RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Open chest wound (S21), Rib fracture (RIB), Superficial chest injury (S20), Heart injury with hemorrhage into the heart sac [hemopericardium] (S26.0), Traumatic pneumothorax (S27.0)

Emergency medicine

General information

Brief description

Approved
Joint Commission on Health Care Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
dated June 23, 2016
Protocol No. 5

Chest injury- isolated or complex damage to the integrity of the skin, bone frame, and internal organs of the breast.

Open chest wound- damage accompanied by a violation of the integrity of the skin and tissue structures of the chest wall.

Fractures of the sternum - violation of integrity as a result of a direct mechanism of injury. They can be combined with fractures of the middle parts of the ribs. Damage to the sternum can be combined with hemorrhage in the anterior mediastinum and cardiac injury.

Rib fractures- violation of the integrity of the bone or cartilaginous part of one or more ribs.

Heart injury- closed or open myocardial injury with acute hemodynamic impairment.

Accumulation of blood in the pericardial sac as a result of open or closed damage to the coronary vessels and/or myocardial wall.

Pneumothorax- accumulation of air in the pleural cavity as a result of a penetrating chest injury or lung injury.

Hemothorax- accumulation of blood in the pleural cavity due to bleeding from the vessels of the lungs, mediastinum, heart or chest wall. Fresh blood in the pleural cavity coagulates and then, as a result of fibrinolysis, liquefies again. In some cases, liquefaction does not occur; a coagulated hemothorax occurs, which is dangerous in the subsequent development of pleural empyema.

ICD-10 codes

Date of protocol development/revision: 2007 / 2016

Protocol users: doctors of all specialties, nursing staff.

Level of evidence scale:

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population .
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population.
D	Case series or uncontrolled study or expert opinion.

Classification

Classification of chest injuries(according to Komarov B.D., 2002):
· one-sided;
· bilateral.

Classification of chest injuries:
· closed chest injuries.
· open (wounds) chest injuries.

Traumatic chest injuries are divided into:
· isolated injuries of the chest and its organs;
· multiple injuries to the chest and its organs;
· combined injuries of the chest and its organs.

Chest wounds are divided into:

Penetrating chest wounds are:
Stabbed:
· blind, through;

· single, multiple;

Firearms:
· blind, through;
· one-sided, two-sided;
· single, multiple;
· with pneumothorax, with hemothorax, with hemopneumothorax.

The concept of closed (blunt) chest injury includes:
rib fractures;
· damage to the lung with the formation of tension pneumothorax and hemothorax;
lung contusion;
mediastinal emphysema;
· heart bruise.

Open chest wound

Chest wounds are divided into:
· penetrating - with damage to the parietal pleura;
· non-penetrating - without damage to the parietal pleura.

Penetrating chest wounds:
Stabbed:
blind, through;
single, multiple;

Firearms:
blind, through;
one-sided, two-sided;
single, multiple;
with pneumothorax, with hemothorax, with hemopneumothorax;

Sternum fracture:
Closed:
no offset;

· Open:
no offset;
with displacement (antero-posterior displacement of fragments in width and overlap in length).

Depending on the location of the fractures, there are types of "rib valves":
· anterior bilateral floating fractures (ribs are broken on both sides of the sternum and the connection of the anterior chest with the spine is lost);
· anterolateral floating fractures (each rib is broken in two or more places on one side in the anterior and lateral sections);
posterolateral floating fractures (double unilateral fracture of the posterior ribs);
· posterior bilateral floating fractures (fracture of the posterior parts of the ribs occurs on both sides of the spinal column).

Pneumothorax:
· with limited pneumothorax, the lung collapses by less than 1/3;
· with average pneumothorax - from 1/3 to ½ of the lung volume;
· with total pneumothorax, the lung occupies less than half of its normal volume or is completely collapsed.

Closed pneumothorax. The pleural cavity does not communicate with the external environment and the amount of air entering it as a result of injury does not change during chest excursion.

Open pneumothorax. There is a free connection between the pleural cavity and the external environment. During inhalation, air enters in additional quantities into the pleural cavity, and during exhalation, it leaves in the same quantity. With an open pneumothorax, there is no accumulation of air in the pleural cavity. The effect of paradoxical breathing occurs - during inhalation, the lung on the side of the wound collapses, and during exhalation it expands. The effect of pendulum-like air movement occurs: during inhalation, air from the lung on the damaged side enters the healthy lung, and during exhalation, air flows from the healthy lung to the damaged one. Changing intrapleural pressure leads to mediastinal flotation.

Valvular pneumothorax.

Outer: during exhalation, the communication of the pleural cavity with the external environment decreases or stops completely due to the displacement of the tissues of the chest wall (“closing of the valve”). With each inhalation, more air enters the pleural cavity than is expelled during exhalation. There is a constant increase in the volume of air in the pleural cavity. With each inhalation, the collapse of the lung and the displacement of the mediastinum in the opposite direction increases. In the end, the lung on the healthy side is compressed. Increasing intrapleural pressure leads to the release of air into the soft tissues with the formation of subcutaneous emphysema.

Interior: the valve is located in the pulmonary tissue, the pleural cavity communicates with the external environment through the bronchial tree. With each inhalation, air enters the pleural cavity through damaged lung tissue, and during exhalation, it is completely or partially retained in the pleural cavity (“valve closing”). The mechanism of air accumulation and consequences are similar to those with external valve pneumothorax. Gradually, the intrapleural pressure increases so much that it far exceeds the atmospheric air pressure - a tension pneumothorax develops.

Hemothorax

Small hemothorax- the amount of blood shed does not exceed 500 ml. The condition of the victims is relatively satisfactory. You may experience pallor, slight shortness of breath, chest pain and a slight cough.

Average hemothorax- the pleural cavity contains from 500 to 1000 ml of blood. The condition of the victims is moderate. Pallor, shortness of breath, chest pain and cough increase. Percussion above the lungs reveals a dullness along the Demoiseau line (for hemopneumothorax - horizontal level), reaching the lower angle of the scapula. Auscultation above the dullness reveals weakening or absence of breathing. The slightest physical activity aggravates breathing problems.

Large (total) hemothorax- more than 1000 ml of blood flows into the pleural cavity. The severity of the condition is determined not only by impaired external respiration, but also by acute blood loss. The condition is severe or extremely serious. Severe pallor, cyanosis of the skin, shortness of breath, tachycardia, and decreased blood pressure are noted. Patients take a semi-sitting position. Concerned about lack of air, chest pain, cough. Percussion and auscultation reveals an accumulation of fluid above the middle of the scapula.

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS**

Chest injury. Diagnostic criteria:
· presence of a skin wound in the projection and outside the projection of the chest;
· pallor and/or cyanosis of the skin;
· pain, especially with concomitant injuries to the ribs and sternum;



· signs of open pneumothorax;

· subcutaneous emphysema;
mediastinal emphysema;
· increasing symptoms of respiratory and cardiovascular failure.

Physical signs pneumothorax and hemothorax with mediastinal shift to the healthy side.

Fracture of rib(s), sternum.Diagnostic criteria:
· pain at the fracture site, aggravated by forced movements of the chest;
· feeling of suffocation;
· chest pain;
· persistent arterial hypotension with concomitant cardiac injury.

Fractured ribs. Diagnostic criteria:
· local pain, aggravated by breathing and forced movement of the chest (coughing, sneezing, etc.);
Limitation of respiratory excursions on the affected side;
· deformation of the contours of the chest;
Paradoxical breathing of the “rib valve”;
local pain on palpation;
· increased pain in the fracture zone with counter load on the intact parts of the chest (antero-posterior or latero-lateral compression);
· bone crepitus, determined by palpation and/or auscultation over the fracture site during breathing;
· percussion determination of the presence of air and/or blood in the pleural cavity;
Auscultatory detection of lung function on the affected side;
· subcutaneous emphysema;
mediastinal emphysema;
Tachypnea, shallow breathing;
Tachycardia and decreased blood pressure;
· pallor and/or cyanosis of the skin.

Heart injury

Heart injury with hemorrhage into the heart sac [hemopericardium].. Diagnostic criteria:
· the presence of a wound in the projection of the heart or paracardial zone on the anterior, lateral and posterior surface of the chest.
· short-term or prolonged loss of consciousness (fainting, confusion) from the moment of injury.
· feeling of fear of death and melancholy.
Difficulty breathing of varying severity.
· tachypnea (respiratory rate up to 30-40 per minute).
· palpation* - weakened or absent heartbeat.
· percussion* - expansion of the borders of the heart.
· auscultation* - dull or undetectable heart sounds.
· pathological noises - “mill wheel noise”, “murmuring noise”, etc.
· tachycardia.
· low blood pressure.
· ECG signs: decreased wave voltage, concordant shift of the ST interval up or down, smoothness or inversion of the T wave; in case of injury to the coronary arteries - changes characteristic of acute myocardial infarction; intraventricular conduction disorders - deep Q wave, jaggedness and widening of the QRS complex; if the pathways are damaged, there are signs of blockade.

* the presence of subcutaneous emphysema, the presence of blood in the pericardium and mediastinum, pneumothorax can hide these physical signs.

Pericardial cavity tamponade is characterized by:
· Beck's triad: drop in blood pressure, increase in central venous pressure, muffled heart sounds;
· swelling and tension of the neck veins in combination with hypotension;
· paradoxical pulse (often the pulse is small and arrhythmic);
· expansion of the boundaries of cardiac dullness in diameter;
Systolic blood pressure is usually less than 70 mmHg. Art.;
· decrease in systolic blood pressure during inspiration by 20 mm Hg or more. Art. 4;
· diastolic pressure is extremely low or undetectable;
· ECG signs: decreased R wave, T wave inversion, signs of electromechanical dissociation.

Other heart injuries.Diagnostic criteria:
· information about the circumstances of a closed injury (traffic accident, fall from a great height, chest compression);
· persistent arterial hypotension;
loss of consciousness due to cerebral hypoxia;
· palpitations, tachycardia;
shortness of breath of varying severity;
· constant pain in the heart area, not associated with the act of breathing;
· pain behind the sternum radiating to the left arm;
· systolic murmur at the apex;
· pericardial friction noise due to the development of hemopericardium;
· left ventricular failure.

Trauma to other and unspecified organs of the thoracic cavity.Diagnostic criteria:
· the presence of a skin defect, a “sucking” or gaping chest wound;
· pallor or cyanosis of the skin;
· local pain, especially with concomitant injuries to the ribs and sternum;
shortness of breath and difficulty breathing;
· restriction of respiratory movements;
· hemoptysis of varying intensity and duration;
· signs of open pneumothorax: shortness of breath, cyanosis, tachycardia, anxiety and a feeling of fear of death;
· phenomena of hypovolemic shock due to damage to intrathoracic organs and blood vessels;
· subcutaneous emphysema;
mediastinal emphysema;
· increasing phenomena of respiratory and cardiovascular failure (tachypnea, tachycardia, decreased blood pressure);
· physical signs of pneumothorax, including valvular, and hemothorax with a shift of the mediastinum to the healthy side.

Diagnostic algorithm

Chest injury:

· palpation of tissues in the wound area over time to determine the presence of emphysema and the rate of its growth;

Auscultation to determine lung function on the affected side;
· blood pressure measurement and heart rate calculation.
· calculation of NPV.

Fracture of rib(s), sternum:
· examination reveals bruises in the area of ​​injury and above the jugular notch (retrosternal hematoma);
· local pain at the fracture site and step-like deformation when the fragments are displaced are determined by palpation;
· To exclude cardiac injury, an ECG study is necessary.

Fractured ribs:
· examination of the chest to identify deformation and participation of the chest in the act of breathing;
palpation of the ribs to identify local pain, deformation, crepitus, pathological mobility and the presence of a “rib valve”;
· palpation of tissues in the damaged area over time to determine the presence of emphysema and the rate of its growth;
· percussion of the chest to determine the presence of pneumothorax and/or hemothorax;
Auscultation to identify lung function on the affected side;

· calculation of NPV;
· determination of the level of consciousness.

Heart injury:
Heart injury with hemorrhage into the heart sac [hemopericardium].
· visual inspection of the wound and determination of the trajectory of the wound channel;



· blood pressure measurement and heart rate calculation;
· calculation of NPV;


· determination of the level of consciousness.

Other heart injuries:
· examination of the chest to determine signs of closed chest injury;
· percussion determination of the boundaries of cardiac dullness;
· percussion of the chest to determine the presence of concomitant pneumothorax and/or hemothorax;
Auscultation to detect dysfunction of the heart and lungs on the affected side;
· blood pressure measurement and heart rate calculation;
· calculation of NPV;
· visual identification of signs of high central venous pressure (swollen superficial jugular veins, puffiness of the face);
· determination of the central venous pressure level after catheterization of the main veins;
· determination of the level of consciousness.

· visual inspection of the wound and determination of the trajectory of the wound channel;
· percussion determination of the boundaries of cardiac dullness;
· percussion of the chest to determine the presence of concomitant pneumothorax and/or hemothorax;
Auscultation to detect dysfunction of the heart and lungs on the affected side;
· blood pressure measurement and heart rate calculation;
· calculation of NPV;
· visual identification of signs of high central venous pressure (swollen superficial jugular veins, puffiness of the face);
· determination of the central venous pressure level after catheterization of the main veins;
· determination of the level of consciousness.

Diagnostics (hospital)

Diagnostic criteria at the hospital level**:

Diagnostic algorithm: see outpatient level.

List of main diagnostic measures:

Laboratory research:
· UAC;
· CBS;
· biochemical parameters;
Determination of the gas composition of arterial blood.

