Clinical signs of open pneumothorax. Pneumothorax of the lungs: causes and symptoms of the disease

To this topic! Read these articles too:

Pneumothorax is a lung disease in which pleural cavity air accumulates. The air, leaving the lung, enters the cavity, in which before the disease there was a vacuum - negative pressure. Now the air that has entered the pleural cavity, being between two layers of tissue on the one hand, and the lung itself on the other hand, begins to interfere with the normal functioning of the lung. The lung during normal breathing collapses and straightens to the end, with pneumothorax, the resulting air layer does not allow the lung to completely straighten out.

Pneumothorax most often occurs in patients who have been injured chest. But cases of the appearance of pneumothorax, as a complication of any disease, are not excluded. As a rule, pneumothorax occurs spontaneously, its first manifestation is called primary. If it occurs due to a complication of another disease, a manifestation of any pulmonary pathology, then such pneumothorax is called secondary.

Types of pneumothorax

Due to the occurrence

There are several types of pneumothorax according to the complexity of the disease.

Spontaneous- with this form of the disease, there are no clinically significant pathologies.

  • Primary
  • Secondary

Traumatic- in this case, the chest is damaged.

  • Penetrating chest injury
  • Blunt chest trauma

iatrogenic- this type of disease is caused by complications after medical intervention

Due to the environment

  • Closed pneumothorax
  • Open pneumothorax
  • Valvular pneumothorax

Closed pneumothorax- with this type of disease, a small proportion of air enters the pleural cavity, which does not increase with time. This type of disease can be considered the simplest in complexity, because the air in the pleural cavity can resolve itself over time and the collapsed (collapsed) lung will straighten out.

Open pneumothorax- the complexity of this form of the disease is that the lung, collapsed due to damage to the chest (for example, the lung was damaged by a fragment of a rib), must exist in the negative pressure of the pleural cavity, and since damage to the chest established pressure in the pleural cavity equal to atmospheric, then the first thing to do is to restore negative pressure in the pleural cavity by resolving the issue with the injury that led to pneumothorax.

Valvular pneumothorax- most dangerous view diseases. In a patient with this type of disease, a valve structure is formed that allows air from the lung or from the environment into the pleural cavity, but does not allow it to exit back. Thus, with each breath, the pressure in the pleural cavity increases and can lead to a mixture of the mediastinal organs, pleuropulmonary shock, and also the exclusion of the lung from breathing.

According to the severity of the disease

  • Parietal pneumothorax
  • Complete pneumothorax
  • Encapsulated pneumothorax

Parietal pneumothorax- a variation of the disease in which a small amount of air is contained in the pleural cavity, the lung is therefore not fully expanded, and the pneumothorax itself is more accurately described as closed.

Complete pneumothorax- with complete collapse of the lung (compression), air occupies as much space as possible in the pleural cavity, preventing the lung from expanding.

Encapsulated pneumothorax- the least dangerous type of disease, which can be completely asymptomatic. It is formed due to the presence of adhesions between the visceral and parietal pleura.

It is important to note that complete bilateral pneumothorax leads to rapid death if timely failure to necessary assistance due to impaired respiratory function.

Causes of pneumothorax

There can be several causes of pneumothorax, here are some of them:

  • Chest trauma - closed or open, damage to the lung by fragments of the ribs, or penetrating (for example, stab) wounds
  • Iatrogenic damage - as we already wrote, damage that occurred after treatment or surgical intervention, in other words, it is a lung injury when assisting
  • Spontaneous pneumothorax is a disease in which clear reason no disease occurs. I also had this type of pneumothorax.
  • Rupture of bullous emphysema with subsequent release of air from the lung into the pleural cavity, rupture of a lung abscess, spontaneous rupture of the esophagus
  • In patients with tuberculosis, the cause may be a rupture of the cavity or a breakthrough of caseous foci.

Symptoms of pneumothorax

The main symptoms of pneumothorax are chest pain and sudden onset of shortness of breath. In my case, it was a sudden onset of shortness of breath, which I did not attach any importance to, for some time it was difficult for me to breathe, but I continued with my usual activities, just taking a five-minute break to catch my breath.

How is pneumothorax treated?

What to do if you have a pneumothorax? First, immediately agree to hospitalization. It will be surgery department hospital where you will be staying for at least a week. You will need to get used to this idea.

During your stay in the hospital, in case of spontaneous pneumothorax (which is the most common), you will have a Buhlau drain. This is a technique for suctioning air from the pleural cavity by puncturing the chest wall with a special device. A tube will be inserted into the resulting hole on your body, which will be inserted into a special solution at the other end. At the end of this tube will be a valve mechanism that allows air from your pleural cavity to enter the solution but not back out.

It's not scary. You just need to experience it. I, as a person who had never been in hospitals before, was in state of shock. But my lung expanded on the second day after I had the drain installed, and on the third day it was removed. Yes, all this time it will be necessary to move around with a jar and a tube going into it from your body.

After several x-rays, at the discretion of the chief physician, the tube will be removed from your body, and the fully expanded lung will continue to perform its standard function. And you will stay in the hospital for your prescribed 3-4 days of rest, receiving 3 times a day a portion of antibiotics and painkillers. After this period, you (healthy and ready to move mountains!) Will be discharged from the hospital.

Immediately after you find yourself at home, I advise you to find a CT scan room in your city or nearby. It will be necessary to do a CT scan of the chest in order to exclude the possibility of recurrent pneumothorax, as well as to identify the causes of its appearance for the first time.

