Hemothorax clinical guidelines. Diagnosis and treatment of spontaneous pneumothorax. Open chest wound

The term “spontaneous pneumothorax” (SP) (as opposed to the term “traumatic pneumothorax”) was first proposed by A. Hard in 1803. SP is diagnosed in 5-7 people per 100 thousand population per year. Patients with SP make up 12% of all hospitalized patients with acute diseases of the chest organs. Non-traumatic SP can occur due to various diseases, as well as during medical manipulations (iatrogenic pneumothorax (IP)) (Tables 1, 2). Mortality in severe clinical forms of pneumothorax reaches from 1.3 to 10.4%.

The goals of treatment for SP are resolution of pneumothorax (expansion of the lung) and prevention of recurrent pneumothorax (prevention of relapse). Naturally, the tactics for achieving these goals depend on the cause of pneumothorax, its volume and the general condition of the patient. Possible methods of treating pneumothorax (due to the actual evacuation of air from the pleural cavity) include:
- puncture of the pleural cavity with air aspiration;
- drainage of the pleural cavity according to Bulau;
- drainage of the pleural cavity with active aspiration.
Additional administration of drugs for medicinal pleurodesis is aimed at preventing relapse.
Open operations and video-assisted interventions are used for suturing large defects of lung tissue, resection of bullous areas of the lung, single large bullae, etc. In this case, additional mechanical, thermal, and chemical pleurodesis is possible. The effectiveness of pleurodesis performed during surgical interventions is superior to the effectiveness of pleurodesis performed during drainage of the pleural cavity.

The incidence of complications after traditional thoracotomy for SP can reach 10.4-20%, and mortality - 2.3-4.3%, which is associated with the development of complications in the postoperative period, such as pleural empyema, postoperative pneumonia, thromboembolism of the branches of the pulmonary artery .

In recent years, in specialized hospitals for SP, predominantly video-assisted operations have been performed, and among all thoracoscopic operations, video-assisted thoracoscopy (VTS) for SP accounts for about 45%. In many centers, video-assisted thoracoscopy is the primary surgical treatment for pneumothorax. The advantages of the method compared to open thoracotomy are obvious: reduction in operation and drainage time, reduction in the number of postoperative complications, less severe pain in the postoperative period, reduction in the total number of bed days. According to a multicenter study, the rate of recurrence of pneumothorax after VAT is 4%. Other authors note an even lower rate of relapse of SP after VTS treatment - 1.3%, and there are no complications inherent in standard thoracotomy. The incidence of PU development: with transthoracic fine-needle puncture biopsy - 15-37%, on average - 10%; during catheterization of central veins - 1-10%; with thoracentesis - 5-20%; with pleural biopsy - 10%; with transbronchial lung biopsy - 1-2%; during artificial ventilation - 5-15%.

Materials and methods
From 1970 to 2013, 882 patients were treated for pneumothorax in the department of thoracic surgery of City Clinical Hospital No. 61 (in 1970-1986 - 144 people, in 1987-1995 - 174, in 1996-2013 - 564) . Until 1987, the only method of treating pneumothorax accepted in the clinic was drainage of the pleural cavity with active aspiration. For active aspiration, various devices were used: from “OP-1” to the more modern “Elema-N PRO 1” and “Medela”.

Since 1987, in addition to drainage of the pleural cavity, drug pleurodesis began to be used. To carry it out, tetracycline (20 mg per 1 kg of patient’s body weight), morphocycline 0.3 g (daily dose), and more recently doxycycline (20 mg per 1 kg of patient’s body weight) were used. Medical pleurodesis was performed both during surgical and conservative treatment of pneumothorax. During surgical treatment, 0.8 g (maximum daily dose) of a solution of doxycycline in 50 ml of 0.9% NaCl was injected into the pleural cavity. In total, from 1987 to 2013, 250 medicinal pleurodeses were performed during the conservative treatment of pneumothorax. During the period from 1987 to 1995, only 2 operations were performed - atypical lung resections using the UDO, UO, and US staplers. The approach used during the operations was lateral thoracotomy. With the introduction of video endoscopic technologies (since 1996), surgical activity in the treatment of pneumothorax was 28.5%; over the past 3 years, this figure has increased to 61.7% with the development of pneumothorax in patients with bullous pulmonary disease. From 1996 to 2013, a total of 170 operations for pneumothorax were performed.

Endostaplers are used for VTS of atypical resection of bullous areas of lung tissue. In video-assisted operations from a mini-access, the most commonly used staplers are UDO-20 and UDO-30. Thermal surgical instruments were used for coagulation of bullous-fibrotic areas of the lungs and, to a greater extent, for coagulation of subpleural vesicles and thermal pleurodesis.
The operation of choice is VTS with atypical lung resection, coagulation of bullae with thermal surgical instruments, thermal pleurodestruction of the parietal pleura with the same instruments and medicinal pleurodesis with doxycycline solution.

Results and discussion
140 VTS operations were performed: 114 VTS + atypical lung resection (81.4%), 26 VTS + coagulation of bullae and/or depleurized areas of the lung (18.5%). Coagulation of bullae and blebs with a plasma flow has become the most effective. 36 patients underwent atypical lung resection from a mini-thoracotomy approach with video assistance and the use of UDO staplers. Traditional thoracotomy was used 8 times to perform atypical lung resection.

