I'm gonna get started with introductions and welcome everybody to CHEST 2023, welcome to Hawaii. This session is gonna be on management of non-malignant pleural effusion and we have an esteemed faculty here with Dr. Samira Sojai co-chairing this session with me from Vanderbilt. We have Dr. Ren Gillespie from Vanderbilt, one of our thoracic surgeons, and Dr. Chadha from the Icahn School of Medicine. Just some housekeeping issues, feel free to occupy the chairs in the front. On the CHEST app, there is evaluation, so feel free to evaluate each of the speakers in the session itself once the session is completed and that you can claim CME by the end of the conference. So I'm gonna be the first speaker and we're gonna talk about some challenging topics of non-malignant effusions. I'm gonna focus on the multidisciplinary management of chylothorax. We'll keep the questions after all the talks are done, that way we can consolidate all questions and get the opinions of all our experts on the table. So for my talk, I do not have any conflict of interest or any financial disclosures. And I'm gonna start briefly by talking about thoracic duct anatomy, which I think is extremely important to understand as we talk about the management of this challenging entity, chylothorax. So we all know that the thoracic duct begins in the abdomen as the termination of the cisterna chyli. It then enters into the metastinum through the aortic opening of the diaphragm. And then it follows up posterior to the esophagus and anterior to the vertebrae alongside the aorta. And then at the level of the T5, it then turns left, runs, and superior metastinum goes into the IJ and then empties over there. But one important thing to note is that that's basically standard anatomy. But one of the reasons that management of chylothorax could be so challenging is because there are variations, there are duplications, there are anatomical variants that are noted. And these are things that can get affected both from post-operative or traumatic chylothorax and in other scenarios as well. So the purpose of this talk is to focus more on the management aspect, but of course, we cannot forget about the diagnosis of chylothorax. And so if you have a patient with suspected chylothorax, depending upon the etiology or depending upon the clinical scenario, what you're gonna do is do a pleural aspiration by means of either a thoracentesis or by means of intercostal drainage. And what you're gonna see is this classic appearance of this milky white fluid. But you're gonna remember that not all patients with chylothorax do have that classic milky white appearance. A ton of these patients, up to 50%, can have non-milky fluid. And therefore, if chylothorax is in your differential, you should be sending appropriate pleural studies. And so triglycerides level should be sent, traditionally they tend to be more than 110. You should remember that if the patient is NPO, that level could be falsely lower. The fluid itself is mostly exudative, but in patients who have heart failure or other etiologies, it could be transidative. And if you're in doubt, you can send a lipoprotein electrophoresis to determine the presence of chylomicrons in those challenging cases where the numbers are borderline of the patient's NPO. Or you're not really sure and there's a few differential diagnoses. So when you talk about management of chylothorax, it's important to distinguish the etiology of chylothorax, because as you'll see further in the talk, you cannot really determine the optimal management until you find out what the exact etiology is. So for purpose of this talk, we have divided this etiology into two, traumatic and non-traumatic. And when we talk about traumatic, again, there are two broad subgroups. There is a post-operative chylothorax, which includes esophageal surgery, pulmonary resection, other surgeries such as metastatic mass resection, cardiac surgeries, and the chest wall surgeries or bigotomies. But then there's also the blunt trauma, where you have the blunt or penetrating trauma that happens to the chest, where the thoracic duct may get injured at various levels, and you can have a chy leak from the trauma itself. And it's important to distinguish that because the management, depending upon the site of injury and the exact etiology, even in the traumatic subgroup, can be very different. Then the more challenging ones, which is the non-traumatic chylothorax, and these can be broadly classified into two groups. The one is the malignant chylothorax, which as pulmonologists, we tend to face not infrequently in our patients, mostly with liquid malignancies, but also patients who have either tumor in the mediastinum or any metastatic disease in the mediastinum, where you can have obstruction of that thoracic duct draining. And then, of course, the non-malignant etiologies, which are rare, but again, can be very challenging, ranging all the way from lymphangeliomyomatosis to sarcoidosis, heart failure infections, TB infections, yellow nail syndrome. So there are other etiologies of non-malignant effusions, which are rarer and therefore harder to manage. So why do we call chylothorax a multidisciplinary approach? And that's because there are multiple groups that are involved, and it is extremely important to work as a team to manage these patients. There is nutrition medicine. There's, of course, the pharmacologic approach that we have. Us as pulmonologists are doing drainage either both for diagnostic purposes, therapeutic purposes, initially doing tube theracostomies, or even for long-term management of these patients doing palliative procedures. Then there are colleagues from thoracic surgery who are doing these definitive interventions, and our colleague from interventional radiology offering percutaneous interventions, lymphatic interventions for these patients. And so what are the multidisciplinary approaches that we can take? There's, of course, dietary modification. There's pharmacological management. All of us always have that question that comes up in the morning rounds. Should we give this patient one drug, or somatostatin, or acreotide, to manage these patients? There is the thoracic duct ligation with the thoracic surgery colleagues where they can go in and ligate the thoracic duct. There is the lymphangiography for diagnostic purposes, and then thoracic duct embolization, or thoracic duct disruption that can be performed as a percutaneous intervention. And then for patients that require palliative management, either for refractory cases, or for patients with malignant chylothorax, we have pleurodesis, we have total pro-catheter placement, a topic of controversy, of course, and then shunt placements, which are, again, rare, but can be undertaken in terms of pleuroperitoneal or pleurovenous shunts. So I just want to put a brief plug in for a paper that we're actually working on that should be hopefully coming out in the next few months, where because we identified this challenging etiology, what we did was we assembled a group of 27 panelists, and this included a wide variety of experts, including pulmonologists, thoracic surgeons, interventional radiologists, and our colleagues from nutrition medicine, to actually see how we can manage these patients, because the approach could be so challenging, specifically because the etiology could be so variable and wide. So we formulated seven PICO questions, and I'm not going through the questions today, but I will talk about the approaches that we do, and all the data that I present is based upon data that we collected from these papers, and opinions that we got from the experts while formulating this topic. We did review about more than 5,000 publications, and included 62 publications in the final recommendations, hopefully to be coming out in the next few months. So starting with the first approach of dietary management, how do we manage these patients if there's a patient that is presented to you with chylothorax, and then you're called in, or you do a drainage, and you do thoracostomy, and now there's this milky fluid coming out, the chy level is now 7,000. So what are you gonna do for these patients? And these patients may be post-operative, or these patients may be malignant. Well, the first approach is to use medium-chain triglyceride diet, so you use a low-fat, high-protein diet, and to see if these patients respond to that. Some of these patients will, but not all of these patients respond to this measure, and then we have to be more aggressive, where these patients have to go NPO, and then depending upon the clinical condition, also consider total parental nutrition, and again, this is more relevant if you look at the studies, if the data mostly comes from the post-operative management group. What is the success rate of this kind of intervention? As you can see, the number, it could be very wide, ranging all the way from 20% to 76%, and this is because the etiology of the chylothorax could be very different. Again, as I said, the data primary comes from post-operative chylothorax, so if you have a patient with post-operative chylothorax, as an initial step, these patients are started on a low-fat, high-protein diet, MCTs to make sure that the essential, the fatty chains are replaced, which bypasses the circulation, and at the same time, if they're not responding, then you're gonna move to the next step of making them NPO and consider total parental nutrition to slow down. And what does that do? Well, there are two effects. One, if you're gonna be considering a surgical intervention, if you're gonna see if these patients are responding to conservative measures, or