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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5769_Библиотеки_им_академика_М_И_Перельмана
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460 oracic ultrasound
Many agents are used to induce a chemical pleurodesis: tetracycline derivatives (doxycycline
and minocycline), talc, bleomycin, mitoxantrone, silver nitrate, Corynebacterium parvum,
OK-432 (Streptococcus pyogenes) and povidone iodine.
At present, talc seems to have shown some superiority (positive feedback varying between
81% and 100%) compared to tetracycline and bleomycin, while povidone iodine appears
just as effective and more practical
46-47
.
A major advantage of the suspension of talc in liquid (talc slurry) and povidone iodine is
that they can be instilled through small pleural catheters. Table 9 summarizes the pleurodesis
procedure using small-caliber catheters.
Table 9 – Pleurodesis procedure using small-caliber catheters (10-14 F)
• Ultrasound-guided anesthesia of the parietal puncture site (lateral-posterior position through
the costophrenic angle)
• Ultrasound-guided insertion of a drainage (pigtail 10-14 F)
• Fluid drainage with ultrasound control of the expansion of the lung (expanded lung produces a
wall contact (sliding) and strengthens its artifactual specular component (B or A Lines)
• Echographic confirmation of the position of the tube and its effectiveness in draining
• Possible administration of pre-medication (analgesics, anxiolytics)
• Instillation of lidocaine (3 mg/kg, maximum dose 250 mg) in the pleural cavity
• Instillation of the sclerosing agent (4-5 g of sterile talc in 50 ml of saline solution 0.9%) (20 ml
of 10% povidone iodine in 50-80 ml of saline solution)
• Clamping of the tube for 1-2 hours
• Removal of the tube after 24-48 hours.
e administration of chemical agents for pleurodesis is however not without risks. After
instillation or pulverization of talc, cases of interstitial pneumonia, ALI and ARDS have
been reported
48-50
. It is likely that these complications are less frequent with talc particles >
15 microns (graded talc). Some studies using graded talc have not shown cases of pneumonia
or ARDS51.
Parenchymal problems (ARDS, pneumonia) have never been reported with povidone-iodine,
although experience with this product is more limited52.
Table 10 summarizes the complications reported with the administration of talc and povidone
iodine for pleurodesis.
Re-expansion pulmonary edema
e re-expansion pulmonary edema (RPE)53 sometimes develops in the lung re-expanded
after drainage of pleural fluid or air. So it is a complication of pleural drains.
is rare type of edema, with high protein content, is caused by impaired capillary leakage
in a restrained and quickly re-expanded organ. RPE rarely develops in the lungs collapsed for
less than three days, and it is most frequent in the case of PNX evacuation.
RPE produces dyspnea and hypoxemia. e protein fluid54 accumulates quickly (less than
an hour from lung re-expansion) in interstitial tissue and alveolar spaces. is event usually
Interventional chest ultrasound 461
affects the re-expanded lungs, but it rarely appears in the controlateral lung. Its severity may
be significant. e frequency of RPE is estimated in numerous studies between 0% and 1%55.
Table 10 – Complications reported with the administration of talc and povidone iodine for pleurodesis
procedure
Agent Complications
Talc Common: pain, mild fever
ARDS (3-9%)
Pneumonia (5%)
Respiratory failure (7-8%)
Unilateral edema (16%)
Povidone iodine Pleural pain (8%)
Hypotension (rare)
Fever (relatively frequent)
Empyema (rare)
Optic neuritis (very rare, only with high doses)
From an echographic point of view, its early detection and prevention are interesting. e
diagnosis is easy. RPE is announced by an interstitial syndrome (white lung) in re-expanded
regions where it was not present. It typically spares the hemithorax without effusion.
For preventing this disease, it is preferable that the drained volume does not exceed 1.5 l.
M
oreover individuals at risk (those with lung collapse that lasts for a longer time) need
special attention.
e occurrence of symptoms requires the temporary suspension (half an hour or more) of
the procedure. In the absence of symptoms, major and inveterate pneumothorax should be
drained gradually, especially in young people.
