Pneumothorax disease. Pneumothorax: what is it? Causes, symptoms and treatment of pneumothorax. Qualified medical care

Pneumothorax is an accumulation of air in the pleural cavity - a normally slit-like space between the parietal (external, lining the chest wall from the inside) and visceral (internal, covering the lung) pleura.

There are traumatic, spontaneous and iatrogenic pneumothorax. Traumatic pneumothorax occurs as a result of a penetrating wound of the chest or damage to the lung (for example, fragments of broken ribs). Spontaneous (spontaneous) pneumothorax develops as a result of a sudden violation of the integrity of the visceral pleura, not associated with trauma or any medical and diagnostic manipulation, leading to the flow of air from the lung into the pleural cavity. Iatrogenic pneumothorax is a complication of medical procedures.

Depending on the presence of communication with the environment, there are closed, open and valvular pneumothorax. Closed called pneumothorax, in which the pleural cavity has no communication with the external environment and the amount of air that has entered it during injury does not change depending on the respiratory movements.

At open pneumothorax there is a free connection of the pleural cavity with the external environment, as a result of which, during inhalation, air is additionally “sucked” into the pleural cavity, and during exhalation it comes out (“squeezed out”) in the same volume. Thus, with an open pneumothorax, there is no accumulation of air in the pleural cavity, and due to the unhindered movement of air through a defect in the chest wall, the lung on the side of the wound collapses during inhalation, and during exhalation it increases in volume (straightens), that is, the effect of paradoxical breathing occurs .

At valvular pneumothorax, unlike open, during exhalation, the communication of the pleural cavity with the external environment decreases or completely stops due to the displacement of the tissues of the lung itself or the soft tissues of the chest, which can be compared with covering the valve. As a result, more air enters the pleural cavity during inspiration than during expiration. Consequently, during breathing there is a constant increase in the amount of air in the pleural cavity, which leads to progressively increasing compression of the lung, displacement of the mediastinal organs in the opposite (healthy) direction, which disrupts their function, primarily squeezing large vessels, and with further progression leads to compression of the second lung on the "healthy" side.

If the air valve is located in the lung and the pleural cavity communicates with the external environment through the bronchial tree, then such a valvular pneumothorax is called internal. If the valve is located in the wound of the chest wall, such a valvular pneumothorax is called outdoor. Independently, the internal and external valves cease to function when, at the height of maximum inhalation, the pressure in the pleural cavity reaches the pressure of the external environment, but at the same time, intrapleural pressure during expiration significantly exceeds atmospheric pressure. The so-called tension pneumothorax, which is the outcome of the valvular and essentially represents a closed pneumothorax. However, tension pneumothorax differs from a closed pneumothorax by a much higher air pressure in the pleural cavity, a significant displacement of the mediastinal organs, compression of the lungs (complete on the side of the lesion and partial on the opposite, “healthy” side).

Depending on the volume of air in the pleural cavity and the degree of collapse of the lung, there are limited (small), medium and large, or total, pneumothorax. At limited pneumothorax lung collapses by less than 1/3 of its volume, with average- from 1/3 to 1/2 of the volume. At big, or total, pneumothorax, the lung occupies less than half of the normal volume or is completely compressed by air.

Possible causes of pneumothorax

The causes of spontaneous pneumothorax can be (arranged in descending order of frequency):

1. Bullous lung disease.
2. Pathology of the respiratory tract (chronic obstructive pulmonary disease, cystic fibrosis, status asthmaticus).
3. Infectious diseases (pneumocystis pneumonia, pulmonary tuberculosis).
4. Interstitial lung diseases (sarcoidosis, idiopathic pneumosclerosis, Wegener's granulomatosis, lymphangioleiomyomatosis, tuberous sclerosis).
5. Connective tissue diseases (rheumatoid arthritis, ankylosing spondylitis, polymyositis, dermatomyositis, scleroderma, Marfan's syndrome).
6. Malignant neoplasms (sarcoma, lung cancer).
7. Thoracic endometriosis.

With spontaneous pneumothorax, the disease develops, as a rule, after physical exertion or strong straining, accompanied by an increase in intrapulmonary pressure.

Traumatic pneumothorax can occur with the following chest injuries:

1. Penetrating wounds of the chest (stab-cut, gunshot).
2. Closed trauma of the chest (damage by fragments of broken ribs, traumatic rupture of the lung).

Iatrogenic pneumothorax can develop as a complication of the following diagnostic and therapeutic procedures:

1. Puncture of the pleural cavity.
2. Catheterization of the central vein.
3. Biopsy of the pleura.
4. Transbronchial endoscopic lung biopsy.
5. Barotrauma during artificial ventilation of the lungs.

In the past, the technique of therapeutic pneumothorax was used, in particular, in the treatment of cavernous pulmonary tuberculosis, when air was specially introduced into the pleural cavity in order to artificially ensure the collapse of the lung.

Symptoms of pneumothorax

The main manifestations of pneumothorax are due to the sudden appearance and gradual accumulation (with valvular pneumothorax) of air in the pleural cavity and compression of the lung, as well as displacement of the mediastinal organs.

The onset of the disease is sudden: after a traumatic effect on the chest (with traumatic pneumothorax) or physical exertion, straining (with spontaneous). There are sharp stabbing or squeezing pains in the corresponding half of the chest, which are most often localized in the upper chest, give to the neck, shoulder or arm; sometimes pain can spread mainly to the abdomen and lower back. At the same time, the patient has a peculiar feeling of tightness in the chest, as well as a subjective feeling of lack of air, which is accompanied by an increase in the frequency and depth of respiratory movements. With a large pneumothorax, the severity of shortness of breath is significant, it is accompanied by pallor or cyanosis (bluish coloration of the skin due to the accumulation of carbon dioxide in the blood), palpitations, and a feeling of fear. Trying to reduce pain and shortness of breath, the patient seeks to limit movement, takes a forced position of the body (half-sitting with an inclination to the affected side or lying on the affected side).

