les autres (19 patients) avaient eu une radiographie pulmonaire anteroposterieure en position couchee. Quinze (79 %) des PTX detectes par des radiographies pulmonaires anteroposterieure en position couchee etaient occultes. Seulement 10 (8 %) etaient occultes lorsqu&apos;on a utilise la radiographie pulmonaire en position debout (p < 0,001). Le PTX post-traumatique etait occulte dans les radiographies pulmonaires de 17 % (25/146) des patients. Quatorze (56 %) des patients qui avaient un PTXO ont subi une thoracostomie comparativement a 95 % (115/121) des patients qui avaient un PTX evident (p < 0,001). Conclusion: La radiographie pulmonaire habituelle des traumatises rate jusqu&apos;a 17 % du total des PTX chez les patients traumatises par un mecanisme perforant. Ce pourcentage atteint presque 80 % pour les radiographies pulmonaires anteroposterieures en position couchee. La radiographie pulmonaire en position debout detecte 92 % des PTX et est disponible pour la plupart des patients qui n&apos;ont pas de traumatisme rachidien. La frequence du recours a la thoracostomie chez les patients qui ont un PTX evident est beaucoup plus elevee que chez ceux qui ont un PTXO dans les cas de traumatisme contondant et perforant., Occult pneumothorax (OPTX) is a pneumothorax (PTX) diagnosed by computed tomography (CT) that had not been previously identified by a supine anteroposterior (AP) chest radiograph. (1-7) With the increasing use [...]

Supine anteroposterior chest radiography is an insensitive test for posttraumatic pneumothoraces. Computed tomography often detects pneumothoraces that were not diagnosed on chest radiography (occult pneumothoraces). Whereas the incidence of occult pneumothoraces approximates 5% of all trauma registry patients, this value approaches 15% among injured patients undergoing computed tomography. Up to 76% of all pneumothoraces may be occult to supine chest radiography with real-time interpretation by trauma teams. Although the size and intrathoracic distribution (anterior) of overt and occult pneumothoraces are similar, significantly more patients with occult pneumothoraces undergo tube thoracostomy compared with those with overt pneumothoraces. This pattern extends both to patients receiving mechanical ventilation and those with penetrating trauma. As an early clinical predictor available during the resuscitation of a trauma patient, only subcutaneous emphysema is predictive of a concurrent occult pneumothorax. The majority of patients with occult pneumothoraces (85%) do not have subcutaneous emphysema, however. Thoracic ultrasonography, as part of a bedside extended focused assessment with sonography for trauma examination, detects 92%-100% of all pneumothoraces and represents a simple extension of the clinician&apos;s physical examination. The final remaining question is whether clinicians can safely omit tube thoracostomy in some patients with occult pneumothoraces concurrent to positive pressure ventilation. This omission would avoid subjecting patients to the 22% risk of major chest tube-related insertional, positional and infective complications. La radiographie pulmonaire anteroposterieure en supination ne constitue pas un test sensible pour le pneumothorax posttraumatique. La tomodensitometrie detecte souvent des pneumothorax non diagnostiques au moyen d&apos;une radiographie pulmonaire (pneumothorax occultes). L&apos;incidence des pneumothorax occultes atteint environ 5 % du total des patients inscrits au registre des traumatismes, mais cette valeur atteint presque 15 % chez les patients traumatises soumis a une tomodensitometrie. Jusqu&apos;a 76 % des pneumothorax peuvent etre occultes a une radiographie pulmonaire en supination interpretee par des equipes de traumatologie. Meme si la taille et la distri bu tion intrathoracique (anterieure) des pneumothorax evidents et occultes se ressemblent, il y a beaucoup plus de patients atteints d&apos;un pneumothorax occulte qui subissent une thoracostomie a drain comparativement a ceux qui ont un pneumothorax evident. Cette tendance s&apos;avere a la fois pour les patients recevant une ventilation mecanique et pour ceux qui ont subi un traumatisme penetrant. Comme predicteur clinique precoce disponible au cours de la reanimation d&apos;un patient traumatise, seul l&apos;emphyseme sous-cutane est predicteur d&apos;un pneumothorax occulte simultane. La majorite des patients qui ont un pneumothorax occulte (85 %) n&apos;ont toutefois pas d&apos;emphyseme sous-cutane. L&apos;echographie thoracique, comme element d&apos;une evaluation convergente etendue effectuee au chevet par sonographie pour examen du traumatisme, permet de detecter de 92 % a 100 % des pneumothorax et represente un simple prolongement de l&apos;examen medical du clinicien. La derniere question a resoudre consiste a determiner si les cliniciens peuvent omettre sans danger la thoracostomie a drain chez certains patients qui ont un pneumothorax occulte pendant qu&apos;ils sont soumis a une ventilation a pression positive. Cette omission eviterait de soumettre les patients aux 22 % de risque de complications majeures reliees a l&apos;insertion et au positionnement du drain thoracique, ainsi qu&apos;a l&apos;infection., Occult pneumothoraces are a relatively recent radiological phenomenon. (1-5) They are de fined as pneumothoraces detected with thoracic or abdominal computed tomography (CT) that were not diagnosed on preceding supine [...]

