Pneumothorax lung treatment. Pneumothorax of the lung - causes, diagnosis, treatment, surgery and prevention

A suddenly out of breath person requires emergency care. Often such symptoms appear with pneumothorax, which is open, closed, spontaneous, etc. Below we will analyze what are the causes of different forms of the disease, what signs they have, and what first treatment is required.

What it is

Pneumothorax is a phenomenon in which air enters the pleural cavity and accumulates there. As a result, the normal functioning of the pulmonary system is disrupted and the person suffers from symptoms of improper breathing and related signs. Pathology has different causes, it is typical for adults of age 18-45 years old.

During an attack, the patient needs emergency care, because due to a severe pneumothorax, breathing can completely stop and the person will die. Below we will take a closer look at what first symptoms the disease has and how to provide first aid.

Due to excessive accumulation of air in the space of the pleura, there is a short-term or long-term impairment of lung function, which can lead to cardiovascular insufficiency. The main factor leading to pneumothorax is the presence of defects and damage in the pleura sheets through which air enters the space between them. Damage occurs for various reasons, due to injuries, other mechanical influences, etc.

As a result, intrapleural pressure is greatly increased, which is normally lower than atmospheric pressure. This ends with the collapse of the lung, which is also called collapse.

In addition to rapid and difficult breathing, the main symptom of pneumothorax is a sharp pain syndrome in the chest. A constant lack of oxygen leads to blanching and cyanosis of the skin, which is especially noticeable on the face. A person begins to literally suffocate and, if he is late with emergency care and subsequent treatment, he is able to die.

ICD-10 code

Pneumothorax of various types according to the international classification is included in the class J93. At the same time, spontaneous has a code according to ICD-10 - J93.1.

Classification and types

According to the main classification, pneumothorax is divided into two global types that characterize the presence of communication with the external environment:

• Open means the entry of air through external defects on the body, which is typical for various injuries leading to depressurization of the respiratory organs from the outside.
• Closed pneumothorax is not in contact with the external environment, damage is present from within the lung. Usually it is milder, the symptoms and signs are less pronounced, but it comes on suddenly without noticeable reasons for others, which does not allow you to quickly understand what the problem is and quickly respond adequately.

The following type of classification divides the disease according to its prevalence, the disease is classified as:

• Unilateral when only one lung collapses.
• Bilateral- the pathological condition affects both lungs. This type is more dangerous, since there is no reserve lung lobe through which it is possible to maintain the supply of oxygen to the body.

Classification for reasons divides pneumothorax into:

1. Traumatic, appearing with a penetrating wound in the chest, for example, with a knife or with a fracture of the ribs and damage to the lungs by their fragments.
2. Spontaneous, which is always closed, and comes on completely unexpectedly. It is difficult to treat in such a situation, since the exact cause is not clear.
3. A tension pneumothorax means that the pleural area receives air, but it does not leave it and gradually fills from the inside. This state is called complete collapse.
4. Secondary, meaning a consequence of any disease of the lungs or adjacent organs.
5. Artificial, also called iatrogenic. It is specially created by the doctor as part of a special treatment, such as a pleural biopsy.

To characterize pneumothorax, it is important to divide it according to how much gas is in the interpleural zone. According to this type, pathology is classified into:

• Partial (partial, limited), when the lung does not fall completely;
• Total;

The reasons

The whole set of factors leading to pneumothorax is divided into three subgroups:

• Respiratory diseases;
• Injuries, wounds, wounds;
• Measures necessary for any treatment;

Various internal problems with the lungs and associated organs often lead to spontaneous pneumothorax, which appears without apparent underlying causes. Usually the symptoms of the disease appear:

1. due to bullous disease;
2. with airway obstruction, cystic fibrosis, status asthmaticus;
3. as a result of infectious lesions such as pneumonia, tuberculosis;
4. with pathologies in the connective structures of the lungs due to rheumatoid arthritis, ankylosing spondylitis, polymyositis;
5. with a cancerous tumor and lung metastases;
6. as a consequence of breast endometriosis;

Consider what causes pneumothorax in different types.

