Detection of small pneumothorax is carried out using. Pneumothorax - diagnosis and treatment. Risk factors for spontaneous pneumothorax are

Pneumothorax is usually recognized already at stage of history taking and physical examination. Localized pain in the chest on the affected side is associated with the entry of air into the pleural cavity or tension of the adhesions. Then the pain may gradually subside. The severity of dyspnea does not always correlate with the volume of pneumothorax. Patients develop a cough that is dry or with sputum, which in turn is determined by concomitant diseases. Among other complaints, we can note general weakness, headache, palpitations, hemoptysis, pain in the epigastric region, etc. These complaints are not constant and are of little value for diagnosis. Up to 6% of patients have no complaints at all. With pneumothorax, three main physical signs are revealed: the absence or significant decrease in vocal tremor, with percussion over these areas a tympanic sound, and the auscultatory absence or weakening of respiratory sounds. With accompanying pleural effusion, there is a splashing sound, sometimes patients themselves feel the fluid in the pleural cavity. A pathognomonic sign is subcutaneous emphysema or mediastinal emphysema, which can occur anywhere in the chest wall or neck (gas syndrome).

Radiation research methods (radiography, fluoroscopy, tomography) by detecting air in the pleural cavity can definitively confirm the diagnosis. Chest X-ray (performed during inhalation and exhalation) reveals the presence of air in the pleural cavity by the absence of a vascular pattern in the lateral parts of the affected side and the presence of a clear border of the collapsed lung (not to be confused with the medial edge of the scapula!). Research shows that pneumothorax is best recognized on inspiratory radiographs. If the pneumothorax is small, then air can only be seen on an x-ray taken during exhalation. Repeated x-ray examinations may be required over a short period of time to determine the progression of the pneumothorax.

Air that has entered the pleural cavity usually envelops the lung in the form of a light stripe, which, when examined in the anterior position, is projected along the lateral wall of the chest. The visceral pleura of a collapsed lung is sometimes clearly visible. Due to a compensatory increase in blood supply to the pulmonary pattern, the pattern is more intense on the healthy side; a displacement of the heart to the opposite side is often observed, and when pneumothorax is complicated by exudative pleurisy, a horizontal fluid level is observed.

The readings of the pressure gauge - pneumothorax apparatus - are very important for diagnosis. Changes in intrapleural pressure make it possible to determine the type of pneumothorax. Negative pressure is characteristic of closed spontaneous pneumothorax, bronchial pressure close to atmospheric (fluctuations between -2 and +2 or -1 and +1) - for open, increasing positive pressure - for tension valve pneumothorax.

When air is removed from the pleural cavity in the case of a closed pneumothorax, the negative pressure increases; with an open pneumothorax, the pressure does not change; with a valve pneumothorax, the positive intrapleural pressure decreases slightly, but after a short period of time it rises again to the initial values. In some cases, to determine the presence of a pleuropulmonary fistula, coloring (methylene blue) or odorous substances are injected into the pleural cavity. The appearance of colored sputum or a smell in the exhaled air serves as evidence of the existence of a functioning fistula.

Closed pneumothorax is rarely complicated by exudative pleurisy. Open pneumothorax, as well as valve pneumothorax, are always complicated by purulent pleurisy with mixed microbial flora.

The clinical course of open pneumothorax is longer than closed pneumothorax, mainly due to the rapid (after 2-3 days) appearance of effusion in the pleural cavity. Valvular pneumothorax is the most severe. Increasing positive pressure in the pleural cavity increases shortness of breath; the patient is agitated in the first hours after the formation of valve pneumothorax. Excitement is a characteristic symptom of the initial period of oxygen starvation. Valvular (tension) pneumothorax usually leads to weakening of cardiac activity.

Complications of pneumothorax with purulent tuberculous pleurisy, especially of mixed etiology, aggravate the patient’s condition and worsen the prognosis.

