PYOPNEUMOTHORAX (grech, pyon pus + pheumothorax) — simultaneous accumulation of pus, and also gas or free air in a pleural cavity.
On prevalence and localization distinguish the following types of P.: total (intense and not intense) and limited (sacculated) — pristenochny, apical, interlobar, paramediastinal, epiphrenic, multichamber, including reported and not reported (fig. 1). On P.'s etiology subdivide according to a type of the activator which caused suppuration in a lung and a pleural cavity.
S. I. Spasokukotsky allocates the following a wedge, forms P.: acute, soft, erased. Emergence of these forms depends on localization of basic process in a lung, character of microflora, expressiveness of suppurative process in a lung, reaction of a pleura to inflammatory process. On time of development of P. at pneumonia distinguish parapnevmoni-chesky and metapneumonic forms.
can be P.'s Cause: pneumonia (see), abscess and gangrene of a lung (see. Lungs ), tuberculosis (see. Tuberculosis of a respiratory organs ), the getting wounds of a thorax (see. Breast ), operations and diagnostic manipulations on bodies of a chest and abdominal cavity, infringement and perforation of a hollow abdominal organ at phrenic hernia (see. Diaphragm ), etc. Tubercular P. arises at break subkortikalno of the located caseous centers or as a result of accession to tubercular process of a banal infection with the subsequent destruction of pulmonary fabric and break of an intra pulmonary cavity (cavities) in a pleural cavity. One of the reasons of P. is the empyema of a pleura caused by Clostridium perfringens — the microbe leading to emergence of gas in a tight pleural cavity.
The pathogeny and pathological anatomy
Irrespective of an etiology of the necrotic centers or abscesses of change of a pleura breaking in a pleural cavity in the field of break are same and depend on a stage of process (the menacing break, open pulmonary and pleural fistula, the covered pulmonary and pleural fistula). The stage of the menacing break is characterized by existence of small subplevralno located is purulent - the necrotic center which destroys the corresponding part of a pleura. From a pleural cavity this center is separated by the lamina formed by a boundary membrane and a surface collagenic layer of a pleura; mesh collagenic and elastic layers at the same time are destroyed.
After a nroryv of the subpleural necrotic center (a stage of open pulmonary and pleural fistula) the small site of irregular shape formed by a friable detritis is defined. Outside the necrotic zone is limited by a narrow layer of the inflamed pulmonary fabric. In case of break of abscess diameter of fistula reaches sometimes 3 cm and more, on a pleura the big ulcer surface which is crateriform shipped in tissue of a lung is defined. The amount of the gas which got into a pleural cavity depends not only on the size of fistula and abscess. Decisive factors at the same time are the intensity of gas intake in a pleural cavity depending on caliber of the reported bronchial tube and its passability and also speed of a resorption of gas from a pleural cavity. In the presence in the bronchial tube draining a purulent pleural cavity, a valve mechanism the intense P. which is characterized by supertension in a pleural cavity develops.
In a stage of the covered pulmonary and pleural fistula the opposite edges of fistula together with the neighboring sites of a pleura stick together and defect is closed. The future of the covered fistulas is various: they cicatrize or open again in a pleural cavity. At the getting wounds of a thorax of P. arises owing to infection of the blood which streamed in a pleural cavity. Most often in these cases of P. develops at hit in a pleural cavity of foreign bodys (splinters, scraps of clothes).
Changes in an organism at P. are caused, on the one hand, by suppuration, a resorption of waste products of microorganisms and disintegration of fabrics. These factors cause development is purulent - resorptive fever (see) or exhaustions, and in certain cases the phenomena of heavy intoxication with signs shock (see). On the other hand, at the expressed fluid accumulation and gas in a pleural cavity are possible a circulatory disturbance and breath, characteristic for massive closed or valve pheumothorax (see).
The clinical picture
the Clinical picture depends on the speed of emergence of P. and expressiveness is purulent - resorptive fever.
The acute form of a pyopneumothorax is characterized by a picture of a collapse (falling of the ABP, pallor of skin, cold sweat etc.), sharp pain in the corresponding half of the thorax expressed by intoxication and respiratory insufficiency. Acute development of P. can cause emergence of symptoms of an acute abdomen (a muscle tension of a front abdominal wall, Shchetkin's symptom — Blyumberg). At percussion of lungs on the party of defeat the bandbox sound appears, at auscultation — weakening of respiratory noise, the bronchial breath sometimes weakened with an amphoric shade. At total P. with rather small amount of liquid pus definition of the capotement described by Hippocrates is sometimes possible (see. Hippocrates capotement ). Radiological over a horizontal fluid level in a pleural cavity the air bubble (fig. 2) is visible.
