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Objective: To compare the diagnostic rate and safety of postoperative complications between transbronchial cryobiopsy (TBCB) and transbronchial lung biopsy (TBLB) in patients with lung transplantation. Methods: A retrospective analysis of patients who underwent TBCB or TBLB in the Department of Lung Transplantation in China-Japan Friendship Hospital from June 2017 to June 2024 was conducted to determine the postoperative complications and analyze clinical characteristics, procedures, diagnostic rates and safety. Results: Thirty-five and 153 patients with lung transplantation received TBCB and TBLB, respectively. Patients who received TBCB had lower preoperative oxygenation index ( t' =2.4, P <0.01). Meanwhile, the pathological diagnosis rate (85.7% vs. 45.7%, χ ²=18.27, P <0.01) and clinical diagnosis rate (94.2% vs. 69.9%, χ ²=8.80, P <0.01) of patients who received TBCB were significantly higher than those who received TBLB. There was no significant difference in the incidence of severe bleeding (2.9% vs. 0.7%, χ ²=1.3, P =0.86) and pneumothorax (0 vs. 3.9%, χ ²=0.43, P =0.24) between patients receiving TBCB and TBLB. The most common complications after lung transplantation in the group of TBCB were chronic lung allograft dysfunction (45.4%, 15/33), antibody mediated rejection (18.2%, 6/33) and organizing pneumonia (12.2%, 4/33). While antibody mediated rejection (29.9%, 32/107), chronic lung allograft dysfunction (16.8%, 18/107), and pneumonia (16.8%, 18/107) were more frequent in the patients who received TBLB. Conclusions: TBCB has a high diagnostic value for postoperative complications after lung transplantation, with an acceptable complication rate of bleeding and pneumothorax.

Vaping-associated spontaneous pneumothorax (VASP) is a new diagnosis created to describe spontaneous pneumothorax associated with the use of vape devices. We describe a case of bilateral VASP in a previously healthy 15-year-old male who was vaping cannabis concentrate. This is the first case report of VASP involving the sole usage of cannabis concentrate. This patient reported vaping for only 6 months before initial presentation. As rates of vaping cannabis concentrate increase among adolescents, VASP should be considered in the differential diagnosis of chest pain in adolescents who vape nicotine or cannabis., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: To date there are no data on sex aspects evaluating outcomes of interventional pneumology (IP). Our aim was to investigate sex differences in transbronchial lung cryobiopsy (TBLC) outcomes in the diagnosis of interstitial lung disease (ILD)., Methods: All consecutive (TBLC)s performed for ILD evaluation between Nov 17 and Dec 21 at a tertiary referral center for ILDs and IP were analyzed. The indication for the procedure was determined by a multidisciplinary discussion (MDD). Final results including bronchoalveolar lavage (BAL) and histology were discussed in a 2nd MDD and outcomes and procedure related complications were assessed., Results: TBLC was performed in 406 patients (38.4 % female/67.8 years/FVC 76.8 %). Among 32 interventionalists, 16 females performed 53 % of interventions. Females had longer procedure times (29.9 vs. 26.6 min, p = 0.046), used fluoroscopy more often (76.7 vs. 50.3 %, p < 0.001) and obtained more samples (3.6 vs. 3.2, p = 0.021) than their male counterparts. No difference was found for major bleeding or pneumothorax. MDD was able to conclude on a diagnosis in 88.4 % of interventions performed by women and in 78.5 % performed by men (p = 0.010). In a multivariate analysis, female gender (OR 1.93) and lower FVC% values (OR 0.98) were significantly associated with diagnostic yield, whereas the number of biopsies, professional experience, use of fluoroscopy or antiplatelet drugs were not relevant., Conclusion: The results of this study strengthen the role of women in endoscopy and may help to motivate women to pursue a career in IP., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: FCT received research funding from Octapharma Pharmazeutika Produktionsgeselltschaft m.b.H. to conduct this study; the funder had no influence on the evaluation and interpretation of the data. FCT has received honoraria for lectures from Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Grifols, Novartis, CSL Behring. She participates in an Advisory Board for CSL Behring, GlaxoSmithKline and Boehringer Ingelheim, outside the submitted work. RE reports honoraria or payment for lectures and presentations from Broncus, Olympus, Pentax, Pulmonx, Astra Zeneca. He joins the data safety monitoring board for Intuitive Surgical Inc, outside the submitted work. FJFH reports Research Support from Olympus Medical, Pulmonx, Broncus, Uptake Medical, Roche Diagnostics, BMBF, DFG, EU, Klaus-Tschira Stiftung, BMG; Lecturing honoraria from Pulmonx, Uptake Medical, Roche Diagnostics, Astra Zeneca, Boehringer Ingelheim, Novartis, Berlin Chemie, Chiesi, Medupdate, Erbe, GSK and consulting activities for Olympus Medical, Pulmonx, Broncus – Uptake Medical, Roche Diagnostics, Astra Zeneca, J&J, Karger, LÄK, Boston Scientific, Dinova, Nanovation, Free Flow Medical, Erbe, outside the submitted work. KKo. Has received honoraria for lectures from Berlin-Chemie, Astra Zeneca and Boston Scientific, outside the submitted work. KKa has received honoraria for lectures form Berlin-Chemie, Astra Zeneca, Boehringer Ingelheim, Insmed, outside the submitted work. JDM, CA, MS, ME, MP, MK have nothing to disclose., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO 2 levels in the air flow from the chest drainage using capnography., Methods: This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL., Results: Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67 ml/min). AL patients had higher intrapleural CO 2 levels (median 24 mmHg) (p < 0.001). Median chest drainage duration was 2 days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO 2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO 2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001)., Conclusions: Intrapleural CO 2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO 2 in the identification of AL. Further studies should be performed to identify a CO 2 cutoff that will standardize the management of chest drainage., (© 2024. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Purpose: To compare the effectiveness of 2 track sealing techniques following computed tomography (CT)-guided lung biopsy using either gelatin sponge slurry (GSS) or saline to reduce the rate of postbiopsy pneumothorax., Materials and Methods: In this prospective study, a total of 266 patients (median age, 66.2 years; range, 25.5-89.2 years; 150 men) were included between July 2019 and January 2023. The patients referred for a CT-guided lung biopsy, in whom the needle would pass through aerated lung, were randomly assigned to either the GSS sealing technique group (n = 132) or the saline track sealing technique (n = 134) in a 1:1 ratio. All biopsies were performed using a 19-gauge coaxial needle in a tertiary hospital by 1 of 4 interventional radiologists with varying levels of experience (F.C., L.G., P.L., C.V.). The outcomes were pneumothorax occurrence, pneumothorax-related intervention (simple aspiration and/or drainage), and biopsy-related hospital stay length., Results: Pneumothorax rates were 12.1% in the GSS group and 24.6% in the saline group (P = .008). Hospital length of stay was significantly shorter in the GSS group (P = .003). The need for pneumothorax-related intervention did not reach statistical significance between the groups (6.8% vs 12.7%; P = .107). In the multiple logistic regression analysis, track sealing with GSS was a protective factor for pneumothorax (odds ratio [OR], 0.44; 95% CI, 0.22-0.87; P = .019), and emphysema was associated with higher risk of pneumothorax (OR, 2.67; 95% CI, 1.31-5.44; P = .007)., Conclusions: Track sealing with GSS following a CT-guided lung biopsy is significantly more effective than saline in reducing postbiopsy pneumothorax and results in shorter hospital stay., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Transbronchial lung cryobiopsy (TBLC) has emerged as a promising diagnostic tool for interstitial lung disease (ILD). This study aimed to assess the initial experience, procedural learning curve, and influence of sedative medications on complication rates, particularly bleeding and pneumothorax, in the implementation of a TBLC program for ILD diagnosis., Methods: In this retrospective cohort study, we analysed 119 patients who underwent TBLC at Nippon Medical School Hospital from April 2021 to March 2024. Procedural times, complication rates, and histopathological outcomes were evaluated. The learning curve was assessed using cumulative sum (CUSUM) analysis, focusing on procedure time and biopsy yield. The association between sedative medication dosages and bleeding risk was also examined., Results: The overall diagnostic yield was high, with alveolar tissue obtained in 97.5% of cases and a definitive pathological diagnosis achieved in 81.5% of patients. CUSUM analysis revealed a proficiency threshold at approximately 56 cases, with improved efficiency and biopsy yield in the consolidation phase. Fentanyl dosage was significantly associated with reduced bleeding complications (odds ratio 0.51, 95% confidence interval 0.27-0.97, p = 0.041)., Conclusions: TBLC is a safe and effective diagnostic tool for ILDs, with a manageable learning curve for procedural efficiency. Sedation, particularly fentanyl dosage, may plays a crucial role in minimizing complications, but further research is needed to clarify this relationship. These findings support the adoption of TBLC as a standard diagnostic approach for ILD and highlight the importance of adequate training and optimized sedation protocols to ensure safety and efficacy in clinical practice., (© 2024. The Author(s).)

