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A tentative guide for thoracic surgeons during COVID-19 pandemic
The Cardiothoracic Surgeon Pub Date : 2020-07-02 , DOI: 10.1186/s43057-020-00026-z
Ahmed Ghoniem , Amr Abdellateef , Amr Ibrahim Osman , Hany Hasan Elsayed , Hussein Elkhayat , Waleed Adel

Currently, there is not enough evidence to support the best practice for thoracic surgery practice during pandemic and the situation is highly dynamic on day to day basis.

Thoracic surgery may not seem to be in the frontline with managing COVID-19 patients, but we do have a key role to play and this must be planned. In response to pressures of the current pandemic, the elective component of our work has stopped. However, the non-elective patients (emergency, urgent, and trauma) will continue to need appropriate care and reactivation of service after situation becomes more stable.

We should seek to provide the best local solutions in conjunction with the recent national guidelines to continue the proper management of patients while ensuring proper resource allocation in response to COVID-19 with proper protection to the surgical stuff. In addition, we need to consider the possibility that the surgical facility for emergency surgery may be compromised in the near future due to a combination of factors including medical staff sickness, supply chain, and the use of theaters and anesthetic staff work in ICU instead. This is a possible scenario and plans are needed.

As the wider healthcare response intensifies, we may also need to work outside of our specific areas of training and expertise, and we must plan to learn new skills and practice.

Proper communication (could be telecommunication) with cardiothoracic patients awaiting operations is a must in the for-coming period. Explaining that there is no harm to wait for a few weeks for appropriate cases and the plan to allocate resources can provide re assurance for many elective patients feeling the danger of delay. Maximize virtual follow-up (phone call check) to avoid the need for patients to attend hospital. Consenting patients for surgery in this period should always include a hospital-acquired risk to develop a COVID-19 infection.

In this review, we try to point out the idea of triage of thoracic surgery patients, precautions for use of bronchoscopy, and chest tubes as the most procedures done with possible aerosol generation and when can we reactivate our thoracic surgery service.

Phase 1 (semi-urgent cases) of the COVID-19

Here, the hospital resources are not exhausted, COVID trajectory is not in a rapid escalation phase, and the tertiary center ICU vent capacity is still available. Surgical services are offered for those where survival could be affected in the next few days if no intervention is performed (Table 1) [1].

Table 1 Summary for decision-making in different pathologies during phase 1

Full size table

No standard definition exists so far for the urgent cases that need to be done nor consensus on which patient cannot wait without further progression and surgeons will always balance between patients with risk of significant deterioration and availability of resources [2].

Avoid the routine use of critical care unit wherever possible (pre-op preparation, ERAS, pain relief)

Phase 2: urgent setting

In this phase we see many COVID-19 patients with limited ICU capacity and an escalating COVID trajectory.

Surgical management only offered for those who would not survive for few days if not operated upon (Table 2) [1].

Table 2 Summary for decision-making in different pathologies during phase 2

Full size table

Phase 3: full outbreak of COVID 19

All resources are routed to COVID-19 patients and there is no ICU capacity.

Thoracic surgery procedures are only performed for patients who are likely to die within the next few hours if no intervention is performed (Table 3) [1].

Table 3 Summary for decision-making in different pathologies during phase 3

Full size table

Trauma patients

Management of trauma patients is highly dependent on healthcare facility because even if COVID-19 screening test is available at initial assessment, negative test results do not exclude the presence of infection [2].

So, if the patient needs emergency interventions, he should be considered as a positive case with the following precautions:

Full personal protective equipment (gowns, gloves, surgical masks, and face shield) are highly recommended.
Minimize transfer these patients to multiple areas inside the hospital.
Diagnostic procedures that would not affect the decision should be avoided.
All members of the trauma unit should be familiar with the infection control protocols.

If the patient needs urgent or elective interventions, CBC, body temperature, and CT chest should be done first and reported if consistent with COVID-19 or not.

Returning to the usual surgical routine is within the scope of every surgeon now. Too many factors need to be taken in consideration; the limited resources as chain of supplies, number of nurses, available ICU beds, personal protective equipment (PPE), the limited access to diagnostic procedures as pulmonary function tests, bronchoscopy and the availability of PCR, and other tests for every patients and medical stuff. Early results from CovidSurg study show that patients whom discovered to be COVID positive perioperatively had a high complication and mortality rates [3], making the decision for operating every non-urgent case during the pandemic without rolling out the possibility of infection is a high risk operation. As a result, a very large number of operations will be postponed due to disruption caused by COVID-19 and in a recent study they concluded that it would take a median 45 weeks to clear the backlog of operations resulting from COVID-19 disruption if surgery services increase the normal surgical volume rate by 20% during the post-pandemic era [4].