can you get away with a non-surgical intervention, or for patients who have non-malignant etiologies, what you're trying to do is slow down the chy leak so then there could be spontaneous healing of that thoracic duct leak, or at the same time, if you're considering an alternative intervention, such as pleurodesis, you can get a pleural space that is dry enough where your pleurodesis will work. Again, as you, all of these studies, these measures were not used by themselves, but they were basically part of a multi-modal approach where other interventions were deployed along with the dietary measures. So that brings us to our second possible intervention, which is pharmacologic therapy. And if you look at the extensive data available, there are basically three or four drugs that have been studied for this subgroup. There is these alpha vasoconstrictors, which are midodrine, and there was a case report, I think, we found of etiolephrine, there's oleostat, but the primary use of the drug is basically somatostatin analogs or octreotide. And so the largest data for this comes from the study, the meta-analysis that was done in 2015, where there was one systematic review performed, which included 19 studies. All of these patients actually had postoperative chylothorax, but the important part to note is that the most of these studies were actually case reviews on animal studies. There were only two studies, which I believe, 20 or 40 patients that had a larger number. What we did see was that consistently across most studies, 16 out of 19, there was benefit of octreotide in this subgroup, but the success rate was variable. And there was a high variability in the quality of the studies, so how much we can infer in the absence of a randomized control trial or specific larger prospective studies is limited. So how do you bring this to clinical practice? Well, we know that from the data that we reviewed that the evidence for use is limited. So when can you consider this? Well, if you have a patient with persistent high-volume chylothorax, then you can, you will do tubular costomy and institute dietary measures in these patients. And if the patient is a candidate for surgery or a percutaneous intervention, that that's what's gonna be a definitive intervention in those subgroups. But if your patient is either waiting for a response and at the same time you're thinking, is there anything else we can do, or the patient is not a candidate for surgery and you're thinking about what are the palliative interventions you can pursue in these patients, these may be subgroups of patients that you can consider octreotide specifically because that has the largest data for use to see if we can either slow down or in conjunction with other therapies, help these patients symptomatically. It is recommended that when we did the survey of the group itself, majority of the panelists did say that they do not use somatostatin analogs or octreotide routinely in their practice. So something that is an option that is available, but the data is extremely, extremely weak. So I just want to present two case scenarios that will try to distinguish how management of chylothorax and the traumatic versus non-traumatic or post-operative versus non-traumatic subgroup can be very different. So consider this first case, which is a 65-year-old female with no major comorbidities, underwent a right lower level of activating for a stage one lung cancer, and then the post-operative course was unfortunately complicated by this high volume chylothorax. This patient, of course, was seen by a surgery team, became NPO, was started on TPN. And so the question for the group in morning rounds is what is the next best step in management? And think about that as we think about our options that we have. And again, don't think of these options as one option being the best option, but how you're thinking of continuum of options that are available in your armamentarium as you're trying to manage these patients. So the first option we discussed was the pharmacological management of somatostatin analogs. Of course, you could do a diagnostic lymphangiography to see if you can identify that site of chylet and then do a thoracic duct embolization in the same case. You can consider repeat thoracic surgery intervention of VATs with ligation of the thoracic duct. Or you're like, okay, this patient is not an operative candidate, or you know what, just from the symptomatic standpoint, let's just put a Plorex in this patient, and then we'll follow this patient as outpatient. And then let's contrast this scenario with a 52-year-old male who actually presents to the hospital with absolutely new symptoms of dyspnea, was found to have a large-sided diagnostic, a large-sided effusion. You do a diagnostic thoracentesis, and you're seeing milky white fluid. Your fellow who's doing the drainage now calls you and is like, hey, the triglyceride levels are 350. What do we do next? You assess and you send for flow cytometry, and then you get a biopsy of the axillary or one of the cervical lymph nodes, and you come up with a diagnosis of diffused large B-cell lymphoma. And now this patient, of course, three days later is dyspneic again. You repeat an x-ray or do a thoracic ultrasonography, and you determine that this patient has reaccumulation effusion. And now this patient does not have a tube thoracostomy, and the question for you and your fellow is like, hey, Dr. Agarwal, what are we gonna do for this patient? And so what are your options? Again, the options are similar. You will undertake dietary modification with pharmacological management with somatostatin analogs. You call your IR colleagues, hey, can you do a lymphangiography in this patient? Can you do embolization? Again, you call your thoracic surgery colleagues, hey, can we do a VATS and a thoracic duct ligation? Or what you say is you call your oncology team, you have a diagnosis, let's start treatment as soon as possible, but the patient is still symptomatic. You decide to take this patient to the bronchoscopy suite, place a trauma per catheter, and then follow up our patient to wait for the disease-directed therapy to work. So this is a video of these options that we just talked about. This is a thoracic duct ligation, a robotic VATS procedure, where what the surgeon is doing is basically isolating the thoracic duct, and once they isolate the thoracic duct, again, Dr. Ganesh, we can talk more about the surgical details if needed, but a suture is being placed to ligate the thoracic duct itself. And so what is the data for thoracic duct ligation? And again, bringing back to the most important question of what is the etiology, because as you can see on the left versus the right of your screen, the management and the outcomes are very different, and the studies actually are very different for groups that had postoperative chylothorax versus those who had non-traumatic chylothorax. So on the left of the screen, what you're seeing is there are multiple studies. There's consistent data that patients who are good reoperative candidates, cessation of leak was seen in 90% of the patients, and again, this data cannot be extrapolated to those who have blunt injury. Compare that to the right of your screen, and what you can see is there are basically three studies which have demonstrated that there's thoracic duct ligation approach in patients with non-traumatic chylothorax. You can imagine most of these patients with concurrent malignancies, poor functional status, not really the best surgical candidates, and you can imagine from the thoracic surgery standpoint, as we saw from the video, there's not really a site of single leak, right? These patients who have diffused chylothorax because of this non-traumatic etiologies, they have leaks at multiple sites, and so it's hard for the surgeon to then go in, and there's one option of doing a mass ligation, but again, the outcomes from those studies are not very promising, and so the surgical options tend to be limited in this subgroup. So what is the other option that we have? Well, we have our IR colleagues who can do a lymphangiography, so you can see what is happening right now is they candidated the thoracic duct either using intranodal approach or the abdominal approach. Then they do a contrast injection. They use an oil-based dye, and then they're basically trying to see is there any leak that is happening, and once they identify the leak, in the same procedure, if they're able to cannulate, what you can see here is they're cannulating the thoracic duct. Once the cannulation is completed, there is a couple of options available. There is either deployment of a coil or you can do deployment of glue, or sometimes those are done in unison, and you can see here a coil is being deployed right there as we see on the top right. A coil is being deployed, and then that is followed by injection of glue, and so you have this option of embolization if you can access the thoracic duct. So what is the data for this lymphangiography and thoracic duct embolization? Again, important to distinguish this both from the post-operative standpoint compared to the non-traumatic group, and you can see compared to a previous slide, the data is slightly reversed, right? So on the left of your screen, what you're seeing is patients who underwent thoracic duct embolization. If they have successful cannulation of the thoracic duct, they have pretty good outcomes, but that is not always the case, and you can see that when clinical success may not match up to technical success, so meaning that even if you have technical success that you have achieved embolization, that may