PHEUMOTHORAX

From Big Medical Encyclopedia

PHEUMOTHORAX (grech, pneuma air + thorax an armor, a breast) — the morbid condition which is characterized by accumulation of air between a visceral and parietal pleura.

The item can be unilateral or bilateral, depending on the volume of a gas bubble — chastrtchny or full (total), at the same time the lung is fallen down (kollabirutsya) partially or completely.

Air can get into a pleural cavity at disturbance of an integrity of a chest wall or at injury of a lung, is rare from any body chest ilp an abdominal cavity (pish, Evodius, a stomach, intestines) at damage of its walls and diaphragms. If free air freely comes to a pleural cavity at a breath and comes out it during an exhalation, P. call open. If the opening, through a cut air comes to a pleural cavity, was closed owing to the shift of fabrics on site of wound and postuprtvshiya in a pleural cavity air has no escaping it, pheumothorax call closed.

If during a breath air comes to a pleural cavity, and during an exhalation there are obstacles for a vykhozhdeniye of air outside through a wound, the air volume and pressure in a pleural cavity gradually increase. Usually it happens at rather small wounds, at to-rykh the wound channel can be blocked by soft tissues of a chest wall («the sucking wounds»). The item in this case is called valve, or valve. Valve P. is quite often observed also in the presence of the traumatic bronchopleural message.

The etiology and a pathogeny

Distinguish traumatic, operational, spontaneous, and also artificial P. (see. Pheumothorax artificial ). Leads damage of a chest wall or tissue of a lung to traumatic P.'s emergence. Especially often it arises at getting fire (bullet or fragmental) the wounds of a breast which are followed by destruction of edges and muscles (see. Breast ). In field surgery along with primary (arising during wound) distinguish for the second time the opened P. as a result of discrepancy of seams of the taken-in wound of a thorax, usually on 4 — the 15th day after wound what is promoted suppuration of a wound, development of an empyema of a pleura. In peace time traumatic P. is observed by hl. obr. owing to bruises of a breast (transport and household traumatism) or after the getting wounds of a thorax the pricking or cutting weapon. At wounds in a pleural cavity along with air blood usually accumulates — - there is a hemopneumothorax (see. Hemothorax ).

During operations on the bodies of a chest cavity connected with opening of a chest cavity the Item is inevitable operational, ilp surgical. It can be unilateral (a pneumonectomy, heart and gullet operations) or bilateral (chrezdvukhplevralny access at operation at the same time on both lungs or on heart). At division of pleural unions of P. it is sometimes formed on the opposite side at accidental injury of a mediastinal pleura, especially if the patient has a so-called mediastinal hernia. Bilateral P. can arise during the median sternotomip applied at operations for tumors of a mediastinum, heart diseases and a pericardium, and also at bilateral interventions on lungs.

Spontaneous P. is characterized spontaneous, as if without the visible reasons, by the accumulation of air in a pleural cavity which is not connected with a bruise of a chest wall or pulmonary fabric as a result of an injury or to lay down. actions. Though spontaneous P. arises against the background of the seeming wellbeing, these or those are always found in patients, limited changes in a lung (violent emphysema, cysts, a pneumosclerosis, pleural unions) which lead to a rupture of pulmonary fabric and a visceral pleura, a vykhozhde-niya of air in a pleural cavity are more often. According to Institute пуль^юноло-гии M3 of the USSR, full a wedge, wellbeing before spontaneous P.'s emergence it was observed only at 27% of patients, the constant or often becoming aggravated dry or unproductive cough disturbed 28% of patients, 22% of patients were subject to frequent respiratory infections and almost as much pneumoscientific Production Enterprises of a pla of tuberculosis were repeatedly treated apropos hron (11 and 12% respectively). After P.'s elimination rentgenol, symptoms of the disease preceding P. were defined approximately at a half of patients (52%) that testifies to quite often asymptomatic current patol, process in a lung. T. about. spontaneous P. not less than in 2/3 cases is connected with hron, the nespetsifpchesky diseases of lungs proceeding with small symptomatology ilp subclinically, generally with hron. bronchitis (see) and emphysema of lungs (see).