After a PNX drainage, sonography can evaluate the normal parietal contacts and can define
the subpleural pattern, that in case of edema is clearly altered by an interstitial syndrome.
After drainage of liquid, compressed lung regains ventilation and reappears as an artifactual
field, often with rare persistent B Lines.
Lung abscess
Currently, pyogenic lung abscesses are rare. Ultrasound diagnosis for an abscess, as long as it
reaches the pleura, is easy. e evidence of a lesion with mixed echogenicity, with a variable
fluid and/or necrotic component, sometimes with air, is suggestive. e use of echographic
contrast media (LCEUS) is useful for assessing fluid and necrotic components.
Lung abscesses are most commonly managed by medical therapy using prolonged antibiotics (1-3 months). Medical treatment can be failed if the abscess cavity is large (> 6 cm), the
patient is old and when the immunity is compromised. Certain aerobic pathogens (Klebsiella
pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus) are associated with medical treatment failure.
Eleven to 21% of patients eventually require surgical or percutaneous drainage. Surgery is
usually associated with high morbidity and mortality. CT guided percutaneous drainage of a
lung abscess is considered the first option for subjects with a deep located abscess.
However, lesions with a pleural contact allow to ultrasound guided needle puncture and
can be easily treated percutaneously, if other methods (medical therapy, bronchoscopic
462 oracic ultrasound
drainage) are not effective. e safety of the procedure is guaranteed by a large wall contact,
which provides access to the abscess cavity without piercing the aerated lung parenchyma56.
Generally the drainage of an abscess is practiced using a 7-14 Fr catheter, introduced by the
Seldinger’s tecnique. e drainage catheter is connected to a self-contained suction system,
such as Hemovac drain or Pleur-evac®. e regression of the lesion takes place in 10-15 days
in 73-100% of cases57.
If the abscess has rigid not easily collapsible walls, its disappearance may require 4-5 weeks.
e rapid decompression of a lung abscess may induce intracavitary hemorrhage.
Hemothorax
Hemothorax shows peculiarities that deserve a separate discussion.
Firstly, many hemothoraces (and hemo-pneumothorax) affects subjects with major trauma.
In these cases, the usual approach is the standard pleural drainage with large tubes (according
to ATLS), because the blood that tends to clot may be difficult to drain58.
Secondly, in the traumatized patient the indication to proceed with an open technique is
dictated by the coexistence of a pneumothorax and by the need to stabilize the patient as
quickly as possible, monitoring the losses (if the tube output is > 200 ml/h, it indicate the
implementation of further actions).
Spontaneous hemothorax is rarer, and it may be a complication of the anticoagulant therapy.
Moreover, hemothorax affects neoplastic subjects, patients with broken pleural adhesions, or
with more factors coexisting. Even patients with minor trauma, with circulatory and respiratory stability may have a bloody and radio-occult effusion in the chest.
Although there are no comparative studies, it is likely that many subjects with hemothorax may
benefit from ultrasound-guided insertion of medium/small bore catheters. For this purpose,
the sonographic appearance of the effusion could help. In fact, fresh blood or sero-hematic
effusions, drainable with relative ease, appear transonic or mildly corpuscular. e presence
of reticulated branches of fibrin or of dense material on lungs and diaphragm, cause more
difficult drainage. Finally, the presence of intrapleural clots requires the placement of a large
tube and predicts the possible treatment failure.
e formation of fibrous adhesions requires the use of selectively directed drains, or surgical
treatment. e thoracic drainages do not always ensure complete evacuation of a hemothorax. An ineffective tube or catheter allows the formation of a retained hemothorax (5%)59,
which may have consequences such as alterations on the respiratory dynamics or infectious
complications. In the study of Kimbrell and colleagues60, on 203 patients with traumatic
hemothorax treated with tube, 12.3% had a retained hemothorax. When a retained hemothorax occurs, the treatment options are the administration of intrapleural fibrinolytic drugs or
video-assisted thoracoscopy (VAT)61. Echography allows to define the fibrous encapsulation,
the fibrin content of the flud, the effectiveness of the drainage, the correct positioning of the
tube, or the need for inserting additional tubes62.