With a significant volume of air in the pleural cavity, protrusion and limitation of the mobility of the corresponding half of the chest, lagging behind the healthy one in the act of breathing, which, on the contrary, breathes heavily, as well as smoothness of the intercostal spaces on the affected side, can be determined. Often, especially with traumatic pneumothorax, subcutaneous emphysema is observed on the affected half of the chest - accumulation of air in the subcutaneous tissue of the chest wall, which can spread to other areas of the body with tension pneumothorax.

Survey

With percussion (percussion - tapping on individual parts of the body with subsequent analysis of the sound phenomena that occur at the same time), the doctor determines the "box" (loud and low, similar to the sound that occurs when tapping on an empty box) character of percussion sound on the side of pneumothorax, and when auscultation of the lungs (auscultation - listening to sounds generated during the functioning of organs) reveals the absence or weakening of breathing on the side of pneumothorax while breathing is preserved on the healthy side.

X-ray of a patient with right-sided total pneumothorax (on the X-ray - on the left). The arrow marks the border of the collapsed lung.

In making a diagnosis, an X-ray examination of the chest is of great importance, in which free gas in the pleural cavity is determined, a compressed lung, the degree of collapse of which depends on the size of the pneumothorax; with tension pneumothorax, the mediastinum shifts to the healthy side. Computed tomography of the chest allows not only to detect the presence of free gas in the pleural cavity (even with a small limited pneumothorax, the diagnosis of which using conventional radiography is often quite difficult), but also to detect a possible cause of spontaneous pneumothorax (bullous disease, post-tuberculosis changes, interstitial lung disease).

Computed tomogram of the chest of a patient with left-sided pneumothorax (on the tomogram - on the right). Free gas in the pleural cavity is marked with an arrow.

What tests should be taken if pneumothorax is suspected.

Laboratory examination for pneumothorax, as a rule, has no independent diagnostic value.

Treatment of pneumothorax

Treatment tactics depend on the type of pneumothorax. Expectant conservative therapy is possible with small limited closed pneumothoraxes: the patient is provided with rest, painkillers are given. With a significant accumulation of air, drainage of the pleural cavity with the so-called passive aspiration using the Bobrov apparatus is shown.

Drainage of the pleural cavity is performed under local anesthesia in the patient's sitting position. A typical place for drainage is the second intercostal space along the anterior surface of the chest (with limited pneumothoraxes, a point is chosen above the place of greatest accumulation of air), where a thin needle is injected layer by layer into soft tissues with a 0.5 solution of novocaine with a volume of 20 ml, after which the doctor cuts the skin and injects into trocar is a special tool consisting of a sharp stylet inserted into a hollow sleeve (tube). After removing the stylet through the channel of the sleeve (tube) of the trocar, the surgeon introduces a drain into the pleural cavity, and removes the sleeve. The drainage is fixed to the skin and connected to the Bobrov bank for passive aspiration. If passive aspiration is ineffective, active aspiration is used, for which a system of drains and Bobrov's jars are connected to a vacuum aspirator (suction). After complete expansion of the lung, the drainage from the pleural cavity is removed.

Drainage of the pleural cavity is considered a relatively simple surgical operation that does not require any preliminary preparation from the patient.

In traumatic open pneumothorax with massive damage to the lung, an emergency operation under general anesthesia is indicated, which consists in suturing the lung defect, stopping bleeding, layer-by-layer suturing of the chest wall wound and draining the pleural cavity.

With spontaneous pneumothorax, especially recurrent, to determine the nature of the pathology that led to it, they resort to thoracoscopy - an endoscopic examination method that consists in examining the patient's pleural cavity with a special instrument - a thoracoscope inserted through a puncture in the chest wall. If bullae are detected during thoracoscopy in the lung, which led to the development of pneumothorax, it is possible to surgically remove them using special endoscopic instruments.

With the ineffectiveness of drainage with passive or active aspiration and endoscopic techniques for thoracoscopy in stopping pneumothorax, as well as its recurrence, they resort to open surgery - thoracotomy, in which the pleural cavity is opened with a wide incision, the immediate cause of pneumothorax is identified and eliminated. In order to prevent recurrence of pneumothorax, the formation of adhesions between the visceral and parietal pleura is artificially caused.

Complications of pneumothorax

The main complications of pneumothorax are acute respiratory and cardiovascular failure, especially pronounced in tension pneumothorax and due to compression of the lungs and mediastinal displacement. With pneumothorax unresolved for a long time, reactive pleurisy may develop as a reaction of the pleura to the presence of air in the pleural cavity in the form of inflammation with fluid production; in case of infection, pleural empyema (accumulation of pus in the pleural cavity) or pyopneumothorax (accumulation of pus and air in the pleural cavity) may develop. In the case of a prolonged collapse of the lung caused by pneumothorax, sputum is difficult to expel from it, which clogs the lumen of the bronchi and contributes to the development of pneumonia. Sometimes pneumothorax, especially traumatic, is accompanied by the development of intrapleural bleeding (hemopneumothorax), while signs of respiratory failure are accompanied by symptoms of blood loss (pallor, increased heart rate, decreased pressure, and others); intrapleural bleeding can also complicate spontaneous pneumothorax.

Forecast

Tension pneumothorax is a serious, life-threatening condition that can be fatal due to the development of acute respiratory and cardiovascular failure due to compression of the lungs and displacement of the mediastinal organs. Bilateral pneumothorax is also extremely dangerous. Any pneumothorax requires immediate hospitalization of the patient in a surgical hospital for surgical treatment. With adequate timely treatment, spontaneous pneumothorax usually has a favorable prognosis, and the prognosis of traumatic pneumothorax depends on the nature of concomitant injuries to the chest organs.

Surgeon Kletkin M.E.

Pneumothorax (Greek pneuma, "air" + thorax, "chest, chest") - the accumulation of air in the pleural cavity. This is an acute condition in which the patient needs to be hospitalized in a surgical hospital.

Types and causes of pneumothorax

Pneumothorax is an emergency condition that occurs when air enters the pleural cavity.