Background: Computed tomography (CT)-guided lung biopsy is a widely used technique for the diagnosis of pulmonary lesions and with a high technical success rate and diagnostic accuracy. On the other hand, it is associated with a high risk of complications, especially pneumothorax. Various methods have been tried to reduce the incidence of pneumothorax, but no established method exists. The purpose of this study was to evaluate whether the combination of tract sealing with normal saline and rapid rollover can reduce the rate of pneumothorax and chest tube insertion after CT-guided lung biopsy., Methods: We reviewed all CT-guided lung biopsies performed at a single institution between October 2016 and December 2021. Before August 2019, no specific additional techniques were employed to mitigate complications (Group 1). In contrast, after September 2019, normal saline for tract sealing was injected during needle removal, and if pneumothorax was observed during the intervention, the patient was rolled over into the puncture-site down position immediately after needle removal (Group 2). The rate of complications was compared between the two groups., Results: 130 patients in Group 1 and 173 in Group 2 were evaluated. There was no significant difference in pneumothorax rate between the two groups (30.0% vs. 23.1%, P = .177). A chest tube was inserted in 10 of 130 patients in Group 1 and only in 1 of 173 in Group 2 (P = .001). There were no complications associated with this combinational technique., Conclusions: The combination of normal saline injection and rapid rollover significantly reduced the incidence of pneumothorax requiring chest tube insertion after CT-guided lung biopsy. Therefore, normal saline injection and rapid rollover can serve as a preventive method for severe pneumothorax in CT-guided lung biopsy., (© 2024. The Author(s).)

Objectives: To explore the role of nodule-pleural relationship, including nodule with pleural tail sign (PTS), nodule with pleural contact and nodule with pleural unrelated in CT-guided percutaneous transthoracic needle biopsy (PTNB)-induced pneumothorax, and whether employing different puncture routes has an impact on the incidence of pneumothorax in PTNB of nodules with PTS., Methods: Between April 1, 2019, to June 30, 2021, 775 consecutive PTNB procedures of pulmonary nodules in the Peking University Cancer Hospital were retrospectively reviewed. The univariate and multivariate regression analysis were used to identify the risk factors for pneumothorax in PTNB., Results: The nodule with pleural contact group has a lower incidence of pneumothorax than the nodule with PTS group (p = 0.001) and the nodule with pleural unrelated group (p = 0.002). It was observed that a higher incidence of pneumothorax caused by crossing PTS compared with no crossing PTS (p < 0.001). Independent risk factors for pneumothorax included crossing PTS (p < 0.001), perifocal emphysema (p < 0.001), biopsy side up (p < 0.001), longer puncture time (p < 0.001), deeper needle insertion depth (intrapulmonary) (p < 0.001) and nodules in the middle or lower lobe (p = 0.007)., Conclusion: Patients with crossing PTS, a nodule in the middle or lower lobe, longer puncture time, biopsy side up, deeper needle insertion depth (intrapulmonary), and perifocal emphysema were more likely to experience pneumothorax in PTNB. When performing the biopsy on a nodule with PTS, selecting a route that avoids crossing through the PTS may be advisable to reduce the risk of pneumothorax., (© 2024. The Author(s).)

Objective: Although ultrasound can be considered an assistant method, successful placement of a central venous catheter (CVC) in infants is still challenging. The incidence of CVC placement-related complications is still high. Therefore, this systematic review aimed to synthesize evidence to assess the effects of ultrasound-guided CVC placement on adverse outcomes in infants and neonates aged <12 months., Methods: PubMed, Ovid, EMBASE, and the Cochrane Library were searched to identify potentially relevant studies. The main outcome was the incidence of adverse events, which included inadvertent arterial puncture, hematoma, pneumothorax and hemothorax, catheter kinking, threading, and malpositioning problems, venous thrombosis, catheter-related infection, phlebitis, and cardiac tamponade., Results: Eleven studies involving 2097 patients were included in the final analysis. The odds of inadvertent arterial puncture, and catheter kinking, threading, and malpositioning problems were lower in the ultrasound group than in the control group. No significant difference was detected in the incidence of hematoma or venous thrombosis between the control and ultrasound groups. Other complications, such as pneumothorax, hemothorax, phlebitis, and cardiac tamponade, rarely occurred., Conclusion: Ultrasound-guided CVC placement can improve the safety of punctures in neonates and infants. CVC punctures should be guided in real-time by ultrasound., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

Background: Small-bore wire-guided thoracostomy tubes (SBWGTT) are commonly used in cats to manage pleural disease and generally have a low complication rate. Our study aimed to explore the correlation between recumbency of cats, placement method, and the occurrence of insertional complications to identify risk factors during SBWGTT placement. In this experimental cadaveric study, SBWGTT placement using a modified Seldinger technique was conducted in 24 feline cadavers. Cats, euthanized for reasons unrelated to the study, were randomly assigned to pleural effusion (EFF; n = 12) and pneumothorax (PNEU; n = 12) groups. Each cadaver was intubated and ventilated with a peak inspiratory pressure (PIP) of 10 mmHg, and sterile saline or air was instilled into the thorax over a 5 mm thoracoscopic trocar in the fourth intercostal space (ICS). Instillation was stopped when the lateral thoracic wall to lung distance (TWLD) reached 10 to 12 mm, measured with ultrasound in the favorable position. Sternal recumbency was the favorable position for the EFF group, and lateral recumbency for the PNEU group. Following the placement of the first SBWGTT in each group, the cadavers were positioned unfavorably (lateral recumbency for EFF group, sternal recumbency for PNEU group), and a second drain was introduced contralaterally. A bilateral 8th ICS thoracotomy was then performed to visually assess intrathoracic structures and drain integrity. A binary logistic regression mixed model was conducted to determine interaction between the induced condition and body position., Results: A total of 48 SBWGTTs were placed, with complications observed in 33.3% (8/24) of cases. Five of these were major complications consisting of lung lacerations. Complications were more common in the unfavorable position, accounting for 75% of cases, although this result was not statistically significant. The odds of complication rates were > 70% in the unfavorable position and decreased with an increase in TWLD (< 30%)., Conclusion: Complications associated with SBWGTT placement are influenced by recumbency, although the data did not reach statistical significance. Placing cats in lateral recumbency for pneumothorax treatment and sternal recumbency for pleural effusion treatment may reduce insertional complications., (© 2024. The Author(s).)

