Pneumothorax - Causes, symptoms and treatment. MF.

Pneumothorax - an accumulation of air in the pleural cavity - a slot-like space in the norm between the parietal( external, lining the inside of the chest wall) and the visceral( internal, covering the lungs) of the pleura.

There are traumatic, spontaneous and iatrogenic pneumothorax. Traumatic pneumothorax occurs as a result of a penetrating chest injury or damage to the lung( for example, fragments of broken ribs). Spontaneous pneumothorax develops as a result of a sudden disruption of the integrity of the visceral pleura resulting from the flow of air from the lung to the pleural cavity, which is not associated with trauma or any medical-diagnostic manipulation. Iatrogenic pneumothorax is a complication of medical manipulation.

Depending on the availability of communication with the environment, a closed, open and valve pneumothorax is distinguished. Closed is called pneumothorax, in which the pleural cavity has no communication with the external environment and the amount of air trapped in it during an injury does not change with respiratory movements.

With open pneumothorax , there is a free connection of the pleural cavity with the external environment, so that during inspiration, the air is additionally "sucked" into the pleural cavity, and during exhalation it exits( "squeezed out") in the same volume. Thus, with open pneumothorax there is no accumulation of air in the pleural cavity, and in view of the unimpeded movement of air through the defect in the chest wall, the lung on the side of injury during inspiration subsides, and during expiration increases in volume( straightens), that is, the effect of paradoxical breathing occurs.

With the valve pneumothorax , unlike the open, during expiration, the communication of the pleural cavity with the external environment decreases or completely ceases due to the displacement of the tissues of the lungs or soft tissues of the chest, which can be compared with the covering of the valve. In this connection, during inhalation, a larger volume of air enters the pleural cavity than it does during exhalation. Consequently, during the breathing there is a constant increase in the amount of air in the pleural cavity, which leads to a progressively increasing compression of the lung, a shift in the mediastinal organs to the opposite( healthy) side, which disrupts their function, primarily by squeezing large vessels, and, with further progression, leads tosqueezing the second lung on the "healthy" side.

If the air valve is located in the lung and the pleural cavity communicates with the external environment through the bronchial tree, then this valve pneumothorax is called the internal .In case the valve is located in the wound of the chest wall, such a valve pneumothorax is called external .Independently, the internal and external valves cease to function when, at the height of the maximum inspiration, the pressure in the pleural cavity reaches the external environment pressure, but the intrapleural pressure during exhalation is much higher than the atmospheric pressure. The so-called strain pneumothorax is developing, which is the valve outcome and is essentially a closed pneumothorax. However, from closed pneumothorax, the strained differs by a much higher air pressure in the pleural cavity, a significant displacement of the mediastinal organs, compression of the lungs( complete on the side of the lesion and partial - on the opposite, "healthy" side).

Depending on the volume of air in the pleural cavity and the degree of lung decay, there are limited( small), medium and large, or total, pneumothorax. With the limited pneumothorax , the lung drops to less than 1/3 of its volume, with the average of the - from 1/3 to 1/2 volume. With large , or total, pneumothorax, the lung takes less than half the normal volume or is completely compressed by air.

Possible causes of pneumothorax

The causes of spontaneous pneumothorax can be( located in descending frequency):

1. Bullous disease of the lungs.
2. Pathology of the respiratory tract( chronic obstructive pulmonary disease, cystic fibrosis, asthmatic status).
3. Infectious diseases( pneumocystis pneumonia, pulmonary tuberculosis).
4. Interstitial lung diseases( sarcoidosis, idiopathic pneumosclerosis, Wegener's granulomatosis, lymphangioleiomyomatosis, tuberous sclerosis).
5. Diseases of connective tissue( rheumatoid arthritis, ankylosing spondylitis, polymyositis, dermatomyositis, scleroderma, Marfan syndrome).
6. Malignant neoplasms( sarcoma, lung cancer).
7. Thoracic endometriosis.

With spontaneous pneumothorax, the disease develops, usually after physical exertion or severe straining, accompanied by increased intrapulmonary pressure.

Traumatic pneumothorax can occur with the following thoracic injuries:

1. Penetrating chest wounds( stab-cut, gunshot).
2. Closed chest trauma( broken fracture of fractured ribs, traumatic rupture of the lung).

Iatrogenic pneumothorax can develop as a complication of the following diagnostic and therapeutic manipulations:

1. Puncture of the pleural cavity.
2. Central vein catheterization.
3. Pleural biopsy.
4. Transbronchial endoscopic biopsy of the lung.
5. Barotrauma with artificial ventilation of the lungs.

In the past, a method of therapeutic pneumothorax was used, in particular, in the treatment of cavernous pulmonary tuberculosis, when air was specially introduced into the pleural cavity to artificially provide a decrease in the lung.

Symptoms of pneumothorax

The main manifestations of pneumothorax are caused by the sudden appearance and gradual accumulation( with valve pneumothorax) of air in the pleural cavity and compression of the lungs, and by the displacement of the mediastinal organs.

The onset of the disease is sudden: after a traumatic effect on the chest( with traumatic pneumothorax) or physical exertion, straining( with spontaneous).There are sharp stitching or constrictive pains in the corresponding half of the chest, which are most often located in the upper parts of the chest, are given to the neck, shoulder or arm;sometimes pain can spread mainly to the abdomen and lower back. Simultaneously, the patient has a peculiar feeling of tightness in the chest, as well as a subjective feeling of lack of air, which is accompanied by an increase in the frequency and depth of respiratory movements. With a large pneumothorax, the manifestation of dyspnea is significant, it is accompanied by pallor or cyanosis( bluish coloration of the skin due to the accumulation of carbon dioxide in the blood), rapid heartbeat, a sense of fear. Trying to reduce pain and shortness of breath, the patient seeks to limit movement, takes the forced position of the body( half-sitting with a slant to the sore side or lying on the diseased side).