Symptoms of pneumothorax

Pneumothorax is associated with accumulations of air masses in the pleural zone, which leads to compression of the lungs and their displacement. This situation turns into the following pronounced symptoms:

• The process of inhalation is highly complicated, the patient breathes superficially and often;
• There is a dry cough;
• The heart is accelerated (tachycardia) and beats irregularly;
• There is pain inside the chest;
• The skin of the face and body turns pale and then turns blue due to oxygen deficiency;
• Of the psychological factors, signs of fear and depression are noticeable;
• Falling below normal blood pressure;
• Under the skin, manifestations and symptoms of emphysema are noticeable, i.e. air pockets
• The sick person takes a comfortable posture in a sitting or semi-sitting position;
• The department of sweat increases;

The extent to which the symptoms of pneumothorax will be expressed depends on the causes of the disease.

1. With a spontaneous form in the chest, severe pain is felt in the place where the breakthrough occurred. At first, the pain sensations are characterized by many as sharp, in the future they become aching and dull.
2. Valvular pneumothorax leads to the fact that the patient is very excited, a stabbing pain center is felt in the sternum. Among other signs, there is a sensation of pain symptoms in the shoulder blades, collarbone, and belly.

With open, intense pleural and other types of pneumothorax, during a spontaneous or obvious exacerbation, the patient quickly weakens. At such a moment, he needs urgent first aid, otherwise there may be serious consequences and complications, up to death.

Effects

Due to the rapid development of symptoms of pneumothorax, consequences can only be avoided in half of the cases. In other situations, the following consequences are formed after:

• Pleural emphysema with the development of purulent pleurisy, pyothorax.
• Intrapleural bleeding due to damage to lung structures.

With valve-type pneumothorax, subcutaneous emphysema is often formed when air accumulates under the epidermis.

In the absence of treatment and chronic pneumothorax, the lung tissue is gradually replaced by connective tissue, due to which the organ wrinkled, loses elasticity and functionality. All this leads to lack of heart and death.

Diagnostics

The primary diagnosis of "pneumothorax" is made during the initial examination, based on what symptoms the patient suffers from. To do this, the doctor pays attention to:

1. a posture when a sitting or half-sitting position is taken, in which it is easier to breathe;
2. the presence of cold sweat on the skin, shortness of breath, cyanosis or pallor;
3. Expanded spaces between the ribs with restriction of the course of the chest from the side of the focus;
4. low blood pressure, tachycardia, change in the position of the heart in the direction of a normal lung;

The best diagnostic method for pneumothorax is considered x-ray. This is a fast and affordable method with sufficient accuracy. An x-ray is needed during inhalation or exhalation, depending on the extent of the lesion.

A photo. What can be seen on x-ray

If necessary, differentiation from other diseases is carried out tomography, which gives a more accurate result. During diagnosis, pneumothorax is important to separate from:

• Asphyxia;
• Pleurisy;
• emphysema;
• aortic aneurysms;
• Diaphragmatic hernia;

First aid

A situation of acute lack of air is associated with pneumothorax, threatening death, so it is important to know how to provide first aid to people with such a pathology.

First of all, an ambulance is called by number 103 , while it is necessary to explain that the case is emergency and requires the urgent arrival of doctors. Prior to the arrival of doctors it is necessary:

1. stop bleeding;
2. Do not allow air to enter the pleural space;

It is impossible to give additional specific instructions, since much depends on individual factors, the depth of the wound, etc.

Arriving medical workers should provide medical emergency assistance - administer the necessary drugs, based on the patient's condition, urgently hospitalize him in the pulmonology department, where first aid will consist of a pleural puncture to remove air bubbles from the pleura zone.

Treatment of pneumothorax

The patient undergoes the first treatment while still in the ambulance, it consists of:

• In oxygen therapy;
• Pain relief, since the process of such defective breathing causes noticeable pain;
• Suppression of cough causing pain symptoms;
• Pleural puncture;

Further therapy is determined by the type of pneumothorax:

The terms of treatment vary from a couple of weeks to 6-8 months, based on the causes and severity of the condition.

Rehabilitation

According to statistics, every fifth person who has had a pneumothorax caused by an internal disease is prone to relapse due to a violation of the recovery and rehabilitation regimen. Under such conditions, the exacerbation can be bilateral, which carries huge risks of death, so during the recovery period, you need to adhere to a number of rules and principles:

• Within a month after discharge, do not experience even minor physical exertion, do not fly on airplanes, as sharp drops in atmospheric pressure occur during the flight;
• Exclude other types of activity in which the ambient pressure "jumps" sharply;
• To give up smoking;
• Be examined for infectious pathologies of the lungs;

Forecast

With pneumothorax of any kind, immediate hospitalization is required with emergency first aid and subsequent diagnosis of the condition of the lungs and pleural cavity. The prognosis of survival is highly dependent on the characteristics and type of pathology. With a bilateral form, the survival rate is about 50%.