In recent years (2003-2013), 165 patients with JP were observed in the thoracic department of City Clinical Hospital No. 61, 94 patients were transferred from Moscow hospitals and 71 from other departments of the hospital. The main causes of PU were: catheterization of the central (mainly subclavian) vein and pleural puncture for hydrothorax of various origins, less often - barotrauma during artificial ventilation of the lungs, and even less often - during transthoracic or transbronchial puncture biopsy of the lung. The main reason for transfer to the department from other hospitals was the recurrence of pneumothorax after short-term drainage of the pleural cavity: the drainage was removed on the first day (or immediately) after expansion of the lung, which required repeated (often multiple) drainage of the pleural cavity. Early removal of the drainage was explained by the fear of infection of the pleural cavity and the development of associated complications - pleural empyema.

Relapses during the treatment of SP using drainage and puncture of the pleural cavity were observed in 21.5% of cases; with drainage followed by medicinal pleurodesis - in 5.5%. There were no early relapses (after drainage without pleurodesis, recurrent pneumothorax developed in 4.9% of cases in the next 10 days after discharge). The only complication of drainage of the pleural cavity is subcutaneous emphysema. There were no complications associated with medicinal pleurodesis.

In accordance with national clinical guidelines for the diagnosis and treatment of SP, expectant management is acceptable if the volume of spontaneous limited apical pneumothorax is less than 15% in patients with no dyspnea. If such patients have bullous disease and there are no contraindications, relapse prevention will involve surgical treatment to the extent of resection of bullous areas of lung tissue. When the volume of pneumothorax is up to 30% in patients without severe dyspnea, a single pleural puncture with air aspiration can be performed. Prevention of relapse is achieved in the same way as in the previous case.
Drainage of the pleural cavity is indicated when the volume of pneumothorax is more than 30%, recurrent pneumothorax, ineffective puncture, in patients with dyspnea and patients over 50 years of age. Key points of correct placement of drainage: mandatory polypositional x-ray examination before drainage and monitoring the position of the drainage with its correction as necessary after manipulation.
However, the results of treatment of SP exclusively with punctures and drainage of the pleural cavity in patients with bullous disease cannot be considered satisfactory: recurrence of pneumothorax is observed in 20-45% of cases when treated with pleural punctures, in 12-18% after closed drainage of the pleural cavity. In this regard, at present, in the absence of contraindications to VTS, operations with marginal resection and thermal destruction of bullous areas of the lung are performed in all patients with bullous lung disease.
The operation is completed with medicinal pleurodesis with solutions of tetracycline antibiotics in order to obliterate the pleural cavity, which serves as the prevention of pneumothorax even if the bulla ruptures (Fig. 1-4).

UP, unlike SP, develops against the background of healthy lung tissue or changes in the lung parenchyma that are insufficient for spontaneous lung rupture, so UP is an indication only for conservative treatment. In this case, it is important that active aspiration continues until the lung is completely expanded, and for at least 5-7 days after expansion, until adhesions develop in the pleural cavity. When the lung is expanded, there is no danger of infection of the pleural cavity and the development of pleural empyema, since there is no actual cavity in the pleura.

Literature
1. Shulutko A.M., Ovchinnikov A.A., Yasnogorodsky O.O., Motus I.Ya. Endoscopic thoracic surgery. M.: Medicine, 2006. 392 p.
2. Rabedzhanov M.M. The role of videothoracoscopy in the diagnosis and choice of treatment for spontaneous pneumothorax: Abstract of thesis. ...cand. honey. Sci. M., 2007. 25 p.
3. Noppen M., Schramel F. Pneumothorax // Eur Respir Mon. 2002. Vol. 22. R. 279-296.
4. Schramel F.M., Postmus P.E., Vanderschueren R.G. Current aspects of spontaneous pneumothorax // Eur Resp J. 1997. Vol. 10. R. 1372-1379.
5. Mospanova E.V. Medicinal pleurodesis in the treatment of spontaneous pneumothorax and hydrothorax: Dis. ...cand. honey. Sci. M., 1993. 106 p.
6. Mansfield P.F., Hohn D.C., Fornage B.D. et al. Complications and failures of subclavian vein catheterization // N Eng J Med. 1994. Vol. 331. R. 1735-1738.
7. Grogan D.R., Irwin R.S., Channick R. et al. Complications associated with thoracocentesis. A prospective, randomized study comparing three different methods // Arch Intern Med. 1990. Vol. 150. R. 873-877.
8. Blasco L.H., Hernandez I.M.S., Garrido V.V. et al. Safety of transbronchial biopsy in outpatients // Chest. 1991. Vol. 99. R. 562-565.
9. Poe R.H. Sensitivity, specificity, and predictive values ​​of closed pleural biopsy // Arch Intern Med. 1984. Vol. 144. R. 325-328.
10. Gammon R.B., Shin M.S., Buchalter S.E. Pulmonary barotrauma in mechanical ventilation. Patterns and risk factors // Chest.1992. Vol. 102. R. 568-572.
11. Light R.W., O’Hara V.S., Moritz T.E. et al. Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax: results of a Department of Veterans Affairs Cooperative Study // JAMA. 1990. Vol. 264. R. 2224-2230.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other spontaneous pneumothorax (J93.1), Spontaneous tension pneumothorax (J93.0)

Thoracic surgery

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Spontaneous pneumothorax is a pathological condition characterized by the accumulation of air between the visceral and parietal pleura, not associated with mechanical damage to the lung or chest as a result of injury or medical manipulation, infectious or tumor destruction of lung tissue. .