Diagnosis of the disease

For installation accurate diagnosis The patient needs a chest X-ray. The collapsed lung will be visible on the x-ray with the naked eye, and in my case, the problem was noticed even on the fluorography. In order to identify small pneumothoraxes or to find out the cause of the disease, computed tomography of the chest is used. It is designed for layer-by-layer examination of the respiratory organs and identification of the cause of pneumothorax.

Video about pneumothorax

Closed trauma of the chest: damage to the lung by fragments of the ribs;

Open trauma of the chest: penetrating wounds;

Iatrogenic injuries (complication after therapeutic or diagnostic intervention): lung injury when trying to catheterize the subclavian vein, acupuncture, blockade of the intercostal nerve, pleural puncture;

Spontaneous pneumothorax;

Nonspecific pneumothorax: bullae rupture ( focal bullous emphysema), cysts, breakthrough of a lung abscess into the pleural cavity (pyopneumothorax), spontaneous rupture of the esophagus;

Tuberculous pneumothorax: rupture of the cavity, breakthroughs of caseous foci;

An artificial pneumothorax is applied with therapeutic purpose for lungs, with diagnostic for thoracoscopy, for differential diagnosis chest wall formations.

What are the types of pneumothorax?

In relation to the environment, there are:

Closed pneumothorax some amount of gas enters the pleural cavity, which does not increase. Message from external environment is not available, so it will be discontinued. It is considered the easiest type of pneumothorax, since the air can potentially gradually dissolve from the pleural cavity on its own, while the lung expands.

Open pneumothorax the presence of an opening in the chest wall, freely communicating with the external environment, therefore, a pressure equal to atmospheric pressure is created in the pleural cavity. At the same time, the lung collapses, because essential condition for straightening the lung is a negative pressure in the pleural cavity. The collapsed lung is switched off from breathing, gas exchange does not occur in it, the blood is not enriched with oxygen.

Valvular ("tense") pneumothorax progressive accumulation of air in the pleural cavity. Occurs in the case of the formation of a valve structure that allows air to pass in one direction, from the lung or from the environment into the pleural cavity, and prevents its exit back. Air enters at the moment of inhalation, and at the moment of exhalation, without finding an exit for itself, it remains in the pleural cavity. A triad is characteristic of valvular pneumothorax: positive intrapleural pressure, leading to the exclusion of the lung from breathing, the attachment of irritation of the nerve endings of the pleura, leading to pleuropulmonary; persistent displacement of the mediastinal organs, which disrupts their function, primarily squeezing large vessels; acute respiratory failure.

Depending on the volume of air in the pleural cavity and the degree of collapse of the lung, a complete and partial pneumothorax is distinguished.

Bilateral complete pneumothorax if no help is provided, it leads to rapid lethal outcome due to critical violation respiratory function.

Symptoms of pneumothorax

The clinical picture depends on the mechanism of the onset of the disease, the degree of lung collapse and the cause that caused it.

The disease begins acutely after physical exertion, coughing fit or without visible reasons with a sharp stabbing radiating to the neck, upper limb, sometimes in the upper half of the abdomen, aggravated by breathing, coughing or chest movements, shortness of breath, dry. The patient breathes often and superficially, there is severe shortness of breath, feels "lack of air." Paleness or blueness (cyanosis) skin in particular faces.

With an open pneumothorax, the patient lies on the side of the injury, tightly pressing the wound. When examining the wound, air suction noise is heard. Foamy blood may come out of the wound. Chest movements are asymmetrical.

Complications

Occur frequently (up to 50% of cases). These include: intrapleural due to tear lung tissue, serous-fibrinous pneumopleurisy with the formation of a "rigid" lung (the formation of mooring - cords from connective tissue excluding expansion of the lung), pleural empyema (purulent, pyothorax). With valvular ("tense") pneumothorax, subcutaneous emphysema may develop (accumulation of a small amount of air under the skin in the subcutaneous fat).

In 15 - 50% of patients, recurrences of pneumothorax are observed.

What can you do?

First aid for pneumothorax

If a pneumothorax is suspected, call immediately ambulance or see a doctor because it is emergency situation, especially if there is valvular pneumothorax which, if the necessary assistance is not provided, can lead to death.

If there is an open pneumothorax, it must be turned into a closed pneumothorax by applying an airtight, airtight dressing (“occlusive dressing”) to the open wound chest. For example, this can be done with oilcloth material or an intact sealed plastic film, and a thick cotton-gauze bandage is also quite suitable.

What can a doctor do?

Your doctor will do a thorough examination of the chest for possible injury, after which he will prescribe all necessary research including, first of all, chest X-ray.

Treatment for pneumothorax includes:

Immediate hospitalization in the surgical department;

Elimination of pneumothorax by sucking air from the pleural cavity and restoring negative pressure in it.

Closed pneumothorax proceeds benignly and gradually resolves. But sometimes a pleural puncture is necessary to remove air.

An open pneumothorax requires an initial transfer to a closed pneumothorax (that is, the elimination of communication with the external environment by hermetic suturing of the wound).

Valvular pneumothorax requires surgical intervention.

DEFINITION.

Pneumothorax- presence of air in the pleural cavity .

RELEVANCE.

The incidence of primary spontaneous pneumothorax (PSP) is 7.4-18 cases per 100 thousand people per year among men and 1.2-6 cases per 100 thousand people per year among women. PSP is most common in tall, thin boys and men under 30 and rare in people over 40.

