Download Management of a Giant Fluid- Thoracostomy Tube

tracheotomy-related complications
documented. Cot¬
in
with SGS, a
that
children
opinion
of
a
stent
results in a
without
insertion
tracheotomy
more severe stenosis. Contamination of the injured
prolongs healing
larynx through thethetracheotomyto wound
and predisposes
patient more prolific scarring.
Surgical reconstruction of the larynx should be consid¬
ered in children with SGS who require a tracheotomy.3
The safety and efficacy of single-stage LTR has been
well established.1415 The procedure can be used to
facilitate early decannulation and, in some patients, to
avoid tracheotomy altogether as in patient 1. Since most
of the cardiac procedures are performed in patients at a
very young age, the early decannulation following an
LTR permits the return of normal laryngeal function
and the development of spoken language. In this series,
four patients were successfully extubated in the oper¬
ating room after the LTR and had no further problems.
The longest postoperative intubation was for 10 days to
stent a collapsed graft. At the last review, seven of the
eight patients had satisfactory airways, and in one of
them an additional cardiac operation was performed
ton13 is of the
uneventfully.
Many suggestions have been put forward to minimize
the risk of complications secondary to hypoperfusion
and impaired gas exchange during cardiac surgery.
Mythen and Webb8 recommend usingto perioperative
colloid improve cir¬
plasma volume expanders withevents.
culation and prevent hypoxic
Early extubation
after cardiac surgeiy is now being advocated because
evidence suggests that it does not affect morbidity or
mortality.1617 The anesthesia technique used and the
patient's medical condition are the major factors in¬
volved in accomplishing this goal. Widespread accep¬
tance of this policy along with the use of properly sized
tubes, good endotracheal tube fixation, and adequate
sedation when the patient is intubated will probably
reduce the incidence of endotracheal tube trauma. Any
child who has a difficult postextubation period following
cardiac surgery should be examined with a flexible
fiberoptic laryngotracheoscope before he or she leaves
the ICU. If laryngeal edema or ulceration has occurred,
the cardiac anesthesia team should be alerted before
any subsequent procedure. Adequate mucosal perfusion
during surgery and early extubation following it may
prevent the progression to
SGS.
Conclusion
References
2
JA,
Beste D.
Diagnosis
clamp technique on cardiac and cerebral compli¬
during coronary bypass surgery. J Card Surg 1995;
10(4 suppl) :498-502
Fallon P, Aparicio JM, Eliott MJ, et al. Incidence of neuro¬
logical complications of surgery for congenital heart disease.
aortic cross
cations
5
Arch Dis Child 1995; 72:418-22
6 Mills SA. Risk factors for cerebral injury and cardiac surgery.
Ann Thorac Surg 1995; 59:1296-99
7 Tanaka K, Kumon K, Yamamoto F, et al. Respiratoiy care of
pediatric patients requiring prolonged intubation after car¬
diac surgery. Crit Care Med 1986; 14:617-19
8 Mythen MG, Webb AR. Perioperative plasma volume expan¬
sion reduces the incidence of gut mucosal hypoperfusion
during cardiac surgery. Arch Surg 1995; 130:423-29
9 Hachenberg T, Tenling A, Nystrom SO, et al. Ventilationperfusion inequality in patients undergoing cardiac surgery.
Anesthesiology 1994; 80:509-19
10 Holinger PH, Kutnick SL, Schild JA, et al. Subglottic stenosis
on infants and children. Ann Otol Rhinol Laryngol 1976;
85:591-99
11 Fearon B, Cotton R. Surgical correction of subglottic stenosis
of the larynx in infants and children. Ann Otol Rhinol
Laryngol 1974; 83:428-31
12 Gianoli GJ, Miller RH, Guarisco JL. Tracheotomy in the first
year of life. Ann Otol Rhinol Laryngol 1990; 99:896-901
13 Cotton RT. Management and prevention of subglottic steno¬
sis in infants and children. In: Bluestone CD, Stool SE,
Scheetz MD, eds. Pediatric otolaryngology. Philadelphia: WB
Saunders, 1990; 1194-1204
14 Seid AB, Pransky SM, Kearns DB. One stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg 1991; 117:408-10
15 Rothschild MA, Cotcamp D, Cotton RT. Post-operative
medical management in single stage laryngotracheoplasty.
Arch Otolaryngol Head Neck Surg 1995; 121:1175-79
16 Cheng DC. Pro: Early extubation after cardiac surgeiy de¬
creases
intensive care unit
Anesth 1995; 9:460-64
17
stay and cost. J Cardiothorac Vase
Hickey RF, Cason BA. Timing of tracheal extubation in adult
cardiac surgery patients. J Cardiovasc Surg 1995; 10:340-48
Management of a Giant Fluidfilled Bulla by Closed-Chest
Thoracostomy Tube Drainage4
Kirschner, MD; William Stauffer, MD;
Charles Krenzel, MD; and Peter G. Duane, MD
Lawrence S.
SGS is a hitherto unreported complication of cardiac
surgeiy in children. The severity of stenosis does not
appear to be related to the number of cardiac procedures.