If the communication between the environment and the pleural cavity has stopped, pneumothorax is called closed. If there is free access of air to the pleural cavity and exit from it, this is an open pneumothorax. With valvular pneumothorax, inhaled air enters the pleural cavity, but cannot exit it and accumulates, which leads to displacement of the lung and other organs of the chest.

According to the mechanism of development, pneumothorax is distinguished:

spontaneous,
traumatic,
artificial.

Spontaneous pneumothorax

Spontaneous pneumothorax develops when the inner pleura is torn and air from the lungs enters its cavity. This condition is more common in younger, underweight men. It can be caused by a malformation of the lungs, and can also be a complication of various lung diseases: tuberculosis, bullous emphysema, cyst, lung abscess, etc., in which air cavities can form in the lungs. With a strong cough, deep breathing, sudden movements, during stress, the wall of such a cavity is damaged, and air escapes between the pleura. When pus enters the pleural cavity, a serious complication develops - pleural empyema.

Traumatic pneumothorax

This condition occurs with an open chest wound or with blunt chest trauma with lung injury. Less commonly, the cause of pneumothorax is complications of medical manipulations - pleural puncture, bronchoscopy with removal of a foreign body, etc. Operational pneumothorax can occur during interventions accompanied by opening the chest.

Artificial pneumothorax

Previously, this method was used to treat pulmonary tuberculosis to collapse the resulting cavities - caverns. In modern conditions, air is introduced into the pleural cavity during its endoscopic examination, with certain types of X-ray examination under the strict supervision of medical personnel.

Symptoms of pneumothorax

Spontaneous pneumothorax develops suddenly, manifested by acute "dagger" pain in the chest,. Sometimes there is a dry cough. A sick person cannot lie down, usually takes a semi-sitting position. With valvular pneumothorax, shortness of breath quickly increases, the face turns blue, weakness increases, loss of consciousness may develop.

With a small volume of air entering the pleural cavity, the pain quickly subsides, sometimes shortness of breath and palpitations persist. Pneumothorax may not manifest itself clinically (asymptomatic course).

With traumatic pneumothorax, the general condition of the patient suffers significantly. Shortness of breath is expressed (the frequency of respiratory movements reaches 40 per minute), cyanosis of the skin. Arterial pressure decreases, pulse quickens, develops. From a wound on the chest wall, when breathing, blood is released with air bubbles. Particularly dangerous is valvular pneumothorax, in which air quickly accumulates in the pleural cavity, causing lung collapse, displacement and compression of the mediastinal organs (heart, large vessels, bronchi).

In traumatic pneumothorax, air sometimes spreads into the subcutaneous tissue of the face, neck, and chest wall. These parts of the body thicken, take on a swollen appearance. If you touch the skin with subcutaneous emphysema, you can feel a characteristic sound that resembles the crunch of snow.

Treatment of pneumothorax

In a surgical hospital, the pleural cavity is drained, into which air has entered.

A patient with symptoms of pneumothorax should be immediately taken to a surgical hospital. When providing first aid, you need to give the patient a semi-sitting position. If there is a wound in the chest with the release of blood from it with air bubbles, it is urgent to apply a sealing bandage on it with an adhesive plaster or ordinary oilcloth or cellophane. It is important to allow air to enter the pleural cavity!

With a sharp drop in blood pressure, severe shortness of breath, cyanosis of the face, an urgent pleural puncture with a thick needle is indicated. It is carried out in the II / III intercostal space along the midclavicular line. The needle is fixed to the skin with adhesive tape.

During transportation, painkillers can be administered to the patient. With the development of cardiopulmonary insufficiency, resuscitation is carried out.

In a hospital, the pleural cavity is drained to remove air and prevent infectious complications. The drain is removed 1-2 days after the lung is fully expanded. If drainage is ineffective or in severe cases, an operation is immediately performed with suturing of the lung defect and restoring the integrity of the pleura.

Features of pneumothorax in children

Immediately after the first few breaths, the newborn may develop spontaneous pneumothorax. It occurs with uneven expansion of the lungs, especially against the background of malformations. In children under 3 years of age, this condition can be a complication. At an older age, pneumothorax occurs during a cough during an attack of bronchial asthma, inhalation of a foreign body, etc. This condition can be a complication of lung ventilation during various operations.

Pneumothorax in children may not manifest itself clinically. Sometimes it is possible to note a short-term cessation of breathing, in more severe cases - palpitations, cyanosis of the skin, convulsions.

The principles of treatment of pneumothorax in children are the same as in adults.

Which doctor to contact

In case of chest injuries or any conditions when there is acute chest pain, severe shortness of breath and the patient's health deteriorates quickly, it is necessary to call an ambulance, which will take the victim to the surgical hospital. After eliminating this life-threatening condition, the patient is examined by a pulmonologist to diagnose the underlying disease that led to the development of pneumothorax.

The first channel, the program "Live is great!" with Elena Malysheva, column "About medicine" on the topic "Pneumothorax" (from 34:05):

Educational video "Puncture of the pleural cavity with tension pneumothorax."

Pneumothorax is the accumulation of gas in the pleural cavity, as a result of which there is a fall of the lung tissue with mediastinal displacement. This, in turn, leads to compression of the large blood vessels of the mediastinum, disruption of blood circulation in it and a disorder of the respiratory function.

The air in the lungs enters through the cavity that has formed there for a number of different reasons. Often, during a pneumothorax, the life of the victim is endangered. To seek timely medical help, you should be able to recognize the first signs of this disease.

Reasons for the development of the disease

Pneumothorax of the lung is a respiratory condition that can occur due to many provoking factors. The disease develops due to two main reasons: mechanical damage to the chest, as well as the presence of certain diseases that destroy lung tissue. In the second case, the patient must know the first signs of lung destruction.