The soft form of a pyopneumothorax is caused by break of a pulmonary suppurative focus in the closed (sacculated) space that is shown by moderate a chest cavity pain on the party of defeat, an aggravation of symptoms of the patient, increase of symptoms of intoxication. The physical research allows to define availability of gas and liquid in the relevant department of a chest cavity.
The final diagnosis of P. is established with the help rentgenol, researches.
At the erased form of a pyopneumothorax the moment of penetration of gas and pus into a pleural cavity is clinically difficult audible. Radiological limited P.
the Diagnosis is defined the wedge, pictures, data rentgenol is established on the basis. researches. Besides, at all forms P. plays a large role in diagnosis pleurocentesis (see).
Differential diagnosis Items carry out with phrenic hernias, the inborn suppurated cyst of a lung, abscess of a lung.
Moving of a stomach to a chest cavity and a fluid level in it at left-side phrenic hernias can simulate P. Odnako at the same time there are no temperature reactions and symptoms of purulent intoxication, characteristic of P. At hernia the sunk-down stomach is noted, at auscultation the hyperperistalsis of intestines is defined. The ring-shaped enlightenments with a fluid level caused by moving to a chest cavity of loops of intestines can remind a picture of the multichamber Item. At the slightest suspicion of phrenic hernia it is necessary to refuse a diagnostic puncture of a pleural cavity and to resort to a contrast rentgenol, to a research went. - kish. path.
The suppurated inborn cysts of a lung of the big sizes also sometimes remind a picture P. In this case for differential diagnosis carry out rentgenol. a research in lateroposition: at P. exudate, moving, spreads on a free pleural cavity, at a cyst — only in a cavity of a cyst. On survey roentgenograms and on tomograms at cysts of a lung it is possible to define contours of a cover of a cyst.
Abscesses of a lung are located is more or less central, are followed by perifocal infiltration and the expressed changes from bronchial tubes of affected areas of a lung. In some cases differential diagnosis subplevralno of the located abscess of a lung and the sacculated P. is extremely difficult.
Treatment includes local and general actions. Treats local pleurocentesis (see) with evacuation of air and pus and the subsequent aspiration drainage (see) a pleural cavity. As a temporary measure for this purpose it is possible to use a passive drainage across Byulau (see. Byulau drainage ). At an acute form P. at the same time for removal of the patient from the shock caused by massive intoxication and a hypoxia — carry out hemodilutions) (reopoliglyukin, etc.), an oxygenotherapy, cardiac glycosides, glucocorticoids, heparin enter. Further P.'s treatment is conducted according to the principles of treatment purulent pleurisy (see). Bronchopleural fistulas complicate full processing of a purulent pleural cavity antiseptic agents because of a pelting of wash liquid in bronchial tubes and do not allow to pressurize a pleural cavity. In these cases temporary occlusion of the draining bronchial tube by its blockade by a collagenic or porolonovy sponge by means of the bronchoscope is used. Previously on the party of defeat enter solution into a pleural cavity methylene blue and at an open drainage stack the patient on a healthy side. The painted liquid, flowing into bronchopleural fistula, allows to define the bronchial tube which is subject to occlusion. In case of impossibility to straighten a lung and to liquidate P.'s cavity after the most achievable sanitation an operative measure like pleurolobectomy, more rare is shown pleurectomies (see) in combination with a decortication of a lung and closing of bronchial fistula. In cases when the volume of a lung reduced as a result patol of process or the previous resection, does not allow to count on filling with pulmonary fabric of all pleural cavity, there are indications to to a thoracoplasty (see).
At small cavities with the closed bronchopleural fistula the purulent cavity manages to be liquidated by means of repeated long washings and active aspiration drainage.
the Forecast at timely diagnosis and adequate treatment of P. in general favorable, however in many respects depends on extent of destruction of a lung.