After drainage of a hemothorax, the administration of a first generation cephalosporin is indicated for 24 hours63. Figure 30 illustrates a monitoring algorithm, useful in case of hemothorax.
Pneumothorax: therapeutical notes
Currently the ultrasound diagnosis of pneumothorax is shared by many specialists and is
based on numerous literature data. For the application of ultrasound-guided interventional
Interventional chest ultrasound 463
Hemothorax. Quali/
quantitative assessment
Major trauma
PNX
Instable patient
Respiratory distress
Volume > / = 1000 ml
Presence of clots/fibrin
Urgent thoracic drainage (ATLS) with tube
Resolution Resolution
Echographic
monitoring
Persistent drainage
(> 200 ml/h for 4 hours)
Surgery
STOP
Echo-guided thoracic drainage with
NO
Single trauma
Stable patient
No PNX
Volume < 1000 ml
Transonic fluid
catheter 10/14 Fr
YES
Echographic
monitoring
Retained
hemothorax
Retained
hemothorax
Figure 30 – Monitoring algorithm in case of hemothorax.
techniques, we must distinguish the treatment of traumatic pneumothorax from that of
spontaneous or iatrogenic pneumothorax
64
.
In trauma patients a hypertensive pneumothorax requires immediate needle decompression,
followed by the application of a large bore thoracostomy tube, according to ATLS (Advanced
Trauma Life Support – American College of Surgeons). Even for simple traumatic pneumothorax, especially if large, a 24-28 Fr tube should be put into the pleural cavity.
In the case of hemopneumothorax the diameter of the tube should be greater (32-40 Fr), to
drain air, blood, and prevent a retaneid hemothorax.
In the presence of spontaneous or iatrogenic pneumothorax, status and age of the patient, rather
than the air volume, influence treatment choices, and less invasive options. Iatrogenic PNX
are frequently small and do not need therapy. Small sized asymptomatic primary spontaneous
pneumothorax in young people, may also be treated conservatively, without hospitalization.
464 oracic ultrasound
A spontaneous pneumothorax in older former smoker, associated with lung disease, should
be considered as a secondary pneumothorax usually requiring drainage. Spontaneous hypertensive pneumothorax requires prompt needle decompression. e stability of the patient
(Table 11) allows the possibility of different choices.
We believe that ultrasound guidance and less invasive methods can be used for many of these
patients.
Table 11 – Stability criteria of PNX
Respiratory rate < 24/min
Absence of dyspnea at rest
Heart rate > 60/min or < 120/min
Normal blood pressure
Saturation on room air > 90%
Absence of hemothorax
Treatment options may include the following:
• Simple needle aspiration
• Use of small size catheters (<14 Fr)65
• Application of small or medium-sized (10-22 Fr) thoracostomy tubes66.
e simple aspiration of pneumothorax (with needle or catheter) may be as effective as the
classic tube thoracostomy when a small (anterior) primary or secondary PNX is diagnosed.
Its success rate is variable between 37% and 75%. e same treatment is valid for iatrogenic
pneumothorax67 which, if small, can be treated conservatively.
In our opinion, for the PNX decompression, the sonoguided application of a small catheter
(10F) is preferable to the use of a needle.
Application of minimally invasive catheters in PNX patients
Many spontaneous PNXs may be treated accessing the pleural cavity with a small tube (8-12 Fr
pigtail type or similar) under ultrasound guidance68 (Figs. 31-32-33).
e patient is lying in the supine position, and the access is located in the second intercostal
space on the midclavicular line. Otherwise, the patient is in his/her (contro)lateral decubitus,
and the needle accesses the pleural space through the fourth-fifth intercostal space on the
midaxillary line. anks to the evidence of signs of pneumothorax, the access way does not
depend on anatomical landmarks.
