With an open pneumothorax, air accumulates. Pneumothorax of the lung - causes, diagnosis, treatment, surgery and prevention

Pneumothorax of the lungs - the appearance of air accumulation in the pleural cavity. This is fraught with serious consequences, the lungs cannot function normally, the respiratory function is impaired. This condition is becoming more and more common these days. It occurs in patients aged 20-40 years.

The injured person needs to start providing emergency care as soon as possible, since pneumothorax can be fatal. In more detail, what kind of disease it is, what causes and symptoms, as well as first aid for pneumothorax and effective treatment - later in the article.

Pneumothorax: what is it?

Pneumothorax is an excessive accumulation of air between the pleural layers, leading to short-term or long-term impairment of the respiratory function of the lungs and cardiovascular insufficiency.

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 a collapse of part or the whole lung (partial or complete collapse of the lung).

Patient with pneumothorax experiencing severe pain in the chest, breathing fast and shallow, with shortness of breath. Feeling short of breath. Paleness or cyanosis of the skin, in particular the face, is manifested.

• In the international classifier of diseases ICD 10 pneumothorax is: J93.

Disease classification

Pneumothorax can be of two fundamentally different types, depending on the origin and communication with the external environment:

1. open, when gas or air enters the pleural cavity from the external environment through defects in the chest - wounds, while there is a depressurization of the respiratory system. In the case of an open pneumothorax, it changes and this leads to the fact that the lung collapses and no longer performs its functions. Gas exchange in it stops, and oxygen does not enter the blood;
2. Closed - no contact with the environment. In the future, an increase in the amount of air does not occur and theoretically this species can resolve spontaneously (it is the easiest form).

Distribution type:

• unilateral. They speak about its development if only one lung collapses;
• bilateral. Both the right and left lobes of the lungs collapse in the victim. This condition is extremely dangerous for a person’s life, so he needs to start providing emergency care as soon as possible.

Also distinguished:

• Traumatic pneumothorax occurs as a result of a penetrating wound of the chest or damage to the lung (for example, fragments of broken ribs).
• spontaneous pneumothorax that occurs without any previous disease, or a disease that was latent;
• Tension pneumothorax is a condition when air enters the pleural cavity, but there is no way out, the cavity is filled with gas. There is a complete collapse of the lung and the air does not enter it even with a deep breath.
• secondary - arising as a complication of pulmonary or extrapulmonary pathology,
• artificial or iatrogenic - doctors create if certain manipulations are necessary. These include: biopsy of the pleura, the introduction of a catheter into the central veins.

According to the volume of air that entered the cavity between the pleura, the following types of pneumothorax are recognized:

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

According to the presence of complications:

• Complicated (, bleeding, mediastinal and subcutaneous emphysema).
• Uncomplicated.

The reasons

Etiological factors that can lead to the development of pneumothorax are divided into three groups:

• Diseases of the respiratory system.
• Injuries.
• Medical manipulations.

The causes of spontaneous pneumothorax of the lung can be (arranged in descending order of frequency):

• Bullous lung disease.
• Pathology of the respiratory tract (chronic obstructive pulmonary disease, cystic fibrosis, status asthmaticus).
• Infectious diseases (pneumocystis,).
• Interstitial lung diseases (sarcoidosis, idiopathic pneumosclerosis, Wegener's granulomatosis, lymphangioleiomyomatosis, tuberous sclerosis).
• Connective tissue diseases (ankylosing spondylitis, polymyositis, dermatomyositis, scleroderma, Marfan's syndrome).
• Malignant neoplasms (sarcoma, lung cancer).
• Thoracic endometriosis.

Symptoms of pneumothorax of the lungs

The main manifestations of pneumothorax are due to the sudden appearance and gradual accumulation of air in the pleural cavity and compression of the lung by it, as well as the displacement of the mediastinal organs.

Common symptoms in adults:

• it is difficult for the patient to breathe, he has superficial frequent breathing;
• cold sticky sweat appears;
• an attack of dry cough;
• the skin becomes bluish;
• cardiopalmus; sharp pain in the chest;
• fear; weakness;
• decrease in blood pressure;
• subcutaneous emphysema;
• the victim takes a forced position - sitting or half-sitting.

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

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

Complications

Complications of pneumothorax occur frequently, according to statistics - half of all cases. These include:

• pleural empyema - purulent pleurisy, pyothorax;
• intrapleural bleeding as a result of tearing of the lung tissue, serous-fibrinous pneumopleuritis with the formation of a "rigid" lung,.