General information

(Greek pnéuma - air, thorax - chest) - accumulation of gas in the pleural cavity, leading to collapse of lung tissue, displacement of the mediastinum to the healthy side, compression of the blood vessels of the mediastinum, lowering of the dome of the diaphragm, which ultimately causes respiratory dysfunction and blood circulation In pneumothorax, air can penetrate between the layers of the visceral and parietal pleura through any defect on the surface of the lung or in the chest. Air penetrating into the pleural cavity causes an increase in intrapleural pressure (normally it is lower than atmospheric pressure) and leads to the collapse of part or the whole lung (partial or complete collapse of the lung).

Causes of pneumothorax

The mechanism of development of pneumothorax is based on two groups of reasons:

Pneumothorax Clinic

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

A patient with an open pneumothorax takes a forced position, lying on the injured side and tightly pressing the wound. Air is sucked into the wound with noise, foamy blood mixed with air is released from the wound, the excursion of the chest is asymmetrical (the affected side lags behind when breathing).

The development of spontaneous pneumothorax is usually acute: after a coughing attack, physical effort, or without any apparent reason. With the typical onset of pneumothorax, a piercing stabbing pain appears on the side of the affected lung, radiating to the arm, neck, and behind the sternum. The pain intensifies with coughing, breathing, and the slightest movement. Often pain causes the patient to have a panicky fear of death. Pain syndrome in pneumothorax is accompanied by shortness of breath, the severity of which depends on the volume of collapse of the lung (from rapid breathing to severe respiratory failure). Pallor or cyanosis of the face appears, and sometimes a dry cough.

After a few hours, the intensity of the pain and shortness of breath weaken: the pain bothers you at the moment of taking a deep breath, shortness of breath manifests itself with physical effort. The development of subcutaneous or mediastinal emphysema is possible - the release of air into the subcutaneous tissue of the face, neck, chest or mediastinum, accompanied by swelling and a characteristic crunch upon palpation. On auscultation on the side of the pneumothorax, breathing is weakened or not heard.

In approximately a quarter of cases, spontaneous pneumothorax has an atypical onset and develops gradually. Pain and shortness of breath are minor, and as the patient adapts to new breathing conditions, they become almost unnoticeable. An atypical form of the course is characteristic of limited pneumothorax, with a small amount of air in the pleural cavity.

Clearly clinical signs of pneumothorax are determined when the lung collapses by more than 30-40%. 4-6 hours after the development of spontaneous pneumothorax, an inflammatory reaction from the pleura occurs. After a few days, the pleural layers thicken due to fibrin deposits and edema, which subsequently leads to the formation of pleural adhesions, making it difficult to straighten the lung tissue.

Complications of pneumothorax

Complicated pneumothorax occurs in 50% of patients. The most common complications of pneumothorax are:

• hemopneumothorax (when blood enters the pleural cavity)
• pleural empyema (pyopneumothorax)
• rigid lung (not expanding as a result of the formation of connective tissue cords)
• acute respiratory failure

With spontaneous and especially valvular pneumothorax, subcutaneous and mediastinal emphysema can be observed. Spontaneous pneumothorax occurs with relapses in almost half of patients.

Diagnosis of pneumothorax

Already upon examination of the patient, characteristic signs of pneumothorax are revealed:

• the patient takes a forced sitting or semi-sitting position;
• the skin is covered with cold sweat, shortness of breath, cyanosis;
• expansion of the intercostal spaces and chest, limitation of chest excursion on the affected side;
• decreased blood pressure, tachycardia, displacement of the boundaries of the heart in a healthy direction.

Specific laboratory changes for pneumothorax are not determined. Final confirmation of the diagnosis occurs after an X-ray examination. When radiography of the lungs, on the side of the pneumothorax, a zone of clearing is determined, devoid of a pulmonary pattern on the periphery and separated by a clear boundary from the collapsed lung; displacement of the mediastinal organs to the healthy side, and the dome of the diaphragm downwards. During diagnostic pleural puncture, air is obtained, the pressure in the pleural cavity fluctuates within zero.