Background: In this paper, a rare case is reported, where the patient is a 74-year-old man. He suffered from recurrent pneumothorax within half a year and experienced a relapse after receiving conservative treatments., Case Presentation: Diagnostic workup revealed a cystic lesion in the right middle lobe, which has been interpreted as a bulla during the initial chest CT scan. Due to recurrent pneumothorax and poor response to the conservative treatments, the patient underwent bullectomy and pleurodesis. The pathology showed that the wall of the cystic lesion was invasive adenocarcinoma., Conclusions: This case highlights the importance of monitoring cystic lesions in the lungs, especially in patients with a history of smoking and emphysema., (© 2024. The Author(s).)

Background: Spontaneous pneumothorax is a common clinical condition due to several etiologies. Appropriate radiologic assessment helps avoid re-imaging and guide individualized management., Objective: To describe the etiologic factors of spontaneous pneumothorax in children from a radiological perspective., Materials and Methods: Thirty-nine children with spontaneous pneumothorax were evaluated according to their demographic characteristics, the presence of underlying lung diseases, and imaging findings., Results: Twenty-one patients without underlying lung disease were assessed as primary spontaneous pneumothorax; eight of these 21 patients (38.9%) had subpleural air cysts in the apices/upper lobes of the lung on chest computed tomography (CT). In the remaining 18 patients with secondary spontaneous pneumothorax, the most common causes were respiratory diseases (33.3%), infectious lung diseases (33.3%), interstitial lung diseases (27.7%), and connective tissue diseases (5.5%). The mean age of children with secondary spontaneous pneumothorax was lower than that of children with primary spontaneous pneumothorax (P = 0.002). Recurrences occurred in 11 patients (52.3%) with primary spontaneous pneumothorax and three patients (16.6%) with secondary spontaneous pneumothorax. Bilateral pneumothorax was observed in three of the 18 patients with secondary spontaneous pneumothorax., Conclusion: Identifying the etiologic factors of spontaneous pneumothorax may help clinicians plan how to reduce the risk of recurrence. Radiologists should keep in mind the possible underlying diseases and assess imaging methods in children with spontaneous pneumothorax for subpleural air cysts and be suspicious about an underlying disease in cases of bilateral pneumothorax and in younger patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Single lung transplantation (SLT) is a viable option for patients with end-stage pulmonary parenchymal and vascular diseases. However, various diseases can occur in native lungs after SLT., Methods: Between January 2000 and December 2021, 35 patients underwent cadaveric SLT and survived for more than 30 days in our hospital. Among these 35 patients, 10 required surgery for diseases that developed in their native lungs. The clinical characteristics of these 10 patients and the outcomes of native lung surgery (NLS) were investigated., Results: Among these ten patients, the indications for lung transplantation were chronic obstructive pulmonary disease and idiopathic interstitial pneumonia in three patients each, and lymphangioleiomyomatosis and collagen vascular disease-related interstitial pneumoniain two patients each. The causes of NLS included pneumothorax (n = 4), primary lung cancer (n = 2), native lung hyperinflation (n = 2), and pulmonary aspergilloma (n = 2). The surgical procedures were pneumonectomy (n = 7), lobectomy (n = 2), and alveolar-pleural fistula repair (n = 1). Only one postoperative complication, empyema, was treated with antibiotics. The 5-year overall survival rates after transplantation with and without NLS were 70.0% and 80.0%, respectively, and did not differ to a statistically extent (p = 0.56)., Conclusion: NLS is an effective treatment option for diseases that develop in the native lungs after SLT., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Objective: To investigate the association of smoking with the outcomes of percutaneous transthoracic needle biopsy (PTNB)., Methods: In total, 4668 PTNBs for pulmonary lesions were retrospectively identified. The associations of smoking status (never, former, current smokers) and smoking intensity (≤ 20, 21-40, > 40 pack-years) with diagnostic results (malignancy, non-diagnostic pathologies, and false-negative results in non-diagnostic pathologies) and complications (pneumothorax and hemoptysis) were assessed using multivariable logistic regression analysis., Results: Among the 4668 PTNBs (median age of the patients, 66 years [interquartile range, 58-74]; 2715 men), malignancies, non-diagnostic pathologies, and specific benign pathologies were identified in 3054 (65.4%), 1282 (27.5%), and 332 PTNBs (7.1%), respectively. False-negative results for malignancy occurred in 20.5% (236/1153) of non-diagnostic pathologies with decidable reference standards. Current smoking was associated with malignancy (adjusted odds ratio [OR], 1.31; 95% confidence interval [CI]: 1.02-1.69; p = 0.03) and false-negative results (OR, 2.64; 95% CI: 1.32-5.28; p = 0.006), while heavy smoking (> 40 pack-years) was associated with non-diagnostic pathologies (OR, 1.69; 95% CI: 1.19-2.40; p = 0.003) and false-negative results (OR, 2.12; 95% CI: 1.17-3.92; p = 0.02). Pneumothorax and hemoptysis occurred in 21.8% (1018/4668) and 10.6% (495/4668) of PTNBs, respectively. Heavy smoking was associated with pneumothorax (OR, 1.33; 95% CI: 1.01-1.74; p = 0.04), while heavy smoking (OR, 0.64; 95% CI: 0.40-0.99; p = 0.048) and current smoking (OR, 0.64; 95% CI: 0.42-0.96; p = 0.04) were inversely associated with hemoptysis., Conclusion: Smoking history was associated with the outcomes of PTNBs. Current and heavy smoking increased false-negative results and changed the complication rates of PTNBs., Clinical Relevance Statement: Smoking status and intensity were independently associated with the outcomes of PTNBs. Non-diagnostic pathologies should be interpreted cautiously in current or heavy smokers. A patient's smoking history should be ascertained before PTNB to predict and manage complications., Key Points: • Smoking status and intensity might independently contribute to the diagnostic results and complications of PTNBs. • Current and heavy smoking (> 40 pack-years) were independently associated with the outcomes of PTNBs. • Operators need to recognize the association between smoking history and the outcomes of PTNBs., (© 2024. The Author(s).)