With valvular pneumothorax, the formation of subcutaneous emphysema is not excluded - the accumulation of a small amount of air under the skin in the subcutaneous fat.

Long-term pneumothorax often ends with the replacement of lung tissue with connective tissue, wrinkling of the lung, loss of elasticity, development of pulmonary and heart failure, and death.

Diagnostics

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;
• decrease in blood pressure, tachycardia, displacement of the borders of the heart in a healthy direction.

Of the instrumental examination methods, the “gold standard” is chest x-ray in a sitting or standing position. To diagnose pneumothorax with a small amount of air, fluoroscopy or expiratory radiography is used.

The final diagnosis is made according to the results of a radiograph or tomography, on the basis of which pneumothorax is differentiated with the following diseases:

• Asphyxia;
• pleurisy;
• myocardial infarction;
• diaphragmatic hernia.

First aid

Pneumothorax in valvular or open form is one of the urgent conditions, upon the occurrence of which an ambulance should be called immediately. Then be sure to do the following:

• stop the process of filling the pleural cavity of the victim with air;
• stop bleeding.

The first emergency aid for any type of pneumothorax is not only the use of drug therapy, but also the observance of a certain regimen.

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

Treatment of pneumothorax

Treatment of pneumothorax begins in the ambulance. Doctors do:

• oxygen therapy;
• anesthesia (this is an important point in the treatment, painkillers are necessary for the patient both at the stage of lung decline and during its expansion);
• remove the cough reflex;
• perform a pleural puncture.

Depending on the type of disease, the treatment will be as follows:

1. Small closed limited pneumothorax- most often does not require treatment. It spontaneously resolves after a few days without causing serious disorders;
2. when closed, the trapped air is aspirated using a puncture system;
3. when open - first they transfer it to a closed one, sewing up the hole. Further, the air is sucked off through the puncture system;
4. with valvular - they transfer it to an open view with a thick needle and then treat it surgically;
5. with recurrent- surgical removal of its cause. For patients over the age of 50 with recurrent pneumothorax, it is preferable to use not a simple pleural puncture, but the installation of a drainage tube and active air aspiration.

Treatment and rehabilitation last from 1-2 weeks to several months, it all depends on the cause.

Rehabilitation after pneumothorax

1. After leaving the hospital, a patient who has had a pneumothorax of the lungs should refrain from any physical activity for 3-4 weeks.
2. Air travel is prohibited for 2 weeks after treatment.
3. You should not engage in parachuting, diving - all this causes pressure drops.
4. It is strictly forbidden to smoke, you should definitely quit this dangerous habit.
5. Doctors also advise to be tested for tuberculosis, COPD.

In 20% of cases, patients experience a relapse of the pathology, especially if it is caused by a primary disease. Such a condition of a person is considered dangerous when the pleural cavity is filled with air from both sides. This usually results in acute respiratory distress and death.

The bilateral form of pneumothorax is characterized by a favorable outcome in only 50% of cases.

Forecast

Any pneumothorax of the lungs requires immediate hospitalization of the patient in a surgical hospital for surgical treatment. The sooner a patient diagnosed with symptoms of the disease is sent to the hospital, the greater the chance for successful treatment.

Spontaneous pneumothorax is a condition characterized by an accumulation of air in the pleural cavity (the space that protects the lungs). The cause may be of a spontaneous type, such as trauma, and medical procedures. The main symptoms of pneumothorax are chest pain and difficulty breathing.

Let's look at the features of this pathology and therapies that allow you to return to normal life.

What is pneumothorax

term pneumothorax designate a pathology in which there is a sudden accumulation of air in the pleural cavity.

The accumulation of air at the level of the pleural space, in which the pressure must be less than atmospheric, leads to increased pressure on the lungs and limit their ability to expansion, causing labored breathing and pain during the act of breathing, up to lung collapse.

Although this may depend on many factors, current research confirms the link between pneumothorax and smoking: those who smoke more than 20 cigarettes a day have a 100(!) times increased risk.

Classification of pneumothorax depends on causes and injury

Pneumothorax can be divided into different categories, depending on what caused it and how it manifests itself.

Depending on what provoked the development of pneumothorax:

• Spontaneous: occurs spontaneously, without any trauma. May be congenital or caused by disease. It has a recurrent character, that is, after the first time there is a 50% chance that the attack will happen again.
• Traumatic: the cause is a physical trauma that causes air to enter the pleural cavity.

