Dan Ostlie

41 statements · 2 topics · summaries given as host listed separately

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once you have A defined uh emyema, i.e., oculations with, you know, greater than 100,000 white cells, then you're down the pathway. Is, is really antibiotics the right choice and probably not, honestly, you need to do something to get, get the, uh, the fibrinous X8 out of the chest

quote · Empyema

I don't think it makes a lot of sense to say you're going to prophylactically do the other side

quote · Empyema

The Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax in adult patients.

guideline · Primary Spontaneous Pneumothorax

For small apical pneumothorax (2cm) after VATS with pleurodesis where the lung is adherent and patient is asymptomatic, observation with repeat chest X-ray in 48 hours is appropriate rather than reintervention.

clinical · Primary Spontaneous Pneumothorax

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Dan's statements about Empyema 11 statements

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Empyema and Pneumothorax: Update Course 2014

Statement Stage 2 empyema is defined by loculated pleural effusion with greater than 100,000 white cells Open

Quotation once you have A defined uh emyema, i.e., oculations with, you know, greater than 100,000 white cells, then you're down the pathway. Is, is really antibiotics the right choice and probably not, honestly, you need to do something to get, get the, uh, the fibrinous X8 out of the chest Open

Statement Once stage 2 empyema is present, antibiotics alone are insufficient and intervention is needed to remove fibrinous exudate Open

Statement The Kansas City trial using TPA showed length of stay 6.8 days, cost $11.6K, 7.5% complication rate, and 15% failure rate Open

Statement Both fibrinolytic trials demonstrate 85% success rate, meaning 15% of patients require subsequent surgical intervention Open

Statement In the Kansas City VATS cohort, 2 children required oscillator support and 1 developed renal failure requiring hemodialysis; no such complications occurred in the TPA arm Open

Statement Ultrasound can sometimes fail to distinguish intraparenchymal necrotic lung from pleural effusion, requiring CT for accurate diagnosis Open

Statement Before the era of VATS, the standard was to wait for a second pneumothorax before performing anterior thoracotomy for bleb resection and pleural abrasion Open

Quotation I don't think it makes a lot of sense to say you're going to prophylactically do the other side Open

Quotation the talc lap thoracoscopically just snows so beautifully everywhere Open

Statement Mechanical pleurodesis is considered adequate when small blood vessels become prominent on the pleural surface Open

Dan's statements about Primary Spontaneous Pneumothorax 30 statements

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Spontaneous Pneumothorax

Statement Primary spontaneous pneumothorax is more common in males by approximately 3 to 1. Open

Statement In a multi-institutional retrospective study of 81 patients from three institutions over 13 years, chest tubes worked approximately 50% of the time for primary spontaneous pneumothorax. Open

Statement Patients who receive chest tube treatment and resolve have approximately 50% failure rate (recurrence requiring reoperation). Open

Statement Patients who fail chest tube management in hospital and subsequently undergo VATS have a failure rate of 25-30%. Open

Statement Patients who undergo immediate VATS have a failure rate of 10-15%. Open

Statement The Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax in adult patients. Open

Statement In most large studies of primary spontaneous pneumothorax, the mean age is around 20-22 years, making this primarily a young adult disease. Open

Statement The average age in pediatric spontaneous pneumothorax studies has been 15.5-16 years. Open

Statement There is no published documentation of tension physiology occurring with spontaneous pneumothorax. Open

Quotation I'm not aware of a published paper that Documents tension physiology for a spontaneous pneumothorax Open

Statement In the 81-patient retrospective study across three institutions over 13 years, no patients presented with tension physiology from spontaneous pneumothorax. Open

Statement In the Midwest Consortium prospective study of 33 patients from 9 institutions over 2 years, 50% of patients failed initial aspiration (had recurrent pneumothorax within 6 hours). Open

Statement Of the 17 patients who failed aspiration, 12 were managed with chest tubes; 83% of those chest tube patients ultimately failed (persistent air leak requiring VATS or recurrent pneumothorax). Open