Possible causes of the development of the disease:

chest injuries (open, penetrating and closed, which are accompanied by a fracture of the ribs);
damage to the lung during some medical manipulations (puncture of the pleural cavity, installation of a subclavian catheter, etc.);
some diseases of the respiratory system (tuberculosis, abscess, emphysema);
spontaneous rupture of the esophagus (Boerhaave's syndrome);
features of the body, implying the underdevelopment of the pleural petals.

Sometimes in medical practice, the method of imposing an artificial pneumothorax is used.

This method allows you to stop pulmonary bleeding, helps to cure some forms of tuberculosis.. As a rule, the treatment is long and the patient knows in advance about the method by which the therapy is carried out.

Classification

There are various types of pneumothorax, which are divided by classification based on the causes of their occurrence, localization and extent of the lesion. Depending on how much the lung tissue and pleura have suffered, the pulmonologist prescribes a treatment plan and voices the prognosis.

Depending on the extent of damage to the lung tissue, it happens:

Total pneumothorax (complete). It is characterized by complete compression of the lung due to the release of a large amount of gas into the pleural cavity.
Limited pneumothorax (partial). The fall of the respiratory organ is incomplete.

If the lesion is on the left side, a left-sided pneumothorax is diagnosed, on the right lung - a right-sided pneumothorax. There is also a bilateral type of the disease, which develops due to the total compression of two lungs at the same time and is fraught with the rapid death of the victim.

Also, the disease is divided according to the causes of occurrence:

Traumatic pneumothorax. This option is possible with damage to the chest. It develops as a result of a penetrating wound (for example, a stab wound), as well as due to injury to the lung tissue by a fragment of a rib with an open or closed fracture.
Spontaneous. It occurs due to the rapid rupture of lung tissue against the background of a chronic disease or predisposing factors. So, the cause of primary (idiopathic) pneumothorax can be congenital insufficiency of pleural tissue, strong laughter or a sharp cough, rapid diving to depth, as well as flying on an airplane. Secondary develops due to severe lung diseases.
Artificial. It is created intentionally under the supervision of a competent specialist for the treatment of certain respiratory diseases.

Pneumothorax can be complicated by various pathologies or occur without them. The clinical picture of the disease also depends on the amount of air that has entered the pleural cavity, its circulation in the wound.

According to the air from the environment:

Closed. There is a single entry of a small amount of air into the pleural cavity, after which its volume no longer changes.
Open. There is a visual defect of the sternum, through which, with each breath, air enters the cavity, and when exhaled, it exits. The process may be accompanied by audible squelching and gurgling.
Valve. Has the most severe consequences. During a tension pneumothorax, with each breath, air enters the peripulmonary space, but it does not escape to the outside.

Each of the conditions, regardless of severity, requires a thorough examination by a doctor and competent treatment. This will help to minimize the risk of relapse, and in some cases save the life of the victim.

Symptoms

Signs of pneumothorax are difficult to miss. The clinical picture is pronounced, there may be signs of oxygen starvation, as well as the consequences of circulatory disorders, which occurs due to compression of the mediastinum.

Symptoms of pneumothorax of the lungs:

pain in the affected area of a stabbing nature, which can radiate to the arm, back, neck;
painful sensations are significantly increased during movement, when coughing, talking, sneezing;
fear of death caused by severe pain and the inability to take a full breath;
the victim takes a forced position;
shortness of breath, less often - dry cough;
swelling of the neck veins;
pallor, and then cyanosis (blue) of the skin;
violation of the rhythm of heart contractions, signs of arrhythmia;
if the pneumothorax is open, one can visually observe the air entering the wound, then foamy blood is released from it.

Depending on the location and extent of the lesion, symptoms may be mild. After a few hours, the symptoms subside significantly, pain and shortness of breath appear only during body movements. Sometimes emphysema develops, which is the release of accumulated air under the skin.

A few hours later, inflammation of the pleura develops. The clinical picture differs in severity if the lung tissue is damaged by more than 40%.

The accumulation of air in the pleural cavity is a life and health threatening condition, therefore, when the first signs of the disease appear, you should immediately seek medical help. It is especially necessary to monitor their well-being for those patients who suffer from chronic diseases of the pulmonary and digestive systems.

Diagnostics

Pneumothorax of the lungs is determined by the method of complex diagnostics, which includes a survey and examination of the victim, as well as x-rays and lung punctures, if necessary.

Laboratory blood tests, as a rule, do not clarify the clinical picture. In the analyzes, one can trace the dynamics of a concomitant disease that contributed to the rupture of lung tissue. In arterial blood, hypoxemia (accumulation of foreign gases in it) can be observed.

Survey

To correctly assess the condition of the victim, the pulmonologist needs to conduct a thorough survey. This will help to identify the causes of pneumothorax development, prescribe the correct treatment.

During the initial visit, a complete history of life and a specific disease is collected, during a second visit to the doctor, the patient answers questions that relate exclusively to the disease.

What a specialist needs to know to make a diagnosis:

the presence of any chronic diseases;
what are the symptoms of the disease;
when and because of what the pain appeared, its nature, intensity;
whether there has been a recent blow, fall or other mechanical impact that could provoke compression of the lung.

It is necessary to answer the doctor's questions as detailed and quickly as possible, you should not be silent about existing diseases. If there is an allergy to any medications, you need to tell the medical staff about it. After the interview, an examination and additional examinations are carried out.

Inspection

The position of the patient can be visually assessed. As a rule, it is forced, on the side in which the descent of the lung occurred. If the wound is open, the specialist notes its size, the presence of foam in the blood. During auscultation, breathing is practically not audible on the affected side.

The pulmonologist also evaluates the nature of shortness of breath, which is frequent, superficial during pneumothorax.. Percussion of the affected side is a box sound (deaf, hollow). Excursion of the chest from the side where the pneumothorax occurred is slightly behind the healthy one.

Radiography

On x-rays, you can observe an extensive light zone, which is located on the side of the lesion.. Pulmonary pattern is not visible. There is a clear boundary between the healthy and the affected lung. Mediastinal displacement is visually noticeable, the dome of the diaphragm is lowered.

