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An Analysis of Patients who Underwent Tube Thoracostomy in the Emergency Department: A Single Center Study

An Analysis of Patients who Underwent Tube Thoracostomy in the Emergency Department: A Single... costomy in the emergency department (ED). The secondary aim of the study was to evaluate parameters such as the diagnosis for which the patients underwent tube thoracostomy, the imaging techniques used during diagnosis, and complications related to the procedure. MATERIALS AND METHODS: This prospective study was conducted in the ED between June 1, 2015 and May 31, 2016. The study included 125 patients aged >18 years, of both sexes, who presented to the ED during this period and who underwent tube thoracostomy. RESULTS: The patients comprised 91 (73%) males and 34 (27%) females. Of the 125 patients, 21 (17%) presented directly to the ED, 8 (6%) were referred from a polyclinic, 82 (66%) were brought by ambulance, and 14 (11%) were referred from another center. Reasons for presentation were traumatic in 64 (51%) and non-traumatic in 61 (49%) patients. The leading diagnosis was pneumothorax in 98 (78.4%) cases. The procedure of tube thoracostomy was performed by an emergency medicine (EM) resident for 26 (21%) cases and by a thoracic surgery resident for 99 (79%) cases. Complications were observed at the rate of 3.8% in the procedures performed by the EM residents and at 4% in those performed by the thoracic surgery residents. The mean follow-up time of the patients with tube thoracostomy was 7.5±4.4 days. CONCLUSION: In intensive trauma centers, in particular, and in centers where procedures such as central venous catheterization and diagnostic thoracentesis are frequently performed, it would be useful for EM physicians to undergo training in performing tube thoracos- tomy to a level where they are able to intervene in an emergency situation such as traumatic or iatrogenic pneumothorax. KEYWORDS: Emergency department, pneumothorax, tube thoracostomy Received: 08.05.2018 Accepted: 02.07.2018 INTRODUCTION Tube thoracostomy (TT) is a surgical method that is commonly used by thoracic surgeons. Because it is a life-saving procedure, general surgeons, intensive care unit (ICU) physicians, and emergency department (ED) physicians may be required to perform it [1]. TT is defined as a procedure in which a drainage tube is placed to remove air, fluid, blood, th th pus, or bile from the pleural cavity. The procedure is usually performed from the 4 or 5 intercostal space over the anterior or mid axillary line [2]. Tube thoracostomy was first described by Hippocrates. In 1876, Hewett was the first to use a completely closed intercos- tal drainage system [2]. In the 1950s, Maloney and Gray introduced the terms “tube thoracostomy,” “closed thoracos- tomy,” and “closed drainage” for chest trauma patients [3]. Indications for TT are pneumothorax (PTX), hemothorax, pleural effusion, chylothorax, and bronchopleural fistula [4]. The aim of this study was to determine the demographic and clinical characteristics of patients who underwent TT in the ED. Parameters such as the diagnosis for which TT was performed, the imaging techniques used during diagnosis, and complications related to the procedure were evaluated. MATERIALS AND METHODS This prospective study was conducted with patients aged >18 years who underwent TT in the ED between June 1, 2015 and May 31, 2016, at our emergency medicine (EM) department after obtaining approval from ethics committee of Erciyes University Clinical Research (Date: May 22, 2015; number: 2015/264). Informed consent was obtained from all the patients. Address for Correspondence: Necmi Baykan, Clinic of Emergency, Nevşehir State Hospital, Nevşehir, Turkey E-mail: drnecmibaykan@gmail.com ©Copyright 2019 by Turkish Thoracic Society - Available online at www.turkthoracj.org 25 Turk Thorac J 2019; 20(1): 25-9 The following criteria for each patient were recorded: name, 20.8% with pneumonia, and 4.2% with trauma. In patients age, and sex, the diagnosis for which TT was performed, the presenting with trauma, the most frequently observed addi- etiology of the diagnosis, whether or not there was any other tional thoracic pathology associated with trauma was rib system pathology in addition to the main diagnosis, the type fracture in 35.2%, followed by pulmonary contusion in 20% of surgeon performing the TT (thoracic surgery resident or (Table 1). EM resident), whether or not complications developed after The most frequent concomitant systemic pathologies other the procedure, and if so, the nature of the complications. than thoracic in the trauma patients were observed in the Finally, the ED outcome of the patient and duration of follow- central nervous system (CNS) (37%), musculoskeletal system up were recorded. (25%), and gastrointestinal system (GIS) (15.6%) cases (Table The study included 125 patients who underwent TT in the 2). The TT was performed by a thoracic surgery resident in ED. Patients aged <18 years and those who had undergone 79.2% cases and by an EM resident in 20.8%. TT at another center and were then transferred were exclud- The complication rate following the procedure performed by ed from the study. the thoracic surgeons was 4%, the most common complica- Statistical Analysis tion being diaphragm laceration (Table 3). The complication Data obtained in the study were analyzed using Statistical rate following the procedure performed by the EM residents Package for the Social Sciences version 15.0 for Windows was 3.8%. The difference between the two types of surgeons software (SPSS Inc.; Chicago, IL, USA). Data were stated as with respect to the outcome of the procedure was not statisti- number (n) and percentage (%), and numerical variables were cally significant (p=0.964). stated as the arithmetic mean ± standard deviation. The Chi- square test was used for the analysis of categorical variables. Of the total patients, 58.4% were admitted to ICUs and 26.4% to wards; 11.2% of the patients were transferred to RESULTS ICUs of other institutions and 4% were exitus in the ED. The The 125 patients included in the study comprised 91 (73%) males and 34 (27%) females, with a mean age of 45.4±21.2 Table 1. Concomitant thoracic pathologies years; 64 (51%) cases presented for traumatic reasons and 61 Pathology (n) (%) (49%) for non-traumatic reasons. Rib fracture 44 35.2 When the means of arriving at the ED were evaluated, it was Pulmonary contusion 25 20 observed that 21 (17%) patients presented directly to the ED, Clavicle fracture 7 5.6 8 (6%) were referred from a polyclinic, 82 (66%) were Scapula fracture 6 4.8 brought by ambulance, and 14 (11%) were referred from Sternum fracture 3 2.4 another