Stages of empyema.
\r\n\tFood insecurity results in fear of hunger and starvation that ultimately affects one’s ability to work for sustainability and economic growth of the country. In addition to this, food insecurity results in various chronic diseases due to reduce immunity that ultimately, a burned on the county economy. Therefore, this book will intend to discuss in detail about the food insecurity challenges and their effect on the quality of life. This book will also aim to provide an overview about the new trends and future prospective that help to resolve the food security issues.
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by"}}]},onlineFirst:{chapter:{type:"chapter",id:"79221",title:"Surgical Challenges of Chronic Empyema and Bronchopleural Fistula",doi:"10.5772/intechopen.100313",slug:"surgical-challenges-of-chronic-empyema-and-bronchopleural-fistula",body:'Empyema is a common clinical problem to both pulmonary physicians and thoracic surgeons. It affected 65,000 patients annually in the US [1]. Thanks to the advent of antibiotics and continuous advancement of minimally invasive procedures, most acute empyema patients can now receive tube thoracostomy and/or video-assisted thoracoscopic surgeries (VATS) to alleviate the infection with good recovery [2]. Empyema, also known to be pleural empyema or thoracic empyema, is defined as infection in the pleural cavity. The most common scenario is that the patient has a prior or ongoing pneumonia which the infection has extended to the lung surface, causing a series of inflammation and infection response on the visceral pleura and therefore parietal pleura. The products of the infection then accumulate in the pleural space resulting in empyema. Some patients would develop pleuritic pain which they easily mistake it as muscle strains or sprains, so they tend to overlook the real problem and lead to delay diagnosis. There are also a lot of other reasons that can eventually cause empyema, such as trauma, invasive procedures (including thoracic operation), liver abscess, spinal abscess, mediastinitis (because in the vicinity of an infection source) or being transmitted through hematogenous route.
According to American Thoracic Society classification, empyema is divided into three stages (Table 1) [3, 4]. In the early stage of pleural cavity infection, some fibrin would develop in this avascular space along with some body fluid. It is often recognized as parapneumonic pleural effusion. At this exudative phase, most fluid in the pleural cavity can be drained by a chest tube. If the infectious process continues and the fluid accumulates, the fluid will become thicker with more fibrin deposition. This second stage is often characterized by loculated pleural effusion which makes it difficult to drain all effusion in different areas with a single chest tube. Patients with this true empyema stage often require surgical intervention to deloculate the effusion for complete drainage. Fibrinolytic agent is another option for non-surgical candidate. When the disease progresses, more and more fibrin pile up and the fluid becomes denser and denser. A thick peel will form to cover all contact surfaces, including lung, inner chest wall, diaphragm, and mediastinum. This final stage of empyema, organizing phase, will restrict lung expansion and hence reduce lung compliance. More aggressive treatment modalities should always be considered to avoid long-term lung function impairment.
Stage | Phase | Characteristics | Status of Lung Parenchyma | Treatment |
---|---|---|---|---|
I | Exudative (Acute) | Pleural membrane thickening Fibrin deposition Presence of exudative fluid | Compliant Reexpansion possible with evacuation of fluid | Thoracentesis Closed-tube thoracostomy |
II | Fibrinopurulent | Extensive fibrin deposition Pleural fluid becomes turbid or purulent Presence of loculated empyema | Partial compliance Lung entrapment due to fibrin deposition | Closed-tube thoracostomy with/ without fibrinolytics VATS Thoracotomy |
III | Organized (Chronic) | Fibroblast in growth Thickened pus Granulation tissue replacement of the pleural space | No compliance Lung completely entrapped by fibrous peel | VATS (decortication) Thoracotomy (decortication) Open window thoracostomy |
Since empyema equals to infected pleural cavity, the primary goal is to treat the infection. There are a few recognized treatment principles to such disease. First, sterilization of the pleural space. Second, adequate drainage. Third, optimizing lung expansion and reducing potential pleural space. These principles will be explained in detail below.
Just like treating other infectious disease, removal of pus or necrotic tissue and antibiotics therapy are the two key components to successful treatment. In empyema, sterilization targets not only the pleural space but also the original infection source, such as pneumonia or liver abscess. To select effective antibiotics, obtaining cultures are important so that adjustment can be made according to susceptibility test after empirical antibiotics. Other effective ways to lower the pathogen colonization in the pleural cavity are removal of the infectious debri and irrigation. These procedures, debridement and irrigation, are often carried out during the surgery, either through VATS or thoracotomy. Although some doctors believe irrigation may result in unstable hemodynamics as capillary permeability increases due to transient bacteremia, the author thinks it is reasonable to do so as it is easier and faster to achieve sterilization. If the patient’s blood pressure drops during the surgery, it is suggested to irrigate the pleural cavity with some diluted epinephrine with cautious monitoring. Since the patient’s capillary permeability may increase, it is possible that the patient would develop tachycardia and hypertension if the medication is well-absorbed by the pleura.
Unlike airway, pleural cavity is a closed space. The fluid should be drained adequately to avoid further or repeated infection. A chest tube is sufficient for simple parapneumonic pleural effusion (stage I empyema) while complicated pleural effusion (stage II empyema) or organizing empyema (stage III empyema) often requires surgical intervention and a chest tube(s) after the surgery for adequate drainage.
When the empyema reaches to its final stage --- organizing stage, the lung would become completely trapped and therefore poorly expanded. This not only leads to restrictive lung (impaired lung function), but also leaves a potential dead space in the pleural cavity. This space would possibly result in repeated infection. Therefore, the initial treatment goal of empyema should also include best pleural apposition to prevent chronicity. To achieve this, remove “peels” from the lung and other pleural surfaces. This surgical procedure is known as “Decortication.” As long as it is feasible, removing all debri and resuming patients’ optimal pulmonary function are always recommended. However, there could be exceptions that the lung fails to fill the pleural cavity. If this is the case, other measures should be taken to reduce the potential pleural space.