Introduction: Transbronchial lung cryobiopsy (TBLC) is increasingly used to diagnose interstitial lung disease (ILD). The 1.1-mm cryoprobe has recently been available in clinical practice. The diagnostic yield and safety of TBLC using a 1.1-mm cryoprobe need to be confirmed., Methods: A prospective, randomized controlled trial was conducted in patients with suspected ILD and randomly assigned to 1.1-mm and 1.9-mm cryoprobe groups. The primary outcome was the diagnostic yield of multidisciplinary discussion. Secondary outcomes were sample quality and incidence of complications. The tension and stress effects during TBLC onto the target lobe caused by 1.1-mm and 1.9-mm cryoprobes were also evaluated using finite element analysis., Results: A total of 224 patients were enrolled. No significant differences were observed in the diagnostic yield (80.4% vs. 79.5%, p = 0.845) and sample quality scores (5.73 ± 0.64 vs. 5.66 ± 0.77; p = 0.324) between the 1.9-mm cryoprobe group and 1.1-mm cryoprobe group. The average surface areas of samples in 1.1-mm cryoprobe group were smaller, while no difference in sample weights was observed. A decreased incidence of moderate bleeding was found in the 1.1-mm cryoprobe group (17.0% vs. 6.2%, p = 0.027), while there was no difference in the incidence of the pneumothorax, there was a trend to higher rate of pneumothorax in 1.1-mm group. In finite element analysis, the 1.1-mm cryoprobe required the largest tension and produced the largest stress., Conclusion: Compared with a 1.9-mm cryoprobe, there was no difference in specimen quality or diagnostic rate but smaller sample size with a 1.1-mm cryoprobe. There was a decreased risk of moderate bleeding, but a trend towards increased risk for pneumothorax with 1.1-mm cryoprobe., Trail Registration: Clinicaltrials.gov identifier NCT04047667; registered August 4, 2019., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Thoracic endometriosis syndrome gives rise to various clinical and radiological manifestations. We reviewed the records of patients operated for intrathoracic migration of abdominal viscera through a diaphragmatic hernia secondary to thoracic endometriosis., Methods: We retrospectively reviewed the single-center prospective collected database of all patients operated for thoracic endometriosis during the twenty years. All cases in which an abdominal organ was found to be herniated into the thoracic cavity were retrieved. Clinical and pathological data are presented and analyzed., Results: Twenty women of median age 36 (range 25-58) years were operated for endometriosis-related diaphragmatic hernia. The hernia was diagnosed concomitantly with endometriosis-related pneumothorax in 13 cases and during the exploration of catamenial thoracic pain in seven cases. There were 18 cases on the right side and two cases on the left side. The median diameter of the hernia was 8 cm (2.5-20 cm). In seventeen cases, the hernia was repaired by direct suture, and in three cases a heterologous prosthesis was positioned. At follow-up, two patients had an episode of recurrent pneumothorax., Conclusions: Diaphragmatic hernia should be ruled out in the presence of endometriosis-related pneumothorax or catamenial thoracic pain. Surgery is indicated to make a pathological diagnosis, restore anatomy, and prevent recurrence in patients presenting with pneumothorax., (© 2024. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Systemic air embolism is a rare but potentially life-threatening complication of computed tomography (CT)-guided lung biopsy. The largest lung biopsy audits report an incidence rate of approximately 0.061% for systemic air embolism, with a mortality rate of 0.07-0.15%. A prompt diagnosis with high index of suspicion is essential, and hyperbaric oxygen treatment (HBOT) is the definitive management. We report the case of a 44-year-old lady who developed a lateral ST elevation myocardial infarction from coronary artery air embolism following CT-guided lung biopsy for evaluation of a left lung lesion. The biopsy was performed in the right lateral decubitus position, and the patient reported chest pain after coughing during the procedure. The clinician decided to proceed, taking four biopsy samples as no pneumothorax was identified in the intraprocedural CT image. The patient was noted to have hypotension with ongoing chest pain post-procedure. Resuscitative measures were taken to stabilise her haemodynamics, and she was successfully treated with HBOT with total resolution of air embolism. She developed a left sided pneumothorax post-treatment and needed intercostal chest drain insertion. The left lung fully re-expanded, and the patient was discharged home after day two of admission., Competing Interests: The authors report no conflicts of interest in this work., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

Background: This study aimed to evaluate the efficacy and safety between electromagnetic navigational bronchoscopy (ENB) and computed tomography (CT)-guided percutaneous localization before resection of pulmonary nodules., Methods: Pubmed, Embase, Web of Science, and the Cochrane Library databases were searched from January 1, 2000 to April 30, 2022, for relevant studies. Two reviewers conducted the search, selection, and extraction of data from eligible studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. The primary outcome was the localization success rate, and the secondary outcomes were the pneumothorax incidence and localization time. The meta-analysis was performed by Review Manager 5.4. The protocol for the meta-analysis was registered on PROSPERO (Registration number: CRD42022345972)., Results: Five cohort studies comprising 441 patients (ENB group: 185, CT group: 256) were analyzed. Compared with the CT-guided group, the ENB-guided group was associated with lower pneumothorax incidence (relative ratio = 0.16, 95% confidence interval [CI]: 0.04-0.65, P = .01). No significant differences were found in location success rates (relative ratio = 1.01, 95% CI: 0.98-1.05, P = .38) and localization time (mean difference = 0.99, 95% CI: -5.73 to 7.71, P = .77) between the ENB group and CT group., Conclusion: Both ENB and CT-guided are valuable technologies in localizing lung nodules before video-assisted thoracoscopic surgery based on current investigations. ENB achieved a lower pneumothorax rate than the CT-guided group. In our opinion, there is no perfect method, and decision-making should be given the actual circumstances of each institute. Future prospective studies in the form of a randomized trial are needed to confirm their clinical value., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

A female of reproductive age presents to the emergency department with progressive dyspnoea due to pneumothorax. She has a history of lymphangioleiomyomatosis (LAM) diagnosed by lung biopsy 15 years ago following incidental finding of pneumothorax. Despite various procedural and medicinal treatments, she continued to have recurrent pneumothorax, with three hospital admissions over the preceding 3 months. LAM is a rare cystic lung disease affecting the lymphatic system, which most commonly affects women of childbearing age. It can be diagnosed via imaging or tissue biopsy (gold standard). Treatment can be difficult, and it often requires highly specialised care by pulmonologists and often confers significant limitations to patients' independence and quality of life. Family physicians are often part of multidisciplinary team to provide care to patients with rare chronic conditions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Limited evidence exists regarding the link between coronavirus disease 2019 (COVID-19) and pneumothorax. Therefore, we aimed to evaluate the occurrence rate of pneumothorax in hospitalized patients with COVID-19 and compare the risk of pneumothorax between patients with COVID-19 and influenza. This retrospective cohort study used patient data from the National Health Insurance Service of South Korea. Patients diagnosed with COVID-19 (December 2019 to December 2021) and influenza (January 2019 to December 2021) who required hospitalization and respiratory support were included. We identified 46,460 patients with COVID-19 and 6,117 with influenza. The occurrence rate of pneumothorax was 0.74% in patients with COVID-19. In an inverse probability of treatment weighting matched cohort, the Cox proportional hazards regression model showed that COVID-19 was not associated with an increased risk of pneumothorax compared to influenza (hazard ratio, 1.22; 95% confidence interval, 0.75-1.99). However, the risk of pneumothorax associated with COVID-19 compared to influenza was significantly higher in patients without chronic lung disease than in those with (P for heterogeneity = 0.037). In conclusion, COVID-19, compared with influenza, is not associated with an increased risk of pneumothorax; however, it is associated with an increased risk in patients without chronic lung disease., (© 2024. The Author(s).)

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., Clinicaltrials: gov ID: NCT06182007 (retrospectively registered)., Trial Registration: NCT06182007 (retrospectively registered)., (© 2024. The Author(s).)

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.