center. Pneumomediastinum 1 0.8 Prior to TT, the imaging techniques used for the patients who Other 3 2.4 underwent TT for any reason in the ED included posterior- anterior pulmonary radiography (21.6%), thoracic computed tomography (CT) (56.8%), and both imaging methods (20.8%). Table 2. Concomitant other system pathologies in Imaging was not performed before the procedure in 1 patient traumatic patients who was believed to have tension pneumothorax (PTX). Additional system pathology (n) (%) PTX was diagnosed in 78.4%, pleural fluid in 19.2%, and CNS pathology 24 37.5 hemothorax in 24.8% patients. In 4 patients, PTX and pleural Musculoskeletal pathology 16 25.0 fluid were observed and in 24 patients, PTX and hemothorax GIS pathology 10 15.6 were observed. CVS pathology 6 9.4 Of the patients with PTX, 59.1% had PTX due to trauma. GUS pathology 1 1.6 Isolated PTX was observed in 51.6% patients and hemo- CNS: central nervous system; GIS: gastrointestinal system; GUS: pneumothorax in 37.5%. In 95.8% patients diagnosed with genitourinary system; CVS: cardiovascular system pleural fluid, TT was employed because of non-traumatic reasons. All hemothorax cases were associated with trau- matic etiology. Tension PTX was considered in 1 patient. Table 3. Complications that developed after tube thoracostomy Of the patients who underwent TT because of spontaneous PTX, 88.4% were males and 11.6% were females. The differ- Complication (n) (%) ence in occurrence of PTX between the sexes was statisti- Diaphragm laceration 2 1.6 cally significant (p=0.003). The mean age of patients with Tube malposition 1 0.8 spontaneous PTX was 35.6±19.2 years (range, 18-74 years). Subcutaneous advancement of the tube 1 0.8 Of the patients who underwent TT because of pleural fluid, Persistent air leakage 1 0.8 75% were observed to be associated with malignancy, Kantar et al. Tube Thoracostomy in the Emergency Department mean follow-up period of the patients who underwent TT formed to confirm the presence of pleural fluid observed on was 7.5±4.4 days (range, 0-27 days). PA pulmonary radiograph obtained before TT in non-trauma patients; and CT was considered for further testing of patients DISCUSSION in whom PTX was suspected but not observed on PA pulmo- nary radiograph. When the demographic characteristics of the patients includ- ed in the study were evaluated, it was observed that 91 The diagnoses of the patients were made using the imaging (72.8%) of the patients were males and 34 (27.2%) were techniques. According to this, PTX was diagnosed in 98 females and the mean age of the whole sample was 45.4 (78.4%) patients, hemothorax in 31 (24.8%), and pleural years. In a study by Edaigbini et al. [5], 63.5% of the patients fluid in 24 (19.2%). In a study of trauma patients by Ball et were males and 36.5% were females with a mean age of al. [7], TT was employed because of PTX in 62%, hemo- 34.85 years. In a study on PTX, Inci et al. [6] reported that pneumothorax in 30%, and hemothorax in 8% patients. A 82.2% of their cases were males and 17.8% were females. In total of 1,042 patients were analyzed by Kong et al. [11], and a study by Ball et al. [7], of the 61 patients who underwent TT was determined to have been performed because of a TT, 77% were males and 23% females, whereas Menger et diagnosis of PTX in 37%, hemoneumothorax in 33%, hemo- al. [8] reported 73.4% males and 26.6% females in a similar thorax in 30%, and tension PTX in 8% patients. In another study. Though the current study evaluated patients who study by Kong et al. [12], PTX was diagnosed in 72%, hemo- underwent TT for more than one indication, the age and sex pneumothorax in 15%, hemothorax in 11%, and tension of the patients were found to be similar to that mentioned in PTX in 2% patients. In a study by Afshar et al. [13], PTX was previous reports. diagnosed in 37%, hemothorax in 35%, and hemopneumo- thorax in 26.3% patients. The findings of the current study When the means of arriving at the ED was evaluated, it was regarding the diagnoses showed great similarity to those of observed that 82 (66%) were brought by ambulance, previous studies. 21(17%) presented directly to the ED, 14 (11%) were referred from another center, and 8 (6%) were referred from a poly- The patients of the current study who underwent TT because clinic. Of the patients referred from polyclinics, iatrogenic of PTX were sub categorized further. The primary cause in PTX was determined in 87.5% and these were observed these patients was trauma; PTX was traumatic in 58 (59.2%) secondary to lung biopsy. From the literature, no study with of 98 cases, spontaneous in 26 (26.5%), and iatrogenic PTX information on the means through which the patients pre- in 13 (13.3%). In 1 (1.0%) case, tension PTX was considered. sented to the ED was found. Thus, the current study is of In study by Ince et al. [6] which examined PTX cases, 66.2% value with respect to TT applications in the ED and the diag- were observed to be spontaneous PTX, 24.8% traumatic, and nostic spectrum. 9% iatrogenic. Cho et al. [14] reported non-traumatic PTX cases to be 96% spontaneous PTX and 4% iatrogenic PTX. In the current study, traumatic causes were present in 64 The hospital where the current study was conducted serves (51.2%) cases and non-traumatic in 61 (48.8%) cases. In the as a regional trauma center. Therefore, this can be consid- literature, it is seen that PTX cases or pleural effusion cases ered to be the reason for the higher rate of occurrence of are examined in isolated trauma patients. As the aim of the traumatic PTX cases than non-traumatic PTX cases. In addi- current study was to examine TT cases in the ED and the tion, majority of the spontaneous PTX cases were diagnosed patients presenting to the ED were in a very broad diagnostic in polyclinics that were associated with underlying pulmo- spectrum, no comparison was performed with studies exam- nary diseases, which were then followed up in the relevant ining TT employed for a single diagnosis. polyclinic. This can be considered the reason for the low rate When the imaging techniques employed for diagnostic pur- of the spontaneous PTX cases determined in the ED. poses were examined, it was found that posterior-anterior Therefore, the findings of the spontaneous PTX cases in the pulmonary radiography was performed for 27 (21.6%) current study are proportionally lower in comparison with patients, thoracic CT for 71 (56.8%), and both imaging meth- the literature. ods were used for 26 (20.8%). In study by Ball et al. [9], The 26 patients of the current study with spontaneous PTX 1,121 patients were examined; PA pulmonary radiography diagnosis comprised 23 (88.4%) males and 3 (11.6%) was used for 87% whereas PA pulmonary