In these positions, an area of the chest wall in which the sliding sign and B lines are absent is
sonographically identified. At this point the thickness of the chest wall is accurately measured.
Lung points, if any, must be highlighted, because they externally delimit the intrapleural air
collection.
It is important to remember that lung points at the midclavicular (mammillary) line identify
minimal/anterior PNX, while PNXs with lung points extended beyond the mammillary line
are anterolateral PNX.
e needle used for the initial puncture may be marked, so that it can be inserted to a maximum length of 3-4 mm greater than the thickness of the wall. Alternatively, the needle can
be inserted with the aspirating syringe and its penetration is stopped as soon as the syringe
aspirates air.
Interventional chest ultrasound 465
Figure 31 – Mini-invasive treatment of left spontaneous pneumothorax. Diagnostic chest X-ray (left).
After pigtail manual aspiration (center). After catheter removal at 24 hours (right).
Figure 32 – Same patient of Fig. 31. Control CT after one week. Apical emphysematous bubbles. No
pneumothorax.
Figure 33 – Catheter evacuation of traumatic right pneumothorax in ER, after sonographic diagnosis
(see fig. 34 for CT images). A: local anesthesia. B: pleural puncture after ultrasound assessment of
the presence of retroparietal air. C: guidewire insertion. D: dilator insertion. E-F: Pigtail insertion.
G: manual air aspiration. H: postprocedural ultrasound assessment. I: Final appearance.
466 oracic ultrasound
Figure 34 – Traumatic right pneumothorax. Right: Same patient after air aspiration by 10 F catheter.
Once the needle tip is into the pleural space, it acts as a tool for inserting a guide wire or,
directly, a soft catheter, which is generally a 8-10 Fr pigtail.
We have employed this technique for the treatment of spontaneous pneumothorax of any
size and for small traumatic PNX to accelerate their resolution (Figs. 33-34).
rough the tube into the pleural cavity, the air may be aspirated with a large syringe
(Fig. 33 G), observing the progression of lung points until they disappear (Fig. 33 H). Once
the lung is fully re-expanded, the ultrasound examination determines if the PNX develops
again or not. is assessment indicates a new aspirations or the application of a Heimlich
valve for 24 hours (Fig. 35).
Figure 35 – Heimlich unidirectional valve for pneumothorax evacuation.
Repeated aspirations without re-expansion of the lung, after evacuation of 4 l of air, suggest
the persistence of an air leak. In these cases the placement of a larger tube is necessary.
In our experience, the overall success rate is about 70%. Patients who respond to this treatment report less pain, less disability and better compliance to the overall management.
ere is some evidence that an ultrasound-guided mini-invasive treatment of PNX could be
applied to minimal or anterolateral traumatic PNX, that do not require mechanical ventilation or positive pressure mask.
Interventional chest ultrasound 467
Is rapid air elimination always necessary in stable patients?
Two main observation should be considered:
• e presence of intrapleural air in itself is not an indication for intervention.
• Expanding the collapsed lung is not desirable to stop the air leak.
e primary objective of both simple aspiration and chest drainage should be the recovery
of acute respiratory dysfunction and subsequent complications. Obviously, this objective is
inalienable if the patient shows cardiorespiratory signs and symptoms.
e secondary objective is the management of air leak. is treatment has not been clarified
in published trials and, therefore, it is not possible to extrapolate definitive conclusions.
Some evidences suggest that observational treatment to avoid lung expansion could help in
sustention of closing the perforation and, consequently, the air leak.
In our experience, the success rate of air aspiration in spontaneous pneumothorax is higher
when the drainage (if necessary) is delayed by 24 hours or more.
The false pneumothorax
“ere are rare cases, however, in which a rapid roentgenologic examination may suggest a localized
pneumothorax or hydropneumothorax, when in reality neither condition exists. French writers,
who were among the first to recognize this condition, applied the term “faux pneumothorax” to
these roentgnenologic aberrations”.
Stivelman BP. False pneumothorax. JAMA 1920;74:12-14.