Byline: Selahattin Katar (1), Celal Devecioglu (1), Mehmet KervancA+-oglu (1), Refik Ulku (2) Keywords: Symptomatic spontaneous pneumothorax; Term newborn Abstract: The causes and risk factors of symptomatic spontaneous pneumothorax in term newborns are not completely understood. In the present study, our aim was to investigate the risk factors for and clinical and laboratory characteristics of term newborns with spontaneous symptomatic pneumothorax and to evaluate the outcome of management in this condition. A total of 11 term newborns admitted to the newborn intensive care unit with a diagnosis of symptomatic spontaneous pneumothorax were included during a 22-month period. Female to male ratio was 4:7, mean gestational age was 39.5 weeks, and 63% were delivered with a cesarean section, 18% of patients had renal and 55% had congenital cardiac anomalies. Rate of cardiac anomalies was more frequent in the study group compared to control group. Echocardiography in addition to renal ultrasonography may also be needed in term newborns with spontaneous symptomatic pneumothorax and further studies may be warranted to evaluate this association. Author Affiliation: (1) Department of Pediatrics, Dicle University Faculty of Medicine, Diyarbakir, Turkey (2) Department of Thorax Surgery, Dicle University Faculty of Medicine, Diyarbakir, Turkey Article History: Registration Date: 10/07/2006 Accepted Date: 10/07/2006 Online Date: 03/08/2006

Byline: Seema K. Pursnani (1), John B. Amodio (2), Hua Guo (3), M. Alba Greco (3), Evan P. Nadler (1) Abstract: Persistent interstitial pulmonary emphysema (PIPE) is a syndrome characterized by air-leakage in the perivascular tissues of the lung, primarily affecting mechanically ventilated neonates. Reports in the literature of infants developing PIPE with no history of respiratory distress syndrome (RDS) or mechanical ventilation are scarce. Here, we present a case of a 3-month-old former full term male infant with no history of RDS or mechanical ventilation who presented with focal cystic lung disease associated with spontaneous tension pneumothorax. He was ultimately found to have PIPE based on pathologic evaluation of the resected cystic region. We believe that focal PIPE should be included in the differential diagnosis of cystic lung disease in a full term, unventilated infant, even when spontaneous pneumothorax is the presenting entity. Author Affiliation: (1) Division of Pediatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10 W, New York, NY, 10016, USA (2) Department of Radiology, New York University School of Medicine, New York, NY, USA (3) Department of Pathology, New York University School of Medicine, New York, NY, USA Article History: Registration Date: 06/04/2006 Accepted Date: 14/03/2006 Online Date: 22/04/2006