With accumulation of experience of diagnosis (see. Torakoskopiya ) and operational treatment of spontaneous P. it became clear that in most cases preferential in upper shares of lungs uviform air shots (bulls) located under a visceral pleura are observed single or multiple thin-walled, sometimes. Bulls arise at various, both cicatricial, and inflammatory processes, leading to disturbance of passability of small bronchial tubes that creates difficulties in regional ventilation of the lungs and leads to build-up of pressure in distal departments of pneumatic ways. Thin-walled air shots form as a result of a rupture of hyperinflate, atrophied interalveolar partitions. Though the specific reasons of the bronchial obstruction leading to focal subpleural alveolar destruction can be various, including and the postponed tuberculosis, long overseeing by patients shows that bulls most often are manifestation diffusion emphysemas (see). Air, getting under a visceral pleura, big subpleural bubbles can become the reason of its amotio and education sometimes enough (blebs), and having got into a mediastinum, to cause emergence of mediastinal emphysema. The spontaneous P. complicating a current of a number of disseminprovanny processes in lungs (a sarcoidosis, a histiocytosis of X, a leiomyomatosis, a fibroziruyushchy alveolitis — Hammen's disease — Rich, etc.), is also connected with a rupture of emphysematous bulls or with disturbance of an integrity of the band educations which are manifestation of an outcome of a diffusion pneumosclerosis in a so-called cellular lung. Isolated cases of inborn family P. connect with genetically determined emphysema and inborn inferiority of a visceral pleura. Spontaneous P. can be caused by spontaneous perforation of a pleura at a heart attack of a lung, solitary or multiple cysts of lungs, an atelectasis of a lung, eosinophilic infiltrate, abscess, gangrene, an echinococcosis of a lung, a silicosis.

The pulmonary tuberculosis which at the beginning of the current century was considered the main reason for P. is observed no more than in 10% of cases of spontaneous

P. U of suffering from tuberculosis lungs spontaneous P. can arise during the progressing of tubercular process, at limited specific changes, caseous pneumonia, fibrous and cavernous process. As a result of destructive changes in a pleura perforation subplevralno of the located tuberculous focus, a cavity is possible. Besides, spontaneous P.'s development in suffering from tuberculosis lungs can happen owing to an anguish of a lung the stretched pleural unions. At an empyema of a pleura of a tubercular etiology spontaneous P. can arise owing to break of pus from a pleural cavity in a bronchial tube with formation of bronchopleural fistula (see. Bronchial fistula ) and a pyopneumothorax (see).

Pathophysiological disturbances

the Pathophysiological disturbances arising at P. depend on the volume of the air which came to a pleural cavity, the speed of its receipt and other factors. At the closed P. with a small amount of the air which came to a pleural cavity these disturbances are small, at the expressed P. there are very considerable frustration, at open P. they are most expressed. Along with the arising usually full collapse of a lung the shift and fluctuations (flotation) of a mediastinum are noted during a breath and an exhalation that conducts to an excess and a prelum of venas cava, reduction of inflow of blood to heart. Disturbances of gas exchange at open P. are substantially connected with emergence of so-called paradoxical breath (movement of air during an exhalation from healthy in the fallen-down easy and return receipt it during a breath). Such pendulum movement of an air flow sharply reduces efficiency of breath and increases the volume of so-called dead space of lungs. Cardiopulmonary disturbances can quickly progress at valve P.'s development as a result of gradual increase in air volume in a pleural cavity and the progressing build-up of pressure in it. If the conditions promoting a vykhozhdeniye of air outside, napr are not created drainage of a pleural cavity is not made, then air begins to get into hypodermic cellulose or a mediastinum, hypodermic or mediastinal emphysema develops (see. Pneumomediastinum , Emphysema ), suffocation accrues, the volume of systolic emission of blood decreases. The developing progressing pulmonary and heart failure (see. Pulmonary heart ) can lead to a lethal outcome.

Clinical manifestations

widely vary Clinical manifestations from easy forms P. before heavy manifestations with sharp disturbance of breath and blood circulation. Degree of manifestation a wedge, P.'s signs is caused by P.'s type, expressiveness of commissural process, size of the pulmonary and pleural message, speed of receipt and volume of the air which accumulated in a pleural cavity, existence or lack of a valve mechanism, degree of shift of a mediastinum to the opposite side, disturbances of functions of the second lung and cardiovascular system.

