Pneumothorax - Causes, Symptoms and Treatment .MF .
Pneumothorax - accumulation of air in the pleural cavity - slotted in the normal space between the parietal (outer lining the inside of the chest wall) and visceral (internal, covering the lung), pleura.
There are traumatic, spontaneous and iatrogenic pneumothorax. Traumatic pneumothorax arises as a result of penetrating wounds of the chest or lung damage (for example, the fragments of broken ribs). Spontaneous (spontaneous) pneumothorax develops as a result of a sudden, not associated with an injury or a medical diagnostic manipulation of compromising the integrity of the visceral pleura, resulting in a flow of air from the lung into the pleural cavity. Iatrogenic pneumothorax is a complication medical procedures.
Depending on the availability of communication with the environment distinguish closed, and the valve open pneumothorax.Closed called pneumothorax, pleural cavity in which no communication with the external environment and the amount of air that has entered the trauma she does not chan
When open pneumothorax there is a loose connection of the pleural cavity with the external environment, so that during inhalation air is additionally "sucked" into the pleural cavity, and during exhalation leaves ( "squeezed") in the same volume.Thus, when the open pneumothorax occurs air accumulation in the pleural cavity, and in view of the smooth movement of air through a defect in the chest wall lung on the side of injury during inspiration collapses, and during exhalation increases in volume (straightened), that is, an effect of paradoxical breathing.
When valve pneumothorax , unlike open during exhalation message pleural cavity with the environment is reduced or completely stopped due to the displacement of the lung tissue or soft tissue of the chest that can be compared with the valve shielding.In this regard, during inspiration in the pleural cavity enters a larger volume of air than the leaves during exhalation.Thus, during breathing is a constant increase in the amount of air in the pleural cavity, which results in progressively increasing compression of the lung, the displacement bodies of the mediastinum to the opposite (healthy) side, which impairs their function primarily squeezing large vessels, and with a further progression leads tocompression of the second light in the "healthy" side.
If the air valve is located in the lung and pleural cavity communicates with the outside through the bronchial tree, such a valve called a pneumothorax internal .If the valve is positioned in the wound of the chest wall, called a valve pneumothorax outer .Independently inner and outer valves cease to function when the maximum height inspiratory pressure in the pleural cavity reaches ambient pressure, but intrapleural pressure during exhalation is much greater than atmospheric.Is developing the so-called tense pneumothorax , which is the outcome of the valve and its essence is a closed pneumothorax.However, from a closed pneumothorax stressful differs much higher air pressure in the pleural cavity, a significant shift of mediastinal organs, lung compression (on the affected side full and partial - on the opposite, a "healthy" side).
Depending on the volume of air in the pleural cavity, and wears off much light distinguish a limited (small), medium and large, or total pneumothorax.When limited pneumothorax lung collapses in less than 1/3 of its volume, with average - from 1/3 to 1/2 volume.When large , or total, pneumothorax lung is less than half the normal amount of air or fully preloaded.
Possible causes pneumothorax
reasons for spontaneous pneumothorax may be (arranged by descending frequency):
1. bullous lung disease.
2. Pathology of the respiratory tract (chronic obstructive pulmonary disease, cystic fibrosis, asthma status).
3. Infectious diseases (Pneumocystis pneumonia, pulmonary tuberculosis).
4. Interstitial lung disease (sarcoidosis, idiopathic pulmonary fibrosis, Wegener granulёmatoz, lymphangioleiomyomatosis, tuberous sclerosis).
5. connective tissue diseases (rheumatoid arthritis, ankylosing spondylitis, polymyositis, dermatomyositis, scleroderma, Marfan syndrome).
6. Malignant neoplasms (sarcoma, lung cancer).
7. Thoracic endometriosis.
When spontaneous pneumothorax disease develops, usually after physical exertion or excessive straining, accompanied by an increase in intrapulmonary pressure.
Traumatic pneumothorax may occur if the following lesions of the chest:
1. Penetrating injuries of the chest (stab, gunshot).
2. Closed chest injury (damage to the fragments of broken ribs, traumatic lung rupture).
Iatrogenic pneumothorax may develop as a complication following diagnostic and therapeutic procedures:
1. Puncture of the pleural cavity.
2. Catheterization of central veins.
3. pleural biopsy.
4. transbronchial endoscopic biopsy of the lung.
5. Barotrauma during mechanical ventilation.
In the past, we used a procedure therapeutic pneumothorax, in particular, in the treatment of cavernous pulmonary tuberculosis, especially when the air is injected into the pleural cavity, to provide artificial light spadenie.
symptoms of pneumothorax
main symptoms of pneumothorax caused by the sudden appearance and gradual accumulation (with valve pneumothorax), air in the pleural cavity and the compression of them light, and the displacement of the mediastinal organs.
sudden onset of the disease: after a traumatic impact on the thorax (in traumatic pneumothorax) or physical exertion, straining (for spontaneous).There are sharp stabbing or squeezing pain in the corresponding half of the chest, which most often are located in the upper chest, radiating to the neck, shoulder or arm;Sometimes the pain can spread mostly on the abdomen and lower back.At the same time the patient a peculiar feeling of tightness in the chest, as well as the subjective feeling of lack of air, which is accompanied by increase of the frequency and depth of breathing movements.With a large pneumothorax, the severity of dyspnea is large, it is accompanied by pallor or cyanosis (bluish color of the skin, caused by the accumulation of carbon dioxide in the blood), heart palpitations, anxiety.Trying to reduce pain and shortness of breath, the patient tends to limit the movement of the body receives a forced position (half-sitting with a slope in the direction of the patient or the patient lying on the side).