In a relationship spontaneous pneumothorax additional division can be made:

• Primary: also called primitive or idiopathic, occurs spontaneously, without disease or injury. Caused by the rupture of small air bubbles that may be between the pleural cavity and the lungs. As a rule, spontaneous healing occurs within 10 days. The patient may not experience any symptoms or feel a slight "prick" at the moment the air bubble bursts. It mainly affects males, aged 18 to 40 years.
• Secondary: this pneumothorax develops as a result of certain diseases respiratory tract such as chronic obstructive pulmonary disease, emphysema, certain lung tumors, cystic fibrosis, interstitial lung disease, and connective tissue disease.
• Pneumothorax of the newborn: can be caused by diseases such as respiratory distress syndrome or meconium aspiration syndrome. It is asymptomatic and therefore poses a potentially fatal threat to the child.

AT depending on localization we can distinguish two types of pneumothorax:

• Apical: occurs at the apex of the lungs and does not include other parts of the lung parenchyma. Often associated with spontaneous idiopathic pneumothorax.
• Bilateral synchronous: occurs simultaneously on both lungs.

There are other classifications of pneumothorax based on various parameters:

• Hypertensive: one of the most severe forms of pneumothorax. Associated with the constant ingress of air into the pleural cavity without the possibility of exit of this air. The pressure in the pleural cavity is constantly increasing, which leads to collapse of the lungs and respiratory failure.
• iatrogenic: Caused by medical procedures such as puncture when placing a central venous catheter or performing a biopsy of the pleura. May occur after thoracentesis or after surgery.
• Open: occurs when there is a connection between the external environment and the pleural cavity, for example, after a physical or mechanical injury. This leads to a continuous accumulation of air and the pressure inside the pleural cavity becomes equal to atmospheric pressure.
• Closed: determined by a small accumulation of air in the pleural cavity, without connection with the external environment. Also called a partial pneumothorax, as the pressure in the pleural cavity remains lower than atmospheric pressure.
• Hemothorax: occurs when blood enters the pleural cavity. It may be caused by trauma. Its severity correlates with the amount of accumulated blood.
• Menstrual: This is a type of pneumothorax that occurs as a result of endometriosis and usually occurs during the menstrual cycle or within 72 hours of the onset of menstruation.
• Therapeutic: a type of pneumothorax that occurs in tuberculosis patients when the tuberculous cavity is purposefully destroyed to speed up the healing process.

Symptoms of pneumothorax

Pneumothorax appears suddenly and may be accompanied by the following symptoms:

• Labored breathing: from mild shortness of breath to collapse of the lungs.
• Chest pain: may be mild, as in the case of primary spontaneous pneumothorax, in which the pain is similar to a small needle prick, or intense and sharp, as in the case of a collapsed lung.
• Cardiopalmus: (tachycardia) associated with sudden oxygen deficiency (hypoxia).
• Less specific symptoms: agitation, feeling of suffocation, weakness, cough, fever and intense sweating.

Causes of pneumothorax: diseases, injuries and procedures

Pneumothorax is a pathology based on various causes, some of them are pathological, others are traumatic, and others are iatrogenic (associated with medical or pharmacological procedures).

Among the causes of pneumothorax we have:

• lung disease: chronic obstructive pulmonary disease, sarcoidosis, cystic fibrosis, pulmonary emphysema, pulmonary fibrosis and bronchial asthma.
• Connective tissue diseases: certain diseases of the connective tissue of the lung, such as Wegener's granulomatosis or Marfan's disease.
• infections: some viral infections such as HIV or bacterial infections such as tuberculosis, pneumonia, pleurisy, bronchitis.
• Malignant neoplasms: most often pneumothorax is caused by sarcomas that metastasize to the lungs, as well as bronchial cancer, lung cancer and primary mesothelioma.
• Medical procedures: Medical procedures sometimes resulting in pneumothorax include thoracentesis, pleural biopsy, mechanical ventilation, lung surgery, placement of venous catheters, and thoracic biopsy.
• Chest injury: any mechanical or physical injury associated with a contusion of the chest or creating a communication channel between the pleural cavity and the external environment can cause pneumothorax. Examples include gun or stab wounds, traffic accidents, airbag deployment, and workplace injuries.
• Non-pathological air bubbles: the formation of air bubbles, which can then burst and cause pneumothorax, may be due to non-pathological causes. For example, riding a roller coaster, being at high altitude (such as in the mountains or on an airplane), practicing extreme sports (such as diving), strenuous physical effort (such as going to the gym).

