Folk remedies for lung disease pneumothorax. Diagnosis and treatment of spontaneous pneumothorax

Pneumothorax is a disease that causes the accumulation of air in the pleural cavity of the lungs. They are being depressurized.

Air penetration into the pleura contributes to an increase in pressure. Then there is a partial or complete decline of the lung.

The condition of the person is very serious and needs urgent help. Pneumothorax can be open or closed. Its occurrence is often due to lung disease or injuries (stab wounds, bullet wounds, and so on).

What it is?

Pneumothorax - accumulation of air or gases in the pleural cavity. It can occur spontaneously in people without chronic lung disease ("primary"), as well as in people with lung disease ("secondary") and artificial pneumothorax (introduction of air into the pleural cavity, leading to the collapse of the affected lung). Many pneumothoraxes occur after a chest injury or as a complication of medical treatment.

Symptoms of pneumothorax are determined by the size and speed of air entering the pleural cavity; these include in most cases chest pain and difficulty breathing. Diagnosis in some cases can be made by physical examination, but sometimes a chest x-ray or computed tomography (CT) scan is needed. In some situations, pneumothorax leads to severe lack of oxygen and low blood pressure, progressing to cardiac arrest if left untreated; This condition is called a tension pneumothorax.

Small spontaneous pneumothorax usually resolves spontaneously and no treatment is required, especially in cases without underlying lung disease. For large pneumothorax or severe symptoms, air can be evacuated with a syringe or a unilateral Bulau drain inserted to remove air from the pleural cavity. Sometimes surgical measures are necessary, especially if the drainage tube is ineffective or if repeated episodes of pneumothorax occur. If there is a risk of repeated episodes of pneumothorax, various treatments may be used, such as the use of pleurodesis (sticking of the lungs to the chest wall).

Causes of pneumothorax

Depending on the origin, spontaneous primary and secondary, traumatic, iatrogenic pneumothorax are distinguished.

Primary spontaneous

Formed for no apparent reason. His reasons:

• Congenital weakness of the pleural tissues bursting when coughing, laughing, increased stress;
• genetic defect- insufficient production of α-1-antitrypsin;
• sudden pressure drop(when flying by plane, diving).

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Secondary

It develops more often in older people in the presence of lung diseases:

• chronic and hereditary(bronchial asthma, cystic fibrosis, COPD);
• infectious(pneumonia, tuberculosis);
• oncologically x (lung cancer).

Traumatic

Cause of injury:

• Open - cut, chipped, gunshot;
• closed - obtained during a fight, falling from a great height.

iatrogenic

Formed during surgery:

• When ventilating the lungs;
• cardiopulmonary resuscitation and;
• puncture of the pleural cavity.

Classification

There are various types of pneumothorax, which are divided by classification based on the causes of their occurrence, localization and extent of the lesion. Depending on how much the lung tissue and pleura have suffered, the pulmonologist prescribes a treatment plan and voices the prognosis.

Depending on the extent of damage to the lung tissue, it happens:

1. Total pneumothorax (complete). It is characterized by complete compression of the lung due to the release of a large amount of gas into the pleural cavity.
2. Limited pneumothorax (partial). The fall of the respiratory organ is incomplete.

If the lesion is on the left side, a left-sided pneumothorax is diagnosed, on the right lung - a right-sided pneumothorax. There is also a bilateral form of the disease, which develops due to the total compression of two lungs at the same time and is fraught with the rapid death of the victim.

Also, the disease is divided according to the causes of occurrence:

1. Traumatic pneumothorax. This option is possible with damage to the chest. It develops as a result of a penetrating wound (for example, a stab wound), as well as due to injury to the lung tissue by a fragment of a rib with an open or closed fracture.
2. Spontaneous. It occurs due to the rapid rupture of the lung tissue against the background of a chronic disease or predisposing factors. So, the cause of primary (idiopathic) pneumothorax can be congenital insufficiency of pleural tissue, strong laughter or a sharp cough, rapid diving to depth, as well as flying on an airplane. Secondary develops due to severe lung diseases.
3. Artificial. It is created intentionally under the supervision of a competent specialist for the treatment of certain respiratory diseases.

According to the air from the environment:

1. Closed. There is a single entry of a small amount of air into the pleural cavity, after which its volume no longer changes.
2. Open. There is a visual defect of the sternum, through which, with each breath, air enters the cavity, and when exhaled, it exits. The process may be accompanied by audible squelching and gurgling.
3. Valve. Has the most severe consequences. During a tension pneumothorax, with each breath, air enters the peripulmonary space, but it does not escape to the outside.

Each of the conditions, regardless of severity, requires a thorough examination by a doctor and competent treatment. This will help to minimize the risk of relapse, and in some cases save the life of the victim.

Medical therapy for pneumothorax

Drug therapy for the treatment of pneumothorax is of a conservative type, since it does not involve the removal of the lung or its segments.

The methods used depend on the circumstances:

• Observation: This is not a real treatment, as it consists in observing the patient for several hours and days to assess whether medical intervention is required. In asymptomatic or stable cases, oxygen therapy may be sufficient to promote lung expansion.
• Pleurocentosis: consists in sucking out fluid and air that may accumulate in the pleural cavity. It is used mainly in the case of hypertensive pneumothorax, and consists in the introduction of a needle at chest level and the subsequent pumping out of fluid and air located at the level of the pleural cavity.
• Pleural drainage: used in cases of emergency or when the level of intrapleural pressure is too high. It consists in introducing a tube into the pleural cavity, allowing excess air to escape.

Surgical intervention

If medical methods of treatment have not brought improvement, in particular, if after a week of application of drainage there are no signs of recovery.

Today, one of the most commonly used methods is thoracoscopy, a method similar to laparoscopy that allows surgical manipulation through one to three punctures in the patient's chest.

Thoracoscopy performed under general anesthesia and in four stages:

• Step 1: Examination of the lung parenchyma. This stage is used for primary idiopathic pneumothorax, which is not associated with lung damage or parenchymal changes.
• Step 2: Look for adhesions between the pleura and lungs, which are common in cases of active pneumothorax. This step is often used for recurrent pneumothorax.
• Stage 3: Look for small air bubbles less than 2 cm in diameter causing damage to lung tissue and vascularization of emphysema.
• Stage 4: Look for vesicles larger than 2 cm in diameter. This is often seen in patients suffering from bronchitis or bullous dystrophy.

New technologies are less invasive than those used a few years ago and thus recovery is much faster.

Reasons for development

The lung has no muscle tissue, so it cannot expand itself to provide breathing. The mechanism of inspiration is as follows. In the normal state, the pressure inside the pleural cavity is negative - less than atmospheric pressure. When the chest wall moves, the chest wall expands, due to the negative pressure in the pleural cavity, the lung tissues are “caught” by the traction inside the chest, the lung straightens out. Further, the chest wall moves in the opposite direction, the lung returns to its original position under the action of negative pressure in the pleural cavity. This is how a person performs the act of breathing.

If air enters the pleural cavity, then the pressure inside it increases, the mechanics of lung expansion is disturbed - a full-fledged act of breathing is impossible.

Air can enter the pleural cavity in two ways:

• with damage to the chest wall with a violation of the integrity of the pleural sheets;
• with damage to the organs of the mediastinum and lungs.

The three main components of pneumothorax that create problems are:

• the lung cannot expand;
• air is constantly sucked into the pleural cavity;
• the affected lung swells.

The impossibility of expanding the lung is associated with the re-entry of air into the pleural cavity, blockage of the bronchus against the background of previously noted diseases, and also if the pleural drainage was installed incorrectly, which makes it work inefficiently.

Air suction into the pleural cavity can pass not only through the formed defect, but also through the hole in the chest wall, made for the installation of drainage.

Pulmonary edema may occur as a result of stretching of the lung tissue after medical actions aimed at quickly resuming negative pressure in the pleural cavity.

Pneumothorax - causes

Sometimes the pathology in question occurs spontaneously, especially in young men who are predisposed to it due to age, heredity, lifestyle or hobby. The main causes of pneumothorax:

• trauma;
• diseases of the respiratory system;
• medical interventions.

This form of the disease occurs with severe damage to the chest. An open pneumothorax is an accumulation of air between the pleural lobes, which has an outlet to the outside. When you inhale, the gas fills the cavity, and when you exhale, it comes back. The pressure in the shell gradually equates to atmospheric pressure, so the lung cannot expand. Because of this, it ceases to participate in the respiratory processes and supply the blood with oxygen.

A variant of the open is valvular pneumothorax of the lung. This condition is characterized by displacement of the tissues of the damaged organ, bronchi or muscles. As a result, air fills the pleural cavity during inhalation, but is not completely exhaled. The pressure and volume of gas between the petals is constantly increasing, which leads to displacement of the heart and large vessels and flattening of the lung. There is a strong violation of blood circulation, respiration and oxygen metabolism.

Closed pneumothorax

Provocateurs of this type of pathology can be light bruises and superficial injuries. Similarly, it is observed when spontaneous pneumothorax occurs, the causes of which have not yet been established. The accumulation of air between the petals of the lung membrane is formed because a small defect appears in the pleura. Damage to the cavity has no exit to the outside, and the volume of gas in it does not increase. Gradually, the air resolves on its own, even without medical intervention, and the defect closes.

Symptoms and first signs

The severity of symptoms of pneumothorax depends on the cause of the disease and the degree of compression of the lung.

A patient with an open pneumothorax takes a forced position, lying on the injured side and tightly clamping the wound. Air is sucked into the wound with noise, foamy blood with an admixture of air is released from the wound, chest excursion is asymmetric (the affected side lags behind when breathing).

The development of spontaneous pneumothorax is usually acute: after a bout of coughing, physical effort, or for no apparent reason. With a typical onset of pneumothorax, a piercing stabbing pain appears on the side of the affected lung, radiating to the arm, neck, and behind the sternum. The pain is aggravated by coughing, breathing, the slightest movement. Often the pain causes a panic fear of death in the patient. Pain in pneumothorax is accompanied by shortness of breath, the severity of which depends on the volume of lung collapse (from rapid breathing to severe respiratory failure). There is pallor or cyanosis of the face, sometimes a dry cough.

After a few hours, the intensity of pain and shortness of breath weaken: the pain bothers at the time of a deep breath, shortness of breath manifests itself with physical effort. Perhaps the development of subcutaneous or mediastinal emphysema - the release of air into the subcutaneous tissue of the face, neck, chest or mediastinum, accompanied by swelling and a characteristic crunch on palpation. Auscultatory on the side of pneumothorax, breathing is weakened or not heard.

In about a quarter of cases, spontaneous pneumothorax has an atypical onset and develops gradually. Pain and shortness of breath are minor, as the patient adapts to new breathing conditions, they become almost invisible. The atypical form of the flow is characteristic of a limited pneumothorax, with a small amount of air in the pleural cavity.

Clearly clinical signs of pneumothorax are determined when the lung collapses by more than 30-40%. 4-6 hours after the development of spontaneous pneumothorax, an inflammatory reaction from the pleura joins. After a few days, the pleural sheets thicken due to fibrin overlays and edema, which subsequently leads to the formation of pleural adhesions that make it difficult to straighten the lung tissue.

Symptoms

Symptoms of pneumothorax appear due to the accumulation of air in the pleural cavity. Their development depends on the stages of lung reduction.

The size of the collapsed lung is divided into:

• small (up to 25%);
• medium (50-70%);
• total (100%);
• tense (displaced mediastinum).

Spontaneous pneumothorax is:

• primary (idiopathic);
• secondary (symptomatic);
• recurrent look.

