PHEUMOTHORAX ARTIFICIAL

From Big Medical Encyclopedia

PHEUMOTHORAX ARTIFICIAL (grech, pneuma air + grech, thorax a breast, an armor) — one of methods of a collapsotherapy consisting in administration of air in a pleural cavity for the purpose of creation of conditions for fall of the affected lung; it is applied at special indications to treatment of patients with destructive forms of a pulmonary tuberculosis, sometimes with the diagnostic purpose.

For the first time P. and. it was applied in 1882 by the Italian doctor Forla-nini (S. Forlanini). In Russia the first messages on P.'s use and. were made A. N. Rubel (1912) and A. Ya. Shternberg (1921). In the subsequent Pct it was developed by F. A. Mikhaylov (1952), V. A. Ravich-Shcherbo (1953), etc.

Mechanism to lay down. P.'s actions and. completely it is not studied. In the reduced lung elastic walls of a cavity are fallen down and favorable conditions for its healing are created. Strengthening about - and lymphokineses leads a shelter to improvement of oxidation-reduction processes in fabrics, promoting desintoxication of an organism, destruction of toxins of mycobacteria of tuberculosis and products of fabric disintegration, decrease in hypersensitivity of an organism and development of reparative processes. Such understanding of the mechanism of action of Pct unlike former views about «rest» of a kollabprovanny lung was widely adopted.

Before implementation in practice of antibacterial agents P. and. was considered as the most effective method of treatment of a pulmonary tuberculosis.

Indications to P.'s imposing and. the TB patient in the conditions of effective use of modern antituberculous remedies (see) were considerably narrowed. However combined treatment by methods of chemotherapy and P. and. it continues to be applied in cases when it is impossible to carry out adequate long chemotherapy owing to features of work of the patient, his personal qualities, at intolerance of antituberculous remedies, and also at pregnancy, a diabetes mellitus etc. P. is most effective and. at recently arisen tubercular process; at a focal and infiltrative pulmonary tuberculosis in a phase of disintegration, cavernous tuberculosis with an elastic cavity, is more rare at the limited disseminated (preferential unilateral) process in a phase of disintegration. Item and. it can be imposed according to urgent indications at pulmonary bleeding.

With the diagnostic purpose P. and. it is applied at rentgenol, a research to identification or specification of localization various patol. educations in a chest cavity: ganglioneuromas in a postmediastinum, foreign bodys (in pulmonary fabric or a chest wall), before an operative measure concerning a tuberculoma for specification of a condition of a pleural cavity (existence of commissures or an obliteration).

In case of an obliteration of a pleural cavity pheumothorax (extrapleural pheumothorax) or filling of a cavity with oil (see. Oleothorax ) apply after various operative measures, including extrapleural pneumolysia (see).

Contraindications to P. and. are hron, widespread fibrous and cavernous tuberculosis, a pneumosclerosis, emphysema of lungs, the expressed phenomena of a pulmonary heart, severe short wind, neprekrashchayushchpysya cough, a regional arrangement of destructive process, massive pleural stratifications after the postponed exudative pleurisy, epilepsy.

Technique

P. and. it is recommended to impose after a course of antibacterial therapy lasting from 2 up to 4 months, edges removes tubercular intoxication, promotes a rassasyvaniye infiltrative p fresh focal changes in lungs. P. applied on display-npyam against the background of antibacterial therapy and. increases efficiency of treatment, and also firmness of treatment with the minimum residual changes, without causing essential deviations in a functional condition of an organism, in particular from external respiration, cardiovascular system.

Fig. 1. The device for imposing of artificial pheumothorax of LPO «Red Guard»: 1 — a cylinder, 2 — the guide is resistant for movement of a cylinder, 3 - the tube connecting cylinders, 4 — a tube with a cannula for air delivery in a needle, 5 — the basis of the device, 6 — the manometer, 7 — the three-way distribution cock, 8 — a rubber tube for forcing of air, 9 - the panel of the device.

For P.'s imposing and. use the special devices giving air to a pleural cavity. Kachkachev's systems which were earlier widely used the device and the device for imposing of Pct released by the Leningrad production association «Krasnogvardeets» (fig. 1) are known. These devices work by the principle of communicating vessels. The device for pheumothorax is supplied with the U-shaped liquid manometer which is the controlling element, two reported cylinders to a half filled with liquid (2,5% solution carbolic to - you), and a needle for administration of air in a pleural cavity.

Fig. 2. Diagrammatic representation of a stage of imposing of artificial pheumothorax (frontal section): 1 — the manometer (shows negative pressure in a pleural cavity); 2 — a parietal pleura; 3 — a visceral pleura; 4 — a needle (the end of a needle is in a pleural cavity).

