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We describe a case of prolonged SARS-CoV-2 RNA shedding in an HIV-negative 21-year-old man recovering from abdominal and thoracic trauma. Nasopharyngeal (NP) swabs collected at 12 time points over a 95-day span all tested positive for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR). Genotyping revealed canonical beta-variant E484K and N501Y mutations at earlier time points. Human rhinovirus, coronavirus NL63 and respiratory syncytial virus B were detected at different time points by RT-PCR. Full blood analysis at time point 9 (day 82) showed leukopenia with lymphocytosis. The patient's NP swab tested negative for SARS-CoV-2 by RT-PCR 101 days after the first positive test. The prolonged duration of SARS-CoV-2 RNA shedding in the context of trauma presented here is unique and has important implications for COVID-19 diagnosis, management and policy guidelines.

Abstract: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians., Level of Evidence: Consensus algorithm from the Western Trauma Association, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician., Methods: We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan., Results: With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69)., Conclusion: In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax., Competing Interests: Declaration of competing interest Xavier Bobbia declares a competing interest as an US teacher for GE (GE Medical Systems Ultrasound) customers. The other authors state that they have no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax., Purpose: To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax., Methods: This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States., Results: A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO 2 :FiO 2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH 2 O vs 39ml/cmH 2 O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04)., Conclusion: The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Abstract: Patients with extensive deep burns usually experience infections and organ dysfunction. Proactive and effective wound repair is key to treatment. If large wounds remain open, systemic infection and multiple organ dysfunction syndrome can occur, threatening the lives of patients. Current wound repair methods include skin grafts, flap repair, negative-pressure wound therapy, and cellular and/or tissue-based products. For deep, complex burn wounds, a single form of treatment is usually ineffective. This article reports a rare case of burn wound repair. The patient was burned by a charcoal flame on multiple parts of his body after carbon monoxide poisoning. Pneumothorax and acute renal failure occurred after the injury, accompanied by multiple osteonecroses of the trunk and lower limbs. A multidisciplinary team formulated an individualized treatment plan; the diverse treatments included closed chest drainage, continuous renal replacement therapy, infection control, analgesia, wound debridement, negative-pressure wound therapy, cellular and/or tissue-based products, autologous dermal scaffold graft, skin grafts, flap transposition, platelet-rich plasma, and rehabilitation, which ultimately saved the patient's life and led to healing of all the wounds., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Here, we report a case of malignant pleural mesothelioma (MPM) that was very difficult to diagnose. A 62-year-old woman with a surgical history of recurrent bilateral pneumothorax was admitted to our hospital with severe dysphagia. Computed tomography (CT) detected stenosis in the lower esophagus. Immunohistochemical examination of a biopsy sample from the stenotic region was suggestive of MPM. Chemotherapy was initiated, but the patient soon weakened and died. Autopsy revealed atypical cells, identical to those seen in the biopsy sample which had spread into the stenotic esophagus and entire thoracic cavity. Although neither pleural thickening/nodules nor asbestos bodies were observed, we finally diagnosed the tumor as a biphasic-type MPM. We re-examined previous surgical specimens of pneumothorax and acknowledged foci of bland mesothelial cell proliferation which had the same pathological findings as tumor cells at autopsy. The lack of asbestos exposure and pleural thickening, an initial manifestation of pneumothorax, and faint cytological atypia prevented an early diagnosis. In cases of recurrent pneumothorax in elderly patients, MPM should be included in the differential diagnosis., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Introduction: Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period., Methods: Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM., Results: These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it., Discussion: When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens., (Copyright © 2020 by The American College of Gastroenterology.)