Precautions for bronchoscopy

Bronchoscopic procedures are aerosol-generating procedures (AGPs).
Indications for bronchoscopy should consider the potential for transmission of COVID-19 infection.
All foreign body inhalation patients with respiratory distress should have their bronchoscopy done without delay.
Make sure that your bronchoscopy set is sterilized (autoclave preferred) before starting the procedure
Minimize the personnel in OR to the least possible
Standard Personal protective equipment (surgical masks, eye protection) for all bronchoscopy patients
Avoid high flow jet oxygen ventilation whenever possible

For cases of suspected COVID-19, this should only occur in exceptional circumstances when bronchoscopy cannot be deferred and (FFP3 respirator, long-sleeved gown, gloves, eye protection) should be worn and safely taken off and dispose appropriately as instructed by infection control staff.

Chest tube in era of COVID-19

Indications and triage

Insertion of intercostal drain (ICD) during COVID-19 pandemic could be indicated for a well-known hospitalized COVID-19-positive patients or usual patients who visit any hospital emergency department for traumatic or non-traumatic pneumothorax or pleural effusion. Despite presence of theoretical higher risk of infection in case of dealing with COVID-19-positive patient, healthcare workers’ (HCW) precautions may minimize that risk as HCW would take complete caution by wearing personal protective equipment (PPE) and by keeping vigilant not to catch infection. Actually, the silent risk is to go for ICD insertion in a COVID-19 asymptomatic carrier [5].

The symptoms that carry the indication for chest tube insertion could mask the symptoms of a COVID-19 infection. Examples include empyema and large pneumothoraces causing fever and dyspnea, similar to COVID-19 symptoms, so a triage can be carried out primarily and further categorization of patients according to urgency is better to be based on special protocol or algorithm for every thoracic surgery unit. Any patient should be dealt with as assumed COVID positive until proved otherwise [6, 7].

Preparation

Preparation of drainage system

Higher risk of aerosol production is raised in cases of pneumothorax with active air leak. The most common available drainage system at our community is the traditional under water-seal collectors which have an outlet vent to atmosphere. When air passes from thoracic cavity to the water in the containers, it causes bubbling with the transmission of air via the outlet vent to the atmosphere causing potential environmental aerosol viral infection. Also, even though digital chest drainage systems do not have an outlet vent to room air, they are not closed systems and the air may escape from them into the air without any specific viral filter [8].

So, in spite of closed suction drainage system is advised to be used to limit aerosolization, there is a general acceptance on use of viral filter as purifying media between the drain and the suction system or the atmosphere whatever the open or closed drainage system is used. Site of application of the viral filter would be distal to the outlet vent. According to the recently published reports, different forms of high-efficiency particulate air (HEPA) viral filters have been used [6,7,8].

Use of viral filter in chest tubes has not been examined yet on evidence-based criteria, but it depends on the rationale of its proved ability to filter smaller viruses like hepatitis C whose average diameter is of about 55 nm compared to SARS Cov-2 diameter which varies from 60 to 140 nm [8].

Lessening of viral load also could be managed at an earlier level through adding sterilizing solution like; dilute household bleach (5.25–6.15% sodium hypochlorite) with ratio of 1:50 to the fluid in the water seal [6] ordinary betadine used for wound care and alcohol 70% were also used by many senior surgeons as they used to do in the TB era.

In advance preparation of the drainage system depends on creation of ready sterile connected set starts up by a suitable size chest drain firmly connected through a connector to an underwater seal container having sterile solution and its outlet vent is connected to HEPA filter through a cut endotracheal tube (Fig. 1). This pre-prepared drainage system is so crucial to prevent any potential aerosol infection in the time consumed preparing the drainage system after insertion of the ICD inside the thoracic cavity.

Precaution during the technique

-Before starting the procedure, prepare the whole connected drainage set including the drain and underwater seal carrying a viral filter as described before.

-It is better to direct the patient’s face to the opposite side during the procedure and advise him to wear a surgical mask to reduce viral load exhaled (if not impairing his breathing).

-Make the skin incision as small as possible to avoid air or fluid leak around the tube.