From a thoracic surgeon’s point of view towards managing empyema, it is always “the earlier the easier.” In an acute setting of empyema (stage I or II), most patients can be cured by tube thoracostomy or VATS [2]. This further emphasizes the fact that early diagnosis and early aggressive treatment to prevent chronicity are crucial. In addition, the choice of first intervention is important as well. According to the literature, failure of the first attempted procedure was an independent predictor of death [5]. As a result, operation is the most successful initial procedure in this study. More and more studies demonstrated good outcomes of early surgical intervention treating complex empyema [5, 6]. Furthermore, VATS decortication is found to be superior to open surgery in the management of primary empyema [7]. In the author’s hospital, empyema is a surgical disease. Once the diagnosis is made, almost all patients need surgical consult for further treatment planning. All surgeons tacitly agree that VATS is the gold standard procedure to treat acute empyema in the author’s institution.
There are still certain patients who will eventually continue to have the infection and enter to a chronic phase. Several causes of chronic empyema include delayed diagnosis, retained hematoma in the pleural cavity, bronchopleural fistula with continuous airway secretion spillage, a large potential pleural space (e.g. post lung resectional empyema) which is prone to have repeated infection, and the patient is too ill to receive definite treatment at the initial acute phase. Among all the causes, the author thinks that retained hematoma in the pleural cavity is the most preventable cause of chronic empyema. Blood clots are perfect culture medium for bacteria, so it is important to avoid too much oozing when one performs VATS debridement and decortication on empyema patients, especially those who have liver cirrhosis, end stage renal disease, or other bleeding tendency. Adequate hemostasis and diluted epinephrine irrigation are helpful to prevent retained hematoma. If retained hematoma still happens, at least it is detectable from the drainage fluid. The drained fluid would be bloody initially then turned to dark brown and remained in this color without turning to light yellow. As one recognizes the sign of retained hematoma in the pleural cavity, it is often required to do another operation to remove all the blood clots to prevent chronic empyema.
In this section, the focus will be solely on the treatment options of chronic empyema and to which treatment principles that each option fits in.
When dealing with empyema, following the above mentioned three treatment principles is the key to success. Although the principles are the same in different stages, treatment strategies may vary, especially in the chronic stage. Treating chronic empyema is more complicated, more unpredictable, and therefore more challenging. It may require staged operations, different surgical approaches, and there is no standardized option. Before establishing treatment plan for chronic empyema patients, comprehensive understanding between each option is necessary.
Decortication can be done either through VATS or thoracotomy. It is basically surgeon’s preference. During the same surgery, debridement is also done so that non-viable tissue and debri are removed to achieve “cleaning” in the pleural cavity. In stage III empyema, the lung is always restricted by thickened “cortex,” so freeing the lung by decortication can optimize lung expansion and reduce the potential pleural space. Choosing proper surgical instruments accelerates the procedure. In the author’s experience, Roberts artery forceps or long Kelly forceps are best tools to separate the lung from the overlying “cortex.” This separation process can be done sometimes with the operated lung ventilating so that the correct pleural plane is evident. If pleural apposition still cannot be achieved after decortication, make sure to check the lung surface again. There may be some remnant peel from the multi-layered peel that restricts lung expansion. Sometimes the peel is extremely thick and firm. Using a scalpel cautiously to slit through the peel will aid in removal.
*Fitting in the treatment principles sterilization of the pleural cavity and reducing potential pleural space by optimizing lung expansion.
To optimize lung expansion, there are several other ways, but none are as effective as decortication.
Some of these patients are ventilator dependent while others are not. If they still require ventilator support, it is acceptable to increase positive end-expiratory pressure (PEEP) a little, by 1 or 2 cmH2O, to further expand the lung. If patients can be weaned off from ventilator successfully after the operation, a strategical management option is to delay extubation time by 0.5 to 1 day. This may also allow the lung to further expand.
*Fitting in the treatment principle reducing potential pleural space by optimizing lung expansion.
Positive airway pressure expands the lung from internal while negative pleural pressure provides a tractive force externally. A suction pressure of −20 cmH2O is usually recommended with a traditional chest drainage system. Other modality that can create negative pressure in the pleural cavity is Vacuum-assisted closure (VAC) therapy. (see 4.4).
*Fitting in the treatment principles drainage and reducing potential pleural space by optimizing lung expansion.
OWT was first described by Robinson in 1916 and then revised by Leo Eloesser in 1935 which was also called Eloesser flap thoracostomy window [8]. However, the most adopted OWT is modified by Symbas and coworkers in 1971 as modified Eloesser flap [9].
This procedure, an open drainage method, is often saved as the last resort to treat chronic empyema, especially when the pleural infection is difficult to be managed by debridement and decortication. It is also a treatment option for critically ill patients who are too weak to receive decortication. As the name presents itself, OWT is to create a window through the patient’s chest so serial dressing changes are feasible to clean the infected pleural cavity and therefore alleviate the septic condition. The advantage of OWT is that it is proved to be safe and effective [10]. On the other hand, it affects the patient’s appearance and may cause chronic pain after chest wall resection. Some of the patients will need another surgery to close up the wound.
*Fitting in the treatment principles sterilization of the pleural cavity and drainage.
The most common use of OWT is modified Eloesser flap [11]. The window is usually created at the basal part of the hemithorax where most of the infected material accumulates (Figure 1). After confirming the chest CT image, an inverted U-shaped incision is made at this area. Electrocautery is used for dissection till the rib cage. In order to create a sufficient window, two or three ribs need to be resected. Then, the tongue-shaped muscular-cutaneous flap is folded inward and sutured to the diaphragm (Figure 2). The remaining wound edge is sutured to the pleura so that the window can be maintained for a period of time without spontaneous closure. It is also imperative that the window is large enough for the convenience of frequent wet packings. Another key point that must be mentioned is the timing of OWT creation. From the Massera et al. study [12], immediate OWT requires lesser time for the resolution of empyema comparing to the delayed OWT after prolonged chest tube drainage. As a result, the median OWT closure time (between performing and closing of OWT) of immediate OWT was 8 months shorter than that of delayed OWT. The timing of attempted closure should be carefully decided by the surgeon after a thorough evaluation of the empyema patient’s condition. This includes free from recurrent disease, good recovery of the pleural cavity with coverage by healthy granulation tissue, the patient’s general condition, and to a lesser degree by the normalization of inflammatory parameters [12, 13]. Methods of OWT closure please see 4.6.2 below.