Objective: Nasal Intermittent Positive Pressure Ventilation (NIPPV) is an effective therapy for infants in respiratory distress. We here report the safety of a novel, low-cost, non-electric bubble NIPPV device in comparison with bubble NCPAP., Study Design: At Paramitha Children's Hospital (Hyderabad, India), preterm (n = 60) neonates with moderate respiratory distress were pragmatically allocated to bubble NCPAP (5-8 cm H 2 O) or bubble NIPPV (P high 8-12 cm H 2 O/P low 5-8 cm H 2 O) based on staff and equipment availability. Primary outcomes to assess safety included clinically relevant pneumothorax, nasal septal necrosis, or abdominal distention., Results: One patient in each arm developed minor nasal septal injury (grade 3 on NCPAP, grade 2 on NIPPV); no patients in either arm developed a clinically significant pneumothorax or abdominal distention., Conclusion: The similar rates of nasal septal injury, pneumothorax and abdominal distention suggest that bubble NIPPV has a similar safety profile as bubble NCPAP for preterm infants in respiratory distress., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Differentiating between giant pulmonary bullae and pneumothorax can pose a challenge in clinical settings. A chest CT scan during the patient's health assessment revealed that approximately 40% of the right chest cavity was filled with air, leading to incomplete expansion of the right lung. The patient was initially misdiagnosed with pneumothorax in the emergency department and subsequently underwent closed thoracic drainage without experiencing any improvement in symptoms. Upon further examination through thoracoscopy, the patient was correctly diagnosed with a giant pulmonary bulla. Upon reviewing the patient's chest CT scan, we were able to identify key distinguishing features between giant pulmonary bullae and pneumothorax., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Yefei Zhan reports financial support was provided by Ningbo No.2 Hospital (Project No. 2023-Y06). Yefei Zhan reports financial support was provided by Ningbo Municipal Health Commission (Project No. 2022-F16). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Transbronchial lung cryobiopsy (TBLC) is a new technique for obtaining high-quality and large-sized lung tissues, as compared to transbronchial forceps biopsy (TBFB), and is useful in the diagnosis of diffuse lung disease (DLD). We aimed to evaluate the safety of TBLC as compared to TBFB in DLD patients in Japan using a nationwide database., Methods: Data were retrospectively collected from the Japanese Diagnosis Procedure Combination database from April 1, 2020 to March 31, 2022. Eligible patients (n = 9673) were divided into the following two groups: those who underwent TBFB (TBFB group, n = 8742) and TBLC (TBLC group, n = 931). To compare the outcomes between the two groups, a stabilized inverse probability of treatment weighting (IPTW) was applied using propensity scores. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, complications (mechanical ventilation, pneumothorax, and bleeding), and length of hospital stay after bronchoscopy., Results: The crude in-hospital mortality rates were 3.2% and 0.9% in the TBFB and TBLC groups, respectively. The stabilized IPTW analysis showed no significant difference in the in-hospital mortality rates between the two groups; the odds ratio of the TBLC group as compared with the TBFB group was 0.73 (95% confidence interval: 0.34-1.60; p = 0.44). Moreover, the secondary outcomes did not significantly differ between the two groups., Conclusions: TBLC for DLD patients had a similar mortality and complication rates as TBFB., Competing Interests: Declaration of competing interest Dr. H. Yasunaga reports receiving grants from the Ministry of Health, Labor, and Welfare, Japan and the Ministry of Education, Culture, Sports, Science, and Technology, Japan during the conduct of the study. The other authors have no conflicts of interest., (Copyright © 2024 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

This report highlights the early and unusual detection of a pneumopericardium by echocardiography prior to potential development of cardiocirculatory compromise. It is important to consider pneumopericardium into the differential diagnosis when difficulties arise in the visualization of the heart by conventional echocardiography. Pneumopericardium is associated with a high mortality rate and may be effectively treated by immediate insertion of a pericardial catheter., (© 2023. The Author(s).)

Background and Objectives : Postoperative pulmonary complications (PPCs) are common in patients who undergo cardiac surgery and are widely acknowledged as significant contributors to increased morbidity, mortality rates, prolonged hospital stays, and healthcare costs. Clinical manifestations of PPCs can vary from mild to severe symptoms, with different radiological findings and varying incidence. Detecting early signs and identifying influencing factors of PPCs is essential to prevent patients from further complications. Our study aimed to determine the frequency, types, and risk factors significant for each PPC on the first postoperative day. The main goal of this study was to identify the incidence of pleural effusion (right-sided, left-sided, or bilateral), atelectasis, pulmonary edema, and pneumothorax as well as detect specific factors related to its development. Materials and Methods : This study was a retrospective single-center trial. It involved 314 adult patients scheduled for elective open-heart surgery under CPB. Results : Of the 314 patients reviewed, 42% developed PPCs within 12 h post-surgery. Up to 60.6% experienced one PPC, while 35.6% developed two PPCs. Pleural effusion was the most frequently observed complication in 89 patients. Left-sided effusion was the most common, presenting in 45 cases. Regression analysis showed a significant association between left-sided pleural effusion development and moderate hypoalbuminemia. Valve surgery was associated with reduced risk for left-sided effusion. Independent parameters for bilateral effusion include increased urine output and longer ICU stays. Higher BMI was inversely related to the risk of pulmonary edema. Conclusions : At least one PPC developed in almost half of the patients. Left-sided pleural effusion was the most common PPC, with hypoalbuminemia as a risk factor for effusion development. Atelectasis was the second most common. Bilateral effusion was the third most common PPC, significantly related to increased urine output. BMI was an independent risk factor for pulmonary edema development.

Iatrogenic pneumothorax is a relevant complication of computed tomography (CT)-guided percutaneous lung biopsy. The aim of the present study was to analyze the prognostic significance of texture analysis, emphysema score and muscle mass derived from CT-imaging to predict postinterventional pneumothorax after CT-guided lung biopsy. Consecutive patients undergoing CT-guided percutaneous lung biopsy between 2012 and 2021 were analyzed. Multivariate logistic regression analysis included clinical risk factors and CT-imaging features to detect associations with pneumothorax development. Overall, 479 patients (178 females, mean age 65 ± 11.7 years) underwent CT-guided percutaneous lung biopsy of which 180 patients (37.5%) developed pneumothorax including 55 patients (11.5%) requiring chest tube placement. Risk factors associated with pneumothorax were chronic-obstructive pulmonary disease (COPD) (p = 0.03), age (p = 0.02), total lung capacity (p < 0.01) and residual volume (p = 0.01) as well as interventional parameters needle length inside the lung (p < 0.001), target lesion attached to pleura (p = 0.04), and intervention duration (p < 0.001). The combined model demonstrated a prediction accuracy of the occurrence of pneumothorax with an AUC of 0.78 [95%CI: 0.70-0.86] with a resulting sensitivity 0.80 and a specificity of 0.66. In conclusion, radiomics features of the target lesion and the lung lobe CT-emphysema score are predictive for the occurrence of pneumothorax and need for chest insertion after CT-guided lung biopsy., (© 2024. The Author(s).)

