Air in the lungs causes and treatment of puncture. What is the danger of pneumothorax - the accumulation of air in the pleural cavity? How does the disease manifest itself?

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 occurs most often in tall, thin boys and men under 30 years of age and rarely in people over 40 years of age.

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

Classification of pneumothorax.

1. Spontaneous pneumothorax:

Primary;

Secondary.

2. Traumatic

Due to a penetrating chest injury;

Due to blunt chest trauma.

3. Iatrogenic.

Due to transthoracic needle aspiration;

Due to the placement of a subclavian catheter;

Due to thoracentesis or pleural biopsy;

Due to barotrauma.

By prevalence there are: 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), using modern research methods (computed tomography and thoracoscopy), emphysema-like changes (bulae and subpleural blebs), mainly in the apical parts of the lungs, are found to be more than in 80% of patients. The risk of developing PSP is 9–22 times higher in smokers than in non-smokers. Such a strong association between smoking and the occurrence of PSP suggests the presence of a specific pulmonary pathology. Indeed, relatively recently it was discovered that among smoking patients who underwent PSP, morphological changes in lung tissue in 87% of patients correspond to the picture of respiratory bronchiolitis.

The most common causes of VSP

Respiratory diseases:

COPD, cystic fibrosis, severe exacerbation of bronchial asthma.

Infectious lung diseases:

Pneumonia caused by Pneumocystis carinii; tuberculosis, abscess pneumonia (anaerobes, staphylococcus).

Interstitial lung diseases: 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), SSP develops in 2–6% of cases, of which 80% occur against the background of Pneumocystis pneumonia. VSP is a common (morbidity 6–20%) and potentially life-threatening complication (mortality 4–25%) of cystic fibrosis, occurring predominantly in men with a low body mass index, severe obstructive disorders (forced expiratory volume in 1 second - FEV 1 - less 50%) and chronic colonization Pseudomonas aeruginosa. In some rare lung diseases, belonging to the group of cystic lung diseases, the incidence of VSP is extremely high: up to 25% in histiocytosis X (eosinophilic granuloma) and up to 80% in lymphangioleiomyomatosis. The frequency 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 difficulty of diagnosing them using chest x-ray. Computed tomography (CT) of the chest can detect up to 40% of 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%; during catheterization of central veins (especially the subclavian vein) – 1 – 10%; with thoracentesis – 5 – 20%; with pleural biopsy – 10%; with transbronchial lung biopsy – 1 – 2%; during artificial pulmonary 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 mmHg. 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 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 a consequence 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 communication allows air into the pleural cavity only during inhalation; during exhalation it closes and prevents the evacuation of air. As a result of this “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.

History, complaints and physical examination:

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

The leading complaints with pneumothorax are chest pain and shortness of breath;

The pain is often described by patients as “sharp, piercing, dagger-like”, intensifies during inspiration, and can radiate to the shoulder of the affected side;

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

Less commonly, pneumothorax may cause symptoms such as dry cough, sweating, general weakness, and anxiety;

Symptoms of the disease most often subside within 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 small pneumothorax (less than 15% hemothorax), physical examination may not reveal any changes;

Tachycardia (more than 135 bpm), hypotension, paradoxical pulsus, distended jugular veins and cyanosis are signs of tension pneumothorax;

Possible development of subcutaneous emphysema;

The patient's survey should include questions about smoking history, episodes of pneumothorax and the presence of lung diseases (COPD, asthma, etc.), HIV, as well as hereditary Marfan 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 the collapse and decreased ventilation of the affected lung with preserved pulmonary perfusion (shunt effect). Hypercapnia develops rarely, only in patients with severe underlying lung diseases (COPD, cystic fibrosis); respiratory alkalosis is quite often present.

During VSP RaO2<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 T waves in leads V 1 – V 3.

X-ray of the chest organs.

To confirm the diagnosis, a chest x-ray is necessary (the optimal projection is anteroposterior, with the patient in an upright position).

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

A common finding in pneumothorax is displacement of the mediastinal shadow to the opposite side. 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 shift of the mediastinum is not a sign of 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 data in favor of pneumothorax, radiographs in the lateral position or lateral position on the side (decubitus lateralis) are indicated, which allows confirming the diagnosis in an additional 14% of cases.