The disease is accompanied by an attack of coughing. There is a stabbing pain in the part of the diseased lung, which eventually turns into aching. This is accompanied by cyanosis of the face (blue color of the skin due to the accumulation of carbon dioxide in the blood), pallor. Pain may increase with movement, breathing, and coughing. The patient may have panic attacks. Trying to reduce shortness of breath and pain, the patient most often lies on the sore side or sits down with an inclination to the sore side.

Pneumothorax - first aid during an attack

Pneumothorax is an extremely severe pathological process of the respiratory system, which can lead to irreversible processes in the body and death. The provision of first aid in case of an attack of the disease should be urgent. When a patient develops a sharp relapse or an acute attack of pneumothorax, one cannot do without medical help, an ambulance should be called immediately.

How can the patient be helped? If a pneumothorax is caused by a penetrating wound to the chest, the wound must be closed to prevent air and blood from escaping. To do this, use rags or bandages with cotton. To stop air from escaping through the wound, you can use a film that closes the hole. If possible, items that will be used to cover the wound should be disinfected as much as possible. The film must cover the wound hole hermetically, otherwise there will be no point in such a bandage.

If valvular pneumothorax occurs, oxygen should be given by pulmonary puncture. But to do this correctly, without harm to health, only a person with a medical education or the skills to carry out this manipulation can. The puncture allows you to straighten the lung, prevent fusion of the mediastinum and displacement of the internal organs.

Prevention

There are no specific preventive measures in this case.

Primary

Based on maintaining the health of the whole organism:

• Complete cessation of smoking;
• regular long walks;
• doing breathing exercises;
• timely diagnosis lung diseases and their treatment;
• injury avoidance chest.

Secondary

Its purpose is to prevent the development of relapses:

• Union of pleural sheets;
• removal of the cause of the disease.

Complications

Complications of pneumothorax are common and occur in half of the patients:

1. Pleurisy is a common consequence of pneumothorax of the lung. It is often accompanied by the formation of adhesions, which interferes with the normal expansion of the lung.
2. The mediastinum is filled with air, which leads to spasm of the heart vessels.
3. Air enters the subcutaneous tissue, the so-called subcutaneous emphysema.
4. Bleeding in the pleural region.
5. With a long course of the disease, the affected lung begins to overgrow with connective tissue. It shrinks, loses its elasticity, and is unable to straighten itself after the removal of air masses from the pleural region. This leads to respiratory failure.
6. Pulmonary edema.
7. With an extensive area of ​​lung tissue damage, a fatal outcome is possible.

Pneumothorax - symptoms

The clinical picture depends on the form and severity of the condition, the volume of air that accumulates in the pleural region. Sometimes there are practically no signs of pneumothorax. This is especially characteristic of the spontaneous primary type of pathology. In other cases, pneumothorax of the lung may have the following symptoms:

• chest pain radiating to the shoulder from the injured side;
• dry cough;
• dyspnea;
• increased heart rate;
• panic fear of death;
• secretion of cold viscous sweat;
• weakness in the body;
• purple-blue skin tone;
• whistling during breathing (with open pneumothorax of the lung);
• protruding spaces between the ribs;
• noticeable protrusion of the chest;
• swelling under the skin (emphysema), when pressed, a crunch is heard, as if from snow;
• lowering blood pressure;
• fainting.

Diagnostics

Diagnosis of pneumothorax is based on data obtained during the examination and examination of the patient. Percussion reveals a box or tympanic sound extending to the lower ribs, displacement or expansion of the boundaries of cardiac dullness. Palpation is determined by the weakening or absence of voice trembling. Breathing is weakened or not audible.

X-ray examination allows to detect the zone of enlightenment and displacement of the mediastinal organs, there is no pulmonary pattern. A more detailed image can be obtained using computed tomography. Additional diagnostic methods are: pleural puncture with manometry, videothoracoscopy, blood gas analysis, electrocardiography.

With hemopneumothorax and pyopneumothorax, a diagnostic puncture is performed to determine the cellular composition and the presence of pathogenic microbes.

Kinds

According to the volume of lung collapse, pneumothorax is divided into:

• small (less than 25%)
• medium (from 50% to 75%)
• total (100%)
• tense (displaced mediastinum)

The pathological condition under consideration is also divided into:

• open P. (the pleural cavity communicates with the surface of the chest, air enters through the wound during the exhalation period)
• closed P. (air enters the pleural cavity from the bronchus during inspiration)
• valvular (air from the bronchus enters the pleural cavity during inhalation, and during exhalation, the hole in the bronchus is blocked by a piece of bulla or a piece of lung, the air does not exit into the bronchial tree, collapsing more and more with each breath)

Pneumothorax according to localization is divided into two types:

• unilateral
• bilateral (rare)

Hemopneumothorax and pyopneumothorax, subspecies of pneumothorax, pass with a pronounced cardio-pulmonary syndrome, which in its manifestations resembles respiratory failure and myocardial infarction. Pyopneumothorax occurs when the bronchus stump fails after lung resection, an abscess ruptures from the lung, bronchopleural fistula. The collapse of the lung is provided in such cases not only by pus, which accumulates, but also by the flow of air. Pyopneumothorax, especially in young patients, must be distinguished during diagnosis from lobar emphysema (mediastinal displacement is noted in this disease), from diaphragmatic hernia (there are symptoms of intestinal obstruction). In adult patients, there may be a lung cyst of enormous size, in which there is no intoxication.

Primary spontaneous pneumothorax fixed in patients who did not tolerate and do not currently have lung diseases. Thin tall people who are less than 20 years old are especially noted. It is believed that the process is a consequence of the direct rupture of the subpleural apical vesicles or bullae due to heredity or smoking.

Pneumothorax often develops at rest, but sometimes it can also occur during exertion, when a person tries to stretch or reach for some objects. Primary spontaneous pneumothorax can also occur when flying at high altitude (when the pressure inside the lung changes unevenly), while jumping into the water.

Secondary spontaneous pneumothorax found in people with lung disease. It is often caused by ruptured vesicles or bullae if the person has severe chronic obstructive pulmonary disease; Pneumocystis jiroveci infection in HIV-infected individuals; it also happens with any parenchymal lung diseases, including cystic fibrosis. The prognosis of secondary pneumothorax is considered more serious than primary because it occurs in older people who have less compensatory reserve of lung and heart function.

Menstrual pneumothorax- a rare form of secondary spontaneous pneumothorax that develops within 2 days after the onset of menstrual bleeding in premenopausal women and sometimes in postmenopausal women taking estrogen. The cause is intrathoracic endometriosis, suggesting that migration of the abdominal endometrium through diaphragmatic defects or pelvic vein embolization is also important. During menstruation, a defect is formed in the pleura due to rejection of the endometrium.

Traumatic pneumothorax- a frequent complication of blunt and penetrating wounds of the chest.

Treatment of pneumothorax

Pneumothorax is a condition that requires emergency care, which will be provided in a hospital. Pneumothorax is treated by surgeons and pulmonologists. Open pneumothorax requires an airtight bandage, valvular - urgent puncture with air removal and further surgery to eliminate the suction valve.

Further treatment in the hospital will depend on the causes of pneumothorax - this is the removal of air, the restoration of normal pressure inside the pleura, and the suturing of wounds, the removal of fragments of the ribs, operations on the lung, etc.

In order to prevent the development of pneumothorax again, a pleurodesis procedure is performed - the creation of artificial adhesions in the pleura with a fully expanded lung.

Types of pneumothorax

Depending on the communication with the external environment, the following types are distinguished:

• Closed– there is no communication with the environment, the amount of trapped air is constant. The lightest form, often spontaneously resolves;
• open- there is a relationship with the environment. Functions of a lung are considerably broken;
• valve- characterized by the formation of a valve that allows air to enter the pleural cavity, but does not let it out. With each breath, the volume of air in the cavity increases. The most dangerous type - the lung ceases to function, pleuropulmonary shock develops, blood vessels are compressed, the heart and trachea are displaced.

Surgical intervention

With a penetrating wound in the chest cavity (for example, in the conditions of hostilities), after which pneumothorax develops and a one-sided air leak occurs, there is a need for pre-medical intervention. For this, decompression needles were developed, which, with the right manipulations, pump out the air entering the pleural cavity, due to which the pressure can stabilize. Special occlusive dressings (films) have also been developed on an adhesive basis, which stick even to wet skin, creating an airtight overlap at the wound site and not allowing the pressure in the chest to equal atmospheric pressure.

Pneumothorax in any of its manifestations requires surgical intervention. These include the following types of procedures:

• Closed type - with the help of a puncture, air is pumped out of the pleural cavity.
• Open type - thoracoscopy or thoracotomy is performed with a check of the lung tissue and pleura. The defect is sutured, thereby stopping the flow of air into the pleural cavity. Then the event is repeated as with a closed type.
• Valvular pneumothorax - puncture with a thick needle. After that, they are treated surgically.
• Recurrent pneumothorax - its causes are surgically removed. Often, not an ordinary pleural puncture is performed, but a drainage tube is installed to pump out air.

Treatment

Pneumothorax is a pathological process that poses a threat to the life of the patient. Patients with pneumothorax are hospitalized in a surgical hospital. Treatment of the disease should begin before the arrival of the ambulance team. The patient should be helped - to calm, limit the mobility of the chest and provide sufficient oxygen. The ambulance doctor examines the patient, feels the chest, prescribes the necessary diagnostic tests.

Drainage of the pleural cavity

If a large amount of air accumulates in the pleural cavity, it is drained using the Bobrov apparatus or an electric aspirator. This is a simple medical procedure that does not require special preparation of the patient.

The procedure is carried out under local anesthesia. The patient is seated and the place of installation of the drainage is chipped with Novocain. Then a trocar is inserted, with the help of which drainage is established. It is fixed to the skin and attached to Bobrov's jar. If this method of drainage becomes ineffective, proceed to active aspiration. The drainage is connected to an electric pump and drained until the lung is fully expanded, confirmed by radiography.

Surgery

If active aspiration does not allow stopping pneumothorax or its recurrence occurs, they proceed to surgical treatment - thoracotomy.

The pleural cavity is opened, the cause of the pathology is eliminated, and then the existing defect in the lung tissue is sutured, bleeding is stopped and the wound is sutured in layers, leaving a drainage tube.

Indications for thoracotomy are:

• Ineffective drainage of the pleural cavity,
• Bilateral spontaneous pneumothorax
• hemopneumothorax,
• Relapses of pathology caused by bullous emphysema.

Treatment and emergency care

The main goal of treating pneumothorax is to remove air from the pleural cavity and prevent recurrence of the disease. At the same time, the tactics of managing patients can differ significantly. It depends:

• on the type and size of pneumothorax;
• the severity of its course;
• presence of pleural effusion and associated pathology.

The main methods of treatment of this pathological condition are:

1. Observation and oxygen therapy.

It is usually used in patients with primary spontaneous or simple iatrogenic pneumothorax without severe clinical symptoms. Such patients are observed for some time and X-ray control is carried out, assessing the rate of air resorption in the pleural cavity. Oxygen therapy is used to speed up this process. If the pneumothorax does not resolve within a week, then active intervention is necessary.

1. Aspiration of air from the pleural cavity.

The procedure is performed in the absence of suspicion of the continued flow of air into the pleural cavity. To perform it, a puncture is made in the second intercostal space along the midclavicular line and air is removed with a syringe.