radiography and females with a mean age of 35.6±19.2 years (range, 18-74 CT were used for 13% patients. Ince et al. [6] examined PTX years). In a study of spontaneous PTX by Olesen et al. [15], cases and reported that PA pulmonary radiography was 83% were males and 17% females with a mean age of employed to 64.3% patients, thoracic CT to 8.5%, and both 25.2±7.1 years. Yang et al. [16] reported these rates as 84% imaging methods were used in 27.2%. In a study of patients males and 16% females with a mean age of 22.9±8.1 years. with blunt chest trauma, Kaya et al. [10] reported the use of PA pulmonary radiography in 42.4% patients, and PA pulmo- While the gender rates in this study were similar to the lit- erature, the mean age was a little higher than the literature. nary radiography together with thoracic CT in 56.6%. The The reason for the high mean age could be the inclusion of current study showed some differences from the literature regarding the use of imaging techniques. secondary spontaneous PTX cases in the current study. The reason for the greater rate of use of CT for patients in the When the additional thoracic pathologies and the additional current study can be attributed to the reason that patients systemic pathologies were evaluated in the current study, a presented to the ED because of multitrauma; CT was per- combination of several pathologies was commonly observed. Turk Thorac J 2019; 20(1): 25-9 The most frequently observed pathology was rib fracture in Complications were observed in 5 (4%) of the 125 patients 44 (35.2%) patients. Pulmonary contusion was determined in after TT was performed in the ED. These complications 26 (20%) patients, clavicle fracture in 7 (5.6%), scapula frac- included diaphragm laceration in 2 (1.6%), tube malposition ture in 6 (4.8%), sternum fracture in 3 (2.4%), and pneumo- in 1 (0.8%), and advancement of the tube subcutaneously in 1 (0.8%). As persistent air leakage was observed after TT in mediastinum in 1 (0.8%) (thorax pathologies were observed in traumatic patients). Systemic pathologies, those not in the 1 (0.8%) patient, further treatment was given. Of the 5 patients with complications, TT was performed by an EM thorax, were observed in the CNS in 24 (19.2%) cases, the musculoskeletal system in 16 (12.8%), the GIS in 10 (0.8%), resident in 1 case and by a thoracic surgery resident in 4 the cardiovascular system in 7 (5.6%), and the genitourinary cases. system (GUS) in 2 (1.6%). In 1 patient, sepsis was deter- In a study by Deneuville [22], complication rates according mined as an additional systemic pathology. In a study by to the type of surgeon performing TT were observed to be Leblebici et al. [17], thoracic pathologies in patients with 6.8% in thoracic surgery and 65% in the other group which chest trauma were reported as rib fracture in 29.5%, pulmo- included ED and ICU physicians. Martin et al. [24] reported nary contusion in 10.9%, clavicle fracture in 2.7%, scapula the complication rate as 6% after TT was performed by sur- fracture in 2.0%, and sternum fracture in 0.7%. In the same geons and 13% after the procedure was performed by ED study, additional systemic pathologies were as follows: GIS physicians. Duong et al. [21] found the complication rate (29.3%), CNS (25.2%), and musculoskeletal system (21.8%). after TT to be 37.2%. Of note, 20.6% of the complications were reported to be various tube malpositionings, 1.1% were In patients examined in a study by İmamoğlu et al. [18], rib fracture was observed in 36.4%, pulmonary contusion in intercostal vessel injuries, 1.1% were retroperitoneal place- ment, and other complications were in the category of late 12.7%, clavicle fracture in 5.5%, sternum fracture in 3.6%, complications. Ball et al. [7] reported a complication rate of and scapula fracture in 2.7%. Demirhan et al. [19] deter- 22.4% in trauma patients who underwent TT. It was noted mined rib fractures in 30% of the thoracic trauma patients, that 11.8% of the complications were due to malposition and pulmonary contusion in 2.4%, clavicle fracture in 1%, and 7.9% were interventional complications (intercostal artery sternum fracture in 0.9%. Afacan et al. [20] were reported injury and pulmonary artery injury). other systemic pathologies in thoracic trauma patients as 46% musculoskeletal system, 21.1% CNS, 8.9% GIS, and 2.5% A complication rate of 16.8% was reported by Edaigbini et GUS. The rate of occurrence of rib fracture as additional tho- al. [5] Complications were as follows: 1.2% malposition, racic pathology in the current study was similar to the rates 1.8% removal of the tube from the wrong place, 0.6% tube previously reported in the literature, but the rates of the extra- obstruction, and others were late complications such as thoracic pathologies did not show a similarity. This can be empyema and sepsis. The complication rate observed in the due to the inclusion of multitrauma patients in the current current study was extremely low compared to that in the lit- study, whereas most of the other studies only examined tho- erature. This can be attributed to the study center which is a racic trauma. In several studies in Turkey, the most common university hospital where there are specialist EM and tho- concomitant systemic pathologies in thoracic trauma patients racic surgery physicians available 24 hours. Moreover, as the have been observed to be in the musculoskeletal system and hospital is a large trauma center, many TT procedures are CNS. Similarly, in the current study, CNS and musculoskeletal performed and therefore the team had sufficient expertise in system pathologies were determined to be the most common this field. However, because only the complications devel- concomitant pathologies in trauma patients. oped after TT was performed in the ED were evaluated, it was not possible to make a comparison with other studies in In 26 (20.8%) patients in the current study, TT was performed the literature with respect to late complications. by an EM resident and in 99 (79.2%) cases by a thoracic sur- gery resident. In a study by Duong et al. [21], it was reported When the patients included in this study were examined with that TT was performed by ED physicians in 74.3% and by respect to hospitalized follow-up and continuation of treat- surgeons in 14.9%, and for the remaining 10.8%, the unit ment after the TT procedure, 73 (58.4%) patients were admit- performing TT was not specified. In a study by Ball et al. [7], ted to the ICU, and 33 (26.4%) to clinic wards. As vacant TT was performed by a general surgeon in 36.8% of cases, by beds could not be found in the hospital for 14 (11.2%) an EM specialist in 26.3%, and by various other branch spe- patients, they were transferred to other institutions, and 5 cialists in 36.9%. A study by Deneuville [22] reported that the (4.0%) patients were exitus in the ED. procedure was performed by thoracic surgeons in 68.8% and by ED and ICU physicians in 31.2%. In a study conducted in In a study by Çorbacıoğlu et al. [25], 18.1% of patients were the ED by Sethuraman et al. [23], the procedure was per- admitted to ICU, 34.2% to wards, and the exitus rate was formed by EM residents in 74.3% and by surgeons in 14.9%. 