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

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

Types of pneumothorax

Due to the occurrence

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

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

• Primary
• Secondary

Traumatic- in this case, the chest is damaged.

• Penetrating chest injury
• Blunt chest trauma

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

Due to the environment

• Closed pneumothorax
• Open pneumothorax
• Valvular pneumothorax

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

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

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

According to the severity of the disease

• Parietal pneumothorax
• Complete pneumothorax
• Encapsulated pneumothorax

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

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

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

It is important to note that a complete bilateral pneumothorax leads to rapid death if the necessary assistance is not provided in a timely manner due to impaired respiratory function.

Causes of pneumothorax

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

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

Symptoms of pneumothorax

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

How is pneumothorax treated?

What to do if you have a pneumothorax? First, immediately agree to hospitalization. This will be the surgical department of the hospital, where you will stay for at least a week. You will need to get used to this idea.

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

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

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

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

Diagnosis of the disease

• Radiography
• CT scan

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

Video about pneumothorax

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 TB patients when the tuberculous cavity is deliberately 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 diseases: 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 bubbles 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.

DEFINITION.

Pneumothorax- presence of air in the pleural cavity .

RELEVANCE.

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

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

CLASSIFICATION.

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

Classification of pneumothoraxes.

1. Spontaneous pneumothorax:

Primary;

Secondary.

2. Traumatic

Due to a penetrating wound of the chest;

Due to blunt trauma to the chest.

3. Iatrogenic.

Due to transthoracic needle aspiration;

Due to the placement of a subclavian catheter;

Due to thoracocentesis or pleural biopsy;

due to barotrauma.

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

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

ETIOLOGY.

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

The most common causes of SVD

Respiratory diseases:

COPD, cystic fibrosis, severe exacerbation of bronchial asthma.

Infectious diseases of the lungs:

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

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

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

Tumors: lung cancer, sarcoma.

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

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

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

PATHOGENESIS.

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

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

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

DIAGNOSTICS.

Anamnesis, complaints and physical examination:

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

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

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

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

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

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

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

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

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

Possible development of subcutaneous emphysema;

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

Laboratory research:

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

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

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

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

X-ray of the chest organs.

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

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

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

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

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

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

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

CT scan.

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

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

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

Determining the size of pneumothorax.

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

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

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

TREATMENT.

Treatment goals:

resolution of pneumothorax.

Prevention of repeated pneumothoraxes (relapses).

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

Observation and oxygen therapy;

simple aspiration;

Installation of a drainage tube;

Chemical pleurodesis;

Surgery.

Observation and oxygen therapy.

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

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

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

Simple aspiration

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

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

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

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

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

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

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

Chemical pleurodesis.

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

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

Surgical treatment of pneumothorax

The objectives of the surgical treatment of pneumothorax are:

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

performing pleurodesis.

Indications for surgical intervention are:

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

bilateral spontaneous pneumothorax;

contralateral pneumothorax;

spontaneous hemopneumothorax;

recurrence of pneumothorax after chemical pleurodesis;

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

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

urgent events.

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

Patient education:

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

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

The patient should be advised to stop smoking.

FORECAST.

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

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

Pneumothorax (Greek pneuma, "air" + thorax, "chest, chest") - the accumulation of air in the pleural cavity. This is an acute condition in which the patient needs to be hospitalized in a surgical hospital.

Types and causes of pneumothorax

If the communication between the environment and the pleural cavity has stopped, pneumothorax is called closed. If there is free access of air to the pleural cavity and exit from it, this is an open pneumothorax. In valvular pneumothorax, inhaled air enters the pleural cavity, but cannot exit it and accumulates, which leads to displacement of the lung and other organs of the chest.

According to the mechanism of development, pneumothorax is distinguished:

• spontaneous,
• traumatic,
• artificial.