I. INTRODUCTORY PART

Protocol name: Spontaneous pneumothorax
Protocol code:

ICD-10 code:
J 93 spontaneous pneumothorax
J 93.0 spontaneous tension pneumothorax
J 93.1 other spontaneous pneumothorax

Abbreviations used in the protocol:
BPD - bullous lung disease
BEL - bullous pulmonary emphysema
IHD - coronary pulmonary disease
CT - computed tomography
SP - spontaneous pneumothorax,
CFG OGK - digital fluorography of the chest organs,
ECG - electrocardiogram,
VATS - video-assisted thoracoscopic surgery

Date of development of the protocol: year 2013
Patient category: adult patients with pneumothorax
Protocol users: Thoracic surgeons, pulmonologists, therapists, cardiologists, phthisiatricians and oncologists in hospitals and outpatient clinics.

Note: This protocol uses the following classes of recommendations and levels of evidence:

Classification

Clinical classification:
- Primary (idiopathic) pneumothorax
- Secondary (symptomatic) pneumothorax
- Catamenial (menstrual) pneumothorax

Primary (idiopathic) pneumothorax persists in the ratio of 5:100 thousand people: among men 7.4:100 thousand, among women 1.2:100 thousand of the population, it occurs most often in people of working age from 20-40 years.
Secondary (symptomatic) pneumothorax is: among men 6.3:100 thousand, among women 2.0:100 thousand of the population, covers a wider age range and is often one of the manifestations of pulmonary tuberculosis.
Catamenial (Menstrual) pneumothorax is a rare form of pneumothorax that occurs in women. More than 230 cases of catamenial pneumothorax have been described worldwide.

Depending on the type of pneumothorax, there are :
- Open pneumothorax.
- Closed pneumothorax.
- Tension (valve) pneumothorax.

With an open pneumothorax, there is a connection between the pleural cavity and the lumen of the bronchus and, therefore, with atmospheric air. On inhalation, air enters the pleural cavity, and on exhalation it leaves it through a defect in the visceral pleura. In this case, the lung collapses and is switched off from breathing (lung collapse).
With a closed pneumothorax, air that has entered the pleural cavity and caused partial and complete collapse of the lung subsequently loses contact with atmospheric air and does not cause a threatening condition.
With valve pneumothorax, air freely enters the pleural cavity during inspiration, but its exit is difficult due to the presence of a valve mechanism.
According to their prevalence, they are divided into: total and partial pneumothorax.
Depending on the presence of complications: uncomplicated and complicated (bleeding, pleurisy, mediastinal emphysema).

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic:
1. History taking
2. Inspection, auscultation and percussion of the chest
3. General blood test
4. General urine test
5. Biochemical blood tests
6. Blood for blood type and Rh factor
7. Blood coagulogram
8. Microreaction
9. Blood test for hepatitis and HIV
10. Feces on worm eggs
11. ECG
12. Radiography in two projections

Additional:
1. Computed tomography of the chest organs in spiral mode
2. Fiberoptic bronchoscopy
3. Consultations with specialists (according to indications)

Diagnostic tactics at the outpatient (prehospital) stage:
- If sudden (spontaneous) pain appears in the chest and suspicion of SP occurs, a chest x-ray (in anterior and lateral projections) is indicated.
- If it is impossible to carry out radiography, it is necessary to send the patient to a surgical hospital.

Diagnostic tactics in a general surgical hospital.
The main goal of diagnostics in a surgical hospital is to establish an accurate diagnosis and determine therapeutic and surgical tactics.
- X-ray of the chest organs in frontal and lateral projections during exhalation (direct observation, lateral projection on the side of pneumothorax);
- CT scan of the chest in a spiral mode (additionally, according to indications);
It is recommended to use computed tomography in the differential diagnosis of pneumothorax and bullous emphysema, if improper placement of drainage is suspected, and in cases where the interpretation of a chest radiograph is difficult due to the presence of subcutaneous emphysema (level C).

Diagnostic tactics in the thoracic department.
To determine the cause of spontaneous pneumothorax, it is recommended to perform a CT examination of the thoracic segment and, based on its results, make a decision on planned surgical treatment.

Diagnostic criteria
SP in most cases occurs at a young age and is characterized by a relapsing course.
The reasons for SP may be:
1. Pulmonary emphysema, most often bullous (71-95%)
2. COPD
3. Cystic fibrosis
4. Bronchial asthma
5. Rheumatoid arthritis
6. Ankylosing spondylitis
7. Dermatomyositis
8. Systemic scleroderma
9. Marfan syndrome
10. Ehlers-Danlos syndrome
11. Idiopathic pulmonary fibrosis
12. Sarcoidosis
13. Histiocytosis X
14. Lymphangioleiomyomatosis
15. Pulmonary endometriosis

Complaints and anamnesis:
In the classic version, the joint venture begins with the appearance of:
- sudden pain in the chest,
- non-productive cough,
- shortness of breath.
In 15 - 21% of cases, pneumothorax is asymptomatic or with a blurred clinical picture without characteristic complaints of respiratory failure. .

Physical examination:
The main signs of pneumothorax during an objective examination of the patient are:
- forced position, pale skin, cold sweat and/or cyanosis
- expansion of the intercostal spaces, lag in breathing of the affected half of the chest, swelling and pulsation of the neck veins, subcutaneous emphysema is possible.
- upon percussion, weakening or absence of vocal tremor on the affected side, tympanic sound (with the accumulation of fluid in the pleural cavity in the lower parts, dullness is determined), displacement of the area of ​​the apical impulse and the boundaries of cardiac dullness to the healthy side.
- weakening of breathing upon auscultation
In the process of diagnosis and selection of treatment tactics, complicated forms of spontaneous pneumothorax require a special approach:
- tension pneumothorax
- hemothorax, ongoing intrapleural bleeding
- bilateral pneumothorax
- pneumomediastinum.