OWT. An OWT on the patient’s left-side chest wall.
Coronal view of the Eloesser flap window. Demonstrating the supposition of the skin surface of the inferiorly based soft tissue flap to the diaphragmatic surface. (Adapted from Denlinger [
VAC is a negative pressure wound therapy that is widely used in acute and extended open wounds. The first case report of intrathoracic VAC therapy was published in 2006 [14]. Varker et al. managed a postlobectomy empyema patient with VAC device successfully after open debridement of the empyema cavity. In the next following decade, with the popularity of VAC therapy, it was proved that it is safe and efficient to fight against all kinds of intrathoracic infections [13, 15, 16, 17].
VAC device is able to create a negative pressure wound environment that promotes wound healing by reducing edema, promoting granulation tissue formation and perfusion, and removing exudate and infectious material. As to treating chronic empyema, it is a useful tool to apply on an open wound such as an OWT after debridement of the pleural cavity (Figure 3). In the setting of intrathoracic VAC usage, it may reduce the duration and frequency of dressing changes necessary for spontaneous chest closure or a space filling procedure, reducing patient’s discomfort, and resolving the infectious process faster [18]. When compared with conventional management of OWT, VAC therapy accelerates wound healing and helps re-expansion of residual lung parenchyma in patients with OWT [19]. In selected patients, applying Mini-VAC procedure can even avoid OWT by insertion of the ALEXIS (Applied Medical, Rancho Santa Margarita, CA, USA) wound retractor to create a similar window effect without resecting the ribs which preserves the chest wall integrity and avoids the consequences that OWT can cause (Figure 4) [20]. However, the biggest disadvantage of this device is that it is not suitable for everyone. VAC device should be used cautiously or be avoided on patients with bleeding tendency, presence of malignancy, or unstable hemodynamics. Because VAC creates a negative pressure environment, it may lead to continuous bleeding, promote cancer growth, or deteriorate hypotension. The reason why hypotension may develop is probably due to the negative pressure effect intrathoracically causing decreased cardiac output. Thus, intrathoracic application in older patients must be monitored closely and should be avoided on patients with poor cardiac function.
Intrathoracic VAC therapy. VAC therapy is applied through the patient’s OWT.
Mini-VAC procedure. VAC therapy is applied through the ALEXIS wound retractor which creates a similar window effect without resecting the ribs.
*Fitting in the treatment principles drainage and reducing potential pleural space by optimizing lung expansion.
VAC therapy is designed to be applied on open wounds. To treat chronic empyema with VAC, an open chest wound or an OWT must be created during the surgical intervention. Some authors advocate leaving the thoracotomy wound open directly after the operation [13, 14] while others create an OWT to make dressing changes easier [17, 18, 19]. It is reasonable to decide on an individual basis depending on the size and depth of the residual pleural space. A large and deep residual pleural space is preferred for OWT. The advantage of OWT is that the chest will stay open for a longer period because of the inverted skin flap compared to just leaving the thoracotomy wound open. OWT would avoid the skin from healing before complete eradication of the infected pleural cavity. It is contraindicated to apply VAC on a dirty wound with necrotic tissue that has yet to be debrided. After adequate debridement in the pleural cavity, VAC sponges (GranuFoam) are inserted in the residual pleural space to fill the entire cavity. Placing the sponges directly in contact with exposed blood vessels, anastomotic sites, organs, or nerves are prohibited, except for the lungs. According to the literature [13, 21] and the author’s personal experiences, VAC dressing can be safely applied directly on the visceral pleura or lung parenchyma without any complications. The negative pressure can be set at -50 mmHg from the start, and gradually increased to -125 mmHg if the patient does not have any discomfort. The dressing change should be done at least twice a week, and it can be performed at the bedside. During the VAC therapy period, the skin covered by the dressing should be well protected to prevent skin maceration problems. If negative pressure fails to be maintained due to significant air leak caused by bronchopleural fistula (BPF), combining a one-way valve may solve this issue [21].
When dealing with postpneumonectomy empyema (PPE), VAC therapy should be used carefully, especially for patients who develop the complication shortly after the initial surgery. This is because negative pressure would shift the mediastinum which may cause heart or great vessels herniation leading to obstructive shock or even cardiac arrest. On the contrary, if PPE is developed at a later stage, such events will not happen as the mediastinal shift has already completed and the patient’s body has compensated it well.
There are two scenarios where chronic empyema patients would need an empyema tube for long-term drainage. One is that the patient is too unstable and fragile to receive general anesthesia and adequate surgical intervention. To alleviate the septic condition, empyema tube (tube thoracostomy) can be placed to decrease the burden of infection until definite treatment can be initiated. Another scenario is that the chronic empyema is somehow localized in a small area without systemic infection. It is either a tube thoracostomy left after previous surgical intervention or a new chest tube inserted into this localized area for drainage if the patient is not a surgical candidate.
In the author’s opinion, this treatment option is only reserved for those who are not able to receive other definite treatment because of the low success rate, and not all infected materials can be drained adequately. However, if adequate drainage can be achieved, the tube may be slowly retracted over a period of weeks to months while the infected space heals behind it [3].
*Fitting in the treatment principle drainage.