or may not be reflected in the clinical success, and one of the major limitations, as I'm sure you can imagine going back to your centers, and you start consulting our colleagues, and they're like, oh, I've never done this before, right? So we have to understand that it is limited to centers of expertise, so if you're a center that does this about 700 cases a day, then that's a different scenario from a center that does two cases a year, and so it is important to remember what your limitations are. As compared to that, for the group of non-traumatic chylothorax, you can see that the data is pretty good if they're able to achieve cannulation. Again, these patients tend to be poor surgical candidates, and so if they have a high-volume chylic, it is something that can be considered as a reasonable alternative. Again, if they don't have high-volume and low-volume, but it is persistent, we actually have the option of referring them to centers of expertise so they can actually travel, unlike the post-operative patients, which sometimes can be challenging, and again, important caveat to remember from all these studies is that technical success may not translate into clinical success, and so not only does it matter that the pictures look better, but the patient actually has cessation of chyli. So that brings us to the big question, the question that we have discussed at length in our consensus guidelines, so what do you do first? Do you do surgery first, or do you do embolization first? And so again, I want to bring you back to the first slide that I presented, which is it is extremely dependent upon the etiology, and why is that? So let's say you're a patient with post-operative chylothorax. Most of these patients are actually coming out of the operating room with a tube. Let's say this is a patient that does not have a tube for whatever reason, or the chylothorax is delayed, then you're gonna do a tube thoracostomy, and then you're gonna institute conservative measures, and then what you're gonna do is classify these patients into both the speed of the chyli and the persistence of the chyli. So let's say you have a low-volume chyli. You have 200 cc's coming out every day, it is persistent, and at that point, you're thinking about the operative candidacy, but it is reasonable to pursue either approach, so you could do a lymphangiogram with TDE, or a VATS with thoracic duct ligation. But that is very different from a high-volume chylothorax, and this is even more relevant in the post-esophagectomy subgroup, because those in the studies tended to have the best outcomes with thoracic duct ligation. So here, you're gonna assess the reoperative candidacy, and if they are reoperative candidates, then you're gonna pursue a VATS ligation, and then you may pursue a concurrent pleurodesis on the same side during that procedure itself. But if your patient is not a candidate for surgery, they are high-risk, or the mortality, as determined by the surgical group, is extremely high, these are the patients that you're gonna speak to your IR colleagues, and do a lymphangiogram, and do a thoracic duct embolization. It's important to remember that the data, actually, is pretty good for both of these interventions. It's just that if you could do a definitive intervention with surgery, then that's a reasonable approach. So the important thing to remember is that these decisions should not be happening in isolation, but they should be happening as part of your multidisciplinary group, where your pulmonologist, your thoracic surgeon, and radiologist are making this decision together. But again, this is, as I mentioned, slightly different from a patient that has blunt or penetrating trauma, because unlike surgery, where you have some semblance of where the injury might be, in these patients, you may not know, actually, where the injury is happening. And so in these patients, if they present to your ER, these patients are getting a tube thoracostomy, you're gonna institute conservative measures. And then, for the determination of the chyli, the surgeon is probably gonna ask for a lymphangiogram, right, because they don't really know if the injury has happened at the level of T7, or the level of T4. And so if a lymphangiogram is being done, and you have to be at the center of expertise where embolization could be performed, then you can do that as a combined procedure. There's no reason to do a lymphangiogram, and then pursue surgery, and so that may be considered as a single intervention. But if it was unsuccessful, or it was determined that you are at the center where this cannot be performed, then a VAT thoracic duct ligation, especially if you can identify the site of chyli, is an approach with relatively good outcomes, again, extrapolating data from the postoperative chylothorax group. And then, of course, you can consider pleurodesis in this subgroup of patients. So I'll pause for a second, and then talk about reoperative candidates in post-traumatic chylothorax, and then differentiate that from non-traumatic chylothorax, because management of non-traumatic chylothorax could be extremely challenging and different. So in non-traumatic chylothorax, again, these patients are presenting to you, and these patients will now undergo pleural drainage. It may be a tube thoracostomy, or it just may be a thoracentesis, and then you're instituting conservative measures in these patients, and then what you're assessing is the volume of leak. If these patients are reaccumulating in two days, where then you have to go and do a tube thoracostomy, versus these patients already have a chest tube in place, and are having high output drainage, these are patients that you can consider a lymphangiogram, and a thoracic duct embolization. You would call your IR colleagues and pursue this intervention, because these patients are not gonna be able to get out of the hospital. These patients are gonna be distancing so quickly that instituting disease-directed therapy could be very challenging in this group, especially in the malignant subgroup. And then, if that was unsuccessful, then you can consider calling your thoracic surgery colleagues, I'm sure they'll not be very excited, in order to pursue surgery in these groups, to make sure that that's an option with thoracic duct ligation. And this is the subgroup where the mass duct ligation may need to be pursued, because the site of chi leak could be diffused. But again, the outcomes, as I showed earlier, is not the best in that subgroup itself. If it is successful, where you have either stopped the leak, or you have been able to slow down the leak, then you are gonna send these patients, either consider inpatient treatment or outpatient treatment as quickly as possible, because especially in the malignant subgroup, the definitive intervention is that disease-directed therapy. And if these patients do tend to occur slowly, meaning that the intervention was partially successful, then you can consider either IPC or pleuralesis in these patients for symptomatic relief, because the priority is to keep them out of the hospital so they can complete disease-directed therapy, because you're not gonna achieve remission without that. Similarly, if you have a patient up front who has a low-volume, persistent chylothorax, then you would wanna start disease-directed therapy as soon as possible. You may consider either repeated thoracentesis or IPC placement as a stopgap measure, keeping in mind all the limitations of that. Or if you have a patient with low-volume intermittent drainage requirements, then these patients don't even need IPC. What you can do is start disease-directed treatment, and I'm sure all of us have patients that you need to drain every two months, every three months with a chylothorax, and so you're not gonna try to do a definitive intervention of those patients, because the most important thing in that subgroup is the quality of life, especially in that malignant subgroup. So that's pretty much basically the approach that you're gonna take. So things to remember, again, from this flowchart is you wanna define the volume, you wanna define the persistence, and you wanna define the speed of recurrence. And just a quick detail about teloperocatheter placement, the dogma is that they're not safe, but I just wanna highlight two studies quickly that talk about teloperocatheter, where if you look, there was good pleurodesis rates in those patients, and the nutritional outcomes, as long as it's done in a manner and you take out the catheter in a timely manner, it's pretty decent. And so we do not have to believe the dogma that these patients cannot get teloperocatheter, specifically in that subgroup of patients with malignant chylothorax. So just to summarize, conservative management of chylothorax includes dietary measures, such as an MCT diet with escalation to NPO and TPN based upon response, limited data to support the role of pharmacologic therapy. Again, definitive management for high-volume chylothorax includes ligation and embolization. And the first line is based upon etiology, operative candidacy, local expertise, and the most important thing is the multidisciplinary discussion. And then palliative interventions, such as IPC, pleurodesis, or shunts, are for patients that are either refractory or for non-traumatic chylothorax with low-volume output while they're waiting for disease response to the treatment they undergo. And I'll be happy to take any questions at the end. So we'll move on to the next session pretty quickly, and I want to introduce my colleague, Udit Chadha, who is the Associate Professor of Medicine and Thoracic Surgery, and the