pneumothorax - it is the excessive accumulation of air between the pleural sheets, resulting in a short-term or long-term disorder of the respiratory function of the lungs and cardiovascular disease.All cases of pneumothorax can be attributed to one of the three basic forms: iatrogenic (a complication of diagnostic and therapeutic procedures), traumatic (there is a direct connection to the traumatization of the bone apparatus chest cavity) or spontaneous pneumothorax lung (sudden violation of the integrity of visceral pleural sheets).
In a situation when the pleural cavity has no direct communication with the ambient air, the volume of air that has entered the time of the injury to one or both poevralnye cavity is stagnant, so there is a closed pneumothorax.
Open pneumothorax develops when the defect between the pleural cavity and the environment is maintained, whereby the air is smoothly like accumulates between the pleura and removed from the pleural cavity during the respir
valve pneumothorax similar open on pathogenic mechanisms of occurrence, but its main difference is that during the act of breathing is shifted soft tissue structures of the chest, whereby air is increasingly accumulated in the pleural cavity, rather than removed from it.At the initial stage of the compensatory mechanisms to cope with the increasing intrapleural pressure, but in a situation where the level of intrapleural pressure higher than atmospheric pressure, there is a tension pneumothorax, which greatly increase the weight of the patient's condition and needs immediate surgery.
in establishing an accurate diagnosis is necessary to assess not only the volume of air in the pleural cavity, but also the degree of lung collapse, which largely affects the violation of the respiratory function.Also atelectasis on the affected side can be observed signs of accumulation of fluid or blood in the pleural cavity.In this situation, it is a gemopnevmotorakse and the amount of therapeutic measures depend on the severity of the disease.Another type is pneumoempyema pneumothorax, that is the combined accumulation of pus and air in one or both of the pleural cavity.
Each of the three main forms of pneumothorax may develop under the influence of a etipatogeneticheskogo factor or combination thereof.
pneumothorax traumatic genesis triggered a traumatic effect on the organs of the chest cavity: gunshot and stab damage penetrating the chest cavity, the impact on the organs of the chest cavity with a blunt object, causing rib fractures with displacement of fragments or rupture of the lung parenchyma.
Iatrogenic nature pneumothorax involves unilateral or bilateral accumulation of air in the pleural cavity, triggered incorrectly perform diagnostic or therapeutic procedures (pleural puncture with damage to lung tissue, pleural biopsy catheter through a central venous access, endoscopic transbronchial biopsy perforated bronchial wall, barotrauma ascomplication of mechanical ventilation).
of spontaneous pneumothorax can not be tied to any specific etiological factor, as it occurs against the backdrop of well-being, but there are pathological conditions which are at risk and able to act as an agent provocateur pneumothorax: pathology bronchopulmonary system lung (chronic obstructive pulmonary diseaselungs, asthma, cystic fibrosis, emphysematous bulla), lung disease infectious nature (tuberculosis, Pneumocystis pneumonia, lung abscess), pathology of pulmonary interstitial (Wegener's granulomatosis, sarcoidosis, idiopathic pulmonary fibrosis), systemic disease of the connective tissue (scleroderma, dermatomyositis, rheumatoid arthritis), malignant tumors in the lung (sarcoma, central lung cancer).
There is a separate nosological form of "menstrual pneumothorax", the manifestations of which have a clear dependence on the timing of the onset of menstruation and women suffering from endometriosis.This pathology is extremely rare, and in most cases does not require a specific diagnosis.
clinical manifestations of the patient's symptoms and their severity depends on the type of pneumothorax, the volume of air in the pleural cavity and compensatory capacity of the organism.The presence or absence of signs of cardiovascular and respiratory failure depends on the degree of compression kollabirovaniya lung and mediastinal organs.
In the classic form of pneumothorax is a sudden medical emergency which is characterized by a sudden debut of clinical symptom and rapid increase in symptoms.The first sign of pneumothorax is a sharp stabbing pain in the chest, often without a clear localization and of referred to the shoulder girdle, neck and the upper half of the abdomen.Some patients did not feel severe pain syndrome, and complained of severe shortness of breath and difficulty breathing, and therefore, increases the frequency and depth of breathing movements.