A previously healthy 37-year-old man presented with fevers and myalgias for a week with a minimal dry cough. Initial SARS-CoV-2 nasopharyngeal testing was negative, but in light of high community prevalence, he was diagnosed with COVID-19, treated with supportive care and self-quarantined at home. Three days after resolution of all symptoms, he developed sudden onset chest pain. Chest imaging revealed a large right-sided pneumothorax and patchy subpleural ground glass opacities. IgM and IgG antibodies for SARS-CoV-2 were positive. His pneumothorax resolved after placement of a small-bore chest tube, which was removed after 2 days.This case demonstrates that patients with COVID-19 can develop a significant pulmonary complication, a large pneumothorax, despite only minimal lower respiratory tract symptoms and after resolution of the original illness. Medical professionals should consider development of a pneumothorax in patients who have recovered from COVID-19 and present with new respiratory symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Spontaneous pneumothorax is a common problem globally. Bullas and blebs have been implicated in this problem, but the etiology of their formation is unknown. We aim to show the relation between a novel clinical finding, the pulmonary delayed inflation (PDI) sign, and the etiology of bulla and bleb formation in young patients., Methods: We retrospectively analyzed data from 111 patients with pneumothorax and a control group of 27 patients. We evaluated the relation between the PDI sign and other clinical factors., Results: The PDI sign was observed in 78 patients. Of these, 75 exhibited the PDI sign in only the upper lobe. Regardless of smoking status, patients 34 years of age or younger had a significantly higher incidence of the PDI sign than, patients 55 years of age or older and control patients. The inflation time in patients 34 years of age or younger, regardless of smoking status, was significantly longer than in patients 55 years of age or older and patients in the control group. There was no significant association between inflation time and the presence of asthma., Conclusions: The novel PDI sign is seen in patients 34 years of age or younger. Because this sign may indicate a peripheral bronchial abnormality and may be related to the formation of blebs and bullae in young patients with spontaneous pneumothorax, it is possible that it can be used to develop effective treatments for pneumothorax in young patients.

Introduction: Spontaneous pneumothorax occurs rarely during pregnancy with less than 100 cases reported in the English literature. There is no strong evidence concerning the treatment of spontaneous pneumothorax during pregnancy and labor. The aim of this study is to systematically review all the reported cases and to suggest recommendations for its diagnosis and treatment., Methods: A PubMed research was conducted. The following data were collected: maternal age, gestation age (weeks), presence of underlying lung pathology, initial management, definitive management, obstetric outcome, and the complications for the mother and the fetus., Results: Eighty-seven cases were identified. The mean maternal age was 27 years (standard deviation [SD] ± 6). The mean gestational age was 25 weeks (SD ± 11.4). In 37.9% of cases, there was no underlying lung disease. In the majority of cases (67.4%), the initial treatment was the placement of a chest tube. In 48% of cases, the pneumothorax was resolved with conservative treatment. Surgical therapy was performed either antepartum or postpartum. In 58.6% of cases, there was a vaginal delivery, spontaneous or instrumental. In three cases (3.4%), there were fetal complications., Conclusion: The analysis of the current literature provides low evidence, since there are only case reports and small case series. It is likely that the frequency of this condition is underestimated. However, this analysis permits to draw some conclusions concerning the timing of pneumothorax treatment, the operative strategy, and the mode of delivery to decrease the risk for the mother and the fetus., Competing Interests: None., (Thieme. All rights reserved.)