Instrumental studies:
· ECG;
· X-ray of the chest organs.

List of additional diagnostic measures:
· Ultrasound of the chest organs;
· CT;
· MRI.

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Treatment

Drugs (active ingredients) used in treatment

Groups of drugs according to ATC used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT**

Treatment tactics**

Chest injury
· application of an aseptic protective dressing;
· applying a sealing bandage in the presence of open pneumothorax;
· covering the wound with a sterile towel in the case of a large defect in the chest wall, followed by fixation with a circular bandage;
· drainage of the pleural cavity in the 2-3 intercostal space along the midclavicular line by introducing 3-4 Dufault needles or a trocar in the presence of valvular tension pneumothorax; a rubber valve is attached to the free end of the needle or tube;
· drainage of the pleural cavity in the 7-8 intercostal space along the posterior axillary line in the presence of large hemothorax;
· intravenous administration of crystalloid and colloid solutions to replenish the bcc: if blood pressure is not determined, then the infusion rate should be 300-500 ml/min; in case of shock of I-II degree, up to 800-1000 ml of polyionic solutions are injected intravenously; in case of more severe circulatory disorders, a jet IV injection of dextrans or hydroxyethyl starch should be added at a dose of 5-10 ml/kg until blood pressure stabilizes at 90-100 mm Hg. Art.;
· in case of low hemodynamic parameters, despite rehydration - administration of vasopressor and glucocorticoid drugs in order to gain time and prevent cardiac arrest on the way to the hospital: dopamine 200 mg in 400 ml of plasma replacement solution IV in quick drops, prednisolone up to 300 mg IV V;
· administration of sedatives in case of psychomotor agitation;
· anesthesia to suppress the pain reaction and improve coughing up sputum: 2 ml of 0.005% fentanyl solution with 1 ml of 0.1% atropine solution;
· in case of acute respiratory failure - inhalation of oxygen;
· with increasing mediastinal emphysema - drainage of the anterior mediastinum;
· to combat shock and breathing disorders, a vagosympathetic blockade according to Vishnevsky is performed on the affected side;
· tracheal intubation and mechanical ventilation when acute respiratory failure worsens;
· in case of stopping effective blood circulation - resuscitation measures;
· transportation of victims is carried out in a horizontal position with the head end raised by 30° or in a half-sitting position.

· 0.25% solution of novocaine, no more than 500 ml of 0.25% solution and 150 ml of 0.5% solution [B].


· dopamine - the initial infusion rate is 2-5 mcg/kg per minute, can be increased gradually from 5 to 10 mcg/kg/min to an optimal dose of 50 mcg/kg/min [A];

No.

Fracture of rib, sternum

Sternum fracture:
· injection of a 1% procaine solution into the fracture site;
· bilateral vagosympathetic blockade according to Vishnevsky in acute respiratory failure;
· oxygen therapy;
· for unrelieved pain, administration of narcotic analgesics;
· in case of psychomotor agitation, administration of sedatives;
· for persistent hypotension caused by cardiac contusion, the use of crystalloid, colloid and vasopressor drugs;
· when effective blood circulation stops, carrying out resuscitation measures;
· transportation of the victim to a trauma hospital in a horizontal position with the head end elevated by 30°.

List of essential medications:
· procaine 1% and 0.25% solution (B) no more than 500 ml of 0.25% solution and 150 ml of 0.5% solution;
· 0.85% sodium chloride solution - average dose of 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B]
Dextran-60 90-minute (accelerated) regimen in which treatment can be started within 6 hours of the onset of symptoms: [A]
15 mg - intravenous (IV) bolus;
50 mg - IV infusion over the first 30 minutes, followed by an infusion of 35 mg over 60 minutes until the maximum dose is reached - 100 mg.

Diazepam 0.2 mg/kg. The commonly used dose in adults is 10 to 20 mg, but dosage increases may need to be increased depending on clinical response [A];
· Sodium hydroxybutyrate is administered to adults at the rate of 70-120 mg/kg body weight, to weakened patients - 50-70 mg/kg body weight. Inject the solution slowly, at a rate of 1-2 ml/min [C];

· fentanyl to reduce severe pain - intramuscularly or intravenously, 0.5 - 1 - 2 ml (0.025 - 0.05 - 0.1 mg fentanyl) [A];
Ibuprofen is prescribed at an initial dose of 200 mg 3 times a day [B].

List of additional medications: No.

Fractured ribs


· Local blockade of the fracture zone and paravertebral blockade with 1% procaine solution.
· In case of multiple rib fractures, additional cervical vagosympathetic blockade according to Vishnevsky is performed on the affected side.
· With the front “rib valve”, placing a load (bag of sand) on the floating segment.

· Additionally, for external valvular and necessarily for internal valvular pneumothorax - drainage of the pleural cavity in the 2-3 intercostal spaces along the midclavicular line by introducing 3-4 Dufaux-type needles or trocars; A rubber valve is attached to the free end of the needle or tube.

· Anesthesia - 2 ml of 0.005% fentanyl solution with 1 ml of 0.1% atropine solution.
· Intravenous administration of crystalloid and colloid solutions to replenish bcc: if blood pressure is not determined, then the infusion rate should be 300-500 ml/min; in case of shock of I-II degree, up to 800-1000 ml of polyionic solutions are injected intravenously; in case of more severe circulatory disorders, a jet IV injection of dextrans or hydroxyethyl starch should be added at a dose of 5-10 ml/kg until blood pressure stabilizes at 90-100 mm Hg. Art.
· In case of low hemodynamic parameters, despite rehydration - administration of vasopressor and glucocorticoid drugs in order to gain time and prevent cardiac arrest on the way to the hospital: dopamine 200 mg in 400 ml of plasma replacement solution IV in quick drops, prednisolone up to 300 mg IV V.



· Tracheal intubation and mechanical ventilation for apnea, respiratory rhythm disturbances, decompensated acute respiratory failure (RR less than 12 or more than 30), traumatic shock of the 3rd degree.

· Transport immobilization (according to indications).
· Transportation of victims is carried out in a horizontal position with the head end raised by 30°.

List of essential medications:

· 0.85% sodium chloride solution - average dose of 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B]
Dextran-60 90-minute (accelerated) regimen in which treatment can be started within 6 hours of the onset of symptoms: [A]
15 mg - intravenous (IV) bolus;
50 mg - IV infusion over the first 30 minutes, followed by an infusion of 35 mg over 60 minutes until the maximum dose is reached - 100 mg.
· 0.25% solution of novocaine, not more than 500 ml of 0.25% solution and 150 ml of 0.5% solution [B].
Diazepam 0.2 mg/kg. The commonly used dose in adults is 10 to 20 mg, but dosage increases may need to be increased depending on clinical response [A];
· Sodium hydroxybutyrate is administered to adults at the rate of 70-120 mg/kg body weight, to weakened patients - 50-70 mg/kg body weight. Inject the solution slowly, at a rate of 1-2 ml/min [C];
· dopamine - the initial infusion rate is 2-5 mcg/kg per minute, can be increased gradually from 5 to 10 mcg/kg/min to an optimal dose of 50 mcg/kg/min [A];
· fentanyl to reduce severe pain - intramuscularly or intravenously, 0.5 - 1 - 2 ml (0.025 - 0.05 - 0.1 mg fentanyl) [A];
Ibuprofen is prescribed at an initial dose of 200 mg 3 times a day [B].

List of additional medications: No.

Heart injury

Heart injury with hemorrhage into the cardiac sac [hemopericardium]
If the victim is unconscious, restore airway patency (triple Safar maneuver, airway).
· In case of pericardial tamponade - puncture of the pericardium according to Larrey and evacuation of liquid blood from the pericardial cavity; Drainage of the pericardial cavity with a subclavian catheter is allowed.
· Infusion of crystalloid and colloid solutions: if blood pressure is not determined, then the infusion rate should be 300-500 ml/min.; in case of shock of I-II degree, up to 800-1000 ml of polyionic solutions are injected intravenously; in case of more severe circulatory disorders, a jet IV injection of dextrans or hydroxyethyl starch should be added at a dose of 5-10 ml/kg until blood pressure stabilizes at 90-100 mm Hg. Art.
· Pain relief.
· For psychomotor agitation - sedatives.
· Oxygen therapy.
· In case of severe hypoxia - tracheal intubation, mechanical ventilation.
· If there is a wounding object (melee weapon) in the heart, the latter is removed*.
· If effective blood circulation stops, resuscitation measures**.
· Transport the victim in a horizontal position with the head end elevated by 30°.

* The current recommendation to leave bladed weapons in the cavity of the heart during transportation has serious and sometimes fatal disadvantages:
· a foreign body in the heart does not act as a tampon; the danger of blood loss when removing bladed weapons is greatly exaggerated, because the heart itself “closes” the wound channel during systole, because three muscle layers of the myocardium contract in opposite directions;
· unremoved edged weapons carry a real risk of damage to coronary vessels and conduction tracts with each contraction of the heart;
· in case of cardiac arrest, unremoved edged weapons significantly complicate resuscitation.

The only contraindication for removing bladed weapons from the heart is the shape of the striking end (such as a “fish hook” or “harpoon”), damage to which is extremely rare.

** In case of pericardial tamponade, Larrey puncture of the pericardium and evacuation of liquid blood are necessary before resuscitation.

List of essential medications:
· 0.85% sodium chloride solution - average dose of 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B]
Dextran-60 90-minute (accelerated) regimen in which treatment can be started within 6 hours of the onset of symptoms: [A]
15 mg - intravenous (IV) bolus;
50 mg - IV infusion over the first 30 minutes, followed by an infusion of 35 mg over 60 minutes until the maximum dose is reached - 100 mg.
· 0.25% solution of novocaine, not more than 500 ml of 0.25% solution and 150 ml of 0.5% solution [B].
Diazepam 0.2 mg/kg. The commonly used dose in adults is 10 to 20 mg, but dosage increases may need to be increased depending on clinical response [A];
· Sodium hydroxybutyrate is administered to adults at the rate of 70-120 mg/kg body weight, to weakened patients - 50-70 mg/kg body weight. Inject the solution slowly, at a rate of 1-2 ml/min [C];
· dopamine - the initial infusion rate is 2-5 mcg/kg per minute, can be increased gradually from 5 to 10 mcg/kg/min to an optimal dose of 50 mcg/kg/min [A];
· fentanyl to reduce severe pain - intramuscularly or intravenously, 0.5 - 1 - 2 ml (0.025 - 0.05 - 0.1 mg fentanyl) [A];
Ibuprofen is prescribed at an initial dose of 200 mg 3 times a day [B].

List of additional medications: No.

Other heart injuries
· if the victim is unconscious - restoration of airway patency (triple Safar maneuver, air duct);
· infusion of crystalloid and colloid solutions;
· in case of pericardial tamponade - puncture of the pericardium according to Larrey and evacuation of liquid blood from the pericardial cavity;
· pain relief with narcotic analgesics;
· for psychomotor agitation - sedatives;
· oxygen therapy;
· in case of severe hypoxia - tracheal intubation, mechanical ventilation;
restoration of hemodynamics;
· when effective blood circulation stops - resuscitation measures;
· transporting the victim in a horizontal position with the head end elevated by 30°.

List of essential medications:
· 0.85% sodium chloride solution - average dose of 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B]
Dextran-60 90-minute (accelerated) regimen in which treatment can be started within 6 hours of the onset of symptoms: [A]
15 mg - intravenous (IV) bolus;
50 mg - IV infusion over the first 30 minutes, followed by an infusion of 35 mg over 60 minutes until the maximum dose is reached - 100 mg.
· 0.25% solution of novocaine, not more than 500 ml of 0.25% solution and 150 ml of 0.5% solution [B].
Diazepam 0.2 mg/kg. The commonly used dose in adults is 10 to 20 mg, but dosage increases may need to be increased depending on clinical response [A];
· Sodium hydroxybutyrate is administered to adults at the rate of 70-120 mg/kg body weight, to weakened patients - 50-70 mg/kg body weight. Inject the solution slowly, at a rate of 1-2 ml/min [C];
· dopamine - the initial infusion rate is 2-5 mcg/kg per minute, can be increased gradually from 5 to 10 mcg/kg/min to an optimal dose of 50 mcg/kg/min [A];
· fentanyl to reduce severe pain - intramuscularly or intravenously, 0.5 - 1 - 2 ml (0.025 - 0.05 - 0.1 mg fentanyl) [A];
Ibuprofen is prescribed at an initial dose of 200 mg 3 times a day [B].

List of additional medications: No.