Byline: Daniel Lichtenstein (1), Gilbert Meziere (2), Philippe Biderman (1), Agnes Gepner (2) Keywords: Pneumothorax Intensive care unit Ultrasound diagnosis Lung, ultrasound diagnosis Thorax, ultrasound diagnosis Abstract: Objective: We studied an ultrasound sign, the fleeting appearance of a lung pattern (lung sliding or pathologic comet-tail artifacts) replacing a pneumothorax pattern (absent lung sliding plus exclusive horizontal lines) in a particular location of the chest wall. This sign was called the 'lung point'. Design: Prospective study. Setting: The medical ICU of a university-affiliated teaching hospital. Patients: The 'lung point' was sought in 66 consecutive cases of proven pneumothorax analyzable using ultrasound -- including 8 radio-occult cases diagnosed by means of CT -- and in 233 consecutive hemithoraces studied by CT and free of pneumothorax -- including 17 cases where pneumothorax was suspected. Results: The 'lung point' was observed in 44 of 66 cases of pneumothorax (including 6 of 8 radio-occult cases) and in no case in the control group. The location of this sign roughly correlated with the radiological size of the pneumothorax. The 'lung point' therefore had an overall sensitivity of 66% (75% in the case of radio-occult pneumothorax alone) and a specificity of 100%. Conclusion: The presence of a 'lung point' allows positive diagnosis of pneumothorax at the bedside using ultrasound. Author Affiliation: (1) Service de Reanimation Medicale, Hopital Ambroise-Pare, 9 avenue Charles-de-Gaulle, 92100 Boulogne (Paris), France (2) Service de Reanimation Polyvalente, Centre Hospitalier General, Saint-Cloud (Paris), France Article History: Received Date: 16/09/1999 Accepted Date: 03/07/2000 Article note: Final revision received: 27 June 2000 Electronic Publication

Byline: A. Herrejon (1), I. Inchaurraga (1), C. Vivas (1), J. Custardoy (2), J. Marin (3) Keywords: Key words: Spontaneous pneumothorax--Pleural pressure--Resolution time. Abstract: To assess whether pleural pressure (PP) measurement is helpful in evaluating the evolution of spontaneous pneumothorax (SP). To measure the inspiratory and expiratory PP at tidal volume in the SP in 85 cases. Ninety-one percent were cured with medical treatment, whereas the remaining 9% required surgery. In the cases medically resolved, the inspiratory pleural pressure (IPP) was -9 +- 5 mbar, and the expiratory pleural pressure (EPP) was -3 +- 6 mbar, whereas in the surgical cases, IPP was -7 +- 2 mbar (p= not significant), and EPP was 1 +- 3 mbar (p &lt 0.01). In the SP cases, which resolved in less than 7 days of drainage, IPP was -10 +- 5 mbar, and EPP was -3 +- 5 mbar, whereas IPP was -8 +- 3 mbar (p &lt 0.01), and EPP was 0 +- 4 mbar (p &lt 0.001) in those cases in which SP resolution required more than 7 days. The sensitivity to predict the need for surgery with an EPP aY= 2 mbar was 100%, with a specificity of 49%. The cutoff of the curve was aY= 1 mbar, with a sensitivity of 65% and specificity of 70%. The values of PP at the end of an expiration to tidal volume were negative in the SP cases, which were resolved by medical treatment, whereas they were atmospheric in those cases that required surgery. The static inspiratory and expiratory PP in the SP cases requiring thoracic drainage during &lt 7 days showed more negative PP than those that resolved in a period longer than 7 days. Author Affiliation: (1) Department of Pneumology, Dr. Peset Hospital. Valencia, Spain, ES (2) Department of Internal Medicine. La Vega Baixa Hospital, Orihuela, Alicante, Spain, ES (3) Department of Pneumology, Universitary Clinic Hospital, Valencia, Spain, ES Article note: Accepted for publication: 11 August 2000