Quotation 83% of the patients who failed and got a chest tube failed their chest tube Open

Statement Of the 5 patients who failed aspiration and went directly to VATS, none had recurrence. Open

Statement Of the 16 patients who passed aspiration and went home, 40% returned with recurrent pneumothorax. Open

Statement The positive predictive value of aspiration for successful treatment is 83%, with a negative predictive value of 56%. Open

Statement If immediate VATS were performed on all patients, approximately 25-30% would receive an unnecessary operation (those who would have done well with aspiration alone). Open

Quotation I start everybody out with aspiration at this point, I don't put chest tubes in anybody Open

Statement Current recommended algorithm: all patients receive initial aspiration; if pneumothorax recurs within 6 hours, proceed directly to VATS rather than chest tube management. Open

Statement In the three-institution retrospective study, patients who underwent pleurodesis at VATS had the same recurrence rate as those who underwent VATS without pleurodesis. Open

Quotation I do not do pleurodesis. I think that Um, there's good data that suggests that pleurodesis is not beneficial in preventing recurrence Open

Statement A Chinese randomized trial of 289 patients (average age 22) comparing wedge resection with versus without mechanical pleurodesis showed identical recurrence rates between groups. Open

Statement The Chinese pleurodesis study used standardized mechanical pleurodesis with sandpaper, abrading the parietal pleura at the apex until bleeding in all cases. Open

Statement There is no large study evidence that chemical pleurodesis reduces recurrence rates at initial VATS for spontaneous pneumothorax. Open

Statement CT scans may identify blebs that are incidental findings in patients who never develop pneumothorax, potentially leading to overtreatment of clinically irrelevant findings. Open

Quotation CT scans may be overcalling. Findings that may be more common than we've that we've historically have expected and then is that driving us to make a decision based upon a finding that may not be clinically relevant Open

Statement For patients who fail initial VATS, thoracoscopic pleurectomy (stripping parietal pleura from apex down to a couple ribs above the diaphragm) is a salvage option. Open

Statement Thoracoscopic pleurectomy is an arduous, bloody operation that is extremely painful, typically requiring epidural analgesia and 7-10 day hospitalization. Open

Statement For small apical pneumothorax (2cm) after VATS with pleurodesis where the lung is adherent and patient is asymptomatic, observation with repeat chest X-ray in 48 hours is appropriate rather than reintervention. Open

Summaries Dan gave as host · 6 summaries

Recaps of other experts' statements, not Dan's own clinical position.

Summaries Dan gave as host · Empyema 6 summaries

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Empyema and Pneumothorax: Update Course 2014

Host summary Dan Ostlie summarizing the discussion: A meta-analysis of 170 patients showed primary VATS (M3 arm) had better outcomes than chest tube with fibrinolytic followed by delayed thoracoscopy/thoracotomy, but the VATS cases were concentrated in later years creating temporal bias Open

Host summary Dan Ostlie summarizing the discussion: A trial of 60 patients comparing urokinase versus saline with small versus large drains showed small tube with urokinase performed better than other combinations, with no operations required Open

Host summary Dan Ostlie summarizing the discussion: The London (Great Ormond Street) trial using urokinase showed length of stay 6 days, cost 13 (units unclear), 9% complication rate, and 16% failure rate Open

Host summary Dan Ostlie summarizing the discussion: 2001 Adelphi consensus guidelines stated there was no role for simple aspiration in pneumothorax management Open

Host summary Dan Ostlie summarizing the discussion: A Cochrane review (2007) with one RCT comparing manual aspiration versus chest tube in patients aged 16 and older showed 59% immediate success rate with aspiration, 50% avoided hospitalization, and no difference in overall hospital stay or recurrence rate Open

Host summary Dan Ostlie summarizing the discussion: 2010 British Thoracic Society guidelines recommend simple aspiration as first-line therapy for pneumothorax Open