0.8%. Kong and Clarke [12] reported ICU admittance to be In the literature, it was seen that the rate of procedures applied 15% and the mortality rate to be 4%. by ED physicians was higher in some studies and the rate applied by surgical branches was higher in some studies. In When the hospitalization data of the current study patients the current study, the rate of TT performed by ED physicians were examined, the rates of admittance to ICU were found was observed to be slightly lower than the rates reported in the to be higher than those in the literature. The reason for this literature. However, as there is no other study in Turkey that higher rate of ICU admittance could be the patients requiring has examined patients who underwent TT in the ED, the find- admittance after TT because of the presence of comorbidities ings are important with respect to creating national data. such as malignancy or the presence of additional pathologies Kantar et al. Tube Thoracostomy in the Emergency Department 4. Kwiatt M, Tarbox A, Seamon MJ, et al. Thoracostomy tubes: a such as multitrauma. The mortality rate in the ED was found comprehensive review of complications and related topics. Int J to be low compared to that reported in several studies in the Crit Illn Inj Sci 2014;4:143-55. literature. This could be due to mortality in critical patients 5. Edaigbini SA, Delia IZ, Aminu MB, et al. Indications and com- at the scene before being brought to hospital and also it plications of tube thoracostomy with improvised underwater could be due to the necessary treatment being administered seal bottles. Niger J Surg 2014;20:79-82. [CrossRef] rapidly as there is an experienced team on duty for 24 hours 6. Ince A, Ozucelik DN, Avci A, et al. Management of pneumotho- a day at the hospital. The mean follow-up period of the rax in emergency medicine departments: multicenter trial. Iran patients with TT was 7.5±4.4 days (range, 0-27 days). Ince et Red Crescent Med J 2013;15:e11586. [CrossRef] al reported that the follow-up period as 5.6 days in patients 7. Ball CG, Lord J, Laupland KB, et al. Chest tube complications: who underwent TT because of PTX [6]. The data obtained in how well are we training our residents? Can J Surg 2007;50:450- the current study related to follow-up periods with TT were 8. Menger R, Telford G, Kim P, et al. Complications follow- found to be consistent with that in the literature. ing thoracic trauma managed with tube thoracostomy. Injury 2012;43:46-50. [CrossRef] One limitation of this study is that it is single-centered. We 9. Ball CG, Dente CJ, Kirkpatrick AW, et al. Occult pneumothora- believe that better quality studies will be with larger popula- ces in patients with penetrating trauma: Does mechanism mat- tions and very self-centered. ter? Can J Surg 2010;53:251. 10. Kaya Ş, Çevik AA, Acar N, et al. A study on the evaluation of In conclusion, although TT is a primary procedure routinely pneumothorax by imaging methods in patients presenting to the employed by thoracic surgeons, it is currently often per- emergency department for blunt thoracic trauma. Ulus Travma formed by EM residents and specialists. At intensive trauma Acil Cerrahi Derg 2015;21:366-72. [CrossRef] centers, in particular, and at centers where procedures such 11. Kong VY, Oosthuizen GV, Clarke DL. What is the yield of rou- as central venous catheterization and diagnostic Thoracentesis tine chest radiography following tube thoracostomy for trauma? are frequently performed, it would be useful for EM doctors Injury 2015;46:45-8. [CrossRef] to undergo training in TT to a level where they are able to 12. Kong VY, Clarke DL. The spectrum of visceral injuries secondary to intervene in an emergency situation such as traumatic or misplaced intercostal chest drains: experience from a high volume trauma service in South Africa. Injury 2014;45:1435-9. [CrossRef] iatrogenic PTX. Although TT seems to be a simple procedure, 13. Afshar MA, Mangeli F, Nakhaei A. Evaluation of injuries caused when it is performed without sufficient experience, knowl- by penetrating chest traumas in patients referred to the emer- edge, and skill, severe complications or even death can gency room. Indian J Surg 2015;77:191-4. [CrossRef] result. Careful application of the procedure with diligent 14. Cho S, Lee EB. Management of primary and secondary pneumo- aftercare will reduce potential complications, shorten the thorax using a small-bore thoracic catheter. Interact Cardiovasc length of hospital stay, and minimize costs. Thorac Surg 2010;11:146-9. [CrossRef] 15. Olesen WH, Lindahl-Jacobsen R, Katballe N, et al. Recurrent primary spontaneous pneumothorax is common following chest Ethics Committee Approval: Ethics committee approval was received tube and conservative treatment. World J Surg 2016;40:2163- 70. [CrossRef] for this study from the ethics committee of Erciyes University Clinical 16. Yang HC, Kim S, Yum S, et al. Learning curve of single-incision Research (Date: May 22, 2015; number: 2015/264). thoracoscopic surgery for primary spontaneous pneumothorax. Informed Consent: Written informed consent was obtained from all Surg Endosc 2017;31:1680-7. [CrossRef] patients who participated in this study. 17. Leblebici İH, Kaya Y, Koçak AH. Analysis of 302 cases with chest trauma. Turk Gogus Kalp Dama 2005;13:392-6. Peer-review: Externally peer-reviewed. 