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

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

CT scan.

For diagnosing small pneumothoraxes, CT is a more reliable method compared to radiography.

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

CT is indicated to determine the cause of VSP (bullous emphysema, cysts, interstitial lung diseases, etc.).

Determination of 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 for calculating the volume of pneumothorax based on X-ray and CT imaging methods. Some consensus documents propose an even simpler approach to determining the volume of pneumothorax:

pneumothoraxes are divided 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 divided depending on the distance between the apex of the lung and the dome of the chest: small pneumothorax with 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 ourselves to observation only (i.e. without performing procedures aimed at evacuating air) for small-volume PSP (less than 15% or when the distance between the lung and the chest wall is 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 resolution rate of pneumothorax is 1.25% of the hemothorax volume within 24 hours. Thus, a 15% pneumothorax volume will require approximately 8–12 days to completely resolve.

All patients, even with normal arterial blood gas composition, are prescribed oxygen - oxygen therapy can speed up the resolution of pneumothorax by 4-6 times. Oxygen therapy leads to denitrogenation of the blood, 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 pulmonary pathology. In patients with COPD and other chronic lung diseases, blood gas monitoring is necessary when prescribing oxygen, as hypercapnia may increase.

In case of severe pain, analgesics are prescribed, including narcotic ones; 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 of more than 15%; patients with VSP (with a distance between the lung and the chest wall of less than 2 cm) without severe dyspnea, under 50 years of age. Simple aspiration is carried out using a needle or, preferably, a catheter, which is inserted into the 2nd intercostal space along the midclavicular line, aspiration is carried out using a large syringe (50 ml), after completion of air evacuation, the needle or catheter is removed. Some experts recommend leaving the catheter in place for 4 hours after suctioning is completed.

If the first attempt at aspiration fails (the patient's complaints persist) and evacuation is less than 2.5 liters, repeated attempts at aspiration 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 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 in 33–67% with VSP.

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 over 50 years of age. Choosing the correct size of drainage tube is very important because the diameter of the tube, and to a lesser extent its length, determines the flow rate through the tube.

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, infections of the pleural cavity, subcutaneous emphysema. During the installation of a drainage tube, it is necessary to carry out intrapleural injection of local anesthetics (1% lidocaine 20–25 ml).

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

The use of suction (a source of negative pressure) is not necessary when draining the pleural cavity. The drainage tube is removed 24 hours after air has stopped flowing through it, if, according to a chest x-ray, expansion of the lung has been achieved.

Chemical pleurodesis.

One of the main tasks in the treatment of pneumothorax is to prevent repeated pneumothorax (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 layers of the pleura, which leads to obliteration of the pleural cavity. Chemical pleurodesis is indicated for: patients with the first and subsequent VSP and patients with the second and subsequent PSP, since this procedure helps prevent the occurrence of recurrent pneumothorax.

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

Surgical treatment of pneumothorax

The objectives of surgical treatment of pneumothorax are:

resection of bullae 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 (related to flying, diving).

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

Urgent events.

For tension pneumothorax it is indicated immediate thoracentesis(using a needle or cannula for venipuncture no shorter than 4.5 cm, in the 2nd intercostal space along 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 (parachuting, diving, diving).

The patient should be advised to quit smoking.

FORECAST.

Mortality from pneumothorax is low, 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 patients with COPD, when pneumothorax develops, the risk of death increases 3.5 times and averages 5%.

With pneumothorax, gas accumulates in the pleural cavity. In this case, irreversible phenomena occur in the lung tissues. The lung tissue begins to collapse. The blood vessels are compressed, and the dome of the diaphragm lowers.

The functional features of the respiratory and circulatory system begin to be disrupted. Air begins to penetrate the surface of the lung. The pressure inside the pleura increases. And it happens. A rather serious condition, in which not only lung function is impaired, but the respiratory system is also significantly affected.

Pneumothorax occurs as a result of various diseases. This includes injuries and injuries. In case of pneumothorax, immediate medical attention must be provided, otherwise the patient may soon die.

What it is?