Trauma to other and unspecified thoracic organs

Emergency aid tactics:
· Prevention or elimination of asphyxia - cleaning the mouth and nose from blood clots and foreign particles.
· Applying an aseptic protective dressing in the presence of a chest wound.
· Applying a sealing bandage in the presence of open pneumothorax or external valve pneumothorax.
· Covering the wound with a sterile towel, over which a polyethylene sheet is applied, in the case of a large defect in the chest wall, followed by fixation with a circular bandage.
· Additionally, for external valvular and necessarily for internal valvular pneumothorax - drainage of the pleural cavity in the 2-3 intercostal spaces along the midclavicular line by introducing 3-4 Dufaux-type needles or trocars; A rubber valve is attached to the free end of the needle or tube.
· Drainage of the pleural cavity in the 7-8 intercostal space along the posterior axillary line in the presence of large hemothorax.
· Intravenous administration of crystalloid and colloid solutions to replenish the bcc: if blood pressure is not determined, then the infusion rate should be 300-500 ml/min.; in case of shock of I-II degree, up to 800-1000 ml of polyionic solutions are injected intravenously; in case of more severe circulatory disorders, a jet IV injection of dextrans or hydroxyethyl starch should be added at a dose of 5-10 ml/kg until blood pressure stabilizes at 90-100 mm Hg. Art.
· In case of low hemodynamic parameters, despite rehydration, administration of vasopressor drugs in order to gain time and prevent cardiac arrest on the way to the hospital.
· Administration of sedatives in case of psychomotor agitation.
· Anesthesia to suppress the pain reaction and improve coughing up sputum: 2 ml of 0.005% fentanyl solution with 1 ml of 0.1% atropine solution.
· If acute respiratory failure develops, inhale oxygen through a mask.
· With increasing emphysema of the mediastinum, drainage of the anterior mediastinum.
· To combat shock and breathing disorders, a vagosympathetic blockade according to Vishnevsky is performed on the affected side.
· Tracheal intubation and mechanical ventilation when acute respiratory failure worsens.
· In case of stopping effective blood circulation - resuscitation measures.
· Transportation of victims is carried out in a horizontal position with the head end raised by 30° or in a half-sitting position.

List of essential medications:
· procaine 1% and 0.25% solution (B) no more than 500 ml of 0.25% solution and 150 ml of 0.5% solution;
· 0.85% sodium chloride solution - average dose of 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B]
Dextran-60 90-minute (accelerated) regimen in which treatment can be started within 6 hours of the onset of symptoms: [A]
15 mg - intravenous (IV) bolus;
50 mg - IV infusion over the first 30 minutes, followed by an infusion of 35 mg over 60 minutes until the maximum dose is reached - 100 mg.
· 0.25% solution of novocaine, not more than 500 ml of 0.25% solution and 150 ml of 0.5% solution [B];
Diazepam 0.2 mg/kg. The commonly used dose in adults is 10 to 20 mg, but dosage increases may need to be increased depending on clinical response [A];
· Sodium hydroxybutyrate is administered to adults at the rate of 70-120 mg/kg body weight, to weakened patients - 50-70 mg/kg body weight. Inject the solution slowly, at a rate of 1-2 ml/min [C];
· dopamine - the initial infusion rate is 2-5 mcg/kg per minute, can be increased gradually from 5 to 10 mcg/kg/min to an optimal dose of 50 mcg/kg/min [A];
· fentanyl to reduce severe pain - intramuscularly or intravenously, 0.5 - 1 - 2 ml (0.025 - 0.05 - 0.1 mg fentanyl) [A];
· atropine single - 0.001 g, daily - 0.003 g [B].

Mandatory constant monitoring of hemodynamic parameters!
List of additional medications:
· polyglucin 400.0 ml, 90-minute (accelerated) regimen in which treatment can be started within 6 hours after the onset of symptoms[A];
· *Sodium chloride, potassium chloride, sodium hydrochloride 400.0 ml, Average dose 1000 ml per day as an intravenous continuous drip infusion at an administration rate of 540 ml/hour (up to 180 drops/minute) [B];
· *Dextrose 5% - 400.0 ml, Subcutaneously (up to 500 ml), intravenous drip at a rate of 7 ml/min (150 drops/min), maximum daily dose 2000 ml. [IN]

· consultation with a surgeon to determine further treatment tactics (operative or conservative);
· consultation with a traumatologist to determine further treatment tactics (operative or conservative);
· consultation with an anesthesiologist-resuscitator to assess the severity of the condition, determine the anesthetic risk, and preoperative preparation.

Stabilization of the patient's condition.

Treatment (inpatient)

DIAGNOSTICS AT THE INPATIENT LEVEL**

Treatment tactics**: see outpatient level.

Surgical intervention: if indicated according to existing surgical protocols.

Other treatments: does not exist.

Indications for consultation with specialists: see outpatient level.

Indications for transfer to the intensive care unit:
If vital functions are impaired, the patient should be immediately hospitalized in the ICU.

Indicators of treatment effectiveness: see outpatient level.

Hospitalization

Indications for planned hospitalization: no

Indications for emergency hospitalization:
· victims with open, combined and closed isolated chest trauma, accompanied by respiratory and circulatory disorders, are subject to emergency hospitalization in a hospital;
· victims with chest injuries should be transported on a stretcher, in a semi-sitting position;
· During transportation, it is necessary to constantly monitor the frequency and depth of breathing, pulse condition and blood pressure.

Information

Sources and literature

1. Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2016
   1. 1) Baksanov Kh.D. Tactics of treatment of combined craniocerebral and skeletal trauma / Kh.D. Baksanov, A.K. Zhigunov, I.A. Mizeev, etc. // Disaster Medicine, No. 4.-2015. P.20-23 2) Sokolov V.A. Multiple and combined injuries/V.A.Sokolov//Medicine.-2006. P.29-33 3) Sokolov V.A. Road traffic injuries /V.A.Sokolov//Medicine.-2009. P.48-56 4) Anikin L.N. Polytrauma/L.N.Anikin//Medicine.-2014. 39s. 5) Agadzhanyan V.V. Hospital mortality in polytrauma and the main directions of its reduction / V.V. Agadzhanyan, S.A. Kravtsov, A.V. Shatalin, etc.//Polytrauma, No. 1.-2015. P.6-15

Information

Abbreviations used in the protocol:

ICD	- International Classification of Diseases
Heart rate	- Heart rate
HELL	- Blood pressure
SpO2	- Blood oxygen saturation level
CPR	- Cardiopulmonary resuscitation
CT	- Computed tomography
MRI	- Magnetic resonance imaging
mechanical ventilation	- Artificial ventilation
CBS	- Acid-base state
ECG	- Electrocardiography
RaCO 2	- Partial pressure of carbon dioxide in arterial blood
RaO 2	- Partial pressure of oxygen in arterial blood

List of protocol developers:
1) Nurila Amangalievna Maltabarova - Candidate of Medical Sciences at Astana Medical University JSC, Professor of the Department of Emergency Care and Anesthesiology, Reanimatology, Member of the International Association of Scientists, Teachers and Specialists, Member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
2) Sarkulova Zhanslu Nukinovna - Doctor of Medical Sciences, Professor, RSE at the West Kazakhstan State Medical University named after Marat Ospanov, head of the department of emergency medical care, anesthesiology and resuscitation with neurosurgery, chairman of the branch of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan in the Aktobe region
3) Alpysova Aigul Rakhmanberlinovna - Candidate of Medical Sciences, RSE at the Karaganda State Medical University, head of the department of ambulance and emergency medical care No. 1, associate professor, member of the Union of Independent Experts.
4) Alexey Ivanovich Kokoshko - Candidate of Medical Sciences, JSC "Astana Medical University", Associate Professor of the Department of Emergency Care and Anesthesiology, Reanimatology, member of the International Association of Scientists, Teachers and Specialists, member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
5) Akhilbekov Nurlan Salimovich - RSE at the Republican Air Ambulance Center, Deputy Director for Strategic Development.
6) Grab Alexander Vasilievich - GKP at the RVC "City Children's Hospital No. 1" Health Department of the city of Astana, head of the resuscitation and intensive care department, member of the Federation of Anesthesiologists and Resuscitators of the Republic of Kazakhstan.
7) Boris Valerievich Sartaev - RSE at the Republican Medical Aviation Center, doctor of the mobile air ambulance team.
8) Dyusembayeva Nazigul Kuandykovna - Candidate of Medical Sciences, Astana Medical University JSC, head of the department of general and clinical pharmacology.

Conflict of interest: absent.

List of reviewers: Sagimbayev Askar Alimzhanovich - Doctor of Medical Sciences, Professor of JSC National Center for Neurosurgery, Head of the Quality Management and Patient Safety Department of the Quality Control Department.

Conditions for reviewing the protocol: review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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PROJECT

Working group for the preparation of the text of clinical recommendations:

Prof. , Associate Professor (Department of Thoracic Surgery, Russian Medical Academy of Postgraduate Education, Moscow).

Societies: National Thoracic Section of the Russian Society of Surgeons, Association of Thoracic Surgeons of Russia

Composition of the expert committee: Prof. (St. Petersburg), prof. (Moscow), prof. (Samara), prof. (Moscow), corresponding member. RAMS, prof. (Krasnodar), prof. (Kazan), prof. (Moscow), prof. (Saint Petersburg)

Foreign experts: prof. Stephen Cassivi (Rochester, USA), Academician of the Russian Academy of Medical Sciences, prof. Gilbert Massard (Strasbourg, France), prof. Enrico Ruffini (Torino, Italy), prof. Gonzalo Varela (Salamanca, Spain)

Edited by: Academician of the Russian Academy of Medical Sciences, professor

Introduction: Perhaps, none of the urgent pulmonary diseases has caused as much discussion about surgical tactics as spontaneous pneumothorax - from a purely conservative approach to prophylactic bilateral resections of the apical segments of the lungs.

It should be recognized that after any treatment for spontaneous pneumothorax, relapses are possible. According to the summary data of the world literature, the number of relapses during drainage is 30 - 36% (M. Almind, 1989; P. Andrived, 1995; F. Rodrigues Panadero, 1997); with pleurodesis 8 – 13% (M. Almind, 1989; S. Boutin, 1995; C. Khawand, 1995); with lung resection 4 - 8% (, 1997; H. P. Becker, 1997); with lung resection in combination with pleurodesis or pleurectomy 1.5 - 2% (1997; 2000; D. M. Donahue, 1993).

Etiology and pathogenesis: It should be noted that most often “spontaneous” pneumothorax is secondary - simply, due to a number of circumstances, the primary disease, the complication of which was pneumothorax, remained undiagnosed. Pneumothorax is a common complication of a number of diseases, some of which are presented in Table 1.

Considering this far from complete list of diseases, we have to admit that most of them are never diagnosed in emergency surgical care. Therefore, when assessing the effectiveness of surgical treatment from the point of view of the possibility of avoiding postoperative relapses, one should clearly understand that, almost always, pneumothorax is not an independent disease, but a manifestation of other, much more complex pathological processes in the lung tissue and, first of all, pulmonary emphysema .

Table 1. Lung diseases and systemic diseases, which are a common cause of secondary pneumothorax

Respiratory diseases	Chronic obstructive pulmonary disease
Cystic fibrosis
Interstitial lung diseases	Sarcoidosis
Idiopathic pulmonary fibrosis
Histiocytosis X
Lymphangioleiomyomatosis
Infectious lung diseases	Pneumonia Pneumocystis carinii
Systemic connective tissue diseases
Ankylosing spondylitis
Polymyositis/dermatomyositis
Systemic scleroderma
Marfan syndrome
Ehlers–Danlos syndrome
Other	Endometriosis

Currently, the problems of studying the etiology and methods of treating spontaneous pneumothorax are inextricably linked with lung diseases that cause bullous emphysema. Bullous pulmonary emphysema is the cause of spontaneous pneumothorax in 71–95% of cases.

According to the WHO definition, pulmonary emphysema is “an anatomical change in the lungs, characterized by a pathological expansion of the air spaces located distal to the terminal bronchioles and accompanied by destructive changes in the alveolar walls.” There are primary emphysema, which develops in the lungs that do not have any other pathology and is an independent nosological form, as well as secondary, complicating diseases that cause bronchial obstruction, such as chronic bronchitis, bronchial asthma and chronic obstructive pulmonary disease.

Over the past 20 years, a number of scientific papers have appeared on the genetically determined nature of emphysema and spontaneous pneumothorax, caused by hereditary deficiency of elastase inhibitors, such as alpha-1-antitrypsin and alpha-2-macroglobulin. In this case, destruction of the elastic framework of the lung occurs due to excessive accumulation of proteolytic enzymes, which are produced mainly by neutrophils and alveolar macrophages, and enzymatic disintegration of interalveolar septa occurs, fusion of individual alveoli into larger bullous formations.

In secondary emphysema, chronic inflammatory diseases of the bronchi play an important role, the most common of which is chronic obstructive bronchitis. In addition to disturbances in bronchial obstruction, inflammatory changes in the wall of the small bronchi, extending to the respiratory bronchioles and alveoli, are of significant importance. In this case, obstruction occurs in the bronchioles and smallest bronchi with a valve effect in the form of local bronchospasm, accumulation of viscous secretion or stenosis. If the bronchial patency is disrupted at the above level, the pores of Conn'a expand and flatten, which leads to a slow accumulation of air, constant stretching of the alveoli, atrophy of the partitions between them, and thin-walled tense air cavities arise that can reach gigantic sizes. The formation of such cavities is a characteristic sign of bullous emphysema; air cavities, the wall of which is the visceral pleura, are called blebs, and in cases where the wall is represented by overstretched lung parenchyma - bullae.

Spontaneous pneumothorax can be caused not only by rupture of the wall of the bleb or bulla. In 1976, H. Suzuki proved the presence of micropores with a diameter of 10 μm in the bulla wall, which can cause spontaneous pneumothorax without rupture of the bullae. More rare causes of spontaneous pneumothorax are rupture of the lung parenchyma by adhesions (in 3–5% of patients) and perforation of congenital lung cysts (in 1–3%).

Prevalence. In general, the incidence of pneumothorax ranges from 7.4 to 18 cases per 100 thousand people per year among men and from 1.2 to 6 cases per 100 thousand people per year. According to data obtained during a general medical examination of the population of the USSR, pneumothorax was diagnosed in 0.3% of all pulmonary patients who applied to medical institutions.

Clinical picture pneumothorax is quite typical: the patient complains of arching pain, often radiating to the shoulder, shortness of breath, and a constant dry cough. A physical examination reveals a lag in breathing of half the chest, sometimes widening of the intercostal spaces, tympanitis, weakening of breathing, weakening of voice tremors and increased conduction of heart sounds.