The incidence of secondary spontaneous pneumothorax (SSP) is 6.3 cases per 100 thousand people per year among men and 2 cases per 100 thousand people per year among women.

CLASSIFICATION.

All pneumothoraxes can be divided into spontaneous - not associated with any obvious cause, traumatic - associated with direct and indirect chest trauma, and iatrogenic - associated with medical interventions. In turn, spontaneous pneumothoraxes are divided into primary - arising in a person without background pulmonary pathology, and secondary - arising against the background of lung diseases.

Classification of pneumothoraxes.

1. Spontaneous pneumothorax:

Primary;

Secondary.

2. Traumatic

Due to a penetrating wound of the chest;

Due to blunt trauma to the chest.

3. Iatrogenic.

Due to transthoracic needle aspiration;

Due to the placement of a subclavian catheter;

Due to thoracocentesis or pleural biopsy;

due to barotrauma.

By prevalence, they distinguish: total(regardless of the degree of collapse of the lung in the absence of pleural adhesions) and partial or partial (with obliteration of part of the pleural cavity).

Depending on the presence of complications: 1) uncomplicated; 2) complicated (bleeding, pleurisy, mediastinal emphysema).

ETIOLOGY.

Despite the fact that the modern definition requires the absence of lung disease in primary spontaneous pneumothorax (PSP), with the help of modern research methods (computed tomography and thoracoscopy), emphysema-like changes (bulls and subpleural vesicles - blebs), mainly in the apical regions of the lungs, are detected by more than in 80% of patients. The risk of developing PSP is 9 to 22 times higher in smokers than in non-smokers. This strong association between smoking and PSP suggests some pulmonary pathology. Indeed, relatively recently it was found that among smoking patients who underwent PSP, morphological changes in lung tissue in 87% of patients correspond to the pattern of respiratory bronchiolitis.

The most common causes of SVD

COPD, cystic fibrosis, severe exacerbation of bronchial asthma.

    Infectious diseases of the lungs:

pneumonia caused by Pneumocystis carini; tuberculosis, abscess pneumonia (anaerobes, staphylococcus aureus).

    Interstitial lung disease: sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis X, lymphangioleiomyomatosis.

    Systemic connective tissue diseases: rheumatoid arthritis, ankylosing spondylitis, polymyositis / dermatomyositis, systemic scleroderma, including hereditary syndromic (Marfan syndrome, Ehlers-Danlos syndrome) and non-syndromic forms of connective tissue dysplasia.

Tumors: lung cancer, sarcoma.

Secondary spontaneous pneumothorax (SSP) is most common in patients with chronic obstructive pulmonary disease (COPD) - 26 cases per 100 thousand people per year, mainly at the age of 60-65 years. Among patients infected with the human immunodeficiency virus (HIV), SVD develops in 2–6% of cases, 80% of them on the background of pneumocystis pneumonia. CVD is a common (morbidity 6-20%) and potentially life-threatening complication (mortality 4-25%) of cystic fibrosis, occurs predominantly in men with a low body mass index, severe obstructive disorders (forced expiratory volume in 1 second - FEV 1 - less than 50%) and chronic colonization Pseudomonas aeruginosa. In some rare lung diseases belonging to the group of cystic lung diseases, the incidence of SCD is extremely high: up to 25% in histiocytosis X (eosinophilic granuloma) and up to 80% in lymphangioleiomyomatosis. The incidence of pneumothorax in tuberculosis is currently low and amounts to only 1.5%.

Pneumothorax occurs in 5% of all patients with multiple injuries, in 40-50% of patients with chest injuries. A characteristic feature of traumatic pneumothorax is their frequent combination with hemothorax - up to 20%, as well as the complexity of their diagnosis using chest x-ray. Computed tomography (CT) of the chest can detect up to 40% of the so-called occult, or hidden, pneumothorax.

The incidence of iatrogenic pneumothorax depends on the type of diagnostic procedures performed: with transthoracic needle aspiration 15–37%, on average 10%; with catheterization of the central veins (especially the subclavian vein) - 1 - 10%; with thoracocentesis - 5 - 20%; with a biopsy of the pleura - 10%; with transbronchial lung biopsy - 1 - 2%; during artificial lung ventilation (ALV) - 5 - 15%.

PATHOGENESIS.

Under normal conditions, there is no air in the pleural cavity, although the intrapleural pressure during the respiratory cycle is mostly negative - 3-5 cm of water. Art. below atmospheric. The sum of all partial pressures of gases in capillary blood is approximately 706 mm Hg. Art., therefore, for the movement of gas from the capillaries into the pleural cavity, an intrapleural pressure of less than -54 mm Hg is required. Art. (-36 cm of water column) below atmospheric, which almost never happens in real life, so the pleural cavity is free of gas.

The presence of gas in the pleural cavity is the result of one of 3 events: 1) direct communication between the alveoli and the pleural cavity; 2) direct communication between the atmosphere and the pleural cavity; 3) the presence of gas-forming microorganisms in the pleural cavity.

The flow of gas into the pleural cavity continues until the pressure in it becomes equal to atmospheric pressure or the communication is interrupted. However, sometimes the pathological message lets air into the pleural cavity only during inhalation, closes during exhalation and prevents the evacuation of air. As a result of such a "valve" mechanism, the pressure in the pleural cavity can significantly exceed atmospheric pressure - a tension pneumothorax develops. High intrapleural pressure leads to displacement of the mediastinal organs, flattening of the diaphragm and compression of the unaffected lung. The consequences of this process are a decrease in venous return, a decrease in cardiac output, and hypoxemia, which leads to the development of acute circulatory failure.