1. Drainage.

Drainage of the pleural cavity can be carried out using a thin catheter (3-6 mm) or simple drainage (9 mm). The first option is considered less traumatic, but such a catheter cannot cope with the continued massive intake of air or significant accumulation of fluid.

Drainage is installed in the third or fourth intercostal space along the midclavicular or anterior axillary line. In this case, it is recommended to create a subcutaneous tunnel one intercostal space upwards in order to control the direction of the tube and prevent air from entering the pleural cavity after removal of the drains.

After drainage is established, passive or active drainage is performed using valve systems.

1. Chemical pleurodesis.

This procedure is used in patients with secondary spontaneous or recurrent pneumothorax. Its essence lies in the introduction into the pleural cavity of special substances that cause aseptic inflammation and adhesion of the parietal and visceral pleura with obliteration of its cavity. For this purpose, drugs from the tetracycline group or a suspension of talc can be used.

1. Surgery.

Surgery for pneumothorax can be done in two ways:

• thoracoscopic surgery,
• open thoracotomy.

Preference is given to the first method, as it is considered less traumatic and quite effective. Its implementation is shown in the following cases:

• lack of effect from less invasive intervention;
• spontaneous hemopneumothorax;
• bilateral or contralateral lesion;
• pneumothorax in people of certain professions associated with air travel or diving.

In the presence of ongoing bleeding, pneumothorax as a result of rupture of part of the respiratory tract, damage to the esophagus, or concomitant trauma to the chest, an open thoracotomy is performed.

After discharge from the hospital, such patients are advised to stop smoking, and also avoid physical exertion and air travel for 2 weeks.

Causes of closed pneumothorax

All the causes that lead to the occurrence of a closed pneumothorax can be divided into two groups:

• pathological;
• traumatic.

They are united by one thing - the penetration of air into the pleural cavity. But the ways of such penetration are fundamentally different from each other.

note

In the case of pathological causes, air enters the pleural cavity from other organs and tissues of the human body or from the outside, in the case of traumatic causes, only from the outside. There are cases of a combination of these two paths, but they are quite rare.

Pathological causes of the described disease are:

• bullous emphysema - foci of increased airiness of the lung;
• bronchial asthma - a violation of the bronchi, which is manifested by a deterioration in their patency and the regular occurrence of asthma attacks;
• tuberculosis - damage to the lungs by mycobacterium tuberculosis (Koch's wand);
• pneumosclerosis - germination of the lung parenchyma with connective tissue fibers;
• malformations of the lung

and others.

The mentioned pathologies can progress to the moment when the lung tissue is destroyed, and air from it enters the pleural cavity. Provocative impetus are various actions:

• physical exercises;
• fast walk;
• jumping;
• cough;
• straining in childbirth;
• straining when trying to empty the bowels in case of constipation;
• forced breathing.

note

Cases are described when the rupture of altered lungs (in the presence of bullae) with the release of air into the pleural cavity occurred due to forced breathing during intense sex.

As traumatic causes that can provoke the occurrence of a closed pneumothorax, may, in turn, be:

• medical manipulations;
• external injury.

Medical manipulations, as a result of which a closed pneumothorax may occur, are:

• diagnostic;
• medical.

Of the diagnostic to the development of the described disease most often lead:

• biopsy - taking fragments of suspicious tissues with subsequent study in the laboratory under a microscope;
• thoracoscopy - examination of the chest from the inside using a thoracoscope (endoscopic equipment with a built-in optical system and illumination), which was introduced through a small incision in the chest wall;
• pleural puncture;
• insertion of a subclavian catheter

and others.

Therapeutic manipulations that can lead to the development of a closed pneumothorax are any medical assistance on the chest organs, which is accompanied by damage to the pleura. As a rule, this is:

• resuscitation measures - in particular, indirect heart massage, which may be accompanied by a fracture of the ribs and damage to the pleura by their fragments;
• deliberate creation of an artificial closed pneumothorax (it is created for certain diseases - in particular, for cavernous pulmonary tuberculosis)

Injury to the chest and the occurrence of a closed pneumothorax during medical procedures can lead to:

• insufficient experience of the medical worker or lack of any experience in carrying out such procedures;
• inaccurate medical procedures;
• technical difficulties - in particular, those associated with the peculiarities of the anatomical structure of the patient and / or with pre-existing disorders;
• haste in the provision of medical care due to the critical condition of the patient, which requires rapid medical manipulations.

External injuries are injuries caused by an external (non-medical) traumatic factor - cut, stab, torn, chopped, gunshot wounds. They lead to:

• rib fractures;
• rupture of the pleura and lungs without damage to the chest wall;
• penetrating wounds of the chest wall

Factors that contribute to the weakness of the tissues of the pleura and lung, as a result of which their traumatization occurs even with a slight impact of a traumatic agent, have also been studied. Most often it is:

• congenital pathologies;
• endocrine disorders;
• bad habits.

note

Of the congenital pathologies that lead to tissue weakness and, as a result, the occurrence of a closed pneumothorax, dysplasia, the underdevelopment of tissues, plays the greatest role.

How can endocrine disorders contribute to closed pneumothorax? They are pathologies, against the background of which the metabolism in tissues is disturbed, because of which they weaken. As a rule, these are violations of thyroid hormones that regulate metabolic processes in all organs and tissues:

• hypothyroidism - a decrease in their number;
• hyperthyroidism - their enhanced production.

Of the bad habits, smoking contributes most to the occurrence of the described violation. Against its background, the lung tissue weakens and breaks through even with little effort.

Bullous emphysema complicated by pneumothorax

Bullous emphysema often leads to right-sided pneumothorax. In a mild form, the pathology can go away on its own.

https://feedmed.ru/bolezni/organov-dyhaniya/pnevmotoraks-legkih.html

This is possible in those patients who previously had healthy lungs, did not smoke.

Complicated pneumothorax develops more often in smokers. Bullous emphysema is the cause of recurrent pneumothorax.

The bulla gradually builds up pressure, for example, during intense physical activity, or a strong cough, other movements or actions leading to the activation of the lungs. A breakthrough may form, air is forced into the pleural region, and collapse occurs.

Bullous pneumothorax, often affects one lung, but in severe cases, the disease captures both. Pneumothorax on the background of bullous emphysema sometimes leads to pleural bleeding.

The disease in a mild form is asymptomatic, or has minor manifestations that the patient does not pay attention to. Meanwhile, the pathology continues to develop and relapse occurs over time.

Recurrent pneumothorax is much more serious than the primary one. Therefore, if there were already similar symptoms with the further occurrence of complications, even with the most minor manifestations of the pathology, it is necessary to be examined by a specialist.

The mechanism of development of pneumothorax in lung bullosis is caused by an increase in pressure in the affected bullae when some movement is made that causes straining or straining of the lungs. A banal cough at this moment can contribute to the rupture of the thin pleural wall.

At this point, there is pain, shortness of breath, and other symptoms indicating pneumothorax.

The appearance of these signs is a reason to consult a doctor. Therefore, if bullous respiratory disease has already been diagnosed, then one should try to avoid those situations that cause bullae to rupture.

As a preventive measure for emphysema, it is urgent to quit smoking, avoid places where there is a possibility of spraying harmful substances, and avoid viral infections.

Lifespan

Life expectancy is higher if the main treatment is carried out on time. In addition, the duration of life is influenced by the course of the disease. If pneumothorax is the result of injuries, then this does not affect life expectancy.

If serious lung diseases are involved in the process, then life expectancy is reduced. In addition, its quality is declining. And the development of respiratory failure leads to death.

It is necessary to carry out timely diagnosis, to treat the disease in time. Based on the diagnosis and identification of the underlying disease. This allows you to take immediate action and significantly increase life expectancy.

Forecast

With timely recognition and treatment of pneumothorax, the prognosis is favorable. The most severe risks to life occur with tension pneumothorax.

After a patient first had a spontaneous pneumothorax, over the next 3 years, a relapse can be observed in half of the patients. . Such a high percentage of recurrent pneumothorax can be prevented by applying such methods of treatment as:

• video-assisted thoracoscopic surgery, during which the bullae are sutured;
• pleurodesis (artificially induced pleurisy, due to which adhesions form in the pleural cavity, fastening the lung and chest wall
• and many others.

After applying these methods, the likelihood of recurrent pneumothorax is reduced by 10 times.

Kovtonyuk Oksana Vladimirovna, medical commentator, surgeon, medical consultant

• Folk remedies for dry cough

• Valvular pneumothorax: symptoms and emergency care

Symptomatic signs

Symptoms and treatment of pathology are interrelated concepts. Therefore, before the patient is given medical care, it is important to make sure that the patient has pneumothorax.

We list the symptoms that accompany all types of lung pathology:

• Sharp pain syndrome in the chest area;
• Dry cough;
• Dyspnea.

With closed pathology, such manifestations are very similar to signs of pneumonia.

Note!

A characteristic symptom of air damage to the organs of the chest cavity is the forced sitting position of the patient. The patient cannot change the position of the body.

With the traumatic nature of the pathology, the chest is always damaged. The symptomatology is pronounced and manifests itself in such signs:

• Pain in the area of ​​injury;
• Breathing is frequent and labored;
• Tachycardia;
• The skin becomes blue or very pale;
• Panic shortness of breath;
• Dry type cough, appears in attacks;
• Blood flows out of an open wound filled with air bubbles;
• After the spread of air in the tissues, swelling begins;
• After penetrating wounds, “squishing” sounds are heard during the breathing of the victim.

Diagnosis and treatment of pathology should be carried out as soon as possible in order to prevent serious complications.

We will follow the development of pneumothorax and the specifics of each type of emergency care.

open form

Help with open pneumothorax before medical intervention is to transfer it to the closed type. To do this, perform the following steps:

• Sit the patient in such a way that the upper body rises above the lower;
• Disinfect the open wound with an antiseptic;
• Cover the chest wound with a sterile cloth or wipes;
• Lay cellophane over sterile wipes;
• Apply a tight bandage;
• Give the victim an analgesic.

The bandage for open pneumothorax should be of a pressure type in order to maximally block the subsequent penetration of air into the wound.

Note!

For these purposes, a "turtle" type of dressing is used, which will firmly hold the dressings on the wound.

valve shape

With valvular pneumothorax, care should be urgent, as this is the most dangerous form of pathology. The main task of the rescuer is to stop the penetration of air into the pleural compartment and reduce its pressure.

Emergency care for valvular pneumothorax begins with standard actions:

• Giving the patient the correct position of the body;
• Taking analgesics;
• oxygen inhalation.

Such a patient should be immediately hospitalized, since the transfer of the valvular form to the closed form will require surgical intervention. Before hospitalization, arriving doctors will puncture the pleural space to reduce the volume of air that has entered its cavity.

tense form

No less dangerous is the variety of valve shape - tense. First aid for tension pneumothorax requires quick and somewhat specific actions.

To "help" the accumulated air to leave the pleural area, you need to use a thick needle. She is given an injection on the skin along the upper edge of the rib. In order not to be mistaken with the puncture point, the following manipulations are carried out:

1. Find the middle of the clavicle;
2. Step back from it down 3-5 cm;
3. Feel the rib;
4. Under it, make a puncture.

If you did everything correctly, then after the puncture you will hear a characteristic whistling sound that indicates the release of air.

Note!

The development of tension pneumothorax is rapid. If the patient is not helped in time, death may occur in 20-30 minutes.

spontaneous form

Given the unexpectedness of the onset of an attack, it is important not to get confused in the first minutes of the manifestation of the pathology. Emergency care for spontaneous pneumothorax will not be able to stop the accumulation of air, as it enters the pleura from the lungs. Therefore, it is necessary to call professional doctors as soon as possible, who, using hardware techniques, will confirm the diagnosis and begin treatment, most often surgery.