Treatment of pneumothorax

First aid

Pneumothorax is a medical emergency that requires immediate medical attention. Any person should be ready to provide emergency assistance to a patient with pneumothorax: calm him down, ensure sufficient oxygen access, and immediately call a doctor.

For open pneumothorax, first aid consists of applying an occlusive dressing to hermetically seal the defect in the chest wall. An airtight bandage can be made from cellophane or polyethylene, as well as a thick cotton-gauze layer. In the presence of valvular pneumothorax, an urgent pleural puncture is necessary to remove free gas, straighten the lung and eliminate displacement of the mediastinal organs.

Qualified help

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

In case of closed pneumothorax, air is aspirated through a puncture system (a long needle with an attached tube) in a small operating room, observing asepsis. Pleural puncture for pneumothorax is performed on the injured side in the second intercostal space along the midclavicular line, along the upper edge of the inferior rib. In case of total pneumothorax, in order to avoid rapid expansion of the lung and the patient's shock reaction, as well as in case of defects in the lung tissue, drainage is installed in the pleural cavity, followed by passive aspiration of air according to Bulau, or active aspiration using an electric vacuum device.

Treatment of open pneumothorax begins with its transfer to a closed one by suturing the defect and stopping the flow of air into the pleural cavity. In the future, the same measures are carried out as for closed pneumothorax. In order to reduce intrapleural pressure, valve pneumothorax is first converted into open pneumothorax by puncture with a thick needle, then surgically treated.

An important component of the treatment of pneumothorax is adequate pain relief both during the period of collapse of the lung and during its expansion. In order to prevent recurrence of pneumothorax, pleurodesis is performed with talc, silver nitrate, glucose solution or other sclerosing drugs, artificially causing an adhesive process in the pleural cavity. For recurrent spontaneous pneumothorax caused by bullous emphysema, surgical treatment (removal of air cysts) is indicated.

Forecast and prevention of pneumothorax

In uncomplicated forms of spontaneous pneumothorax, the outcome is favorable, however, frequent relapses of the disease are possible in the presence of lung pathology.

There are no specific methods for preventing pneumothorax. It is recommended to carry out timely therapeutic and diagnostic measures for lung diseases. Patients who have had pneumothorax are advised to avoid physical activity and be examined for COPD and tuberculosis. Prevention of recurrent pneumothorax consists of surgical removal of the source of the disease.

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 a 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 lung collapse and its severity are 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

Pneumothorax is a disease characterized by the accumulation of air in the pleural cavity, which leads to complete or partial collapse of the lung, compression of the mediastinal vessels, prolapse of the diaphragm, followed by impaired circulatory and respiratory functions. The disease can occur spontaneously or develop due to medical procedures, existing injuries or lung diseases.

Types of pneumothorax

According to the method of entry and movement of gas in the pleural cavity, they are distinguished:

• Closed pneumothorax: characterized by the entry of air from the bronchus directly into the pleural cavity during inspiration. It has the mildest course, but can provoke infection in the presence of inflammatory processes in the bronchi;
• Open pneumothorax: characterized by the presence of damage in the chest wall, through which the pleural cavity communicates with the external environment. Along with inhalation, air enters the pleural cavity and is released during exhalation through a defect in the visceral pleura. With open pneumothorax, the pressure in the pleural cavity is compared with atmospheric pressure, which causes collapse of the lung and its exclusion from breathing;
• Tension “valvular” pneumothorax: a valve structure is formed that allows air into the pleural cavity during inhalation and prevents it from escaping into the environment during exhalation. At the same time, the volume of air in the pleural cavity gradually increases. Valve pneumothorax is characterized by: positive pressure inside the pleura, irritation of its nerve endings, persistent displacement of the mediastinal organs.

Menstrual and traumatic, primary and secondary spontaneous pneumothorax are also distinguished.