We describe an elderly patient presenting with pneumothorax, cystic lung disease and a scalp lesion. The pneumothorax resolved after placing a chest tube and suction but recurred within a week. Progression of cystic features was also seen, and biopsies of the lung and scalp lesions were performed. Immunohistochemistry was positive for markers of endothelial cells (CD31 and ERG) and negative for markers expected to be positive in alveolar cells (keratin AE1/AE3 and TTF-1), supporting the diagnosis of metastatic angiosarcoma. Palliative chemotherapy did not prevent progression and the patient expired soon after. In describing the clinico-radiological correlation of metastatic angiosarcoma, we also briefly describe the approach to cystic lung disease. Understanding the pathophysiology of cyst formation in metastatic angiosarcoma may help clinicians to better appreciate and manage the full spectrum of cystic lung disease, especially with atypical features., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Transbronchial lung cryobiopsy (TBLC) is an alternative to surgical lung biopsy for histopathological evaluation of unclassifiable interstitial lung disease (ILD) or ILD diagnosed with low confidence. This meta-analysis synthesised current literature regarding cryobiopsy diagnostic performance and safety, focusing on procedural and sampling techniques., Methods: Medline and Embase were searched on 11 April 2022. Studies included adults with unclassifiable ILD, reporting diagnostic yield, complications and methodological techniques of TBLC. Meta-analyses were performed for diagnostic yield, pneumothorax and bleeding. Subgroup analyses and meta-regression assessed methodological variables. PROSPERO registration: CRD42022312386., Results: 70 studies were included with 6183 participants. Diagnostic yield of TBLC was 81% (95% CI 79-83%, I 2 =97%), with better yield being observed with general anaesthesia (p=0.007), ILD multidisciplinary meeting prior to cryobiopsy (p=0.02), 2.4 mm cryoprobe (p=0.04), higher mean forced vital capacity (p=0.046) and higher mean diffusing capacity for carbon monoxide (p=0.023). Pneumothorax rate was 5% (95% CI 4-5%, I 2 =91%), with higher rates associated with a 2.4 mm cryoprobe (p<0.00001), routine post-procedure imaging (p<0.00001), multiple lobe sampling (p<0.0001), reduced mean diffusing capacity for carbon monoxide (p=0.028) and general anaesthesia (p=0.05). Moderate-to-severe bleeding rate was 12% (11-14%, I 2 =95%) and higher rates were associated with a 2.4 mm cryoprobe (p=0.001) and bleeding score selection (p=0.04)., Interpretation: Patient characteristics and modifiable factors, including procedural methods and anaesthetic techniques, impacted diagnostic yield and safety outcomes of TBLC in people with unclassifiable ILD and contributed to heterogeneity of clinical outcomes. These variables should be considered for individualised clinical decision making and guideline development and warrant routine reporting in future research., Competing Interests: Conflict of interest: J.A. Lachowicz reports grants from University of Melbourne, and payment or honoraria for lectures, presentations, manuscript writing or educational events from AstraZeneca. N.E. Smallwood reports grants from NHMRC, MRFF, Cancer Council Australia, Fisher & Paykel Healthcare (FPH), Windermere Foundation, Lung Foundation Australia and Lord Mayor's Foundation Melbourne, consultancy fees from The Limbic and Orchard Consulting, payment or honoraria for lectures, presentations, manuscript writing or educational events from GlaxoSmithKline, Boehringer Ingelheim, AstraZeneca, FPH and Health Ed, support for attending meetings from Chiesi and Boehringer Ingelheim, leadership roles with the Thoracic Society of Australia and New Zealand (Board Director and past state president), Victorian Doctors’ Program (Board Director), European Respiratory Society (Co-chair guidelines committee), and receipt of equipment, materials, drugs, medical writing, gifts or other services from FPH. J.D. Prasad, P. Patel and C. Voutier have nothing to disclose. Y.H. Khor reports grants from NHMRC, MRFF, Air Liquide Healthcare, Austin Medical Research Foundation, Lung Foundation Australia/Thoracic Society of Australia and New Zealand and RACP, and leadership roles with the Thoracic Society of Australia and New Zealand (Board director, Special Interest Group Convenor), American Thoracic Society (Clinical Problems Assembly Program Committee; guideline methodologist) and European Respiratory Society (Associate editor for European Respiratory Journal). D.P. Steinfort reports grants from the Australian National Health and Medical Research Council (Leadership Investigator Grant (#2008317))., (Copyright ©The authors 2024.)

Background: Spontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assisted thoracoscopic surgery., Case Presentation: A 19-year-old Japanese male was diagnosed with left pneumothorax and underwent chest tube drainage. A total of 10 hours after admission, the patient developed dyspnea, chest pain, and sudden massive bloody effusion. Contrast-enhanced computed tomography revealed contrast extravasation near the left lung apex, and spontaneous hemopneumothorax was diagnosed. Angiography revealed bleeding from a branch of the subscapular artery and transcatheter arterial embolization was performed. The patient underwent video-assisted thoracoscopic surgery and recovered uneventfully., Conclusions: Anesthesiologists involved in urgent surgeries must be aware that a patient with spontaneous pneumothorax can develop a hemopneumothorax, even when full lung expansion has been obtained following chest tube drainage, owing to latent aberrant artery disruption. Interprofessional team engagement is essential for spontaneous hemopneumothorax management., (© 2024. The Author(s).)

Background: We aimed to investigate the clinical characteristics and outcomes of patients with isolated left-sided congenital diaphragmatic hernia (CDH) who developed preoperative pneumothorax and determine its risk factors., Methods: We performed an international cohort study of patients with CDH enrolled in the Congenital Diaphragmatic Hernia Study Group registry between January 2015 and December 2020. The main outcomes assessed included survival to hospital discharge and preoperative pneumothorax development. The cumulative incidence of pneumothorax was estimated by the Gray test. The Fine and Gray competing risk regression model was used to identify the risk factors for pneumothorax., Results: Data for 2858 neonates with isolated left-sided CDH were extracted; 224 (7.8%) developed preoperative pneumothorax. Among patients with a large diaphragmatic defect, those with pneumothorax had a significantly lower rate of survival to discharge than did those without. The competing risks model demonstrated that a patent ductus arteriosus with a right-to-left shunt flow after birth (hazard ratio [HR]: 1.78; 95% confidence interval [CI]: 1.21-2.63; p = 0.003) and large defects (HR: 1.65; 95% CI: 1.13-2.42; p = 0.01) were associated with an increased risk of preoperative pneumothorax. Significant differences were observed in the cumulative incidence of pneumothorax depending on defect size and shunt direction (p < 0.001)., Conclusions: Pneumothorax is a significant preoperative complication associated with increased mortality in neonates with CDH, particularly in cases with large defects. Large diaphragmatic defects and persistent pulmonary hypertension were found to be risk factors for preoperative pneumothorax development., Level of Evidence: LEVEL Ⅲ Retrospective Comparative Study., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Ventilation-perfusion SPECT with or without CT using technetium 99m ( 99m Tc)-diethylenetriaminepentaacetic acid (DTPA) has been used to identify patterns typical of cardiopulmonary diseases, such as pulmonary embolism, pneumonia, heart failure, and obstructive lung disease. This case demonstrates the utility of a ventilation scan with SPECT/CT using 99m Tc-DTPA for investigating the cause of a persistent complex pneumothorax in a patient with severe chronic obstructive pulmonary disease who recently underwent endobronchial valve placement. Keywords: CT-Spectral Imaging (Multienergy), SPECT/CT, Thorax, Lung Supplemental material is available for this article. © RSNA, 2024.