Clagett procedure was first described by Clagett and Geraci in 1963 [22]. It is a method that obliterate the pleural cavity with antibiotic solution. As a precondition of the procedure, there must be no BPF and the pleural cavity should be sterilized by debridement and irrigation. In other words, if the patient has BPF and primary repair is impossible, Clagett procedure is not suitable for the patient. Nonetheless, this procedure has a good overall success rate in selected patients (no BPF at the time of the procedure), range from 81–100% [12, 23, 24, 25]. Those who fail from the procedure are mainly due to persistent or recurrent BPF.
*Fitting in the treatment principle reducing potential pleural space.
After confirming that there is no active BPF in the pleural cavity or it is firmly closed, antibiotic fluid can be instilled to fill the remaining pleural cavity after it is fully cleansed. DAB solution (gentamicin 80 mg/L, neomycin 500 mg/L, and polymyxin B 100 mg/L) is one of the antibiotic solution choices [23]. The combination of the fluid can be chosen according to the microbiological findings [26].
Tissue flap transposition technique is frequently used in chronic empyema patients for the purpose of either closure of the BPF or OWT, and/or obliteration of the residual pleural space. It can also be used for the prophylactic reinforcement of a bronchial stump after major lung resection to avoid BPF formation. Because the flap tissue is full of mesenchymal cells, it can promote granulation tissue growing under good circulation and secure the bronchial stump as a backup layer. A bulky muscle flap is extremely helpful to reduce the residual pleural space while a smaller residual space only requires a smaller tissue flap. However, not every patient is medically fit for long-hour flap surgery especially the critically ill. A successful flap reconstructive surgery is determined by a well-perfused flap which is highly dependent on patients’ stable hemodynamics.
*Fitting in the treatment principle reducing potential pleural space.
Tissue flaps commonly used in chronic empyema are latissimus dorsi (LD) muscle flap (Figure 5), serratus anterior (SA) muscle flap, pectoralis major (PM) muscle flap, intercostal muscle flap, pedicled omental flap, and other free flaps. LD is the largest muscle among all chest wall muscles. Therefore, it is an ideal option for pleural cavity obliteration. However, if the patient has received a standard posterolateral thoracotomy previously, this muscle may have been compromised and hence not suitable. PM flap is another good alternative for it is the second largest chest wall muscles. Because of its anatomy and orientation, PM flap is particularly useful to obliterate the apical residual pleural space [3, 27]. Although SA flap and intercostal muscle flap are relatively small compared to LD and PM flaps, they can be sufficient to help accelerate BPF healing as long as the pedicle is healthy. Omental flap is another option if no chest wall muscle is available [28]. However, entering the peritoneal cavity may potentially spread the infection and complicate the situation. Sometimes the remaining pleural space is too big that only by combining two flaps will fill the space [27]. Free flap may also be considered in highly selected patients.
LD muscle flap. Harvest of the LD muscle flap to reinforce the PPE BPF closure.
Thoracoplasty has a long history in the field of thoracic surgery. It was first described by Estlander in the late 19th century when tuberculosis was a troublesome pandemic without medical cure [29]. The original concept of this surgery is to collapse the chest wall to minimize the cavitary pleural space caused by mycobacterium. To achieve this goal, multiple ribs are resected resulting in loss of rigid chest wall configuration and therefore obliteration of the infected pleural space. Although it is an effective way to fill the potential pleural space, this procedure can cause significant morbidity, including chronic pain, chest wall deformity, thoracic spine scoliosis, limited ipsilateral shoulder range of motion, and finally resulting in poor quality of life.
*Fitting in the treatment principle reducing potential pleural space.
Thoracoplasty can be classified into three types, full, extended, and tailored thoracoplasty. Full thoracoplasty is defined as removing first 11 ribs to collapse the whole hemithorax. Extended thoracoplasty, on the other hand, is removing 7 to 9 ribs while tailored thoracoplasty is removing fewer than 5 ribs at certain area [30]. Resection of 7 ribs can lead to approximately 50% reduction of the pleural space, and resection of 5 ribs results in 25% reduction (Figure 6) [31]. The key to a successful thoracoplasty is complete resection of the targeted ribs which means from the transverse process of the thoracic spine posteriorly to the costosternal joint anteriorly. In the modern era, this procedure is seldom conducted alone. Combining with muscle flap transposition is an effective alternative so that chest wall deformity can be less significant [32, 33].
Thoracoplasty. Complete resection of the 4 right upper ribs. (Adapted from Lewis and Wolfe [
Managing chronic empyema is art. There is no standardized option. Knowing the different measures in depth and applying each principle with these measures will certainly increase the success rate of treatment. Making a customized treatment plan according to the patient’s physical condition, complications, and special requirements cannot be emphasized enough. There are special circumstances which will be introduced below for better understanding of how to put the different treatment options in use.
The main issue contributed by post-resectional empyema is that the residual pleural space is often large. The treatment strategy therefore should be emphasized on how to fill the space. If post-lobectomy empyema occurs in a delayed setting, the size of the residual pleural space would not be a concern because the pleural cavity should have been remodeled by diaphragm elevation, mediastinum shifting, and narrowing of the intercostal space over time. However, if post-resectional empyema happens in an acute phase when the remodeling has not been completed yet, different filling procedures should always be considered. For instance, if a patient who is medically fit for surgery develops a post-lobectomy empyema in a delayed phase, VATS or thoracotomy debridement and decortication are usually amenable to solving the problem.