Features of a pyopneumothorax at children
P. is the most frequent form of inflammatory process in a pleural cavity at children. In absolute majority of cases it develops as a complication of the abscessing bacterial pneumonia caused more often by staphylococcus. Much less often P. caused by an exogenous or endogenous injury of a gullet, bronchial tubes, the getting wounds of a thorax, break in a pleural cavity of the suppurated inborn cysts of a lung meets. At P. children often leads to development of sepsis or arises against the background of a septicopyemia, being one of secondary suppurative focuses. At children of the first three years of life intense P. of which the heaviest is characteristic a wedge, a picture is most often observed. The child suddenly has a sharp concern which is followed by the attack of short wind which is speeded up, shallow breathing, is frequent with the groaning complicated exhalation, the accruing cyanosis. The child rushes about in a bed, «gasps» a mouth; there are symptoms of a collapse; temperature increases. Soon excitement is replaced by slackness and a hypodynamia. In the absence of the adequate help the increasing respiratory and cardiovascular insufficiency creates direct threat for life of the child.
At total not intense P. and limited forms P. a wedge, a picture less heavy. It consists of symptoms of disorder of breath and intoxication and the more so it is expressed, than the age of the child is less.
To lay down. tactics at P. at children provides a combination of an intensive care to the local actions directed to a raspravleniye of a lung and sanitation of a pleural cavity. Repeated pleurocenteses are reasonable only at the limited forms P. proceeding with moderate accumulation of exudate. A traditional method of treatment of P. at children is drainage of a pleural cavity — passive or with active aspiration of air and exudate. Thanks to simplicity, availability and efficiency this method gained the greatest distribution. In the course of drainage at any ways of aspiration widely apply fractional or constant washing of a pleural cavity solutions of antiseptic agents and antibiotics. Since drainage of a pleural cavity not always provides a raspravleniye of a lung, apply other methods, in particular Hartl (1958) method providing the forced raspravleniye of a lung through an endotracheal tube under anesthetic. G. A. Bairov, B. Peplov (1963) recommend to create at the time of inflating of a lung depression in a pleural cavity by means of a Janet's syringe. In all cases after inflating of a lung drainage with active aspiration is necessary.
For the purpose of «cauterization» of bronchopleural fistulas and acceleration of a raspravleniye of a lung A. D. Hristich, M. S. Gelberg (1974) recommend to use intrapleural introduction of Iodolipolum and Iodinolum, other researchers — proteolytic enzymes for acceleration of a lysis of fibrin.
At P.'s treatment carry out also temporary sealing (occlusion) of the bronchial tube bearing peripheral bronchopleural fistulas that allows to eliminate immediately dumping of air and the anoxemia caused by it. The temporary atelectasis of the struck share allows to liquidate pheumothorax. At the same time other shares finish and are well ventilated. At occlusion of the affected bronchial tube the best conditions for healing of peripheral bronchopleural fistulas are created, to-rye there are impassable, and formations of pleural unions in the field of the straightened shares. As a rule, temporary occlusion results in positive dynamics of purulent process in a pleura that it is possible to explain with the termination of an aerobronkhogen-ny reinfitsirovaniye, a raspravleniye of a lung and elimination of a residual cavity. It allows to reduce terms of drainage sharply.
Considerable experience of surgeries on a lung and a pleura at P. at children is accumulated. Nek-ry surgeons find reasonable only late operations when long drainage leads to improvement of the general state, but the lung remains not straightened. Others consider that in the acute period operative measures with single-step sanitation of purulent process in a lung and a pleura are shown. Need for similar operations arises generally at chest age. Most of surgeons resort to an operative measure at inefficient drainage within several days. The volume of operative measures is defined by character and prevalence of suppurative focuses in a lung. At superficial abscesses and bronchopleural fistulas a pnevmoabstsessotomiya with the subsequent sewing up of tissue of lung, sewing up of fistulas and other options of economical operations (a regional, plane, wedge-shaped resection) are possible. At deep abscessing make a typical pneumonectomy (see. Lobectomy , Pneumonectomy , Segmentectomy ).
At P. children even at modern opportunities of treatment remains the terrible disease which is followed by failures in 10 — 20% of cases, and its danger is inversely proportional to age of the child.
The remote forecast at the children who transferred P., in general favorable however is observed formation hron, nonspecific inflammatory process owing to irreversible changes in pulmonary fabric. For full rehabilitation and early detection of adverse effects, especially after P. against the background of the deep abscessing pulmonary processes cured by not operational methods, the children who transferred P. are on dispensary observation.
Prevention consists in timely recognition and effective treatment of inflammatory processes in a lung.
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