Pleural puncture

It is performed under local anesthesia using a hollow needle, which is inserted into the intercostal space from the back. During the procedure, all the accumulated air is removed, after which the nature of the contents of the pleural cavity is specified in the laboratory.

Also, the biomaterial is sent for bacteriological, cytological examination. In severe cases, if the puncture does not alleviate the condition of the victim, thoracoscopy is performed for medical reasons.

Treatment

It will be difficult for a person who does not have sufficient knowledge in the medical field to carry out the necessary therapeutic measures and provide first aid to the victim. Therefore, it is better to entrust the evacuation of accumulated air to professionals.

There are no methods of treatment that give a 100% guarantee against repetition of the pathology. Therefore, therapy has 3 goals: to eliminate the cause of occurrence, resolve pneumothorax in a particular case, and prevent the likelihood of relapse.

Oxygen therapy

Medical supervision without any serious interventions is indicated in the case of a non-extensive pneumothorax, when tissue damage is not more than 15%. In such cases, self-absorption of air from the cavity is possible, which takes about 1-2 weeks.

Oxygen therapy is indicated for all patients suffering from lung tissue prolapse.. The procedure helps the body recover faster, reduces the risk of complications. In patients with a history of COPD or other chronic diseases, it is necessary to control the concentration of gases in the blood.

Aspiration of the contents of the pleural cavity

Evacuation of the contents of the cavity is performed using a catheter or hollow needle. The procedure is carried out by a competent specialist, since a non-professional is able to pierce an artery and some vital organs. In one session, it is allowed to remove no more than 4 liters of air. This should be done gradually to prevent mediastinal displacement.

If symptoms persist a few hours after aspiration, respiratory function is not restored, the installation of a drainage system is indicated.

Indications for the procedure:

multiple relapses of the disease;
age over 50;
lack of success during aspiration.

A special drainage tube is installed in the intercostal space, which helps to remove excess air. At the end, an air or water lock is attached. In the second case, you can track the smallest gas leak, so this technique is more popular. Removal of drainage occurs a day after the complete cessation of the discharge of air masses, if radiography confirms the expansion of the lung.

The introduction of the pleural cavity of special substances (chemical pleurodesis)

This procedure is carried out to prevent possible relapses, if their probability is high enough. To do this, special substances are introduced into the pleural cavity that contribute to its obliteration, that is, the fusion of the pleura sheets with each other. The introduction is carried out through the drainage system. Chemical pleurodesis helps to minimize the risks of recurrence of the disease to almost zero levels.

Surgical intervention

The operation is performed when it is impossible to use alternative methods of treatment or their ineffectiveness. In this case, a thoracotomy or thoracoscopy is performed. Surgery is the most effective treatment for pneumothorax and its subsequent relapses.

When is it held:

lung tissue does not straighten out a week after drainage;
there is a relapse after chemical pleurodesis;
if the victim got the disease due to a certain profession (pilot, diver and others);
complicated pneumothorax.

The decision to carry out the operation is made by the commission, analyzing all the previous actions of the medical staff and having studied the analyzes of the victim. The intervention is also carried out if the cause of the disease is an open wound. It is sutured, after which the patient is observed and the necessary measures are taken to treat pulmonary pneumothorax.

Prevention, possible complications, prognosis

The concept of pneumothorax is familiar to many people suffering from other chronic lung diseases. It is a serious complication that, if not properly treated, can lead to the death of the victim.

The most favorable prognosis is if tissue damage is no more than 15%. The most critical conditions are diagnosed in the case of spontaneous bilateral pneumothorax. The success of treatment depends on the speed of contacting a doctor and subsequent resuscitation.

What can be done for prevention:

stop smoking;
treat concomitant diseases of the lungs, digestive tract;
once every six months, come for a consultation with a pulmonologist, especially if shortness of breath occurs;
lead a healthy lifestyle;
limit the number of flights;
do not go deep.

As a rule, pneumothorax does not occur without any reason.. If a person is attentive to his health, undergoes preventive examinations in a timely manner and consults doctors at the slightest sign of deterioration, the risk of serious illnesses is reduced significantly.

Pneumothorax is defined as the presence of air or gas in the pleural space, such as the space between the visceral and parietal pleura, which can impair oxygenation and ventilation in the lungs. Clinical results depend on the degree of lung collapse on the side of the lesion. If the pneumothorax is significant, it may cause mediastinal shift and compromise hemodynamic stability. Air can enter the intrapleural space through a chest injury or from the side easily, which is observed in some complex pathologies.

Reasons for the development of pneumothorax

Spontaneous pneumothorax is divided into two types:

Primary, which occurs in the absence of specified lung disease.
Secondary, developing due to any lung disease.

The causes of primary spontaneous pneumothorax are unknown, but established risk factors include male gender, smoking, and a family history of pneumothorax. Various underlying mechanisms are discussed below.

Secondary spontaneous pneumothorax occurs in a variety of lung diseases. The most common is chronic obstructive pulmonary disease (COPD), which accounts for about 70% of cases.

Known lung conditions that can greatly increase the risk of pneumothorax are:

Respiratory tract diseases - COPD, especially with emphysema and the development of cavities with air, status asthmaticus, cystic fibrosis.
Pulmonary infections - pneumocystis pneumonia, tuberculosis, necrotizing pneumonia.
Interstitial lung disease - sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis, lymphangioleiomyomatosis.
Connective tissue diseases - rheumatoid arthritis, Bechterew's disease, polymyositis and dermatomyositis, systemic scleroderma, Marfan syndrome and Ehlers-Danlos syndrome.
Oncological diseases - lung cancer, sarcomas involving the lungs.
Menstrual pneumothorax associated with the menstrual cycle and concomitant endometriosis.

In children, measles, echinococcosis, penetration of a foreign body into the lungs, and other diseases, such as congenital malformations of the cystic adenomatoid and congenital lobar emphysema, can become additional causes.