At P.'s imposing and. the patient is stacked on a healthy side under which the elastic roller is enclosed, the hand bent in an elbow joint is raised or a zakinuta for the head. The place of a puncture of a chest wall is chosen individually; most often it is made in axillary area, in the fourth — the fifth mezhreberye on the upper edge of an edge, using a sterile inoculating or steel needle. A needle quickly pass skin and hypodermic cellulose and more slowly a parietal pleura (at the same time the feeling of passing through an obstacle appears), and then the needle as if fails to the free space (fig. 2).

At the time of penetration of a needle into a pleural cavity on the manometer there are expressed fluctuations of negative pressure then it is possible to start administration of air in a pleural cavity. Lack of fluctuations on the manometer indicates that the needle or did not pass a parietal pleura, or is in a lung, or was corked. In this case air cannot be entered. At emergence from a gleam of a needle of blood the needle needs to be taken immediately in order to avoid development of an air embolism. If fluctuations on the manometer around zero small, air it is impossible to enter also since the needle is in a gleam of a bronchial tube.

At administration of air one of cylinders of the device is lifted on big height, at the same time liquid comes from it to the cylinder located below forces out the air which is there which under small pressure through a needle is forced in a pleural cavity. For the first time enter 200 — 300 cm 3 air.

Treatment by method P. and. it can be divided into three periods: formation of a gas bubble and creation of a collapse of a lung; P.'s preservation and. by periodic inflations of air; P.'s termination and. and raspravleniye of a lung.

In the period of formation of a gas bubble for creation of an optimum collapse of a lung in addition blow air at first every other day on 200 — 300 cm 3 (2 — 3 times), then two times a week on 300 — 400 cm 3 during 1 — 2 week. Gradually intervals between inflations extend up to 5 — 7 days, and increase amount of the entered air to 400 — 500 cm 3 depending on pressure in a pleural cavity, a cut shall be negative and optimum in each case.

Fig. 3. Diagrammatic representation of options of artificial pheumothorax: and — optimum — inefficient, in — selection and positive (the center of destruction is closed) — selection and negative; 1 — a gas bubble, 2 — a kollabirovanky lung, 3 — pleural commissures, 4 — not fallen down cavity.

In total for optimum P.'s creation and. it is necessary 1 month (fig. 3, a). Formation of a gas bubble and creation of a collapse of a lung is carried out under a weekly rentgenol, control; this period comes to the end with assessment of efficiency of P. and. according to clinicoradiological and a lab. researches. Item and. is effective if it is possible to adjust an optimum gas bubble, to create the collapse of a lung providing fall of a cavity of destruction, the termination of bakterpo-allocation and elimination a wedge, displays of tuberculosis.

To interfere with therapeutic effect of P. and. pleural unions which do not allow to be fallen down to the cavity located in a zone of pleural unions (fig. 3 can, first of all. б). In such cases make torakoskopiya (see) and an intrapleural perezhiganiye of commissures (see. Thoracocautery ). If unions of a massivna, then only partial (selection) P. is possible to create and., which can be effective (selection and positive) if the center of destruction is closed (fig. 3, f?). If patol, changes are located in the site of a lung which does not work well a call-birovat (selection and negative Pct), to lay down. the effect is not reached also P. and. it has to be stopped (fig. 3, d). Sometimes fall of a cavity does not happen even at full! a collapse of a lung, napr when rigidity of its walls at the expense of fibrosis develops. At absence to lay down. P.'s effect and. stop and apply other methods of treatment.

In the period of preservation of P. and. in a condition of a collapse periodically make blowing of air in a pleural cavity for deduction of a lung. Most often inflations do once a week; sometimes, at the slowed-down rassasyvaniye of air, is more rare — 1 time in 10 — 14 days. The period of preservation of Pct - 1,5 — 2 years. At P.'s combination and. with lechengsy antituberculous remedies duration of this period is reduced to 6 months. In order to avoid development of so-called rigidity of a lung it is not necessary to support P. and. more than 2 years.

During P.'s termination and. reduce amount of the air entered into a pleural cavity, increase intervals between introductions. If as a result of a thickening of a visceral pleura rigidity of a lung, then a lung, despite a rassasyvaniye of air developed, does not finish what high negative pressure in a pleural cavity testifies to, or it finishes very slowly. At emergence of the first signs of rigidity of easy P. and. it is recommended to stop. Duration of the period of the termination of P. and. depends on elasticity of a lung. At the remained elasticity the lung finishes within 1 — 2 month, in case of the developed rigidity of a lung terms of its raspravleniye increase to 3 — 6 months and more. Bilateral P. and., and also P.'s combination and. and pneumoperitoneum (see) are applied in isolated cases.