The clinical picture of traumatic P. is defined by P.'s character (closed, open, valve) and the size of a gekhmotoraks. In detail traumatic P.'s clinic — see. Breast .

Spontaneous P. most often occurs at the age of 20 — 40 years, at men by 8 — 14 times more often than at women. In 20% of cases of spontaneous P. the beginning can be atypical, imperceptible for patients. It is accepted to call such P. asymptomatic; it appears an accidental find during routine maintenances. However the acute subacute beginning of a pla spontaneous is more often observed P. Zabolevaniye begins suddenly, often among full health, sometimes as a result of physical tension (especially at the closed glottis) or after a fit of coughing. Bystry intake of air in a pleural cavity in most cases is followed by the sharp pricking stethalgias, poyavlenpy asthmas, dry cough, heartbeat, sometimes cyanosis that is connected with fall (collapse) of a lung and shift of a mediastinum. Expansion of intercostal spaces and reduction of respiratory excursions on the party of defeat, a tympanites, weakening of respiratory noise are observed. If there are pleural unions (commissures), there is limited (wasps umkovanny) P. if they are absent, then usually he is total.

Valve intense spontaneous P. — the most severe form of P., at a cut of disorder of breath and blood circulation quickly progress. In these cases the sudden beginning with bystry increase of an asthma, cyanosis and feeling of suffocation is observed. The patient becomes uneasy, breath becomes frequent, becomes superficial, auxiliary muscles participate in breath. Sharply developing symptoms can be also a sign of bilateral spontaneous P. which meets very seldom.

At an uncomplicated current defect on a visceral pleura is closed by a fibrinny film, pressurized and begins to live. Within 1 — 3 month air resolves. Repeated emergence of P. (recurrent P.) it is observed in 12 — 15% of cases.

At spontaneous P. quite often there are complications; from them the heavy should consider the acute progressing intense P. Razryv of cortical department of a lung in places of fixing to a chest wall vaskulyarizirovanny pleural commissure at a number of patients leads it to intrapleural bleeding — a spontaneous hemopneumothorax. In late terms at hit in a pleural cavity of pathogenic microflora, especially at repeated pleurocenteses, the seroznofibrinozny pneumopleuritis with education on the surface of a lung dense shvart therefore it cannot finish any more razvgshatsya («a rigid lung»). Development of a purulent infection in a residual pleural cavity leads to emergence of an acute empyema (see. Pleurisy ). P.'s transition in hron, a form is also considered as a complication. Most of researchers considers that spontaneous P.'s existence allows to qualify it St. 3 months as chronic. P.'s transition in hron, a form is quite often observed at TB patients at break of a cavity and infection of a pleural cavity.

Diagnosis. At survey and physics flax a research of a thorax at the closed P. with considerable accumulation of air in most cases reveal «classical» symptoms of P., the mentioned vpy. With the diagnostic purpose the pleurocentesis with a manometriya of intrapleural pressure is recommended (see. Breath , Pheumothorax artificial ). At the closed spontaneous P. pressure in a pleural cavity most often negative, at opened — about zero, at valve always positive. How pressure after aspiration of air changes (remains at the initial level, slightly decreases pl becomes negative), it is possible to judge existence of the bronchopleural message, its size and character of the Item. At deaerating from a pleural cavity in case of the closed P. negative pressure increases, at opened — does not change, at valve — positive pressure decreases a little (approaches zero), but soon increases to initial figures.

Fig. 1. The roentgenogram of a thorax at right-hand pheumothorax: transparency of the right half of a thorax is increased, the arrow specified the drawn-in lung, the thin drainage entered by B the right pleural cavity for aspiration of air, at the left — a shadow of a catheter in a subclavial vein is visible.