Director of the Pleural Disease Service at the Icahn School of Medicine at Mount Sinai, and he's going to be discussing the role of fibrinolytics and surgery in the management of empyema. All right, thank you for introducing me, Abhi. This topic, unlike the previous one, does have evidence, but the problem with the evidence is that there's a lot of institutional variation in practice, so there is a lot of controversy that we still haven't addressed, and I'll do my best at suggesting what I think is the best approach to patients with empyema. I have no non-intellectual conflicts to disclose, so let's talk about intraplural enzyme therapy first. That is, fibrinolytic, which most commonly is TPA, and then DNAs. Now, TPA is the only lytic that has been studied in combination with DNAs, so we use it most often, even though randomized data comes with TPA. Now, TPA breaks septations, and possibly because of its secretogenic action, causes a lavage effect, and DNAs, on the other hand, breaks down extracellular DNA and reduces the viscosity of the pleural fluid as a consequence. So by giving these agents in conjunction, what you are hoping for is easier clearance of the pleural space and potentially breaking down biofilms so that antibiotics can penetrate the pleura better. Now, this is a big oversimplification, but it's the simplest way to understand these two agents in conjunction. Now, this is a contrast-enhanced ultrasound, and this is after injection of TPA, and on the left, you can see that the contrast gets nowhere, but after 15 minutes of clamping the tube, you can see some contrast percolating into other locules, and then 60 minutes later, it's everywhere. The purpose of showing this is that I think a 60-minute clamp time is probably appropriate, and that is something that is also, has been treated with debate before. Now, the question is, when do we use it? Do, if a patient presents with empyema, you've diagnosed a patient with pleural fluid or complicated paranormic effusions, do you give it right away, or do you wait and give it? And I've called that wait-and-giving approach subsequent. Now, these are the two big trials that encouraged interest in fibrinolytic therapy, and what is important to see is that the placebo group in both studies did pretty well. So, in the MIS-2 study, which used TPA and DNAs in combination, 84% of the patients did not need any surgical intervention. So, saline flushes alone worked. So, my conclusion from that is, once you insert a chest tube, you verify its patency, and you drain the fluid, wait and watch, but don't wait and watch too long, because within an hour or so, you really know whether that fluid is going to drain or not. You don't have to wait a whole 24 hours to decide whether that tube is going to do its job or not. So, within an hour, you can make a decision that yes, this tube is working, and I can continue saline flushes, or no, it's not working, and let's try TPA-DNAs. Now, the disadvantage of giving everyone TPA-DNAs up front, one is cost. Now, if you do give six doses, it's approximately $7,000. One third of the patients have pain, and one in 20, 5% of them, will have bleeding. So, you're giving a therapy that may not be needed with potential downsides. And in this multicenter retrospective study from 24 centers across the US and UK, which looked at almost 1,900 patients, the bleeding rate was also 4%. But importantly, these bleeds aren't benign. 25% needed surgery, and 50% needed transfusions. So, a 5% bleeding rate is something to take with seriousness. So, make a quick decision, whether you need TPA-DNAs or not, but don't give it to everyone right off the bat. I know that's what MISTU did, but waiting an hour is not gonna hurt anyone. Now, the question is, you see this, does this change the likelihood of giving TPA-DNAs? And the brief answer is no, based on MISTU. Probably the correct answer is maybe, but we don't know. You know, we see these loculations often. Seeing them implies that you could need TPA-DNAs, but it doesn't change your approach. Still try the chest tube with flushing. If it doesn't work within an hour or so, you can give the TPA-DNAs. Let's say you decide to give TPA-DNAs. What dose do you use? Now, the recommended dose is 10 and five, because that's what MISTU did. But remember, MISTU empirically chose their dose. This is not based on any dose escalation studies done by the authors. So, can this dose be lowered? And the brief answer is maybe yes. You can see the small thing I've written on the side there. A study in 25 horses used a median dose of 3.75 milligrams of TPA. And you can only imagine how big a horse, plural spaces, right, compared to us. So, there were two studies that prospectively, non-randomized, looked at this. And this was the ADAPT and ADAPT2 study coming out of Australia. And both of them showed decent outcomes. Approximately a 90% success rate of treatment success and avoiding surgery in patients in whom you used either five milligrams of TPA in the first study, or 2.5 milligrams of TPA in the second study. But what you do see is that providers do tend to escalate the dose if the 2.5 doesn't work. So, bear in mind that you may start at 2.5, but you may have to escalate the dose if you do choose this approach. What is interesting, though, the five milligram study did not show any reduction in bleeding compared to 10 milligrams. But the 2.5 milligram study had only two bleeds. One of them was in a patient who had a dose escalation to 10 milligrams. So, potentially, there may be a difference in bleeding with a lower dose. So, you can consider starting lower. We don't have good evidence to say this yet. But maybe you can do this in somebody who cannot hold the anticoagulation. So, in that same study of 24 centers, there was almost a 10% bleeding rate in patients who had concurrent anticoagulation and TPA DNAs being administered. Now, you give TPA DNAs, do you have to give six doses three days? The answer is no. You know, you give one, two, three doses and you're seeing effect and you've met your desired outcome. That's it, stop. There's no reason to keep giving this. And you can see, even in the randomized trial of the MIS-2, only 33% of the patients completed six doses. And the median number of doses in like two other big studies was only like three and five doses. So, you don't need to complete the predefined, this is not an antibiotic course, so don't have to say everyone gets six doses. So, individualize your dosing, individualize your schedule until you meet your outcome of success. So, the next question is, what is success? Success is either you get the beautiful outcome of complete radiological clearance, you've cleared the pleural space, everything's good and well. Or, importantly, you get a decent radiological improvement and you have clinical defervicence. You are not going to clear the space completely in a majority of patients. So, getting a CT scan and seeing a small residual collection and targeting that collection when the patient is doing much better after your intervention is not the right approach. And you can see this is an old study. Now, this is streptokinase and placebo. You can see that the drug doesn't work. But the point of this is that the first point there is discharge. And then you go up to six months and you can see that in all the patients in the study, the vital capacity tends to improve and the X-ray will get better with time. And this was also assessed in a study out of Australia in 62 patients where they looked for decent radiological improvement and clinical defervicence. Your goal is not to make the X-ray look completely better. Your goal is to make the patient look better. And none of these patients had recurrent infections, no one had delayed complications, no one had residual pleural thickening, and everyone returned to their prior employment. What is failure? If you have no or minimal radiological improvement or you have a lack of clinical defervicence. But you can decide this quickly. Don't wait for six doses of TPA. You know, if two, three, four doses aren't working, 24 to 48 hours should be enough for you to say that okay, this isn't working. Thoracic surgery, please do something. And this is very important because the more you delay that, the more difficult you're gonna make your surgeon's job. Once you get into week two, you can see that these are rates of conversion to thoracotomy from vats in patients with empyema. It goes up pretty dramatically. And really, you know, what you're worried about with surgery is morbidity and maybe a small mortality risk. And if you're going to do a thoracotomy over vats, that morbidity is gonna be much higher. So let's say someone does need surgery. The question is, first of all, why? Why do we do surgery? The goal of surgery is to, again, evacuate the space and re-expand the lung if it's significantly compromised. And this hopefully leads to better outcomes, quicker discharge. Now, the question is again, should we do surgery first? If surgery does everything perfectly, then should surgery be offered first in someone in whom a chest tube and flushing and antibiotics is not working? And we go back to this classic thing where, you know, a legendary physician said that empyema needs three inches of cold steel instead of the fool of a physician and the surgeon didn't support his colleague, saying that I prefer to die by the hand of God than with the help of a surgeon. And unfortunately, both these patients died of empyema, refusing their own divisions or own specialties hands. So this question is still not answered, but we can extrapolate, right? In MIS-2, when you gave tPA DNAs, only 4% of the