Chest radiography has been the most important investigational technique in patients with
pneumothorax for almost a century. e radiologic diagnosis of pneumothorax in pre-CT
era was considered reasonably straightforward. Although it was not uncommon for a small
pneumothorax to pass unrecognized, there was rarely difficulty in the diagnosis of an acute
pneumothorax , provided that careful examination of the chest was carried out. In particular,
the specificity of chest X-ray for the detection of pneumothorax has always been considered
near 100%.
In the pre-CT era, there was no possibility for confirming a false pneumothorax, and the
possible “drainage” of a false pneumothorax obviously produced a real pneumothorax.
In our experience, a false radiographic pneumothorax may rarely occurs. Chest ultrasound
may easily discover these misinterpretations, and appears as a useful tool to avoid unnecessary procedures (Fig. 36).
Monitoring lung expansion after drainage of pneumothorax
In our experience this is a useful application not considered in the literature.
e main echographic feature of PNX is the disappearance of the pleural sliding. Sliding is
the movement of the echogenic pleural line with its artifacts generated by fine irregularities of
the lung surface (short comet tails, B Lines). Lungs that are not in contact with the wall, leave
space to specular air artifacts, consisting of horizontal reverberations, without “pulmonary”
background and without significant movements.
e image of the border area between the fully expanded lung and its collapsed portion is
very peculiar. At this level the dynamic differences between the fixed and moving pleural line
are enhanced (lung points)69.
468 oracic ultrasound
Figure 36 – False radiologic pneumothorax in a decompensated heart failure patients (top left). Left
hemithorax sonographic scan shows B-lines over all the surface. The heart window is not hidden and,
obviously, CT imaging shows wet lungs and no pneumothorax. B- lines and the clear appearance of the
heart exclude pneumothorax.
In the case of a drained pneumothorax, knowing in advance the degree of lung collapse according to the position of the lung points, it is easy to monitor the appearance of unequivocal signs of parietal contact of the expanded lung (the sliding). In our experience these signs
correlate well with the radiographic appearance.
Finally, the use of ultrasound allows to define the coexistence of blood in the pleural space
and its quantification (Clips 3-6).
Clips 3, 4, 5, 6 – Ultrasound monitoring of lung re-expansion of a
pneumothorax in the course of the aspiration with pigtail catheter. The probe
is placed and maintained in the parasternal region. In Clip 3 there is no
pleural sliding. Clip 5 clearly shows a lung point and Clip 6 only a small
remaining PNX. The re-expansion takes place within a few minutes (see clock
in the upper right corner).
Chest tube related complications
Cumulative rates of early (< 24 hours post placement) and late (>24 hours post placement)
chest tube complications are approximately 3 and 10% respectively. e number of anatomic structures potentially affected during catheters and chest tubes placement is large, and
Interventional chest ultrasound 469
Figure 37 – Biopsy needle used in the thorax. A. Chiba needle (A), Automated core biopsy needle
(B) and automated core biopsy needle using a vacuum device (Biomoll®) (C). B: Achieve® and Biomoll®
needle tips. C: Chiba needle for aspiration cytology.
it includes thoracic and extrathoracic organs: primary and secondary injuries of the lung,
intercostal/intrathoracic vasculature, esophagus, stomach, liver, spleen, diaphragm, major
blood vessels and the heart.
e best approach for preventing injuries during chest catheters and tube placement is summarized in few points.
• Make a definite diagnosis. Especially when chest X-ray is ambiguous, often chest ultrasound
is resolutive (e.g. white hemythorax).
• Consider the best way to access the pleural space according to the pathology, but always
scan with ultrasound the expected path of your device (needle, trocar).
• Use the less traumatic system (e.g. Seldinger method).
• Always identify by ultrasound important structures and vital organs (vessels, heart, dia-
phragm, liver, spleen, lung), including intercostal and internal mammary vessels.
• If possible, perform an echoguided access into the pleural space or inside your target,
avoiding dangerous paths.
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