Laboratory research: not informative

Instrumental studies:
- X-ray of the chest organs in frontal and lateral projections during exhalation (direct view, lateral projection on the side of pneumothorax): a collapsed lung is determined, the presence of free air; :
- ECG (for the purpose of differential diagnosis with ischemic heart disease);
- CT scan of the chest in a spiral mode: CT picture of pneumothorax, bullous changes. :

Indications for consultation with specialists:
Specialists of a different profile - in the presence of corresponding concomitant pathology or in case of secondary and recurrent pneumothorax during planned hospitalization.
Anesthesiologist: to determine the type of anesthesia if surgical intervention is necessary, as well as to coordinate the tactics of managing the preoperative period.
Resuscitator: to determine indications for treating a patient in an intensive care unit, to coordinate the tactics of managing a patient with SP.

Differential diagnosis

Differential diagnosis:

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals: Complete expansion of the lung on the side of the pneumothorax.

Treatment tactics

Non-drug treatment
Diet: table No. 15, bed rest during hospitalization.

Drug treatment
Antibiotic therapy is not the main conservative treatment method. Its main purpose is preventive and for complicated forms of SP. The duration of therapy in the postoperative period depends on the characteristics of the clinical course. In complicated cases, it can be prolonged according to indications. The absence of symptoms of fever within 24 hours and normal white blood cell counts are criteria for stopping antibiotic therapy.

Other treatments

Surgical intervention

Treatment tactics at the outpatient (prehospital) stage
In case of tension pneumothorax, puncture or drainage is indicated on the side of the pneumothorax in the II intercostal space along the midclavicular line or along the lateral surface of the chest in the III-VII intercostal space for the purpose of decompression of the pleural cavity

Treatment tactics in a general surgical hospital
"Minor surgery" - Drainage of the pleural cavity: The pleural cavity should be drained with drainage with a diameter of at least 14 Fr -18 Fr with active aspiration with a vacuum of 20-40 cm of water. Art. or according to Bulau. (level B)
Active aspiration of the pleural cavity using vacuum aspirators (stationary and portable).

To decide on further management tactics, an examination by a thoracic surgeon is necessary.

N/B! SP with ongoing intrapleural bleeding, tension pneumothorax against the background of a drained pleural cavity is an indication for emergency or urgent surgery. After elimination of complications, pleural induction is required. Anti-relapse surgery is not recommended for patients with uncomplicated course of SP in a non-specialized surgical hospital.

Treatment tactics in the thoracic department
- when a patient is admitted to the thoracic department after an X-ray examination, if it is impossible to perform an urgent CT scan, a diagnostic thoracoscopy is performed. Depending on changes in the pleural cavity, the procedure can be completed by draining the pleural cavity or performing anti-relapse surgical treatment.
- if a patient with SP is transferred from another medical institution with an already drained pleural cavity, it is necessary to assess the adequacy of the drainage function. If the drainage is functioning adequately and diagnostic thoracoscopy has been performed in another medical institution, repeated drainage is not required, and the decision on the need for anti-relapse surgery is made based on the established cause of SP.
- if air flow through the drains continues for 72 hours, thoracoscopic surgery or video-assisted mini-thoracotomy is also indicated. The extent of surgery depends on the specific intraoperative finding.
- in case of relapse of SP, it is necessary to drain the pleural cavity, achieving expansion of the lung. Surgical treatment should be carried out in a delayed or planned manner.

N/B! Anti-relapse treatment is surgery in the chest cavity to identify and eliminate the cause of pneumothorax, as well as induce pleura in one way or another to prevent recurrence of pneumothorax.

After any method of treating spontaneous pneumothorax, conservative or surgical, relapses are possible.

N/B! If the patient refuses hospitalization, the patient and his relatives should be warned about the possible consequences. The situation must be documented by an appropriate entry in the medical record and medical history.

It is preferable to perform anti-relapse surgery in a low-traumatic manner using video-assisted thoracoscopic technology or video-assisted technology (VATS). (level C). If technical difficulties are expected during thoracoscopy, surgery from a thoracotomy or sternotomy approach is possible. .
For patients who need anti-relapse treatment, but have contraindications to surgical treatment, pleural induction and pleurodesis using chemical sclerosants introduced into the drainage or through a trocar are possible.

The purpose of surgical intervention for SP:
1. Inspection of the lung and pleural cavity with elimination of the source of air intake by:
- resection of bullae
- dressings of bullae
- suturing of broncho-pleural fistula
- coagulation bullae
- excision, suturing or stitching of other bullae that do not contain a defect
- pleurectomy
- pleurodesis
- economical resection of the lobe
Regardless of the presence or absence of bullous changes, a biopsy of the lung tissue is necessary.

N/B! The volume and method of surgical treatment is determined by the severity and nature of changes in the lung and pleural cavity, the presence of complications, the age and functional state of the patient. Surgical tactics may change intraoperatively.

Preventive actions: There is no special prevention of SP.