patients needed surgery. So it's a little dramatic extrapolation, but you'd be operating on 96% of the patients in MIS-2 who would never need surgery. So the real, I think the, simplifying it, I think the best answer is patients who are medical treatment failures or those who have already advanced disease to that fibrotic pleural rind, stage three empyema, the organizing phase all the way on the right, should probably get surgery because it might be better. And just for the sake of time, I'm gonna skip this video on surgery. But again, the goal of surgery, again, is you're removing all the fibrous pleural rind, you're freeing the lung, you're freeing the costophenic sulcus, you're taking out any visceral pleural rind or debriding anything over there as well. And these are studies that are basically trying to compare surgery and interpleural enzyme therapy upfront to see which one is better. MIS-3 is the most promising one that is spoken about a lot. And there is a initial feasibility population of 25 patients in each group where they randomized patients 24 hours after standard care. And really what you can see that the time to intervention was a little longer with surgery, which is expected. And then so far, what they are seeing is that there's no difference in length of stay between the IET and the VATS group. And the largest improvement in quality of life was in the IET group. But this means nothing. This is just to show that there are ongoing trials to determine whether there will be a cohort of patients in whom upfront surgery may be the best therapy. We don't know that yet. So to summarize my approach to managing empyema, is you put a chest tube, and the chest tube should be a small board chest tube, and antibiotics. And within an hour or so, you can decide whether flushing alone is gonna suffice. If it's not working, try tPA-DNAs. Call your surgeons at the same time, get them on board right away, but try tPA-DNAs at that point. And within two to four doses, you know whether tPA-DNAs is gonna work or not. If it is working, which means you have either the miraculous complete radiological resolution, or the more common scenario of partial resolution with clinical defibrillators, that's great, that's success. But if it fails, then they need surgery. But all these decisions have to be made within two to three days. No, don't call the surgeon on day seven or day 10. That's not the right approach. I think that's my last slide, thank you. Okay, and I wanna invite for the next talk Dr. Shojai. Dr. Shojai is Associate Professor of Medicine and Thoracic Surgery at the Vanderbilt University and the Director of the Parallel Disease Service. And she's gonna be talking about an approach to care of patients with hepatic hydrothorax. Welcome, Dr. Shojai. Hi, everyone. It's lovely to be here. Thank you for being here to listen to our talks in this session. What I want to discuss here, first of all, no conflict of interest, is that a lot of the data that you've had here, especially from the first talk, which is chylothorax and this one, which is nonmalignant pleural effusions, especially hepatic hydrothorax, come from data that are very limited. So that's one of the things that I want to disclose is that it's super important to keep in mind a lot of what we refer to comes from retrospective studies. A lot of them come from case reports and case series. And so what I'm gonna try to do during this talk is to highlight the study's limitations. So when you go back and use those studies in your practice, you sort of see if this actually applies to your population and what are the selection biases to watch out for. So I'm going to briefly talk about the epidemiology and prognosis of nonmalignant effusions in general, and then I'll focus on hepatic hydrothorax. So we'll talk about the role of different therapeutic measures, and we'll go over each one of these step-by-step. So a little bit about epidemiology. 1.5 million nonmalignant effusions in general in the U.S., and about 1.1 to 1.3 of them come from heart failure, liver failure, and generally nonmalignant effusions, as opposed to malignant cases. These lead to about 187,000 thoracentesis per year, and we know that the nonmalignant cases could be either infection, inflammation, or they could be translative effusions, mostly due to organ failure. I want to highlight this very elegant study done by Steve Walker in Nick Meskell's lab in England. This is a study looking at 356 patients prospectively, and following up the patients for about 12 months to decide what their diagnosis was. These diagnoses were decided by two separate pulmonologists who were blinded to the case. Took about seven years to complete this study, and here's what they found. So first of all, just a snapshot of what the population looked like. About 40% of the patients actually had infection, so infection was the largest population that was included. About 20% were, 25% were heart failure, and about 20% of them had bilateral effusion, but what I want to point out is they used multiple logistic regression to look at different predictors of outcome in these populations, and here's what they found. Patients who had translative effusion and those who had bilateral effusion fared far worse than the other patients, and this is really important to keep in mind, and so these were mostly patients who had organ failure. To break this down further, they looked at different organs and noted that really patients who suffered from liver, kidney, or heart failure were the patients who did the worst. Their one-year survival was quite poor, and this is what I want to gather from this slide. Something that I want you to take away from this talk is that these patients are really just non-malignant effusions. I really refrain from calling them benign because the perspective as you walk in to see this patient is that this is a patient who needs palliative measure, just like when you see a patient with malignant effusions, and if you have that perspective in mind, your care may be a bit different. So how about hepatic arteriosclerosis? Let's just go over a case just to remind everybody of what you see so frequently in practice. 54-year-old gentleman comes in with Nash cirrhosis, has had three thoracentesis. He's responded beautifully every time, significant improvement in symptoms. Every time you drained about two liters of fluid, and the patient eventually was sent for VAT, for tips, responded nicely for about two months, and they're back again because fluid is back again. This is not uncommon. As opposed to chylothorax, which we were talking earlier, which is not as frequent, this is not very uncommon to see in our practices, mainly because hepatic arteriosclerosis keep coming back. And so what do you do with these patients? So hepatic arteriothorax happens in about two to 3% of all effusions, so not as frequent as you would think. Having said that, about 21 to 26% of them are refractory. What refractory means here, that's a key word here, is refractory to medical therapy. So this is a patient who's entirely optimized on salt restriction and diuretics, and is still coming back with recurrent pleural effusion, as well as sometimes ascites. About 85% of these patients have right-sided effusions. So I've highlighted this slide here in the year 1986. This was a protocol that was put out by hepatologists primarily for the management of hepatic arteriothorax. We have actually not changed this up to just a few years ago. Most of what we did was really assess the patient, see if they're a transplant candidate, followed by tips, if the patient is a tips candidate, and then followed by repeat thoracentesis. The changes that have happened within the past decade I will highlight in the next slide. So because the number of comparative trials in this field is extremely low, I have tried to include all of them. This is one of them. The numbers are very small, but what it shows is the medical management group, which is those who went through medical therapy but also received thoracentesis, had a very poor survival compared to those who had tips and transplant. Now, I want to highlight these two points here. The tips group was only eight patients, and transplant was only five patients, so the comparison is not easy. But what it's trying to show is that the survival is about a year, median of about a year, but once you go back and look at the data, you realize the median is actually 167. These patients do quite poorly and die rapidly, not because of their effusion, because of their organ failure, but the effusion debilitates them further. I don't want you to necessarily look into the details of this table. What I want to highlight is the results. This is a meta-analysis looking at eight studies. The last one was from 2010, and there are numerous studies following this, which I'll highlight soon, but what it shows is that patients who received tips responded in about 75% of the time. What it doesn't say is that only 50% of the patients who were referred to tips received tips, so tips does not happen for everyone. Not everybody's a candidate. Among those who are candidates, the 75% that respond don't respond fully. 