How can this concept be characterized? Pneumothorax is the formation of air in the chest. Pneumothorax is divided into several types. Depending on the causes of pneumothorax, the following types are distinguished:

• traumatic;
• spontaneous;
• artificial.

Naturally, traumatic pneumothorax is a disease resulting from injuries. This also occurs as a result of closed injuries to internal organs. Spontaneous pneumothorax has a specific cause of disruption in the lung tissue. Various diseases matter.

Artificial pneumothorax is a special way of introducing air into the pleural area. This is necessary for carrying out therapeutic and diagnostic measures. There are also closed and open pneumothorax depending on the cause.

Causes

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

Other causes of pneumothorax are medical conditions. What diseases exactly cause pneumothorax? These diseases include:

• bullous disease;
• lung abscess;
• esophageal rupture;
• pyopneumothorax.

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

Symptoms

What are the main clinical signs of pneumothorax? The main symptoms of pneumothorax include stabbing pain on the side of the affected lung. The clinical presentation of pneumothorax depends on the type of disease. With open pneumothorax, the following symptoms are distinguished:

• forced position;
• bleeding from the wound;
• the injured side does not participate in the act of breathing.

The patient lies on the injured side, pressing the wound tightly. In this case, air is sucked into the wound, foamy blood is released. The affected side is not breathing. This is the severity of the disease.

Spontaneous pneumothorax manifests itself quite acutely. That is, external factors contributing to pneumothorax are involved in this process. In this case, these factors include:

• coughing attack;

In some cases, spontaneous pneumothorax is an independent disease. Or as a result of various diseases. Common symptoms of pneumothorax include:

• stabbing pain;
• sometimes the pain radiates to the sternum, arm, neck.

Accordingly, the resulting pain causes psychological problems in the patient. The patient is afraid of death. Often the skin becomes agitated and cyanosis occurs. Including pallor and dry cough.

A significant symptom of pneumothorax is shortness of breath. Rapid breathing may occur, including respiratory failure. Respiratory failure is characteristic of severe pneumothorax.

But after a certain time, shortness of breath disappears. Subcutaneous emphysema develops. It should also be noted that auscultation reveals weakened breathing or its complete absence. The development of inflammatory reactions in the pleura is of great importance.

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Diagnostics

A visual examination of the patient is of great importance in the diagnosis of pneumothorax. This reveals a certain position and cold skin. Including lowering blood pressure. Anamnesis is also important in diagnosis.

Anamnesis includes collecting the necessary information. This primarily applies to spontaneous pneumothorax. Since spontaneous pneumothorax often reveals various pathologies. The history includes both the time of onset of pneumothorax and clinical signs.

In the diagnosis of pneumothorax, laboratory tests are practically irrelevant. Since the picture of blood and urine does not reveal pathological changes. Chest radiography is of great importance in diagnosis.

X-ray examination reveals changes on the side of the pneumothorax. On the side of the pneumothorax, a clearing zone is determined. In this case, there is no pulmonary pattern. Puncture of the pleural cavity is widely used in the diagnosis of pneumothorax. It allows you to obtain air in which there is no pressure in the pleura. Or it is at zero.

Naturally, it is necessary to diagnose pneumothorax immediately. Therefore, diagnosis is used immediately after first aid. Diagnostics is also aimed at consultation with specialists. This is especially true for a pulmonologist.

Prevention

How can you prevent pneumothorax? Its prevention is possible if the following measures are taken:

• treatment of the underlying disease;
• prevention of mechanical damage;
• prevention of damage during diagnostic and treatment procedures;
• injury prevention.

These measures allow for the prevention of pneumothorax. And eliminating the diseases that caused pneumothorax allows not only to improve the patient’s condition, but also to prevent complications. Including the development of pneumothorax.

Certain therapeutic measures aimed at curing lung diseases are indicated. The timeliness of these activities is especially necessary. This helps prevent pneumothorax.

You should also know that patients who have had pneumothorax should avoid physical activity. This helps prevent relapses of the disease. Including helping to prevent complications. In some cases, surgery is required.