Abstract: Pneumothorax is a life-threatening complication during acute asthma attack. However, long-term risk of pneumothorax in asthmatic children remains unknown.In this retrospective cohort study, 333,657 children were defined as asthma cohort and a 1:1 matched non-asthma cohort were generated from 2000 to 2011. At the end of 2012, the incidence of pneumothorax in asthma and non-asthma cohorts and asthma to non-asthma hazard ratios (HRs) with confidence intervals (CIs) of pneumothorax were analyzed.The incidence of pneumothorax was 1.35-fold higher in the asthma cohort than that in the non-asthma cohort. The asthma to non-asthma HRs of pneumothorax were higher in children younger than 6 years (1.76, 95% CI: 1.21-2.57) and in girls (2.27; 95% CI: 1.23-4.16). The HRs of pneumothorax were higher in asthmatic children with more asthma-related out-patient clinic visits/per year (>5 visits; HR: 2.81; 95% CI: 1.79-4.42), more emergency department visits/per year (>4 visits; HR: 1.68; 95% CI: 1.02-2.78), and longer hospitalization days due to asthma (>4 days; HR: 3.42; 95% CI: 1.52-6.94) (P < .0001, the trend test).Asthmatic children had greater risk for pneumothorax, particularly in young children and in those with severe and uncontrolled asthma., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Pulmonary diseases and injury lead to structural and functional changes in the lung parenchyma and airways, often resulting in measurable sound transmission changes on the chest wall surface. Additionally, noninvasive imaging of externally driven mechanical wave motion in the chest (e.g., using magnetic resonance elastography) can provide information about lung stiffness and other structural property changes which may be of diagnostic value. In the present study, a comprehensive computational simulation (in silico) model was developed to simulate sound wave propagation in the airways, parenchyma, and chest wall under normal and pathological conditions that create distributed structural (e.g., pneumothoraces) and diffuse material (e.g., fibrosis) changes, as well as a localized structural and material changes as may be seen with a neoplasm. Experiments were carried out in normal subjects to validate the baseline model. Sound waves with frequency content from 50 to 600 Hz were introduced into the airways of three healthy human subjects through the mouth, and transthoracic transmitted waves were measured by scanning laser Doppler vibrometry at the chest wall surface. The computational model predictions of a frequency-dependent decreased sound transmission due to pneumothorax were consistent with experimental measurements reported in previous work. Predictions for the case of fibrosis show that while shear wave motion is altered, changes to compression wave propagation are negligible, and thus, insonification, which primarily drives compression waves, is not ideal to detect the presence of fibrosis. Results from the numerical simulation of a tumor show an increase in the wavelength of propagating waves in the immediate vicinity of the tumor region. Graphical abstract.

Pneumocytis jirovecii pneumonia (PJP) and Pulmonary TB (PTB) both are common opportunistic infections among HIV infected individuals. But concurrent infections pose a diagnostic challenge owing to similar clinical features. Data suggests a high prevalence of such concurrent infections in developing countries but limited diagnostic modalities especially in resource constraint setup limits accurate diagnosis. At our centre we came across 6 newly diagnosed PTB patients among HIV infected ones had persistent shortness of breath (SOB) and hypoxia despite starting anti-tuberculous treatment (ATT). We excluded concomitant bacterial pneumonia by imaging, sputum examination and blood culture. Serum lactate dehydrogenase (LDH) was estimated and hypoxia by arterial blood gas (ABG). We found all 6 patients had elevated serum LDH, hypoxia and imaging suggestive of PJP were offered sputum for Geisma stain and standard treatment for PJP in form of Bactrim-double strength and steroid. 1 patient had PJ cysts in sputum. 5 patient's classical radiologic findings in form of ground glass opacities in lower lobes along with bilateral infiltrates and 1 had honeycombing. Serum LDH was elevated all 6 subjects. 5 were newly diagnosed HIV and 4 had CD4 count below 50 cells/mm 3 and 2 had below 200 cells/mm 3 .1 patient had developed bilateral pneumothorax as complication. 4 patients responded to treatment and 2 (33.3%) died of respiratory failure during treatment. We were able to diagnose only severe PJP cases as concurrent infection with PTB as there was no availability of broncho alveolar lavage (BAL) as well as direct fluorescent antigen (DFA) test for PJ detection. A high index of suspicion for PJP even in PTB patients with low CD4 count will guide to appropriate therapy for both infections and eventually reduces morbidity and mortality., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Pulmonary lymphangioleiomyomatosis (LAM) is a rare lung disease characterized by diffuse cystic changes caused by a destructive proliferation of smooth muscle-like cells or LAM cells. It is a part of the perivascular epithelioid cell family of tumors. LAM may be associated with the genetic disorder tuberous sclerosis complex or may occur sporadically. Individuals affected by LAM are typically females of child-bearing age who present with recurrent spontaneous pneumothorax. The microscopic findings can be subtle and careful examination is needed to identify the neoplastic cells of LAM. Immunohistochemical markers in cases of LAM demonstrate a characteristic co-expression of myogenic and melanocytic markers. We report a case of a 41-year-old woman who presented with multiple episodes of spontaneous pneumothorax and microscopic findings characteristic of LAM., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Aim: Primary spontaneous pneumothorax (PSP) is a rare pulmonary pathology that occurs in the absence of known lung disease. A retrospective study was performed to evaluate the results and outcome of PSP treatment in adolescents., Methods: The cases with PSP from January 2004 to December 2017 were evaluated for age, sex, family and smoking history, clinical and radiological findings and results of treatment., Results: Ten cases with PSP were included. The mean age of the patients was 15 years (10-17 years) and the male to female ratio was 9:1. Two of the patients (20%) had family history of PSP and four cases (40%) had smoking history. The initial complaints were chest pain (n=8), acute onset of cough (n=1) and breathing difficulty (n=1). Tube thoracostomy was performed in nine cases in which three of them were bilateral. Chest computed tomography (CT) demonstrated bullae (n=4; 40%) and subpleural blebs (n=2; 20%). Pleurodesis with talc was performed in four patients with pneumothorax for longer than a week in follow-up (n=4; 40%). Five cases had recurrent PSP within one year (n=5; 50%) and underwent pleurodesis with talc (n=4), autologous-blood (n=1) and bleomycin (n=1). Bleb excision was performed in two cases with persistent pneumothorax despite pleurodesis., Conclusion: Tube thoracostomy and oxygen supplementation, are considered as initial and adequate treatment of PSP in most of the adolescents. Prolonged air leaks require pleurosdesis as the first line treatment and surgical excision of blebs should be reversed for the patients who are unresponsive to other treatment options., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

