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Each year, millions of pulmonary nodules are identified incidentally or through lung cancer screening, and many involve biopsy to distinguish cancer from benign processes. Both navigational bronchoscopy and computed tomography-guided transthoracic needle biopsy are commonly used in patients undergoing biopsies of peripheral pulmonary nodules, but the relative diagnostic accuracy of these two approaches is unclear. In this multicenter, randomized, parallel-group, noninferiority trial, we assigned patients with an intermediate-risk or high-risk peripheral pulmonary nodule measuring 10 to 30 mm in diameter to undergo navigational bronchoscopy or transthoracic needle biopsy at seven centers across the United States. The primary outcome was diagnostic accuracy, which was defined as the percentage of patients with biopsies that showed a specific diagnosis (cancer or a specific benign condition) that was confirmed to be accurate through 12 months of clinical follow-up (nonferiority margin, 10 percentage points). Secondary outcomes included procedural complications such as the occurrence of pneumothorax. Among the 234 patients included in the primary-outcome analysis (5 of whom were lost to follow-up), biopsy resulted in a specific diagnosis that was confirmed to be accurate through month 12 in 94 of 119 patients (79.0%) in the navigational bronchoscopy group and in 81 of 110 patients (73.6%) in the transthoracic needle biopsy group (absolute difference, 5.4 percentage points; 95% confidence interval, -6.5 to 17.2; P = 0.003 for noninferiority; P = 0.17 for superiority). Pneumothorax occurred in 4 of 121 patients (3.3%) in the navigational bronchoscopy group and in 32 of 113 patients (28.3%) in the transthoracic needle biopsy group and led to the placement of a chest tube, hospital admission, or both in 1 patient (0.8%) and 13 patients (11.5%), respectively. The diagnostic accuracy of navigational bronchoscopy was noninferior to that of transthoracic needle biopsy among patients with peripheral pulmonary nodules measuring 10 to 30 mm. (Funded by Medtronic and others; VERITAS ClinicalTrials.gov number, NCT04250194.).

More than 250 patients with uncomplicated, primary spontaneous pneumothorax were treated conservatively or by pleural intervention. In a complete-case analysis, reexpansion within 8 weeks occurred in 98.5% of the patients in the intervention group and in 94.4% of those in the conservative-management group.

Background The aim of this study is to evaluate cardiovascular and respiratory effects of intrathoracic pressure overshoot (higher than insufflation pressure) in patients who underwent thoracoscopic esophagectomy procedures with carbon dioxide (CO 2 ) pneumothorax. Methods This prospective research included 200 patients who were scheduled for esophagectomy from August 2016 to July 2020. The patients were randomly divided into the Stryker insufflator (STR) group and the Storz insufflator (STO) group. We recorded the changes of intrathoracic pressure, peak airway pressure, blood pressure, heart rate and central venous pressure (CVP) during artificial pneumothorax. The differences in blood gas analysis, the administration of vasopressors and the recovery time were compared between the two groups. Results We found that during the artificial pneumothorax, intrathoracic pressure overshoot occurred in both the STR group (8.9 mmHg, 38 times per hour) and the STO group (9.8 mmHg, 32 times per hour). The recorded maximum intrathoracic pressures were up to 58 mmHg in the STR group and 51 mmHg in the STO group. The average duration of intrathoracic pressure overshoot was significantly longer in the STR group (5.3 ± 0.86 s) vs. the STO group (1.2 ± 0.31 s, P < 0.01). During intrathoracic pressure overshoot, a greater reduction in systolic blood pressure (SBP) (5.6 mmHg vs. 1.1 mmHg, P < 0.01), a higher elevation in airway peak pressure (4.8 ± 1.17 cmH 2 O vs. 0.9 ± 0.41 cmH 2 O, P < 0.01), and a larger increase in CVP (8.2 ± 2.86 cmH 2 O vs. 4.9 ± 2.35 cmH 2 O, P < 0.01) were observed in the STR group than in the STO group. Vasopressors were also applied more frequently in the STR group than in the STO group (68% vs. 43%, P < 0.01). The reduction of SBP caused by thoracic pressure overshoot was significantly correlated with the duration of overshoot ( R = 0.76). No obvious correlation was found between the SBP reduction and the maximum pressure overshoot. Conclusions Intrathoracic pressure overshoot can occur during thoracoscopic surgery with artificial CO 2 pneumothorax and may lead to cardiovascular adverse effects which highly depends on the duration of the pressure overshoot. Trial registration Clinicaltrials.gov ( NCT02330536 ; December 24, 2014).