Diagnosis of pneumothorax, in the case of a typical clinical picture, is not difficult, however, it should be remembered that a hidden and erased clinical picture occurs in more than 20% of cases. These patients have moderate pain of a radiculoneuritic or anginal nature without characteristic pulmonary symptoms and, often, they are unsuccessfully “treated” for ischemic disease, intercostal neuralgia, osteochondrosis and similar diseases. This emphasizes the obligatory X-ray examination for ANY complaints of chest pain.

Diagnostics: The diagnosis of pneumothorax is finally established radiologically. It is mandatory to take radiographs in direct and lateral projections, and in doubtful cases, an additional expiratory photograph in direct projection. The main X-ray symptoms are visualization of the outlined edge of the collapsed lung, displacement of the mediastinum, change in the position of the diaphragm, emphasizing the structure of the ribs and cartilage against the background of air in the pleural cavity. When assessing radiographs, it is necessary to remember the possibility of limited pneumothorax, which usually has an apical, paramediastinal or supradiaphragmatic localization. In these cases, it is necessary to perform inspiratory and expiratory radiographs, comparison of which provides complete information about the presence of limited pneumothorax. An important task of x-ray examination is to assess the condition of the lung parenchyma, both the affected and the opposite lung.

The best of the radiological methods, which provides complete information about the condition of the lung parenchyma, interstitial lung diseases, the location and volume of pneumothorax, the presence and location of pleural adhesions, is spiral computed tomography.

In addition to x-ray examination, the examination standard includes clinical blood and urine tests, a biochemical blood test, determination of blood group and Rh factor, as well as determination of the gas composition and acid-base state of the blood. A study of pulmonary function in pneumothorax is not advisable; it should be performed after the elimination of pneumothorax.

Differential diagnosis: pneumothorax should be differentiated from giant bullae, destructive processes in the lungs, dislocation of hollow organs from the abdominal cavity to the pleural cavity.

Classification: To resolve issues of surgical tactics for spontaneous pneumothorax, its classification is necessary, reflecting those aspects that are important for making tactical decisions. The combined classification is presented in Table 2.

Table 2. Classification of spontaneous pneumothorax

By etiology:	Caused by primary bullous pulmonary emphysema
Caused by primary diffuse pulmonary emphysema
Caused by respiratory disease
Caused by interstitial lung disease
Caused by systemic disease
Caused by avulsion of the pleural commissure
By frequency of education:	Primary
Recurrent
By mechanism:	Closed
Valve
According to the degree of lung collapse:	Apical (up to 1/6 volume)
Small (up to 1/3 volume)
Medium (up to ½ volume)
Large (over ½ volume)
Total (lung completely collapsed)
For complications:	Uncomplicated
Tense
Respiratory failure
Soft tissue emphysema
Pneumomediastinum
Hemopneumothorax
Hydropneumothorax
Pyopneumothorax
Rigid

General principles of treatment. All patients with pneumothorax should be urgently hospitalized in surgical, and, if possible, in thoracic surgical hospitals.

In world practice, two consensus documents are used on the diagnosis and treatment of patients with spontaneous pneumothorax: the British Thoracic Society manual and the American College of Chest Physicians manual. Despite some differences in approaches to patient management, these guidelines use the general principle of gradually increasing the invasiveness of the intervention and propose similar stages of treatment, which include:

Dynamic observation and oxygen therapy

· Pleural puncture

Drainage of the pleural cavity

Closed chemical pleurodesis

· Surgical treatment

The fundamental points for determining surgical tactics for pneumothorax are: the presence of respiratory and, even to a greater extent, hemodynamic disorders, the frequency of formation, the degree of lung collapse and the etiology of pneumothorax. In all cases, it is necessary before surgery to clarify the nature of changes in the pulmonary parenchyma using all possible methods, preferably spiral computed tomography (SCT).

Emergency surgical care for spontaneous pneumothorax should be aimed, first of all, at decompressing the pleural cavity and preventing respiratory and circulatory disorders, and only then at performing radical surgery.

Principles for choosing surgical tactics for spontaneous pneumothorax

The general principles for choosing surgical tactics when providing emergency care for spontaneous pneumothorax, depending on the volume and frequency of pneumothorax formation, are as follows.

Dynamic observation: o It is possible to limit ourselves only to observation without air evacuation with isolated apical pneumothorax in patients without severe dyspnea or with spontaneous pneumothorax of small volume (less than 15%). The resolution rate of pneumothorax is 1.25% of the hemithorax volume in 24 hours. Thus, a 15% volume pneumothorax will require approximately 8–12 days to completely resolve.

Pleural punctures with aspiration: indicated for patients under 50 years of age with the first episode of spontaneous pneumothorax with a volume of 15–30% without severe dyspnea. The puncture is performed using a needle or, preferably, a thin stylet catheter. A typical place for puncture is the 2nd intercostal space along the midclavicular line; however, the puncture point should be determined only after a polypositional X-ray examination, which allows us to clarify the location of adhesions and the largest accumulations of air. Aspiration is carried out using a syringe; after the air evacuation is completed, the needle or catheter is removed. It is important to remember that if the first puncture is ineffective, repeated attempts at aspiration are successful in no more than one third of cases.

Drainage of the pleural cavity: indicated for pneumothorax volume more than 30%, for recurrent pneumothorax, for puncture failure, in patients with dyspnea and in patients over 50 years of age. The key points of correct placement of drainage are: mandatory polypositional x-ray examination before drainage and monitoring the position of the drainage with its correction as necessary after manipulation. It is advisable to perform drainage using a stylet catheter, which is inserted at the point indicated by fluoroscopy (in the absence of adhesions - in the 2nd intercostal space along the midclavicular line), aspiration is carried out using a pleuroaspirator with a vacuum of 5 to 25 cm of water. Art. Drainage of the pleural cavity leads to expansion of the lung in 84–97%.

The question of the advisability of emergency thoracoscopy for spontaneous pneumothorax without preliminary drainage, expansion of the lung and examination of the condition of the lung tissue is debatable.

Performing a one-stage radical operation “ex tempore” is possible for bullous emphysema localized within one lobe and for pneumothorax caused by separation of the pleural commissure. However, the use of such tactics is dangerous because during a thoracoscopic examination one can, unexpectedly, discover that the cause of pneumothorax is widespread diffuse emphysema, or cystic hypoplasia, or one of the interstitial lung diseases, or, even worse, that the pneumothorax developed as a result of a rupture lung cavity or abscess. Obviously, any of these situations will require a completely different surgical procedure, for which the surgeon, anesthesiologist and, most importantly, the patient may not be prepared.

Surgical tactics for spontaneous pneumothorax are as follows. After a physical and polypositional X-ray examination, which allows one to assess the degree of lung collapse, the presence of adhesions, fluid, and mediastinal displacement, it is necessary to perform a puncture or drainage of the pleural cavity.

At the first episode of pneumothorax an attempt at conservative treatment is possible - puncture or drainage of the pleural cavity. If the treatment is effective, SCT should be performed, and if bullae, emphysema and interstitial lung diseases are detected, elective surgery should be recommended. If there are no changes in the lung parenchyma that are subject to surgical treatment, then we can limit ourselves to conservative treatment, recommending that the patient adhere to a regimen of physical activity and SCT monitoring once a year. The exception is for professional indications - patients carrying out their work under conditions of changing external pressure; in these cases, it is advisable to perform a preventive operation – thoracoscopic pleurectomy. This treatment is especially indicated for pilots, paratroopers, divers and musicians who play wind instruments.

If drainage does not lead to expansion of the lung and air flow through the drains continues for 72–120 hours, urgent thoracoscopic surgery is indicated.

If pneumothorax recurs, as a rule, surgery is indicated, however, it is always preferable to first perform drainage of the pleural cavity, achieve expansion of the lung, then perform a CT scan, assess the condition of the lung tissue, paying special attention to signs of diffuse emphysema, COPD and processes of destruction of lung tissue; and the operation should be performed in an emergency-delayed manner.

Surgical procedures for spontaneous pneumothorax.

Drainage of the pleural cavity in spontaneous pneumothorax. The first surgical treatment for pneumothorax is decompression of the pleural cavity through its drainage. There are so many misconceptions associated with this simplest surgical procedure that it rightfully ranks first among the “myths of emergency thoracic surgery.”

The usual point for drainage is the 2nd intercostal space along the midclavicular line. This is true only for large and total pneumothorax in the absence of adhesions in the pleural cavity. Often, as a result of previously suffered diseases of the pleura and lungs, minor injuries, it is in the projection of the 2nd rib that the most pronounced adhesive process is formed. Attempting “standard” chest drainage will result in lung injury or hemothorax.

The correct tactic is a mandatory polypositional X-ray examination - fluoroscopy or radiography in two projections and determining the optimal drainage point.

The next common mistake is the opinion that in order to avoid damage to the lung, drainage should be inserted exclusively “bluntly” - using a clamp and certainly along the upper edge of the rib. Installation of a stylet catheter or drainage through a trocar is much less traumatic, and if the technique is followed, the risk of iatrogenic damage is less than with drainage using a clamp. As for possible damage to the intercostal artery during drainage, it should be remembered that only on the anterior surface of the chest wall is it hidden in the rib groove, and on the posterior and posterolateral surfaces the artery passes through the middle of the intercostal space.

Before drainage, it is correct to perform a puncture of the pleural cavity with a thin needle or, even better, a Veress needle at the point of intended installation of drainage, using aspiration to control the advancement of the needle in the soft tissues. After the needle penetrates the pleural cavity, without pushing it deeply, you should describe a circle in the air with the needle cannula. The same circle describes the end of the needle in the pleural cavity, and you can get a distinct sensation of resistance or “scratching”, which indicates fixation of the lung to the site of intended drainage. If the pleural cavity is free, you should, by aspirating the air, make sure that the needle is in the pleural cavity, fix the direction of the injection and mark on the needle the depth to which the trocar should be inserted. It is necessary to make an incision corresponding to the trocar, apply a suture capturing the muscle layer through the middle of the incision (this will eliminate the need to suture the wound after removing the drainage) and insert a stylet catheter or trocar into the pleural cavity to a given depth.

An elastic tube with a diameter of 5–7 mm is inserted through the trocar. The main mistakes that occur when installing pleural drainage:

1. The drainage tube is inserted deep into the pleural cavity. Correctly insert it to a depth of 2 - 3 cm from the last hole.

2. unreliable fixation of the drainage, in which case it completely comes out of the pleural cavity or falls out partially. In the latter case, the lateral openings end up in the subcutaneous tissue and subcutaneous emphysema develops.

A common misconception is that it is necessary to install a thick drainage for tension pneumothorax, since “thin drainages cannot cope with the release of air.” In fact, failures of fine drainage are more often associated with poor manipulation techniques.

After drainage, air aspiration should be established. Here we encounter polar opposite opinions: some surgeons advocate Bülau drainage, others advocate aspiration with maximum vacuum, and still others indicate specific vacuum numbers. The truth is in the middle: aspiration should be carried out with the minimum vacuum at which the lung is completely expanded. The method for choosing the optimal vacuum is as follows: under fluoroscopy control, we reduce the vacuum to the level when the lung begins to collapse, after which we increase the vacuum by 3–5 cm of water. Art. The most convenient device for aspiration is the OH-D Univac (FTO "Cascade"). When complete expansion of the lung is achieved, there is no passage of air for 24 hours and fluid intake is less than 100-150 ml, the drainage is removed. There is no exact timing for drainage removal; aspiration should be carried out until the lung is completely expanded. X-ray monitoring of lung expansion is performed daily. If air flow from the pleural cavity ceases within 12 hours, the drainage is closed for 24 hours and then an x-ray is taken. If the lung remains expanded, the drainage is removed. In case of repeated lung collapse, active aspiration is continued. If air discharge continues for hours, drainage should be considered ineffective and indications for thoracoscopic surgery should be given.

Pleurodesis. If for some reason it is impossible to perform a radical operation, after drainage, pleurodesis can be performed to obliterate the pleural cavity - the injection of a drug that causes aseptic inflammation and adhesions. For chemical pleurodesis, you can use fine talc powder, a solution of tetracycline or bleomycin.

The most powerful sclerosing agent is talc. You can often hear the opinion that talc is carcinogenic and should not be used for pleurodesis. This is because some types of talc contain asbestos, which is a carcinogen. Conducted by C. Boutine et al. , P. Lange et al. , K. Viskum et al. and the Lyon International Agency for Research on Cancer, a study of 35 years of results from the use of asbestos-free chemically pure talc, did not establish a single case of the development of a tumor of the pleura or lung. The talc pleurodesis technique is quite labor-intensive and requires spraying 3 - 4.5 grams of talc using a special sprayer introduced through a trocar before draining the pleural cavity.

It is important to remember that talc does not cause an adhesive process, but granulomatous inflammation, which results in fusion of the parenchyma of the mantle zone of the lung with the deep layers of the chest wall. Previously performed talc pleurodesis causes extreme difficulties for any subsequent surgical intervention on the breast organs. That is why indications for talc pleurodesis should be strictly limited to only those cases (senile age, severe concomitant diseases, inoperable tumors) when the likelihood that the patient will subsequently require surgery in the obliterated pleural cavity is minimal.