-Once you open the pleura, take care of the first gush of air due to the sudden decompression that carry the potential maximum viral load. To lessen that gush, the surgeon can cover the skin incision by a wet gauze with the non-working hand while the other hand at the same time opening the pleura or inserting the tube. That gauze works as a valve mechanism to prevent exit of air through the skin till insertion of the tube.

-The maximum air leak and bubbling will be at the start with maximum viral load getting out through the vent passing by the viral filter. So, the underwater seal drain could be put temporarily in a loosely closed plastic bag to contain any increased aerosolization after primary pleural decompression, then that plastic bag would be removed.

-If the patient is mechanically ventilated, hold ventilation before entry into the pleural space or until connection of the tube to the drain if not.

-Tighten the skin incision around the tube to prevent any air leakage.

-After finishing the procedure, get rid of disposables along with PPE as per recommended local institutional protocol.

Follow-up of the drain

-Usual follow-up or dressing on the wound should be conducted by HCW while wearing N95 mask, face shield, eye google, gloves, and non-sterile gown.

-Testing of residual air leakage by asking the patient to cough or to take deep breath should be minimized. If it is necessary in case of absent digital calculation system of air leak, the patient should wear a mask and look at the opposite direction while doing that.

-Do not overhandle the tube, e.g., do not pull the tube if kinked as long as it is functioning well. Pulling out the tube will take the contaminated intrathoracic part exposed out.

-If needed, clamp the tube while changing the bottle system or connecting it.

-Follow-up with radiology is better to be done by portable x-ray device inside the ward or inside a specific radiology unit for COVID-positive patients with predetermined transport routes to decrease the possible hospital environmental contamination [9].

Removal of the drain

-Removal of the drain should be in a specific dressing room while wearing full PPE.

-Upon removal of the tube, the procedure should be airtight to prevent any air to get in or out from chest cavity. That could be done through pinching of the skin around the skin opening or covering the skin by a gauze soaked by ointment while pulling out the tube followed by fast tightening of the preplaced suture [6].

Not applicable

AGP:: Aerosol-generating procedures
ERAS:: Enhanced recovery after surgery
FFP3:: Filtering facepiece class 3
ICU:: Intensive care unit
NSCLC:: Non-small cell lung cancer
OR:: Operating room
SBRT:: Stereotactic body radiation therapy
VATS:: Video-assisted thoracoscopic surgery

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Brian, M. and W. Douglas E. 2020, Definition of necessary surgery in the age of COVID-19: an interview with Douglas E. Wood.
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Collaborative CO (2020) Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet
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Authors would like to acknowledge the Egyptian Society of Cardiothoracic Surgery and its board especially prof. Elhusseiny Gamil for their valuable support and encouragement.

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Affiliations

Cardiothoracic Surgery Department, Assiut University Hospitals, Assiut University, Assiut, 71526, Egypt
Ahmed Ghoniem, Amr Ibrahim Osman & Hussein Elkhayat
Mansoura University, Mansoura, Egypt
Amr Abdellateef
Ain Shams University, Cairo, Egypt
Hany Hasan Elsayed
Cairo University, Giza, Egypt
Waleed Adel

Authors

Ahmed GhoniemView author publications
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Amr AbdellateefView author publications
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Amr Ibrahim OsmanView author publications
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Hany Hasan ElsayedView author publications
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Hussein ElkhayatView author publications
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Waleed AdelView author publications
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Contributions

AG: revise the whole manuscript. AA: share in writing the manuscript. AIO: collection of data. HH: share in writing the manuscript and revise the whole manuscript. HE: idea of the manuscript and arrangement of workforce. WA: share in writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Hussein Elkhayat.

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Ghoniem, A., Abdellateef, A., Osman, A.I. et al. A tentative guide for thoracic surgeons during COVID-19 pandemic. Cardiothorac Surg 28, 16 (2020). https://doi.org/10.1186/s43057-020-00026-z

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Received: 07 May 2020
Accepted: 22 June 2020
Published: 02 July 2020
DOI: https://doi.org/10.1186/s43057-020-00026-z

Keywords

COVID-19
Infection control
Thoracic
Surgery

中文翻译：

胸外科医生在COVID-19大流行期间的暂定指南

当前，没有足够的证据支持大流行期间进行胸外科手术的最佳实践，而且这种情况每天都在动态变化。

胸腔外科手术似乎并没有成为治疗COVID-19患者的第一线，但是我们确实扮演着关键角色，这必须有计划地进行。为了应对当前大流行的压力，我们工作的选修部分已经停止。但是，在情况变得更加稳定之后，非选修患者（紧急情况，紧急情况和外伤）将继续需要适当的护理，并重新启动服务。