50% respond completely, but 25% have recurrence of their effusion, and they have to come back and get re-procedurized. Among these, about 25% of them developed hepatic encephalopathy, about 20% of them died within a month, and survival was about 50% in one year. What about the data following 2010? So it's actually not that much different, unfortunately. Although the stents have changed in quality and type, what is shown repeatedly is that patients' risk of readmission is significant, and especially as their age goes up, it is shown that patients still respond to about 50% of the time, and most of them die within one year, or 50% of them die within one year. There are a couple of studies that are currently ongoing. Most of these are in Europe, but there are a few studies that are looking at the type of stent and the risk of re-canalization, or opportunity for re-canalization in these stents, so I look forward to seeing what these show. How about repeat thoracentesis? Again, not many comparative studies. Here's a study that we did looking at those who received repeat thoracentesis and hepatic thorax, and those who didn't, and so what we showed here was that patients' overall risk was actually quite low. Repeat thoracentesis is not a very high-risk procedure. Among 274 patients, there were only 17 complications in hepatic cardiothorax groups, so that's not a large number, but what it shows is that repeat thoracentesis is definitely more risky than in hepatic cardiothorax than in those who don't have hepatic cardiothorax, and the risk continues to increase, and it especially increases when the chance of complication was present in a patient in a prior procedure. Another thing that we noted was that increasing MELD score by one unit would increase your odds of developing a complication by one, and platelet counts of less than 50,000 would increase the odds of bleeding a hemothorax by about 10%, which is important to keep in mind. Regardless, I think repeat thoracentesis is still a safe choice. The problem with this study is that it didn't look at the patient's quality of life. Some patients had up to eight thoracentesis, which is very burdensome for both the patient as well as their family, and this is something that is significantly lacking in most hepatic cardiothorax studies, those patient-centric outcomes. We'll get back to that in a bit. I've highlighted a few papers on role of surgery in patients with hepatic cardiothorax. As you can see, the data here is very, very sparse. I've highlighted one that has 18 patients. It's actually one of the largest numbers, believe it or not. 18 patients selected over a period of five years. What this tells me is very high likelihood of selection bias. Not everybody can go through this. Among these patients, only about half of them responded post-surgery, and about 39% died within three months. Very high morbidity, so important to keep in mind VATs and talc pleurodesis in this population is not like every other case. If I were to call Dr. Gillespie now and say, I have a sick patient with hepatic cardiothorax, she would say, I don't know if I would want to take this patient to the operating room. How about chest tubes and indwelling pleural catheters? So there are lots of studies in this area looking at chest tubes. Most of them are retrospective. I've highlighted this one because it's done a good job of including the complications following a chest tube. The problem with this group is that a chest tube goes in and then you leave the patient, and you don't clamp the tube. So the goal is to empty the chest, and these pleural spaces keep emptying, and so a lot of patients end up with renal failure or electrolyte imbalance. About 33% of the patients in this study died from empyema within three months, and about 80% of them had at least one of these three complications that I just mentioned over a very short time period, so over a period of 30 days. For this reason, to most hepatologists, a chest tube is considered taboo, and tunnel pleural catheters, which are also tubes in the chest, have been treated that way from many people's perspective. What about tunnel pleural catheters? There are a number of papers that have looked at this recently. Only two of what is out there is prospective, and almost none of them look at patient-centric outcome except one, which I will highlight with more care at the end. But really, we don't have much patient-centric outcome in this area, and then as the number of cases increase, as you can see, most of the sample sizes are small, but once you increase the sample size, you'll notice that some patients die with tunnel pleural catheter because of pleural sepsis, not just because of their liver failure. So let's talk about a few of these. Here's one study, a single-center study, looking at patients with hepatic artithorax who ended up with IPCs. Most of these patients actually were bridged to transplant. Mean time to pleurodesis was 118 days, and they reported pleurodesis in about 14% of patients. What I want to highlight here is that all of the patients who pleurodesed, pleurodesed after they received transplant, and so I would really take that data with caution. Every single patient that was considered pleurodesed had their catheter removed about two weeks after transplant. Their risk of complications here, about 16% in Paima, that's the highest complication rate, which is high for IPCs, and it's hard for this population, especially, they're very immunosuppressed. And they also looked at BMI and albumin and noted that albumin level decreased significantly after IPC placement. We don't know what the relevance of this is clinically at this point. Another study, similar, retrospective, but multi-center, looking at 79 patients. In this study, we included 58 patients who were mostly palliative, but there were still a group of patients who were bridged to transplant. Median time to pleurodesis, 55, and spontaneous pleurodesis rate of 28%. I will get back to this in just a few minutes, but in terms of complications, so the two complications that we worry about with chest tubes, renal failure and electrolyte imbalance, were not significant in this group. And I think the main reason is that the goal is not to drain and empty the space. The goal is to drain a liter every other day, and that's what most centers did. Again, complication was the most common presentation, and PAIMO was the most common complication, and two of the patients died from sepsis related to their pleural space, and one of them was a transplant candidate, which is unfortunate and important to keep in mind. Here's a competing risk model looking at catheter removal, considering infection, and catheter dislodgement and death as competing risk. What I want to highlight here, again, is that 28% pleurodesed, basically they met our pleurodesis definition that was set up front, but of those patients, 11 of them had their pleurodesis after they received transplant. So again, I think our idea of pleurodesis in this group is highly overestimated. I think most of these patients who went through transplant had their portal hypertension resolved, and so they didn't have a reason to develop large effusions, and they didn't have ultrasound exam to look at their chest to say, no, there's actually pleural space symphysis. So I really want to, one, is pleurodesis a good endpoint to begin with, but most importantly, I don't think that our data reflects what is true. Let's skip from this for the sake of time. I want to go over this randomized control trial, which was also done in Nick Mascow's group. This is a study done in 13 centers. They looked at and compared IPC versus thoracentesis, and their primary endpoint was three months, so 12 weeks, breathlessness score, and so it's a difficult area to recruit. They screened 22 patients and enrolled 70 patients. Here's a snapshot of the patients. Our focus is hepatic artithrax. A lot of patients were included in this group, but only eight of them received repeat thoracentesis versus eight who received IPC in the hepatic artithrax group. Here's how they did. There was no significant difference in breathlessness score, quality of life, and even hospital length of stay among the entire population, but when you looked at the subgroups, even within the hepatic artithrax group, there was no significant difference. Although the numbers are small, eight in each group, I think this is absolutely the only study that has looked at this. It's important to consider this as looking at patient-centric outcomes in a rigorously monitored randomized trial. One thing to keep in mind is that there was no infection among the groups of hepatic artithrax. Again, the numbers are small, and in an RCT, which is rigorously monitored, I think the risk of infection may be lower, so I would keep that in mind cautiously. Here's a guideline that is yet not published looking at a management of hepatic artithrax. I'm going to blow this up so people can see it. So what do you do for refractory hepatic artithrax? I think the first thing, what I would love for you to take away is multidisciplinary management. So if a patient comes in with hepatic artithrax and you're stuck with repeat thoracentesis is not the best way, I want to do something else, I would include everybody in your team. That's a hepatologist, IR surgery, and a pulmonologist. It's important to have all those players, and especially your transplant surgeons, who may say, please don't put a tube in my patient's chest. They're going to surgery very soon. We're listing them soon. So this is important to keep in mind. If they are a transplant candidate, then they could continue to go on their serial thoracentesis. What we have done with this is that what if the patient is on the list, but it takes longer than two months? Then if you want to consider other methods, you can potentially do that. But again, discuss that with your surgeon. And if they're not a transplant candidate, are they a TIPS candidate? And if they go through TIPS, then that's great. For those who are not a TIPS candidate, they can undergo serial thoracentesis and then consider IPC, consider