Spontaneous pneumothorax requires the following algorithm of actions before the arrival of medical workers:

• Ensure sufficient supply of oxygen;
• Provide complete peace, eliminating panic attacks;
• Apply analgesics to relieve pain.

After spontaneous pneumothorax, half of the patients develop relapses in the form of repeated attacks. The attending physician should warn the patient about the possible consequences, so that if the pathology reappears, the patient knows what to do.

Pathogenesis

In order to competently provide assistance, you need to know how pneumothorax is formed, its types. The physiology of this process lies in the fact that normally the pressure inside the pleural cavity is negative. This helps to keep the lungs in a straightened state, and also accelerates gas exchange in the alveoli. When the tightness of the chest is broken, and atmospheric air begins to fill the pleural cavity, the lungs decrease in volume.

This prevents normal inhalation, and as a result, the person begins to suffocate. In addition, the air compresses and pushes the mediastinal organs: the heart, aorta, esophagus, interfering with their direct functions.

The reasons

The etiology of pneumothorax is mechanical damage. Moreover, mechanical damage can be associated with closed injuries of the chest, open injuries of the chest. And also with lung damage as a result of diagnostic measures.

Another cause of pneumothorax is disease. What diseases cause pneumothorax? These diseases include:

• bullous disease;
• lung abscess;
• rupture of the esophagus;
• pyopneumothorax.

Pyopneumothorax is the breakthrough of an abscess into the pleural cavity. The most severe process as a result of purulent lesions in systemic diseases. In this case, it is often necessary to reorganize the damaged area of ​​​​the lung.

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Survey

With percussion (percussion - tapping on individual parts of the body with subsequent analysis of the sound phenomena that occur at the same time), the doctor determines the "box" (loud and low, similar to the sound that occurs when tapping on an empty box) character of percussion sound on the side of pneumothorax, and when auscultation of the lungs (auscultation - listening to sounds generated during the functioning of organs) reveals the absence or weakening of breathing on the side of pneumothorax while breathing is preserved on the healthy side.

X-ray of a patient with right-sided total pneumothorax (on the X-ray - on the left). The arrow marks the border of the collapsed lung.

In making a diagnosis, an X-ray examination of the chest is of great importance, in which free gas in the pleural cavity is determined, a compressed lung, the degree of collapse of which depends on the size of the pneumothorax; with tension pneumothorax, the mediastinum shifts to the healthy side. Computed tomography of the chest allows not only to detect the presence of free gas in the pleural cavity (even with a small limited pneumothorax, the diagnosis of which using conventional radiography is often quite difficult), but also to detect a possible cause of spontaneous pneumothorax (bullous disease, post-tuberculosis changes, interstitial lung disease).

Computed tomogram of the chest of a patient with left-sided pneumothorax (on the tomogram - on the right). Free gas in the pleural cavity is marked with an arrow.

What tests should be taken if pneumothorax is suspected.

Laboratory examination for pneumothorax, as a rule, has no independent diagnostic value.

Pneumothorax (pneumothorax: Greek pneuma air + thōrax chest, chest)

accumulation of air in the pleural cavity, depending on the type of communication of the pleural cavity containing water with the external environment, closed, open and valve P. are distinguished. If the flow of air into the pleural cavity has stopped, P. is considered closed. When P. is open, air freely enters it, and when exhaled, it moves in the opposite direction. At valve P. air on a breath gets into a pleural cavity, but has no exit from it. P. can be one- and two-sided, depending on the degree of collapse of the lungs, complete and partial. According to the etiology, spontaneous, traumatic (including operational) and artificial pneumothorax are distinguished.

Spontaneous pneumothorax it develops spontaneously; it is not associated with damage to the parietal or visceral pleura as a result of trauma, educational or diagnostic manipulations; primary and secondary spontaneous P. are conventionally distinguished. Primary (idiopathic) is called P., the cause of which could not be established; more often it is caused by the rupture of small subpleural air bubbles (bulls), which are formed in violation of intrauterine development of the lungs. Secondary spontaneous P. is a complication of various lung diseases. It can be caused by air cysts, bullous emphysema, destructive pulmonary tuberculosis, histiocytosis X, pneumoconiosis, occasionally fibrosing alveolitis, chronic obstructive pulmonary disease (chronic bronchitis, bronchial asthma), abscess, gangrene, cancer, hydatid cyst of the lung. A rupture of the pleura and extrapleural adhesions with a strong cough and forced breathing can also lead to secondary spontaneous P..

Morphological changes in spontaneous P. are characterized by an inflammatory reaction of the pleura that occurs 4-6 hours after air enters the pleural cavity. At the same time, hyperemia of the pleura, injection of its vessels are noted, a small amount of serous exudate is formed. After 2-5 days. fibrin overlays appear on the thickened and edematous pleura, the amount of exudate increases. If spontaneous P. persists for more than 2-3 months. the so-called chronic P. with sclerosed and thickened pleura (rigid P.) is formed. In the event of a breakthrough of purulent cavities and the pleural cavity or infection of the pleural effusion (pyopneumothorax), chronic pleural empyema often develops (see Pleurisy), often complicated by a bronchopleural fistula. Sometimes spontaneous P. is followed by intrapleural bleeding (hemopneumothorax).

Spontaneous P. usually occurs after physical or mental stress, coughing, sudden movement, less often in a state of complete rest or during sleep. Most often it is observed in men with asthenic physique. As a rule, spontaneous P. develops acutely, suddenly there is a dagger or stabbing pain in the chest on the side of the lesion with irradiation to the scapula, shoulder or abdominal cavity, shortness of breath, and sometimes dry cough. The patient takes a semi-sitting or sitting position. With intense pain, acute vascular insufficiency may occur. The severity of shortness of breath and the severity of the patient's condition depend on the type of P. (closed, open, valvular), the degree of lung collapse (partial, complete), the nature of the pathological process in the lungs, and also on the state of the function of the respiratory and cardiovascular systems. The most severe is valvular P., in which the excitation of the patient is noted. difficulty in inhaling rapidly progressing shortness of breath and cyanosis, increasing weakness up to loss of consciousness, swelling of the veins of the neck and upper extremities, a slight increase in the volume of the affected half of the chest and expansion of its intercostal spaces can be observed.

With a slow intake of air into the pleural cavity, a gradual collapse of the lung and a good initial state of the respiratory and cardiovascular systems, the pain in the affected half of the chest is insignificant and quickly stops, moderate shortness of breath and tachycardia (subacutely flowing P.) is sometimes noted. Closed P. with a small volume of a gas bubble can proceed asymptomatically (latently flowing P.).

Palpation with spontaneous P. reveals the absence of voice trembling (Voice trembling), percussion - a box or tympanic sound on the side of P. a decrease in the size of relative and absolute cardiac dullness, and with valvular P. - a shift in cardiac dullness to the healthy side, auscultatory - sharply weakened breathing (up to the complete absence of respiratory noise with valvular P.) in the affected area. Physical changes in the initial stage of latent P. may be absent.

Diagnosis is typically based on history and physical examination findings. The final diagnosis is established after an x-ray examination - the only method for diagnosing a latent flowing P. To identify P. and clarify its nature, radiography (X-ray), tomography (Tomography) is used. X-ray of the chest in a direct projection gives an approximate idea of ​​P.'s presence and its nature; it serves as the basis for choosing additional research methods.

The main radiological sign of P. is an area of ​​enlightenment, devoid of a pulmonary pattern, located along the periphery of the lung field and separated from the collapsed lung by a clear border corresponding to the image of the visceral pleura ( rice. one). An x-ray examination can reveal the relationship of the pleural cavity with the external environment. Open P. on inspiration is characterized by an increase in the gas bubble, further collapse of the lung, displacement of the mediastinal organs in the healthy direction, and the dome of the diaphragm downwards. With P. closed, the x-ray picture depends mainly on the amount of air accumulated in the pleural cavity and the associated intrapleural pressure. If the pressure is below atmospheric, the amount of air in the pleural cavity is small and the lung is slightly collapsed, it increases in volume during inspiration, and decreases during expiration. At a pressure above atmospheric pressure, the lung is sharply collapsed, its respiratory excursions are barely noticeable, the mediastinal organs are displaced to the healthy side, the diaphragm is downward. If the pressure in the pleural cavity is equal to atmospheric, the lung is partially collapsed, respiratory excursions are preserved, the mediastinum is slightly displaced.

With valvular P., the collapsed lung does not change its fresh size and configuration during breathing, the degree of lung collapse is maximum, the mediastinum is sharply shifted to the healthy side, and on exhalation it moves somewhat towards the lesion. Prolonged injection of air into the pleural cavity with valvular P. leads to the formation of a tension pneumothorax. In this case, a sharp shift of the mediastinum to the opposite half of the chest, a low location and flattening of the diaphragm are found, gas is often determined in the soft tissues of the chest wall. With total P., gas occupies the entire pleural cavity, the shadow of the mediastinum is shifted to the healthy side, the dome of the diaphragm is downward ( rice. 2).

P.'s identification, small in volume, is promoted by a research in a lateroposition. With a small amount of gas in the pleural cavity and the position of the patient on a healthy side, the so-called sinus symptom is determined, described by V.A. Vasiliev, M.A. Kunin and E.I. Volodin (1956): on P.'s side, there is a deepening of the costophrenic sinus and flattening of the contours of the lateral surface of the diaphragm. If, in addition to air, blood also enters the pleural cavity, a picture of hemopneumothorax occurs with a horizontal border between the two media ( rice. 3).

The cause of spontaneous P. can be established using tomography (computed tomography is the most informative). The presence on the tomograms of ring-shaped shadows along the periphery of the collapsed lung indicates the presence of air cysts or bullae in it, often complicated by pneumothorax.

Pleural puncture with manometry helps to clarify the type of spontaneous P.. With closed spontaneous P., intrapleural pressure indicators are stable, slightly negative (from -3 to -1 cm of water column) or positive (from +2 to +4 cm of water column). With open spontaneous P., they are close to zero (from -1 to +1 cm of water column), with valvular P., they are positive with a tendency to increase. The liquid aspirated from the pleural cavity is sent to the laboratory for the study of microflora and cellular composition. If it is necessary to determine the location and size of the pleural fistula, thoracoscopy is performed (see Pleura).

Differential diagnosis before X-ray examination is carried out with myocardial infarction, pleurisy, pneumonia, perforated stomach ulcer, myositis, intercostal neuralgia. X-ray sometimes it is difficult to distinguish spontaneous P. from a giant air cyst or tuberculous cavity, less often from a diaphragmatic hernia.

Emergency care for spontaneous P. is required relatively rarely. Acute pain in the chest is relieved by the introduction of painkillers (2-3 ml of 1% solution of promedol or 1 ml of 2% solution of omnopon subcutaneously, 1-2 ml of 50% solution of analgin intramuscularly). With increasing shortness of breath and a drop in blood pressure (for example, with valvular P., pneumothorax, accompanied by intrapleural bleeding), urgent pleural puncture and air aspiration are indicated. The needle is inserted in the second intercostal space along the midclavicular line, fixed to the skin with adhesive tape and left in the pleural cavity during the patient's transportation to the surgical department of the hospital. To reduce hypoxia, oxygen inhalations are prescribed.