In patients with alveolar-to-pleural air leak due to recent surgery or trauma, clinicians tend to manage chest tubes with suction therapy. Nonsuction therapy is associated with shorter chest tube duration but also a higher risk of pneumothorax. We sought to develop an intrapleural electrical impedance sensor for continuous, real-time monitoring of pneumothorax development in a porcine model of air leak as a means of promoting nonsuction therapy. Using thoracoscopy, 2 chest tubes and the pleural impedance sensor were introduced into the pleural space of 3 pigs. Continuous air leak was introduced through 1 chest tube by carbon dioxide insufflation. The second chest tube was placed to suction then transitioned to no suction at increasingly higher air leaks until pneumothorax developed. Simultaneously, real-time impedance measurements were obtained from the pleural sensor. Fluoroscopy spot images were captured to verify the presence or absence of pneumothorax. Statistical Analysis Software was used throughout. With the chest tube on suction, a fully expanded lung was identified by a distinct pleural electrical impedance respiratory waveform. With transition of the chest tube to water seal, loss of contact of the sensor with the lung resulted in an immediate measurement of infinite electrical impedance. Pneumothorax resolution by restoring suction therapy was detected in real time by a return of the normal respiratory impedance waveform. Pleural electrical impedance monitoring detected pneumothorax development and resolution in real time. This simple technology has the potential to improve the safety and quality of chest tube management., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim of study: We aimed to investigate whether the difference in pleural pressures (Δ P ) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The Δ P prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of Δ P for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on Δ P . Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The Δ P in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H 2 O, p  < 0.01). The Δ P in patients who required intervention was also significantly higher (14.8 versus 4.2 cm H 2 O, p  < 0.01). A Δ P cutoff value of 8 cm H 2 O was predictive of the occurrence of residual pneumothorax (sensitivity 85.6%, specificity 84.6%) and a value of 12 cm H 2 O was predictive of intervention (sensitivity 84%, specificity 85%). Increasing Δ P was an independent predictor of the occurrence of residual pneumothorax ( p  = 0.008) on the multivariate logistic regression model. Conclusion: Patients with wide Δ P before chest drain removal may be complicated with residual pneumothorax.