Further management
In the postoperative period, the pleural cavity is drained by one or more drainages, depending on the type and volume of surgery. Drains with a diameter of at least 12 Fr. In the early postoperative period, active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is indicated. Art. (level D).
To control the expansion of the lung, a dynamic X-ray examination is performed. The amount is determined by the thoracic surgeon according to indications individually for each patient.
The criteria for the possibility of removing pleural drainage are: complete expansion of the lung according to X-ray examination, no air flow through the drainage for 24 hours, and discharge through the pleural drainage of less than 150 ml/day.
Before removal of chest tubes, patients are advised to receive prophylactic antibiotic therapy.
Discharge in an uncomplicated postoperative period is possible after removal of the pleural drainage, with mandatory X-ray monitoring before discharge.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- complete expansion of the lung, determined radiographically;
- cessation of air flow through the pleural drainage for 24 hours.
Despite the mandatory implementation of all points of the protocol, there must be a personalized and individual approach to each patient based on the actual clinical situation.

Groups of drugs according to ATC used in treatment

Hospitalization

Indications for hospitalization
Emergency hospitalization with an x-ray confirmed diagnosis of SP.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. J. Rivas de Andres, MJimenez Lopez, L. Molins Lopez – Rodd, A. Perez Trullen, J. Torres Lanzase. Recommendations of the Spanish Society of Pulmonology and Thoracis Surgery (SEPAR). Guidelines for the diagnosis and treatment of spontaneous pneumothorax. Ach. Bronconeumol. 2008; 44(8): 437-448. 2. Avilova O.M., Getman V.G., Makarov A.V. Thoracoscopy in emergency thoracic surgery. Kyiv. “Healthy, I” 1986 - 128 p. 3. Akhmed D.Yu. Surgery of small accesses in the correction of spontaneous pneumothorax // Diss... Cand.-M., 2000.-102 p. 4. Bisenkov L.N. Thoracic surgery. Guide for doctors. Saint Petersburg. "ELBI-SPB".2004-928s.ill. 5. Perelman M.I. Current problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16. 6. Katz D.S., Mas K.R., Groskin S.A. Secrets of radiology. Saint Petersburg. 2003 7. Kolos A.I., Rakishev G.B., Takabaev A.K. Current issues in thoracic surgery. Educational and methodological manual. Almaty “Alash” 2006.-147p. 8. Kuzin M.I., Adamyan A.A., Todua F.I. and others. The importance of computed tomography in thoracic surgery // Thoracic and cardiovascular surgery. – 2002. - No. 4. – pp. 49-54. 9. Pakhomov G.A., Khayamov R.Ya. Tactics of treatment of bullae, emphysema, complicated by spontaneous pneumothorax // Materials of the XIV International Congress on Pulmonology. – M., 2004. – P. 303. 10. Putov N.V., Fedoseev G.B. Guide to Pulmonology. – L., 1978. – 385 p. 11. Chukhrienko D.P., Danilenko M.V., Bondarenko V.A., Bely I.S. Spontaneous (pathological) pneumothorax. M. Medicine. 1973 - 296 pp. 12. Yasnogorodsky O.O. Video-assisted intrathoracic interventions // Diss...doct., M., 2000. - 182 p.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers:
Takabaev A.K. - Candidate of Medical Sciences, thoracic surgeon, Associate Professor of the Department of Surgical Diseases No. 2 of the FNPRiDO JSC "Astana Medical University".

Reviewers:
Turgunov E.M. - Doctor of Medical Sciences, professor, surgeon of the highest qualification category, head of the Department of Surgical Diseases No. 2 of the RSE at the Karaganda State Medical University of the Ministry of Health of the Republic of Kazakhstan, independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.

Disclosure of no conflict of interest: There is no conflict of interest.

Indication of the conditions for reviewing the protocol: The protocol is subject to revision once every 3 years, or when new proven data on the surgical treatment of pneumothorax becomes available.

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace a face-to-face consultation with a doctor. Be sure to contact a medical facility if you have any illnesses or symptoms that concern you.
• The choice of medications and their dosage must be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and condition of the patient’s body.
• The MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory" are exclusively information and reference resources. The information posted on this site should not be used to unauthorizedly change doctor's orders.
• The editors of MedElement are not responsible for any personal injury or property damage resulting from the use of this site.

Other spontaneous pneumothorax (J93.1)

Thoracic surgery, Surgery

general information

Short description

Definition:

Spontaneous pneumothorax (SP) is a syndrome characterized by the accumulation of air in the pleural cavity, not associated with lung injury or medical manipulation.

ICD 10 code: J93.1

Prevention:
Induction of pleurodesis, that is, the formation of adhesions in the pleural cavity, reduces the risk of recurrent pneumothorax [A].
Quitting smoking reduces both the risk of developing pneumothorax and the risk of its recurrence [ C].

Screening:
Screening is not applicable for primary pneumothorax.
For secondary - it is aimed at identifying diseases that provoke the development of spontaneous pneumothorax.

Classification

Classifications

Table 1. Classification of spontaneous pneumothorax

Diagnostics

Diagnostics:

Diagnosis of SP is based on the clinical manifestations of the disease, objective and radiological examination data.

In the clinical picture, the main place is occupied by: pain in the chest on the side of the pneumothorax, often radiating to the shoulder, shortness of breath, dry cough.