Single-stage LTR is a safe and effective method of treating
established stenosis.
1 Werkhaven
congenital heart disease. Yonsei Med J 1995; 36:53-7
3 Cotton RT. Pediatric laryngotracheal stenosis. J Pediatr Surg
1984; 19:699-704
4 Aranki SF, Sullivan TE, Cohn LH. The effect of the single
and management of
pediatric laryngeal stenosis. Otolaryngol Clin North Am 1995;
28:797-808
Koh SO, Bang SO, Hong YW, et al. Incidence and predictors
of post extubation laryngeal edema in pediatric patients with
A
53-year-old man was admitted to the hospital for
management of pneumonia and a giant fluid-filled
*From the Pulmonary Disease Division, Department of Medicine
(Drs. Kirschner, Stauffer, and Duane) and the Department of
Krenzel and Duane), Veterans Affairs Medical
Radiologyand(Drs.
University of Minnesota School of Medicine (Drs.
Center,
Kirschner, Stauffer, and Krenzel), Minneapolis
Manuscript received July 17, 1996; revision accepted Novem¬
Reprint
requests: Dr. Duane, Pulmonary (11 IN), Minneapolis VA
Medical
One Veterans
MN
ber 25.
Center,
Drive,
Minneapolis,
1772
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55417
Selected
Reports
bulla. He appeared acutely ill and had persistent
fever despite prolonged therapy with parenteral
antibiotics and aggressive bronchial drainage. Per¬
cutaneous placement of an 8.5F catheter into the
bulla enabled drainage of both fluid and air within
the bulla and led to resolution of his symptoms
within 24 h. This report demonstrates that drainage
of giant fluid-filled bullae may lead to rapid resolu¬
tion of symptoms and describes a novel management
technique for this condition.
(CHEST 1997; 111:1772-74)
prior to this illness showed a bulla in the same location as the
fluid-filled cavity. Second, the CT scan of the chest showed the
fluid in the cavity to form acute angles with the chest wall,
suggesting that fluid was in the lung and not in the pleural space.
Finally, a 24F thoracostomy tube placed into the right pleural
cavity7 drained serosangineous fluid but did not drain the fluidfilled bulla. Because of the persistence of symptoms for 10 days,
it was concluded that the contents of the bulla needed to be
drained. Although aspiration of fluid-filled bullae has been
described,3 the amount of fluid contained within the bulla was
considered to be too large to allow for simple needle aspiration.
Thus, an 8.5F pigtail catheter was placed into the bulla under
fluoroscopic guidance
and attached to a drainage unit under
seal. No air leak was observed coming from the water seal,
suggesting that there was no communication of the bulla with the
tracheobronchial tree. However, the bulla was only partially
water
Key words: bullae; closed thoracostomy tube drainage; fluidcontaining bullae
drained; therefore, suction at 10 cm water pressure was applied
"C1 luid-containing bullae have been sporadically reported
-¦- in the medical
literature; often, they are incidental
findings in patients undergoing an evaluation for pneumo¬
case series, including those from our own
institution, have concluded that patients having fluidcontaining bullae follow a benign course and can be
managed by treating the underlying infection and that
surgical intervention is unwarranted.13 We describe a
patient who came to our hospital acutely ill with a large
fluid-containing bulla; use of recommendations from pre¬
nia.1-6 Previous
reports and case series failed to resolve the patient's
symptoms.17 We describe the management of his disease
vious
with a fluoroscopically placed thoracostomy tube inserted
percutaneously and suggest that this may represent a
viable nonsurgical treatment option for cases in which
symptoms do not resolve with conservative therapy.
Case Report
with a 60 pack-year history of smoking
53-year-old
initially presented to his clinic physician complaining of 4 days of
dyspnea and pleuritic chest pain. A chest radiograph demon¬
strated bullous disease bilaterally but otherwise showed no
abnormalities. He was treated with oral amoxicillin, prednisone,
and bronchodilators, all with minimal effect on symptoms. On
return to the clinic, the patient reported night sweats, fatigue,
dyspnea, inand fevers, and a chest radiograph demonstrated fluid in
a bulla
the right side of the chest. He was treated with
intramuscular ceftriaxone and oral clarithromycin but returned 1
week later with increased dyspnea and fever. At that time, he was
referred to the Minneapolis Veterans Affairs Medical Center for
further evaluation.
Examination revealed a white male patient in moderate dis¬
tress with a temperature of 38.9°C. The lung examination showed
diminished breath sounds on the right side with rales located
anteriorly and posteriorly. A chest radiograph showed a fluidfilled cavity, an infiltrate in the right lung, and a pleural effusion
(Fig 1, top). Prior chest radiographs showed a large bulla without
fluid in the same location.
Sputum and blood cultures were obtained, and therapy was
begun with parenteral ceftriaxone and clindamycin with the plan
to manage his disease conservatively. Cultures showed no growth,
and the patient continued to have daily temperatures of 40°C
despite a number of changes in antibiotic therapy. CT scans of
the chest revealed a giant fluid-filled cavity measuring
10X20X10 cm within the right side of the chest (Fig 1, bottom).