The next most effective drugs for pleurodesis are antibiotics of the tetracycline and bleomycin group. Tetracycline should be administered at a dose of 20–40 mg/kg; if necessary, the procedure can be repeated the next day. Bleomycin is administered at a dose of 100 mg on the first day and, if necessary, pleurodesis of bleomycin 200 mg is repeated on subsequent days. Due to the severity of pain during pleurodesis with tetracycline and bleomycin, it is necessary to dilute these drugs in 2% lidocaine and be sure to premedicate with narcotic analgesics. The method of pleurodesis with these antibiotics is quite simple. After drainage, the drug is administered through a drain, which is clamped for 1 - 2 hours, or, with constant air release, passive aspiration is carried out according to Bulau. During this time, the patient must constantly change body position in order to distribute the solution evenly over the entire surface of the pleura.

The choice of surgical tactics for spontaneous pneumothorax from the perspective of evidence-based medicine.

The British Society of Thoracic Surgeons Guidelines, 2010 summarized the results of level 1 and 2 evidence, based on which it was concluded that pulmonary resection in combination with pleurectomy is the technique that provides the lowest percentage of relapses (~ 1 %). Thoracoscopic resection and pleurectomy are comparable in recurrence rate to open surgery, but are more preferable in terms of pain, duration of rehabilitation and hospitalization, and restoration of external respiratory function.

Operations for spontaneous pneumothorax.

Thus, thoracoscopy is the operation of choice for spontaneous pneumothorax, differing favorably from thoracotomy in its low morbidity, mild postoperative period, rapid patient rehabilitation and good cosmetic result.

Thoracoscopic examination for spontaneous pneumothorax has 3 main goals: diagnosis of the disease that caused the pneumothorax, assessment of the severity of emphysematous changes in the parenchyma, and search for the source of air intake.

Thoracoscopic examination allows not only to visualize changes in lung tissue characteristic of a particular disease, but also, if necessary, to obtain biopsy material for morphological verification of the diagnosis.

To assess the severity of emphysematous changes in the parenchyma, it is most advisable to use the P. C. Antony classification:

· type 1 - a single subpleural bladder less than 1 cm in diameter;

· type 2 - more than one subpleural bladder located within one lobe of the lung;

· Type 3 - more than one subpleural bladder located in different lobes of the lung.

· type 1 - a single thin-walled cavity more than one cm in diameter;

· Type 2 – one or more bullae in combination with a bleb, located within one lobe;

· Type 3 – combined (diffuse and bullous) emphysema, damage to several lobes.

A thorough assessment of the severity of emphysematous changes makes it possible to predict with a high degree of probability the risk of recurrent pneumothorax and make an informed decision about the need to perform an operation aimed at obliterating the pleural cavity.

The success of the operation depends to the greatest extent on whether the source of air supply was found and eliminated. The frequently held belief that with thoracotomy it is easier to detect the source of air intake is only partly true. Indeed, under conditions of one-lung ventilation, necessary for thoracoscopy, the ruptured bulla collapses, and finding it becomes a difficult task.

Many researchers (2000; 2000) note that regardless of the inspection method, in 6–8% of cases of spontaneous pneumothorax the source of air intake cannot be detected. As a rule, these cases are associated with the entry of air through the micropores of an unruptured bulla or occur when a thin pleural adhesion is torn off. According to our data, it is possible to identify the source of air intake during thoracoscopy in 93.7%, and during thoracotomy - in 91.2% of cases. This is due to better visualization during thoracoscopy due to the use of a video system and an 8-fold magnification of the image.

To detect the source of air intake, the following technique is advisable. Pour 250–300 ml of sterile solution into the pleural cavity. The surgeon presses all suspicious areas one by one with an endoscopic retractor, immersing them in liquid. It is not advisable to use endoscopic clamps for this, since, while fixing the lung, they can block the flow of air to the ruptured bulla, and, in addition, the retractor creates the necessary volume for examination when ventilation of the lung is turned on. The anesthesiologist connects the open bronchial canal of the endotracheal tube to the Ambu bag and, at the command of the surgeon, takes a small breath. As a rule, with a thorough sequential inspection of the lung, it is possible to detect the source of air intake. As soon as you can see a chain of bubbles rising from the surface of the lung, you should, carefully manipulating the retractor, turn the lung so that the source of air intake is as close as possible to the surface of the sterile solution. Without removing the lung from under the liquid, it is necessary to grasp its defect with an atraumatic clamp and make sure that the air supply has stopped. After this, the pleural cavity is drained and suturing of the defect or lung resection begins.

If, despite a thorough inspection, the source of air intake could not be detected, it is necessary not only to eliminate the existing intact bullae and blebs, but also, without fail, to create conditions for obliteration of the pleural cavity - to perform pleurodesis or endoscopic parietal pleurectomy.

Pleurodesis during thoracoscopy is performed by applying a sclerosing agent - talc, tetracycline solution or bleomycin - to the parietal pleura. The advantages of pleurodesis under the control of a thoracoscope are the ability to treat the entire surface of the pleura with a sclerosing agent and the painlessness of the procedure.

You can perform mechanical pleurodesis using special thoracoscopic instruments for abrading the pleura or, in a simpler and more effective version, pieces of sterilized metal sponge used in everyday life for washing dishes. Mechanical pleurodesis, performed by wiping the pleura with tuffers, is ineffective due to their rapid wetting, and cannot be recommended for use.

Physical methods of pleurodesis also give good results; they are simple and very reliable. Among them, it should be noted the treatment of the parietal pleura with electrocoagulation - in this case, it is more advisable to use coagulation through a gauze ball moistened with saline solution; This method of pleurodesis is characterized by a larger area of ​​influence on the pleura with a smaller depth of current penetration. The most convenient and effective methods of physical pleurodesis are the destruction of the parietal pleura using an argon plasma coagulator or an ultrasonic generator.

A radical operation for obliteration of the pleural cavity is endoscopic pleurectomy. This operation should be performed according to the following procedure. Using a long endoscopic needle, saline solution is injected subpleurally into the intercostal spaces from the apex of the lung to the level of the posterior sinus. Along the spine at the level of the costovertebral joints, the parietal pleura is dissected along its entire length using an electrosurgical hook. Then the pleura is dissected along the lowest intercostal space at the level of the posterior phrenic sinus. The corner of the pleural flap is grabbed with a clamp, the pleural flap is peeled off from the chest wall using measured traction. The pleura detached in this way is cut off with scissors and removed through a thoracoport. Hemostasis is carried out using a ball electrode. Preliminary hydraulic preparation of the pleura makes the operation easier and safer.

If there is an obvious source of air intake, in order to select the optimal volume of surgery, it is necessary to correctly assess the changes in the lung tissue identified during the audit. To assess the results of thoracoscopic revision of the pleural cavity and select the type of operation, the classification described above by P. C. Antony is most successful.

For type 1 and 2 bleb, it is possible to perform electrocoagulation, suture the lung defect, or perform lung resection within healthy tissue. Electrocoagulation of the bleb is the simplest and, if the technique is carefully followed, the most reliable operation. Before coagulating the surface of the bleb, it is necessary to carefully coagulate its base. If the bleb is small, you can grab the lung tissue underneath it with a clamp and carry out coagulation through the clamp. For larger sizes, it is necessary to carefully coagulate the lung tissue along the border of the bleb with a ball electrode. After coagulation of the underlying lung tissue, the coagulation of the bleb itself begins, and one should strive to ensure that the wall of the bleb is “welded” to the underlying lung tissue, using a non-contact coagulation mode for this. Ligation using a Raeder loop, advocated by many authors, should be considered risky, since the ligature may slip off during lung reexpansion. Suturing with the EndoStitch device or manual endoscopic suture is much more reliable. The suture must be placed 0.5 cm below the base of the bleb and the lung tissue must be tied on both sides, after which the bleb can be coagulated or cut off.

For type 1 and 2 bullae, endoscopic suturing of the underlying parenchyma or lung resection using an endostapler should be performed. Coagulation of bullae should not be used. If a single bulla ruptures no more than 3 cm in size, the lung tissue supporting the bulla can be sutured using a hand suture or the EndoStitch device. In the presence of multiple bullae or blebs localized in one lobe of the lung, if single giant bullae are ruptured, an atypical resection of the lung should be performed within healthy tissue using an endoscopic stapler. More often, for bullae, it is necessary to perform marginal resection, less often - wedge-shaped. When wedge-shaped resection of the 1st and 2nd segments, it is necessary to mobilize the interlobar groove as much as possible and perform the resection by sequentially applying a stapler from the root to the periphery of the lung along the border of healthy tissues.

Endoscopic lobectomy should be performed for cystic hypoplasia of the lung lobe. This operation is much more technically difficult and can only be recommended to surgeons with extensive experience in thoracoscopic surgery. To make endoscopic lobectomy easier and more convenient, before proceeding to the treatment of the elements of the root lobe, you can open the cysts using endoscopic scissors with coagulation. Of course, before this it is necessary to ensure the adequacy of separate intubation. After opening the cysts, the lobe collapses, providing optimal conditions for manipulation at the root of the lung. Endoscopic isolation of the lobar artery and vein, as in traditional surgery, must be performed in accordance with the “golden rule of Overhold”, first treating the visible anterior, then the lateral and only then the posterior wall of the vessel. To isolate the posterior wall of the vessel, it is convenient to use the EndoMiniRetract tool. It is easier to suture selected lobar vessels using the EndoGIA II Universal or Echelon Flex device with a white cassette. In this case, it is technically easier to bring it under the vessel “upside down,” i.e., not with a cassette, but with the thinner mating part of the apparatus downward. You can ligate the vessels using ligatures with tying an extracorporeal knot. The bronchus should be sutured and crossed using a stapler with a blue or green cassette. Removing a lung lobe from the pleural cavity with cystic hypoplasia, as a rule, does not cause difficulties and can be performed through an extended trocar injection.

Endoscopic anatomical resection of the lung is technically complex and requires a large number of expensive consumables. Video-assisted lobectomy from a mini-access does not have these disadvantages, and the course of the postoperative period does not differ from that of endoscopic lobectomy. In addition, mini-thoracotomy allows for palpable inspection of the lung and easy removal of the resected lobe.

The technique for performing video-assisted lobectomy was developed in detail and introduced into clinical practice by T. J. Kirby. The technique is as follows. The optical system is inserted into the 7-8 intercostal space along the anterior axillary line and a thorough visual inspection of the lung is performed. The next thoracoport is installed in the 8-9 intercostal space along the posterior axillary line. The lobe is isolated from the adhesions and the pulmonary ligament is destroyed. Then the intercostal space is determined, the most convenient for manipulations on the root of the lobe, and a mini-thoracotomy 4-5 cm long is performed along it, through which standard surgical instruments are passed - scissors, a pulmonary clamp and dissectors. The intersection of vessels is carried out using the UDO-38 apparatus, with mandatory additional ligation of the central stump of the vessel. The bronchus is carefully isolated from the surrounding tissue and lymph nodes, then sutured with a UDO-38 device and transected. The proximal end of the bronchus is additionally sutured with an enveloping suture with an atraumatic thread. The separation of interlobar fissures is carried out by electrocoagulation or, if they are poorly expressed, by a UDO stapler. Be sure to control hemostasis and aerostasis and complete the operation by draining the pleural cavity with two drains.

The most difficult issue is the surgical treatment of spontaneous pneumothorax with widespread combined (bullous and diffuse) emphysema. Emphysematous lung tissue is extremely easily damaged during any surgical procedure. When it is captured with atraumatic clamps and sutures are applied, more and more new sources of massive air release arise. In addition, a lung that does not collapse when turned off from ventilation creates great difficulties when performing thoracoscopy.

When performing operations for spontaneous pneumothorax in patients with widespread combined emphysema, the following operating principles should be observed.

1. It is preferable to perform anatomical resection of the lung - lobectomy. As a rule, atypical resection in these patients in the postoperative period is complicated by significant and prolonged air discharge and, accordingly, the risk of developing pleural empyema increases.

2. Even if there is an obvious source of air entry, the operation to eliminate it should be supplemented with thoracoscopic pleurectomy. Emphysematous lung tissue is not only easily damaged during surgical manipulations, but also has a tendency to spontaneous rupture during coughing or active aspiration.

3. Attempts to simply suturing a rupture of emphysematous pulmonary tissue are, as a rule, futile, since each suture becomes a new and very strong source of air entry. In this regard, preference should be given to modern stitching machines that use cassettes with gaskets - for example, Duet TRS, or sutures using gaskets. Both synthetic materials, for example, Gore-Tex, and free flaps of biological tissue, for example, a pleural flap, can be used as a gasket. Good results are obtained by strengthening the seam with an application of Tahocomb plate or BioGlue glue.

When applying sutures to emphysematous lung tissue, the following technique can be used: the edges of the rupture of the lung tissue are treated using an argon plasma coagulator, and a sufficiently strong coagulation scab is formed through which the sutures are applied. Good results are obtained by the method of seamless resection of emphysematous lung tissue using the LigaSure device.

Thus, surgical treatment of spontaneous pneumothorax is a complex and multifaceted problem. Often, experienced surgeons call spontaneous pneumothorax “thoracic appendicitis,” implying that this is the simplest operation performed for lung diseases. This definition is doubly true - just as appendectomy can be both the simplest and one of the most complex operations in abdominal surgery, a banal pneumothorax can create difficult problems to overcome during a seemingly simple operation.

The described surgical tactics, based on an analysis of the results of a number of leading thoracic surgery clinics and extensive collective experience in performing operations, both in very simple and in very complex cases of pneumothorax, make it possible to make thoracoscopic surgery simple and reliable, and to significantly reduce the number of complications and relapses.

LITERATURE.