To radiological detection of pheumothorax and its character it is applied multiaxial or Polyposition research (see). The chest fluoroscopy in a direct projection gives an approximate idea of P.'s presence and its character and defines the choice of additional methods of a research. The basic rentgenol, P.'s sign of any etiology is the site of an enlightenment deprived of the pulmonary drawing, located on the periphery of the pulmonary field and separated from the fallen-down lung by the clear boundary corresponding to the image of a visceral pleura (fig. 1). At rentgenol, a research communication of a pleural cavity with the environment comes to light. Open traumatic P. on a breath is characterized by increase in a gas bubble, further spadenpy a lung, smesh, enpy bodies of a mediastinum in the healthy party, smesh; eniye of a dome of a diaphragm from top to bottom. At the closed traumatic P. rentgenol. the picture depends hl. obr. from amount of the air which accumulated in a pleural cavity, and the intrapleural pressure connected with it. Distinguish three types of the closed P.: with pressure below atmospheric, above and equal to it. With a pressure below atmospheric the amount of air in a pleural cavity is small. The lung is kollabirovano insignificant, on a breath it increases in volume, on an exhalation — is fallen down. Prp pressure above atmospheric the lung is sharp kollabirovano, its respiratory excursions are hardly noticeable, bodies of a mediastinum are displaced in the healthy party, the diaphragm is displaced from top to bottom. If pressure at the closed P. equally atmospheric, a lung kollabirovano partially, respiratory excursions are kept, the mediastinum is displaced slightly.

Fig. 2. The roentgenogram of a thorax at total left-side pheumothorax: transparency of the left half of a thorax is increased, the pulmonary drawing is not defined, the shadow of the fallen-down lung is visible (it is specified by an arrow).

At valve (valve) P. the fallen-down lung does not change the sizes and a configuration at breath, extent of fall of a lung maximum, the mediastinum is sharply displaced in the healthy party, and on a breath moves towards defeat a little. Long forcing of air in a pleural cavity at valve P. leads to intense P.'s education; at the same time the sharp shift of a mediastinum in an opposite half of a thorax is found, the diaphragm is located low, flattened, gas in soft tissues of a chest wall Quite often is defined. At total P. gas occupies all pleural cavity, the shadow of a mediastinum is displaced in the healthy party (fig. 2), the dome of a diaphragm falls from top to bottom.

P.'s, small on volume, identification is promoted by a research in a lateroiozition. At a small amount of gas in a pleural cavity on a healthy side the «symptom of a sine» described by V. A. Vasilyev, M. A. Kunin and E. I. Volodin (1956) comes to light: on P.'s party deepening of a costal and phrenic sine and flattening of contours of a lateral surface of a diaphragm is noted.

Point out changes of situation and the sizes of a kollabirovanny lung on a breath and an exhalation safety of elasticity of a visceral pleura and pulmonary fabric. However it is final it is possible to judge a condition of pulmonary fabric at P. only after a full raspravleniye of a lung.

If as a result of an injury gets into a pleural cavity, except gas, also liquid (blood, a lymph), there is a picture of a hydropneumothorax with horizontal border between two environments. The massive hypodermic emphysema complicating traumatic P. is revealed in the pictures made by beams of the increased rigidity.

Spontaneous P.'s reason is established during the use of a tomographic method of a research (see. Tomography ). Existence on tomograms of ring-shaped shadows on the periphery of the fallen-down lung indicates existence in it of band educations (cysts or bulls) which are often the reason of the spontaneous Item.

Angiopuljmonografiya (see) allows to judge a condition of a vascular bed in a kollabirovanny lung. Filling with a contrast agent of branches of a pulmonary trunk in the fallen-down lung indicates its remained functional capacity, dumping of a contrast agent is preferential in a healthy lung — on development of sclerous and cirrhotic changes in a parenchyma of the affected lung.

To visual specification of a surface condition of a lung and establishment of the reason of spontaneous P. it is applied torakoskopiya (see).

Differential diagnosis spontaneous P. it is necessary to carry out with various big air intrathoracic educations: a tubercular cavity (see. Tuberculosis of a respiratory organs ), a retentsionny or bronchogenic cyst (see. Bronchial tubes ), in rare instances with phrenic hernia (see. Diaphragm ). In doubtful cases resort to tomographies (see) or bronchographies (see), and for an exception of phrenic hernia — to a contrast rentgenol, a research of intestines. Besides, at the differential diagnosis it is necessary to remember a number of diseases, at to-rykh the similar wedge, signs are observed: acute pleurisy (see), myocardial infarction (see), acute diseases of upper respiratory tracts, pneumonia (see), emphysema of a mediastinum (see. Pneumomediastinum ), neuralgia (see) and miositis of pectoral muscles.