我们应该寻求与最近的国家指南相结合的最佳本地解决方案，以继续对患者进行适当的管理，同时确保对COVID-19做出适当的资源分配，并对手术材料进行适当的保护。此外，我们需要考虑在不久的将来，由于医务人员疾病，供应链以及使用重症监护病房使用剧院和麻醉人员等多种因素，紧急手术的外科设施可能会受到损害。这是一种可能的情况，需要计划。

随着更广泛的医疗保健反应的加剧，我们可能还需要在我们的特定培训和专业领域之外工作，并且我们必须计划学习新的技能和实践。

在即将到来的时期内，必须与等待手术的心胸患者进行适当的通信（可以是电信）。解释说在适当的情况下等待几个星期没有什么害处，并且分配资源的计划可以为许多选择接受延误的患者提供保证。最大程度地进行虚拟随访（电话检查），以避免患者需要住院。同意在此期间进行手术的患者应始终包括医院获得的发生COVID-19感染的风险。

在这篇综述中，我们试图指出胸外科手术患者分诊的想法，使用支气管镜的预防措施以及胸管作为可能产生气雾剂的大多数程序，以及何时可以重新启动胸外科手术服务。

COVID-19的第1阶段（半紧急情况）

在这里，医院资源没有用尽，COVID轨迹还没有处于快速升级阶段，并且第三中心的ICU通气能力仍然可用。如果不进行任何干预，将为那些可能在接下来的几天内影响生存的患者提供手术服务（表1）[1]。

表1第一阶段不同病理的决策摘要

全尺寸表

迄今为止，尚无针对需要完成的紧急情况的标准定义，也没有就患者无法进一步发展而无法达成共识的共识，并且外科医生将始终在具有严重恶化风险和资源可用性的患者之间取得平衡[2]。

尽可能避免常规使用重症监护病房（术前准备，ERAS，缓解疼痛）

阶段2：紧急设置

在这一阶段，我们看到许多COVID-19患者的ICU能力有限，并且COVID轨迹不断升级。

手术治疗仅适用于如果不进行手术就无法存活几天的患者（表2）[1]。

表2第2阶段中不同病理的决策摘要

全尺寸表

阶段3：COVID 19全面爆发

所有资源都路由到COVID-19患者，并且没有ICU容量。

如果不进行干预，则仅对可能在接下来的几个小时内死亡的患者进行胸外科手术（表3）[1]。

表3第三阶段中不同病理的决策摘要

全尺寸表

创伤患者

创伤患者的管理高度依赖医疗机构，因为即使在初始评估时可以使用COVID-19筛查测试，阴性测试结果也不能排除感染的存在[2]。

因此，如果患者需要紧急干预，应考虑以下预防措施，将其视为阳性病例：

强烈建议使用全套个人防护设备（礼服，手套，手术口罩和面罩）。
尽量减少将这些患者转移到医院内部的多个区域。
应避免使用不会影响决策的诊断程序。
创伤科的所有成员应熟悉感染控制方案。

如果患者需要紧急或选择性干预，应首先进行CBC，体温和CT胸部检查，并报告是否与COVID-19一致。

现在，恢复常规手术方法已成为每个外科医生的职责范围。需要考虑太多因素；供应链资源有限，护士人数，可用的ICU病床，个人防护设备（PPE），获得诊断程序的机会有限，例如肺功能检查，支气管镜检查和PCR的可用性以及每位患者和医疗用品的其他检查。CovidSurg研究的早期结果表明，围手术期发现COVID阳性的患者具有较高的并发症和死亡率[3]，因此决定在大流行期间对每一个非紧急病例进行手术而无需扩大感染可能性的决定是高风险的操作。结果是，

支气管镜检查注意事项

支气管镜检查程序是气雾生成程序（AGP）。
支气管镜检查的适应症应考虑传播COVID-19感染的可能性。
所有患有呼吸窘迫的异物吸入患者均应立即进行支气管镜检查。
在开始操作之前，请确保您的支气管镜已消毒（首选高压灭菌器）
尽量减少OR中的人员
适用于所有支气管镜检查患者的标准个人防护设备（外科口罩，护目镜）
尽可能避免高流量喷射氧气通风