Tension pneumothorax (TPT) identified in the prehospital setting requires prehospital needle decompression (PHND). This study aimed to evaluate complications from PHND when it was performed without meeting clinical criteria. A retrospective review was performed of patients undergoing (PHND) from 2016 through 2022 at a level 1 trauma center. Patient data who received PHND were reviewed. Of 115 patients, 85 did not meet at least one clinical criterion for PHND. The majority of patients in this cohort 76 (89%) required a chest tube and 22 (25%) had an iatrogenic pneumothorax from PHND. 5 patients (6%) were admitted due to iatrogenic PHND. Two vascular injuries in this population were directly due to PHND and required emergency operative repair. This study shows the negative consequences of PHND when performed without clear indications. Several patients underwent unnecessary procedures with significant clinical consequences., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Oral anticoagulation is becoming more common with the aging population, which raises concern for the risk of invasive procedures that can cause bleeding, such as chest tube placement (thoracostomy). With the increase in CT imaging, more pneumothoraces and hemothoraces are being identified. The relative risk of thoracostomy in the presence of anticoagulation is not well-established. The objective of this study was to determine whether pre-injury anticoagulation affects the relative risk of tube thoracostomy following significant chest trauma., Methods: This retrospective cohort study used data from the 2019 American College of Surgeons-Trauma Quality Program (ACS-TQP) database using R version 4.2.2. Data from the database was filtered based on inclusion and exclusion criteria. Outcomes were then assessed with the population of interest. Demographics, vitals, comorbidities, and injury parameters were also collected for each patient. This study included all adult patients (≥18 years) presenting with traumatic hemothorax, pneumothorax, or hemopneumothorax. Patients with missing data in demographics, vitals, comorbidities, injury parameters, or outcomes, as well as those with no signs of life upon arrival, were excluded from the study. Patients were stratified into groups based on whether they had pre-injury anticoagulation and whether they had a chest tube placed in the hospital. The primary outcome was mortality, and the secondary outcome was hospital length of stay (LOS). Logistic and standard regressions were used by a statistician to control for age, sex, and Injury Severity Score (ISS)., Results: Our study population included 72,385 patients (4250 with pre-injury anticoagulation and 68,135 without pre-injury anticoagulation). Pre-injury anticoagulation and thoracostomy were each independently associated with increased mortality and LOS. However, there was a non-significant interaction term between pre-injury anticoagulation and thoracostomy for both outcomes, indicating that their combined effects on mortality and LOS did not differ significantly from the sum of their individual effects., Conclusion: This study suggests that both pre-injury anticoagulation and thoracostomy are risk factors for mortality and increased LOS in adult patients presenting with hemothorax, pneumothorax, or hemopneumothorax, but they do not interact with each other. We recommend further study of this phenomenon to potentially improve clinical guidelines., Level of Evidence: Therapeutic, Level III., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Idiopathic pulmonary fibrosis is the most prevalent form of interstitial lung disease, which presents as usual interstitial pneumonia on histopathology and imaging. It leads to significant lung scarring, damage, and fibrosis and is associated with a high degree of mortality, repeated hospital admissions, and oxygen dependence. Many complications are associated with idiopathic pulmonary fibrosis, which further increases the morbidity of patients. High-resolution computed tomography chest is the imaging modality of choice for usual interstitial pneumonia tracking its progression, evaluating treatment response, and detecting potential complications., Methods: This descriptive cross-sectional study was approved by the Institutional Ethics Committee (Reference number: IEC-INT/2023/Study-1256). Departmental computed tomography report database from November, 2017 to June, 2018 was reviewed and scans with imaging features consistent with the 'usual interstitial pneumonia' pattern were identified. Total sampling method was used and two independent radiologists, blinded to the patient's clinical information, reviewed the high-resolution computed tomography chest scans to assess for imaging features of usual interstitial pneumonia and associated complications. Data was collected and analyzed using Microsoft Excel., Results: There were 65 patients reported as unusual interstitial pneumonia pattern. Emphysema and pneumothorax were identified in 4 (6.15%) and 1 (1.53%) scans, respectively. Two (3.08%) scans showed features of pulmonary arterial hypertension. Ten (15.38%) scans exhibited findings consistent with co-existent or superimposed pulmonary infection. Additionally, features of lung malignancy were identified in high-resolution computed tomography scans of 5 (7.69%) patients., Conclusions: Patients with UIP often experience severe lung scarring, and frequent complications, and require regular chest CT scans to monitor disease progression and identify potential complications.

Background: While spontaneous pneumothorax has been documented in COVID-19 patients, reports on recurrent spontaneous pneumothorax due to cystic lesions in convalescent COVID-19 patients are scarce. The progression of these lung cystic lesions remains inadequately explored., Case Presentation and Literature Review: An 81-year-old male, a non-smoker with a history of rheumatoid arthritis, presented with fever, cough, and expectoration for 14 days. Initially diagnosed with moderate COVID-19, he deteriorated to severe COVID-19 despite adherence to local treatment guidelines. Successive identification of three cystic lesions termed "bulla" or "pneumatocele", and one cystic lesion with air-fluid level, referred to as "pneumo-hamatocele" (PHC), occurred in his lungs. Gradual improvement followed anti-inflammatory therapy and optimal supportive care. However, on day 42, sudden worsening dyspnea prompted a computed tomography (CT) scan, confirming a right spontaneous pneumothorax and subcutaneous emphysema, likely due to PHC rupture. Discharge followed chest tube implementation for pneumothorax resolution. On day 116, he returned to the hospital with mild exertional dyspnea. Chest CT revealed recurrent right pneumothorax from a remaining cyst in the right lung. Apart from our patient, literature retrieval identified 22 COVID-19 patients with spontaneous pneumothorax due to cystic lesions, with a male predominance (95.6%; 22/23). Diagnosis of pneumothorax and lung cystic lesions occurred around day 29.5 (range: 18-35) and day 26.4 (± 9.8) since symptom onset, respectively. Except for one patient whose pneumothorax occurred on day seven of illness, all patients eventually recovered., Conclusions: Recurrent spontaneous pneumothorax secondary to lung cystic lesions may manifest in convalescent COVID-19 patients, particularly males with COVID-19 pneumonia. Chest CT around 2 to 3 weeks post-symptom onset may be prudent to detect cystic lesion development and anticipate spontaneous pneumothorax., (© 2024. The Author(s).)

Background: The incidence of pneumothorax is higher in patients with emphysema who undergo percutaneous lung biopsy. Needle embolization has been shown to reduce the incidence of pneumothorax in patients with emphysema. Existing studies have reported small sample sizes of patients with emphysema, or the degree of emphysema has not been graded. Therefore, the efficacy of biopsy embolization in the prevention of pneumothorax induced by percutaneous pulmonary biopsy in patients with emphysema remains to be determined., Methods: In this retrospective, controlled study, patients with emphysema who underwent CT-guided PTLB were divided into two groups: group A (n = 523), without tract embolization, and Group B (n = 504), with tract embolization. Clinical and imaging features were collected from electronic medical records and Picture Archiving and Communication Systems. Univariate and multivariate analyses were performed to identify risk factors for pneumothorax and chest tube placement., Results: The two groups did not differ significantly in terms of demographic characteristics and complications other than pneumothorax. The incidence of pneumothorax and chest tube placement in group B was significantly lower than in group A (20.36% vs. 46.12%, p < 0.001; 3.95% vs. 9.18%, p < 0.001, respectively). In logistic regression analyses, variables affecting the incidence of pneumothorax and chest tube placement were the length of puncture of the lung parenchyma (odds ratio [OR] = 1.18, 95% confidence interval [CI]: 1.07-1.30, p = 0.001; OR = 1.55, 95% CI: 1.30-1.85, p < 0.001, respectively), tract embolization (OR = 0.31, 95% CI: 0.24-0.41, p < 0.001; OR = 0.39, 95% CI: 0.22-0.69, p = 0.001, respectively), and grade of emphysema., Conclusions: Tract embolization with gelatin sponge particles after CT-guided PTLB significantly reduced the incidence of pneumothorax and chest tube placement in patients with emphysema. Tract embolization, length of puncture of the lung parenchyma, and grade of emphysema were independent risk factors for pneumothorax and chest tube placement., Trial Registration: Retrospectively registered., (© 2024. The Author(s).)