In the hospital, after clarifying the type of spontaneous P. (closed, open, valvular), further treatment tactics are chosen. At the closed spontaneous P. with a collapse of a lung of a small degree are limited to symptomatic therapy and X-ray control in 3-4 days. Delayed expansion of the collapsed lung is an indication for pleural puncture with air aspiration. If it is impossible to straighten the lung, the pleural cavity is punctured with a trocar and its contents are continuously aspirated through the drainage using the Lavrynovych suction apparatus, a device for active drainage of single-use wounds or an electric suction ( rice. four) within 1-2 days; sometimes use valve drainage according to Bulau (see Drainage). With valvular or open P., drainage of the pleural cavity with a thin catheter with constant air aspiration is shown.

With small defects of the visceral pleura (up to 1.5 mm in diameter), diathermic or laser coagulation, or gluing with fibrin glue, can successfully seal the pleural cavity. Large defects in the visceral pleura can close after the introduction of drainage with a vacuum of 15-20 cm of water. Art. within 2-5 days. The drainage from the pleural cavity is removed after 1-2 days. after complete expansion of the lung. To prevent spontaneous P.'s recurrence, talc or tetracycline powder is insufflated into the pleural cavity in order to obliterate it (pleurodesis).

If the above measures are not effective, an operation is indicated - thoracotomy with suturing of the lung defect, resection of a segment or lobe of the lung, pleurectomy with decortication of the lung (see Pleura). At the complicated and recurrent P. operations are carried out without preliminary drainage of a pleural cavity. In patients with widespread changes in the lungs and reduced functional respiratory reserves, long-term drainage of the pleural cavity is indicated in combination with endoscopic occlusion of the bronchopleural fistula with a foam rubber sponge or collagen mass.

The prognosis with timely diagnosis, the absence of complications and rational treatment is favorable in most cases. The prognosis is serious with spontaneous P., complicated by pleural empyema. Lethal outcomes are observed in case of untimely diagnosis of bilateral P. or in case of lung damage that does not allow the use of modern methods of treatment.

Traumatic pneumothorax occurs more often due to an open penetrating wound of the chest or blunt chest trauma with rupture of the lung. It can also be caused by complications of various medical manipulations (pleural puncture, broncho- and esophagoscopy with biopsy of pathologically altered tissue or removal of a foreign body, catheterization of the subclavian vein, etc.), operations accompanied by opening the chest (surgical P.).

In traumatic P., the lung collapses (as in spontaneous P.): due to tissue damage in the pleural cavity, along with a small amount of serous exudate, blood appears, and if the thoracic duct is damaged, lymph appears. If P. does not resolve for a long time, fibrin is deposited on the surface of the pleura, the serous-hemorrhagic fluid turns into purulent.

Clinical manifestations of traumatic P. are the same as in spontaneous P. Open traumatic P. is accompanied by serious disorders of the cardiovascular and respiratory systems, which is caused not only by lung collapse, but also by mediastinal flotation during inhalation and exhalation. The patient's condition is extremely serious, shortness of breath and cyanosis are expressed, the pulse is quickened. Blood pressure is reduced, the number of breaths is more than 40 in 1 min. From the wound of the chest on exhalation and coughing out blood with air bubbles.

The closed traumatic P. arises at the small sizes of the wound channel in a thorax and easy and fast obturation by its blood clots. The severity of symptoms of respiratory failure varies depending on the degree of lung collapse. Valve traumatic P. is formed with a small defect of the chest wall half-covered by soft tissues or with a closed chest injury with lung damage. Increasing intrapleural pressure leads to displacement of the mediastinal organs and partial compression of a healthy lung. The clinical picture is characterized by sharply increasing suffocation, cyanosis, tachycardia. Sometimes at valve and open traumatic P. shock develops. Hemodynamic disorders in this case are aggravated by the displacement of the heart and large vessels of the mediastinum. With traumatic P., air can enter the subcutaneous tissue of the chest, neck, face, and abdomen.

X-ray signs of traumatic P. are the same as in spontaneous: complete or partial collapse of the lung, the presence of air and fluid (blood, lymph) in the pleural cavity, with a significant accumulation of air - a sharp shift of the mediastinal shadow to the healthy side, layers of air in the mediastinum and under skin of the chest wall and neck. The preservation of the visceral pleura and lung tissue is indicated by a change in the position and size of the collapsed lung during inhalation and exhalation. However, it is possible to finally judge the state of the lung tissue only after the lung is completely expanded. If an injury to the trachea, large bronchi or esophagus is suspected, tracheobronchoscopy and contrast x-ray examination of the esophagus are indicated.

Victims with suspicion of traumatic P. are urgently hospitalized in the surgical department of a hospital. To eliminate the clinical symptoms of P. at the prehospital stage, morphine and other analgesics, drugs that stimulate the respiratory and vasomotor centers (caffeine, cordiamine, sulfo-camphocaine) are administered. With open traumatic P. with a gaping wound of the chest wall and valvular traumatic P., open outward (there is a defect in the chest wall), an airtight bandage is urgently applied using a sticky patch or oilcloth. If the valvular traumatic P. is open inside (there is no chest wall defect), an urgent pleural puncture is necessary with a thick needle in the second intercostal space along the midclavicular line. The needle or a thin catheter passed through it is left in the pleural cavity during the entire period of transportation of the patient to the hospital.

In a hospital with closed P. with a small amount of air in the pleural cavity, they are limited to dynamic observation, with a collapse of the lung, a pleural puncture is performed to aspirate air. With open traumatic P. and valvular traumatic P., open outward, surgical treatment of the wound and sealing of the chest is carried out by layer-by-layer suturing and plasty with surrounding tissues. The straightening of the lung with open and valvular traumatic P. (including open inside valve P.) is achieved by draining the pleural cavity. In the case of hemopneumothorax, one catheter is inserted into the upper part of the chest to ensure the removal of air, the other into the lower one to aspirate blood. With intrapleural bleeding, damage to the trachea, large bronchus, esophagus, and extensive lung defect, urgent thoracotomy is indicated. To prevent pleural empyema in traumatic P., broad-spectrum antibiotics are prescribed.

At operational P. in the postoperative period drainage of a pleural cavity is carried out for the purpose of a full straightening of the collapsed lung.

Artificial pneumothorax- the introduction of air into the pleural cavity for therapeutic or diagnostic purposes. The previously widespread introduction of air into the pleural cavity to collapse the affected lung in destructive forms of pulmonary tuberculosis (collapse therapy) in the present. time is rarely used. Air is introduced into the pleural cavity when performing thoracoscopy, in some cases - before an X-ray examination of the chest organs for differential diagnosis of pulmonary and extrapulmonary pathological processes.

Features of pneumothorax in children. In newborns (up to 1-2% of cases), spontaneous P. may develop during the first acts of breathing, when intrabronchial pressure increases due to uneven expansion of the lung tissue. In children of the first three years of life, it often complicates staphylococcal pneumonia. At an older age, spontaneous P. is more often associated with an increase in intrabronchial pressure in whooping cough, bronchial asthma, and aspiration of a foreign body. Spontaneous P.'s cause in childhood can also be a rupture of congenital air cysts. Traumatic P. in children occurs in the same cases as in adults, as well as as a result of damage to the trachea during intubation or inadequate ventilation of the lungs under anesthesia.

Clinical manifestations of P. in children are the same as in adults. They are the harder, the smaller the child's age. In newborns with a slight collapse of the lung, clinical symptoms of P. may be absent, sometimes there is a short-term cessation of breathing, with extensive collapse of the lung, tachycardia, cyanosis and convulsions are observed. An objective study of P. in a newborn can be suspected by a significant shift in the apex heart beat in the healthy direction. A high-quality chest x-ray confirms the diagnosis only with extensive lung collapse. An accurate diagnosis is established using transillumination of the chest with a high-intensity light flux.

The principles of P.'s treatment in children are the same as in adults. At spontaneous P. at newborns carry out a symptomatic therapy; if P.'s clinical symptoms progress, permanent drainage of the pleural cavity with air aspiration is indicated. Indications for surgical treatment of P. in children occur mainly with trauma to the bronchi, esophagus and malformations of the lungs.

Bibliography: Diseases of the respiratory organs, ed. N.R. Paleev. v. 2, p. 399, M., 1989; Vishnevsky A.A. and Shraiber M.I. Military field surgery. M., 1975; Light R.W. Diseases of the pleura, trans. from English, p. 278, M., 1986; Lindenbraten L.D. and Naumov L.B. X-ray syndromes and diagnosis of lung diseases. M., 1972; Rozenshtraukh L.S., Rybakova N.I. and Vinner M.G. X-ray diagnostics of respiratory diseases. M., 1987.

Rice. 1. X-ray of the chest with right-sided pneumothorax: the right lung is collapsed (indicated by an arrow), the rest of the right half of the chest is occupied by an enlightenment devoid of a pulmonary pattern.

Rice. 2. X-ray of the chest with a total (complete) left-sided pneumothorax: the transparency of the left half of the chest is increased, there is no pulmonary pattern, the shadow of a completely collapsed lung is adjacent to the mediastinum (indicated by an arrow).

Rice. 3. X-ray of the chest with right-sided hemopneumothorax in a patient with lung cancer: the right lung is collapsed (indicated by an arrow), the remaining part of the right half of the chest cavity is occupied by an area of ​​enlightenment without a pulmonary pattern (accumulation of air) and shading with a horizontal upper border (blood).

Pneumothorax (pneumothorax; Pneumo- + Greek thōrax chest, chest)

the presence of air or gas in the pleural cavity; arises as a result of an injury, a pathological process, or is created artificially for therapeutic purposes.

Internal pneumothorax (r. internus) - P., in which the pleural cavity communicates with the atmosphere through defects in the lung tissue, trachea or bronchi.

Pneumothorax closed (r. clausus) - P., in which there is no communication between the pleural cavity and the atmosphere.

Artificial pneumothorax (p. artificialis) - P., created by the introduction of air into the pleural cavity for therapeutic or diagnostic purposes.

Valve pneumothorax (p. valvularis) - P., in which air enters the pleural cavity during inhalation, and cannot leave it during exhalation due to blocking of the opening in the pleura.

Tension pneumothorax (r. tensus) - a pronounced degree of valvular P., in which the air pressure in the pleural cavity significantly exceeds atmospheric pressure; accompanied by extremely difficult inspiration, a sharp displacement of the trachea and heart towards the intact half of the chest cavity.

External pneumothorax (r. externus) - P., in which the pleural cavity communicates with the atmosphere through a defect in the chest wall.

Operational pneumothorax - see Surgical pneumothorax.

Pneumothorax open (p. apertus) - P., in which air enters the pleural cavity during inspiration and exits back during expiration.

Cloak-like pneumothorax (r. pallioideus) - closed P., in which air or gas is distributed over the entire outer surface of the lung.

Spontaneous pneumothorax (p. spontaneus) is an internal P. that suddenly develops during any pathological process in the lungs.

Traumatic pneumothorax (r. traumaticus) - P., caused by a violation of the integrity of the pleura, for example, with a penetrating wound of the chest, with a fracture of the rib with damage to the lung.

Surgical pneumothorax (p. chirurgicus; syn. P. operating) - P. that occurs when the pleural cavity is opened during a surgical operation.

General information

(Greek pnéuma - air, thorax - chest) - an accumulation of gas in the pleural cavity, leading to a collapse of the lung tissue, a shift of the mediastinum to the healthy side, compression of the blood vessels of the mediastinum, descent of the dome of the diaphragm, which ultimately causes a disorder in the respiratory function and circulation. With pneumothorax, air can penetrate between the sheets of the visceral and parietal pleura through any defect on the surface of the lung or in the chest. The air penetrating into the pleural cavity causes an increase in intrapleural pressure (normally it is lower than atmospheric pressure) and leads to the collapse of part or the whole lung (partial or complete collapse of the lung).