Causes of pneumothorax

In most cases, the causes of pneumothorax are:

• iatrogenic disorders (due to pleural puncture, acupuncture of the stellate ganglion, attempted catheterization of the subclavian vein);
• chest injuries due to injury or rupture;
• violations of the tightness of the lungs;
• rupture of cysts in bullous emphysema;
• failure of the stump after resection;
• tear due to adhesive pleurodesis;
• damage or separation of the bronchus;
• spontaneous rupture of the esophagus;
• pyopneumothorax (accumulation of pus, atmospheric air and gas in the pleural cavity);
• tuberculosis;
• necrotizing pneumonia;
• cystic fibrosis;
• bronchial asthma;
• lung diseases;
• connective tissue diseases.

Symptoms of pneumothorax

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

The development of spontaneous pneumothorax is usually acute and can occur after physical effort, a coughing fit, or for no reason at all. The first sign of spontaneous pneumothorax is stabbing pain on the side of the lung, which radiates to the arm, behind the sternum and neck. The slightest movement, breathing or coughing may intensify the pain.

Spontaneous pneumothorax is accompanied by shortness of breath, paleness of the face (up to a bluish tint), and a dry cough.

It is also possible to develop mediastinal or subcutaneous emphysema, which provokes the release of air into the subcutaneous tissue of the neck, face, mediastinum or chest.

Also, symptoms of pneumothorax can be: asymmetric movements of the chest, difficulty breathing, the characteristic sound of air being sucked from the chest, swelling of the neck veins, arterial hypotension, a weak but fast pulse.

Diagnosis of pneumothorax

To diagnose the disease, special instrumental studies are carried out, which include:

• chest x-ray (to detect pneumothorax and determine the degree of lung collapse);
• puncture of the pleural cavity (to detect sealing and lung compression syndrome);
• thoracoscopy (to indicate the cause of the disease).

When examining the patient, characteristic signs of pneumothorax may be revealed, such as:

• decreased blood pressure, displacement of the heart border to the healthy side, tachycardia;
• expansion of the chest and spaces between the ribs, limitation of chest excursion on the affected side;
• cold sweat, cyanosis, shortness of breath.

When diagnosed, the patient usually takes a forced semi-sitting or sitting position, which is also a symptom of pneumothorax.

Treatment of pneumothorax

In case of pneumothorax, the patient must receive emergency medical care.

First aid for pneumothorax is to calm the patient, provide him with access to a sufficient amount of oxygen and immediately call a doctor.

In the case of open pneumothorax, first aid consists of applying an occlusive dressing that will hermetically seal the lesion in the chest wall. A similar bandage for first aid for pneumothorax can be made from polyethylene or cellophane, as well as a thick cotton-gauze layer.

For valvular pneumothorax, first aid consists of performing an urgent pleural puncture to remove free air, straighten the lung, and also correctly eliminate the displacement of the mediastinal organs.

Qualified assistance for pneumothorax

To provide medical care for pneumothorax, the patient is hospitalized in a surgical hospital, and, if possible, in pulmonology. The patient undergoes a puncture of the pleural cavity, evacuates free gas and restores negative pressure in the pleural cavity.

For patients with closed pneumothorax, help consists of aspiration of air through the puncture system, observing asepsis in a small operating room. When providing assistance for pneumothorax, pleural puncture is performed on the side of the injury along the midclavicular line in the second intercostal space.

For open pneumothorax, treatment begins with suturing the defect and blocking the flow of air into the pleural cavity. After open pneumothorax is transferred to closed, measures are taken to eliminate it.

An important part of treating pneumothorax is adequate pain relief.

To prevent recurrence of the disease, pleurodesis (artificially created pleurisy) is done with silver nitrate, talc, glucose solution and other sclerosing agents that have the property of artificially causing adhesions in the pleural cavity.

In case of recurrence of spontaneous pneumothorax against the background of bullous emphysema, surgical treatment is prescribed.