18. İmamoğlu OU, Öncel M, Erginel T, et al. Toraks travmalarında yaklaşım: 110 olgunun değerlendirilmesi. Turk Gogus Kalp Author Contributions: Concept - P.D.; Design - Y.K., İ.S.K.; Dama 1999;7:450-3. Supervision - P.D.; Resources - Y.K., N.B.; Materials - Y.K.; Data 19. Demirhan R, Küçük HF, Kargi AB, et al. Evaluation of 572 cases Collection and/or Processing - Y.K., N.B., Ş.Y., N.D.K; Analysis and/or of blunt and penetrating thoracic trauma. Ulus Travma Derg Interpretation - Y.K., P.D.; Literature Search - Y.K., P.D.; Writing 2001;7:231-5. Manuscript - N.B., Ş.Y., N.D.K.; Critical Review - P.D., L.H.; Other 20. Afacan MA, Büyükcam F , Çavuş UY, et al. Acil Servise Başvuran -L.H., N.B., Ş.Y., N.D.K. Künt Toraks Travma Vakalarının İncelenmesi. Kocatepe Tıp Der- gisi 2012;13:19-25. Conflict of Interest: The authors have no conflicts of interest to 21. Duong DK, Mehta SD, Mitchell P, et al. Complications of Tube declare. Thoracostomy Placement in the Emergency Department. Aca- demic Emergency Medicine 2006;13:40. [CrossRef] Financial Disclosure: The authors declared that this study has 22. Deneuville M. Morbidity of percutaneous tube thoracostomy in received no financial support. trauma patients. Eur J Cardiothorac Surg 2002;22:673-8. [CrossRef] 23. Sethuraman KN, Duong D, Mehta S, et al. Complications of tube REFERENCES thoracostomy placement in the emergency department. J Emerg 1. Kesieme EB, Dongo A, Ezemba N, et al. Tube thoracostomy: complica- Med 2011;40:14-20. [CrossRef] tions and its management. Pulm Med 2012;2012:256878. [CrossRef] 24. Martin M, Schall CT, Anderson C, et al. Results of a clinical practice 2. Kuhajda I, Zarogoulidis K, Kougioumtzi I, et al. Tube thora- algorithm for the management of thoracostomy tubes placed for costomy; chest tube implantation and follow up. J Thorac Dis traumatic mechanism. Springerplus 2013;2:642. [CrossRef] 2008;86:2019-22. 25. Çorbacıoğlu SK, Er E, Aslan S, et al. The significance of rou - 3. Monaghan SF, Swan KG. Tube thoracostomy: the struggle to the tine thoracic computed tomography in patients with blunt chest “standard of care”. Ann Thorac Surg 2008;86:2019-22. [CrossRef] trauma. Injury 2015;46:849-53. [CrossRef] http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Turkish Thoracic Journal Unpaywall

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Abstract

costomy in the emergency department (ED). The secondary aim of the study was to evaluate parameters such as the diagnosis for which the patients underwent tube thoracostomy, the imaging techniques used during diagnosis, and complications related to the procedure. MATERIALS AND METHODS: This prospective study was conducted in the ED between June 1, 2015 and May 31, 2016. The study included 125 patients aged >18 years, of both sexes, who presented to the ED during this period and who underwent tube thoracostomy. RESULTS: The patients comprised 91 (73%) males and 34 (27%) females. Of the 125 patients, 21 (17%) presented directly to the ED, 8 (6%) were referred from a polyclinic, 82 (66%) were brought by ambulance, and 14 (11%) were referred from another center. Reasons for presentation were traumatic in 64 (51%) and non-traumatic in 61 (49%) patients. The leading diagnosis was pneumothorax in 98 (78.4%) cases. The procedure of tube thoracostomy was performed by an emergency medicine (EM) resident for 26 (21%) cases and by a thoracic surgery resident for 99 (79%) cases. Complications were observed at the rate of 3.8% in the procedures performed by the EM residents and at 4% in those performed by the thoracic surgery residents. The mean follow-up time of the patients with tube thoracostomy was 7.5±4.4 days. CONCLUSION: In intensive trauma centers, in particular, and in centers where procedures such as central venous catheterization and diagnostic thoracentesis are frequently performed, it would be useful for EM physicians to undergo training in performing tube thoracos- tomy to a level where they are able to intervene in an emergency situation such as traumatic or iatrogenic pneumothorax. KEYWORDS: Emergency department, pneumothorax, tube thoracostomy Received: 08.05.2018 Accepted: 02.07.2018 INTRODUCTION Tube thoracostomy (TT) is a surgical method that is commonly used by thoracic surgeons. Because it is a life-saving procedure, general surgeons, intensive care unit (ICU) physicians, and emergency department (ED) physicians may be required to perform it [1]. TT is defined as a procedure in which a drainage tube is placed to remove air, fluid, blood, th th pus, or bile from the pleural cavity. The procedure is usually performed from the 4 or 5 intercostal space over the anterior or mid axillary line [2]. Tube thoracostomy was first described by Hippocrates. In 1876, Hewett was the first to use a completely closed intercos- tal drainage system [2]. In the 1950s, Maloney and Gray introduced the terms “tube thoracostomy,” “closed thoracos- tomy,” and “closed drainage” for chest trauma patients [3]. Indications for TT are pneumothorax (PTX), hemothorax, pleural effusion, chylothorax, and bronchopleural fistula [4]. The aim of this study was to determine the demographic and clinical characteristics of patients who underwent TT in the ED. Parameters such as the diagnosis for which TT was performed, the imaging techniques used during diagnosis, and complications related to the procedure were evaluated. MATERIALS AND METHODS This prospective study was conducted with patients aged >18 years who underwent TT in the ED between June 1, 2015 and May 31, 2016, at our emergency medicine (EM) department after obtaining approval from ethics committee of Erciyes University Clinical Research (Date: May 22, 2015; number: 2015/264). Informed consent was obtained from all the patients. Address for Correspondence: Necmi Baykan, Clinic of Emergency, Nevşehir State Hospital, Nevşehir, Turkey E-mail: drnecmibaykan@gmail.com ©Copyright 2019 by Turkish Thoracic Society - Available online at www.turkthoracj.org 25 Turk Thorac J 2019; 20(1): 25-9 The following criteria for each patient were recorded: name, 20.8% with pneumonia, and 4.2% with trauma. In patients age, and sex, the diagnosis for which TT was performed, the presenting with trauma, the most frequently observed addi- etiology of the diagnosis, whether or not there was any other tional thoracic pathology associated with trauma was rib system pathology in addition to the main diagnosis, the type fracture in 35.2%, followed by pulmonary contusion in 20% of surgeon performing the TT (thoracic surgery resident or (Table 1). EM resident), whether or not complications developed after The most frequent concomitant systemic pathologies other the procedure, and if so, the nature of the complications. than thoracic in the trauma patients were observed in the Finally, the ED outcome of the patient and duration of follow- central nervous system (CNS) (37%), musculoskeletal system up were recorded. (25%), and gastrointestinal system (GIS) (15.6%) cases (Table The study included 125 patients who underwent TT in the 2). The TT was performed by a thoracic surgery resident in ED. Patients aged <18 years and those who had undergone 79.2% cases and by an EM resident in 20.8%. TT at another center and were then transferred were exclud- The complication rate following the procedure performed by ed from the study. the thoracic surgeons was 4%, the most common complica- Statistical Analysis tion being diaphragm laceration (Table 3). The complication Data obtained in the study were analyzed using Statistical rate following the procedure performed by the EM residents Package for the Social Sciences version 15.0 for Windows was 3.8%. The