对于怀疑为COVID-19的病例，仅在无法推迟支气管镜检查且应穿戴并安全摘除（FFP3呼吸器，长袖长袍，手套，护目镜）的例外情况下，并应按照感染控制的指示适当处置，这种情况才会发生员工。

COVID-19时代的胸管

适应症和分类

对于著名的住院COVID-19阳性患者或因创伤性或非创伤性气胸或胸腔积液前往医院急诊科就诊的普通患者，可能指示在COVID-19大流行期间插入肋间引流（ICD）。尽管理论上在治疗COVID-19阳性患者时存在较高的感染风险，但医护人员（HCW）的预防措施仍可将这种风险降到最低，因为HCW会通过佩戴个人防护设备（PPE）并保持警惕而完全谨慎赶上感染。实际上，沉默的风险是将ICD插入COVID-19无症状载体中[5]。

带有胸管插入指征的症状可能掩盖了COVID-19感染的症状。例子包括脓胸和引起发烧和呼吸困难的大量气胸，类似于COVID-19症状，因此可以首先进行分流，并且最好根据每个胸外科单位的特殊方案或算法，根据紧急情况对患者进行进一步分类。任何患者均应假定COVID阳性，除非另有证明[6，7]。

制备

排水系统的准备

在气胸主动漏气的情况下，产生气雾的风险更高。在我们社区中，最常见的排水系统是传统的水下密封收集器，该收集器具有通向大气的出口。当空气从胸腔传递到容器中的水时，会引起气泡，空气通过出口孔传送到大气中，从而可能引起潜在的环境气溶胶病毒感染。同样，即使数字胸腔引流系统没有通向室内空气的出口，它们也不是封闭系统，并且在没有任何特定病毒过滤器的情况下，空气仍可能从其中逸出进入空气[8]。

因此，尽管建议使用封闭的抽水排水系统来限制雾化，但无论采用开放式还是封闭的排水系统，都应普遍接受使用病毒过滤器作为排水管与抽水系统或大气之间的净化介质。病毒过滤器的应用部位将在出口的远端。根据最近发表的报告，已使用了不同形式的高效微粒空气（HEPA）病毒过滤器[6,7,8]。

尚未根据循证的标准检查在胸管中使用病毒过滤器的情况，但这取决于其被证明具有过滤较小病毒（如丙型肝炎）的能力的理由，丙型肝炎的平均直径比SARS Cov-2直径大约55 nm从60到140 nm不等[8]。

病毒载量的减少也可以通过添加诸如以下的消毒溶液来进行更早的管理。与高级密封剂一样，稀释的家用漂白剂（5.25-6.15％的次氯酸钠）与水封中的液体的比例为1:50 [6]用于伤口护理的普通甜菜碱和70％的酒精也被许多高级外科医师使用。结核病时代。

排水系统的预先准备取决于是否准备好无菌的连接装置，该装置由合适尺寸的胸腔引水管启动，该排水管通过连接器牢固地连接到具有无菌溶液的水下密封容器，其出口孔通过气管插管连接到HEPA过滤器（图。1）。这种预先准备的引流系统对于防止在将ICD插入胸腔后准备引流系统所花费的时间内防止任何潜在的气溶胶感染至关重要。

术中注意事项

-在开始操作之前，请准备整个连接的排水装置，包括排水管和带有病毒过滤器的水下密封装置，如上所述。

-最好在手术过程中将患者的脸对准另一侧，并建议他戴上口罩以减少呼出的病毒量（如果不影响呼吸）。

-使皮肤切口尽可能小，以避免空气或液体泄漏到管子周围。

-一旦打开胸膜，由于突然减压可能会携带最大的病毒载量，请注意第一股空气。为了减少涌出，外科医生可以用不工作的手用湿纱布覆盖皮肤切口，而另一只手同时打开胸膜或插入导管。该纱布用作阀机构，以防止空气穿过皮肤排出，直到插入管子为止。

-最大的漏气和起泡将在最大病毒负荷开始时通过病毒过滤器经过的通风孔排出。因此，可以将水下密封件排水管暂时放置在一个松散封闭的塑料袋中，以容纳在初次胸膜减压后任何增加的雾化作用，然后将其移除。

