You are seeing a young man in the emergency department who gives a history of falling two days ago. He experienced chest pain at the time which has persisted, but he did not immediately seek medical care. He has noticed that he now gets winded when walking quickly or climbing stairs, and describes pleuritic chest pain.
He presents to your emergency room and on exam has a bruise over his left lateral chest wall. Subcutaneous emphysema is present, and breath sounds are absent. Chest x-ray shows a complete pneumothorax on the left.
You carefully prepare and insert a chest tube in the usual position. A significant rush of air occurs, which tapers off over 15 seconds. Here is the followup image:
About 10 minutes later you are called to his room because he is complaining of dyspnea and his oxygen saturation has decreased to 86%. Breath sounds are somewhat decreased and the tube appears to be functioning properly. You immediately obtain another chest x-ray:
What just happened? This is a classic case of unilateral “flash” pulmonary edema after draining the chest cavity. This phenomenon was first described in 1853 in a patient who had just undergone thoracentesis. It is very uncommon, but seems to occur after rapid drainage of air or fluid from the chest cavity.
Here are some interesting factoids from case reports:
- It occurs more often in young men
- It is most common when draining large hemo- or pneumothoraces
- Rapid drainage seems to increase the incidence
- It is likely due to increased pulmonary capillary permeability from inflammatory mediators or changes in surfactant
- Symptoms typically develop within an hour after drainage
What should you do? First, if you are draining a large collection of air or blood, do it slowly. Clamp the back end of the chest tube prior to insertion (you should always do this if you value your shoes) and use it to meter the amount of fluid or air released. I typically let out about 300cc of fluid, then wait a minute and repeat until all the blood has been drained. For air, vent it for 10 seconds, then wait a minute and repeat.
In patients at high risk for this condition, apply pulse oximetry and follow for about an hour. If they still look and feel great, nothing more need be done.
- Fulminant Unilateral Pulmonary Edema After Insertion of a Chest Tube. Dtsch Arztebl Int 105(50):878-881, 2008.
- Reexpansion pulmonary edema after chest drainage for pneumothorax: A case report and literature overview. Respir Med Case Rep 14:10-12, 2015.
- Re-expansion pulmonary edema following thoracentesis, Can Med Assn J 182(18):2000-2002, 2010.
Over the last few days, I’ve reviewed some data on managing hemothorax, as well as the use of lytics. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.
Until now. The trauma group at Vanderbilt published a paper describing their experience with a home-grown practice guideline for managing retained hemothorax. Here’s what it looks like:
I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.
All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.
Here are the factoids:
- There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
- An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
- The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
- Empyema rate was unchanged at 2.5%
- Use of VATS decreased significantly from 8% to 3%
- Use of catheter guided drainage increased significantly from 0.6% to 3%
- Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)
Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.
This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics.
I like this so much that I’ve incorporated parts of it into the chest tube guideline at my center!
Download the practice guideline here.
Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma 82(4):728-732, 2017.
I’ve written about the use of lytics to treat retained hemothorax over the past few days. Although it sounds like a good idea, we just don’t know that it works very well. And they certainly don’t work fast. Lengths of stay were on the order of two weeks in both studies reviewed.
The alternative is video assisted thoracoscopic surgery (VATS). So let’s take a look at what we know about it. This procedure is basically laparoscopy of the chest. A camera is inserted, and other ports are added to allow insertion of instruments to suck, peel, and scrape out the hemothorax.
A prospective, multi-center study was performed over a 2 year period starting in 2009. Twenty centers participated, contributing data on 328 patients with retained hemothorax. This was defined as CT confirmation of retained blood and clot after chest tube placement, with evidence of pleural thickening.
Here are the factoids:
- 41% of patients had antibiotics given for chest tube placement (this is interesting given the lack of consensus regarding their effectiveness!)
- A third of patients were initially managed with observation, and most of them (82%) did not need any further procedures (83 of 101 patients)
- Observation was more successful in patients who were older, had smaller hemothoraces (<300cc), smaller chest tubes (!!, <34 Fr), blunt trauma, and peri-procedure antibiotics (?)
- An additional chest tube was inserted in 19% of patients, image guided drain placement in 5%, and lytics in 5%. Half to two-thirds of these patients required additional management.
- VATS was used in 34% of patients. One third of them required additional management including another chest tube, another VATS, or even thoracotomy.
- Thoracotomy was most likely required if there was a diaphragm injury or large hemothorax (<900cc)
- Empyema and pneumonia were common (27% and 20%, respectively)
Bottom line: There’s a lot of data in this paper. Most notably, many patients resolve their hemothorax without any additional management. But if they don’t, additional tubes, guided drain placement, and lytics work only a third of the time and contribute to additional time in the hospital. Even VATS and thoracotomy require additional maneuvers 20-30% of the time. And infectious complications are common. This is a tough problem!