Rare complaints - usually appear in complicated forms of SP. Changes in voice timbre, difficulty swallowing, an increase in the size of the neck and chest occur with pneumomediastinum and subcutaneous emphysema. With hemopneumothorax, the manifestations of acute blood loss come to the fore: weakness, dizziness, orthostatic collapse. Palpitations and a feeling of interruptions in the heart (arrhythmia) are characteristic of tension pneumothorax. Late complications of pneumothorax (pleurisy, empyema) lead to the patient developing symptoms of intoxication and fever.

With secondary SP, even if it is small in volume, there are more pronounced clinical symptoms, in contrast to primary SP [D].

An objective examination reveals a lag in breathing of half the chest, sometimes widening of the intercostal spaces, a tympanic tone during percussion, weakening of breathing and weakening of vocal tremor on the side of the pneumothorax.

With tension pneumothorax, clinical manifestations are more pronounced [D].

It is mandatory to take radiographs in frontal and lateral projections during inspiration, which are sufficient to make a diagnosis of pneumothorax [A]. In doubtful cases, it is necessary to take an additional expiratory photograph in a direct projection.

The main radiological symptoms of SP are:

• absence of a pulmonary pattern in the peripheral parts of the corresponding hemithorax;
• visualization of the outlined edge of the collapsed lung;

• shadow of a collapsed lung;
• symptom of deep furrows (in lying patients);
• mediastinal shift;
• changing the position of the diaphragm.

When assessing radiographs, it is necessary to remember the possibility of limited pneumothorax, which, as a rule, has an apical, paramediastinal or supradiaphragmatic localization. In these cases, it is necessary to perform inspiratory and expiratory radiographs, the comparison of which provides complete information about the presence of limited pneumothorax.
An important task of x-ray examination is to assess the condition of the lung parenchyma, both the affected and the opposite lung.

When assessing radiographs, pneumothorax should be differentiated from giant bullae, destructive processes in the lungs, and dislocation of hollow organs from the abdominal cavity to the pleural cavity.

Before draining the pleural cavity, it is necessary to perform radiography in 2 projections or polypositional fluoroscopy to determine the optimal drainage point [D].

Spiral computed tomography (SCT) of the chest plays a major role in determining the causes of pneumothorax and differential diagnosis of SP with other pathologies. SCT should be performed after drainage of the pleural cavity and the maximum possible expansion of the lung. With SCT, the following signs are assessed: the presence or absence of changes in the pulmonary parenchyma, such as infiltration, disseminated process, interstitial changes; unilateral or bilateral bullous changes; diffuse emphysema.
Indicators of laboratory tests in cases of uncomplicated spontaneous pneumothorax, as a rule, are not changed.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment:
All patients with pneumothorax should be urgently hospitalized in thoracic surgical hospitals, and if impossible, in emergency surgical hospitals.

Treatment goals for spontaneous pneumothorax:

• expansion of the lung;
• cessation of air flow into the pleural cavity;
• prevention of disease relapse;

• conservative - dynamic observation;
• pleural puncture;
• drainage of the pleural cavity;
• chemical pleurodesis through pleural drainage;
• surgical intervention.

Information

Sources and literature

1. Clinical recommendations of the Russian Society of Surgeons
   1. 1. Bisenkov L.N. Thoracic surgery. Guide for doctors. – St. Petersburg: ELBI-SPb, 2004. – 927 p. 2. Varlamov V.V., Levashov Yu.N., Smirnov V.M., Egorov V.I. A new method of non-operative pleurodesis in patients with spontaneous pneumothorax // Vestn.khir. - 1990. - No. 5. - P.151-153. 3. Porkhanov V.A., Mova V.S. Thoracoscopy in the treatment of bullous pulmonary emphysema complicated by pneumothorax // Chest and heart. vascular surgery. - 1996. - No. 5. - pp. 47-49. 4. Pichurov A.A., Orzheshkovsky O.V., Petrunkin A.M. et al. Spontaneous pneumothorax - analysis of 1489 cases // Vetn. Surgery named after I.I.Grekova. – 2013. – Volume 172. – P. 82-88. 5. Perelman M.I. Current problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16. 6. Seagal E.I., Zhestkov K.G., Burmistrov M.V., Pikin O.V. Thoracoscopic surgery. “House of Books”, Moscow, 2012.- 351 p. 7. Filatova A.S., Grinberg L.M. Spontaneous pneumothorax - etiopathogenesis, pathomorphology (literature review) // Ural. honey. magazine - 2008. - No. 13. - P. 82-88. 8. Chuchalin A.G. Pulmonology. National leadership. Brief edition. GEOTAR-Media. 2013. 800s. 9. Yablonsky P.K., Atyukov M.A., Pishchik V.G., Bulyanitsa A.L. The choice of treatment tactics and the possibility of predicting relapses in patients with the first episode of spontaneous pneumothorax // Medicine XXI century - 2005. - No. 1. – P.38-45. 10. Almind M., Lange P., Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis // Thorax.- 1989.- Vol. 44.- No. 8.- P. 627 - 630. 11. Baumann M.H., Strange C., Heffner J.E., et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement // Chest. - 2001. - Vol. 119. - No. 2. - P. 590–602. 12. Boutin C., Viallat J., Aelony Y. Practical thoracoscopy / New York, Berlin, Heidelberg: Springer-Verlag. - 1991. - 107 p. 13. British Thoracic Society Pleural Disease Guideline, 2010 //Thorax.- 2010.- vol. 65, Aug.- suppl. 2.- 18 –31. 14. Kelly A.M., Weldon D., Tsang A.Y.L., et al. Comparison between two methods for estimating pneumothorax size from chest x-rays // Respir. Med. – 2006. – Vol. 100. – P. 1356-9. 15. Kocaturk C., Gunluoglu M., Dicer I., Bedirahan M. Pleurodesis versus pleurectomy in case of primary spontaneous pneumothorax // Turkish J. of Thoracic and Cardiovasc. Surg.- 2011.- vol. 20, N 3.- P. 558-562. 16. Ikeda M. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax, with special reference to the operative indication considered from its contralateral occurrence rate // Nippon Kyobi Geka. Gakhai Zasshi.- 1985.- V.14.- No. 3.- P.277 - 282. 17. MacDuff A., Arnold A., Harvey J. et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 // Thorax. – 2010. - Vol. 65. - Suppl. 2. – P. ii18-ii31. 18. Miller W.C., Toon R., Palat H., et al. Experimental pulmonary edema following reexpansion of pneumothorax // Am. Rev. Respira. Dis. – 1973. – Vol. 108. – P. 664-6. 19. Noppen M., Alexander P., Driesen P. et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study // Am. J. Respira. Crit. Care. Med. - 2002. - Vol. 165. - No. 9. - P. 1240-1244. 20. Noppen M., Schramel F. Pneumothorax // European Respiratory Monograph. - 2002. - Vol. 07. - No. 22. - P. 279-296. 21. Pearson F.G. Thoracic Surgery. - Philadelphia, Pennsylvania: Churchill Livigstone, 2002. - 1900c. 22. Rivas J. J., López M. F. J., López-Rodó L. M. et al. Guidelines for the diagnosis and treatment of spontaneous pneumothorax / Spanish Society of Pulmonology and Thoracic Surgery // Arch. Bronconeumol. - 2008. - Vol. 44. - No. 8. - P. 437-448. 23. Sahn S.A., Heffner J.E. Spontaneous pneumothorax // N. Engl. J. Med. - 2000. - Vol. 342. - No. 12. - P. 868-874. 24. Shields T.W. General Thoracic Surgery. - New York: Williams@Wilkins, 2000. - 2435c. 25. Up Huh, Yeong-Dae Kim, Yeong Su Cho et al. The effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion // Korean J. of Thoracic and Cardiovasc. Surg.- 2012.- vol. 45, N 5.- P. 316-319.