surgery if possible. But again, I would take all of that within a discussion of a multidisciplinary team, as well as your patient, which is, I think, very, very important. One other thing that I want to point out is, I don't know how many of you send your patients for TIPS revision. I try to do that every time. If a patient responds to TIPS beautifully, when they come back, and if their effusion is back again in two, three months, I often send the patient back to IR for TIPS revision and at least assessment. And not infrequently, the TIPS revision actually happens and patient responds again, at least for another few months. So something to consider, which doesn't have enough evidence on it, hopefully soon. So include a multidisciplinary team around you when you take care of these patients. Consider transplantation as the first and only curative method. So really try to get these patients to their transplant team and their hepatology team, if that's possible, to consider transplant. In terms of management of symptoms, serial thoracentesis is overall considered low risk and a good method. About other methods to use for patients who are undergoing transplant evaluation, serial thoracentesis is an option. If they are not and you want to consider other methods, chest tubes and pleurodesis are generally not reported to have good outcomes. So I would try to avoid them as much as possible. And IPCs, especially once you discuss this with your patient and your multidisciplinary team. A little bit about the questions that are still missing here. So what is the efficacy of talc pleurodesis in this population, which has no comparative trials? What is the optimal drainage if a patient has IPC, which has no data? And I think it's important to keep this in mind. What is the role of ambulatory talc through IPC in this population, which has no data? And finally, the management of ascites in the context of hepatic cardiothorax. Again, none of these areas have data and hopefully will be topics of future research. And with that, we are ready for our next talk. Thank you. Now, it's my pleasure to present the next speaker, Dr. Erin Gillespie, who is a dear friend and colleague. Dr. Gillespie is the Director of Thoracic Robotic Surgery at Vanderbilt currently, and I'm very sad to say, but very happy for her to say, that she's soon joining Crichton University as the Chief of Thoracic Surgery there and as an Associate Professor of Thoracic Surgery. Looking forward to hearing this. Thank you. Hello, everybody. How cool that we get to all get together in such a beautiful location. I'm gonna wrap up this session talking just a little bit about sort of management of hemothorax and how I approach it. As mentioned, my credentials are changing just a little bit in the near future. So if you have questions, you'll be able to reach out to me at a different location in a couple of weeks. These are my disclosures. None are pertinent to this talk, other than things bleed and I'm one of the people that gets called to fix them. I'm gonna skip over our objectives and let's dive right in. So let's talk a little bit, what is a hemothorax? Very simple, right? It's a collection of blood in the pleural space. Now, there are some more complex definitions that we can play with. So what the percentage of hematocrit is. The caveat is, the longer the blood's been in there, it can actually change the ballast. It's oncotic, it'll pull fluid in, so I don't hang my hat on specific hematocrit numbers. What's our etiology? Well, a lot of this is gonna be traumatic and most of the data that we have is gonna come from the trauma literature as a result. And just like a lot of the talks you've heard today, there's a lot of controversies, there's a lot of arguments. Every paper that comes out is saying that the other one is wrong. I'm gonna touch on some of those controversies and try to give sort of practical guide for things that we think about. Coagulopathy is definitely a problem. Myatrogenic, so we cause bleeding as well. Line insertions. Vascular and then neoplastic. So I put neoplastic on here because I think this is an important one. If you see nodularity and you're thinking of something like mesothelioma, you're thinking of something like angiosarcoma, you're gonna think about a different treatment approach. You might not just wanna put a chest tube in this patient, you might wanna do some kind of an examination, pleuroscopy, vats, to be able to help make a diagnosis as well as treating the problem. Tenants of management. So first and foremost, we need to address the cause. So again, a lot of these patients are coming in as traumas, emergencies. ATLS protocol, right? So we're going through our ABCDEs. Even if it's a post-operative surgical patient, so after cardiotomy, after thoracic surgery, after any kind of surgery, resuscitation is so key and then getting that patient managed, identifying the source. We really wanna control the pleura, right? We wanna make sure that we're evacuating the entire hemothorax and then also achieving excellent pulmonary expansion. And then of course monitoring for complete resolution. And we'll talk a little bit about how we think about complete resolution. So what are a couple of our treatment options? Well, I really sort of put them into two different categories. And so one is going to be thinking about our chest tubes, the other one is surgical management. And why are we so keen about making sure that our evacuation is really great? Well, one of the potential risks of leaving blood in a pleural space is of course empyema. And then I also think about two other categories. So early entrapment. So if you have a patient who has blood in their chest, it's pushing on the lung, it's causing pulmonary collapse, you've got atelectasis, this can lead to pneumonia, we've got sick patients potentially on the vent and then that can potentially progress to empyema as well. And then late entrapment. These are the patients that we've sort of had a long standing either fluid or blood collection in the chest, they develop a fibrothorax and now there's a really thick rind around that lung, which makes it difficult to achieve expansion with any intervention other than surgery. From a surgeon's perspective and you've heard this from all of my esteemed colleagues today, the longer you wait, the harder the surgery is. And so I'm gonna bring in some of the time considerations as we talk too. So what are some of the things that we think about when we're choosing an intervention, right? So a lot of people panic, should we put in a chest tube or not? I'm gonna tell you, honestly, I think for a hemothorax, a chest tube as a starting point is always okay. So I'm gonna caveat the rest of these comments with that. So first and foremost, what is the underlying cause? What is causing the bleeding? There are some things that are surgical emergencies causing bleeding that we don't need to debate about, right? That's very, very easy answer, that patient needs to go to the operating room. How much drainage do you need? What size of tube? So I think that controversy is one of the biggest within management of a hemothorax, even within the trauma literature itself. Now, I will tell you this, everybody finally agrees that a 36 and a 40 French chest tube should not be put in. I think that's a victory. Nobody needs a garden hose. Now, there are some people who still firmly believe that 28 is a really great place to start. There are some programs that have moved all the way down to pigtails, and we're talking about eight French, we're talking about 14 French. Here's what I think that we actually should be doing. I think size is an important consideration, but even more important is getting a tube in safely and getting it to the right location. I think the argument should be less about size, okay, not 40, don't put in the 40, but when we're thinking about the other pieces, getting it in the right location and getting it working effectively. If it's a really, really big volume, sometimes having something just a little bit bigger is gonna help, because you can get more flow through that tube, right? Pusui's law, we've got radius to the fourth power divided by eight times length. We need something that's gonna be able to help us drain. Think about the patient's body habitus. If you have someone who has a huge amount of subcutaneous tissue, trying to get a tube in that's not going to kink in the sub-Q is gonna be really, really important, and making sure we're thinking about fluids, we want it posterior, we want it basilar. What do you have available to help you put in the tube? Do you have an ultrasound available to you in the trauma bay? Most of the time, they don't have an ultrasound, they're putting in things blindly, and so being able to make a little incision and direct the tube with your finger can get it in a higher percentage of time into the right location. We want to achieve expansion and complete drainage, really, really, really key thing in balancing our patient factors. So surgical indications. As I mentioned, some of these are sort of easy answers. If we know that a patient has a great vessel or chest wall injury that is just absolutely exsanguinating, that patient needs to go to the operating room so we can get control of that. If the person has tamponade, we gotta get them to the operating room to address that, unless you have someone who can run down and put a quick tube in the pericardium. Other things that we think about, so hypovolemic shock with injury or huge amounts of blood out of a chest tube that's already placed, so 1,500 mLs in a 24-hour period or 300 to 500 mLs for two to four