Combined treatment by antituberculous remedies and P. and. effectively, by data to A. E. Rab cinchona (1960) at 94,5% of patients, according to M. A. Klebanov (1961) at 93,2%, according to L. S. Kartoziya (1965) at 90,2 — 94,7%. To define P.'s efficiency and. in 70 — 80 it is not possible in view of rare use of this method.

Complications

Complications at P.'s carrying out and. can be connected with errors in the equipment of a puncture, inflation and other reasons. The most terrible complication is the air embolism arising at wound a needle of a lung and hit of air in a blood vessel. Air embolism (see) it is shown by suddenly coming pallor, spasms, a loss of consciousness. The patient in this case needs to be laid in the provision of Trendelenburga (see. Trendelenburga situation ), to enter caffeine, at disorders of breath lobelia, Cytitonum, Sulfocamphocainum, to carry out an artificial respiration, inhalation of oxygen and other resuscitation actions (see. Resuscitation ). In order to avoid this complication of P. and. it is necessary to impose only at the expressed fluctuations of negative pressure in a pleural cavity revealed on the manometer.

At the increased painful sensitivity which is shown sharp pain in the place of a puncture or prp traumatic carried out manipulation there can be plevropulmonalny shock (see), followed by a faint. In these cases to the patient caffeine or Cordiaminum is entered, at the proceeding pains — analginum and other anesthetics.

At a puncture (a prick internal) pheumothorax arises a needle of a visceral pleura and wound of a lung traumatic; such complication is more often it is possible at primary imposing of Pct; at the same time even before administration of air fall of a lung develops or at introduction of small amounts of air (50 — 150 — 200 cm 3 ) there is inadequately big collapse of a lung. If traumatic pheumothorax develops at repeated inflations of air, the patient has a short wind, tachycardia, stitches, a pneumorrhagia; sometimes traumatic pheumothorax proceeds without subjective feelings and is shown only at roentgenoscopy by an inadequate collapse of a lung. Special treatment at this complication is not required; rest is appointed to 2 — 4 days, symptomatic means.

Sometimes P. and. is complicated by spontaneous pheumothorax (see), resulting from a rupture of a thin pleural union, the site of the lung located subplevralno bullezno changed. Klinrshesky manifestations same, as well as at traumatic pheumothorax. Further inflations in such cases stop.

In the period of formation of a gas bubble air can get couple-mediastinalno. Clinically at such patients pains in heart, feeling of weight behind a breast, tachycardia are noted; the diagnosis is made at rentgenol, a research. These phenomena are gradually liquidated; only occasionally the complication has resistant character.

At any stage P. and. in the presence of pleural commissures, not fallen down cavity, the continuing bakterio-allocation the pneumopleuritis can develop, however more often it develops in the first months after an initiation of treatment; also a late pneumopleuritis is possible. The pneumopleuritis is manifestation of activity of tuberculosis. The sub-plevralpo located centers, tubercular to damage of a pleura can be its source. Exudate at the same time happens serous or purulent. At emergence of a pneumopleuritis of Pct stop, repeatedly aspirate exudate, trying to obtain an active raspravleniye of a lung and an obliteration of a pleural cavity.

At the combined use of antituberculous remedies and P. and. frequency of a pneumopleuritis considerably decreased, by data A. G. Homenko (1958) — to 11%, L. A. Vinnik (1960) — to 6,6%, L. S. Kartoziya (1965) - to 11,3%.

The patients treated in last Pct are under dispensary observation. At nek-ry patients, it is long the treated P. and. or transferred a pneumopleuritis, there are pleural commissures, the restriction of mobility of a diaphragm, residual changes in a type of the centers of fibrosis of pulmonary fabric which are quite often bringing to hron, to dysfunctions of breath are noted.

See also Collapsotherapy , Tuberculosis of a respiratory organs .



Bibliography: Rabukhin A. E. Himioterapiya of TB patients, page 300, M., 1970; Ravich-Shcherbo V. A. A pulmonary tuberculosis at adults, page 131, M., 1953; Rubel And, N. Artificial pheumothorax at treatment of a pulmonary tuberculosis, SPb., 1912; Harcheva K. A. A collapsotherapy in complex treatment of suffering from tuberculosis lungs, L., 1972; D u m and of e S t F. e. a. La pratique de pneumothorax therapeutique. P., 1945; F o of 1 n i n i C. Primi tentativi di pneu-motorace artificiale della tisi polmonare. gozz. med. Torino, p. 381, 401, 1894.


A. G. Homenko; B. I. Belkevich (tekhn.).

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