Complications and consequences of pneumothorax

If pneumothorax is not treated promptly, it can lead to dangerous complications that lead to the death of the patient.

Complications may include:

• Hypertensive pneumothorax associated with the continuous accumulation of air in the pleural cavity.
• Education pneumomediastinum, that is, the accumulation of air at the level of the mediastinum.
• Appearance hemothorax, that is, bleeding at the level of the pleural cavity.
• relapse, that is, the occurrence of recurrent pneumothorax.
• The consequences of these complications can be serious and lead to respiratory failure, cardiac arrest, and death of the subject.

Diagnosis: Patient examination and tests

Diagnosis of pneumothorax is based on instrumental examination and differential diagnosis with other diseases. The first step is patient examination which includes taking a medical history and auscultation of the chest.

Then the doctor conducts a differential diagnosis to distinguish pneumothorax from:

• Pleurisy: accumulation of fluid in the pleural cavity.
• Pulmonary embolism: this is a blockage of the pulmonary arteries, caused, for example, by air bubbles, has symptoms such as choking and hemoptysis.

In addition to differential diagnosis, a number of instrumental studies are carried out:

• chest x-ray: In the case of pneumothorax, mediastinal displacement is visible on the image. In addition, you can notice the presence of a pleural air damper (i.e., accumulation of air) in the upper lobes of the lungs.
• chest ultrasound: used to detect a closed pneumothorax after trauma, as it turns out to be a more sensitive method of investigation than radiography in this case.

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 of 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 can 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, which allows surgical manipulations through one to three punctures on the patient's chest.

Thoracoscopy performed under general anesthesia and in four stages:

• Stage 1: Examination of the lung parenchyma. This stage is used for primary idiopathic pneumothorax, which is not associated with lung damage or parenchymal changes.
• Stage 2: search for adhesions between the pleura and lungs, which are often found in cases of active pneumothorax. This step is often used for recurrent pneumothorax.
• Stage 3: search for small air bubbles, the diameter of which does not exceed 2 cm, causing damage to the lung tissue and vascularization of emphysema.
• Stage 4: looking 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.

Pneumothorax is an excessive accumulation of air between the pleural layers, leading to short-term or long-term impairment of the respiratory function of the lungs and cardiovascular insufficiency.

All cases of pneumothorax can be attributed to one of three main forms: iatrogenic (a complication of diagnostic and therapeutic manipulations), traumatic (there is a direct connection with traumatization of the bone apparatus of the chest cavity) or spontaneous pneumothorax of the lung (sudden violation of the integrity of the visceral pleural sheet).

In a situation where the pleural cavity does not have direct communication with the ambient air, the volume of air that has entered one or both poevralny cavities at the time of injury remains at the same level, therefore, a closed pneumothorax occurs.

An open pneumothorax develops when a defect between the pleural cavity and the environment persists, as a result of which air freely accumulates between the pleura and is removed from the pleural cavity during respiratory movements.

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 pneumothoraxes or severe symptoms, air can be evacuated with a syringe or a unilateral Bullau 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).

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 type 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.

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 . 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.

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 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.

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.

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.

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.

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 broken ribs, lung surgery, 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.

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.

Forecast and prevention

Usually, simple manifestations of the disease do not have adverse consequences for the human body. The prognosis is determined by the degree and extent of damage to the respiratory system. The sooner help is provided, the less likely the condition will worsen.

Up to 40% of people may experience a relapse. Usually, a recurrence occurs within six months after the first attack.

Percentage of death:

• HIV-infected - no more than 25%.
• In people with congenital cystic fibrosis, with the development of unilateral pneumothorax 5%. Bilateral gives 25%.
• In people with chronic obstructive pulmonary disease, an average of 5%.

There are no special medical measures to prevent the occurrence of pneumothorax. To reduce the risk of developing severe pathology, it is important to always seek medical help in a timely manner in the development of diseases of the internal organs of the respiratory system. This is especially true of bronchitis, asthma, pneumonia.

Patients who have suffered pneumothorax need to be attentive to their health. Heavy physical activity is excluded. Once a year, a complete medical examination is required, with special attention paid to a chest x-ray and blood and sputum tests for tuberculosis. With frequently recurring relapses, the only treatment for pneumothorax is an operation - thoracoscopy.

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

Open trauma of the chest: penetrating wounds;

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

Spontaneous pneumothorax;

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

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

Artificial pneumothorax is applied with a therapeutic purpose in the lungs, with a diagnostic one for thoracoscopy, for the differential diagnosis of chest wall formations.