Prevention

To prevent the development of pneumothorax, it is necessary to promptly carry out therapeutic and diagnostic measures for lung diseases.

People who have had an illness should avoid physical activity.

The manual reflects modern views on the etiology, pathogenesis, and classification of the main respiratory diseases studied in accordance with the work program in internal medicine. Information is provided on the epidemiology, clinical picture of diseases, criteria for their diagnosis, differential diagnosis, treatment and prevention.

The manual is supplemented with information about the condition of the organs and tissues of the oral cavity in diseases of the respiratory system and considers the tactics of a dentist in the presence of this pathology for students studying at the Faculty of Dentistry. Candidate of Medical Sciences, dentist Trukhan Larisa Yurievna took part in writing the subsections “Changes in organs and tissues of the oral cavity” and “Tactics of a dentist.”

– 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 (if the 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, it takes approximately 8-12 days for a 15% pneumothorax to completely resolve.

Oxygen therapy is indicated for all patients with pneumothorax, even with normal arterial blood gas composition, since the administration of oxygen 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.

For severe pain, analgesics, including narcotics, are prescribed. If pain is not controlled with narcotic analgesics, an epidural (bupivacaine, ropivacaine) or intercostal blockade may be performed.

Simple aspiration(pleural puncture with aspiration) are indicated for patients with a PSP volume 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, younger than 50 years. Simple aspiration is carried out using a needle or, preferably, a catheter. A needle or catheter is inserted into the 2nd intercostal space along the midclavicular line. Aspiration is carried out using a large syringe (50 ml). Once air evacuation is complete, the needle or catheter is removed. Some experts recommend leaving the catheter in place for 4 hours after completing aspiration. Simple aspiration leads to expansion of the lung in 59–83% of cases in patients with PSP and in 33–67% of patients with VSP.

If the first attempt at aspiration fails (the patient's complaints persist) and evacuation of less than 2.5 liters, in a third of patients success is achieved with a second attempt. If after aspiration of 4 liters of air there is no increase in resistance in the system, then there is probably persistence of the pathological message and the installation of a drainage tube is indicated for such a patient.

Drainage of the pleural cavity(using a drainage tube). Installation of the drainage tube is shown:

– 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 drain tube size is very important because the diameter of the tube and, to a lesser extent, its length determine the air flow rate.

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, and large vessels; pleural cavity infections; subcutaneous emphysema. During the installation of a drainage tube, local anesthetics (1% lidocaine 20–25 ml) must be injected intrapleurally.

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

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 the air has stopped flowing through it, if the chest x-ray indicates expansion of the lung.

Chemical pleurodesis. One of the main tasks in the treatment of pneumothorax is the prevention of repeated pneumothorax (relapses), however, neither simple aspiration nor drainage of the pleural cavity affects 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, as well as 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. In preparation for this procedure, adequate intrapleural anesthesia (at least 25 ml of 1% lidocaine solution) is necessary. 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:

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

2) 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 (VAT) and open thoracotomy.

In many centers, the main surgical method for treating pneumothorax is VAT, which is associated with such advantages of this method as compared to open thoracotomy, such as a reduction in operation and drainage time, a decrease in the number of postoperative complications and the need for analgesics, a decrease in hospitalization time for patients, and less pronounced gas exchange disorders.

Urgent events. For tension pneumothorax, immediate thoracentesis is indicated (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.

Prevention. Secondary prevention involves patient education.

1. The patient should avoid physical activity and air travel for 2–4 weeks.

2. Avoid changes in barometric pressure (skydiving, diving, diving).

3. Stop smoking.

Forecast. Mortality from pneumothorax is low; higher – with secondary pneumothorax. In patients with COPD, when pneumothorax develops, the risk of death increases by 3.5 times and averages 5%. Mortality in patients with cystic fibrosis with unilateral pneumothorax is 4%, with bilateral pneumothorax – 25%.

In HIV-infected patients, in-hospital mortality is 25%. The average survival after pneumothorax is 3 months.