With considerable air volume in the pleural cavity, protrusion and restriction of mobility of the corresponding half of the thorax can be determined, its lag in the act of breathing from the healthy one, which, on the contrary, breathes intensively, and also the smoothness of the intercostal spaces on the affected side. Often, especially with traumatic pneumothorax, subcutaneous emphysema is observed on the affected half of the thorax - an accumulation of air in the subcutaneous tissue of the thoracic wall, which can spread to other areas of the body with a strained pneumothorax.

Survey

When percussion( percussion - tapping on individual parts of the body with subsequent analysis of the sound phenomena that occur in this case), the doctor determines the "boxed"( loud and low, similar to the sound that occurs when tapping an empty box), the percussion sound on the side of pnemothorax, and with auscultation of the lungs( auscultation - listening to sounds produced during the functioning of organs) reveals the absence or loss of respiration on the side of pneumothorax with the saved breathing on the healthyth party.

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

In the diagnosis is of great importance chest X-ray, in which the free gas in the pleural cavity is determined, the lung is compressed, the degree of its decay depends on the magnitude of pneumothorax;with intense pneumothorax, the mediastinum shifts to a healthy side. Computed tomography of the thoracic organs allows not only to detect the presence of free gas in the pleural cavity( even with a small limited pneumothorax, the diagnosis of which with conventional radiography is often quite difficult), but also to detect a possible cause of spontaneous pneumothorax( bullous disease, posttuberculous changes, interstitialdiseases of the lungs).

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

What tests should I take if I suspect a pneumothorax.

Laboratory examination with pneumothorax, as a rule, does not have an independent diagnostic value.

Treatment of pneumothorax

Therapeutic tactics depend on the type of pneumothorax. Expectant conservative therapy is possible with small limited closed pneumothorax: the patient provides peace, gives painkillers. With a significant accumulation of air, drainage of the pleural cavity with so-called passive aspiration is demonstrated with the help of Bobrov's apparatus.

Drainage of the pleural cavity is performed under local anesthesia in the patient's sitting position. A typical place for drainage is the second intercostal space along the front surface of the chest( with limited pneumothoraxes choose a point above the site of the greatest air accumulation), where a thin needle is layerwise injected into soft tissues with a 0.5 ml solution of novocaine with a volume of 20 ml, after which the doctor nicks the skin and inserts intoPleural cavity trocar - a special tool consisting of an acute stiletto inserted into the hollow shell( tube).After extraction of the stylet through the channel of the sleeve( tube) of the trocar, the surgeon inserts a drain into the pleural cavity and removes the liner. Drainage is fixed to the skin and connected to Bobrov's bank for the implementation of passive aspiration. If passive aspiration is ineffective, active aspiration is used, for which the system of drainage and Bobrov's cans are connected to a vacuum aspirator( suction).After complete dilution of the lung, drainage from the pleural cavity is removed.

Drainage of the pleural cavity is considered a relatively simple surgical operation that does not require any preliminary preparation from the patient.

Diagram of the device trocar.

In case of traumatic open pneumothorax with massive lung damage, an urgent operation under general anesthesia is indicated, consisting of suturing the lung defect, stopping bleeding, layer-by-layer suturing of the wound of the chest wall and drainage of the pleural cavity.

In spontaneous pneumothorax, especially recurrent, to determine the nature of the pathology leading to it, thoracoscopy is used - the method of endoscopic examination, which consists in examining the pleural cavity of the patient with a special instrument - a thoracoscope inserted through the puncture of the chest wall. If found during thoracoscopy in the lung bulla, which led to the development of pneumothorax, it is possible to surgically remove them using special endoscopic instruments.

In case of ineffective drainage with passive or active aspiration and endoscopic procedures in thoracoscopy in pneumothorax relief, as well as in its relapses resort to open surgical intervention - thoracotomy, in which the pleural cavity is opened with a wide incision, the immediate cause of pneumothorax is detected and eliminated. In order to prevent the recurrence of pneumothorax, the formation of fusion between the visceral and parietal pleura sheets is artificially induced.

Complications of pneumothorax

The main complications of pneumothorax are acute respiratory and cardiovascular insufficiency, especially pronounced with intense pneumothorax and due to compression of the lungs and displacement of the mediastinum. With the unresolved pneumothorax for a long time, it is possible to develop reactive pleurisy as a pleural reaction to the presence of air in the pleural cavity in the form of inflammation with the production of fluid;in case of infection, the development of pleural empyema( accumulation of pus in the pleural cavity) or pyopneuromotorax( accumulation of pus and air in the pleural cavity) is possible. In the case of a prolonged recession of the lung caused by pneumothorax, spitting of the sputum obstructs the lumen of the bronchi and promotes the development of pneumonia. Sometimes pneumothorax, especially traumatic, is accompanied by the development of intrapleural bleeding( hemopneumothorax), while signs of respiratory failure are joined by symptoms of blood loss( pallor, heart rate, pressure drop and others);intrapleural bleeding can also complicate spontaneous pneumothorax.

Forecast

Tense pneumothorax is a serious, life-threatening condition that can be fatal due to the development of acute respiratory and cardiovascular failure due to compression of the lungs and displacement of the mediastinal organs. Also, bilateral pneumothorax is extremely dangerous. Any pneumothorax requires immediate hospitalization of a patient in a surgical hospital for surgical treatment. With adequate timely treatment, spontaneous pneumothorax has, as a rule, a favorable prognosis, and the prognosis of traumatic pneumothorax depends on the nature of concomitant injuries of the thoracic organs.

Doctor surgeon Kletkin ME