Background: The notion that smoking cannabis may damage the respiratory tract has been introduced in recent years but there is still a paucity of studies on this subject. The aim of this study was to investigate the relationship between cannabis smoking, pneumothorax and bullous lung disease in a population of operated patients., Methods and Findings: We performed a retrospective study on patients operated on for spontaneous pneumothorax. Patients were divided into three groups according to their smoking habit: cannabis smokers, only-tobacco smokers and nonsmokers. Cannabis lifetime exposure was expressed in dose-years (1d/y = 1 gram of cannabis/week for one year). Clinical, radiological and perioperative variables were collected. The variables were analyzed to find associations with smoking habit. The impact of the amount of cannabis consumption was also investigated by ROC curves analysis. Of 112 patients, 39 smoked cannabis, 23 smoked only tobacco and 50 were nonsmokers. Median cannabis consumption was 28 dose/years, median tobacco consumption was 6 pack/years. Cannabis smokers presented with more severe chronic respiratory symptoms and bullous lung disease and with a higher incidence of tension pneumothorax than both tobacco smokers and nonsmokers. Cannabis smokers also developed a larger pneumothorax, experienced prolonged postoperative stay and demonstrated a higher incidence of pneumothorax recurrence after the operation than nonsmokers did. The risk of occurrence of chronic respiratory symptoms and bullous lung disease in cannabis smokers was dose-related., Conclusions: Cannabis smoking seems to increase the risk of suffering from respiratory complaints and can have detrimental effects on lung parenchyma, in a dose-dependent manner. Cannabis smoking also negatively affected the outcome of patients operated for spontaneous pneumothorax. A history of cannabis abuse should always be taken in patients with pneumothorax. There may be need for a specific treatment for pneumothorax in cannabis smokers., Competing Interests: The Authors have declared that no competing interests exist

In the past, many case series have reported the effectiveness of autologous blood patch pleurodesis (ABPP) in recurrent secondary spontaneous pneumothorax (SSP), particularly in those who were unfit for surgery. We describe two cases of persistent air leak in pneumoconiosis and pulmonary fibrosis with bronchiectasis, whereby the techniques employed had improved the success rate of ABPP. The determining factors that lead to the success of ABPP were determined by the volume of autologous blood instilled, Trendelenburg position post instillation, and early chest physiotherapy with mobilisation by application of pneumostat.

A diver practicing controlled emergency ascent training on the island of Guam suffered bilateral pneumothorax, pneumomediastinum, coronary arterial gas embolism, and developed multiple organ dysfunction syndrome. Due to limitations of available resources he was medically managed in the intensive care unit until he could be transferred to University of California San Diego for definitive management. We provide an account of our management of the patient, the pathophysiology of injury as well as a review of the safety of recreational diving skills training, current standards of practice and potential pitfalls when considering proper management of a critically injured diver., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

Background: The initial management of pneumothorax remains controversial, and we speculated that this might be because there is no method available for evaluation of air leak during initial management. We have developed a system for measurement of intrapleural pressure in pneumothorax to address air leak without the need for chest drainage. The aim of this clinical study was to confirm the ability of this measurement system and to determine the clinical impact of management of air leak., Methods: Patients in whom need aspiration was indicated for spontaneous pneumothorax were enrolled in the study. The intrapleural pressure was measured during stable breathing and data recorded when patients were coughing were excluded., Results: Eleven patients were enrolled in the study between December 2016 to July 2017. The patterns in change of intrapleural pressure varied widely depending on the state of the pneumothorax. The mean intrapleural pressure values on end-inspiration and end-expiration in patients with persistent air leak was significantly lower than those in patients without persistent air leak (p = 0.020). The number of negative mean pressure recordings in end-inspiration and end-expiration was significantly lower in patients with persistent air leak than in those without persistent air leak (p = 0.0060)., Conclusions: In this study, we demonstrated that intrapleural pressure could be successfully measured and visualized in patients with pneumothorax. Whether or not the pressure value is a predictor of persistent air leak needs to be confirmed in the future.