1. Ahmed of small approaches in the correction of spontaneous pneumothorax // Diss... Cand.-M., 2000.-102 p.

2. Perelman problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16.

3. Yasnogorodsky intrathoracic interventions // Diss... doc., M., 200 p.

4. Almind M., Lange P., Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis // Thorax.- 1989.- Vol. 44.- No. 8.- P.

5. Boutin C., Viallat J., Aelony Y. Practical thoracoscopy / New York, Berlin, Heidelberg: Springer-Verlag. - 199p.

6. British Thoracic Society Pleural Disease Guideline 2010 //Thorax.- 2010.- vol. 65, Aug.- suppl. 2.- ii 18 – ii 31.

7. Kocaturk C., Gunluoglu M., Dicer I., Bedirahan M. Pleurodesis versus pleurectomy in case of primary spontaneous pneumothorax // Turkish J. of Thoracic and Cardiovasc. Surg.- 2011.- vol. 20, N 3.- P. 558-562.

8. Ikeda M. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax, with special reference to the operative indication considered from its contralateral occurrence rate // Nippon Kyobi Geka. Gakhai Zasshi.- 1985.- V.14.- No. 3.- P.

9. Up Huh, Yeong-Dae Kim, Yeong Su Cho et al. The effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion // Korean J. of Thoracic and Cardiovasc. Surg.- 2012.- vol. 45, N 5.- P. 316-319.

The term “spontaneous pneumothorax” (SP) (as opposed to the term “traumatic pneumothorax”) was first proposed by A. Hard in 1803. SP is diagnosed in 5-7 people per 100 thousand population per year. Patients with SP make up 12% of all hospitalized patients with acute diseases of the chest organs. Non-traumatic SP can occur due to various diseases, as well as during medical manipulations (iatrogenic pneumothorax (IP)) (Tables 1, 2). Mortality in severe clinical forms of pneumothorax reaches from 1.3 to 10.4%.

The goals of treatment for SP are resolution of pneumothorax (expansion of the lung) and prevention of recurrent pneumothorax (prevention of relapse). Naturally, the tactics for achieving these goals depend on the cause of pneumothorax, its volume and the general condition of the patient. Possible methods of treating pneumothorax (due to the actual evacuation of air from the pleural cavity) include:
- puncture of the pleural cavity with air aspiration;
- drainage of the pleural cavity according to Bulau;
- drainage of the pleural cavity with active aspiration.
Additional administration of drugs for medicinal pleurodesis is aimed at preventing relapse.
Open operations and video-assisted interventions are used for suturing large defects of lung tissue, resection of bullous areas of the lung, single large bullae, etc. In this case, additional mechanical, thermal, and chemical pleurodesis is possible. The effectiveness of pleurodesis performed during surgical interventions is superior to the effectiveness of pleurodesis performed during drainage of the pleural cavity.

The incidence of complications after traditional thoracotomy for SP can reach 10.4-20%, and mortality - 2.3-4.3%, which is associated with the development of complications in the postoperative period, such as pleural empyema, postoperative pneumonia, thromboembolism of the branches of the pulmonary artery .

In recent years, in specialized hospitals for SP, predominantly video-assisted operations have been performed, and among all thoracoscopic operations, video-assisted thoracoscopy (VTS) for SP accounts for about 45%. In many centers, video-assisted thoracoscopy is the primary surgical treatment for pneumothorax. The advantages of the method compared to open thoracotomy are obvious: reduction in operation and drainage time, reduction in the number of postoperative complications, less severe pain in the postoperative period, reduction in the total number of bed days. According to a multicenter study, the rate of recurrence of pneumothorax after VAT is 4%. Other authors note an even lower rate of relapse of SP after VTS treatment - 1.3%, and there are no complications inherent in standard thoracotomy. The incidence of PU development: with transthoracic fine-needle biopsy - 15-37%, on average - 10%; during catheterization of central veins - 1-10%; with thoracentesis - 5-20%; with pleural biopsy - 10%; with transbronchial lung biopsy - 1-2%; during artificial ventilation - 5-15%.

Materials and methods
From 1970 to 2013, 882 patients were treated for pneumothorax in the department of thoracic surgery of City Clinical Hospital No. 61 (in 1970-1986 - 144 people, in 1987-1995 - 174, in 1996-2013 - 564) . Until 1987, the only method of treating pneumothorax accepted in the clinic was drainage of the pleural cavity with active aspiration. For active aspiration, various devices were used: from “OP-1” to the more modern “Elema-N PRO 1” and “Medela”.

Since 1987, in addition to drainage of the pleural cavity, drug pleurodesis began to be used. To carry it out, tetracycline (20 mg per 1 kg of patient’s body weight), morphocycline 0.3 g (daily dose), and more recently doxycycline (20 mg per 1 kg of patient’s body weight) were used. Medicinal pleurodesis was performed in both surgical and conservative treatment of pneumothorax. During surgical treatment, 0.8 g (maximum daily dose) of a solution of doxycycline in 50 ml of 0.9% NaCl was injected into the pleural cavity. In total, from 1987 to 2013, 250 medicinal pleurodeses were performed during the conservative treatment of pneumothorax. During the period from 1987 to 1995, only 2 operations were performed - atypical lung resections using the UDO, UO, and US staplers. The approach used during the operations was lateral thoracotomy. With the introduction of video endoscopic technologies (since 1996), surgical activity in the treatment of pneumothorax was 28.5%; over the past 3 years, this figure has increased to 61.7% with the development of pneumothorax in patients with bullous pulmonary disease. From 1996 to 2013, a total of 170 operations for pneumothorax were performed.

Endostaplers are used for VTS of atypical resection of bullous areas of lung tissue. In video-assisted operations from a mini-access, the most commonly used staplers are UDO-20 and UDO-30. Thermal surgical instruments were used for coagulation of bullous-fibrotic areas of the lungs and, to a greater extent, for coagulation of subpleural vesicles and thermal pleurodesis.
The operation of choice is VTS with atypical lung resection, coagulation of bullae with thermal surgical instruments, thermal pleurodestruction of the parietal pleura with the same instruments and medicinal pleurodesis with doxycycline solution.

Results and discussion
140 VTS operations were performed: 114 VTS + atypical lung resection (81.4%), 26 VTS + coagulation of bullae and/or depleurized areas of the lung (18.5%). Coagulation of bullae and blebs with a plasma flow has become the most effective. 36 patients underwent atypical lung resection from a mini-thoracotomy approach with video assistance and the use of UDO staplers. Traditional thoracotomy was used 8 times to perform atypical lung resection.

In recent years (2003-2013), 165 patients with JP were observed in the thoracic department of City Clinical Hospital No. 61, 94 patients were transferred from Moscow hospitals and 71 from other departments of the hospital. The main causes of PU were: catheterization of the central (mainly subclavian) vein and pleural puncture for hydrothorax of various origins, less often - barotrauma during artificial ventilation of the lungs, and even less often - during transthoracic or transbronchial puncture biopsy of the lung. The main reason for transfer to the department from other hospitals was recurrence of pneumothorax after short-term drainage of the pleural cavity: the drainage was removed on the first day (or immediately) after expansion of the lung, which required repeated (often multiple) drainage of the pleural cavity. Early removal of the drainage was explained by the fear of infection of the pleural cavity and the development of associated complications - pleural empyema.

Relapses during the treatment of SP using drainage and puncture of the pleural cavity were observed in 21.5% of cases; with drainage followed by medicinal pleurodesis - in 5.5%. There were no early relapses (after drainage without pleurodesis, recurrent pneumothorax developed in 4.9% of cases in the next 10 days after discharge). The only complication of drainage of the pleural cavity is subcutaneous emphysema. There were no complications associated with medicinal pleurodesis.

In accordance with national clinical guidelines for the diagnosis and treatment of SP, expectant management is acceptable if the volume of spontaneous limited apical pneumothorax is less than 15% in patients with no dyspnea. If such patients have bullous disease and there are no contraindications, relapse prevention will involve surgical treatment to the extent of resection of bullous areas of lung tissue. When the volume of pneumothorax is up to 30% in patients without severe dyspnea, a single pleural puncture with air aspiration can be performed. Prevention of relapse is achieved in the same way as in the previous case.
Drainage of the pleural cavity is indicated when the volume of pneumothorax is more than 30%, recurrent pneumothorax, ineffective puncture, in patients with dyspnea and patients over 50 years of age. Key points of correct placement of drainage: mandatory polypositional x-ray examination before drainage and monitoring the position of the drainage with its correction as necessary after manipulation.
However, the results of treatment of SP exclusively with punctures and drainage of the pleural cavity in patients with bullous disease cannot be considered satisfactory: recurrence of pneumothorax is observed in 20-45% of cases when treated with pleural punctures, in 12-18% after closed drainage of the pleural cavity. In this regard, at present, in the absence of contraindications to VTS, operations with marginal resection and thermal destruction of bullous areas of the lung are performed in all patients with bullous lung disease.
The operation is completed with medicinal pleurodesis with solutions of tetracycline antibiotics in order to obliterate the pleural cavity, which serves as the prevention of pneumothorax even if the bulla ruptures (Fig. 1-4).

UP, unlike SP, develops against the background of healthy lung tissue or changes in the lung parenchyma that are insufficient for spontaneous rupture of the lung, so UP is an indication only for conservative treatment. In this case, it is important that active aspiration continues until the lung is completely expanded, and for at least 5-7 days after expansion, until an adhesive process develops in the pleural cavity. When the lung is expanded, there is no danger of infection of the pleural cavity and the development of pleural empyema, since there is no actual cavity in the pleura.

Literature
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2. Rabedzhanov M.M. The role of videothoracoscopy in the diagnosis and choice of treatment for spontaneous pneumothorax: Abstract of thesis. ...cand. honey. Sci. M., 2007. 25 p.
3. Noppen M., Schramel F. Pneumothorax // Eur Respir Mon. 2002. Vol. 22. R. 279-296.
4. Schramel F.M., Postmus P.E., Vanderschueren R.G. Current aspects of spontaneous pneumothorax // Eur Resp J. 1997. Vol. 10. R. 1372-1379.
5. Mospanova E.V. Medicinal pleurodesis in the treatment of spontaneous pneumothorax and hydrothorax: Dis. ...cand. honey. Sci. M., 1993. 106 p.
6. Mansfield P.F., Hohn D.C., Fornage B.D. et al. Complications and failures of subclavian vein catheterization // N Eng J Med. 1994. Vol. 331. R. 1735-1738.
7. Grogan D.R., Irwin R.S., Channick R. et al. Complications associated with thoracocentesis. A prospective, randomized study comparing three different methods // Arch Intern Med. 1990. Vol. 150. R. 873-877.
8. Blasco L.H., Hernandez I.M.S., Garrido V.V. et al. Safety of transbronchial biopsy in outpatients // Chest. 1991. Vol. 99. R. 562-565.
9. Poe R.H. Sensitivity, specificity, and predictive values ​​of closed pleural biopsy // Arch Intern Med. 1984. Vol. 144. R. 325-328.
10. Gammon R.B., Shin M.S., Buchalter S.E. Pulmonary barotrauma in mechanical ventilation. Patterns and risk factors // Chest.1992. Vol. 102. R. 568-572.
11. Light R.W., O’Hara V.S., Moritz T.E. et al. Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax: results of a Department of Veterans Affairs Cooperative Study // JAMA. 1990. Vol. 264. R. 2224-2230.

■ During VSP p a O 2< 55 мм рт.ст. и pa CO 2 >50 mmHg observed in 15% of patients.

■ ECG changes are usually detected only with tension pneumothorax: deviation of the electrical axis of the heart to the right or left depending on the location of the pneumothorax, a decrease in voltage, flattening and inversion of T waves in leads V1–V3.

X-ray of the chest organs

To confirm the diagnosis, it is necessary to conduct a chest x-ray (the optimal projection is anteroposterior, with the patient in an upright position).

Radiographic sign of pneumothorax - visualization of a thin line of visceral pleura (less than 1 mm), separated from the chest (Fig. 1).

Pneumothorax

Res. 1. Secondary spontaneous pneumothorax on the right in a patient with Pneumocystis pneumonia.

■ A common finding in pneumothorax is displacement of the mediastinal shadow to the opposite side. Since the mediastinum is not a fixed structure, even a small pneumothorax can lead to displacement of the heart, trachea and other elements of the mediastinum, so contralateral shift of the mediastinum is neither a sign of severe pneumothorax nor a sign of tension pneumothorax.

■ About 10–20% of pneumothoraxes are accompanied by the appearance of a small pleural effusion (within the sinus), and in the absence of expansion of the pneumothorax, the amount of fluid may increase.

■ In the absence of signs of pneumothorax according to the radiograph in the anteroposterior projection, but in the presence of clinical data in favor of pneumothorax, radiographs in the lateral position or lateral position on the side are indicated ( decubitus lateralis), which allows confirming the diagnosis in an additional 14% of cases.

■ Some guidelines recommend that in difficult cases, radiography be performed not only at the height of inspiration, but also at the end of expiration. However, as recent studies have shown, expiratory films have no advantages over conventional inspiratory films. Moreover, vigorous exhalation can significantly aggravate the condition of a patient with pneumothorax and even lead to asphyxia, especially with tension and bilateral pneumothorax. That's whyX-ray at expiratory height is not recommended for the diagnosis of pneumothorax.

Radiological sign of pneumothorax in a patient in a horizontal position (usually during mechanical ventilation) - a sign of a deep sulcus (deep sulcus sigh) - deepeningcostophrenicangle, which is especially noticeable when compared with the opposite side (Fig. 2).