DIAGNOSTICS.

Anamnesis, complaints and physical examination:

Pneumothorax is characterized by an acute onset of the disease, usually not associated with physical activity or stress;

Leading complaints in pneumothorax are chest pain and shortness of breath;

Pain is often described by patients as "sharp, piercing, dagger", intensifies during inhalation, may radiate to the shoulder of the affected side;

The severity of dyspnea is associated with the size of the pneumothorax, with secondary pneumothorax, as a rule, more severe dyspnea is observed, which is associated with a decrease in the respiratory reserve in such patients;

Less often, with pneumothorax, symptoms such as dry cough, sweating, general weakness, anxiety can be observed;

Symptoms of the disease most often subside after 24 hours from the onset of the disease, even in the absence of therapy and maintaining the same volume of pneumothorax;

Physical signs of pneumothorax: limitation of the amplitude of respiratory excursions, weakening of breathing, tympanic sound during percussion, tachypnea, tachycardia;

For a small pneumothorax (less than 15% of a hemothorax), a physical examination may reveal no change;

Tachycardia (greater than 135 beats), hypotension, paradoxical pulse, jugular venous distention, and cyanosis are signs of tension pneumothorax;

Possible development of subcutaneous emphysema;

Questioning the patient should include questions about smoking experience, episodes of pneumothorax and the presence of lung diseases (COPD, asthma, etc.), HIV, as well as Marfan's hereditary diseases, Ehlers-Danlos syndrome, osteogenesis imperfecta.

Laboratory research:

When analyzing gases arterial blood hypoxemia (PaO2< 80 мм рт.ст.) наблюдается у 75% больных с пневмотораксом.

The presence of underlying lung disease and the size of pneumothorax are closely related to changes in arterial blood gas composition. The main cause of hypoxemia is collapse and decreased ventilation of the affected lung with preserved pulmonary perfusion (shunt effect). Hypercapnia develops rarely, only in patients with severe background diseases lungs (COPD, cystic fibrosis), respiratory alkalosis is quite often present.

At VSP PaO2<55 мм рт. ст. и РаСО2>50 mmHg Art. observed in 15% of patients.

ECG changes are usually detected only with tension pneumothorax: deviation of the electrical axis of the heart to the right or left, depending on the location of the pneumothorax, a decrease in voltage, flattening and inversion of the T waves in leads V 1 -V 3.

X-ray of the chest organs.

To confirm the diagnosis, it is necessary to conduct a chest x-ray (the optimal projection is anteroposterior, with the patient in the vertical position).

The radiographic sign of pneumothorax is visualization of a thin line of visceral pleura (less than 1 mm) separated from the chest.

A common finding in pneumothorax is the displacement of the shadow of the mediastinum in the opposite direction. Since the mediastinum is not a fixed structure, even a small pneumothorax can lead to displacement of the heart, trachea, and other elements of the mediastinum, so contralateral mediastinal displacement is not a sign of a tension pneumothorax.

About 10-20% of pneumothoraxes are accompanied by the appearance of a small pleural effusion (within the sinus), and in the absence of expansion of the pneumothorax, the amount of fluid may increase.

In the absence of signs of pneumothorax, according to the radiograph in the anteroposterior projection, but in the presence of clinical evidence in favor of pneumothorax, radiographs are indicated in the lateral position or lateral position on the side (decubitus lateralis), which allows confirming the diagnosis in an additional 14% of cases.

Some guidelines recommend that in difficult cases, X-rays be taken not only at the height of inhalation, but also at the end of exhalation. However, as some studies have shown, expiratory images do not have advantages over conventional inspiratory ones. Moreover, vigorous expiration can significantly aggravate the condition of a patient with pneumothorax and even lead to asphyxia, especially with tension and bilateral pneumothorax. Therefore, radiography at the height of exhalation is not recommended for the diagnosis of pneumothorax.

The X-ray sign of pneumothorax in a patient in a horizontal position (more often with mechanical ventilation - mechanical ventilation) is a sign of a deep groove (deep sulcus sigh) - a deepening of the costophrenic angle, which is especially noticeable when compared with the opposite side.

CT scan.

For the diagnosis of small pneumothoraxes, CT is more reliable than radiography.

For the differential diagnosis of large emphysematous bullae and pneumothorax, computed tomography (CT) is the most sensitive method.

CT scan is indicated to find out the cause of SVD (bullous emphysema, cysts, interstitial lung disease, etc.).

Determining the size of pneumothorax.

The size of pneumothorax is one of the most important parameters that determine the choice of treatment tactics for patients with PSP. Several formulas have been proposed to calculate the volume of pneumothorax based on X-ray and CT imaging techniques. Some consensus documents offer an even simpler approach to sizing a pneumothorax:

    pneumothoraxes are subdivided into small and large when the distance between the lung and the chest wall is less than 2 cm and more than 2 cm, respectively;

    pneumothoraxes are subdivided depending on the distance between the top of the lung and the dome of the chest: small pneumothorax at a distance of less than 3 cm, large - more than 3 cm;

TREATMENT.

Treatment goals:

    resolution of pneumothorax.