Treatment

Lech. actions depend on a type of the Item. Waiting conservative therapy (rest, symptomatic, anesthetics) is applied only at small P. (air occupies less than 25% of volume of a pleural cavity). For acceleration of a raspravleniye of a lung resort to active aspiration of air from a pleural cavity. Air at the closed P. of any etiology is deleted in time pleurocentesis (see). At traumatic open P. the urgent operation consisting in audit of the place of small damage, a stop of bleeding, layer-by-layer sewing up of a wound of a chest wall and drainage of a pleural cavity is shown. Introduction of a drainage with active or if it for any reasons is impossible, with passive aspiration of air (across Byulau) is an urgent and effective method of elimination of intense (valve) traumatic P. (see. Aspiration drainage , Byulau drainage , Breast , Drainage ).

Spontaneous P.'s treatment depending on indications can be both conservative, and operational. Overwhelming number of patients, at to-rykh it arose for the first time, recovers by aspiration of air from a pleural cavity by means of pleurocenteses or drainage. The drainage tube is entered through a trocar best of all in the second mezhreberye in front or in the third — in axillary area. The torakoskopiya is made for definition of nature of pathology, existence of the pleuropulmonary message and its look before this manipulation. Deaerating through a drainage is carried out by means of a vacuum system. Introduction to a pleural cavity of various substances (talc, 40% solution of glucose, Iodinolum, etc.) with the purpose to cause an aseptic inflammation and an obliteration of a pleural cavity (pleurodesis) is applied seldom since does not guarantee against P.'s recurrence and is followed by complications (a pneumopleuritis, an extensive fibrothorax, persistent pains). The TB patient, at to-rykh infection of a pleural cavity it is the most probable, along with aspiration of air the pleural cavity is irrigated with solutions antituberculous remedies (see). Sometimes, despite aspiration, it is not possible to straighten a lung because of the continuing intake of air through pleuropulmonary fistulas. In this case very effective was a method of temporary occlusion of bronchial tubes of the corresponding share semi-biological or synthetics (a porolonovy sponge, etc.) within 5 — 12 days.

Operational treatment it is undertaken at 5 — 15% of patients generally at the complicated spontaneous P., impossibility of a raspravleniye of a lung because of large or multiple pleuropulmonary fistulas, existence in it big band educations or a frequent recurrence. In time thoracotomies (see) the pleuropulmonary message which arose in surface layers of a lung by excision (ektomiya) or sewing up (plication) of bulls and subplev ra is eliminated with l of py bubbles patol. If it appears insufficiently for sealing of a lung, make economical, usually atypical, resections. In isolated cases resort to lobectomies (see). Reliably prevents a recurrence pleurectomy (see), after a cut the lung strongly grows together with a chest wall. Most of surgeons prefers to make it along with the listed above interventions. In the postoperative period the active raspravleniye of a lung by drainage of a pleural cavity and continuous aspiration of air and exudate is obligatory. At chronic P., «a rigid lung» and the created bronkhopulmonalny fistulas difficult recovery pleurectomy operations are shown or decortications of a lung (see) with liquidation of the bronchopleural message and if necessary a resection of the struck part of a lung.

In the conditions of an intubation anesthesia with neurovegetative blockade and artificial ventilation of the lungs operational P., even bilateral, does not lead to the expressed disturbances of a hemodynamics and gas exchange and does not make heavier performing surgeries. By the end of operation after a raspravleniye of lungs and drainage of a pleural cavity air from it is deleted and P. is liquidated.

The forecast

the Forecast in case of spontaneous P. at timely and rational treatment favorable; the lethality is connected generally with its complications or the previous pulmonary pathology. Traumatic P.'s forecast depends on the nature of damages of bodies of a thorax, volume and P.'s type, and also timeliness to lay down. actions.