11.5% of people with spontaneous pneumothorax have a family member who previously suffered from this disease. Hereditary predisposing pathologies can be:

Marfan syndrome.
Homocystinuria.
Ehlers-Danlos syndrome.
Alpha-1 antitrypsin deficiency resulting in emphysema.
Burt-Hogg-Dube syndrome.

In general, these conditions cause other symptoms besides pneumothorax, which is more often just an additional sign.

Traumatic pneumothorax may result from blunt trauma or penetrating injury to the chest wall. The most common mechanism is the penetration of sharp bone fragments from rib fractures that damage lung tissue. Traumatic pneumothorax may also occur in patients who have been near the explosion, although there may not be obvious chest trauma.

Medical procedures, such as inserting a central venous catheter into one of the chest veins or taking biopsy samples from lung tissue, can also lead to pneumothorax. Mechanical positive pressure ventilation or mechanical non-invasive ventilation can lead to barotrauma associated with a pressure drop, which often leads to pneumothorax.

Divers who use special systems for breathing, swimming to great depths, often damage their lungs and pleura. Divers often suffer from pneumothorax as a result of barotrauma from a sudden rise from depth, or from holding their breath for a long time.

How is the disease classified according to the leading factor?

Spontaneous pneumothorax is usually investigated in detail in search of a treatment approach that ranges from observation to active intervention. Primary spontaneous pneumothorax occurs due to the absence of underlying lung disease and provoking factors as well. In other words, air enters the intrapleural space without prior trauma and without an underlying history of clinical lung disease.

However, many patients labeled as primary pneumothorax often have subclinical lung disease that results in pleural vesicles that can be detected by computed tomography (CT). The classic patient with this form of the disease is usually aged 18-40, tall, thin, and often a heavy smoker.

Secondary spontaneous pneumothorax occurs in patients with a wide range of lung parenchymal diseases.. Patients have an underlying pulmonary pathology that alters the normal structure of the lungs. Air enters the pleural cavity through distended or damaged alveoli. The clinical picture of these patients may include more severe symptoms and complications due to comorbidities.

Iatrogenic pneumothorax is, in fact, traumatic, as it appears due to damage to the pleura and is secondary to a diagnostic or therapeutic procedure. Half a century ago, iatrogenic pneumothorax was predominantly the result of the deliberate introduction of air into the pleural cavity to treat tuberculosis.

Traumatic pneumothorax from blunt trauma or penetrating injury occurs as a result of a violation of the parietal or visceral sheet of the pleura. The therapy steps for traumatic pneumothorax are similar to those for disease resulting from non-traumatic causes. If the injury causes communication of the pleural cavity with the external environment or leads to hemodynamic disturbances, the pleural cavity is drained to remove air, which allows the lungs to open.

There is a subset of traumatic varieties of pneumothorax classified as atypical—they cannot be seen on x-ray, but they can be distinguished on CT. In a word, the pathological processes of pneumothorax can be observed and treated if they are symptomatic.

Tension pneumothorax

This type of pneumothorax is a life-threatening condition that develops when air is trapped in the pleural space under positive pressure. Air masses displace mediastinal structures and impair cardiac function. Saving a patient's life is only possible in a modern intensive care unit. Since tension pneumothorax occurs infrequently and has potentially devastating results, a high index of suspicion, knowledge of basic emergency chest decompression procedures is important for all healthcare professionals. Immediate chest decompression is mandatory if a tension pneumothorax is suspected. The situation requires urgent radiographic confirmation.

Pneumomediastinum

Pneumomediastinum represents the presence of gas in the tissues of the mediastinum, appears there spontaneously, after a medical procedure or injury. Pneumothorax may occur secondary to pneumomediastinum.

Symptoms of the development of pneumothorax

Symptoms of pneumothorax vary depending on its type.

Spontaneous and iatrogenic pneumothorax

As long as the air bladder does not rupture and cause a pneumothorax, no clinical signs or symptoms are present in spontaneous pneumothorax. Young and otherwise healthy patients can tolerate the major physiological consequences of reduced lung capacity and oxygen partial pressure deficiency tolerably well with minimal changes in quality of life. However, if underlying lung disease is present, then pneumothorax may cause respiratory distress.

The classic signs of pneumothorax are the development of three chest pains and shortness of breath. As a rule, both symptoms are present in 64-85% of patients. Chest pain, described as severe and stabbing, often radiates to the ipsilateral shoulder and worsens with inspiration. With secondary pneumothorax, chest pain will manifest itself with more pronounced clinical symptoms.

Shortness of breath is characterized, as a rule, by a sudden onset and is more severe in secondary spontaneous pneumothorax due to a decrease in the respiratory reserve of the lungs. Anxiety, coughing, and non-specific symptoms such as general malaise and fatigue are less common. The most common underlying anomaly in spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD) and cystic fibrosis.

Spontaneous pneumothorax usually develops at rest. By definition, this type of illness is not associated with trauma or stress. Symptoms of iatrogenic pneumothorax are similar to spontaneous pneumothorax and depend on the age of the patient, the presence of concomitant lung diseases and the degree of pneumothorax.

A history of previous pneumothorax is critical, as recurrence is common, with an incidence of 15-40%. Up to 15% of recurrences may occur on the contralateral side. Secondary pneumothorax is often more likely and recurs in cystic fibrosis in 68-90% of cases. No study found that the number or size of vesicles found in the lungs can be used to predict relapse.

Tension pneumothorax

Signs and symptoms of tension pneumothorax tend to be more dramatic than simple pneumothorax, and correct clinical interpretation is critical to diagnosis and treatment. Tension pneumothorax is classically characterized by hypotension and hypoxia. On examination, there are no sounds of breathing, there is a deviation of the trachea from the affected side. The chest may be distended, and jugular vein swelling and tachycardia are common.

Symptoms of a tension pneumothorax may include:

Chest pain (in 90% of patients).
Shortness of breath (80%).
Anxiety.
Fatigue.
Sharp or dull pain in the epigastrium (rare).

Menstrual pneumothorax

Women aged 30-40 years who seek help with characteristic symptoms of right pneumothorax within 48 hours after the onset of menstruation give rise to suspicion of menstrual pneumothorax.