Tomorrow, I’ll try to roll it all together and suggest an algorithm to try to optimize both outcomes and cost.
Reference: Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study. 72(1):11-24, 2012.
Yesterday, I reviewed a small case report that was published a couple of years ago on lytics for treatment of retained hemothorax. But surely, there must be something better, right?
After digging around, I did find a paper from 2007 that prospectively looked at protocolized management of retained hemothorax, and its aftermath. It was carried out at a busy Level I trauma center over a 16 month period.
All patients with a hemothorax treated with chest tube received daily chest x-rays. Those with significant opacification on day 3 underwent CT scan of the chest. If more than 300 cc of retained blood was present, the patient received streptokinase or urokinase (surgeon preference and drug availability) daily, and rolled around in bed for 4 hours to attempt to distribute it. The chest tube was then unclamped and allowed to drain. This was repeated for 3 days, and if there was still opacification, a repeat CT was obtained. If the volume was still greater than 300 cc, the cycle was repeated for the next 3 days. If the opacification cleared at any point, or the repeat CT showed less than 300 cc, the protocol was stopped and the chest tube removed. If the chest was still opacified after 6 days, VATS was offered.
Here are the factoids:
- A total of 203 patients with hemothorax were admitted during the study period and 25 (12%) developed a retained hemothorax
- While a few had treatment start within 4 days, the majority did not receive lytics until day 9 (range 3 –30 days!)
- The average length of time in hospital after start of lytics was 7 days, leading to a total length of stay of 18 days
- 92% of patients had “effective” evacuation of their retained hemothorax, although 1 had VATS anyway which found only 100 cc of fluid
- 16 patients had “complete” evacuation, and 5 had “partial” evacuation
- There were no hemorrhagic complications, but one third of patients reported significant pain with drug administration
Bottom line: Sounds good, right? The drug seems reasonably effective, although lengths of stay are relatively long. However, streptokinase and urokinase are no longer available in the US, having been replaced with tissue plasminogen activator (tPA). This paper does a cost analysis of lytics vs VATS and found that the former treatment cost about $15000 (drug + hospital stay) vs $34000 for VATS. However, a big part of this was that the drug only cost about $75 per dose. tPA is much more expensive.
So once again, small series, longer lengths of stay, but at least nicely done. Unfortunately, the drug choice is no longer available so use of tPA tilts the balance away from lytics.
Reference: Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. J Trauma 62(5):1175-1179, 2007.
Hemothorax is a common complication of chest trauma, occurring in about one third of cases. It is commonly treated with a chest tube, which usually takes care of the problem. But in a few cases some blood remains, which can result in an entrapped lung or empyema.
There are several management options. Historically, these patients underwent thoracotomy to peel out the fibrinous collection stuck to lung and chest wall. This has given way to the more humane VATS procedure (video assisted thoracoscopic surgery) which accomplishes the same thing using a scope. In some cases, another tube can be inserted, sometimes under CT guidance, to try to drain the blood.
So what about lytics? It’s fibrin, right? So why not just dissolve it with tissue plasminogen activator (tPA)? There have been very few studies published over the years. The most recent was in 2014. I’ll review it today, and another tomorrow. Finally, I’ll give you my thoughts on the best way to deal with retained hemothorax.
Here are the factoids:
- This was a single center, retrospective review of data from 1.5 years beginning in 2009
- A total of seven patients were identified, and most had hemothorax due to rib fractures. Three presented immediately after their injury, 4 were delayed.
- Median time from injury to chest tube placement was 11 days
- Median time the chest tube was in place was 13 days, with an average hospital stay of 14 days
- Patients received 1 to 5 treatments, averaging 24mg per dose
- There was one death in the group, unrelated to TPA treatment
- No patient “required” VATS, but one underwent thoracotomy, which turned out to be for a malignancy
Bottom line: The authors conclude that tPA use for busting retained hemothorax is both safe and effective. Really? With only seven patients? The biggest problem with this study is that it uses old, retrospective data. We have no idea why these patients were selected for tPA in this 5-year old cohort of patients. Why did it take so long to put in chest tubes? Why did the chest tubes stay in so long? Maybe this is why they were in the hospital so long?
Plus, tPA is expensive. A 100mg vial runs about $6000. Does repeatedly using an expensive drug and keeping a patient in the hospital an extra week or so make financial sense? So it better work damn well, and this small series doesn’t demonstrate that.
Tomorrow, I’ll look at the next most recent paper on the topic, from way back in 2004.
Reference: Evaluation of chest tube administration of tissue plasminogen activator to treat retained hemothorax. Am J Surg 267(6):960-963, 2014.