Post-pneumonectomy empyema (PPE) is notorious for its high morbidity and mortality rate [12]. It is a challenging situation clinically, especially when BPF is present (Figure 7). According to the literature [12, 25, 30], approximately 65 to 84% PPE patients have BPF. Closure of the BPF is imperative or else spillage from the infected cavity into the airway can cause pneumonia or even acute respiratory distress syndrome (ARDS). On the other hand, the secretion from the airway would also leak into the pleural space continuously and contaminate the cavity. After closing the BPF, as per treatment of other empyema, sterilization of the cavity with debridement, irrigation, parenteral antibiotics, and adequate drainage, the most important is effective obliteration of the remaining pleural space. Since the BPF is often failed by primary suture alone, covering the stump with pedicled muscle flap ensures secondary healing as well and obliteration the pleural space at the same time. For example, if a debilitated patient suffers from severe sepsis caused by late onset right-sided PPE with BPF, it is reasonable to lay out a staged surgical plan. First, do a tube thoracostomy and forbid the patient to lie in a left decubitus position to protect the contralateral lung. This first stage is for drainage and lung protection. Second, perform simple debridement, OWT, and primary BPF repair added on a buttressed intercostal muscle flap. Instead of frequent dressing changes after OWT, VAC therapy can be initiated under the circumstance without any contraindication. VAC dressings can be changed at least twice a week. After a period of aggressive treatment plus appropriate nutritional support, successful BPF closure, a clean pleural cavity covered with healthy granulation tissue, and improved physical status of the patient can be expected. The second stage is for sterilization of the pleural space and open drainage. The third stage is purely for filling. Choose an appropriate procedure, such as Clagett procedure, to obliterate the pleural cavity.
PPE with BPFs. (A) from the thoracoscopic view of the BPFs (B) from the bronchoscopic view of the BPFs.
As mentioned in the last paragraph, BPF connects the bronchus to the pleural cavity leading to infection burden and possible respiratory distress. Life threatening events, such as ARDS or septic shock, must be managed as top priority. Successful closure of the BPF may prevent those critical situations from happening. As long as the patient’s physical condition is suitable for intervention, attempts to close the BPF should be carried out as early as possible.
There are several ways to manage BPF, either bronchoscopically or surgically. Treatment choices mainly depend on patients’ clinical status, duration before the development of BPF, and number and size of the BPF [30]. An algorithm for treatment of BPF at the European Oncologic Institute [34] (Figure 8) was created according to these principles. If the BPF occurs in an early setting (<14 days after surgery), surgical repair of the bronchial stump is always encouraged. In a delayed setting (>14 days after surgery), bronchoscopic application with sealants, fibrin glue, silver nitrate, coils, endobronchial stents, Endobronchial Watanabe Spigot, or atrial septal defect occluder device [35, 36, 37, 38] can be used for small BPF size <8 mm or for patients who are physically unfit for surgery. As for BPF size >8 mm, patients who are fit for surgery, patients who had failure from other treatment strategies, surgical intervention is unavoidable. In addition to primary closure of the bronchial stump, muscle flap transposition to cover the sutured stump provides a good environment for secondary healing which may increase the success rate of closure. If the BPF is deemed to be closed during the operation, Clagett procedure may be considered after thorough cleansing of the infected pleural cavity. Since continuous spillage from the BPF may occur, therefore OWT is often a treatment option to enable frequent dressing changes to eliminate the infection.
Management of PPE BPF: EOI algorithm. (Adapted from Mazzella et al. [
At times, malignant pleural effusion can be infected either through hematogenous or direct inoculation by invasive procedures. The treatment principles are essentially the same. Sterilization of the pleural cavity and adequate drainage are not difficult to achieve. Since the pleura tumor cells cannot be eradicated immediately by surgical procedures or medical treatment, it is almost impossible to fully expand the lung via decortication and therefore a possible residual pleural space which can cause repeated infection. Under this circumstance, a thorough decortication is not practical because tumor cells are prone to bleed and cause the underneath lung tissue to be more fragile. Too much “peeling” will lead to excessive bleeding resulting in hematoma retention and causing the lung to tear. To weigh the benefits and risks of surgical intervention is crucial since the patient’s life expectancy may be limited. From the author’s personal experience, debridement, irrigation, and limited decortication followed by a tube thoracostomy are sufficient to treat the infected pleural cavity.
Although some surgical measures for chronic empyema originated from treating tuberculous (TB) empyema [8, 29], such as Eloesser flap thoracostomy window and thoracoplasty, these intensive procedures are now rarely used to treat TB empyema. It is not that TB empyema patients do not need invasive procedures, but it is that most of these patients can be managed by tube thoracostomy or VATS debridement with decortication. When it comes to uncontrolled TB empyema with initial treatment attempt failure, more aggressive modalities should be considered which are the same as treating other bacterial chronic empyema.
Double lumen endotracheal tube intubation is frequently seen in thoracic surgery for lung isolation. It can be an adjunct to help with BPF treatment after pneumonectomy if the patient still requires ventilator support or to protect the remaining lung from fistular spillage. Application of this device would help ventilate the remaining side of the lung and leave the fistular side of the hemithorax unventilated to accelerate fistular healing. However, the diameter of the double lumen tube is certainly greater than the single lumen tube which would make the patient feel uncomfortable if not sedated. Another frequently encountered issue is that the left-sided tube tip would slide outward easily, and this malposition may cause failure of lung isolation. Although the whole diameter of the double lumen is greater than the single lumen tube, each individual double lumen tube diameter is smaller. This would make it difficult to clean the airway by suction as the suction tip may not always reach to the proper depth. As a result, airway hygiene may become a serious issue if the tube is placed in the bronchus for a long time.
With the development of modern medicine and minimally invasive technology, the role of both bronchoscopic and thoracoscopic (VATS) procedures have become increasingly important replacing some of the traditional surgeries in treating chronic empyema. More studies should focus on solving existing issues like, Mini-VAC replacing OWT completely, customized device to help repairing BPF, and 3D bioprinting assisting BPF closure. The author believes that chronic empyema management is still evolving, and look forward to less traumatic ways of approach with better outcome in the future.
Treating chronic empyema and BPF are certainly clinical challenges that thoracic surgeons would encounter from time to time. It is necessary to thoroughly comprehend each treatment option and some management key points of different situations. With the development of modern technology, more treatment modalities can be anticipated.
The author has nothing to declare.