Pneumomediastinum

Pneumomediastinum must be differentiated from spontaneous pneumothorax. Patients may or may not be asymptomatic as this variety is easily tolerated, although mortality in the event of esophageal rupture is very high. This usually occurs when intrathoracic pressure rises significantly, for example, during exacerbation of bronchial asthma, coughing, vomiting, childbirth, convulsions. In many patients with pneumomediastinum, rupture of the esophagus is possible as a result of endoscopy.

Other symptoms may include chest pain, usually radiating to the neck, back, or shoulders, worsened by deep breathing, coughing, or lying on the back. In addition, shortness of breath, neck or jaw pain, dysphagia, dysphonia, and abdominal pain are common. Mediastinal injury, although present in 6% of patients, does not result in serious injury.

Clinical signs of pneumothorax can range from completely asymptomatic to life-threatening respiratory failure. Symptoms may include:

Sweating.
Splinting of the chest wall to relieve pain.
Cyanosis (in case of tension pneumothorax).

Affected patients may also have mental status changes, including reduced alertness and, rarely, loss of consciousness.

Respiratory symptoms may include the following:

Respiratory failure is considered a universal symptom. Respiratory arrest is possible.
Tachypnea or bradypnea as a preterminal phenomenon.
Asymmetric expansion of the lungs: the displacement of the mediastinum and trachea to the opposite side can occur with a high probability in tension pneumothorax.
Shallow breathing.
Breathing sounds in the lungs are heard only in the unaffected half of the chest.
Hyperpersonnance on percussion: a rare symptom that may be absent even at an advanced stage of the disease.
Decreased tactile sensitivity.
Pathological noises in the lungs - wet rales, shortness of breath.

Cardiovascular indicators can manifest themselves as follows:

Tachycardia is the most common. If the heart rate is faster than 135 beats per minute, this may indicate a tension pneumothorax.
Paradoxical pulse.
Hypotension should be considered as a non-specific symptom, although it is generally considered the key sign of a tension pneumothorax.
Swelling of the jugular veins.

Surgical treatment for gas accumulation in the pleural cavity and possible complications

Medicines may be needed to treat the lung disorder that causes pneumothorax. For example, intravenous antibiotics are included in the treatment of pneumothorax, in the presence of a complication in the form of staphylococcal pneumonia. In addition, studies show that giving prophylactic antibiotics during chest tube insertion can reduce the incidence of complications such as emphysema.

Obviously, the use of analgesics can provide patient comfort until drainage of the pleural cavity with a tube is excluded. Some authors advocate the use of intercostal nerve blocking to improve patient comfort and reduce the need for narcotic analgesics.

In patients with recurrent pneumothorax who are not candidates for surgery, sclerotherapy with talc or doxycycline may be highly relevant.

The decision to monitor or treat with immediate intervention is influenced by risk assessment in relation to patient care and the likelihood of possible spontaneous resolution or relapse.

The following is a possible behavior of a specialist depending on the condition of a patient with pneumothorax:

Asymptomatic - the decision to treat is guided by an assessment of the long-term risk of recurrence.
Symptoms present but clinically stable - simple aspiration and delayed hospitalization for spontaneous pneumothorax if the patient is stable. In addition, a small catheter or chest tube to remove air is recommended.
A complex course with characteristic symptoms, including pain - the installation of a chest tube and observation during hospitalization.
A life-threatening course - pneumothorax causing hemodynamic instability is life-threatening, which requires immediate placement of a drainage tube.

If the patient has had repeated episodes of pneumothorax, or if the lung remains unexpanded 5 days after insertion of the chest tube, surgery may be necessary. The surgeon may use treatment options such as thoracoscopy, electrocoagulation, laser treatment, vesicle resection, or open thoracotomy.

Other signs requiring immediate surgical intervention:

Persistent air leakage into the pleura for longer than 7 days.
Periodic manifestations of ipsilateral pneumothorax.
Contralateral pneumothorax.
Bilateral pneumothorax.
Patients with acquired immunodeficiency syndrome.

Misdiagnosis is the most common complication. A simple pneumothorax can turn into a tense one. In addition, if pneumothorax does not exist, the patient may develop it after decompression with the instrument needle. The needle can injure the lung, although this is rare. And it can cause significant lung damage or hemothorax. If the needle is initially too medial to the sternum, the instrument can lead to hemothorax from rupturing the lower set of intercostal vessels or the internal mammary artery.

Damage to the intercostal neurovascular bundle and lung parenchyma may occur after drainage of the pleural cavity with a tube, especially if trocars are used. In addition, an increased risk of postoperative bleeding is due to the process of lung transplantation for medical pleurodesis and surgery.

Complications of pneumothorax include the following:

Hypoxemic respiratory failure.
Stopping breathing or cardiac activity.
Hemopneumothorax.
Bronchopulmonary fistulas.
Pulmonary edema.
Empyema.
Pneumomediastinum.
Pneumopericardium.
Pneumoperitoneum.
Pyopneumothorax.

Complications of surgical procedures include:

Acute respiratory distress.
Infection of the pleural cavity.
Skin or systemic infection.

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Pneumothorax of the lung (from the Greek “pnéuma” - air, “thorax” - chest) is a pathological condition in which air enters the pleural cavity and accumulates there, due to which the lung tissue collapses, blood vessels are compressed and the dome of the diaphragm descends. Acute disorders of respiratory and circulatory functions arising as a result of pathology are dangerous for human life.

To understand exactly how the disease develops, you need to understand a little about the anatomy of the chest and the serous sac in it - the pleura.

The pleura is the serous membrane that covers the lungs. It is thin and smooth, consisting of elastic fibers. In fact, there are three separate "bags" in the chest cavity - for both lungs and for the heart.