difference between the two types of surgeons software (SPSS Inc.; Chicago, IL, USA). Data were stated as with respect to the outcome of the procedure was not statisti- number (n) and percentage (%), and numerical variables were cally significant (p=0.964). stated as the arithmetic mean ± standard deviation. The Chi- square test was used for the analysis of categorical variables. Of the total patients, 58.4% were admitted to ICUs and 26.4% to wards; 11.2% of the patients were transferred to RESULTS ICUs of other institutions and 4% were exitus in the ED. The The 125 patients included in the study comprised 91 (73%) males and 34 (27%) females, with a mean age of 45.4±21.2 Table 1. Concomitant thoracic pathologies years; 64 (51%) cases presented for traumatic reasons and 61 Pathology (n) (%) (49%) for non-traumatic reasons. Rib fracture 44 35.2 When the means of arriving at the ED were evaluated, it was Pulmonary contusion 25 20 observed that 21 (17%) patients presented directly to the ED, Clavicle fracture 7 5.6 8 (6%) were referred from a polyclinic, 82 (66%) were Scapula fracture 6 4.8 brought by ambulance, and 14 (11%) were referred from Sternum fracture 3 2.4 another center. Pneumomediastinum 1 0.8 Prior to TT, the imaging techniques used for the patients who Other 3 2.4 underwent TT for any reason in the ED included posterior- anterior pulmonary radiography (21.6%), thoracic computed tomography (CT) (56.8%), and both imaging methods (20.8%). Table 2. Concomitant other system pathologies in Imaging was not performed before the procedure in 1 patient traumatic patients who was believed to have tension pneumothorax (PTX). Additional system pathology (n) (%) PTX was diagnosed in 78.4%, pleural fluid in 19.2%, and CNS pathology 24 37.5 hemothorax in 24.8% patients. In 4 patients, PTX and pleural Musculoskeletal pathology 16 25.0 fluid were observed and in 24 patients, PTX and hemothorax GIS pathology 10 15.6 were observed. CVS pathology 6 9.4 Of the patients with PTX, 59.1% had PTX due to trauma. GUS pathology 1 1.6 Isolated PTX was observed in 51.6% patients and hemo- CNS: central nervous system; GIS: gastrointestinal system; GUS: pneumothorax in 37.5%. In 95.8% patients diagnosed with genitourinary system; CVS: cardiovascular system pleural fluid, TT was employed because of non-traumatic reasons. All hemothorax cases were associated with trau- matic etiology. Tension PTX was considered in 1 patient. Table 3. Complications that developed after tube thoracostomy Of the patients who underwent TT because of spontaneous PTX, 88.4% were males and 11.6% were females. The differ- Complication (n) (%) ence in occurrence of PTX between the sexes was statisti- Diaphragm laceration 2 1.6 cally significant (p=0.003). The mean age of patients with Tube malposition 1 0.8 spontaneous PTX was 35.6±19.2 years (range, 18-74 years). Subcutaneous advancement of the tube 1 0.8 Of the patients who underwent TT because of pleural fluid, Persistent air leakage 1 0.8 75% were observed to be associated with malignancy, Kantar et al. Tube Thoracostomy in the Emergency Department mean follow-up period of the patients who underwent TT formed to confirm the presence of pleural fluid observed on was 7.5±4.4 days (range, 0-27 days). PA pulmonary radiograph obtained before TT in non-trauma patients; and CT was considered for further testing of patients DISCUSSION in whom PTX was suspected but not observed on PA pulmo- nary radiograph. When the demographic characteristics of the patients includ- ed in the study were evaluated, it was observed that 91 The diagnoses of the patients were made using the imaging (72.8%) of the patients were males and 34 (27.2%) were techniques. According to this, PTX was diagnosed in 98 females and the mean age of the whole sample was 45.4 (78.4%) patients, hemothorax in 31 (24.8%), and pleural years. In a study by Edaigbini et al. [5], 63.5% of the patients fluid in 24 (19.2%). In a study of trauma patients by Ball et were males and 36.5% were females with a mean age of al. [7], TT was employed because of PTX in 62%, hemo- 34.85 years. In a study on PTX, Inci et al. [6] reported that pneumothorax in 30%, and hemothorax in 8% patients. A 82.2% of their cases were males and 17.8% were females. In total of 1,042 patients were analyzed by Kong et al. [11], and a study by Ball et al. [7], of the 61 patients who underwent TT was determined to have been performed because of a TT, 77% were males and 23% females, whereas Menger et diagnosis of PTX in 37%, hemoneumothorax in 33%, hemo- al. [8] reported 73.4% males and 26.6% females in a similar thorax in 30%, and tension PTX in 8% patients. In another study. Though the current study evaluated patients who study by Kong et al. [12], PTX was diagnosed in 72%, hemo- underwent TT for more than one indication, the age and sex pneumothorax in 15%, hemothorax in 11%, and tension of the patients were found to be similar to that mentioned in PTX in 2% patients. In a study by Afshar et al. [13], PTX was previous reports. diagnosed in 37%, hemothorax in 35%, and hemopneumo- thorax in 26.3% patients. The findings of the current study When the means of arriving at the ED was evaluated, it was regarding the diagnoses showed great similarity to those of observed that 82 (66%) were brought by ambulance, previous studies. 21(17%) presented directly to the ED, 14 (11%) were referred from another center, and 8 (6%) were referred from a poly- The patients of the current study who underwent TT because clinic. Of the patients referred from polyclinics, iatrogenic of PTX were sub categorized further. The primary cause in PTX was determined in 87.5% and these were observed these patients was trauma; PTX was traumatic in 58 (59.2%) secondary to lung biopsy. From the literature, no study with of 98 cases, spontaneous in 26 (26.5%), and iatrogenic PTX information on the means through which the patients pre- in 13 (13.3%). In 1 (1.0%) case, tension PTX was considered. sented to the ED was found. Thus, the current study is of In study by Ince et al. [6] which examined PTX cases, 66.2% value with respect to TT applications in the ED and the diag- were observed to be spontaneous PTX, 24.8% traumatic, and nostic spectrum. 