During surgery, it is necessary to remove the source of the disease. This is especially true for recurrent pneumothorax. After all, pneumothorax in the presence of lung diseases can be repeated repeatedly.

Treatment

Treatment measures for pneumothorax are aimed at providing first aid to the patient. First aid is as follows:

• application of an occlusive dressing;
• pain relief with narcotic and non-narcotic drugs;
• intravenous administration of morphine in saline solution;
• analeptics;
• use of transfusion therapy;
• rheopolyglucin;
• oxygen therapy.

A mandatory condition is hospitalization in the surgical department of the hospital. The application of an occlusive dressing involves the process of preventing air from entering the pleural cavity. The introduction of narcotic and non-narcotic drugs helps reduce the pain threshold.

Transfusion therapy allows you to ensure the blood circulation process. With normal breathing parameters. It will also provide other physiological conditions.

In addition to the above assistance, a puncture of the pleural cavity should be performed. This event allows you to restore negative pressure. Including evacuating air from the pleura.

Treatment of open pneumothorax allows you to convert pneumothorax into a closed form. In this case, the defect of the pleural cavity is sutured. Valvular pneumothorax is converted into open pneumothorax. This is done using a puncture with a thick needle.

If recurrent pneumothorax occurs, then surgery is indicated. It involves removing air cysts. In turn, it ensures the effectiveness of treatment measures.

In adults

Pneumothorax occurs in adults at any age. Most often this is the middle age category. Mostly pneumothorax often occurs in males. Although it sometimes occurs in women.

Spontaneous pneumothorax is common in men. In this case, the age category from twenty years to fifty is important. Spontaneous pneumothorax can also occur in people actively involved in sports. For example, swimming. Maybe for pilots too. This is due to the following processes:

• diving;
• deep immersion in water;
• flying an airplane at high altitude.

Secondary pneumothorax in adults may be a consequence of active tuberculosis. It is known that tuberculosis usually affects males. This is due to poor nutrition, unhealthy lifestyle and other pathologies.

Social insecurity of people, including economic, often contributes to tuberculosis. Tuberculosis is the most serious lung disease. At the same time, the massive spread of Koch's bacillus leads not only to diseases of the internal organs, but also to changes in the pleural cavity.

Clinical signs of pneumothorax in adults include the phenomena of unilateral and bilateral pneumothorax. Bilateral pneumothorax is most dangerous. Leads to respiratory failure. What complications occur with pneumothorax?

Complications of pneumothorax can be different. In one case or another, any complications contribute to the development of the following pathological processes:

• exudative pleurisy;
• hemopneumothorax;
• acute respiratory failure;
• pleural empyema;
• subcutaneous emphysema.

In children

Pneumothorax in children occurs as a result of various pathological processes. This includes congenital pathologies. As well as inflammatory processes and injuries.

Pneumothorax is especially dangerous in the newborn state. Newborn babies may experience a lack of breathing. The process subsequently leads to rupture of the lung tissue. If various complications occur, pneumothorax may result from:

• blockage of breathing with mucus;
• blockage of breathing by amniotic fluid.

If a child has suffered from pneumonia, then the cause of pneumothorax is pneumonia. Of course, in the absence of proper treatment or untimely therapy. Symptoms of childhood pneumothorax are as follows:

• cyanosis;
• anxiety;
• dry cough;
• tissue tension on the affected side;
• a sharp deterioration in health;
• cardiopalmus;
• dyspnea.

These signs are most appropriate in newborns. And also in older children. This requires appropriate diagnostics. Since just examining a sick child is not sufficient for diagnosis.

It should be noted that pneumothorax in premature infants has the most unfavorable prognosis. If there is a blood disease together with pneumothorax, then fatal outcomes are possible. The younger the child, the more severe the pneumothorax.

Forecast

For pneumothorax, the prognosis depends on its type. And also on the course of the disease and the presence of concomitant pathologies. The prognosis is also unfavorable when relapses occur.

Spontaneous pneumothorax may have a favorable prognosis. If the underlying disease is eliminated. Since the further course of pneumothorax depends on the presence of the underlying disease.

The prognosis also depends on the age of the patient. And also from the possible causes of this condition. If the causes are congenital, then pneumothorax often recurs. That is why we can talk about an unfavorable prognosis.