With a significant amount of air in the pleural cavity can be defined and limiting protrusion corresponding half of the mobility of the chest, its lag in breathing of a healthy, which, on the contrary, breathing hard, and smoothed intercostal gaps on the affected side.Often, especially in traumatic pneumothorax, on the affected side of the chest there is subcutaneous emphysema - the accumulation of air in the subcutaneous tissue of the chest wall, which may, at the tense pneumothorax spread to other areas of the body.
When percussion (percussion - tapping on certain parts of the body, followed by analysis of sound events that occur at the same time), the doctor determines the "box" (loud and low, similar to the sound that occurs when effleurage on the empty box) the nature of percussion sounds onpnemotoraksa side and lung auscultation (auscultation - listening to sounds generated in the process of functioning of organs) detects the absence or weakening of breath on the side of pneumothorax when a stored breathing on the healthy side.
radiograph of the patient with a right pneumothorax total (on the X-ray - left).The arrow marked by the boundary sleeping easy.
The diagnosis of great importance to have chest X-ray, which is determined at the free gas in the pleural cavity, preloaded light, the degree of which depends on the value wears off pneumothorax;at tense pneumothorax shifts the mediastinum in a healthy way.Computed tomography of the chest can not only detect the presence of free gas in the pleural space (even for a small limited pneumothorax, diagnosis is by means of a conventional X-ray is often quite difficult), but also to find possible cause of spontaneous pneumothorax (bullous disease posttuberkulёznye changes, interstitiallung disease).
Computed tomography of the chest of the patient cells with a left-sided pneumothorax (by CT scan - right).Free gas in the pleural cavity is marked by an arrow.
What tests will have to hand over a suspected pneumothorax.
Laboratory examination with pneumothorax, as a rule, does not have independent diagnostic value.
Treatment of pneumothorax
Medical tactic depends on the type of pneumothorax.Expectant conservative therapy available for small private limited pneumothorax: provide the patient peace, give painkillers.With a significant accumulation of air shows thoracostomy with a so-called passive aspiration using Bobrov apparatus.
thoracostomy produced under local anesthesia in a patient sitting position.A typical place for drainage is the second intercostal space on the anterior surface of the thorax (at limited pneumothorax selected point above the point where the greatest accumulation of air) in which a thin needle is introduced in layers into soft tissue 0.5 of novocaine solution volume of 20 ml, after which the doctor incised the skin and enters intopleural cavity trocar - a special tool consisting of a sharp stylet, vstalennogo in the hollow shell (tube).After removing the stylet sleeve through channel (tube) of the trocar the surgeon enters the pleural cavity drainage, and the sleeve is removed.Drain fixed to the skin and connected to the bank Bobrova for passive aspiration.With the ineffectiveness of passive aspiration resort to an active aspiration, for which a system of drains and banks Bobrova is connected to a vacuum aspirator (suck).After complete straightening easy drainage of the pleural cavity is removed.
thoracostomy is considered a relatively simple surgical procedure, the patient does not require any prior training.
scheme trocar device.
When traumatic open pneumothorax with massive damage of the lung shows emergency surgery under general anesthesia, which consists in suturing the defect light, stop bleeding, layered suturing wounds of the chest wall and drainage of pleural cavity.
In spontaneous pneumothorax, especially recurrent, to determine the nature of the pathology which led to him resorted to thoracoscopy - endoscopic examination method, is to study the pleural cavity of the patient using a special tool - thoracoscope introduced through the puncture of the chest wall.If you find during thoracoscopy in lung bullae, which led to the development of pneumothorax, possibly surgical removal by means of special endoscopic instruments.
With the ineffectiveness of drainage with passive or active aspiration and endoscopic techniques during thoracoscopy in relieving pneumothorax, as well as his recurrent resort to open surgery - thoracotomy, in which the pleural cavity is opened wide cut, identify and eliminate the direct cause of pneumothorax.In order to prevent recurrence of pneumothorax artificially induce the formation of adhesions between the visceral and parietal pleura.
major complications were pneumothorax acute respiratory and cardiovascular failure, especially when expressed tense pneumothorax and the resulting compression of the lungs and mediastinal shift.If unresolved for a long time pneumothorax may develop reactive pleurisy pleura as a reaction to the presence of air in the pleural cavity in the form of inflammation with development of liquid;in the event of the accession of infection may develop pleural empyema (accumulation of pus in the pleural cavity) or pneumoempyema (accumulation of pus and air in the pleural cavity).In the case of long-term lung wears off, caused by pneumothorax, from his difficult expectoration of sputum, which occludes the lumen of the bronchi and promotes the development of pneumonia.Sometimes pneumothorax, especially traumatic, accompanied by the development of intrapleural bleeding (gemopnevmotoraks), while to the signs of respiratory failure join the symptoms of blood loss (pallor, increased heart rate, pressure drop, etc.);intrapleural bleeding can be complicated and spontaneous pneumothorax.
Tense pneumothorax is a serious, life-threatening condition that can lead to death due to the development of acute respiratory and cardiovascular failure caused by compression of the lungs and mediastinum displacement bodies.It is also extremely dangerous bilateral pneumothorax.Any pneumothorax requires immediate hospitalization in a surgical hospital for surgery.With adequate timely treatment of spontaneous pneumothorax is usually favorable prognosis and prognosis of traumatic pneumothorax depends on the nature of the collateral damage of the chest.
Surgeon Kletkin ME