Features of pheumothorax at children

Etiol, P.'s factors at children are various. The sharp increase in intra bronchial pressure leading to a rupture of alveoluses and a visceral pleura that can be connected with manipulations concerning asphyxia and with resuscitation actions is so-called spontaneous P.'s reason of newborns (a laringoskopiya, an intubation of a trachea with the subsequent artificial ventilation, etc.).

At children of more advanced age can lead increase in intra bronchial pressure at whooping cough, bronchial asthma, aspiration of a foreign body to spontaneous P.'s emergence. One of the most frequent reasons of P. is the gap subplev rat py cavities or superficially located microabscesses at destructive pneumonia which occurs preferential at children of the first three years of life. In most cases they are followed pyopneumothorax (see), but sometimes exudate in a pleural cavity does not come to light radiological, at punctures. Inborn intense air cysts of lungs can be also complicated by P. owing to their gap. P. at children is frequent develops in the postoperative period after interventions on a lung. It usually disturbance of tightness of the operated lung is the reason, insolvency of a stump of a bronchial tube or seams on a lung is more rare. Injuries of a thorax occur at children considerably less than at adults, but also can be followed by development of the Item. A specific place in P.'s genesis is held by the complications arising at various medical manipulations. It is necessary to carry a wrong puncture of a lung at a diagnostic pleurocentesis to them, at a puncture and catheterization of a subclavial vein. There is a danger of emergence of P. at the bronkhoskopiya which is carried out without anesthesia, especially during removal of foreign bodys, edges can be connected as with difficulties of endobronchial manipulations in the conditions of insufficient anesthesia, and with sharp increase in intra bronchial pressure because of cough. Cough can cause P.'s development and at a tracheostomy under local anesthesia. In order to avoid it the specified diagnostic and to lay down. manipulations at children are carried out under anesthetic with muscle relaxants and artificial ventilation of the lungs that excludes or sharply reduces risk of development of P. Besides, at P. children can be a consequence of damage of chest department of a gullet, possible at an ezofagoskopiya the rigid endoscope without anesthesia, at rough manipulations in connection with removal of foreign bodys, at bougieurage of cicatricial narrowings via the esophagoscope or blindly through a mouth. The item can arise during artificial ventilation of the lungs if pressure in respiratory tracts sharply increases.

The mechanism of pathophysiological disturbances and clinical manifestations of P. at children the same, as at adults. At intense P. they that it is heavier, than the age of the child is less. At not intense P. expressiveness a wedge, manifestations is proportional to degree of a collapse of a lung. At limited P. a wedge, symptoms scanty.

In P.'s diagnosis Physical data (easing or lack of breath have a certain value at auscultation and increase in a sound at percussion); at survey it is possible to notice lag of respiratory excursions on the party of defeat, and at early children's age at intense P, even protrusion of the struck party. Pry the slightest suspicion on P. the X-ray analysis of a thorax is necessary (in two projections in vertical position of the patient). The diagnosis is finally confirmed and specified at pleurocentesis (see).

Differential diagnosis is carried out with the inborn localized emphysema, inborn intense air cysts of lungs (see. Lungs, malformations ), the acquired emphysema of a lung (e.g., at aspiration of a foreign body), phrenic hernia (see. Diaphragm ).

P.'s treatment is usually begun with a puncture of a pleural cavity. At P. with the functioning bronchopleural fistula, especially at intense P., drainage of a pleural cavity with active aspiration of air is more proved (see. Aspiration drainage ). Degree of a raspravleniye of a lung is controlled radiological. If active aspiration is followed by increase of a hypoxia owing to massive dumping of air through fistulas, resort to drainage across Byulau (see. Byulau drainage ). In similar cases, and also at a neraspravleniya of a lung at drainage of a pleural cavity of more effective, though, artificial sealing of bronchial system is more difficult (see. Pyopneumothorax ). The method guarantees immediate elimination of P. and a raspravleniye of healthy departments of a lung. Indications to an operative measure arise at P. complicating inborn malformations of a lung (inborn air cysts, the inborn localized emphysema) and also at P. as a result of macroperforation of a gullet, a rupture of a primary bronchus at the closed injury, injuries of bronchial tubes at endobronchial manipulations.



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B. L. Toluzakov; V. I. Geraskin (it is put. hir.), M. K. Shcherbatenko (rents.), V. D. Yampol (ftiz.).

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