Background Spontaneous pneumothorax is an uncommon complication of COVID-19 viral pneumonia. The exact incidence and risk factors are still unknown. Herein we review the incidence and outcomes of pneumothorax in over 3000 patients admitted to our institution for suspected COVID-19 pneumonia. Methods We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with a spontaneous pneumothorax were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Data regarding their clinical outcomes were gathered. Each case was presented as a brief synopsis. Results Three thousand three hundred sixty-eight patients were admitted to our institution between March 1st, 2020 and June 8th, 2020 for suspected COVID 19 pneumonia, 902 patients were nasopharyngeal swab positive. Six cases of COVID-19 patients who developed spontaneous pneumothorax were identified (0.66%). Their baseline imaging showed diffuse bilateral ground-glass opacities and consolidations, mostly in the posterior and peripheral lung regions. 4/6 cases were associated with mechanical ventilation. All patients required placement of a chest tube. In all cases, mortality (66.6%) was not directly related to the pneumothorax. Conclusion Spontaneous pneumothorax is a rare complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. Clinicians should be vigilant about the diagnosis and treatment of this complication.

PurposeEspecially in elderly and multimorbid patients, Coronavirus Disease 2019 (COVID-19) may result in severe pneumonia and secondary complications. Recent studies showed pneumothorax in rare cases, but tension pneumothorax has only been reported once.Case presentationA 47-year-old male was admitted to the emergency department with fever, dry cough and sore throat for the last 14 days as well as acute stenocardia and shortage of breath. Sputum testing (polymerase chain reaction, PCR) confirmed SARS-CoV-2 infection. Initial computed tomography (CT) showed bipulmonary groundglass opacities and consolidations with peripheral distribution. Hospitalization with supportive therapy (azithromycin) as well as non-invasive oxygenation led to a stabilization of the patient. After 5 days, sputum testing was negative and IgA/IgG antibody titres were positive for SARS-CoV-2. The patient was discharged after 7 days.On the 11th day, the patient realized pronounced dyspnoea after coughing and presented to the emergency department again. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. Negative pressure therapy resulted in regression of the pneumothorax and the patient was discharged after 9 days of treatment.ConclusionTreating physicians should be aware that COVID-19 patients might develop severe secondary pulmonary complications such as acute tension pneumothorax.Level of evidenceV

Objective Surgery is one of the preferred primary treatments for primary spontaneous pneumothorax (PSP); however, postoperative recurrent pneumothorax (PORP), defined as recurrence on the same side, occurs in 3–13% of cases. While environmental factors have been implicated in PSP occurrence, their role in PORP remains unclear. This study aimed to investigate the impact of environmental factors on the onset of PSP and PORP in the same patient population. Methods Between 2009 and 2019, a total of 442 patients (aged ≤ 40 years) underwent 486 surgeries for PSP, with 43 patients (8.8%) experiencing a first PORP. Management of PORP included reoperation (29 patients), pleural drainage with chemical pleurodesis (4 patients), and conservative observation (10 patients). In this case-crossover study, the day of symptom onset for PSP and PORP was designated as the “case day.” To evaluate potential lag effects, the days leading up to symptom onset, ranging from 1 day prior (lag day 1) to 7 days prior (lag day 7), were also analyzed as “case days.” Unidirectional matched control days were selected 14–21 days before the case day (lag day 0). Results Elevated PM 2.5 levels were significantly associated with PSP onset at lag day 0 and lag day 1, with increased odds observed at these time points ( p  =  0.04 and p  = 0.02, respectively). No such association was found for PORP patients. Meteorological factors did not appear to influence PSP or PORP risk. Seasonally, both the PSP incidence and the PORP incidence were significantly greater in autumn and spring than in summer and winter ( p  <  0.001 ). Conclusion PSP and PORP demonstrate seasonal clustering, with higher incidences in autumn and spring. Elevated PM 2.5 levels appear to contribute to PSP onset but not PORP, suggesting that air pollution may be a potential trigger for PSP. Further research is needed to clarify environmental influences and optimize tailored management strategies. Clinical trial number Not applicable.

Pneumothorax represents a common clinical problem. An overview of relevant and updated information on epidemiology, pathophysiology, and management of spontaneous (primary and secondary), catamenial, and traumatic (iatrogenic and noniatrogenic) pneumothorax is given.