The pleura itself is built from two sheets:

Pleura visceralis (pleura pulmonalis) is a visceral (lung) sheet that sticks directly to the tissue of the lungs, separating their lobes from each other.
Pleura parietalis is an outer leaf that serves to strengthen the chest.
Both sheets are connected along the lower edge of the root of the respiratory organ, forming a single serous sac. The slit-like space formed in the sac is called the cavitas pleuralis (pleural cavity). Normally, it contains a small amount of liquid, 1-2 ml, which prevents the visceral and outer layers from touching. Due to this, it is possible to maintain a negative pressure in the pleural cavity, created there due to two forces: inspiratory stretching of the chest wall and elastic traction of the lung tissue.
If, for any reason (chest injury, pathology of the respiratory system, etc.), air enters the pleural cavity from the outside or from the inside, the atmospheric pressure is balanced, the lungs collapse completely or partially, that is, their complete or partial collapse occurs.

Why does pneumothorax develop?

The causes of the pathological condition can be divided into two large groups:

Mechanical damage and trauma to the lungs or chest. These causes of pneumothorax are as follows:
- closed trauma (respiratory organs are damaged by fragments of ribs, for example);
- penetrating injury (or open injury);
- iatrogenic damage (the development of the disease is possible when performing diagnostic or therapeutic procedures, such as pleural puncture, installation of a subclavian catheter, etc.);
- procedures in the treatment of tuberculosis - pneumothorax is created artificially.
Respiratory pathology. The occurrence of pneumothorax may have such internal causes:
- bullous emphysema (rupture of air cysts);
- ruptured lung abscess;
- rupture of the esophagus;
- with tuberculosis - a breakthrough of caseous foci;
- other.

How is pathology classified?

It should be mentioned that in addition to gas, blood, pus, and other fluids can accumulate in the pleura. Therefore, there is such a classification of damage to the serous sac:

pneumothorax (which, in fact, is what we are talking about);
hemothorax (blood accumulates in the pleural cavity)
chylothorax (accumulation of chylous fluid occurs);
hydrothorax (transudate accumulates);
pyothorax (pus enters the cavity of the serous sac).

The classification of the disease itself is quite complicated, it is based on several criteria.

For example, depending on the cause of occurrence, the following types of pneumothorax are distinguished:

According to the volume of air that entered the cavity between the pleura, the following types of pneumothorax are recognized:

partial (partial or limited) - lung collapse is incomplete;
total (complete) - there was a complete collapse of the lung.

There is a classification according to how the pathology spread:

unilateral (a lung fell asleep on one side);
bilateral (the patient's condition is critical, there is a threat to his life, since the collapsed lungs can completely turn off from the act of breathing).

According to whether there is a communication with the environment, classify:

closed pneumothorax. This condition is considered the easiest, its treatment is not always required: a small amount of air can resolve spontaneously.
Open pneumothorax. It usually develops due to the presence of damage to the chest wall. The pressure in the pleural cavity becomes equal to atmospheric, the respiratory function is impaired.
Tension pneumothorax. In this pathological condition, something like a valvular structure is formed, which allows air to enter the serous sac on inspiration and prevents its release on expiration. Due to irritation of the nerve endings on the sheets of the pleura, pleuropulmonary shock and acute respiratory failure occur.

Clinical picture of pneumothorax

To confirm the diagnosis and determine the tactics of treatment is possible only by taking an x-ray. But the symptoms of the disease are quite bright, their severity is influenced by the causes of the disease and the degree of lung collapse.

It is difficult to confuse an open pneumothorax - a person is forced to lie down on the injured side, air is sucked in with noise through the wound, and foamy blood comes out on exhalation.

Symptoms of the spontaneous development of the disease are pain on the side of the chest where the lung is damaged, paroxysmal cough, shortness of breath, tachycardia, cyanosis.

The patient characterizes the pain as a dagger, penetrating. It gives to the neck and arm, intensifies with inhalation. Sometimes there are symptoms such as sweating, drowsiness, anxiety, fear of death.

When examining the chest, a lag in breathing of its damaged side is visible. On auscultation from this side, breathing is heard weakly, otherwise it is not heard at all.

Symptoms of the presence of air in the pleural cavity in newborns and babies up to 12 months are anxiety, difficulty breathing, puffiness of the face, shortness of breath, cyanosis, a sharp deterioration in the condition, refusal to eat.

The closed form of the disease is sometimes asymptomatic.

Diagnostics

If the doctor suspected pneumothorax, it should be treated immediately, the doctor:

asks the patient to describe his symptoms;
asks the patient about whether he smokes and for how long, whether he has a history of diseases of the lungs and respiratory organs, whether he has tuberculosis, whether he is a carrier of HIV;
appoints laboratory tests (the gas content of arterial blood is examined);
He ordered an EKG and X-ray.

X-ray of the lungs

X-ray is the main way to determine if there is air in the pleural cavity, how much the lung has fallen asleep, and, therefore, prescribe the correct treatment and save the patient's life.

To confirm pneumothorax, an X-ray of the chest is taken in the anteroposterior projection, the patient is in an upright position.

An x-ray may show a thin line of the visceral pleura. Normally, it is not visible, but in the presence of air in the cavity, it can separate from the chest.

X-ray also shows that the mediastinum has shifted in the opposite direction.

In every fourth case of pneumothorax, a small amount of fluid enters the pleura. This can also be seen with x-rays.

If the presence of air in the pleura is not confirmed in the picture, but the description of the symptoms gives the right to assume pneumothorax, an x-ray is taken again, while the patient is placed on his side. The study shows a deepening of the costophrenic angle.

How to treat pneumothorax

Usually, with a traumatic pneumothorax, the patient needs urgent medical attention even before they are taken to a medical facility and they have an x-ray.

Before the paramedics arrive:

calm the person
restrict his movements;
give air access;
when the disease is open, try to apply a compressive bandage to seal the injury; for this, a plastic bag, a fabric folded several times, is suitable.

Direct treatment of the patient occurs in a surgical hospital, it depends on the type of disease. Basically, by performing a puncture, air is evacuated from the pleural cavity, and negative pressure is restored there.

It also implies treatment and pain relief during periods of collapse and expansion of the lungs.