■ For diagnosing small pneumothoraxes, CT is a more reliable method compared to radiography. The sensitivity of CT in detecting pneumothorax after transthoracic lung biopsy is 1.6 times higher.

■ For the differential diagnosis of large emphysematous bullae and pneumothorax, the most sensitive method is CT WITH .

■ CT is indicated to determine the cause of secondary spontaneous pneumothorax (bullous emphysema, cysts, ILD, etc.) D.

Determining the size of pneumothorax

The size of pneumothorax is one of the most important parameters determining the choice of treatment tactics. The widest application

Pneumothorax

Res. 2. Pneumothorax in a patient during mechanical ventilation: sign of deep sulcus sigh, white arrows.

Pneumothorax

knowledge was obtained by the Light formula, based on the position that the volume of the lung and the volume of the hemithorax are proportional to the size of their diameters raised to the third power. The size of pneumothorax using the Light formula is calculated as follows:

Volume of pneumothorax (%) = (1 - DL 3 / DH 3 ) × 100,

where DL is the diameter of the lung, DH is the diameter of the hemithorax on a chest x-ray (Fig. 3).

In patients with PSP, the correlation between the calculated data and the volume of air obtained by simple aspiration is r = 0.84 (p< 0,0001), т.е. метод может быть рекомендован для широкого использования в клинической практике. Пример расчёта объёма пневмоторакса по предложенной формуле представлен на рис. 4.

Res. 3. Determination of time	Res. 4. Example of calculating the volume of pneumothorax
measure of pneumothorax.	according to the Light formula.
Some agreement documents propose even more
a simple approach to determining the volume of pneumothorax; for example, in
In the British Thoracic Society manual, pneumothoraxes are divided into
divided into small and large with a distance between the lung and chest
wall< 2 см и >2 cm respectively.
Recurrent pneumothorax
■ Relapses, e.g. development of repeated pneumothorax after re-
recurrent primary pneumothorax, are one of the important
nary aspects of patient management. Relapses, as a rule, are not
degrade the course of traumatic and iatrogenic pneumothorax.
According to an analysis of literature data, the relapse rate
1–10 years after the experience, PSP ranges from 16 to
	Pneumothorax

52%, averaging 30%. The majority of relapses occur in the first 0.5–2 years after the 1st episode of pneumothorax.

■ After recurrent pneumothorax, the likelihood of subsequent recurrences increases progressively: 62% after the 2nd episode and 83% after the 3rd pneumothorax.

■ In one of the largest studies, which included 229 patients with VSP, the relapse rate was 43%.

■ The main risk factors for the development of relapses in patients with spontaneous pneumothorax (both with PSP and SSP) are the presence of pulmonary fibrosis, age over 60 years, high stature and low nutritional status of patients. The presence of subpleural bullae is not a risk factor for relapse.

Differential diagnosis

■ Pneumonia ■ Pulmonary embolism

■ Viral pleurisy ■ Acute pericarditis

■ Acute coronary syndrome ■ Rib fracture

■ Treatment goals: resolution of pneumothorax and prevention of repeated pneumothorax (relapses).

■ Indications for hospitalization. Hospitalization is indicated for all patients with pneumothorax.

■ Treatment tactics. Currently, there are two known consensus documents on the diagnosis and treatment of patients with spontaneous pneumothorax - the British Thoracic Society manual (2003) and the American College of Chest Physicians manual (2001). Despite some differences in approaches to patient management tactics, these guidelines suggest similar stages of patient treatment: observation and oxygen therapy simple aspiration installation of a drainage tube chemical spitting

	rhodesis surgical treatment.
	Observation and oxygen therapy
	■ Limit yourself to observation only (i.e., without performing the procedure
Pneumothorax	A small volume memory bandwidth (less than 15% or at a distance between
	mithorax within 24 hours. Thus, for complete
	lungs and chest wall less than 2 cm, in patients without protrusion
	associated dyspnea), with VSP (at a distance between the lung and
	chest wall less than 1 cm or with an isolated apex
	nom pneumothorax, in patients without severe dyspnea)C. Sco-
	the rate of resolution of pneumothorax is 1.25% of the volume of the

A 15% pneumothorax will require approximately 8–12 days to resolve.

■ All patients, even with a normal arterial blood gas composition, are prescribed oxygen (10 l/min through a mask, but a positive effect is also observed when oxygen is administered through cannulas), since oxygen therapy can accelerate the resolution of pneumothorax in 4–6 timesC. The administration of oxygen is absolutely indicated for patients with hypoxemia, which can occur with tension pneumothorax even in patients without underlying pulmonary pathology. In patients with COPD and other chronic lung diseases, blood gas monitoring is necessary when prescribing oxygen, as hypercapnia may increase.

■ For severe pain syndrome, it is prescribed analgesics, including narcotics; If pain is not controlled with narcotic analgesics, an epidural or intercostal blockade may be performed D.

Simple aspiration

■ Simple aspiration (pleural puncture with aspi-
walkie-talkies) are indicated for patients with PSP with a volume of more than 15%; pain-
nym with VSP (at a distance between the lung and the chest wall
less than 2 cm, without severe dyspnea, younger than 50 years) B.
■ Simple aspiration is carried out using a needle or, preferably,
more precisely, catheters that are inserted into the 2nd intercostal space in the middle
nonclavicular line; aspiration is carried out using a large
th syringe (50 ml); after the air evacuation of the needle is completed
After completing aspiration, leave the catheter in place for 4 hours.
■ If the first attempt at aspiration fails (complaints persist
patient) and evacuation less than 2.5 l repeated attempts to aspirate
tions can be successful in a third of casesB.
■ If after aspiration of 4 liters of air there is no increase in
resistance in the system, then presumably there is persistent
tendency of pathological communication, such a patient is indicated
installation of drainage tubeC.	Pneumothorax
after 7 days - 93 and 85%, and the number of relapses during the year -
■ Simple aspiration leads to expansion of the lung into 59–83%
with PSP and 33–67% with VSP. According to one of the recent
of randomized trials that included patients with
new PSP, immediate success with simple aspiration
tion and drainage of the pleural cavity were 59 and 64%,

26 and 27%. However, despite the similar effectiveness of the two methods, simple aspiration had important advantages: the procedure is less painful and can be performed in non-specialized departments (reception room, therapy department, etc.).

Drainage of the pleural cavity

	■ Drainage of the pleural cavity using drainage pipes -
	ki is indicated: if simple aspiration fails in patients with PSP;
	with relapse of PSP; with VSP (at a distance between the lung and
	chest wall more than 2 cm, in patients with dyspnea and older
	50 years old)B .
	■ Selecting the correct drainage tube size is very important.
	value (tube diameter and, to a lesser extent, its length
	determine the flow rate through the tube). Patients with PSP re-
	It is recommended to install small diameter tubes 10–14 FC
	(1 French - F = 1/3 mm). Stable patients with VSP who
	tubes with a diameter of 16–22 F. Patients with pneumothorax, developing
	during mechanical ventilation, who have a very high risk of developing
	bronchopleural fistula or tension formation
	(28-36 F). Patients with traumatic pneumothorax (due to
	large diameter tubes (28–36 F).
	■ Placement of a drainage tube is a more painful procedure
	compared with pleural puncturesC and is associated (very rarely)
	ko!) with complications such as penetration into the lungs, heart,
	stomach, large vessels, pleural cavity infections.
	When installing a drainage tube, it is necessary to carry out
	intrapleural injection of local anesthetics (1% lidocaine
	20–25 ml)B .
	■ Drainage of the pleural cavity leads to expansion of the lung
	■ Do not use suction (a source of negative pressure)
	mandatory when performing drainage of the pleural strip -
Pneumothorax	tee. Currently, the most accepted technique is to add
	up to – 20 cm water column B .
	connection of the drainage tube to the “water lock” (data on the
	There is no advantage of the Heimlich valve over the “water lock”.
	the leakage flow persists for more than 48 hours after drainage installation
	no tubeB. The optimal pressure level is -10

■ Early use of suction after chest tube placement (especially in patients with PSP that occurred several days ago) may lead to the development of reexpansion ( ex vacuo) pulmonary edema. Clinically, reexpansion pulmonary edema is manifested by coughing and increased shortness of breath or the appearance of chest congestion after insertion of a drainage tube. On a chest x-ray, signs of edema may be visible not only in the affected lung, but also on the opposite side. The prevalence of reexpansion pulmonary edema when using suction can reach 14%, and its risk is significantly higher with the development of pneumothorax for more than 3 days, complete collapse of the lungs, and young patients (less than 30 years).

■ When air bubbles are released, clamping (squeezing) the drainage tube is unacceptable, since such an action can lead to the development of tension pneumothorax WITH . There is no consensus on the need to clamp the tube when air loss stops. Opponents of the method fear the development of repeated pulmonary collapse, and supporters talk about the possibility of detecting a small “leak” of air, which the “air lock” cannot detect.

■ The drainage tube is removed 24 hours after air has stopped flowing through it, if (according to a chest x-ray) expansion of the lung has been achieved.

Chemical pleurodesis

■ One of the leading tasks in the treatment of pneumothorax is to prevent
rotation of repeated pneumothoraxes (relapses), but no
flock aspiration, nor drainage of the pleural cavity is
help reduce the number of relapses.
■ Chemical pleurodesis is a procedure in which
the pleural cavity is injected with substances leading to aseptic
to whom inflammation and adhesion of the visceral and parietal leaves -
pleura, which leads to obliteration of the pleural cavity.
■ Chemical pleurodesis is indicated for: patients with first and subsequent
mi VSP and patients with the second and subsequent PSP, since	Pneumothorax
no intrapleural anesthesia - at least 25 ml of 1% solution
helps prevent recurrence of pneumothorax.
■ Chemical pleurodesis is usually performed by insertion through
doxycycline drainage tube (500 mg in 50 ml saline)
solution) or a suspension of talc (5 g in 50 ml of physiological
solution). Before the procedure, it is necessary to carry out adequate

ra lidocaineS. After administration of the sclerosing agent, the drainage tube is closed for 1 hour.

The number of relapses after the introduction of tetracycline is 9–25%, and after the introduction of talc - 8%. Complications that can occur when talc is administered into the pleural cavity - acute respiratory distress syndrome (ARDS), empyema, acute respiratory failure - cause some concern. The development of ARDS may be associated with a high dose of talc (more than 5 g), as well as with the size of the talc particles (smaller particles undergo absorption with the subsequent development of a systemic inflammatory response); It is characteristic that cases of ARDS after the administration of talc have been reported mainly in the USA, where the particle size of natural talc is much smaller than in Europe.

Surgical treatment of pneumothorax

	Objectives of surgical treatment of pneumothorax: resection of bullae
	and subpleural vesicles (blebs), suturing of pulmonary defects
	of tissue, performing pleurodesis.
	Indications for surgical intervention:
	lack of expansion of the lung after drainage
	for 5–7 days;
	bilateral spontaneous pneumothorax;
	contralateral pneumothorax;
	spontaneous hemopneumothorax;
	recurrence of pneumothorax after chemical spewing
	pneumothorax in people of certain professions (associated with
	flying, diving).
	All surgical interventions can be divided into two:
	type: video-assisted thoracoscopy (VAT) and open to-
	Racotomy. In many centers, VAT is the main surgical
	method of treating pneumothorax, which is associated with advantages
	method (compared to open thoracotomy): reduction in time
	time of operation and drainage time, reduction in the number of post-
	surgical complicationsB and the need for analgesicsB, reduced
Pneumothorax	change in the time of hospitalization of patients, less pronounced
	time of drainage of the pleural cavity (Table 2).
	gas exchange disorders. Number of recurrent pneumothoraxes after
	VAT is 4%, which is comparable to the number of relapses after usual
	thoracotomy - 1.5%. In general, the effectiveness of pleurodesis
	performed during surgical interventions, excellent
	dits the effectiveness of chemical pleurodesis performed in

Table 2. Anti-relapse effectiveness of therapy

Urgent events

For tension pneumothorax it is indicated immediate tracocentesis(using a needle or cannula for venipuncture no shorter than 4.5 cm, in the 2nd intercostal space along the midclavicular line), even if it is impossible to confirm the diagnosis using radiography.

Patient education

■ After discharge from the hospital, the patient should avoid physical activity for a period of time. 2–4 weeks and air travel for 2–4 weeks.

■ The patient should be advised to avoid changes in barometric pressure (parachuting, diving).

■ The patient should be advised to quit smoking.

Indications for consultation with specialists

■ If there are difficulties in interpreting chest x-ray data, consultation with a specialist in x-ray methods is indicated.

■ Consultation with a pulmonologist (or intensive care specialist) and a thoracic surgeon is necessary: ​​when performing invasive procedures (installation of a drainage tube), determining indications for pleurodesis, additional measures (thoracoscopy, etc.).

Further management

■ Once the pneumothorax resolves, a chest x-ray is recommended.

■ Consultation with a pulmonologist via 7–10 days after discharge from the hospital.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other spontaneous pneumothorax (J93.1), Spontaneous tension pneumothorax (J93.0)

Thoracic surgery

General information

Brief description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Spontaneous pneumothorax is a pathological condition characterized by the accumulation of air between the visceral and parietal pleura, not associated with mechanical damage to the lung or chest as a result of injury or medical manipulation, infectious or tumor destruction of lung tissue. .