    Prevention of repeated pneumothoraxes (relapses).

therapy tactics. All patients with pneumothorax should be hospitalized in a hospital. The following stages of patient management are distinguished:

Observation and oxygen therapy;

simple aspiration;

Installation of a drainage tube;

Chemical pleurodesis;

Surgery.

Observation and oxygen therapy.

It is recommended to limit yourself to observation only (i.e. without performing procedures aimed at evacuating air) with a small volume of PSP (less than 15% or with a distance between the lung and chest wall less than 2 cm) in patients without severe dyspnea, with VSP (with a distance between the lung and the chest wall of less than 1 cm or with isolated apical pneumothorax), also in patients without severe dyspnea. The rate of resolution of a pneumothorax is 1.25% of the volume of the hemothorax within 24 hours. Thus, it will take approximately 8–12 days to completely resolve a 15% pneumothorax.

All patients, even with a normal gas composition of arterial blood, are shown the appointment of oxygen - oxygen therapy can accelerate the resolution of pneumothorax by 4-6 times. Oxygen therapy leads to blood denitrogenization, which increases the absorption of nitrogen (the main part of the air) from the pleural cavity and accelerates the resolution of pneumothorax. The administration of oxygen is absolutely indicated for patients with hypoxemia, which can occur with tension pneumothorax, even in patients without underlying lung pathology. In patients with COPD and other chronic lung diseases, when oxygen is administered, blood gas monitoring is necessary, since an increase in hypercapnia is possible.

With pronounced pain syndrome analgesics are prescribed, including narcotic ones, in the absence of pain control with narcotic analgesics, epidural (bupivacaine, ropivacaine) or intercostal blockade is possible.

Simple aspiration

Simple aspiration (pleural puncture with aspiration) is indicated for patients with PSP with a volume of more than 15%; patients with SVD (with a distance between the lung and the chest wall of less than 2 cm) without severe dyspnea, younger than 50 years. Simple aspiration is performed using a needle or, preferably, a catheter, which is inserted into the 2nd intercostal space in the midclavicular line, aspiration is performed using a large syringe (50 ml), after air evacuation is completed, the needle or catheter is removed. Some experts recommend leaving the catheter in place for 4 hours after aspiration is complete.

If the first aspiration attempt fails (the patient's complaints persist) and evacuation of less than 2.5 liters, repeated aspiration attempts can be successful in a third of cases. If, after aspiration of 4 liters of air, there is no increase in resistance in the system, then presumably there is a persistence of the pathological message and the installation of a drainage tube is indicated for such a patient.

Simple aspiration leads to expansion of the lung in 59-83% with PSP and 33-67% with PSP.

Drainage of the pleural cavity (using a drainage tube). Installation of a drainage tube is indicated: if simple aspiration fails in patients with PSP; with relapse of PSP; with VSP (with a distance between the lung and the chest wall of more than 2 cm) in patients with dyspnea and older than 50 years. Choice right size drainage tube is very important, since the diameter of the tube and, to a lesser extent, its length determine the flow rate through the tube.

Installation of a drainage tube is a more painful procedure compared to pleural punctures and is associated with complications such as penetration into the lungs, heart, stomach, large vessels, pleural cavity infections, subcutaneous emphysema. During the installation of the drainage tube, it is necessary to carry out intrapleural insertion local anesthetics(1% lidocaine 20–25 ml).

Drainage of the pleural cavity leads to the expansion of the lung in 84-97%.

The use of suction (a source of negative pressure) is not mandatory when draining the pleural cavity. The drainage tube is removed 24 hours after the cessation of air discharge through it, if, according to the chest x-ray, the lung is expanded.

Chemical pleurodesis.

One of the leading tasks in the treatment of pneumothorax is the prevention of repeated pneumothoraxes (relapses), however, neither simple aspiration nor drainage of the pleural cavity can reduce the number of relapses. Chemical pleurodesis is a procedure in which substances are introduced into the pleural cavity, leading to aseptic inflammation and adhesion of the visceral and parietal pleura, which leads to obliteration of the pleural cavity. Chemical pleurodesis is indicated: in patients with the first and subsequent SSP and in patients with the second and subsequent PSP, since this procedure helps prevent recurrence of pneumothorax.

Chemical pleurodesis is usually performed by injecting doxycycline (500 mg in 50 ml) through a drainage tube. physiological saline) or a suspension of talc (5 g in 50 ml of saline). Before the procedure, it is necessary to conduct adequate intrapleural anesthesia - at least 25 ml of 1% lidocaine solution. After the introduction of the sclerosing agent, the drainage tube is closed for 1 hour.

Surgical treatment of pneumothorax

The objectives of the surgical treatment of pneumothorax are:

    resection of bulls and subpleural vesicles (blebs), suturing of lung tissue defects;

    performing pleurodesis.

Indications for surgical intervention are:

    lack of expansion of the lung after drainage for 5-7 days;

    bilateral spontaneous pneumothorax;

    contralateral pneumothorax;

    spontaneous hemopneumothorax;

    recurrence of pneumothorax after chemical pleurodesis;

    pneumothorax in people of certain professions (associated with flights, diving).

All surgical interventions can be conditionally divided into two types: video-assisted thoracoscopy(BAT) and open thoracotomy. In many centers, VAT is the main surgical method for the treatment of pneumothorax, which is associated with the advantages of the method compared to open thoracotomy: a reduction in the time of surgery and drainage, a decrease in the number of postoperative complications and the need for analgesics, a decrease in the time of hospitalization of patients, less pronounced gas exchange disorders.

urgent events.