Causes of pneumothorax

The mechanism of development of pneumothorax is based on two groups of causes:

Clinic of pneumothorax

The severity of symptoms of pneumothorax depends on the cause of the disease and the degree of compression of the lung.

A patient with an open pneumothorax takes a forced position, lying on the injured side and tightly clamping the wound. Air is sucked into the wound with noise, foamy blood with an admixture of air is released from the wound, chest excursion is asymmetric (the affected side lags behind when breathing).

The development of spontaneous pneumothorax is usually acute: after a bout of coughing, physical effort, or for no apparent reason. With a typical onset of pneumothorax, a piercing stabbing pain appears on the side of the affected lung, radiating to the arm, neck, and behind the sternum. The pain is aggravated by coughing, breathing, the slightest movement. Often the pain causes a panic fear of death in the patient. The pain syndrome in pneumothorax is accompanied by shortness of breath, the severity of which depends on the volume of lung collapse (from rapid breathing to severe respiratory failure). There is pallor or cyanosis of the face, sometimes a dry cough.

After a few hours, the intensity of pain and shortness of breath weaken: the pain bothers at the time of a deep breath, shortness of breath manifests itself with physical effort. Perhaps the development of subcutaneous or mediastinal emphysema - the release of air into the subcutaneous tissue of the face, neck, chest or mediastinum, accompanied by swelling and a characteristic crunch on palpation. Auscultatory on the side of pneumothorax, breathing is weakened or not heard.

In about a quarter of cases, spontaneous pneumothorax has an atypical onset and develops gradually. Pain and shortness of breath are minor, as the patient adapts to new breathing conditions, they become almost invisible. The atypical form of the flow is characteristic of a limited pneumothorax, with a small amount of air in the pleural cavity.

Clearly clinical signs of pneumothorax are determined when the lung collapses by more than 30-40%. 4-6 hours after the development of spontaneous pneumothorax, an inflammatory reaction from the pleura joins. After a few days, the pleural sheets thicken due to fibrin overlays and edema, which subsequently leads to the formation of pleural adhesions that make it difficult to straighten the lung tissue.

Complications of pneumothorax

Complicated pneumothorax occurs in 50% of patients. The most common complications of pneumothorax are:

• hemopneumothorax (when blood enters the pleural cavity)
• pleural empyema (pyopneumothorax)
• rigid lung (not expanding as a result of the formation of moorings - connective tissue strands)
• acute respiratory failure

With spontaneous and especially valvular pneumothorax, subcutaneous and mediastinal emphysema can be observed. Spontaneous pneumothorax occurs with relapses in almost half of patients.

Diagnosis of pneumothorax

Already during the examination of the patient, characteristic signs of pneumothorax are revealed:

• the patient takes a forced sitting or semi-sitting position;
• skin covered with cold sweat, shortness of breath, cyanosis;
• expansion of the intercostal spaces and chest, restriction of chest excursion on the affected side;
• lowering blood pressure, tachycardia, displacement of the borders of the heart in a healthy direction.

Specific laboratory changes in pneumothorax are not determined. The final confirmation of the diagnosis occurs after an X-ray examination. When radiography of the lungs on the side of pneumothorax is determined by the zone of enlightenment, devoid of pulmonary pattern on the periphery and separated by a clear boundary from the collapsed lung; displacement of the mediastinal organs to the healthy side, and the dome of the diaphragm downwards. With the behavior of a diagnostic pleural puncture, air is obtained, the pressure in the pleural cavity fluctuates within zero.

Treatment of pneumothorax

First aid

Pneumothorax is a medical emergency requiring immediate medical attention. Any person should be ready to provide emergency assistance to a patient with pneumothorax: calm, ensure sufficient oxygen supply, call a doctor immediately.

With an open pneumothorax, first aid consists in applying an occlusive dressing that tightly closes the defect in the chest wall. An airtight bandage can be made of cellophane or polyethylene, as well as a thick cotton-gauze layer. In the presence of valvular pneumothorax, an urgent pleural puncture is necessary to remove free gas, straighten the lung and eliminate the displacement of the mediastinal organs.

Qualified help

Patients with pneumothorax are hospitalized in a surgical hospital (if possible, in specialized pulmonology departments). Medical care for pneumothorax consists in puncturing the pleural cavity, evacuating air and restoring negative pressure in the pleural cavity.

With a closed pneumothorax, air is aspirated through a puncture system (a long needle with an attached tube) in a small operating room with asepsis. Pleural puncture for pneumothorax is performed on the side of the injury in the second intercostal space along the midclavicular line, along the upper edge of the underlying rib. In case of total pneumothorax, in order to avoid rapid expansion of the lung and a shock reaction of the patient, as well as in case of defects in the lung tissue, drainage is installed in the pleural cavity, followed by passive aspiration of air according to Bulau, or active aspiration using an electrovacuum apparatus.

Treatment of an open pneumothorax begins with its transfer to a closed one by suturing the defect and stopping the flow of air into the pleural cavity. In the future, the same measures are taken as with closed pneumothorax. Valvular pneumothorax in order to lower intrapleural pressure is first turned into an open one by puncture with a thick needle, then it is surgically treated.

An important component of the treatment of pneumothorax is adequate pain relief both during the period of lung collapse and during its expansion. In order to prevent recurrence of pneumothorax, pleurodesis is performed with talc, silver nitrate, glucose solution or other sclerosing drugs, artificially causing adhesions in the pleural cavity. With recurrent spontaneous pneumothorax caused by bullous emphysema, surgical treatment (removal of air cysts) is indicated.

Forecast and prevention of pneumothorax

In uncomplicated forms of spontaneous pneumothorax, the outcome is favorable, however, frequent relapses of the disease are possible in the presence of lung pathology.

There are no specific methods for the prevention of pneumothorax. It is recommended to carry out timely treatment and diagnostic measures for lung diseases. Patients who have had a pneumothorax are advised to avoid physical exertion, be examined for COPD and tuberculosis. Prevention of recurrent pneumothorax consists in the surgical removal of the source of the disease.

Other spontaneous pneumothorax (J93.1)

Thoracic Surgery, Surgery

general information

Short description

Definition:

Spontaneous pneumothorax (SP) is a syndrome characterized by accumulation of air in the pleural cavity, not associated with lung injury and medical manipulations.

ICD 10 code: J93.1

Prevention:
Induction of pleurodesis, that is, the formation of adhesions in the pleural cavity, reduces the risk of recurrence of pneumothorax [BUT].
Smoking cessation reduces both the risk of pneumothorax and its recurrence. [ C].

Screening:
Screening is not applicable for primary pneumothorax.
For the secondary, it is aimed at identifying diseases that provoke the development of spontaneous pneumothorax.

Classification

Classifications

Table 1. Classification of spontaneous pneumothorax

Diagnostics

Diagnostics:

Diagnosis of SP is based on the clinical manifestations of the disease, the data of an objective and x-ray examination.

In the clinical picture, the main place is occupied by: chest pain on the side of pneumothorax, often radiating to the shoulder, shortness of breath, dry cough.

Rare complaints - usually appear in complicated forms of joint venture. A change in the timbre of the voice, difficulty in swallowing, an increase in the size of the neck, chest occur with pneumomediastinum and subcutaneous emphysema. With hemopneumothorax, manifestations of acute blood loss come to the fore: weakness, dizziness, orthostatic collapse. Palpitations, a feeling of interruptions in the work of the heart (arrhythmia) are characteristic of tension pneumothorax. Late complications of pneumothorax (pleurisy, empyema) lead to the appearance of symptoms of intoxication and fever in the patient.

In secondary SP, even if it is small in volume, there is a more pronounced clinical symptomatology, in contrast to primary SP. [D].

An objective examination determines the delay in breathing of half of the chest, sometimes the expansion of the intercostal spaces, tympanic tone during percussion, weakening of breathing and weakening of voice trembling on the side of pneumothorax.

With tension pneumothorax, clinical manifestations are more pronounced [D].

It is mandatory to perform radiographs in direct and lateral projection on inspiration, which are sufficient to make a diagnosis of pneumothorax. [BUT]. In doubtful cases, it is necessary to perform an additional x-ray on exhalation in a direct projection.

The main radiological symptoms of SP are:

• the absence of a pulmonary pattern in the peripheral parts of the corresponding hemithorax;
• visualization of the outlined edge of the collapsed lung;

• shadow of a collapsed lung;
• a symptom of deep furrows (in lying patients);
• mediastinal displacement;
• change in diaphragm position.

When evaluating radiographs, one must be aware of the possibility of limited pneumothorax, which, as a rule, has an apical, paramediastinal, or supraphrenic localization. In these cases, it is necessary to perform inspiratory and expiratory radiographs, the comparison of which provides complete information about the presence of a limited pneumothorax.
An important task of X-ray examination is to assess the state of the lung parenchyma, both the affected and the opposite lung.

When evaluating radiographs, pneumothorax should be differentiated from giant bullae, destructive processes in the lungs, dislocation of hollow organs from the abdominal cavity to the pleural cavity.

Before draining the pleural cavity, it is necessary to perform x-ray in 2 projections or polypositional fluoroscopy to determine the optimal drainage point [D].

Spiral computed tomography (SCT) of the chest plays a major role in determining the causes of pneumothorax and differential diagnosis of SP with other pathologies. SCT should be performed after drainage of the pleural cavity and the maximum possible expansion of the lung. SCT assesses the following signs: the presence or absence of changes in the lung parenchyma, such as infiltration, disseminated process, interstitial changes; unilateral or bilateral bullous changes; diffuse emphysema.
Indicators of laboratory tests in cases of uncomplicated spontaneous pneumothorax, as a rule, are not changed.

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Treatment

Treatment:
All patients with pneumothorax should be urgently hospitalized in thoracic surgical hospitals, and if not possible, in emergency surgical hospitals.

Treatment goals for spontaneous pneumothorax:

• expansion of the lung;
• stopping the flow of air into the pleural cavity;
• prevention of recurrence of the disease;

• conservative - dynamic observation;
• pleural puncture;
• drainage of the pleural cavity;
• chemical pleurodesis through pleural drainage;
• surgical intervention.