Information

Working group for the preparation of the text of clinical recommendations:

Prof. K.G.Zhestkov, Associate Professor B.G.Barsky (Department of Thoracic Surgery, Russian Medical Academy of Postgraduate Education, Moscow), Ph.D. M.A. Atyukov (Center for Intensive Pulmonology and Thoracic Surgery, St. Petersburg State Budgetary Healthcare Institution “GMPB No. 2”, St. Petersburg).

Composition of the expert committee: Prof. A.L. Akopov (St. Petersburg), prof. E.A.Korymasov (Samara), prof. V.D.Parshin (Moscow), corresponding member. RAMS, prof. V.A. Porkhanov (Krasnodar), prof. E.I.Sigal (Kazan), prof. A.Yu. Razumovsky (Moscow), prof. P.K. Yablonsky (St. Petersburg), prof. Stephen Cassivi (Rochester, USA), Academician of the Russian Academy of Medical Sciences, prof. Gilbert Massard (Strasbourg, France), prof. Enrico Ruffini (Torino, Italy), prof. Gonzalo Varela (Salamanca, Spain)

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace a face-to-face consultation with a doctor. Be sure to contact a medical facility if you have any illnesses or symptoms that concern you.
• The choice of medications and their dosage must be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and condition of the patient’s body.
• The MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory" are exclusively information and reference resources. The information posted on this site should not be used to unauthorizedly change doctor's orders.
• The editors of MedElement are not responsible for any personal injury or property damage resulting from the use of this site.

■ During VSP p a O 2< 55 мм рт.ст. и pa CO 2 >50 mmHg 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, decreased voltage, flattening and inversion of T waves in leads V1–V3.

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 an upright position).

Radiographic sign of pneumothorax - visualization of a thin line of visceral pleura (less than 1 mm), separated from the chest (Fig. 1).

Pneumothorax

Res. 1. Secondary spontaneous pneumothorax on the right in a patient with Pneumocystis pneumonia.

■ 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 neither a sign of severe pneumothorax nor 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 are indicated ( decubitus lateralis), 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 recent studies have shown, expiratory films have no advantages over conventional inspiratory films. Moreover, vigorous exhalation can significantly aggravate the condition of a patient with pneumothorax and even lead to asphyxia, especially with tension and bilateral pneumothorax. That's whyX-ray at expiratory height is not recommended for the diagnosis of pneumothorax.

Radiological sign of pneumothorax in a patient in a horizontal position (more often during mechanical ventilation) - a sign of a deep sulcus (deep sulcus sigh) - deepeningcostophrenicangle, which is especially noticeable when compared with the opposite side (Fig. 2).

■ For diagnosing small pneumothoraxes, CT is a more reliable method compared to radiography. The sensitivity of CT in detecting pneumothorax after transthoracic lung biopsy is 1.6 times higher.

■ For the differential diagnosis of large emphysematous bullae and pneumothorax, the most sensitive method is CT WITH .

■ CT is indicated to determine the cause of secondary spontaneous pneumothorax (bullous emphysema, cysts, ILD, etc.) D.

Determining the size of pneumothorax

The size of pneumothorax is one of the most important parameters determining the choice of treatment tactics. The widest application

Pneumothorax

Res. 2. Pneumothorax in a patient during mechanical ventilation: sign of deep sulcus sigh, white arrows.