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The hydration processes of biopolymers have been extensively studied in the past 20 years with reference to a considerable variety of models and concepts. In all recent works, a distinction is made between intracellular water that maintains the ordinary liquid state (bulk water) and water ordered in extended hydrogen‐bonded lattices at the surface and structured in the internal grooves of macromolecules (hydration water) in dependence on the chemical properties of the macromolecule surface. FTIR spectroscopy has been implemented in this field both for the sensitivity in the conformational analysis of biological macromolecules and the reliability in the investigation of the water network. A perturbation technique such as dehydration‐rehydration treatment modifies the macromolecule structure and water distribution. It was applied to two structurally different proteins: lysozyme, a globular (α + β) protein and collagen, a fibrous protein characterized by the triple helix structure. Submitted to the treatment both of them display irreversible conformational changes.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Maria Grazia Bridelli",authors:[{id:"108760",title:"Dr.",name:"Maria Grazia",middleName:null,surname:"Bridelli",slug:"maria-grazia-bridelli",fullName:"Maria Grazia Bridelli"}]},{id:"74096",doi:"10.5772/intechopen.94521",title:"Time Frequency Analysis of Wavelet and Fourier Transform",slug:"time-frequency-analysis-of-wavelet-and-fourier-transform",totalDownloads:1220,totalCrossrefCites:6,totalDimensionsCites:8,abstract:"Signal processing has long been dominated by the Fourier transform. However, there is an alternate transform that has gained popularity recently and that is the wavelet transform. The wavelet transform has a long history starting in 1910 when Alfred Haar created it as an alternative to the Fourier transform. In 1940 Norman Ricker created the first continuous wavelet and proposed the term wavelet. Work in the field has proceeded in fits and starts across many different disciplines, until the 1990’s when the discrete wavelet transform was developed by Ingrid Daubechies. While the Fourier transform creates a representation of the signal in the frequency domain, the wavelet transform creates a representation of the signal in both the time and frequency domain, thereby allowing efficient access of localized information about the signal.",book:{id:"10065",slug:"wavelet-theory",title:"Wavelet Theory",fullTitle:"Wavelet Theory"},signatures:"Karlton Wirsing",authors:[{id:"325178",title:"Dr.",name:"Karlton",middleName:null,surname:"Wirsing",slug:"karlton-wirsing",fullName:"Karlton Wirsing"}]},{id:"52810",doi:"10.5772/65776",title:"Study of Green Nanoparticles and Biocomplexes Based on Exopolysaccharide by Modern Fourier Transform Spectroscopy",slug:"study-of-green-nanoparticles-and-biocomplexes-based-on-exopolysaccharide-by-modern-fourier-transform",totalDownloads:2028,totalCrossrefCites:2,totalDimensionsCites:6,abstract:"The intention of this chapter is to contribute in clarification of nanoparticle synthesis and biocomplexes based on exopolysaccharide, green synthetic method development, their physico‐chemical characterization by modern spectroscopy, as well as testing of their antimicrobial activity. Silver nanoparticles of polysaccharide type have scientific interest, but practical importance too, because of their application in pharmaceutical and cosmetic product development due to proven antimicrobial and antioxidant activities. On the other hand, the biocomplexes based on exopolysaccharides are important in treatment of biometal deficiency in human and veterinary medicine, as well as in metal ion transporting in organism. Despite a number of studies of this kind of complexes, the investigations of effect of their structure to pharmaco‐biological activity are still interesting. It is important that question of interaction between reducing and stabilizing agents with metal ions is still opened. In this respect, the presented chapter offers further progress in the examination of silver nanoparticles and cobalt biocomplex synthesis with dextran oligosaccharides and its derivatives (such as dextran sulfate and carboxymethyl dextran). The complex structure, spectroscopic characterization, and the spectra‐structure correlation have been analyzed by different Fourier transform infrared (FTIR) spectroscopic techniques combined with energy‐dispersive X‐ray (EDX), X‐ray diffraction (XRD), scanning electron microscopy (SEM), and surface plasmon resonance UV‐Vis methods.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Goran S. Nikolić, Milorad D. Cakić, Slobodan Glišić, Dragan J.\nCvetković, Žarko J. Mitić and Dragana Z. Marković",authors:[{id:"23261",title:"Prof.",name:"Goran",middleName:"S.",surname:"Nikolic",slug:"goran-nikolic",fullName:"Goran Nikolic"},{id:"195519",title:"Dr.",name:"Milorad",middleName:null,surname:"Cakic",slug:"milorad-cakic",fullName:"Milorad Cakic"},{id:"195520",title:"MSc.",name:"Slobodan",middleName:null,surname:"Glišić",slug:"slobodan-glisic",fullName:"Slobodan Glišić"},{id:"195521",title:"Prof.",name:"Dragan",middleName:"J.",surname:"Cvetkovic",slug:"dragan-cvetkovic",fullName:"Dragan Cvetkovic"},{id:"195522",title:"Dr.",name:"Žarko",middleName:null,surname:"Mitić",slug:"zarko-mitic",fullName:"Žarko Mitić"},{id:"195523",title:"MSc.",name:"Dragana",middleName:null,surname:"Marković-Nikolić",slug:"dragana-markovic-nikolic",fullName:"Dragana Marković-Nikolić"}]},{id:"53388",doi:"10.5772/66107",title:"Fourier Transform Hyperspectral Imaging for Cultural Heritage",slug:"fourier-transform-hyperspectral-imaging-for-cultural-heritage",totalDownloads:1799,totalCrossrefCites:1,totalDimensionsCites:6,abstract:"Hyperspectral imaging is a technique of analysis that associates to each pixel of the image the spectral content of the radiation coming from the scene. This content can be helpful to recognize the chemical nature of the materials within the scene or to calculate their colours under particular conditions. Different solutions of hyperspectral imager have been realized with different spatial resolution, spectral resolution and range in the electromagnetic spectrum. In particular, improving the spectral resolution allows discriminating smaller features in the spectrum and the unambiguous detection of the absorption bands characteristic of superficial materials. Hyperspectral imagers based on interferometers have the advantage of having a spectral resolution that can be varied according to the needs by changing the optical path delay of the interferometer. A spectrum for each pixel is obtained with an algorithm based on the Fourier transform of the calibrated interferogram. We present the results of the application of a hyperspectral imager based on Fabry‐Perot interferometers to the field of cultural heritage. On different artworks, the hyperspectral imager has been used for pigment recognition, for colour rendering elaborations of the image with different light sources or standard illuminants and for calculating the chromatic coordinates useful for specific purposes.