Exodus

Pneumothorax can be fatal. However, recovery is also possible. Recovery only with uncomplicated forms of pneumothorax. In severe cases, death usually occurs.

If the underlying causes are eliminated, then relapses do not occur. The outcome of severe pneumothorax is respiratory failure. Especially when two lobes of the lung are affected.

Pathology of the lungs leads to irreversible phenomena. Pneumothorax is also aggravated. This condition may occur repeatedly. The outcome is also influenced by the prescribed treatment.

Lifespan

Life expectancy is higher if basic treatment is carried out on time. In addition, life expectancy is influenced by the course of the disease. If pneumothorax is a consequence of trauma, then this does not affect life expectancy.

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

It is necessary to carry out timely diagnosis and treat the disease on time. Rely on the diagnosis and identification of the underlying disease. This allows immediate action to be taken and significantly increases life expectancy.

• Sudden pain in the chest - acute, intensifying during inspiration; may radiate to the shoulder of the affected side.
• Sudden shortness of breath - difficulty breathing, rapid shallow breathing.
• A dry cough is possible.
• Increased heart rate.
• Cold, sticky sweat appears on the skin.
• General weakness.
• Feeling of fear.
• In case of severe respiratory and circulatory disorders - cyanosis of the skin.
• With an open pneumothorax (the presence of a chest wound through which the pleural cavity communicates with the external environment), during inhalation through the wound air is sucked in with a whistle; during exhalation, air comes out through the wound, “foaming” the blood released from the wound.

Forms

• Closed pneumothorax– develops in cases where air enters the pleural cavity through a pleural defect, but the defect is small and quickly closes. There is no communication between the pleural cavity and the environment, and the volume of air entering the pleural cavity does not increase. Clinically, it has the mildest course: a small amount of air can resolve on its own.
• Open pneumothorax- an accumulation of air in the pleural cavity that communicates with the environment through a wound in the chest wall or through a damaged large bronchus. When you inhale, air enters the pleural cavity, and when you exhale, it comes out back. The pressure in the pleural cavity becomes equal to atmospheric pressure, which leads to the collapse of the lung and its exclusion from breathing.
• Valve (tension) pneumothorax- the most difficult option. If the wound is large and a medium-sized bronchus is damaged, a valve structure is formed that allows air into the pleural cavity at the time of inhalation and prevents it from escaping into the environment during exhalation, while the volume of air in the pleural cavity gradually increases. This leads to displacement and compression of the mediastinal organs (heart, large vessels) with significant respiratory and circulatory disorders.

Causes

Based on the causes of occurrence, the following types of pneumothorax are distinguished.

• Spontaneous (spontaneous) pneumothorax– rupture of a bronchus or part of the lung, not associated with mechanical damage to the lungs or chest.
  • Primary(idiopathic) – occurs for no apparent reason. It is more common in young, tall men aged 20-40 years. As a rule, it is based on:
    • genetically determined deficiency of the enzyme alpha-1-antitrypsin, which leads to pathological changes in the lungs;
    • congenital weakness of the pleura, which easily ruptures with strong coughing, laughter, deep breathing, intense physical effort;
    • It is possible to develop spontaneous pneumothorax during deep immersion in water, diving, or flying in an airplane at high altitude (associated with pressure changes).
  • Secondary(symptomatic) – against the background of existing pulmonary pathology:
    • diseases of the respiratory tract, for example, chronic obstructive pulmonary disease (COPD is a chronic inflammatory disease of the respiratory system that occurs under the influence of various environmental factors, the main one of which is smoking, leading to the development of chronic respiratory failure), cystic fibrosis (a hereditary disease characterized by dysfunction of the glands of the external secretions, including bronchial secretions, which leads to the appearance of viscous, thick sputum), severe exacerbation of bronchial asthma;
    • infectious diseases of the lungs: for example, tuberculosis (an infectious disease caused by Mycobacterium tuberculosis), lung abscess (a limited focus of inflammation of the lung tissue with its melting and the formation of a cavity filled with purulent masses), pneumonia (pneumonia) due to HIV infection;
    • lung diseases that affect connective tissue: fibrosing alveolitis, lymphangioleiomyomatosis, sarcoidosis, histiocytosis X;
    • systemic connective tissue diseases affecting the lungs (systemic scleroderma, rheumatoid arthritis, dermatomyositis);
    • tumors (lung cancer).
• Traumatic pneumothorax – for chest injuries:
  • penetrating chest injury;
  • blunt chest trauma.
• Iatrogenic pneumothorax, associated with medical procedures:
  • during a biopsy (taking a small area for examination) of the lungs or pleura;
  • during puncture (puncture of the pleural cavity for the purpose of pumping out pathological contents);
  • when placing a subclavian catheter;
  • during artificial ventilation (barotrauma).