Information

Sources and literature

1. Clinical recommendations of the Russian Society of Surgeons
   1. 1. Bisenkov L.N. Thoracic surgery. Guide for doctors. - St. Petersburg: ELBI-SPb, 2004. - 927 p. 2. Varlamov V.V., Levashov Yu.N., Smirnov V.M., Egorov V.I. A new method of non-surgical pleurodesis in patients with spontaneous pneumothorax // Vestn.hir. - 1990. - No. 5. - C.151-153. 3. Porkhanov V.A., Mova B.C. Thoracoscopy in the treatment of bullous emphysema complicated by pneumothorax. vascular surgery. - 1996. - No. 5. - C. 47-49. 4. Pichurov A.A., Orzheshkovsky O.V., Petrunkin A.M. et al. Spontaneous pneumothorax - analysis of 1489 cases // Vetn. Surgery them. I.I. Grekova. - 2013. - Volume 172. - S. 82-88. 5. Perelman M.I. Actual problems of thoracic surgery // Annals of Surgery.-1997.-№3.-S.9-16. 6. E. I. Sigal, K. G. Zhestkov, M. V. Burmistrov, and O. V. Pikin, Russ. Thoracoscopic surgery. "House of Books", Moscow, 2012.- 351 p. 7. Filatova A.S., Grinberg L.M. Spontaneous pneumothorax - etiopathogenesis, pathomorphology (literature review) // Ural. honey. magazine - 2008. - No. 13. - S. 82-88. 8. Chuchalin A.G. Pulmonology. National leadership. Short edition. GEOTAR-Media. 2013. 800s. 9. Yablonsky P.K., Atyukov M.A., Pishchik V.G., Bulyanitsa A.L. The choice of treatment tactics and the possibility of predicting relapses in patients with the first episode of spontaneous pneumothorax // Medicine XXI century - 2005. - No. 1. - P.38-45. 10. Almind M., Lange P., Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis // Thorax.- 1989.- Vol. 44.- No. 8.- P. 627 - 630. 11. Baumann M.H., Strange C., Heffner J.E., et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement // Chest. - 2001. - Vol. 119. - No. 2. - P. 590–602. 12. Boutin C., Viallat J., Aelony Y. Practical thoracoscopy / New York, Berlin, Heidelberg: Springer-Verlag.- 1991.- 107 p. 13. British Thoracic Society Pleural Disease Guideline, 2010 //Thorax.- 2010.- vol. 65, Aug. suppl. 2.-18-31. 14. Kelly A.M., Weldon D., Tsang A.Y.L., et al. Comparison between two methods for estimating pneumothorax size from chest x-rays // Respir. Med. - 2006. - Vol. 100. - P. 1356-9. 15. Kocaturk C., Gunluoglu M., Dicer I., Bedirahan M. Pleurodesis versus pleurectomy in case of primary spontaneous pneumothorax // Turkish J. of Thoracic and Cardiovasc. Surg.- 2011.- vol. 20, N 3.- P. 558-562. 16. Ikeda M. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax, with special referens to the operative indication considered from its contralateral occurence rate // Nippon Kyobi Geka. Gakhai Zasshi.- 1985.- V.14.- No. 3.- P.277-282. 17. MacDuff A., Arnold A., Harvey J. et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 // Thorax. - 2010. - Vol. 65.-Suppl. 2. – P. ii18-ii31. 18. Miller W.C., Toon R., Palat H., et al. Experimental pulmonary edema following reexpansion of pneumothorax // Am. Rev. Respir. Dis. - 1973. - Vol. 108. – P. 664-6. 19. Noppen M., Alexander P., Driesen P. et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study // Am. J. Respir. Crit. care. Med. - 2002. - Vol. 165. - No. 9. - P. 1240-1244. 20. Noppen M., Schramel F. Pneumothorax // European Respiratory Monograph. - 2002. - Vol. 07. - No. 22. - P. 279-296. 21. Pearson F.G. Thoracic Surgery. - Philadelphia, Pennsylvania: Churchill Livigstone, 2002. - 1900c. 22. Rivas J.J., López M. F. J., López-Rodó L. M. et al. Guidelines for the diagnosis and treatment of spontaneous pneumothorax / Spanish Society of Pulmonology and Thoracic Surgery // Arch. bronconeumol. - 2008. - Vol. 44. - No. 8. - P. 437-448. 23. Sahn S.A., Heffner J.E. Spontaneous pneumothorax // N. Engl. J. Med. - 2000. - Vol. 342. - No. 12. - P. 868-874. 24. Shields T.W. General Thoracic Surgery. -New York: [email protected], 2000. - 2435c. 25. Up Huh, Yeong-Dae Kim, Yeong Su Cho et al. The effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion // Korean J. of Thoracic and Cardiovasc. Surg.- 2012.- vol. 45, No. 5.- P. 316-319.

Information

Working group on the preparation of the text of clinical guidelines:

Prof. K.G. Zhestkov, Associate Professor B.G. Barsky (Department of Thoracic Surgery of the Russian Medical Academy of Postgraduate Education, Moscow), Ph.D. M.A.Atyukov (Center for Intensive Pulmonology and Thoracic Surgery, St. Petersburg State Healthcare Institution "GMPB No. 2", St. Petersburg).

Composition of the committee of experts: Prof. A.L. Akopov (St. Petersburg), prof. E.A. Korymasov (Samara), prof. V.D. Parshin (Moscow), corresponding member. RAMN, prof. V.A.Porkhanov (Krasnodar), prof. E.I.Sigal (Kazan), prof. A.Yu.Razumovsky (Moscow), prof. P.K.Yablonsky (St. Petersburg), prof. Stephen Cassivi (Rochester, USA), Academician of the Russian Academy of Medical Sciences, prof. Gilbert Massard (Strasbourg, France), prof. Enrico Ruffini (Torino, Italy), prof. Gonzalo Varela (Salamanca, Spain)

Attached files

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Patients who have lung injuries may be diagnosed with an open pneumothorax. The lungs are surrounded on all sides by a membrane called the pleura. This shell consists of two layers: the first layer is pulmonary, it surrounds the lung directly, the second layer is parietal, which is located after the first layer and is adjacent to the walls of the chest. The layers are connected by a liquid that is between them and the negative pressure created in the cavity.

With possible injuries, lung injuries or after an illness, air can enter the pleural cavity. If air enters, the pressure in the pleural cavity increases, the layers separate, the injured lung collapses and ceases to function normally. In medicine, this pathological condition caused by the accumulation of air in the pleural cavity is called pneumothorax.

Classification of pneumothorax

The following types of pneumothorax can be distinguished:

• traumatic;
• spontaneous;
• artificial;
• catamenial.

• bilateral;
• one-sided, which is divided into right-handed and left-handed.

• total;
• limited.

• open;
• closed;
• valvular or tension pneumothorax.

The traumatic appearance appears due to a penetrating injury (for example, a gunshot wound) or a closed one (lung contusion). The spontaneous type of the disease is characterized by an unexpected occurrence due to a violation of the integrity of the chest and lung tissues or in various respiratory diseases and congenital anomalies. This type is provoked by a strong cough, laughter or physical exertion. Artificial pneumothorax is created specifically for therapeutic measures, for example, with tuberculosis. This can be a biopsy, when a small piece of the lung is taken for examination or during a puncture, while a hole is made in the pleural cavity to collect pathological contents.

The rarest type of pneumothorax, the pathogenesis of which is still unclear, is the catamenial or menstrual type. It occurs in women of childbearing age, characterized by constantly recurring attacks of the disease. They coincide with menstruation, but can also occur before or after it. Closed pneumothorax is the mildest form of the disease. It occurs due to a closed injury, in which the integrity of the chest is not violated and the empty pleura does not have contact with the external environment. With this type of disease, a certain amount of air enters the pleural cavity, it does not change when breathing, so most often the closed form of the disease goes away on its own.

An open pneumothorax appears due to a penetrating injury to the chest, for example, after a gunshot or knife wound. The pleural cavity is in contact with the external environment through a hole that can be viewed visually. Air enters the pleural cavity during inhalation and exits during exhalation. The incoming air increases the pressure in the pleural cavity, so the lung from the damaged side subsides and ceases to participate in the act of breathing. The open bilateral form of the disease is fatal.

A stressful type of illness is the worst option. In this form, air passes into the pleural cavity during inhalation, but does not exit into the environment during exhalation. Therefore, during the act of breathing in the pleural cavity, the volume of air constantly increases. The lung on the damaged side is compressed and begins to put pressure on the adjacent, healthy one, which leads to squeezing of blood vessels and functional impairment of the lungs.

Total pneumothorax is characterized by complete compression of the lung. The bilateral type is determined by the involvement of two lungs in the pathological process at once. With unilateral pneumothorax, only one lung is involved in the process. This type is divided into right-sided, which affects the right lung, and left-sided. Limited pneumothorax is accompanied by incomplete compression of the lung.

Disease symptoms and diagnosis

The symptomatology of the disease depends on its type. It can occur with various injuries and injuries, with traumatic pneumothorax or suddenly with spontaneous. A person complains of sharp pains in the chest, aggravated by inhalation. The heartbeat quickens, there is a feeling of fear due to lack of air, so the person tries to breathe more often and deeper. The wider the pneumothorax, the more the respiratory apparatus is affected. Significant shortness of breath appears, vascular compression occurs, oxygen stops flowing into the blood, the skin becomes pale or cyanotic. To alleviate the condition, a person takes a forced position. With unilateral pneumothorax, you can visually see an increase in the damaged half, its lag in the act of breathing. With an open pneumothorax, there is a wound through which blood is released during exhalation.

The diagnosis is based on a general examination, which consists of a visual examination of the chest and listening with a stethoscope. An x-ray is also performed, on which you can see areas of enlightenment and displacement of organs. During the puncture, air is found. From laboratory indicators, a study of the gas composition of arterial blood is used. During the study, hypoxemia is observed, that is, a decrease in oxygen in the blood.

pneumothorax treatment

All patients with this disease are hospitalized, adequate treatment is carried out and the cause of the disease is eliminated.

The doctor must remove air and restore negative pressure in the pleural cavity. When closed, self-absorption of air in the pleural cavity is possible. If the air does not go, then it is necessary to carry out an emergency puncture. An operation is performed to eliminate the cause.

With the valve type, it is necessary to reduce intrapleural pressure by puncture, and also to drain using a special tube through which air will flow from the pleural cavity. With open pneumothorax, the patient is provided with rest. A bandage is applied to the wound, which isolates the pleural cavity, and negative pressure is created with the help of a puncture. The bandage should be tight and not let air through. In the case of first aid, this can be a regular plastic bag. To reduce pain, painkillers and analgesics are prescribed. In a surgical hospital, the wound is sutured so that air no longer enters the pleural cavity. Catamenial pneumothorax is treated with hormonal drugs.

A patient who has a suspected pneumothorax requiring emergency hospitalization, with medical care and adequate treatment, has a favorable prognosis. Valvular pneumothorax is considered very life-threatening and can be fatal if not treated promptly.

Pneumothorax is a pathological condition in which air enters the pleural cavity, as a result of which the lung partially or completely collapses. As a result of the decline, the organ cannot perform the functions assigned to it, therefore gas exchange and oxygen supply to the body suffer.

Pneumothorax occurs when the integrity of the lungs or chest wall is compromised. In such cases, often, in addition to air, blood enters the pleural cavity - it develops hemopneumothorax. If the thoracic lymphatic duct is damaged during a chest injury, there is chylopneumothorax.

In some cases, with a disease that provoked pneumothorax, exudate accumulates in the pleural cavity - it develops exudative pneumothorax. If the process of suppuration starts further, it comes pyopneumothorax.

Causes and mechanisms of development

The lung has no muscle tissue, so it cannot expand itself to provide breathing. The mechanism of inspiration is as follows. In the normal state, the pressure inside the pleural cavity is negative - less than atmospheric pressure. When the chest wall moves, the chest wall expands, due to the negative pressure in the pleural cavity, the lung tissues are “caught” by the traction inside the chest, the lung straightens . Further, the chest wall moves in the opposite direction, the lung returns to its original position under the action of negative pressure in the pleural cavity. This is how a person performs the act of breathing.

If air enters the pleural cavity, then the pressure inside it increases, the mechanics of lung expansion is disturbed - a full-fledged act of breathing is impossible.

Air can enter the pleural cavity in two ways:

• with damage to the chest wall with a violation of the integrity of the pleural sheets;
• with damage to the organs of the mediastinum and lungs.

The three main components of pneumothorax that create problems are:

• the lung cannot expand;
• air is constantly sucked into the pleural cavity;
• the affected lung swells.