Indicated for tension pneumothorax immediate thoracentesis(with a needle or cannula for venipuncture no shorter than 4.5 cm, in the 2nd intercostal space in the midclavicular line), even if it is impossible to confirm the diagnosis using radiography.

Patient education:

After discharge from the hospital, the patient should avoid physical activity for 2–4 weeks and air travel for 2 weeks;

The patient should be advised to avoid changes in barometric pressure (skydiving, diving, diving).

The patient should be advised to stop smoking.

FORECAST.

Mortality from pneumothorax is low, more often higher with secondary pneumothorax.

In HIV-infected patients, in-hospital mortality is 25%, and the average survival after pneumothorax is 3 months. Mortality in patients with cystic fibrosis with unilateral pneumothorax is 4%, with bilateral pneumothorax - 25%. In COPD patients with the development of pneumothorax, the risk of death increases by 3.5 times and averages 5%.

Pneumothorax of the lung(from the Greek "pnéuma" - air, "thorax" - chest) - a pathological condition in which air enters the pleural cavity and accumulates there, due to which the lung tissue collapses, squeezed blood vessels and the dome of the diaphragm descends. Arising from pathology acute disorders respiratory and circulatory functions are dangerous to human life.

To understand exactly how the disease develops, you need to understand a little about the anatomy of the chest and the serous sac in it - the pleura.

The pleura is the serous membrane that covers the lungs. It is thin and smooth, consisting of elastic fibers. In fact, there are three separate "bags" in the chest cavity - for both lungs and for the heart.

The pleura itself is built from two sheets:

  1. Pleura visceralis (pleura pulmonalis) is a visceral (lung) sheet that sticks directly to the tissue of the lungs, separating their lobes from each other.
  2. Pleura parietalis is an outer leaf that serves to strengthen the chest.
    Both sheets are connected along the lower edge of the root of the respiratory organ, forming a single serous sac. The slit-like space formed in the sac is called the cavitas pleuralis (pleural cavity). Normally, it contains a small amount of liquid, 1-2 ml, which prevents the visceral and outer layers from touching. Due to this, it is possible to maintain a negative pressure in the pleural cavity, created there due to two forces: inspiratory stretching of the chest wall and elastic traction of the lung tissue.
    If, for any reason (chest injury, pathology of the respiratory system, etc.), air enters the pleural cavity from the outside or from the inside, the atmospheric pressure is balanced, the lungs collapse completely or partially, that is, their complete or partial collapse occurs.

Why does pneumothorax develop?

The causes of the pathological condition can be divided into two large groups:

  1. Mechanical damage and trauma to the lungs or chest. These causes of pneumothorax are as follows:
    • closed trauma (respiratory organs are damaged by fragments of ribs, for example);
    • penetrating injury (or open injury);
    • iatrogenic damage (development of the disease is possible when performing diagnostic or medical procedures such as pleural puncture, installation of a subclavian catheter, etc.);
    • procedures in the treatment of tuberculosis - pneumothorax is created artificially.
  2. Respiratory pathology. The occurrence of pneumothorax may have such internal causes:
    • bullous emphysema (rupture of air cysts);
    • ruptured lung abscess;
    • rupture of the esophagus;
    • with tuberculosis - a breakthrough of caseous foci;
    • other.

How is pathology classified?

It should be mentioned that in addition to gas, blood, pus, and other fluids can accumulate in the pleura. Therefore, there is such a classification of damage to the serous sac:

  • pneumothorax (which, in fact, is what we are talking about);
  • hemothorax (blood accumulates in the pleural cavity)
  • chylothorax (accumulation of chylous fluid occurs);
  • hydrothorax (transudate accumulates);
  • pyothorax (pus enters the cavity of the serous sac).

The classification of the disease itself is quite complicated, it is based on several criteria.

For example, depending on the cause of occurrence, the following types of pneumothorax are distinguished:


According to the volume of air that entered the cavity between the layers of the pleura, they recognize the following types pneumothorax:

  • partial (partial or limited) - lung collapse is incomplete;
  • total (complete) - there was a complete collapse of the lung.

There is a classification according to how the pathology spread:

  • unilateral (a lung fell asleep on one side);
  • bilateral (the patient's condition is critical, there is a threat to his life, since the collapsed lungs can completely turn off from the act of breathing).

According to whether there is a communication with the environment, classify:

  1. closed pneumothorax. This condition is considered the easiest, its treatment is not always required: a small amount of air can resolve spontaneously.
  2. . It usually develops due to the presence of damage to the chest wall. The pressure in the pleural cavity becomes equal to atmospheric, the respiratory function is impaired.
  3. Tension pneumothorax. Wherein pathological condition a valvular structure is formed that allows air to enter the serosa on inspiration and prevents its release on expiration. Due to irritation of the nerve endings on the sheets of the pleura, pleuropulmonary shock and acute respiratory failure occur.

Clinical picture of pneumothorax

To confirm the diagnosis and determine the tactics of treatment is possible only by taking an x-ray. But the symptoms of the disease are quite bright, their severity is influenced by the causes of the disease and the degree of lung collapse.

It is difficult to confuse an open pneumothorax - a person is forced to lie down on the injured side, air is sucked in with noise through the wound, and foamy blood comes out on exhalation.

Symptoms of the spontaneous development of the disease - pain on the side of the chest where the lung is damaged, paroxysmal cough, shortness of breath, tachycardia, cyanosis.