What are the types of pneumothorax?

In relation to the environment, there are:

Closed pneumothorax some amount of gas enters the pleural cavity, which does not increase. There is no communication with the external environment, so its flow stops. It is considered the easiest type of pneumothorax, since the air can potentially gradually dissolve from the pleural cavity on its own, while the lung expands.

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

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

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

Bilateral complete pneumothorax if no assistance is provided, it leads to a rapid death due to a critical impairment of respiratory function.

Symptoms of pneumothorax

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

The disease begins acutely after physical exertion, a fit of coughing, or for no apparent reason with a sharp stabbing that radiates to the neck, upper limb, sometimes to the upper half of the abdomen, aggravated by breathing, coughing or chest movements, shortness of breath, dry. The patient breathes often and superficially, there is severe shortness of breath, feels "lack of air." Pallor or cyanosis (cyanosis) of the skin, in particular the face, is manifested.

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

Complications

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

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

What can you do?

First aid for pneumothorax

If you suspect a pneumothorax, you should immediately call an ambulance or see a doctor, because this is an emergency situation, especially if there is a valvular pneumothorax, which, if the necessary assistance is not provided, can be fatal.

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

What can a doctor do?

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

Treatment for pneumothorax includes:

Immediate hospitalization in the surgical department;

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

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

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

Valvular pneumothorax requires surgical intervention.

Pneumothorax is an accumulation of air in the pleural cavity - a normally slit-like space between the parietal (external, lining the chest wall from the inside) and visceral (internal, covering the lung) pleura.

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

Depending on the presence of communication with the environment, there are closed, open and valvular pneumothorax. Closed called pneumothorax, in which the pleural cavity has no communication with the external environment and the amount of air that has entered it during injury does not change depending on the respiratory movements.

At open pneumothorax there is a free connection of the pleural cavity with the external environment, as a result of which, during inhalation, air is additionally “sucked” into the pleural cavity, and during exhalation it comes out (“squeezed out”) in the same volume. Thus, with an open pneumothorax, there is no accumulation of air in the pleural cavity, and due to the unhindered movement of air through a defect in the chest wall, the lung on the side of the wound collapses during inhalation, and during exhalation it increases in volume (straightens), that is, the effect of paradoxical breathing occurs .

At valvular pneumothorax, unlike open, during exhalation, the communication of the pleural cavity with the external environment decreases or completely stops due to the displacement of the tissues of the lung itself or the soft tissues of the chest, which can be compared with covering the valve. As a result, more air enters the pleural cavity during inspiration than during expiration. Consequently, during breathing there is a constant increase in the amount of air in the pleural cavity, which leads to progressively increasing compression of the lung, displacement of the mediastinal organs in the opposite (healthy) direction, which disrupts their function, primarily squeezing large vessels, and with further progression leads to compression of 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 such a valvular pneumothorax is called internal. If the valve is located in the wound of the chest wall, such a valvular pneumothorax is called outdoor. Independently, the internal and external valves cease to function when, at the height of maximum inhalation, the pressure in the pleural cavity reaches the pressure of the external environment, but at the same time, intrapleural pressure during expiration significantly exceeds atmospheric pressure. The so-called tension pneumothorax, which is the outcome of the valvular and essentially represents a closed pneumothorax. However, tension pneumothorax differs from a closed pneumothorax 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 collapse of the lung, there are limited (small), medium and large, or total, pneumothorax. At limited pneumothorax lung collapses by less than 1/3 of its volume, with average- from 1/3 to 1/2 of the volume. At big, or total, pneumothorax, the lung occupies less than half of the normal volume or is completely compressed by air.

Possible causes of pneumothorax

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

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

With spontaneous pneumothorax, the disease develops, as a rule, after physical exertion or strong straining, accompanied by an increase in intrapulmonary pressure.

Traumatic pneumothorax can occur with the following chest injuries:

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

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

1. Puncture of the pleural cavity.
2. Catheterization of the central vein.
3. Biopsy of the pleura.
4. Transbronchial endoscopic lung biopsy.
5. Barotrauma during artificial ventilation of the lungs.

In the past, the technique of therapeutic pneumothorax was used, in particular, in the treatment of cavernous pulmonary tuberculosis, when air was specially introduced into the pleural cavity in order to artificially ensure the collapse of the lung.

