Pneumothorax: tünetek, a kezelés és az elsősegély

Pneumothorax is a pathological condition in which air enters the pleural cavity, causing the lung to partially or completely collapse.As a result of the fall, the body can not perform its functions, so the gas exchange and oxygen supply of the organism suffers.

Pneumothorax occurs if the integrity of the lungs or chest wall is compromised.In such cases, in addition to the air, blood flows into the pleural cavity in addition to air - the hemopneumotorax develops.If the thoracic lymphatic duct is damaged during thoracic injuries, chylopneumotorax is observed.

In a number of cases, in the disease that provoked pneumothorax, exudate accumulates in the pleural cavity - develops exudative pneumothorax .If the process of suppuration is then started - pyopneumothorax occurs.

Contents:

Causes and mechanisms of development

In the lung there is no muscle tissue, so it can not self expand itself to provide breathing.The inspiration mechanism is the following.In the normal state, the pressure inside the pleural cavity is negative - less than atmospheric pressure.When the chest wall moves, the chest wall expands, due to the negative pressure in the pleural cavity of the lung tissue "picked up" by the pull inside the chest, the lung is straightened

. Then the chest wall moves in the opposite direction, the lung under the influence of negative pressure in the pleural cavity returns to its original position.So in humans, the act of breathing takes place.

If air enters the pleural cavity, then the pressure inside it grows, the mechanics of lung expansion breaks - a complete act of breathing is impossible.

Air can enter the pleural cavity in two ways:

• in case of thoracic wall lesions with a breach of the integrity of the pleural sheets;
• for injuries of the mediastinal and lung organs.

The three main components of pneumothorax that create problems are:

• the lung can not straighten;
• air is constantly sucked into the pleural cavity;
• the affected lung swells.

The impossibility of lung spreading is associated with repeated influx of air into the pleural cavity, bronchial blockage against the background of previously noted diseases, and also if the pleural drainage has been installed incorrectly, which is why it does not work effectively.

Pulmonary edema can occur as a result of stretching of the lung tissue after medical actions aimed at quickly restarting the negative pressure in the pleural cavity.

Pneumothorax happens:

• open - the pleural cavity communicates with the external environment, each time at the time of exhalation a new portion of air enters the pleural cavity, which, however, has the opportunity to exit again;
• closed - if a thoracic wall or bronchus is damaged, a certain volume of air enters the pleural cavity, its further supply is not supported;
• Valve - at the moment of inspiration air gets into the pleural cavity through any opening that during the exhalation closes the lung fragment( or other structure) and does not release air back, the next inhalation into the pleural cavity another portion of air arrives. Such pneumothorax is especially dangerous, because the amount of air in the pleural cavity increases, because of which the lung tissue collapses more and more.

In itself, the presence of air in the pleural cavity would not cause effects if it were not for the buildup of pressure that disturbs the lungs. Therefore, the severity of pneumothorax is assessed by the collapse( collapse) of the lung - it happens:

• small - less than a quarter of the lung tissue slept;
• average - slept from 50% to 75% of this body;
• full - all light falls off;
• intense - the amount of air in the pleural cavity increases to such an extent that it causes not only a decrease in the lung, but also a displacement of the mediastinum( a complex of organs between the lungs) and the deterioration of the venous blood flow to the heart.In turn, the deterioration of venous inflow entails a general decrease in blood pressure. Cardiovascular and respiratory systems can stop their work in a few minutes from the onset of intense pneumothorax .

In general, pneumothorax is one-sided.Two-sided process develops rarely - most often with extensive traumatic lesion of the thorax.

Pneumothorax can occur:

• spontaneously;
• after diseases;
• after injury;
• for menstruation( rare form);
• as a result of the actions of doctors( the so-called iatrogenic pneumothorax).

Primary spontaneous pneumothorax

Occurs in patients who do not currently have lung problems and have not tolerated it previously. In most cases, this pneumothorax occurs in lean, high-growth individuals aged 18 to 20 years. In this case, pneumothorax is explained by the rupture of those lung regions that are close to the pleura, and in which bulbs appeared - cavities formed as a result of rupture of the walls of the alveoli and the fusion of their cavities. The reason for this kind of pneumothorax is:

• is a special hereditary structure of lung tissue;
• smoking.

Primary spontaneous pneumothorax develops most frequently in a state of rest, less often with exercise.For its occurrence, a minimal force is applied, applied to the tissues of the lungs.Frequent treatment of such patients to doctors about pneumothorax, which occurred during jumping into water, or as a result of the fact that a person reached for some object.Cases are described when spontaneous pneumothorax develops with damage to lung tissue as a result of the fact that a person stretches after sleep or prolonged work performed in one static position.Also, spontaneous pneumothorax can occur during flight at high altitude - inside the lung there is a difference in air pressure, its weak spots get an excessive load and literally break.

Secondary spontaneous pneumothorax

Develops in people with lung diseases or who have experienced them in the past. This is mainly due to the rupture of bullae formed as a result of diseases or pathological conditions - first of all:

• bronchial asthma;
• severe course of other chronic obstructive diseases( with obstruction of the respiratory tract fragment);
• any lesions of the lung tissue;
• pathology of connective tissue;
• infection of Pneumocystis jiroveci in HIV-infected patients.