In order to reduce pain and dyspnea the patient is forced to take a position of "lying on the sick side" and limit the depth of the respiratory movements, which is a pathognomonic symptom of pneumothorax.If there is an open type of pneumothorax, then through a wound in the chest is an allocation of frothy blood that comes out with noise.
degree of symptoms of pneumothorax depends on the severity of atelectasis, since the classic symptom develops when the collapse of the lung (in 40-%).When a small amount of free gas in the pleural cavity is observed during a sluggish latent unexpressed pain that is largely negative impact on the timely diagnosis of the disease.
In primary objective examination of the patient revealed severe pallor of the mucous membranes and skin, cyanosis of the upper body and head.The affected side of the chest visually behind in the act of breathing in comparison with the other half, as well as marked protrusion of the intercostal spaces on the side of the alleged pneumothorax.
Traumatic pneumothorax is often accompanied by the spread of air in the intermuscular and subcutaneous space of the chest and neck, and therefore, there are signs of subcutaneous emphysema (increase in the volume of soft tissues, feeling the crunch on palpation).
carefully executed percussion and auscultation of the lungs in 100% of cases can reliably establish the diagnosis "pneumothorax".Thus, during the percussion on the affected side of the chest is determined by an empty box sound, since the conductivity of the air, the sound is very good, while auscultation vesicular breathing completely absent or greatly weakened.
Suspected pneumothorax is an absolute justification for assigning a patient x-ray of the chest cavity, as this method of examination is considered the best in diagnosing the presence of air in the pleural cavity.It is mandatory to perform X-ray standing and lateroposition.Skialogicheskimi signs of pneumothorax is the presence of free gas in the pleural cavity, a decrease in lung volume on the affected side, and in the case of tension pneumothorax is determined by the displacement of the mediastinal structures to the healthy side.
With a limited amount of air in the pleural cavity is necessary to perform a CT scan that can diagnose not only limited pneumothorax, but the cause of its occurrence (tuberculous cavity, emphysematous bullae, lung disease accompanied by interstitial pathology).
should be noted that within days after the development of pneumothorax may join pleural reaction in the form of pleurisy, which manifests itself in the form of fever, pain in the chest when breathing and movements.Subsequently, the growing phenomenon of respiratory failure due to the development of adhesions in the pleural space, which hinders the smoothing of lung tissue.
incidence of spontaneous pneumothorax type is 3-15 cases per 100,000 population.Risk for the disease are young men asthenic physique with bad habits as smoking and alcohol abuse.
is believed that the primary spontaneous pneumothorax occurs when the total absence of pathological changes in the lungs, but numerous randomized trials using VATS and computer tomography proves the presence of subpleural emphysematous bullae located in 90% of cases.
mechanism penetration of free gas into the pleural cavity during the initial pneumothorax is that the inflammatory changes occur primarily small airways, whereby the air existing in the bulls, penetrates into the pulmonary interstitium.Due to the increase of air pressure is rapidly directed to the root of the lung and mediastinal parietal pleura through breaks in the pleural cavity.
Clinical symptoms in primary spontaneous pneumothorax occurs against a background of well-being, and is the first occurrence of acute pain, which is stored in the first day of the disease, then there are only short of breath.The appearance of tachycardia, cyanosis pronounced upper part of the chest, favor the development of tension pneumothorax.
In most cases, developing limited pneumothorax, which does not require specific treatment and are allowed to own.The share of recurrent primary spontaneous pneumothorax account for 30% of cases, and usually between the first episode and recurrent passes and six months.
secondary spontaneous pneumothorax is characterized by a more aggressive and severe, as it occurs against the backdrop of a pulmonary or cardiovascular disease.The incidence of secondary spontaneous pneumothorax is 2-5 cases per 100,000 population, and the risk group are persons of advanced age, chronic lung diseases.
main diagnostic feature of this situation is the presence of chest pain and shortness of breath, although in some cases clinical manifestations rather meager.Relapses of the disease observed in 40% of cases.Symptoms of pneumothorax occur after excessive physical activity or emotional stress.There is a sharp knife-like pain in one or both halves of the chest accompanied by shortness of breath and a dry cough, hoarse.