Diagnostics

• General examination (examination of the chest, listening to the lungs using a phonendoscope).
• X-ray of the chest organs, which allows you to detect air in the pleural cavity (the cavity formed by the layers of the pleura - the outer layer of the lungs). It is the main method for diagnosing pneumothorax.
• Computed tomography – to identify the causes of secondary spontaneous pneumothorax and if radiography is insufficiently informative.
• Study of blood gas composition. The method is auxiliary.
• Electrocardiography (ECG) - allows you to detect changes in the functioning of the heart during tension (valve) pneumothorax. The method is auxiliary.
• A consultation with a thoracic surgeon is also possible.

Treatment of pneumothorax

• If there is a small amount of air in the pleural cavity that does not interfere with the breathing mechanism, it can resolve on its own and does not require treatment.
• Pleural puncture with suction of air from the pleural cavity (the cavity formed by the layers of the pleura - the outer lining of the lungs).
• Drainage of the pleural cavity with the installation of a drainage tube through which air will be removed from the pleural cavity.
• Surgical suturing of ruptured lungs, bronchi, and chest wall wounds.
• Painkillers (for severe pain).
• Oxygen therapy (long-term oxygen supply through special tube systems).
• Pleurodesis is the fusion of the pleura with the help of special drugs injected into the pleural cavity or surgically (for frequently recurring pneumothorax).

Complications and consequences

• Intrapleural bleeding.
• Pleurisy is inflammation of the pleura with the possible formation of adhesions leading to impaired expansion of the lung.
• Subcutaneous emphysema - release of air into the subcutaneous fat. It is defined as areas of swelling, swelling of the subcutaneous tissue, when pressed, a sound resembling the crunch of dry snow occurs.
• Penetration of air into the mediastinal tissue with compression of the heart and large vessels.
• In severe cases (large volume of damage, significant penetrating injury to the chest), death is possible.

Prevention of pneumothorax

• Timely treatment of lung diseases.
• To give up smoking.
• Avoiding chest injuries.
• Prevention of repeated pneumothoraxes (if they are repeated frequently) - pleurodesis (fusion of the pleura with the help of special drugs injected into the pleural cavity or surgically).

Pneumothorax is a pathological condition in which air enters the pleural cavity, causing the lung to partially or completely collapse. As a result of collapse, the organ cannot perform the functions assigned to it, so gas exchange and oxygen supply to the body suffers.

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

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

Causes of occurrence and mechanisms of development

The lung has no muscle tissue, so it cannot expand itself to allow breathing. The inhalation mechanism is as follows. In normal conditions, the pressure inside the pleural cavity is negative - less than atmospheric pressure. When the chest wall moves, the chest wall expands, thanks to the negative pressure in the pleural cavity, the lung tissues are “picked up” by the traction inside the chest, the lung expands . Next, the chest wall moves in the opposite direction, the lung, under the influence of negative pressure in the pleural cavity, returns to its original position. This is how a person performs the act of breathing.

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

Air can enter the pleural cavity in two ways:

• in case of damage to the chest wall with violation of the integrity of the pleural layers;
• with damage to the mediastinal organs and lungs.

The three main parts of pneumothorax that cause problems are:

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

The inability to expand the lung is associated with the re-entry of air into the pleural cavity, blockage of the bronchus due to previously noted diseases, and also if the pleural drainage was installed incorrectly, which is why it does not work effectively.

note

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

Symptoms of pneumothorax

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

Non-traumatic, mild pneumothorax can often pass without any symptoms.