The most common pathology of connective tissue is secondary spontaneous pneumothorax in diseases such as:

• Ehlers-Danlo syndrome( it breaks the formation of collagen that provides elasticity of tissues and their cushioning capabilities that prevent tissues from losing integrity under loadon them);
• ankylosing spondylitis( inflammation of the joints of the spine);
• polymyositis( inflammation of muscle tissue);
• Marfan syndrome( congenital connective tissue disease);
• sarcoma( malignant connective tissue disease)
• rheumatoid arthritis( connective tissue lesion mainly in small joints);
• Tuberculosis sclerosis( proliferation of connective tissue due to tuberculosis);
• systemic sclerosis( proliferation of connective tissue, which is simultaneously observed in many organs).

Secondary spontaneous pneumothorax can develop in some other diseases:

• sarcoidosis( systemic disease with multiple granuloma formation);
• lymphangioleiomyomatosis( cyst formation in the lungs followed by their destruction).

Secondary spontaneous pneumothorax most often occurs with lung tissue lesions such as:

• pneumonia( especially necrotizing form);
• cystic fibrosis( defeat of the glands of the respiratory system);
• tuberculosis;
• idiopathic( for undetectable cause) pulmonary fibrosis( connective tissue germination);
• lung cancer .

If there is a purulent disease of the respiratory system, and air penetrates into the pleural cavity simultaneously with a breakthrough of pus - there is pyopneumothorax.In this case, the "gap" in the tissues, which led to the entry of air into the pleural cavity, is formed due to the rotting of the tissue site. Most often this effect is observed:

• after complete removal of the lung, when suppuration occurs at the site of the superimposed seams, their tightness is not maintained, and air enters from the bronchus into the pleural cavity;
• with breakthrough of lung ulcer;
• because of the formation of a fistula between the bronchus and the pleural cavity.

In this case, the lung is pressured simultaneously by air and pus, which is why its decrease is aggravated.

Secondary spontaneous pneumothorax downstream is more unfavorable than primary because:

• respiratory organs already compromised by the disease;
• is more common in more mature age, when the lungs have lost some of their functional reserves.

Traumatic pneumothorax

Occurs because of chest damage:

• closed - even with the entire chest wall of the lung tissue or mediastinum may be damaged( especially if a person has previously had some kind of pathology of the respiratory system);
• penetrating - most often due to the impact of cutting and cutting objects.

Menstrual pneumothorax

This is a rare type of secondary spontaneous pneumothorax.Develops with intrathoracic endometriosis - a pathological condition, when endometrial cells( the inner shell of the uterus) migrated into the chest cavity, settled down there and menstruated along with an endometrium with normal localization.Menstrual pneumothorax arises because in menstrual bleeding, the intrathoracic endometrium is rejected, and because of this, defect is formed in the pleura. Mainly developed in the following cases:

• in the premenopausal period;
• is less common - during menopause, if a woman takes estrogen preparations.

Iatrogenic pneumothorax

It may occur during the performance of medical or diagnostic procedures, such as:

• pleurocentesis( puncture of pleura sheets - in particular, to determine the contents in the pleural cavity);
• transthoracic needle aspiration( performed for sucking fluid from the pleural cavity);
• artificial lung ventilation( mediastinum is damaged by medical equipment);
• installation of venous catheter in subclavian vein;
• cardiopulmonary resuscitation( due to too intense indirect heart massage ribs are damaged, which, in turn, cut the lung tissue with sharp debris).

  Symptoms of pneumothorax

  The degree of manifestation of pneumothorax symptoms depends on how much the pulmonary tissue has collapsed, but in general they are always pronounced. The main features of this pathological condition:

  • is a permanent, non-intensive chest pain that is worse when coughing or trying to take a deeper breath in or out;
  • increased respiratory rate, developing into shortness of breath - depending on the volume and rate of buildup of pneumothorax, it can be immediately pronounced or gradually increasing
  • cyanosis of the skin( particularly the face and especially the lips): observed if at least 25% of the lungs slept;
  • lag of the affected half of the chest in the act of breathing;
  • characteristic bulging of intercostal spaces - especially pronounced at the time of deep inspiration and during coughing;
  • with a strained pneumothorax, the chest is swollen, the affected side is enlarged.

  Non-traumatic, non-expressed pneumothorax can often occur without any symptoms.

  Diagnosis

  If the symptoms described above are observed after the fact of injury and a defect in the chest tissue is detected - there is every reason to suspect pneumothorax. Non-traumatic pneumothorax is more difficult to diagnose - for this additional instrumental methods of investigation will be needed.

  One of the main methods for confirming the diagnosis of pneumothorax is the radiography of the chest organs when the patient is lying down.In the photographs, a decrease in the lung or its complete absence is fixed( in fact, under the pressure of the air, the lung is compressed into a lump and "merges" with the mediastinal organs), as well as the displacement of the trachea.

