Surface anatomy site for thoracostomy using the axillary hairline

Objective Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space. Methods A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient’s axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces. Results Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower. Conclusions This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains.

Muscle oxygenation maintained during repeated sprints despite inspiratory muscle loading

A high work of breathing can compromise limb oxygen delivery during sustained high-intensity exercise. However, it is unclear if the same is true for intermittent sprint exercise. This project examined the addition of an inspiratory load on locomotor muscle tissue reoxygenation during repeated-sprint exercise. Ten healthy males completed three experimental sessions of ten 10 s sprints, separated by 30 s of passive rest on a cycle ergometer. The first two sessions were “all-out’ efforts performed without (CTRL) or with inspiratory loading (INSP) in a randomised and counterbalanced order. The third experimental session (MATCH) consisted of ten 10 s work-matched intervals. Tissue saturation index (TSI) and deoxy-haemoglobin (HHb) of the vastus lateralis and sixth intercostal space was monitored with near-infrared spectroscopy. Vastus lateralis reoxygenation (ΔReoxy) was calculated as the difference from peak HHb (sprint) to nadir HHb (recovery). Total mechanical work completed was similar between INSP and CTRL (effect size: −0.18, 90% confidence limit ±0.43), and differences in vastus lateralis TSI during the sprint (−0.01, ±0.33) and recovery (−0.08, ±0.50) phases were unclear. There was also no meaningful difference in ΔReoxy (0.21, ±0.37). Intercostal HHb was higher in the INSP session compared to CTRL (0.42, ±0.34), whilst the difference was unclear for TSI (−0.01, ±0.33). During MATCH exercise, differences in vastus lateralis TSI were unclear compared to INSP for both sprint (0.10, ±0.30) and recovery (−0.09, ±0.48) phases, and there was no meaningful difference in ΔReoxy (−0.25, ±0.55). Intercostal TSI was higher during MATCH compared to INSP (0.95, ±0.53), whereas HHb was lower (−1.09, ±0.33). The lack of difference in ΔReoxy between INSP and CTRL suggests that for intermittent sprint exercise, the metabolic O2demands of both the respiratory and locomotor muscles can be met. Additionally, the similarity of the MATCH suggests that ΔReoxy was maximal in all exercise conditions.

Removal of a tracheal foreign body by intercostal thoracotomy in a cat

In this case report, we describe a five-year-old, mixed-breed, neutered male cat weighing 5.7 kg, that was referred to the Near East University Animal Hospital with complaints of dyspnoea, cough and lack of appetite over the preceding two days. Clinical examination revealed marked wheezing during expiration, severe shortness of breath and associated cyanosis. A blood sample was drawn for full blood count, serum biochemical and blood gas analyses. Laterolateral and ventrodorsal radiographic images of the thorax and abdominal region were obtained. A radiopaque foreign body measuring 3 × 9 × 13 mm was detected at the carina of the trachea, aligned in the midst of the fifth–sixth intercostal space. Considering that this foreign body obstructed the tracheal lumen almost completely and had been creating pressure on the tracheal wall for at least two days and also with the aim of preventing potential complications (tracheal rupture, laceration, etc.), after repeated unsuccessful interventions to minimise the time spent under anaesthesia, the object was removed by intercostal thoracotomy. The subject was discharged on the sixth postoperative day and regained its normal state within a short time.

Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma: A Novel Mini-Invasive Technique

We report a novel less-invasive extrapleural pneumonectomy for early-stage malignant pleural mesothelioma without rib spreading. Our approach is unique and differed from the previously reported cases, because we used one skin incision and two small intercostal incisions with videothoracoscopic viewing without rib spreading. The pleural dissection and approach to the hilum for pneumonectomy were performed through a 4- to 5-cm port incision in the sixth intercostal space. Another 4- to 5-cm port was made in the eight intercostal space through the same skin incision and was used for diaphragm resection and reconstruction. At the end of the surgery, the skin incision was enlarged to 8 cm; through which and the first port in the sixth intercostal space, the resected specimen was retrieved. Three cycles of adjuvant chemotherapy followed by radiation therapy were administered. Eleven-month follow-up showed no recurrence.

Effect of ventilation frequency and tidal volume on pleural space thickness in rabbits

The thickness of the pleural space was measured by fluorescence video-microscopy during mechanical ventilation in anesthetized paralyzed rabbits. A transparent parietal pleural window was made in the fourth or sixth intercostal space near midchest by dissection of intercostal muscle and endothoracic fascia. Fluorescence-labeled (fluorescein isothiocyanate) dextran solution (1 ml) was injected into the pleural space via a rib capsule and allowed to mix with the pleural liquid. With the rabbit in the left lateral decubitus position and the pleural window superior, the light emitted from the pleural liquid through the pleural window was measured through the videomicroscope. Both ventilation frequency and tidal volume were varied. Pleural space thickness was determined by in vitro calibration of the pleural liquid at the end of the experiment. At a frequency of 40 breaths/min and a tidal volume of 20 ml, pleural space thickness averaged 35 +/- 15 (SD) microns (n = 7). When frequency was reduced to 8 breaths/min, this value was reduced by 40% to 22 +/- 11 microns. A reduction in tidal volume from 20 to 6 ml at a frequency of 40 breaths/min produced a similar reduction in pleural space thickness. During apnea, pleural space thickness averaged 11 +/- 3 microns. Cardiogenic motion had no measurable effect on pleural space thickness. The increased pleural space thickness with ventilation might serve to reduce the power dissipated due to sliding of the lung relative to the chest wall. Results support the concept of lubrication as the primary function of the pleural space.

THE PASSAGE OF A FOREIGN BODY (FOXTAIL) THROUGH THE BRONCHUS, LUNG, PLEURA, AND THORACIC WALL

The case is presented of a four-year-old boy who ingested a foxtail 5 cm. long. Within 24 hours this produced evidences of right lower lobe pneumonia, the fever responded to sulfathiazole and to penicillin, and the foxtail was removed 14 days after ingestion from a subcutaneous abscess located in the mid-axillary line in the sixth intercostal space. There was rapid regression of the pneumonic signs and evidences of pleural effusion or exudation were lacking. The child recovered without any persistent evidences of intrathoracic damage.

Foreign body in the heart muscle

Hunter, Staub and Lunsford (Arch, of path. A. Lab. Med., Vol. 6, No. 5, 1928) observed a case when a patient with depressive-manic psychosis for the purpose of suicide introduced through the skin of the sixth intercostal space along the left nipple line an aluminum tube from the mouthpiece, 8.9 cm long, and 4 mm in diameter. Within two days, there were no subjective or objective symptoms, and only starting from the third day there was a moderate increase in temperature and an increase in pulse and respiration, which lasted until death, which occurred only on the 9th day, suddenly for 10 with the phenomena of sharp cyanosis , increased heart rate and respiration. An intravital X-ray examination did not reveal any foreign body in either the chest cavity or the heart. An autopsy showed that the tube passed over the apex of the heart through the wall of the left ventricle into its cavity and from there, through the posterior wall, entered into the left lung. There was a slight hemorrhage in the cardiac shirt and fresh fibrinous pericarditis. The authors explain the negative X-ray study by the light permeability of aluminum for all rays, with the exception of the shortest X-rays.

Death from late after heart wounds

The Cossack of the Orenburg Cossack army, 23 years old, received 4 years ago in a fight with a knife in the chest in the area of the sixth intercostal space. After that, two years later, he fell ill with dropsy of the abdomen, which was released according to the patient 3 times.