Hamman's sign refers to an unusual click that occurs in synchrony with heart sounds, and is pathognomonic for left-sided pneumothorax and spontaneous mediastinum. In this case, a 17-year-old man living in a rural area used his smartphone to record an audible clicking sound emanating from his thorax. This occurred following coughing episodes secondary to an upper respiratory tract infection. Initially, this prompted a request for an echocardiogram to exclude structural cardiac anomalies; however, Hamman's sign was also considered. This facilitated the timely diagnosis of pneumothorax to be made via a simple chest radiograph, one of the only imaging modalities available at the patient's rural health service. To promote awareness of this rare clinical phenomenon, this report also presents the patient's own sound recording of Hamman's sign and corresponding chest radiographs., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND Primary spontaneous pneumothorax (PSP) is reported to be more common in young men who are thin and tall. This retrospective study aimed to analyze the clinical and chest wall characteristics associated with PSP. MATERIAL AND METHODS Between January 2008 to December 2017, the clinical and imaging data of 99 patients at first presentation with PSP were compared with 82 age-matched healthy controls. Computed tomography (CT) imaging was used to measure the anteroposterior and transverse diameters of the chest at four levels, including the aortic arch, tracheal bifurcation, right inferior pulmonary vein, and lower sternal edge. Chest deformity was calculated as the ratio of the transverse diameter of the hemithorax divided by anteroposterior diameter. Lung volume and average lung density of 32 cases with PSP were measured and compared with 10 patients without PSP. Intrapleural pressure of 43 cases PSP who were treated with a closed chest drain was measured and compared with 39 patients with mediastinal tumor who underwent thoracoscopic surgery. RESULTS Patients with PSP showed a normal age distribution with a median of 17-18 years. The patients with PSP had significantly reduced anteroposterior and transverse diameters of the chest when compared with controls at four levels on CT (p<0.01). The lung volumes in patients with PSP were significantly reduced when compared with the controls (p<0.05), as were the minimum intrapleural pressure and pressure difference (p<0.05). CONCLUSIONS The findings support that chest wall dimensions may be associated with lung development, which are contributing factors in PSP.

Purpose: Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks., Methods: This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks., Results: Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days)., Conclusions: This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Background: Bedside diagnostic ultrasound for traumatic pneumothorax is easy and reliable. However, the thoracic anatomical locations to be examined are debateable. We aimed to study the anatomical locations of blunt traumatic pneumothoraces as defined by chest CT scan to identify the areas that should be scanned while performing bedside diagnostic ultrasound., Methods: This is a retrospective analysis of a data collected for a previous study in blunt trauma patients at our hospital during a 4-year-period with CT confirmed pneumothoraces. The anatomical distribution of the pneumothoraces and their volume were analyzed. Advanced statistical analysis was performed using repeated measures logistic regression models., Results: Seven hundred three patients had a CT scan of the chest. Seventy-four patients (10.5%) were confirmed to have a pneumothorax. Only 64 were included in the study as they did not have a chest tube inserted before the CT scan. Twelve (18.8%) patients had bilateral pneumothorax. Seventy-six pneumothoraces were identified for which 41 patients had a right-sided pneumothorax and 35 patients had a left-sided pneumothorax. 95.1 % of the pneumothoraces detected on the right side were in the whole parasternal area with 75.6% seen in the lower parasternal region only. Similarly, 97.1 % of the pneumothoraces on the left side were seen in the whole parasternal area with 80% seen in the lower parasternal region only., Conclusions: The current study showed that air pockets of blunt traumatic pneumothoraces are mainly located at the parasternal regions especially in pneumothorax with small volume. We recommend a quick ultrasound scanning of the parasternal regions on both sides of the chest from proximal to distal as the appropriate technique for the detection of pneumothoraces in blunt trauma setting., Competing Interests: Competing interestsThe authors have no conflicts of interest. The authors are responsible for the content of the paper.

Purpose: Lung ultrasound is used for the diagnosis of pneumothorax, based on lung sliding abolition which is a qualitative and operator-dependent assessment. Speckle tracking allows the quantification of structure deformation over time by analysing acoustic markers. We aimed to test the ability of speckle tracking technology to quantify lung sliding in a selected cohort of patients and to observe how the technology may help the process of pneumothorax diagnosis., Methods: We performed retrospectively a pleural speckle tracking analysis on ultrasound loops from patients with pneumothorax. We compared the values measured by two observers from pneumothorax side with contralateral normal lung side. The receiver operating characteristic (ROC) curve was constructed to evaluate the performance of maximal pleural strain to detect the lung sliding abolition. Diagnosis performance and time to diagnosis between B-Mode and speckle tracking technology were compared from a third blinded observer., Results: We analysed 104 ultrasound loops from 52 patients. The area under the ROC curve of the maximal pleural strain value to identify lung sliding abolition was 1.00 [95%CI 1.00; 1.00]. Specificity was 100% [95%CI 93%; 100%] and sensitivity was 100% [95%CI 93%; 100%] with the best cut-off of 4%. Over 104 ultrasound loops, the blinded observer made two errors with B-Mode and none with speckle tracking. The median diagnosis time was 3 [2-5] seconds for B-Mode versus 2 [1-2] seconds for speckle tracking (p = 0.001)., Conclusion: Speckle tracking technology allows lung sliding quantification and detection of lung sliding abolition in case of pneumothorax on selected ultrasound loops.