Diagnostics

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

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

Sometimes radiography can be uninformative - in particular:

• for small pneumothorax;
• when adhesions have formed between the lung or chest wall, partially holding the lung from collapsing; this happens after severe pulmonary diseases or operations for them;
• due to skin folds, intestinal loops or the stomach - confusion arises as to what is actually revealed in the image.

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

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

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

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

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

To confirm pulmonary heart failure, which manifests itself with tension pneumothorax, do.

Differential diagnosis

In its manifestations, pneumothorax may be similar to:

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

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

Sometimes the pain with pneumothorax is similar to pain with:

• diseases of the musculoskeletal system;
• oxygen starvation of the myocardium;
• diseases of the abdominal cavity (may radiate to the stomach).

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

Treatment of pneumothorax and first aid

In case of pneumothorax it is necessary:

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

There is a rule: open pneumothorax should be converted to closed, and valve pneumothorax to open.

To carry out these measures, the patient should be immediately hospitalized in the thoracic or, at a minimum, surgical department.

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

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

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

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

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

Prevention

Primary spontaneous pneumothorax can be prevented if the patient:

• stop smoking;
• will avoid actions that could lead to rupture of weak lung tissue - jumping into water, movements associated with stretching the chest.

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

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

Forecast

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

After a patient first experiences spontaneous pneumothorax, relapse may occur in half of patients over the next 3 years . This high rate of recurrent pneumothorax can be prevented by using treatments such as:

• video-assisted thoracoscopic surgery during which the bullae are sutured;
• pleurodesis (artificially induced pleurisy, as a result of which adhesions are formed in the pleural cavity, holding the lung and chest wall together

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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 one side, and the lung itself on the other side, begins to interfere with the normal functioning of the lung. During normal breathing, the lung collapses and expands completely, but with pneumothorax, the air gap that appears does not allow the lung to expand completely.

Pneumothorax most often occurs in patients who have suffered chest injuries. But cases of pneumothorax as a complication of any disease cannot be 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 based on 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 trauma
• Blunt chest trauma

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

In connection with 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 over 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 a lung that has collapsed due to damage to the chest (for example, the lung was damaged by a fragment of a rib) must exist in negative pressure in the pleural cavity, and since damage to the chest has established pressure in the pleural cavity equal to atmospheric pressure, then the first thing that needs to be done 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 escape back. Thus, with each breath, the pressure in the pleural cavity increases and can lead to confusion of the mediastinal organs, pleuropulmonary shock, as well as the exclusion of the lung from breathing.

According to the severity of the disease

• Parietal pneumothorax
• Complete pneumothorax
• Ensacculated pneumothorax

Parietal pneumothorax- a variation of the disease in which the pleural cavity contains a small amount of air, 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), the air takes up as much space as possible in the pleural cavity, preventing the lung from expanding.

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

It is important to note that 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 injury - closed or open, damage to the lung due to rib fragments or penetrating (for example, knife) wounds
• Iatrogenic injuries - as we have already written, injuries that occurred after medical or surgical intervention, in other words, this is an injury to the lung during the provision of 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 rupture of the cavity or breakthrough of caseous foci

Symptoms of pneumothorax

The main symptoms of pneumothorax are chest pain and sudden 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 to go about my normal activities, simply taking a five-minute break to catch my breath.

How is pneumothorax treated?

What to do if you are diagnosed with 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 thought.

During your hospital stay, in case of spontaneous pneumothorax (which is the most common occurrence), you will have a Bülau drainage. This is a technique for sucking 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, and the other end will be inserted into a special solution. At the end of this tube there 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 have to get over it. I, as a person who had never been in a 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, the tube will be removed from your body at the discretion of your primary care physician, and your fully expanded lung will continue to perform its normal function. And you will remain to rest in the hospital for your prescribed 3-4 days, receiving a dose of antibiotics and painkillers 3 times a day. 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 computed tomography 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 repeated pneumothorax, as well as to identify the reasons for its appearance for the first time.

Diagnosis of the disease

• Radiography
• CT scan

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

Video about pneumothorax