Byline: D. Lichtenstein (1), G. Meziere (2), P. Biderman (1), A. Gepner (2) Keywords: Key words Pneumothorax; Ultrasound diagnosis; Intensive Care Unit; Lung; ultrasound diagnosis Abstract: Objective: Ultrasound artifacts arising from the lung--wall interface are either vertical (comet-tail artifacts) or horizontal. The significance of these artifacts for the diagnosis of pneumothorax was assessed. Design: Prospective clinical study. Setting: The medical ICU of a university-affiliated teaching hospital. Patients: We compared 41 complete pneumothoraces with 146 hemithoraces in 73 critically ill patients in which computed tomography showed absence of pneumothorax. Measurements: The anterior chest wall was investigated in supine patients using a portable device. The test was defined as positive for complete pneumothorax when only horizontal artifacts were visible, and negative when artifacts arising from the pleural line and spreading up to the edge of the screen (referred to as 'comet-tail artifacts') were present. Results: The feasibility was 98 %. Ultrasound showed exclusive horizontal artifacts in all 41 analyzable cases of complete pneumothorax. In the pneumothorax-free group, 'comet-tail artifacts' were present in 87 cases and exclusive horizontal artifacts in 56. Ultrasound as well as computed tomography showed anterior consolidation or anterior pleural effusion in three cases. Horizontal artifacts had a sensitivity and a negative predictive value of 100 % and a specificity of 60 % for the diagnosis of pneumothorax. Horizontal artifacts and absent lung sliding, when combined, had a sensitivity and a negative predictive value of 100 % and a specificity of 96.5 %. Conclusions: Ultrasound detection of the 'comet-tail artifact' at the anterior chest wall allows complete pneumothorax to be discounted. Author Affiliation: (1) Service de Reanimation Medicale, Hopital Ambroise Pare, 9 avenue du General Charles de Gaulle, F-92100 Boulogne (Paris), France Tel. + 33-1-49 09 56 01 Fax + 33-1-49 09 58 92, FR (2) Service de Reanimation Polyvalente, Centre Hospitalier General, Saint Cloud (Paris), France, FR Article note: Received: 11 February 1998 Accepted: 3 February 1999

Byline: Rachna. Wadhwa, Zainab. Ahmad, Mahendra. Kumar Traumatic diaphragmatic hernia (TDH) is generally a consequence of thoraco-abdominal trauma. Anaesthetic problems arise due to herniation of abdominal contents into the thoracic [...]

Byline: C. Kolbitsch (1), A. Pomaroli (1), I. Lorenz (1), M. Gassner (1), T. J. Luger (1) Keywords: Key words Nasogastric feeding tube; misplacement; Nasogastric feeding tube; insertion under direct vision; Bilateral lung transplantation Abstract: We report the case of a pneumothorax caused by the improper placement of a nasogastric feeding tube in a tracheostomized patient after bilateral lung transplantation. We discuss the contribution of low-pressure cuffed tracheostomy tubes to the inadvertent respiratory tract misplacement of a nasogastric feeding tube, as well as the problems of nasogastric feeding tube insertion in the sedated patient, why the previously installed closed-tube thoracostomy did not prevent the pneumothorax and possible pitfalls in confirming the proper position of the nasogastric feeding tube. In conclusion, we stress that in high risk patients a nasogastric feeding tube should only be inserted under direct vision and that a subsequent routine X-ray is mandatory for confirming proper positioning. Author Affiliation: (1) Department of Anaesthesia and Intensive Care Medicine, The Leopold-Franzens-University of Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria FAX: + 43 (5 12) 5 04 24 63 e-mail: christian.kolbitsch@uibk.ac.at, AT Article note: Received: 19 August 1996 Accepted: 27 December 1996

Byline: Chitra. Juwarkar, Deependra. Kamble, Vishal. Sawant Congenital diaphragmatic hernia (CDH) is described as (1) failure of diaphragmatic closure at development, (2) presence of herniated abdominal contents into chest and [...]

Objective : To determine whether video-assisted thoracoscopic surgery is as effective as the traditional open method through axillary thoracotomy for the management of primary spontaneous pneumothorax in adults. Materials and [...]

To the Editor.--This letter calls attention to 3 potentially significant pitfalls that may result from misinterpretation of vascular alterations in the lung and pleural tissues in patients with pneumothorax. Two [...]