-如果患者采用机械通风，则在进入胸膜腔之前应保持通风，如果没有，则应将其连接到引流管。

-拧紧试管周围的皮肤切口，以防止漏气。

-完成程序后，请按照当地推荐的机构规程弃置一次性用品以及PPE。

排水的跟进

-医务人员应在穿N95口罩，面罩，护目镜，手套和非无菌礼服的情况下，对伤口进行通常的随访或换药。

-通过要求患者咳嗽或深呼吸来测试残留的空气泄漏量应减至最少。如果没有漏气的数字计算系统，则有必要时，患者应戴好口罩并朝相反的方向看。

-请勿过度处理试管，例如，只要管子正常工作，请勿拉扯试管。拔出试管将暴露出污染的胸腔内部分。

-如果需要，在更换瓶系统或连接时夹紧管。

-对于有预定运输路线的COVID阳性患者，最好在病房内或特定放射室内部使用便携式X射线设备进行放射学随访，以减少可能的医院环境污染[9]。

排水沟的拆除

-穿着完整的个人防护装备时，应在特定的更衣室中清除排水管。

-取下导管时，该过程应为气密性，以防止任何空气从胸腔进入或流出。可以通过在开孔处捏紧皮肤或用软膏浸透的纱布覆盖皮肤，然后拉出管子，然后快速拧紧预先放置的缝线[6]来完成。

不适用

AGP：: 气雾产生程序
ERAS：: 术后恢复增强
FFP3：: 过滤面罩等级3
重症监护病房：: 重症监护室
非小细胞肺癌：: 非小细胞肺癌
要么：: 手术室
SBRT：: 立体定向放射疗法
增值税：: 电视胸腔镜手术

1。
胸外科手术结果研究网络I（2020）COVID-19胸膜恶性肿瘤手术分类指南：胸外科手术结果研究网络的共识声明。Ann Thorac Surg S0003-4975（20）：30442–2。https://doi.org/10.1016/j.athoracsur.2020.03.005
2。
Brian，M.和W. Douglas E. 2020年，《 COVID-19时代必要手术的定义》：Douglas E. Wood的访谈。
3。
合作CO（2020）围手术期SARS-CoV-2感染手术患者的死亡率和肺部并发症：一项国际队列研究。柳叶刀
4。
COVIDSurg Collaborative，D.Nepogodiev和A.Bhangu（2020）因COVID-19大流行而取消的选择性手术：为手术康复计划提供依据的全球预测模型。Br J Surg。https://doi.org/10.1002/bjs.11746
5，
Li R等人（2020）大量未记录的感染促进了新型冠状病毒（SARS-CoV-2）的快速传播。科学368（6490）：489–493
CAS文章Google学术搜索
6。
Pieracci FM等人（2020）在COVID-19大流行期间进行胸腔镜造口术：AAST急诊外科和重症监护委员会的指导和建议。创伤外科急诊开放5（1）：e000498
文章Google学术搜索
7。
CARVALHO EDA，OLIVEIRA MVBD（2020）COVID-19，用于大流行中胸腔引流的安全模型。巴西科雷吉奥河畔雷维斯塔47
8。
Rajdeep，B。等人，COVID-19：漏气的胸腔引流管–无声的“超级吊具”？2020年。
谷歌学术
9。
世界卫生组织。2020年怀疑有新型冠状病毒（nCoV）感染时在卫生保健中的感染预防和控制[引自2020年6月5日]；可从以下网址获得：https://www.who.int/publications/i/item/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 。

下载参考

作者要感谢埃及心胸外科学会及其董事会特别是教授。Elhusseiny Gamil的宝贵支持和鼓励。

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隶属关系

阿西乌特大学阿西乌特大学医院心胸外科，埃及阿西乌特71526
艾哈迈德·格尼姆（Ahmed Ghoniem），阿姆·易卜拉欣·奥斯曼（Amr Ibrahim Osman）和侯赛因·埃尔哈亚特
曼苏拉大学，埃及曼苏拉
Amr Abdellateef
埃及开罗Ain Shams大学
汉尼·哈桑·埃赛义德
埃及吉萨开罗大学
沃尔德·阿德尔

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Waleed Adel查看作者出版物
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会费

AG：修改整个手稿。AA：分享写作手稿。AIO：数据收集。汉：分享写作手稿，并修改整个手稿。他：手稿的想法和工作人员的安排。华盛顿：分享写作手稿。所有作者阅读并认可的终稿。

通讯作者

对应于侯赛因·埃尔卡亚特。

道德规范的批准和同意参加

不适用

同意发表

不适用

利益争夺

没有

发行人须知

对于已发布地图和机构隶属关系中的管辖权主张，Springer Nature保持中立。

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