consecutive hours, and we think about those numbers both post-trauma and also post-surgery. What about sort of delayed kind of indications for intervention? So retained hemothorax is one, and we can think about that not just for delayed surgery, but also delayed chest tubes, and so usually we talk about a delayed hemothorax as being sort of residual blood in the pleural space after 24 hours, and then times that we think about really kind of taking patients to the operating room in a more timely fashion is tubes not draining well, or you find a missed injury on imaging. So speaking of imaging, images are sort of challenging when we're talking about retained hemothorax. Chest X-rays have some shortcomings because you can hide up to a liter of blood. Remember, some of these patients are sick after surgery, they're sick after trauma, they might have cancer. We're getting chest X-rays that are portable in the bed, they're crooked, they're sort of at weird angles, not always a great way to be able to evaluate our patients, and sometimes we're looking at things sort of like this little bit of a haze down in that left lower lung field, and actually, as it turns out, it's hiding a huge amount of fluid, and so chest CT is a much superior evaluation when we're thinking about evaluating a patient for a retained hemothorax. So if I'm getting a consult on one of these patients, hey, can the chest tube come out? How are things looking? I say, hey, let's think about getting a chest CT scan because that's really gonna help us with decision making. Now, if we have a patient who does have imaging that's concerning for a retained hemothorax, how do we make a decision about a second chest tube versus an operation? Well, I think one of the very first questions is, take a look at what your tube is doing. Is it kinked? Is it in the right location? Do we think that it has been placed in a way that's going to accomplish success? And if it's not, then I think it's very reasonable to think about the placement of a second tube in a more controlled setting. You can use ultrasound, you can use all of your ancillary techniques to be able to help you do that. I think the other big thing to think about is the volume of contents. And so if it's a pretty small volume, and usually the threshold that we use is about 300 mLs, it's actually okay not to go after that aggressively. If it's anything more than that, you're likely to have a lower probability of reabsorbing that and achieving long-term complete expansion. Things that we think about as far as getting a patient to the operating room just a little bit faster are maybe it's not a super easy location to get a drain in. Maybe there's a very high volume of residual contents or a suspected injury like a diaphragmatic injury that can hide sometimes. Some of the predictors of failure of two things. So one, chest tube not working effectively, and two, patients actually having to be converted from vats to open if they need to be taken to the surgery. Higher injury severity score. So if we're thinking about trauma patients coming in, the more injuries they have, the higher likelihood they're gonna need a more aggressive intervention. Higher volume of index hemothorax. Parietal and visceral pleural thickening, just like empyema, are sort of going to predict that our lung is not going to expand as well. And interestingly, for the trauma population, a lack of use of antibiotics has consistently been associated with higher risk of bad outcome at the index setting when a chest tube is being placed. So what's the timing sweet spot? So that's a huge area of debate and controversy, and it's something we think about in all the different facets of pleural disease. For me as a surgeon, one of the things that I think about a lot is the later the vats is performed, the higher risk of needing to convert to open. And so there's a lot of papers that have come out trying to stratify what that timing point is. I think most people can agree now that ideally we wanna be before that 10-day mark, but the earlier the better. And so there's a few papers that have come out trying to stratify patients. So before 10 days, and then we've got people like two to four days, four to six days, greater than six days, and consistently we're forgetting somewhere in that sweet spot between two and four days, patients do better, higher rates of minimally invasive intervention. And so the Trauma East Guidelines that were published in 2021 said, hey guys, we should be doing this and making these decisions in 72 hours if we can, because it's going to have a higher ability of completing the surgery minimally invasively, higher rate of getting complete pulmonary expansion. And so I think that's something that we should think about no matter what the etiology is of hemothorax. How are we doing the surgery? So patient is getting a double lumen tube placed. We always perform these in lateral decubitus position. Obviously VATs, very small incisions. You can do it VATs or you can do it robotically versus an open thoracotomy. The nice thing about VATs is we're usually not breaking ribs. Patients might already have broken ribs. We can still do VATs in that circumstance, totally fine, versus an open thoracotomy where we're usually thinking about shingling a rib and we're actually cutting through musculature. So key goals and things that I'm thinking about as I'm taking the patient to the operating room, are they going to be able to tolerate lung isolation? How bad are their lung injuries otherwise? What else is going on with them? If they can't, then thinking about doing a thoracotomy in those patients and just gently moving the lung out of the way is a completely fine option. So double lumen tube, are they going to be able to tolerate? What are the mechanisms that we can use to completely evacuate the clot and blood? We need to completely free the lung from everything, getting into the fissures, getting all around the hilum, get everything freed from the chest wall. Repairing an injury if present. I put this in because it's really important. Sometimes patients have rib fractures, things like that. If they're in the ICU and they're getting repositioned, sometimes those ribs can cause recurrent shear injuries to intercostal vessels and so you can get re-bleeds. So thinking about additional injury is really important. Obviously, some of these patients are going to be developing empyemas depending on the time period in which we get consulted and so managing that concomitantly. I think about areas of air leak, necrosis, lung injuries from whatever the underlying cause or kind of etiology of the hemothorax is. And then one of the huge most important things I think about is when we're in the operating room, put in enough tubes and position them well. There's no excuse not to have perfect chest tubes if you're putting them in and positioning at that time. And then I have a very, very low threshold for bronch because that can help to get great pulmonary expansion. A lot of times there's some blood in the airways as well. Sometimes there's mucus plugging in the airways as well and it can help to enhance lung expansion at the end of the surgery. Surgical outcomes are actually very good for this. Now, with every surgery we do, with anything we do, there is morbidity, right? And so risks that we think about, bleeding, infection, atrial fibrillation, chyotic fortunately is low. You will never meet a thoracic surgeon who names their kid Kyle. But vats can be very, very, very effective in the post-surgical and addressing a site of bleeding, achieving complete expansion, retained hemothorax after surgery, early vats very effective with morbidity, mortality on par with what we'd expect for other types of vats and interventions, wedge resections, things like that. Surgery versus a tube. Surgery does have slightly lower reintervention rates, which is great. So that is the reason why we really wanna move along that pathway pretty quickly. Vats definitely better than open when it's an option, shorter length of stay, less pain, fewer complications. But at the end of the day, you should never let the size of the incision stand between you and a good surgery. So at the end of the day, the patient has to get a really effective surgery, because that's gonna help to have a better outcome with fewer reintervention rates. So as we think about everything overall, I didn't include the sort of beginning part of the acute. We know the acute, it's high volume bleed after a trauma, after surgery, those patients are gonna go straight to OR. The retained hemothorax are where the decision making is a little bit more complex. Get a CT scan, chest x-rays aren't perfect. If you have less than 300 mLs, you can consider observation or you can consider a surgical evaluation. Now, they are starting to talk about using fibrinolytics in the setting of hemothorax. This is a little bit controversial. It is not approved. I am not going to get into the nitty gritty with that, because it's still early days with gathering information. Most of the studies are fewer than 10 patients. And so I'm gonna kind of, there's stars over by that. If it's greater than 300 mLs and the patient's a good operative candidate, get that patient to the operating room quickly, ideally in that two to four day period. And then if it persists, additional intervention is required. Thank you so much for your attention. Enjoy the rest of the conference. We're happy to take any questions. Thank you.

chylothorax

empyema

multidisciplinary approach

fluid analysis

triglyceride levels

pleurodesis

surgery for empyema

hepatic hydrothorax

chest tubes

individualized management