Several features of the cavity suggested that it was a fluid-filled
bulla rather than a loculated empyema. First, a chest radiograph
A
man
Figure 1. Admission
and CT scan of the chest
radiograph
bulla prior to thoracostomy tube
showing a giant a:fluid-filled
placement.
Top, chest radiograph demonstrating the giant
bulla with an air-fluid level and blunting of the costophrenic
b: CT scan at the midthoracic level confirming the
angle. Bottom,
of the fluid-filled bulla
10X20X10
presence
measuring
cm,
CHEST/111 /6/JUNE, 1997
1773
other bullae, and an infiltrate in the lower lobe of the
right lung with a parapneumonic effusion.
numerous
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to the tube which led to drainage of approximately 500 mL of
cloudy yellowish-green fluid and to marked improvement in the
patient's symptoms within 24 h. Culture of the fluid for routine
bacteria, fungal, and tuberculous organisms showed no growth.
Since the patient's symptoms improved and because there was
concern about producing a percutaneous fistula in the bulla, the
chest tube was removed. A subsequent radiograph and CT scan
of the chest demonstrated a near-complete resolution of the
bulla, a persistent infiltrate in the right upper lobe, as well as a
shift of the mediastinum toward the side of the bulla (Fig 2).
After completing a total of 3 weeks of parenteral antibiotics, the
patient was discharged on a regimen of oral antibiotics and has
for 8 months.
remained asymptomatic
Discussion
The management of symptomatic fluid-filled bullae
secondary to pneumonia is poorly defined in the medical
literature. Early reports suggested that surgical interven¬
tion may be necessary for patients having fluid-containing
bullae and persistent symptoms.4'6 More recently, Mahler
and D'Esopo7 studied a series of patients with fluidcontaining bullae and concluded that this condition is
usually benign and that surgical resection is contraindi¬
cated. The largest and most recent case series by Leatherman et al1 identified eight patients with fluid-filled
bullae, and the authors also concluded that conservative
treatment with antibiotics alone is sufficient for the treat¬
ment of the large majority of cases. However, none of
these studies specifically addresses the treatment of large
fluid-filled bullae in individuals who remain symptomatic
despite antibiotic therapy and ofbronchial drainage. In the
present case, a prolonged trial conservative therapy had
failed, and surgical resection of the bulla was considered
excessively aggressive. Furthermore, aspiration was
not
considered feasible due to the large amount of fluid
contained within the bulla. However, the percutaneous
placement of a catheter into the bulla led to complete
fluid within the bulla and
drainage of both air and
the patient's fever, fatigue, and
expedited the resolution of for
dyspnea without the need surgical intervention.
There are several reasons why our patient may not have
responded to the conservative treatment advocated by Leatherman et al1 and Mahler and D'Esopo.7 The enormous size
of the fluid-filled bulla may have led to poor antibiotic
penetration into the fluid of the bulla. Also, the bulla did not
appear to be in communication widi the bronchial tree.
Furthermore, the fluid contained within the bulla was sterile,
and we suggest that the patient's continued symptoms were
due to inflammatory factors contained in the fluid. This
would be similar to complicated parapneumonic effusions
which are also sterile and produce systemic symptoms in
patients until they are drained. Although the causes of diis
patient's continued signs of active infection may be many, diis
case illustrates that drainage of the contents of a large
fluid-filled bulla in asymptomatic patient may be beneficial to
the patient and may be accomplished by a relatively easy and
simple method.
References
1 Leatherman
2
Figure 2. Chest
radiograph and CT scan of the bulla following
percutaneous placement of an 8.5F catheter into the bulla. Top,
a: chest radiograph showing the catheter as it enters the bulla in
the midclavicular line and drainage of air and fluid from the bulla,
shift of the mediastinum toward the drained bulla.
producingb: chest
CT scan demonstrating near complete drainage
Bottom,
of the bulla, marked shift of the mediastinum to the right, and
consolidation of the upper lobe of the right lung.
JW,
McDonald FM, Niewoehner DE. Fluid-
containing bullae in the lung. South Med J 1985; 78:708-10
Mahler DA, Gerstenhaber BJ, D'Esopo ND. Air-fluid levels
within lung bullae associated with pneumonitis. Lung 1981;
159:163-71
3 Peters JI, Kubitschek KR, Gotlieb MS, et al. Lung bullae with
air-fluid levels. Am J Med 1987; 82:759-63
4 Rothstein E. Infected emphysematous bullae. Am Rev Tuber
1954; 69:287-96
5 Sanford HS, Green RA. Air-fluid levels in emphysematous
bullae. Dis Chest 1963; 43:193-99
6 Weisel W, Slotnik I. Emphysematous bulla complicated
by hemorrhage and infection. Am Rev Tuber 1950; 61:
724-64
7 Mahler DA, D'Esopo ND. Periemphysematous lung infec¬
tion. Clin Chest Med 1981; 2:51-7
1774
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Selected
Reports