The impossibility of expanding the lung is associated with the re-entry of air into the pleural cavity, blockage of the bronchus against the background of previously noted diseases, and also if the pleural drainage was installed incorrectly, which makes it work inefficiently.

note

Air suction into the pleural cavity can pass not only through the formed defect, but also through the hole in the chest wall, made for the installation of drainage.

Pulmonary edema may occur as a result of stretching of the lung tissue after medical actions aimed at quickly resuming negative pressure in the pleural cavity.

Varieties, their features

Pneumothorax happens:

In itself, the presence of air in the pleural cavity would not cause consequences if it were not for the increase in pressure that disrupts the functioning of the lung. Therefore, the severity of pneumothorax is assessed by the collapse (decline) of the lung - it happens:

• small- less than a quarter of the lung tissue fell asleep;
• average- slept from 50% to 75% of this body;
• full- all lung collapses;
• tense- the amount of air in the pleural cavity increases to such an extent that it causes not only the collapse of the lung, but also the displacement of the mediastinum (the complex of organs between the lungs) and the deterioration of venous blood flow to the heart. In turn, the deterioration of venous inflow entails a general decrease in blood pressure. The cardiovascular and respiratory systems may stop working within minutes of the onset of a tension pneumothorax.

Most pneumothorax is unilateral. A bilateral process rarely develops - most often with extensive traumatic damage to the chest.

Pneumothorax can occur:

• spontaneously;
• after diseases;
• after injury;
• during menstruation (rare form);
• as a result of the actions of doctors (the so-called iatrogenic pneumothorax).

Primary spontaneous pneumothorax

It occurs in patients who do not currently have lung pathology, and they did not tolerate it before. In most cases, such pneumothorax occurred in tall thin individuals aged 18 to 20 years. In this case, pneumothorax is explained by the rupture of those parts of the lungs that are close to the pleura, and in which bullae appeared - cavities formed as a result of rupture of the walls of the alveoli and the fusion of their cavities. The cause of this type of pneumothorax is considered:

• special hereditary structure of lung tissue;
• smoking.

Primary spontaneous pneumothorax develops most often at rest, less often during exercise. For its occurrence, a minimum force applied to the tissues of the lungs is sufficient. It is not uncommon for such patients to turn to doctors about pneumothorax that occurred during jumping into the water, or as a result of the fact that a person reached for some object. Cases are described when spontaneous pneumothorax developed when the lung tissue was damaged as a result of the fact that a person was stretching after sleep or prolonged work performed in one static position. Also, spontaneous pneumothorax can occur during a flight at high altitude - there is a difference in air pressure inside the lung, its weak points receive an excessive load and are literally torn.

Secondary spontaneous pneumothorax

It develops in people suffering from lung diseases or who have had them in the past. It mainly occurs due to the rupture of the bullae formed as a result of diseases or pathological conditions - first of all, these are:

Most often, in the pathology of the connective tissue, secondary spontaneous pneumothorax is observed in diseases such as:

• Ehlers-Danlos syndrome (with it, the formation of collagen is disrupted, which ensures the elasticity of tissues and their shock-absorbing capabilities, which do not allow tissues to lose integrity when loaded on them);
• ankylosing spondylitis (inflammation of the joints of the spine);
• polymyositis (inflammation of muscle tissue);
• Marfan syndrome (congenital connective tissue disease);
• sarcoma (malignant tumor of the connective tissue)
• rheumatoid arthritis (connective tissue damage mainly in small joints);
• tuberculous sclerosis (proliferation of connective tissue due to tuberculosis);
• systemic sclerosis (proliferation of connective tissue, which is simultaneously observed in many organs).

Secondary spontaneous pneumothorax can also develop with some other diseases:

• sarcoidosis (systemic disease with the formation of many granulomas);
• lymphangioleiomyomatosis (formation of cysts in the lungs with their subsequent destruction).

It is important to understand

Not all of these diseases (in particular, extrapulmonary) become the direct cause of pneumothorax. The relationship between them is different: these diseases occur as a result of pathological changes in the body, leading to pneumothorax, therefore, they develop at a time when pneumothorax can also occur.

Secondary spontaneous pneumothorax most often occurs with such lesions of the lung tissue as:

If there is a purulent disease of the respiratory system, and air enters the pleural cavity simultaneously with a breakthrough of pus, pyopneumothorax occurs. In this case, the "gap" in the tissues, which led to the entry of air into the pleural cavity, is formed due to rotting of the tissue area. Most often this effect is observed:

• after complete removal of the lung, when suppuration occurs at the site of the sutures, their tightness is not maintained, and air enters the pleural cavity from the bronchus;
• when a lung abscess breaks through;
• due to the formation of a fistula between the bronchus and the pleural cavity.

In this case, air and pus are pressed on the lung at the same time, because of which its fall is aggravated.

Secondary spontaneous pneumothorax downstream is more unfavorable than primary because:

• the respiratory organs are already compromised by the disease;
• more common in older adults, when the lungs have lost some of their functional reserves.

Traumatic pneumothorax

Occurs due to damage to the chest:

• closed- even with a whole chest wall, lung tissue or mediastinum can be damaged (especially if a person has previously been ill with some pathology of the respiratory system);
• penetrating- most often due to the impact of chopping-cutting objects.

Menstrual pneumothorax

This is a rare type of secondary spontaneous pneumothorax. It develops with intrathoracic endometriosis - a pathological condition when the cells of the endometrium (the inner lining of the uterus) migrated into the chest cavity, took root there and menstruate along with the endometrium with normal localization. Menstrual pneumothorax occurs because during menstrual bleeding, the intrathoracic endometrium is rejected, and because of this, defects form in the pleura. It mainly develops in the following cases:

• in the premenopausal period;
• less often - during menopause, if a woman takes estrogen preparations.

Iatrogenic pneumothorax

It can occur during the performance of diagnostic or therapeutic manipulations by medical workers - primarily such as:

• pleurocentesis (puncture of the pleura - in particular, in order to determine the contents in the pleural cavity);
• transthoracic needle aspiration (performed to suck fluid from the pleural cavity);
• artificial ventilation of the lungs (mediastinum is damaged by medical equipment);
• installation of a venous catheter in the subclavian vein;
• cardiopulmonary resuscitation (due to too intense indirect heart massage, the ribs are damaged, which, in turn, injure the lung tissue with sharp fragments).

Symptoms of pneumothorax

The degree of manifestation of symptoms of pneumothorax depends on how much the lung tissue has collapsed, but in general they are always pronounced. The main signs of this pathological condition:

Non-traumatic, unexpressed pneumothoraxes can often resolve without any symptoms.

Diagnostics

If the symptoms described above are observed after the fact of injury, and a defect in the chest tissue is detected, there is every reason to suspect pneumothorax. Non-traumatic pneumothorax is more difficult to diagnose - this will require additional instrumental research methods.

One of the main methods for confirming the diagnosis of pneumothorax is a chest x-ray, when the patient is in the supine position. The pictures show a decrease in the lung or its complete absence (in fact, under air pressure, the lung shrinks into a lump and “merges” with the mediastinal organs), as well as a displacement of the trachea.

Sometimes radiography can be uninformative - in particular:

• with small pneumothoraxes;
• when adhesions have formed between the lung or chest wall, partially keeping the lung from falling; this happens after severe lung diseases or operations for them;
• due to skin folds, intestinal loops or stomach - there is confusion, which is actually revealed in the picture.

In such cases, other diagnostic methods should be used - in particular, thoracoscopy. During it, a thoracoscope is inserted through the hole in the chest wall, with its help they examine the pleural cavity, fix the fact of the collapse of the lung and its severity.

The puncture itself, even before the introduction of the thoracoscope, also plays a role in the diagnosis - with its help, :

• with exudative pneumothorax - serous fluid;
• with hemopneumothorax - blood;
• with pyopneumothorax - pus;
• with chylopneumothorax - a liquid that looks like a fat emulsion.

If air escapes through the needle during the puncture, this indicates a tension pneumothorax.

Also, puncture of the pleural cavity is carried out as an independent procedure - if a thoracoscope is not available, but it is necessary to carry out a differential (distinctive) diagnosis with other possible pathological conditions of the chest and pleural cavity in particular. The extracted contents are sent for laboratory testing.

To confirm the pulmonary heart failure, which manifests itself with tension pneumothorax, an ECG is done.

Differential Diagnosis

In its manifestations, pneumothorax can be similar to:

• emphysema - swelling of the lung tissue (especially in young children);
• hiatal hernia;
• large lung cyst.

The greatest clarity in the diagnosis in such cases can be obtained using thoracoscopy.

Sometimes the pain of pneumothorax is similar to the pain of:

• diseases of the musculoskeletal system;
• oxygen starvation of the myocardium;
• diseases of the abdominal cavity (can be given to the stomach).

In this case, the methods of research that are used to detect diseases of these systems and organs, and consultation of related specialists, will help to make the correct diagnosis.

Treatment of pneumothorax and first aid

In case of pneumothorax it is necessary:

• stop the flow of air into the pleural cavity (for this it is necessary to eliminate the defect through which air enters it);
• Remove existing air from the pleural cavity.

There is a rule: an open pneumothorax should be transferred to a closed one, and a valve pneumothorax should be transferred to an open one.

To carry out these activities, the patient should be immediately hospitalized in the thoracic or at least the surgical department.

Even before the X-ray examination of the chest organs, oxygen therapy is carried out., since oxygen enhances and accelerates the absorption of air by the pleura. In some cases, primary spontaneous pneumothorax does not require treatment - but only when no more than 20% of the lung has fallen asleep, and there are no pathological symptoms from the respiratory system. In this case, constant x-ray monitoring should be carried out to make sure that air is constantly being sucked in and the lung is gradually expanding.

With severe pneumothorax with a significant collapse of the lung, the air must be evacuated. It can be done:

Using the first method, you can quickly save the patient from the consequences of pneumothorax. On the other hand, the rapid removal of air from the pleural cavity can lead to stretching of the lung tissue, which was previously in a compressed state, and its swelling.

Even if, after a spontaneous pneumothorax, the lung has expanded due to drainage, the drainage can be left for a while to be safe in case of recurrent pneumothorax . The system itself is adjusted so that the patient can move around (this is important for the prevention of congestive pneumonia and thromboembolism).

Tension pneumothorax is regarded as a surgical emergency requiring emergency decompression - the immediate removal of air from the pleural cavity.

Prevention

Primary spontaneous pneumothorax can be prevented if the patient:

• give up smoking;
• will avoid activities that can lead to rupture of weak lung tissue - jumping into water, movements associated with stretching the chest.

Prevention of secondary spontaneous pneumothorax is reduced to the prevention of diseases in which it occurs (described above in the section "Causes and development of the disease"), and if they occur, to their qualitative cure.

Prevention of chest injuries automatically becomes the prevention of traumatic pneumothorax. Menstrual pneumothorax is prevented by treating endometriosis, iatrogenic - by improving practical medical skills.

Forecast

With timely recognition and treatment of pneumothorax, the prognosis is favorable. The most severe risks to life occur with tension pneumothorax.

After a patient first had a spontaneous pneumothorax, over the next 3 years, a relapse can be observed in half of the patients. . Such a high percentage of recurrent pneumothorax can be prevented by applying such methods of treatment as:

• video-assisted thoracoscopic surgery, during which the bullae are sutured;
• pleurodesis (artificially induced pleurisy, due to which adhesions form in the pleural cavity, fastening the lung and chest wall
• and many others.

After applying these methods, the likelihood of recurrent pneumothorax is reduced by 10 times.

Kovtonyuk Oksana Vladimirovna, medical commentator, surgeon, medical consultant