9% iatrogenic. Cho et al. [14] reported non-traumatic PTX cases to be 96% spontaneous PTX and 4% iatrogenic PTX. In the current study, traumatic causes were present in 64 The hospital where the current study was conducted serves (51.2%) cases and non-traumatic in 61 (48.8%) cases. In the as a regional trauma center. Therefore, this can be consid- literature, it is seen that PTX cases or pleural effusion cases ered to be the reason for the higher rate of occurrence of are examined in isolated trauma patients. As the aim of the traumatic PTX cases than non-traumatic PTX cases. In addi- current study was to examine TT cases in the ED and the tion, majority of the spontaneous PTX cases were diagnosed patients presenting to the ED were in a very broad diagnostic in polyclinics that were associated with underlying pulmo- spectrum, no comparison was performed with studies exam- nary diseases, which were then followed up in the relevant ining TT employed for a single diagnosis. polyclinic. This can be considered the reason for the low rate When the imaging techniques employed for diagnostic pur- of the spontaneous PTX cases determined in the ED. poses were examined, it was found that posterior-anterior Therefore, the findings of the spontaneous PTX cases in the pulmonary radiography was performed for 27 (21.6%) current study are proportionally lower in comparison with patients, thoracic CT for 71 (56.8%), and both imaging meth- the literature. ods were used for 26 (20.8%). In study by Ball et al. [9], The 26 patients of the current study with spontaneous PTX 1,121 patients were examined; PA pulmonary radiography diagnosis comprised 23 (88.4%) males and 3 (11.6%) was used for 87% whereas PA pulmonary radiography and females with a mean age of 35.6±19.2 years (range, 18-74 CT were used for 13% patients. Ince et al. [6] examined PTX years). In a study of spontaneous PTX by Olesen et al. [15], cases and reported that PA pulmonary radiography was 83% were males and 17% females with a mean age of employed to 64.3% patients, thoracic CT to 8.5%, and both 25.2±7.1 years. Yang et al. [16] reported these rates as 84% imaging methods were used in 27.2%. In a study of patients males and 16% females with a mean age of 22.9±8.1 years. with blunt chest trauma, Kaya et al. [10] reported the use of PA pulmonary radiography in 42.4% patients, and PA pulmo- While the gender rates in this study were similar to the lit- erature, the mean age was a little higher than the literature. nary radiography together with thoracic CT in 56.6%. The The reason for the high mean age could be the inclusion of current study showed some differences from the literature regarding the use of imaging techniques. secondary spontaneous PTX cases in the current study. The reason for the greater rate of use of CT for patients in the When the additional thoracic pathologies and the additional current study can be attributed to the reason that patients systemic pathologies were evaluated in the current study, a presented to the ED because of multitrauma; CT was per- combination of several pathologies was commonly observed. Turk Thorac J 2019; 20(1): 25-9 The most frequently observed pathology was rib fracture in Complications were observed in 5 (4%) of the 125 patients 44 (35.2%) patients. Pulmonary contusion was determined in after TT was performed in the ED. These complications 26 (20%) patients, clavicle fracture in 7 (5.6%), scapula frac- included diaphragm laceration in 2 (1.6%), tube malposition ture in 6 (4.8%), sternum fracture in 3 (2.4%), and pneumo- in 1 (0.8%), and advancement of the tube subcutaneously in 1 (0.8%). As persistent air leakage was observed after TT in mediastinum in 1 (0.8%) (thorax pathologies were observed in traumatic patients). Systemic pathologies, those not in the 1 (0.8%) patient, further treatment was given. Of the 5 patients with complications, TT was performed by an EM thorax, were observed in the CNS in 24 (19.2%) cases, the musculoskeletal system in 16 (12.8%), the GIS in 10 (0.8%), resident in 1 case and by a thoracic surgery resident in 4 the cardiovascular system in 7 (5.6%), and the genitourinary cases. system (GUS) in 2 (1.6%). In 1 patient, sepsis was deter- In a study by Deneuville [22], complication rates according mined as an additional systemic pathology. In a study by to the type of surgeon performing TT were observed to be Leblebici et al. [17], thoracic pathologies in patients with 6.8% in thoracic surgery and 65% in the other group which chest trauma were reported as rib fracture in 29.5%, pulmo- included ED and ICU physicians. Martin et al. [24] reported nary contusion in 10.9%, clavicle fracture in 2.7%, scapula the complication rate as 6% after TT was performed by sur- fracture in 2.0%, and sternum fracture in 0.7%. In the same geons and 13% after the procedure was performed by ED study, additional systemic pathologies were as follows: GIS physicians. Duong et al. [21] found the complication rate (29.3%), CNS (25.2%), and musculoskeletal system (21.8%). after TT to be 37.2%. Of note, 20.6% of the complications were reported to be various tube malpositionings, 1.1% were In patients examined in a study by İmamoğlu et al. [18], rib fracture was observed in 36.4%, pulmonary contusion in intercostal vessel injuries, 1.1% were retroperitoneal place- ment, and other complications were in the category of late 12.7%, clavicle fracture in 5.5%, sternum fracture in 3.6%, complications. Ball et al. [7] reported a complication rate of and scapula fracture in 2.7%. Demirhan et al. [19] deter- 22.4% in trauma patients who underwent TT. It was noted mined rib fractures in 30% of the thoracic trauma patients, that 11.8% of the complications were due to malposition and pulmonary contusion in 2.4%, clavicle fracture in 1%, and 7.9% were interventional complications (intercostal artery sternum fracture in 0.9%. Afacan et al. [20] were reported injury and pulmonary artery injury). other systemic pathologies in thoracic trauma patients as 46% musculoskeletal system, 21.1% CNS, 8.9% GIS, and 2.5% A complication rate of 16.8% was reported by Edaigbini et GUS. The rate of occurrence of rib fracture as additional tho- al. [5] Complications were as follows: 1.2% malposition, racic pathology in the current study was similar to the rates 1.8% removal of the tube from the wrong place, 0.6% tube previously reported in the literature, but the rates of the extra- obstruction, and others were late complications such as thoracic pathologies did not show a similarity. This can be empyema and sepsis. The complication rate observed in the due to the inclusion of multitrauma patients in the current current study was extremely low compared to that in the lit- study, whereas most of the other studies only examined tho- erature. This can be attributed to the study center which is a racic trauma. In several studies in Turkey, the most common university hospital where there are specialist EM and tho- concomitant systemic pathologies in thoracic trauma patients racic surgery physicians available 24 hours. Moreover, as the have been observed to be in the musculoskeletal system and hospital is a large trauma center, many TT procedures are CNS. Similarly, in the current study, CNS and musculoskeletal performed and therefore