Spontaneous pneumothorax

Spontaneous pneumothorax develops when the inner pleura is torn and air from the lungs enters its cavity. This condition is more common in younger, underweight men. It can be caused by a malformation of the lungs, and can also be a complication of various lung diseases: tuberculosis, bullous emphysema, cyst, lung abscess, etc., in which air cavities can form in the lungs. With a strong cough, deep breathing, sudden movements, during stress, the wall of such a cavity is damaged, and air escapes between the pleura. When pus enters the pleural cavity, a serious complication develops - pleural empyema.

Traumatic pneumothorax

This condition occurs with an open chest wound or with blunt chest trauma with lung injury. Less often, complications of medical manipulations - pleural puncture, bronchoscopy with removal of a foreign body, etc. become the cause of pneumothorax. Operational pneumothorax can occur during interventions accompanied by opening the chest.

Artificial pneumothorax

Previously, this method was used to treat pulmonary tuberculosis to collapse the resulting cavities - caverns. In modern conditions, air is introduced into the pleural cavity during its endoscopic examination, with certain types of X-ray examination under the strict supervision of medical personnel.

Symptoms of pneumothorax

Spontaneous pneumothorax develops suddenly, manifested by acute "dagger" pain in the chest,. Sometimes there is a dry cough. A sick person cannot lie down, usually takes a semi-sitting position. With valvular pneumothorax, shortness of breath quickly increases, the face turns blue, weakness increases, loss of consciousness may develop.

With a small volume of air entering the pleural cavity, the pain quickly subsides, sometimes shortness of breath and palpitations persist. Pneumothorax may not manifest itself clinically (asymptomatic course).

With traumatic pneumothorax, the general condition of the patient suffers significantly. Shortness of breath is expressed (the frequency of respiratory movements reaches 40 per minute), cyanosis of the skin. Arterial pressure decreases, pulse quickens, develops. From a wound on the chest wall, when breathing, blood is released with air bubbles. Especially dangerous is valvular pneumothorax, in which air quickly accumulates in the pleural cavity, causing lung collapse, displacement and compression of the mediastinal organs (heart, large vessels, bronchi).

In traumatic pneumothorax, air sometimes spreads into the subcutaneous tissue of the face, neck, and chest wall. These parts of the body thicken, take on a swollen appearance. If you touch the skin with subcutaneous emphysema, you can feel a characteristic sound that resembles the crunch of snow.

Treatment of pneumothorax

A patient with symptoms of pneumothorax should be immediately taken to a surgical hospital. When providing first aid, you need to give the patient a semi-sitting position. If there is a chest wound with the release of blood from it with air bubbles, it is urgent to apply a sealing bandage on it with an adhesive plaster or ordinary oilcloth or cellophane. It is important to allow air to enter the pleural cavity!

With a sharp drop in blood pressure, severe shortness of breath, cyanosis of the face, an urgent pleural puncture with a thick needle is indicated. It is carried out in the II / III intercostal space along the midclavicular line. The needle is fixed to the skin with adhesive tape.

During transportation, painkillers can be administered to the patient. With the development of cardiopulmonary insufficiency, resuscitation is carried out.

In a hospital, the pleural cavity is drained to remove air and prevent infectious complications. The drain is removed 1-2 days after the lung is fully expanded. If drainage is ineffective or in severe cases, an operation is immediately performed with suturing of the lung defect and restoring the integrity of the pleura.

Features of pneumothorax in children

Immediately after the first few breaths, the newborn may develop spontaneous pneumothorax. It occurs with uneven expansion of the lungs, especially against the background of malformations. In children under 3 years of age, this condition can be a complication. At an older age, pneumothorax occurs during a cough during an attack of bronchial asthma, inhalation of a foreign body, etc. This condition can be a complication of lung ventilation during various operations.

Pneumothorax in children may not manifest itself clinically. Sometimes it is possible to note a short-term cessation of breathing, in more severe cases - palpitations, cyanosis of the skin, convulsions.

The principles of treatment of pneumothorax in children are the same as in adults.

Which doctor to contact

In case of chest injuries or any conditions when there is acute pain in the chest, severe shortness of breath and the patient's state of health quickly worsens, it is necessary to call an ambulance, which will take the victim to the surgical hospital. After eliminating this life-threatening condition, the patient is examined by a pulmonologist to diagnose the underlying disease that led to the development of pneumothorax.

The first channel, the program "Live is great!" with Elena Malysheva, column "About medicine" on the topic "Pneumothorax" (from 34:05):

Educational video "Puncture of the pleural cavity with tension pneumothorax."