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Massimo Zucco, Marco Pisani and Tiziana Cavaleri",authors:[{id:"20909",title:"Dr.",name:"Marco Q.",middleName:null,surname:"Pisani",slug:"marco-q.-pisani",fullName:"Marco Q. Pisani"},{id:"20910",title:"Dr.",name:"Massimo E.",middleName:null,surname:"Zucco",slug:"massimo-e.-zucco",fullName:"Massimo E. Zucco"},{id:"194761",title:"Dr.",name:"Tiziana",middleName:null,surname:"Cavaleri",slug:"tiziana-cavaleri",fullName:"Tiziana Cavaleri"}]},{id:"53524",doi:"10.5772/66733",title:"Fourier Analysis for Harmonic Signals in Electrical Power Systems",slug:"fourier-analysis-for-harmonic-signals-in-electrical-power-systems",totalDownloads:4525,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"The harmonic content in electrical power systems is an increasingly worrying issue since the proliferation of nonlinear loads results in power quality problems as the harmonics is more apparent. In this paper, we analyze the behavior of the harmonics in the electrical power systems such as cables, transmission lines, capacitors, transformers, and rotating machines, the induction machine being the object of our study when it is excited to nonsinusoidal operating conditions in the stator winding. For this, a model is proposed for the harmonic analysis of the induction machine in steady‐state regimen applying the Fourier transform. The results of the proposed model are validated by experimental tests which gave good results for each case study concluding in a model proper for harmonic and nonharmonic analysis of the induction machine and for “harmonic” analysis in an electrical power system.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Emmanuel Hernández Mayoral, Miguel Angel Hernández López,\nEdwin Román Hernández, Hugo Jorge Cortina Marrero, José\nRafael Dorrego Portela and Victor Ivan Moreno Oliva",authors:[{id:"187793",title:"Dr.",name:"Emmanuel",middleName:null,surname:"Hernández",slug:"emmanuel-hernandez",fullName:"Emmanuel Hernández"},{id:"202757",title:"Dr.",name:"Miguel Angel",middleName:null,surname:"Hernández López",slug:"miguel-angel-hernandez-lopez",fullName:"Miguel Angel Hernández López"},{id:"202758",title:"Dr.",name:"Hugo Jorge",middleName:null,surname:"Cortina Marrero",slug:"hugo-jorge-cortina-marrero",fullName:"Hugo Jorge Cortina Marrero"},{id:"202759",title:"Dr.",name:"Edwin Román",middleName:null,surname:"Hernández",slug:"edwin-roman-hernandez",fullName:"Edwin Román Hernández"},{id:"202760",title:"Dr.",name:"Victor Iván Moreno",middleName:null,surname:"Oliva",slug:"victor-ivan-moreno-oliva",fullName:"Victor Iván Moreno Oliva"},{id:"202761",title:"Dr.",name:"José Rafael Dorrego",middleName:null,surname:"Portela",slug:"jose-rafael-dorrego-portela",fullName:"José Rafael Dorrego Portela"}]}],mostDownloadedChaptersLast30Days:[{id:"74096",title:"Time Frequency Analysis of Wavelet and Fourier Transform",slug:"time-frequency-analysis-of-wavelet-and-fourier-transform",totalDownloads:1220,totalCrossrefCites:6,totalDimensionsCites:8,abstract:"Signal processing has long been dominated by the Fourier transform. However, there is an alternate transform that has gained popularity recently and that is the wavelet transform. The wavelet transform has a long history starting in 1910 when Alfred Haar created it as an alternative to the Fourier transform. In 1940 Norman Ricker created the first continuous wavelet and proposed the term wavelet. Work in the field has proceeded in fits and starts across many different disciplines, until the 1990’s when the discrete wavelet transform was developed by Ingrid Daubechies. While the Fourier transform creates a representation of the signal in the frequency domain, the wavelet transform creates a representation of the signal in both the time and frequency domain, thereby allowing efficient access of localized information about the signal.",book:{id:"10065",slug:"wavelet-theory",title:"Wavelet Theory",fullTitle:"Wavelet Theory"},signatures:"Karlton Wirsing",authors:[{id:"325178",title:"Dr.",name:"Karlton",middleName:null,surname:"Wirsing",slug:"karlton-wirsing",fullName:"Karlton Wirsing"}]},{id:"74032",title:"Wavelets for EEG Analysis",slug:"wavelets-for-eeg-analysis",totalDownloads:1209,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"This chapter introduces the applications of wavelet for Electroencephalogram (EEG) signal analysis. First, the overview of EEG signal is discussed to the recording of raw EEG and widely used frequency bands in EEG studies. The chapter then progresses to discuss the common artefacts that contaminate EEG signal while recording. With a short overview of wavelet analysis techniques, namely; Continues Wavelet Transform (CWT), Discrete Wavelet Transform (DWT), and Wavelet Packet Decomposition (WPD), the chapter demonstrates the richness of CWT over conventional time-frequency analysis technique e.g. Short-Time Fourier Transform. Lastly, artefact removal algorithms based on Independent Component Analysis (ICA) and wavelet are discussed and a comparative analysis is demonstrated. The techniques covered in this chapter show that wavelet analysis is well-suited for EEG signals for describing time-localised event. Due to similar nature, wavelet analysis is also suitable for other biomedical signals such as Electrocardiogram and Electromyogram.",book:{id:"10065",slug:"wavelet-theory",title:"Wavelet Theory",fullTitle:"Wavelet Theory"},signatures:"Nikesh Bajaj",authors:[{id:"326400",title:"Dr.",name:"Nikesh",middleName:null,surname:"Bajaj",slug:"nikesh-bajaj",fullName:"Nikesh Bajaj"}]},{id:"53524",title:"Fourier Analysis for Harmonic Signals in Electrical Power