PubMed · 12144113
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B E Carey. 2001. Neonatal chylothorax.. https://doi.org/10.1891/0730-0832.20.2.53
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BACKGROUND: Pleural empyema is a collection of pus between the lungs and the chest wall. Approximately 50% of cases complicate pneumonia. There are a variety of treatment options ranging from intravenous antibiotics alone to open thoracotomy and debridement, depending in part on the stage of the empyema and the severity. The condition changes with time, becoming loculated and more difficult to drain. There is much debate about the most appropriate therapy particularly with the advent of new treatments such as fibrinolytic enzymes (e.g. streptokinase, urokinase) and video-assisted thoracoscopic surgery (VATS). OBJECTIVES: To determine which is more effective for the management of empyema: surgical (e.g. thoracoscopy, thoracotomy) or non-surgical techniques (e.g. thoracocentesis, chest tube drainage) and to establish whether there is an optimum time for intervention. SEARCH STRATEGY: The Cochrane Controlled Trials Register and DARE database were searched in addition to the Cochrane Acute Respiratory Infections Group's own register of trials. A specialised topic search with no language restrictions was used to search MEDLINE and EMBASE using Silverplatter. Bibliographies and the reference lists of identified studies and review articles were handsearched. Personal communication with authors and experts in the field is ongoing. SELECTION CRITERIA: Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded. DATA COLLECTION AND ANALYSIS: Trial quality was assessed using Jadad criteria as recommended by the ARI group (Jadad 1996). The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed length of time chest tubes were required, pain, hospital stay and any complications. MAIN RESULTS: Only one small randomised study was identified which met the inclusion criteria. It was conducted in a university thoracic surgery department. There were some methodological quality considerations which cast some doubt on validity ( patient selection, unclear allocation concealment and outcome assessor blinding) and it scored 'B' overall (Jadad score 3). The main results of the study were that when compared with chest tube drainage combined with streptokinase, the video-assisted thoracoscopic surgery (VATS) group had a significantly higher primary treatment success and spent less time in hospital. Each group suffered one mortality. REVIEWER'S CONCLUSIONS: It would appear that for large, loculated pleural empyemas VATS is superior to chest tube drainage with streptokinase in terms of duration of chest tubes and hospital stay. However there are questions about validity and the study is also too small to draw conclusions. There are risks of complications (associated with all treatments) which may not apparent with small numbers. VATS is performed under general anaesthetic and one lung ventilation. Fibrinolytics are also associated with side effects. Further larger multicentre studies need to be conducted.
BACKGROUND: Introducing a chest tube is a routine emergency procedure in trauma victims. Emergency coniotomy or establishing an intraosseous access, however, are not often necessary, but in individual cases these techniques can be decisive for patient survival. The aim of this study was to present and evaluate a model for teaching these techniques, since the majority of emergency physicians do not have adequate experience in this area. METHODS: In November 2001 our institution organized the first workshop on "Invasive emergency techniques (INTECH): chest tube, emergency coniotomy, and intraosseous access" in collaboration with the Institute of Anatomy II of the University of Heidelberg. After presenting basic anatomy and also particular features of the relevant regions of the body, the techniques of introducing a thoracic drainage, performing a coniotomy, and establishing an intraosseous access were presented. Video demonstrations as well as practical exercises on corpses followed the theoretical part of the course. At the end of each lesson, the participants were asked anonymously why they took part in the workshop and about their previous experience with these emergency techniques in written form and also asked to assess the didactic concept of the workshop (scale 1=very good up to 6=very poor). RESULTS: Of the 86 participants, 66 completed the questionnaire (77%) and 40 of the participants had been working as emergency physicians for 6.5+/-6.3 years (range 0.5-22) with approx. 13+/-8 (range 4-30) interventions per month. The most common reason for participating was lack of practice (52%): prior to the workshop, 98% of the emergency physicians had never performed a coniotomy, 85% had never established an intraosseous access, and 28% had never introduced a chest tube in an emergency setting. The theoretical parts of the course received the following scores: "Basic anatomy" 2.3+/-0.8, "coniotomy" 1.7+/-0.7, "intraosseous access" 1.5+/-0.5, and "thoracic drainage " 1.7+/-0.7. In the practical part they were given the scores: "coniotomy" 1.9+/-0.7, and "intraosseous access" and "thoracic drainage" both 1.6+/-0.8. Finally, the "positioning demonstrations" were given scores of 1.7+/-0.8 and the practical exercises as a whole 1.4+/-0.7. CONCLUSIONS: These results show that even emergency physicians with many years of practice have too little knowledge about thoracic drainage, even though it is required in the management of trauma victims. Over 80% of the emergency physicians have no experience with certain other emergency measures recommended as lifesaving in individual cases. Despite the criticism that the participants of the workshop were a selected study group, these numbers seem to reflect reality: Institutions with emergency medicine departments have reported considerable and serious deficiencies in providing emergency care to patients with polytrauma. These gaps could be closed by implementing practice-oriented workshops in collaboration with anatomical institutes. As these institutes use fixated corpses for training purposes, the differences in working with living patients would have to be made clear. In spite of this minor restriction, practical exercises could counteract the deficits in the care of emergency patients and should therefore be integrated into a future educational concept on a long-term basis.