Competing Interests: Nil.

Electrical injuries are a common occurrence and can be minor or even fatal depending on the voltage to which an individual has been exposed to. Electrical current causes tissue damage by producing heat due to local tissue resistance. Serious electrocution may manifest with cutaneous burns, visceral injuries, organ perforation, and cardiac and respiratory effects. Pneumothorax as a complication of electrical injury is a very rare entity. We report one such case of electrical burn injury with right-sided pneumothorax as an immediate complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

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

Pneumothorax management is controversial with no clear agreement for optimum management. The British Thoracic Society suggests needle aspiration first line in primary pneumothorax and the American Thoracic Society advises intercostal drain insertion. The European Respiratory Society task force also suggests needle aspiration in primary pneumothorax and adopts an overall more conservative approach. Ambulatory pneumothorax management has been described for 40 years and recommended in the 2010 British Society pleural guidelines, although overall quality of studies was poor. A new device, the Rocket Pleural Vent (PV) has been on the market for 4 years now and randomised controlled trials are under way, although there are case series suggesting efficacy and low complication rates. The PV allows ambulatory management of pneumothorax. Local guidelines have been developed and 18 devices have been placed in 6 months. We describe our experience based on a patient., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

A 71-year-old man presented to our hospital for dyspnea lasting for the past 3 days. Chest X-ray and computed tomography demonstrated right tension pneumothorax, and an electrocardiogram suggested acute inferior myocardial infarction. Despite the relief of tension pneumothorax, the electrocardiographic findings were not completely resolved. Emergency coronary angiography demonstrated an occlusive lesion in the right coronary artery, and percutaneous coronary intervention was performed successfully. Thereafter, the chest tube was removed, and he was discharged. While rare, multiple life-threatening diseases that present with similar symptoms can coexist, so a re-evaluation after performing the initial treatment for one of these diseases is crucial.

Background: Point of care bedside ultrasound is widely utilized as a rapid technique to evaluate patients with acute pulmonary emergencies, including acute pneumothorax. The presence of a pneumothorax is a known cause of loss of lung sliding by ultrasound examination, but no other risk factors have been clearly identified. We attempted to identify demographic and patient characteristics that are risk factors for loss of ultrasonographic lung sliding in the absence of a pneumothorax., Methods: Data were collected on 159 patients admitted to the medical intensive care unit with acute respiratory failure, undergoing routine admission lung ultrasound. The lung ultrasound examination consisted of 3 views of each hemithorax using a phased array abdominal probe., Results: There were 4 confirmed pneumothoraces out of 20 patients with loss of lung sliding at ≥1 ultrasound interrogation points on either hemithorax. Hypercarbic respiratory failure [odds ratio (OR), 5.59] and low body mass index (OR, 0.88) were statistically significant risk factors for the loss of lung sliding in the absence of pneumothorax. There was a trend toward significance in patients with a known history of a decreased forced expiratory volume 1/forced vital capacity ratio (OR, 0.02), COPD/asthma exacerbation as the cause of their respiratory failure (OR, 4.52) and previous pneumothorax (OR, 11.53)., Conclusion: Common diagnoses and comorbidities are associated with the loss of ultrasonographic lung sliding, in the absence of pneumothorax.

Primary spontaneous pneumothorax is a common problem faced by doctors in medical practice. It is a significant global health problem affecting adolescent and young adults. This article will review the etiopathology, diagnosis and current management guidelines. It aims to improve clinical practice and compliance to the complexities of procedures involved in management., (© 2018 Royal Australasian College of Surgeons.)

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice., (© 2019 John Wiley & Sons Ltd.)