The patient characterizes the pain as a dagger, penetrating. It gives to the neck and arm, intensifies with inhalation. Sometimes there are symptoms such as sweating, drowsiness, anxiety, fear of death.

When examining the chest, a lag in breathing of its damaged side is visible. On auscultation from this side, breathing is heard weakly, otherwise it is not heard at all.

Symptoms of the presence of air in the pleural cavity in newborns and babies up to 12 months are anxiety, difficulty breathing, puffiness of the face, shortness of breath, cyanosis, sharp deterioration conditions, refusal to eat.

The closed form of the disease is sometimes asymptomatic.

Diagnostics

If the doctor suspected pneumothorax, it should be treated immediately, the doctor:

  • asks the patient to describe his symptoms;
  • asks the patient about whether he smokes and for how long, whether he has a history of diseases of the lungs and respiratory organs, whether he has tuberculosis, whether he is a carrier of HIV;
  • appoints laboratory research(the gas content of arterial blood is examined);
  • He ordered an EKG and X-ray.

X-ray of the lungs

X-ray is the main way to determine if there is air in the pleural cavity, how much the lung has fallen asleep, and, therefore, prescribe the correct treatment and save the patient's life.

To confirm pneumothorax, an X-ray of the chest is taken in the anteroposterior projection, the patient is in an upright position.

An x-ray may show a thin line of the visceral pleura. Normally, it is not visible, but in the presence of air in the cavity, it can separate from the chest.

X-ray also shows that the mediastinum has shifted in the opposite direction.

In every fourth case of pneumothorax, a small amount of fluid enters the pleura. This can also be seen with x-rays.

If the presence of air in the pleura is not confirmed in the picture, but the description of the symptoms gives the right to assume pneumothorax, an x-ray is taken again, while the patient is placed on his side. The study shows a deepening of the costophrenic angle.

How to treat pneumothorax

Usually, with a traumatic pneumothorax, the patient needs urgent medical attention even before they are taken to a medical facility and they have an x-ray.

Before the paramedics arrive:

  • calm the person
  • restrict his movements;
  • give air access;
  • at open form disease, try to apply a compressive bandage to seal the injury; for this, a plastic bag, a fabric folded several times, is suitable.

Direct treatment of the patient takes place in surgical hospital, it depends on the type of disease. Basically, by performing a puncture, air is evacuated from the pleural cavity, and negative pressure is restored there.

It also implies treatment and pain relief during periods of collapse and expansion of the lungs.

Forecast

Subject to adequate emergency care, proper treatment and the absence of severe pathologies from the respiratory organs, the outcome of the disease can be quite favorable.

Spontaneous pneumothorax, if the underlying disease is not eliminated, may recur.

Live healthy with Elena Malysheva

Information about the disease from 34:25.

Pneumothorax is a life-threatening medical emergency. Acute pathology often accompanies chest injuries, including gunshots and traffic accidents, and may also occur due to lung disease or as a complication of some medical manipulations.

Pneumothorax of the chest is easy to suspect without instrumental examination. Knowing the symptoms of the condition will help prompt treatment qualified help and the preservation of human life.

Pneumothorax - what is it?

A bit of anatomy. The lungs are covered with a pleura consisting of two sheets. There is no air in the pleural cavity, so the pressure in it is negative. It is this fact that determines the work of the lungs: straightening during inhalation and subsidence during exhalation.

Pneumothorax is a pathological entry of air into the pleural cavity due to its depressurization due to external injury, lung disease and other causes.

At the same time, intrapleural pressure increases, preventing the expansion of the lungs during inspiration. A partially or completely collapsed lung is switched off from the breathing process, blood circulation is disturbed.

The lack of timely assistance most often leads to the development of complications that threaten the life of the patient.

Causes and types of pneumothorax

Depending on the provoking factor, the following types of pneumothorax are divided:

  • Traumatic

Pleural rupture occurs when open injuries(stabbing, gunshot) and closed injuries(damage to the pleura by a broken rib, blunt blow into the chest while maintaining the integrity of the skin).

  • Spontaneous

The main cause of spontaneous pneumothorax is the rupture of pulmonary blisters in bullous disease. The mechanism of occurrence of emphysematous expansions of the lung tissue (bull) has not yet been studied.

However, this disease is recorded in most healthy people, especially after 40 years. Also, spontaneous rupture of the inner pleura and lung occurs with congenitally developed weakness of the pleura, cavernous tuberculosis, abscess/gangrene of the lung.

  • iatrogenic

Damage to the lung with the development of pneumothorax is often a complication of some medical procedures: installation of a subclavian catheter, puncture of the pleura, blockade of the intercostal nerve, cardiopulmonary resuscitation(barotrauma).

  • Artificial

The intentional creation of pneumothorax is resorted to with widespread pulmonary tuberculosis and for diagnostic thoracoscopy.

Pneumothorax is also determined by the following indicators:

  • according to the degree of injury respiratory system- one-sided and two-sided;
  • depending on the degree of lung collapse: small or limited - less than 1/3 of the lung is turned off from breathing, medium - 1/3 - 1/2, total - more than half of the lung;
  • according to the nature of air entering the pleura: closed - the volume of air that once entered does not increase, open - there is a direct communication between the pleural cavity and the environment, and the volume of incoming air constantly increases until the lung completely collapses, the most dangerous tension (valvular) pneumothorax - a valve is formed , passing air in the direction environment- pleural cavity and closing its exit;
  • depending on the complicating consequences - complicated and uncomplicated.