Introduction: The annual report for the National Audit of Cardiac Rhythm Management (CRM) Devices describes procedural activity and complication rates; it is reported through the National Institute of Cardiovascular Outcomes Research (NICOR). NICOR sets a cut off of 15 months following implant to attribute device related complications. However, device related revisions can occur after 15 months and we sought to investigate these and compare them with the NICOR group. Methods: Our devices database was searched for all device procedures during 2018, and all recorded complications. A comparison was made between patients within, and outside of the 15-month reporting period. Complications were classified as wound related, infection, pneumothorax, haematoma, lead displacement and ‘other’ lead complications such as parameter changes or integrity faults. The time from the first device implant to detection of complication was recorded, however some patients underwent further procedures within this period. Statistical analysis was performed with Chi-squared and t-test. Results: 2,393 CRM device procedures were performed at our centre over 2018. A total of 174 (7.28%) complications were recorded, involving 169 patients. 115 (4.81%) complications were recorded across 110 patients, within the 15-month NICOR period, and 59 (2.47%) occurred after 15 months. NICOR mean age was higher than the non-NICOR group (69.8 ± 16.5 versus 63.8 ± 19.0 years, p=0.04) but the proportion of males was similar (57.3 versus 64.4%, p=0.37). All-cause mortality was similar 5five (4.5%) versus 3 (5.1%), p=0.88. As the data was dichotomised by time from implant, mean time from first implant to recorded complication was shorter in the NICOR group compared with the non-NICOR group (1.48 ± 3.09 versus 9.89 ± 5.89 years, p<0.0001). Within the NICOR group (n=115), lead displacements made up the largest proportion, 45 (39.12%), followed by ‘other’ lead complications 16 (13.91%), wound revisions 16 (13.91%), infection 13 (11.30%), pneumothorax 5 (4.35%), haematoma 9 (7.83%) and pericardial effusion 6 (5.22%). By contrast, the non-NICOR complications (n=59) were dominated by ‘other’ lead complications, 37 (61.71%) which primarily related to integrity issues and parameter changes. There was 1 lead displacement beyond 15 months (1.69%), 8 (13.56%) wound revisions and 12 (20.34%) very late infections. There were no reported pneumothoraxes, haematomas or pericardial effusions after 15 months. Discussion: A considerable proportion of complications requiring intervention present many years after the initial implant, and certainly outside of the NICOR reporting window. Although reported locally, this may reflect a significant burden of morbidity related to CRM devices that goes unreported at a national level. Conclusion: Late device related complications falling outside of the NICOR reporting window are an important source of patient comorbidity and they deserve our attention and further investigation. [Image Omitted]

PurposeThe Coronavirus Disease 2019 (COVID-19) may result not only in acute symptoms such as severe pneumonia, but also in persisting symptoms after months. Here we present a 1 year follow-up of a patient with a secondary tension pneumothorax due to COVID-19 pneumonia.Case presentationIn May 2020, a 47-year-old male was admitted to the emergency department with fever, dry cough, and sore throat as well as acute chest pain and shortness of breath. Sputum testing (polymerase chain reaction, PCR) and computed tomography (CT) confirmed infection with the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Eleven days after discharge, the patient returned to the emergency department with pronounced dyspnoea after coughing. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. For a period of 3 months following resolution of the pneumothorax the patient complained of fatigue with mild joint pain and dyspnoea. After 1 year, the patient did not suffer from any persisting symptoms. The pulmonary function and blood parameters were normal, with the exception of slightly increased levels of D-Dimer. The CT scan revealed only discrete ground glass opacities (GGO) and subpleural linear opacities.ConclusionTension pneumothorax is a rare, severe complication of a SARS-CoV-2 infection but may resolve after treatment without negative long-term sequelae.Level of evidenceV.

In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery, in co-operation with the German Society for Pulmonology, the German Radiological Society, and the German Society of Internal Medicine has developed an S3 guideline on spontaneous pneumothorax and post-interventional pneumothorax moderated by the German Association of Scientific Medical Societies. Method: Based on the source guideline of the British Thoracic Society (2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to grade (A: “we recommend”/“we do not recommend,” B: “we suggest”/“we do not suggest”) were determined in 3 consensus conferences by the nominal group process. Results: The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery. Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences, and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of post-interventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax. Discussion: The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.