In a situation where there is a valve pneumothorax, dyspnea progressively increases until apnea is marked asymmetry of the chest due to increase in the affected side, often loss of consciousness due to increasing hypoxia and hypercapnia.If air flows slowly into the pleural cavity, and there are no signs of respiratory and cardiovascular disease, pain is not very pronounced and sometimes pneumothorax occurs completely asymptomatic.
features of an objective examination of the patient with valvular pneumothorax is the presence of tympanic sound on percussion and a decrease in voice shaking on the affected side.Percussion border of cardiac dullness reduced and at the closed tension pneumothorax observed shifting boundaries of cardiac dullness in the opposite direction.
additional research methods necessary for the diagnosis of spontaneous pneumothorax is a standard X-ray projections and lateroskopiya allowing to diagnose even a small amount of free gas.In a situation where there is accumulation of large amounts of air in the left pleural cavity, the diagnosis is difficult because the clinical manifestations and changes in the ECG recording can simulate acute myocardial infarction.In this case, the patient is recommended to define specific troponins, whose level increases with acute coronary insufficiency.
In order to clarify the type of spontaneous pneumothorax is recommended to perform pleural puncture with pressure gauge.For closed type pneumothorax is characterized as a slabootritsatelnye and low positive levels of intrapleural pressure (from -3 to +4 sm.vod.st. sm.vod.st).Outdoor spontaneous pneumothorax is accompanied by intrapleural pressure approximate to zero.When the valve spontaneous pneumothorax is observed sharply positive intrapleural pressure with a progressive increase.
If hydropneumothorax pleural punctate necessarily need to investigate for the presence of specific pathogens, as well as to determine the cellular composition.If the valve is recommended to perform VATS pneumothorax, which can reliably determine the size and location of pleural fistula.
should separately consider the occurrence of spontaneous pneumothorax in a newborn baby, as a consequence of increasing intrabronchial pressure at the moment of first breath, accompanied by smoothing out uneven lung tissue.In older children the appearance of signs of spontaneous pneumothorax is most often associated with increased pressure in the lumen of the bronchi diseases such as whooping cough, asthma, and aspiration of a foreign body.It should be noted that the occurrence of spontaneous pneumothorax in children can be triggered by rupture of congenital or retention cysts Bull.
clinical symptom of pneumothorax in children does not differ from that of an adult, but is characterized by a rapid increase of symptoms and severe convulsive disorders, often complicating timely diagnosis of the underlying disease.
operational benefits in childhood is rarely used, provided reliably diagnosed lung malformation or compromising the integrity of the walls of the bronchial tubes and esophagus.
pneumothorax first aid
first emergency care in any type of pneumothorax is not only in the use of drug therapy, but also subject to a particular regime.The patient is first necessary to provide a complete mental and physical rest in orthostatic position and in this position you need to coach "ambulance" urgently admitted to hospital surgical.
Start resuscitation should be carried out in the car, "first aid".If pneumothorax occurs as a result of injury of the chest and accompanied by bleeding, it is necessary to impose on the wound surface sealing bandage and immediately start the cardiovascular drug therapy: Kordiamin a dose of 2 ml or 1% Mezaton 1 ml subcutaneously;intravenous Korglikon 0.06 ml of 1% in 10 ml isotonic sodium chloride solution;10% sulfokamfokain 3 ml subcutaneously.
To analgesia recommended application Baralginum 5 ml intravenously and in case of need promedol 2% solution with 1 ml of 1% solution of 2 ml diphenhydramine intravenously.
In a situation where there is severe hypoxia and hypercapnia, recommended the use of a mixture of oxygen "laughing gas," and oxygen.
After providing first emergency patient is admitted to hospital surgical.The amount of therapeutic measures conducted for suspected pneumothorax depends on the type of pneumothorax and the presence of comorbidity.
In the case of restricted pneumothorax without signs of compression of mediastinal organs advisable to exercise expectant conservative therapy with providing complete physical and psycho-emotional rest and adequate anesthesia (2% solution omnopon 2 ml subcutaneously).