Spontaneous pneumothorax

If other types of pulmonary pneumothorax have a well-defined external cause, spontaneous pneumothorax can occur even in healthy person with no history of injury or lung disease. Idiopathic (primary) pneumothorax occurs in the following situations:

  • sudden pressure drops during air travel, diving;
  • genetic weakness of the pleura - rupture of the lung tissue and pleural sheet can provoke laughter, physical stress(including straining for constipation), severe cough;
  • congenital deficiency of alpha-1-antitrypsin - provokes the development pathological changes lung tissue.

Secondary spontaneous pneumothorax due to development lung disease, occurs with pathologies:

  • damage to the respiratory tract - cystic fibrosis, emphysema, severe bronchial asthma;
  • connective tissue diseases that affected the lungs - lymphangioleiomyomatosis;
  • infections - abscess, gangrene, tuberculosis, as well as common pneumonia in HIV-infected people;
  • systemic diseases that occur with damage to the lungs - systemic scleroderma, rheumatoid arthritis, polymyositis;
  • oncopathology of the lungs.

The development of pneumothorax is always sudden, the severity of symptoms depends on the degree of collapse of the lung and the presence of complications.

6 main signs of pneumothorax:

  1. Breathing problems - dry cough, shortness of breath, breathing becomes shallow.
  2. The pain is sharp, aggravated by inhalation, radiating to the shoulder from the side of the injury.
  3. Subcutaneous emphysema - occurs when the outer layer of the pleura ruptures, air enters the exhalation subcutaneous tissue, outwardly, swelling with crepitus (crunching of snow) is detected when pressing on it.
  4. Foaming blood from a wound is characteristic of open pneumothorax.
  5. External signs - a forced sitting posture, pallor and cyanosis of the skin (indicates developing circulatory and respiratory failure), cold sweat.
  6. Common symptoms are increasing weakness, panic, palpitations, a drop in a / d, fainting is possible.

First aid for pneumothorax

If symptoms of pneumothorax occur, the only correct tactic is:

  1. Immediate call for an ambulance and urgent hospitalization.
  2. Plain sterile dressing for open pneumothorax. An improperly applied occlusive dressing can lead to a tension pneumothorax and a rapid deterioration in the condition. Therefore, its imposition is carried out only by a physician.
  3. Perhaps the introduction of Analgin (tablets, intramuscular injection).

Applying an occlusive dressing for pneumothorax:

  • Reassure the patient by explaining the algorithm of actions.
  • It is possible to use Promedol for pain relief.
  • Compliance with sterility when opening packages with tools and dressing material using sterile gloves.
  • The position of the patient is a slightly raised hand on the injured side. The dressing is applied on exhalation.
  • Layer-by-layer imposition of cotton-gauze discs on the wound, sealed packaging with a sterile side to the wound and completely covering the pads applied to the wound, tight bandaging.

Diagnostics

  1. Percussion (tapping) - a "box" sound on the side of pneumothorax.
  2. Auscultation (listening) - weakening of breathing on the affected side up to its absence.
  3. X-ray - air in the pleura ( dark spot), a collapsed lung, with the development of a tension pneumothorax - a shift of the mediastinum in a healthy direction.
  4. CT - not only reveals even small volumes of air in the pleura, but also clearly defines the causative disease.

To additional diagnostic examinations applies laboratory analysis the gas component of the blood and ECG (determines the degree of circulatory disorders with a tense form of pneumothorax).

Treatment of pneumothorax

After spontaneous pneumothorax with a limited volume of incoming air, no serious consequences usually does not occur. Even without treatment, small "air" pillows in the pleural cavity can resolve on their own, without giving pronounced clinical symptoms. However, medical supervision of such a patient is mandatory.

In other cases, you need surgical intervention:

  1. Closed pneumothorax- puncture of the pleural cavity and pumping out air. The ineffectiveness of this tactic indicates the entry of air into the pleura through the lungs. In this case, Bulau drainage or active aspiration with electrovacuum equipment is used.
  2. Open pneumothorax- surgery with opening the chest (thoracoscopy, thoracotomy) and revision of the lung tissue and pleura, suturing damage, installing drainage.

If unruptured bullae are found during the operation, in order to avoid recurrent pneumothorax, a decision is made to resect a segment / lobe of the lung, the procedure for creating artificial pleurisy (pleurodesis).

Forecast

Uncomplicated forms of spontaneous pneumothorax usually end favorably. Exodus acute condition with a significant decline in the lung, it depends on the speed of the medical care provided, since inflammation begins to develop after 4-6 hours. Relapses are also not ruled out.

Immediate surgical intervention is required for valvular pneumothorax.

Consequences

  • Pleurisy and purulent empyema lungs with subsequent formation of adhesions and secondary respiratory failure.
  • Intrapleural bleeding.
  • compression of the heart and coronary vessels air entering the mediastinum, the development of acute heart failure.
  • Mortal danger with a large amount of damage and deep injury to the lung tissue.

Pneumothorax - ICD code 10

In the international classifier of diseases ICD 10 pneumothorax is:

Section X J00-J99 - Diseases of the respiratory system

J93 - Pneumothorax

  • J93.0 Spontaneous tension pneumothorax
  • J93.1 Spontaneous pneumothorax other
  • J93.8 - Other pneumothorax
  • J93.9 Pneumothorax, unspecified

Additionally:

  • S27.0 - Traumatic pneumothorax
  • P25.1 - Pneumothorax originating in the perinatal period