the team had sufficient expertise in system pathologies were determined to be the most common this field. However, because only the complications devel- concomitant pathologies in trauma patients. oped after TT was performed in the ED were evaluated, it was not possible to make a comparison with other studies in In 26 (20.8%) patients in the current study, TT was performed the literature with respect to late complications. by an EM resident and in 99 (79.2%) cases by a thoracic sur- gery resident. In a study by Duong et al. [21], it was reported When the patients included in this study were examined with that TT was performed by ED physicians in 74.3% and by respect to hospitalized follow-up and continuation of treat- surgeons in 14.9%, and for the remaining 10.8%, the unit ment after the TT procedure, 73 (58.4%) patients were admit- performing TT was not specified. In a study by Ball et al. [7], ted to the ICU, and 33 (26.4%) to clinic wards. As vacant TT was performed by a general surgeon in 36.8% of cases, by beds could not be found in the hospital for 14 (11.2%) an EM specialist in 26.3%, and by various other branch spe- patients, they were transferred to other institutions, and 5 cialists in 36.9%. A study by Deneuville [22] reported that the (4.0%) patients were exitus in the ED. procedure was performed by thoracic surgeons in 68.8% and by ED and ICU physicians in 31.2%. In a study conducted in In a study by Çorbacıoğlu et al. [25], 18.1% of patients were the ED by Sethuraman et al. [23], the procedure was per- admitted to ICU, 34.2% to wards, and the exitus rate was formed by EM residents in 74.3% and by surgeons in 14.9%. 0.8%. Kong and Clarke [12] reported ICU admittance to be In the literature, it was seen that the rate of procedures applied 15% and the mortality rate to be 4%. by ED physicians was higher in some studies and the rate applied by surgical branches was higher in some studies. In When the hospitalization data of the current study patients the current study, the rate of TT performed by ED physicians were examined, the rates of admittance to ICU were found was observed to be slightly lower than the rates reported in the to be higher than those in the literature. The reason for this literature. However, as there is no other study in Turkey that higher rate of ICU admittance could be the patients requiring has examined patients who underwent TT in the ED, the find- admittance after TT because of the presence of comorbidities ings are important with respect to creating national data. such as malignancy or the presence of additional pathologies Kantar et al. Tube Thoracostomy in the Emergency Department 4. Kwiatt M, Tarbox A, Seamon MJ, et al. Thoracostomy tubes: a such as multitrauma. The mortality rate in the ED was found comprehensive review of complications and related topics. Int J to be low compared to that reported in several studies in the Crit Illn Inj Sci 2014;4:143-55. literature. This could be due to mortality in critical patients 5. Edaigbini SA, Delia IZ, Aminu MB, et al. Indications and com- at the scene before being brought to hospital and also it plications of tube thoracostomy with improvised underwater could be due to the necessary treatment being administered seal bottles. Niger J Surg 2014;20:79-82. [CrossRef] rapidly as there is an experienced team on duty for 24 hours 6. Ince A, Ozucelik DN, Avci A, et al. Management of pneumotho- a day at the hospital. The mean follow-up period of the rax in emergency medicine departments: multicenter trial. Iran patients with TT was 7.5±4.4 days (range, 0-27 days). Ince et Red Crescent Med J 2013;15:e11586. [CrossRef] al reported that the follow-up period as 5.6 days in patients 7. Ball CG, Lord J, Laupland KB, et al. Chest tube complications: who underwent TT because of PTX [6]. The data obtained in how well are we training our residents? Can J Surg 2007;50:450- the current study related to follow-up periods with TT were 8. Menger R, Telford G, Kim P, et al. Complications follow- found to be consistent with that in the literature. ing thoracic trauma managed with tube thoracostomy. Injury 2012;43:46-50. [CrossRef] One limitation of this study is that it is single-centered. We 9. Ball CG, Dente CJ, Kirkpatrick AW, et al. Occult pneumothora- believe that better quality studies will be with larger popula- ces in patients with penetrating trauma: Does mechanism mat- tions and very self-centered. ter? Can J Surg 2010;53:251. 10. Kaya Ş, Çevik AA, Acar N, et al. A study on the evaluation of In conclusion, although TT is a primary procedure routinely pneumothorax by imaging methods in patients presenting to the employed by thoracic surgeons, it is currently often per- emergency department for blunt thoracic trauma. Ulus Travma formed by EM residents and specialists. At intensive trauma Acil Cerrahi Derg 2015;21:366-72. [CrossRef] centers, in particular, and at centers where procedures such 11. Kong VY, Oosthuizen GV, Clarke DL. What is the yield of rou- as central venous catheterization and diagnostic Thoracentesis tine chest radiography following tube thoracostomy for trauma? are frequently performed, it would be useful for EM doctors Injury 2015;46:45-8. [CrossRef] to undergo training in TT to a level where they are able to 12. Kong VY, Clarke DL. The spectrum of visceral injuries secondary to intervene in an emergency situation such as traumatic or misplaced intercostal chest drains: experience from a high volume trauma service in South Africa. Injury 2014;45:1435-9. [CrossRef] iatrogenic PTX. Although TT seems to be a simple procedure, 13. Afshar MA, Mangeli F, Nakhaei A. Evaluation of injuries caused when it is performed without sufficient experience, knowl- by penetrating chest traumas in patients referred to the emer- edge, and skill, severe complications or even death can gency room. Indian J Surg 2015;77:191-4. [CrossRef] result. Careful application of the procedure with diligent 14. Cho S, Lee EB. Management of primary and secondary pneumo- aftercare will reduce potential complications, shorten the thorax using a small-bore thoracic catheter. Interact Cardiovasc length of hospital stay, and minimize costs. Thorac Surg 2010;11:146-9. [CrossRef] 15. Olesen WH, Lindahl-Jacobsen R, Katballe N, et al. Recurrent primary spontaneous pneumothorax is common following chest Ethics Committee Approval: Ethics committee approval was received tube and conservative treatment. World J Surg 2016;40:2163- 70. [CrossRef] for this study from the ethics committee of Erciyes University Clinical 16. Yang HC, Kim S, Yum S, et al. 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Turkish Thoracic JournalUnpaywall

Published: Jan 21, 2019

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