  Sometimes radiography can be of little informative - in particular:

  • with small pneumothorax;
  • when adhesions formed between the lung or chest wall, partially keeping the lung from falling off;This happens after pronounced pulmonary diseases or operations on them;
  • because of skin folds, intestinal loops or stomach - there is confusion, which is actually revealed in the picture.

  In such cases, other diagnostic methods should be used, in particular, thoracoscopy.During it, through the hole in the chest wall, a thoracoscope is inserted, with it, the pleural cavity is inspected, the fact of the recession of the lung and its severity is recorded.

  The puncture itself, even before the thoracoscope is introduced, also plays a role in the diagnosis - it is used to obtain :

  • in exudative pneumothorax - serous fluid;
  • for hemopneumotorax - blood;
  • with pyopneumotorax - pus;
  • with chylopneumotorax is a fluid that looks like a fat emulsion.

  If air escapes through the needle through the needle, this indicates a strained pneumothorax.

  Puncture of the pleural cavity is also performed as an independent procedure - in the event that the thoracoscope is not available, but differential diagnosis should be performed with other possible pathological conditions of the chest and pleural cavity in particular.The extracted contents are sent to a laboratory study.

  To confirm pulmonary heart failure, which is manifested with intense pneumothorax, ECG.

  Differential diagnosis

  In its manifestations, pneumothorax can be similar to:

  • emphysema - bloating of the lung tissue( especially in young children);
  • hernia of the esophageal opening of the diaphragm;
  • a cyst of lung of the big sizes.

  The greatest clarity in diagnosis in such cases can be obtained with the help of thoracoscopy.

  Sometimes the pain with pneumothorax is similar to pain when:

  • diseases of the musculoskeletal system;
  • oxygen starvation of the myocardium;
  • diseases of the abdominal cavity( can give in the stomach).

  In such a case, the methods of research that are used to detect diseases of these systems and organs, and the consultation of related specialists will help to make a correct diagnosis.

  Treatment of pneumothorax and first aid

  In the case of pneumothorax, it is necessary: ​​

  • stop the flow of air into the pleural cavity( it is necessary to eliminate the defect through which air enters it);
  • remove the existing air from the pleural cavity.

  There is a rule: open pneumothorax should be transferred to closed, and valve - to open.

  For these events, the patient should be immediately hospitalized in the thoracic or at least surgical department.

  Before the chest X-ray examination, oxygen therapy is carried out, since oxygen enhances and speeds up the absorption of air by the pleura sheets.In some cases, the primary spontaneous pneumothorax does not require treatment - but only when not more than 20% of the lungs have slept, and there are no pathological symptoms from the respiratory system.At the same time, continuous x-ray monitoring should be done to make sure that air is sucked continuously, and the lung is gradually phased out.

  With pronounced pneumothorax with a significant decrease in lung, air must be evacuated. This can be done:

  • by sucking air with a large syringe( eg a Janet syringe);
  • with the help of drainage of the pleural cavity - one edge of the drainage tube is inserted into the pleural cavity, the other is immersed in a vessel with a liquid, with the act of breathing, air is expelled from the pleural cavity and does not enter back through the drainage tube, this is prevented by liquid in the vessel.

  Using the first method, you can quickly rid the patient of the effects of pneumothorax.On the other hand, rapid removal of air from the pleural cavity can lead to stretching of the lung tissue that was previously compressed and its puffiness.

  Even if after a spontaneous pneumothorax the lung has been drained due to drainage, drainage may be left for some time to be reinsured in case of repeated pneumothorax . The system is set up so that the patient can move( this is important for the prevention of congestive pneumonia and thromboembolism).

  Intensive pneumothorax is regarded as an urgent surgical condition requiring emergency decompression - immediate removal of air from the pleural cavity.

  Prophylaxis

  Primary spontaneous pneumothorax can be prevented if the patient:

  • refuses to smoke;
  • will avoid actions that can lead to rupture of weak lung tissue - diving, movements associated with stretching of the chest.

  Prevention of secondary spontaneous pneumothorax is reduced to the prevention of diseases in which it occurs( described above in the section "Causes and development of the disease"), and if they arise - to a qualitative cure.

  Prevention of chest injuries automatically becomes the prevention of traumatic pneumothorax.Menstrual pneumothorax is prevented by treatment of endometriosis, iatrogenic - by improving practical medical skills.

  Forecast

  With the timely recognition and treatment of pneumothorax, the prognosis is favorable. The most severe risks to life occur with a strained pneumothorax.

  After the patient first developed spontaneous pneumothorax, relapse may occur in half of patients over the next 3 years.Such a high percentage of repeated pneumothorax can be prevented by applying such treatment methods as:

  • videotoracoscopic surgical intervention, during which the bullae are sutured;
  • pleurodesis( artificially induced pleurisy due to which adhesions are formed in the pleural cavity securing the lung and chest wall of
  • and many others

  After application of these methods the probability of occurrence of repeated pneumothorax decreases by a factor of 10.

  Kovtonyuk Oksana Vladimirovna,Medical reviewer, surgeon, consulting physician