Pneumothorax

knowledge was obtained by the Light formula, based on the position that the volume of the lung and the volume of the hemithorax are proportional to the size of their diameters raised to the third power. The size of pneumothorax using the Light formula is calculated as follows:

Volume of pneumothorax (%) = (1 - DL 3 / DH 3 ) × 100,

where DL is the diameter of the lung, DH is the diameter of the hemithorax on a chest x-ray (Fig. 3).

In patients with PSP, the correlation between the calculated data and the volume of air obtained by simple aspiration is r = 0.84 (p< 0,0001), т.е. метод может быть рекомендован для широкого использования в клинической практике. Пример расчёта объёма пневмоторакса по предложенной формуле представлен на рис. 4.

52%, averaging 30%. The majority of relapses occur in the first 0.5–2 years after the 1st episode of pneumothorax.

■ After recurrent pneumothorax, the likelihood of subsequent recurrences increases progressively: 62% after the 2nd episode and 83% after the 3rd pneumothorax.

■ In one of the largest studies, which included 229 patients with VSP, the relapse rate was 43%.

■ The main risk factors for the development of relapses in patients with spontaneous pneumothorax (both with PSP and SSP) are the presence of pulmonary fibrosis, age over 60 years, high stature and low nutritional status of patients. The presence of subpleural bullae is not a risk factor for relapse.

Differential diagnosis

■ Pneumonia ■ Pulmonary embolism

■ Viral pleurisy ■ Acute pericarditis

■ Acute coronary syndrome ■ Rib fracture

■ Treatment goals: resolution of pneumothorax and prevention of repeated pneumothoraxes (relapses).

■ Indications for hospitalization. Hospitalization is indicated for all patients with pneumothorax.

■ Treatment tactics. Currently, there are two known consensus documents on the diagnosis and treatment of patients with spontaneous pneumothorax - the British Thoracic Society manual (2003) and the American College of Chest Physicians manual (2001). Despite some differences in approaches to patient management tactics, these guidelines suggest similar stages of patient treatment: observation and oxygen therapy simple aspiration installation of a drainage tube chemical spitting

A 15% pneumothorax will require approximately 8–12 days to resolve.

■ All patients, even with a normal arterial blood gas composition, are prescribed oxygen (10 l/min through a mask, but a positive effect is also observed when oxygen is administered through cannulas), since oxygen therapy can accelerate the resolution of pneumothorax in 4–6 timesC. 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, blood gas monitoring is necessary when prescribing oxygen, as hypercapnia may increase.

■ For severe pain syndrome, it is prescribed analgesics, including narcotics; If pain is not controlled with narcotic analgesics, an epidural or intercostal blockade may be performed D.

Simple aspiration

26 and 27%. However, despite the similar effectiveness of the two methods, simple aspiration had important advantages: the procedure is less painful and can be performed in non-specialized departments (reception room, therapy department, etc.).

Drainage of the pleural cavity

■ Early use of suction after chest tube placement (especially in patients with PSP that occurred several days ago) may lead to the development of reexpansion ( ex vacuo) pulmonary edema. Clinically, reexpansion pulmonary edema is manifested by coughing and increased shortness of breath or the appearance of chest congestion after insertion of a drainage tube. On a chest x-ray, signs of edema may be visible not only in the affected lung, but also on the opposite side. The prevalence of reexpansion pulmonary edema when using suction can reach 14%, and its risk is significantly higher with the development of pneumothorax for more than 3 days, complete collapse of the lungs, and young patients (less than 30 years).

■ When air bubbles are released, clamping (squeezing) the drainage tube is unacceptable, since such an action can lead to the development of tension pneumothorax WITH . There is no consensus on the need to clamp the tube when air loss stops. Opponents of the method fear the development of repeated pulmonary collapse, and supporters talk about the possibility of detecting a small “leak” of air, which the “air lock” cannot detect.

■ 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

ra lidocaineS. After administration of the sclerosing agent, the drainage tube is closed for 1 hour.

The number of relapses after the introduction of tetracycline is 9–25%, and after the introduction of talc - 8%. Complications that can occur when talc is administered into the pleural cavity - acute respiratory distress syndrome (ARDS), empyema, acute respiratory failure - cause some concern. The development of ARDS may be associated with a high dose of talc (more than 5 g), as well as with the size of the talc particles (smaller particles undergo absorption with the subsequent development of a systemic inflammatory response); It is characteristic that cases of ARDS after the administration of talc have been reported mainly in the USA, where the particle size of natural talc is much smaller than in Europe.

Surgical treatment of pneumothorax

Table 2. Anti-relapse effectiveness of therapy

Urgent events

For tension pneumothorax it is indicated immediate tracocentesis(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 a period of time. 2–4 weeks and air travel for 2–4 weeks.

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

■ The patient should be advised to quit smoking.

Indications for consultation with specialists

■ If there are difficulties in interpreting chest x-ray data, consultation with a specialist in x-ray methods is indicated.

■ Consultation with a pulmonologist (or intensive care specialist) and a thoracic surgeon is necessary: ​​when performing invasive procedures (installation of a drainage tube), determining indications for pleurodesis, additional measures (thoracoscopy, etc.).

Further management

■ Once the pneumothorax resolves, a chest x-ray is recommended.

■ Consultation with a pulmonologist via 7–10 days after discharge from the hospital.