A 38-year-old woman developed a spontaneous right-sided tension pneumothorax during light aircraft travel. The aircraft was diverted to a regional centre, where emergent needle thoracostomy and chest tube insertion were performed. History suggested that this was the second episode of pneumothorax, with an untreated event with similar symptomatology during air travel 1 year ago. She was taken for surgical intervention. Intraoperative findings were of a large right middle lobe cyst of uncertain origin; the procedure was subsequently aborted. A CT chest demonstrated a large multiseptated air-filled pulmonary cystic lesion. Inpatient stay was notable for persistent right pneumothorax with interval cyst rupture. A right middle lobectomy was subsequently performed with histopathology showing a benign epithelioid bronchogenic cyst. Recovery was unremarkable with no residual pneumothorax or further episodes at 2 months postoperatively. Preventative excision of air-filled pulmonary abnormalities should be considered prior to air travel., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom., Method: An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic)., Results: Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24-48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%-3%) and recurrence rates (0%-3%) were stated by 59% and 86%, respectively., Conclusion: There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.

This study aims to explore the effect of sequential acupoint stimulation on the postoperative pulmonary function of patients with spontaneous pneumothorax who underwent video-assisted thoracoscopic surgery (VATS).Using a random number table, the patients were randomly divided into 2 groups: routine nursing group and sequential acupoint stimulation group. Patients in the routine nursing group received standard nursing care of thoracic surgery, while patients in the acupoint group received sequential acupoint stimulation on Shenshu (BL23), Gaohuang (BL43), Feishu (BL13), and Tiantu (CV22). Then, the maximal ventilatory volume (MVV), oxygen saturation (SpO2), postoperative drainage volume, postoperative drainage time, postoperative hospitalization days, and procalcitonin (PCT) were observed on the first, third, fifth and 30th day after VATS operation.On the fifth day after spontaneous pneumothorax was treated with VATS, MVV, and SpO2 of the sequential acupoint stimulation group were significantly higher than those of the routine nursing group (P < .05). On both the third day and fifth day after VATS, PCT of the sequential acupoint stimulation group was significantly lower than that of the routine nursing group (P < .01). Furthermore, the difference in postoperative drainage volume between the 2 groups was not statistically significant (P > .05), while chest tube drainage time (P < .01) and postoperative hospitalization days (P < .05) of the sequential acupoint stimulation group were significantly lower than those of the routine nursing group.In spontaneous pneumothorax patients who underwent VATS, sequential acupoint stimulation nursing was significantly more effective than routine postoperative nursing in promoting postoperative recovery of lung function, alleviating inflammatory response and shortening hospitalization days.

Background: Optimal management of persistent air leaks (PALs) in patients with secondary spontaneous pneumothorax (SSP) remains controversial., Objective: To evaluate the efficacy and safety of endobronchial autologous blood plus thrombin patch (ABP) and bronchial occlusion using silicone spigots (BOS) in patients with SSP accompanied by alveolar-pleural fistula (APF) and PALs., Methods: This prospective multicentre randomized controlled trial compared chest tube-attached water-seal drainage (CTD), ABP, and BOS that were performed between February 2015 and June 2017 in one of six tertiary care hospitals in China. Patients diagnosed with APF experiencing PALs (despite 7 days of CTD) and inoperable patients were included. Outcome measures included success rate of pneumothorax resolution at the end of the observation period (further 14 days), duration of air leak stop, lung expansion, hospital stay, and complications., Results: In total, 150 subjects were analysed in three groups (CTD, ABP, BOS) of 50 each. At 14 days, 60, 82, and 84% of CTD, ABP, and BOS subjects, respectively, experienced full resolution of pneumothorax (p = 0.008). All duration outcome measures were significantly better in the ABP and BOS groups than in the CTD group (p < 0.016 for all). The incidence of adverse events, including chest pain, cough, and fever, was not significantly different. All subjects in the ABP and BOS groups experienced temporary haemoptysis. Spigot displacement occurred in 8% of BOS subjects., Conclusion: ABP and BOS resulted in clinically meaningful outcomes, including higher success rate, duration of air leak stop, lung expansion, and hospital stay, with an acceptable safety profile., (© 2019 S. Karger AG, Basel.)