Systems",slug:"fourier-analysis-for-harmonic-signals-in-electrical-power-systems",totalDownloads:4525,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"The harmonic content in electrical power systems is an increasingly worrying issue since the proliferation of nonlinear loads results in power quality problems as the harmonics is more apparent. In this paper, we analyze the behavior of the harmonics in the electrical power systems such as cables, transmission lines, capacitors, transformers, and rotating machines, the induction machine being the object of our study when it is excited to nonsinusoidal operating conditions in the stator winding. For this, a model is proposed for the harmonic analysis of the induction machine in steady‐state regimen applying the Fourier transform. The results of the proposed model are validated by experimental tests which gave good results for each case study concluding in a model proper for harmonic and nonharmonic analysis of the induction machine and for “harmonic” analysis in an electrical power system.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Emmanuel Hernández Mayoral, Miguel Angel Hernández López,\nEdwin Román Hernández, Hugo Jorge Cortina Marrero, José\nRafael Dorrego Portela and Victor Ivan Moreno Oliva",authors:[{id:"187793",title:"Dr.",name:"Emmanuel",middleName:null,surname:"Hernández",slug:"emmanuel-hernandez",fullName:"Emmanuel Hernández"},{id:"202757",title:"Dr.",name:"Miguel Angel",middleName:null,surname:"Hernández López",slug:"miguel-angel-hernandez-lopez",fullName:"Miguel Angel Hernández López"},{id:"202758",title:"Dr.",name:"Hugo Jorge",middleName:null,surname:"Cortina Marrero",slug:"hugo-jorge-cortina-marrero",fullName:"Hugo Jorge Cortina Marrero"},{id:"202759",title:"Dr.",name:"Edwin Román",middleName:null,surname:"Hernández",slug:"edwin-roman-hernandez",fullName:"Edwin Román Hernández"},{id:"202760",title:"Dr.",name:"Victor Iván Moreno",middleName:null,surname:"Oliva",slug:"victor-ivan-moreno-oliva",fullName:"Victor Iván Moreno Oliva"},{id:"202761",title:"Dr.",name:"José Rafael Dorrego",middleName:null,surname:"Portela",slug:"jose-rafael-dorrego-portela",fullName:"José Rafael Dorrego Portela"}]},{id:"53366",title:"New Spectral Applications of the Fourier Transforms in Medicine, Biological and Biomedical Fields",slug:"new-spectral-applications-of-the-fourier-transforms-in-medicine-biological-and-biomedical-fields",totalDownloads:2369,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"This chapter reviews some recent spectral applications of the Fourier transform techniques as they are applied in spectroscopy. An overview about Fourier transform spectroscopy (FTS) used like a powerful and sensitive tool in medical, biological, and biomedical analysis is provided. The advanced spectroscopic techniques of FTS, such as Fourier transform visible spectroscopy (FTVS), Fourier transform infrared-attenuated total reflectance (FTIR-ATR), Fourier transform infrared-photoacoustic spectroscopy (FTIR-PAS), Fourier transform infrared imaging spectroscopy (FTIR imaging), and their biomedical applications are described. A special attention has been paid to the description of the FTVS method of commercial quantum dots like an innovative and reliable technique used in the field of nanobiotechnology.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Anca Armăşelu",authors:[{id:"189080",title:"Dr.",name:"Anca",middleName:null,surname:"Armăşelu",slug:"anca-armaselu",fullName:"Anca Armăşelu"}]},{id:"53419",title:"Fourier Transform Infrared Spectroscopy in the Study of Hydrated Biological Macromolecules",slug:"fourier-transform-infrared-spectroscopy-in-the-study-of-hydrated-biological-macromolecules",totalDownloads:2474,totalCrossrefCites:3,totalDimensionsCites:15,abstract:"The interaction between biological macromolecules (proteins, nucleic acids, lipids and other biomolecules in the cell) and environmental water is an important determining factor in their conformational properties, stability and function. The hydration processes of biopolymers have been extensively studied in the past 20 years with reference to a considerable variety of models and concepts. In all recent works, a distinction is made between intracellular water that maintains the ordinary liquid state (bulk water) and water ordered in extended hydrogen‐bonded lattices at the surface and structured in the internal grooves of macromolecules (hydration water) in dependence on the chemical properties of the macromolecule surface. FTIR spectroscopy has been implemented in this field both for the sensitivity in the conformational analysis of biological macromolecules and the reliability in the investigation of the water network. A perturbation technique such as dehydration‐rehydration treatment modifies the macromolecule structure and water distribution. It was applied to two structurally different proteins: lysozyme, a globular (α + β) protein and collagen, a fibrous protein characterized by the triple helix structure. Submitted to the treatment both of them display irreversible conformational changes.",book:{id:"5411",slug:"fourier-transforms-high-tech-application-and-current-trends",title:"Fourier Transforms",fullTitle:"Fourier Transforms - High-tech Application and Current Trends"},signatures:"Maria Grazia Bridelli",authors:[{id:"108760",title:"Dr.",name:"Maria Grazia",middleName:null,surname:"Bridelli",slug:"maria-grazia-bridelli",fullName:"Maria Grazia Bridelli"}]}],onlineFirstChaptersFilter:{topicId:"974",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:31,numberOfPublishedChapters:314,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:18,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:14,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"June 11th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,annualVolume:11418,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,annualVolume:11419,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,annualVolume:11420,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. 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He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,annualVolume:11421,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. 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In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. 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He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. 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