We aimed to determine the clinical characteristics of patient self-inflicted lung injury (P-SILI)-associated pneumothorax/pneumomediastinum, to reveal its risk factors, and to assess its impact on severe COVID-19 cases. In total, 229 patients were included in this case-control study. They were randomly divided into either the case group or the control group as per the inclusion and exclusion criteria. The two groups were further analyzed to reveal the risk factors of spontaneous pneumothorax/pneumomediastinum (SP/P). Finally, risk factors for death were analyzed in the case group and the relationship between death and SP/P was also analyzed among all patients. The mean age of patients was 59.69 ± 17.01 years, most of them were male (74.2%), and 62.0% of them had comorbidities upon admission. A respiratory rate higher than 30 BPM was a risk factor for SP/P (OR 7.186, 95% CI 2.414-21.391, P < 0.001). Patients with delayed intubation due to early application of HFNC or NIV had a higher mortality rate when they developed SP/P (P < 0.05). Additionally, advanced age increased the risk of death (P < 0.05). Finally, SP/P may be a risk factor for death among patients with severe COVID-19 (OR 2.047). P-SILI occurs in severe COVID-19 with acute respiratory failure. It is necessary to identify the risk factors of P-SILI, the indicators of severe P-SILI, and the preventive measures., (© 2024. The Author(s).)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Computer tomography (CT)-guided lung biopsy carries the risk of pneumothorax. A variety of other risk factors affect the occurrence of pneumothorax., Objective: Assess the incidence and risk factors associated with pneumothorax complications in CT-guided lung biopsy, and to conduct a quantitative analysis of the variables among the significant risk factors to identify more effective indicators for predicting pneumothorax complications., Design: Retrospective logistic., Setting: Single center in China., Patients and Methods: From June 2017 to May 2021, consecutive patients who underwent CT-guided lung biopsy were identified from the medical record system. Binary logistic regression analysis was used to identify potential risk factors for pneumothorax. Receiver operating characteristic (ROC) curves were constructed for continuous variables to determine cutoff values that optimized sensitivity and specificity., Main Outcome Measures: The incidence and risk factors of pneumothorax in CT-guided lung biopsy., Sample Size: 132 patients., Results: The incidence of pneumothorax was 28.9% (38/132), with 6.8% (9/132) of patients requiring chest tube insertion. Results indicated that smaller lesion size (OR 0.724; 95% CI 0.619-0.848; P =.0001), longer needle tract length (OR 1.320; 95% CI 1.145-1.521; P =.001), multiple passes through the pleura (OR 4.618; 95% CI 1.378-15.467; P =.013), and needle tract length/lesion diameter (L/D) ratio (OR 0.028; 95% CI 0.002-0.732; P =.007) were independent risk factors for pneumothorax. ROC curve analysis determined a cut-off value of 0.81 for the L/D ratio (sensitivity=89.5%, specificity=71.3%). The area under the ROC curve (AUC) values of maximum diameter, needle tract length, and L/D ratio for pneumothorax were 0.749, 0.812, and 0.850, respectively., Conclusions: The L/D ratio, multiple passes through the pleura, longer needle tract length, and smaller lesions were independent risk factors for pneumothorax. A L/D ratio of less than 0.81 may indicate a pneumothorax. It may be necessary to use the proper sealing procedure for this patient group., Limitations: Due to its retrospective nature, there may be inherent selection bias.

Purpose: The aim is to devise a machine learning algorithm exploiting preoperative clinical data to forecast the hazard of pneumothorax post-coaxial needle lung biopsy (CCNB), thereby informing clinical decision-making and enhancing perioperative care., Method: This retrospective analysis aggregated clinical and imaging data from patients with lung nodules (≤3 cm) biopsies. Variable selection was done using univariate analysis and LASSO regression, with the dataset subsequently divided into training (80 %) and validation (20 %) subsets. Various machine learning (ML) classifiers were employed in a consolidated approach to ascertain the paramount model, which was followed by individualized risk profiling showcased through Shapley Additive eXplanations (SHAP)., Results: Out of the 325 patients included in the study, 19.6% (64/325) experienced postoperative pneumothorax. High-risk factors determined were Cancer, Lesion&#95;type, GOLD, Size, and Depth. The Gaussian Naive Bayes (GNB) classifier demonstrated superior prediction with an Area Under the Curve (AUC) of 0.82 (95% CI 0.71-0.94), complemented by an accuracy rate of 0.8, sensitivity of 0.71, specificity of 0.84, and an F1 score of 0.61 in the test cohort., Conclusion: The formulated prognostic algorithm exhibited commendable efficacy in preoperatively prognosticating CCNB-induced pneumothorax, harboring the potential to refine personalized risk appraisals, steer clinical judgment, and ameliorate perioperative patient stewardship., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Secondary spontaneous pneumothorax (SSP) is often linked to chronic obstructive pulmonary disease (COPD). The frequency of SSP occurrence in COPD patients varies among different research findings. SSPs are more commonly found in the elderly population diagnosed with COPD. Previous studies have reported a pneumothorax rate of 26 per 100,000 COPD patients. There is, however, a notable lack of detailed epidemiological information regarding SSP in Asia. Our study focused on determining the occurrence rate of SSP among COPD patients in Taiwan using an extensive national database. Additionally, this study aimed to identify comorbidities associated with SSP in this patient group., Methods: In this study, we used the Longitudinal Health Insurance Database, which contains records of 2 million people who were randomly chosen from among the beneficiaries of the Taiwan National Health Insurance program. The dataset includes information from 2005 to the end of 2017. Our focus was on individuals diagnosed with COPD, identified through ICD-9-CM codes in at least one hospital admission or two outpatient services, with the COPD diagnosis date as the index date. The exclusion criteria included individuals younger than 40 years, those with incomplete records, or those with a previous diagnosis of pneumothorax before the index date. We conducted a matched comparison by pairing COPD patients with control subjects of similar age, sex, and comorbidities using propensity score matching. The follow-up for all participants started from their index date and continued until they developed pneumothorax, reached the study's end, withdrew from the insurance program, or passed away. The primary objective was to evaluate and compare the incidence of pneumothorax between COPD patients and matched controls., Results: We enrolled 65,063 patients who were diagnosed with COPD. Their mean age (±SD) was 66.28 (±12.99) years, and approximately 60 % were male. During the follow-up period, pneumothorax occurred in 607 patients, equivalent to 9.3 % of the cohort. The incidence rate of SSP in COPD patients was 12.10 per 10,000 person-years, whereas it was 6.68 per 10,000 person-years in those without COPD. Furthermore, COPD patients with comorbidities such as atrial fibrillation, congestive heart failure, coronary artery disease, diabetes mellitus, hypertension, and cancer exhibited an increased incidence of SSP compared to COPD patients without such comorbidities. This was observed after conducting a multivariable Cox regression analysis adjusted for age, sex, and other comorbidities., Conclusion: Our study revealed an elevated risk of SSP in patients with COPD. It has also been suggested that COPD patients with comorbidities, such as atrial fibrillation, congestive heart failure, coronary artery disease, diabetes mellitus, hypertension, and cancer, have an increased risk of developing SSP., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Kuang-Ming Liao reports article publishing charges was provided by Chi Mei Medical Center, Chiali. Kuang-Ming Liao reports a relationship with Chi Mei Medical Center, Chiali that includes: employment. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)