Symptoms of pneumothorax

The main manifestations of pneumothorax are due to the sudden appearance and gradual accumulation (with valvular pneumothorax) of air in the pleural cavity and compression of the lung by it, as well as 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 stabbing or squeezing pains in the corresponding half of the chest, which are most often localized in the upper chest, give to the neck, shoulder or arm; sometimes pain can spread mainly to the abdomen and lower back. At the same time, 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 severity of shortness of breath 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, and a feeling of fear. Trying to reduce pain and shortness of breath, the patient seeks to limit movement, takes a forced position of the body (half-sitting with an inclination to the affected side or lying on the affected side).

With a significant volume of air in the pleural cavity, protrusion and limitation of the mobility of the corresponding half of the chest, lagging behind the healthy one in the act of breathing, which, on the contrary, breathes heavily, as well as smoothness of the intercostal spaces on the affected side, can be determined. Often, especially with traumatic pneumothorax, subcutaneous emphysema is observed on the affected half of the chest - accumulation of air in the subcutaneous tissue of the chest wall, which can spread to other areas of the body with tension pneumothorax.

Survey

With percussion (percussion - tapping on certain 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.

Treatment of pneumothorax

Treatment tactics depend on the type of pneumothorax. Expectant conservative therapy is possible with small limited closed pneumothoraxes: the patient is provided with rest, painkillers are given. With a significant accumulation of air, drainage of the pleural cavity with the so-called passive aspiration using the Bobrov apparatus is shown.

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 anterior surface of the chest (with limited pneumothorax, a point is chosen above the place of the greatest accumulation of air), where a thin needle is injected layer by layer into soft tissues with a 0.5 solution of novocaine with a volume of 20 ml, after which the doctor cuts the skin and injects into trocar is a special tool consisting of a sharp stylet inserted into a hollow sleeve (tube). After removing the stylet through the channel of the sleeve (tube) of the trocar, the surgeon introduces a drain into the pleural cavity, and removes the sleeve. The drainage is fixed to the skin and connected to the Bobrov bank for passive aspiration. If passive aspiration is ineffective, active aspiration is used, for which a system of drains and Bobrov's jars are connected to a vacuum aspirator (suction). After complete expansion of the lung, the 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.

In traumatic open pneumothorax with massive damage to the lung, an emergency operation under general anesthesia is indicated, which consists in suturing the lung defect, stopping bleeding, layer-by-layer suturing of the chest wall wound and draining the pleural cavity.

With spontaneous pneumothorax, especially recurrent, to determine the nature of the pathology that led to it, they resort to thoracoscopy - an endoscopic examination method that consists in examining the patient's pleural cavity with a special instrument - a thoracoscope inserted through a puncture in the chest wall. If bullae are detected during thoracoscopy in the lung, which led to the development of pneumothorax, it is possible to surgically remove them using special endoscopic instruments.

With the ineffectiveness of drainage with passive or active aspiration and endoscopic techniques for thoracoscopy in stopping pneumothorax, as well as its recurrence, they resort to open surgery - thoracotomy, in which the pleural cavity is opened with a wide incision, the immediate cause of pneumothorax is identified and eliminated. In order to prevent recurrence of pneumothorax, the formation of adhesions between the visceral and parietal pleura is artificially caused.

Complications of pneumothorax

The main complications of pneumothorax are acute respiratory and cardiovascular failure, especially pronounced in tension pneumothorax and due to compression of the lungs and mediastinal displacement. With pneumothorax unresolved for a long time, reactive pleurisy may develop as a reaction of the pleura to the presence of air in the pleural cavity in the form of inflammation with fluid production; in case of infection, pleural empyema (accumulation of pus in the pleural cavity) or pyopneumothorax (accumulation of pus and air in the pleural cavity) may develop. In the case of a prolonged collapse of the lung caused by pneumothorax, sputum is difficult to expel from it, which clogs the lumen of the bronchi and contributes to the development of pneumonia. Sometimes pneumothorax, especially traumatic, is accompanied by the development of intrapleural bleeding (hemopneumothorax), while signs of respiratory failure are accompanied by symptoms of blood loss (pallor, increased heart rate, decreased pressure, and others); intrapleural bleeding can also complicate spontaneous pneumothorax.

Forecast

Tension 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. Bilateral pneumothorax is also extremely dangerous. Any pneumothorax requires immediate hospitalization of the patient in a surgical hospital for surgical treatment. With adequate timely treatment, spontaneous pneumothorax usually has a favorable prognosis, and the prognosis of traumatic pneumothorax depends on the nature of concomitant injuries to the chest organs.

Surgeon Kletkin M.E.