I. INTRODUCTORY PART

Protocol name: Spontaneous pneumothorax
Protocol code:

ICD-10 code:
J 93 spontaneous pneumothorax
J 93.0 spontaneous tension pneumothorax
J 93.1 other spontaneous pneumothorax

Abbreviations used in the protocol:
BPD - bullous lung disease
BEL - bullous pulmonary emphysema
IHD - coronary pulmonary disease
CT - computed tomography
SP - spontaneous pneumothorax,
CFG OGK - digital fluorography of the chest organs,
ECG - electrocardiogram,
VATS - video-assisted thoracoscopic surgery

Date of development of the protocol: 2013
Patient category: adult patients with pneumothorax
Protocol users: Thoracic surgeons, pulmonologists, therapists, cardiologists, phthisiatricians and oncologists in hospitals and outpatient clinics.

Note: This protocol uses the following classes of recommendations and levels of evidence:

Level of evidence		Description
1++		High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias.
1+		Well-performed meta-analyses, systematic reviews of RCTs, or RCTs with low risk of bias.
1?		Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias.
2++		High-quality systematic reviews, case-control or cohort studies, or high-quality case studies control or cohort studies with a very low risk of data bias or chance and a high probability that the association is causal y.
2+		Well-performed case-control or cohort studies with low risk of bias data, or chance, and the average probability that the relationship is causal.
2?		Case-control or high-risk cohort studies bias, data error or chance and significant risk m that the connection is not causal.
3		Non-analytical studies such as case reports and case series.
4		Expert opinion.
Level of recommendation
A	At least 1 meta-analysis, systematic review, or RCT classified as 1++ and directly applicable to the target population; or systematic review, RCT, or body of evidence consisting primarily of studies classified as 1+ directly applicable to the target group ne population and demonstrating overall homogeneity of results.
B	Body of evidence, including research classified as 2++ directly applicable to the target population and demonstrating overall homogeneity of results or extrapolation Evidence from studies classified as 1++ or 1+.
C	Body of evidence, including research studies classified as 2+ directly applicable to the target population and demonstrating overall homogeneity of results or extra polished evidence from studies classified as 2++.
D	Level of evidence 3 or 4 or extrapolated evidence from studies classified as 2+.

Classification

Clinical classification:
- Primary (idiopathic) pneumothorax
- Secondary (symptomatic) pneumothorax
- Catamenial (menstrual) pneumothorax

Primary (idiopathic) pneumothorax persists in the ratio of 5:100 thousand people: among men 7.4:100 thousand, among women 1.2:100 thousand of the population, it occurs most often in people of working age from 20-40 years.
Secondary (symptomatic) pneumothorax is: among men 6.3:100 thousand, among women 2.0:100 thousand of the population, covers a wider age range and is often one of the manifestations of pulmonary tuberculosis.
Catamenial (Menstrual) pneumothorax is a rare form of pneumothorax that occurs in women. More than 230 cases of catamenial pneumothorax have been described worldwide.

Depending on the type of pneumothorax, there are :
- Open pneumothorax.
- Closed pneumothorax.
- Tension (valve) pneumothorax.

With an open pneumothorax, there is a connection between the pleural cavity and the lumen of the bronchus and, therefore, with atmospheric air. On inhalation, air enters the pleural cavity, and on exhalation it leaves it through a defect in the visceral pleura. In this case, the lung collapses and is switched off from breathing (lung collapse).
With a closed pneumothorax, air that has entered the pleural cavity and caused partial and complete collapse of the lung subsequently loses contact with atmospheric air and does not cause a threatening condition.
With valve pneumothorax, air freely enters the pleural cavity during inspiration, but its exit is difficult due to the presence of a valve mechanism.
According to their prevalence, they are divided into: total and partial pneumothorax.
Depending on the presence of complications: uncomplicated and complicated (bleeding, pleurisy, mediastinal emphysema).

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic:
1. History taking
2. Inspection, auscultation and percussion of the chest
3. General blood test
4. General urine test
5. Biochemical blood tests
6. Blood for blood type and Rh factor
7. Blood coagulogram
8. Microreaction
9. Blood test for hepatitis and HIV
10. Feces on worm eggs
11. ECG
12. Radiography in two projections

Additional:
1. Computed tomography of the chest organs in spiral mode
2. Fiberoptic bronchoscopy
3. Consultations with specialists (according to indications)

Diagnostic tactics at the outpatient (prehospital) stage:
- If sudden (spontaneous) pain appears in the chest and suspicion of SP occurs, a chest X-ray (in anterior and lateral projections) is indicated.
- If it is impossible to carry out radiography, it is necessary to send the patient to a surgical hospital.

Diagnostic tactics in a general surgical hospital.
The main goal of diagnostics in a surgical hospital is to establish an accurate diagnosis and determine therapeutic and surgical tactics.
- X-ray of the chest organs in frontal and lateral projections during exhalation (direct view, lateral projection on the side of pneumothorax);
- CT scan of the chest in a spiral mode (additionally, according to indications);
It is recommended to use computed tomography in the differential diagnosis of pneumothorax and bullous emphysema, if improper placement of drainage is suspected, and in cases where the interpretation of a chest radiograph is difficult due to the presence of subcutaneous emphysema (level C).

Diagnostic tactics in the thoracic department.
To determine the cause of spontaneous pneumothorax, it is recommended to perform a CT examination of the thoracic segment and, based on its results, make a decision on planned surgical treatment.

Diagnostic criteria
SP in most cases occurs at a young age and is characterized by a relapsing course.
The reasons for SP may be:
1. Pulmonary emphysema, most often bullous (71-95%)
2. COPD
3. Cystic fibrosis
4. Bronchial asthma
5. Rheumatoid arthritis
6. Ankylosing spondylitis
7. Dermatomyositis
8. Systemic scleroderma
9. Marfan syndrome
10. Ehlers-Danlos syndrome
11. Idiopathic pulmonary fibrosis
12. Sarcoidosis
13. Histiocytosis X
14. Lymphangioleiomyomatosis
15. Pulmonary endometriosis

Complaints and anamnesis:
In the classic version, the joint venture begins with the appearance of:
- sudden pain in the chest,
- non-productive cough,
- shortness of breath.
In 15 - 21% of cases, pneumothorax is asymptomatic or with a blurred clinical picture without characteristic complaints of respiratory failure. .

Physical examination:
The main signs of pneumothorax during an objective examination of the patient are:
- forced position, pale skin, cold sweat and/or cyanosis
- expansion of the intercostal spaces, lag in breathing of the affected half of the chest, swelling and pulsation of the neck veins, subcutaneous emphysema is possible.
- upon percussion, weakening or absence of vocal tremor on the affected side, tympanic sound (with the accumulation of fluid in the pleural cavity in the lower parts, dullness is determined), displacement of the area of ​​the apical impulse and the boundaries of cardiac dullness to the healthy side.
- weakening of breathing upon auscultation
In the process of diagnosis and selection of treatment tactics, complicated forms of spontaneous pneumothorax require a special approach:
- tension pneumothorax
- hemothorax, ongoing intrapleural bleeding
- bilateral pneumothorax
- pneumomediastinum.

Laboratory research: not informative

Instrumental studies:
- X-ray of the chest organs in frontal and lateral projections on exhalation (direct view, lateral projection on the side of pneumothorax): a collapsed lung is determined, the presence of free air; :
- ECG (for the purpose of differential diagnosis with ischemic heart disease);
- CT scan of the chest in a spiral mode: CT picture of pneumothorax, bullous changes. :

Indications for consultation with specialists:
Specialists of a different profile - in the presence of corresponding concomitant pathology or in case of secondary and recurrent pneumothorax during planned hospitalization.
Anesthesiologist: to determine the type of anesthesia if surgical intervention is necessary, as well as to coordinate the tactics of managing the preoperative period.
Resuscitator: to determine the indications for treating a patient in an intensive care unit, to coordinate the tactics of managing a patient with SP.

Differential diagnosis

Differential diagnosis:

Nosologies	Characteristic syndromes or symptoms	Differentiation test
IHD	Acute pain behind the sternum, squeezing in nature, radiating to the left upper limb. There may be a history of angina or the presence of risk factors (smoking, hypertension, diabetes, obesity).	ECG - signs of ischemia (ST segment isoline, T wave inversion, left leg block)
Lower lobe pneumonia	Productive cough with fever, auscultation - bronchial breathing, crepitating wheezing, dullness on percussion.	X-ray - darkening in the lower parts of the lung on the affected side.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

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Treatment

Treatment goals: Complete expansion of the lung on the side of the pneumothorax.

Treatment tactics

Non-drug treatment
Diet: table No. 15, bed rest during hospitalization.

Drug treatment
Antibiotic therapy is not the main conservative treatment method. Its main purpose is preventive and for complicated forms of SP. The duration of therapy in the postoperative period depends on the characteristics of the clinical course. In complicated cases, it can be prolonged according to indications. The absence of symptoms of fever within 24 hours and normal white blood cell counts are criteria for stopping antibiotic therapy.

Other treatments

Surgical intervention

Treatment tactics at the outpatient (prehospital) stage
In case of tension pneumothorax, puncture or drainage is indicated on the side of the pneumothorax in the II intercostal space along the midclavicular line or along the lateral surface of the chest in the III-VII intercostal space for the purpose of decompression of the pleural cavity

Treatment tactics in a general surgical hospital
"Minor surgery" - Drainage of the pleural cavity: The pleural cavity should be drained with drainage with a diameter of at least 14 Fr -18 Fr with active aspiration with a vacuum of 20-40 cm of water. Art. or according to Bulau. (level B)
Active aspiration of the pleural cavity using vacuum aspirators (stationary and portable).

To decide on further management tactics, an examination by a thoracic surgeon is necessary.

N/B! SP with ongoing intrapleural bleeding, tension pneumothorax against the background of a drained pleural cavity is an indication for emergency or urgent surgery. After elimination of complications, pleural induction is required. Anti-relapse surgery is not recommended for patients with uncomplicated course of SP in a non-specialized surgical hospital.

Treatment tactics in the thoracic department
- when a patient is admitted to the thoracic department after an X-ray examination, if it is impossible to perform an urgent CT scan, a diagnostic thoracoscopy is performed. Depending on changes in the pleural cavity, the procedure can be completed by draining the pleural cavity or performing anti-relapse surgical treatment.
- if a patient with SP is transferred from another medical institution with an already drained pleural cavity, it is necessary to assess the adequacy of the drainage function. If the drainage is functioning adequately and diagnostic thoracoscopy has been performed in another medical institution, repeated drainage is not required, and the decision on the need for anti-relapse surgery is made based on the established cause of SP.
- if air flow through the drains continues for 72 hours, thoracoscopic surgery or video-assisted mini-thoracotomy is also indicated. The extent of surgery depends on the specific intraoperative finding.
- in case of relapse of SP, it is necessary to drain the pleural cavity, achieving expansion of the lung. Surgical treatment should be carried out in a delayed or planned manner.

N/B! Anti-relapse treatment is surgery in the chest cavity to identify and eliminate the cause of pneumothorax, as well as induce pleura in one way or another to prevent recurrence of pneumothorax.

After any method of treating spontaneous pneumothorax, conservative or surgical, relapses are possible.

N/B! If the patient refuses hospitalization, the patient and his relatives should be warned about the possible consequences. The situation must be documented by an appropriate entry in the medical record and medical history.

It is preferable to perform anti-relapse surgery in a low-traumatic manner using video-assisted thoracoscopic technology or video-assisted technology (VATS). (level C). If technical difficulties are expected during thoracoscopy, surgery from a thoracotomy or sternotomy approach is possible. .
For patients who need anti-relapse treatment, but have contraindications to surgical treatment, pleural induction and pleurodesis using chemical sclerosants introduced into the drainage or through a trocar are possible.

The purpose of surgical intervention for SP:
1. Inspection of the lung and pleural cavity with elimination of the source of air intake by:
- resection of bullae
- dressings of bullae
- suturing of broncho-pleural fistula
- coagulation bullae
- excision, suturing or stitching of other bullae that do not contain a defect
- pleurectomy
- pleurodesis
- economical resection of the lobe
Regardless of the presence or absence of bullous changes, a biopsy of the lung tissue is necessary.

N/B! The volume and method of surgical treatment is determined by the severity and nature of changes in the lung and pleural cavity, the presence of complications, the age and functional state of the patient. Surgical tactics may change intraoperatively.

Preventive measures: There is no special prevention of SP.

Further management
In the postoperative period, the pleural cavity is drained by one or more drainages, depending on the type and volume of surgery. Drains with a diameter of at least 12 Fr. In the early postoperative period, active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is indicated. Art. (level D).
To control the expansion of the lung, a dynamic X-ray examination is performed. The amount is determined by the thoracic surgeon according to indications individually for each patient.
The criteria for the possibility of removing pleural drainage are: complete expansion of the lung according to X-ray examination, no air flow through the drainage for 24 hours, and discharge through the pleural drainage of less than 150 ml/day.
Before removal of chest tubes, patients are advised to receive prophylactic antibiotic therapy.
Discharge in an uncomplicated postoperative period is possible after removal of the pleural drainage, with mandatory X-ray monitoring before discharge.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- complete expansion of the lung, determined radiographically;
- cessation of air flow through the pleural drainage for 24 hours.
Despite the mandatory implementation of all points of the protocol, there must be a personalized and individual approach to each patient based on the actual clinical situation.

Groups of drugs according to ATC used in treatment

Hospitalization

Indications for hospitalization
Emergency hospitalization with an x-ray confirmed diagnosis of SP.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. J. Rivas de Andres, MJimenez Lopez, L. Molins Lopez – Rodd, A. Perez Trullen, J. Torres Lanzase. Recommendations of the Spanish Society of Pulmonology and Thoracis Surgery (SEPAR). Guidelines for the diagnosis and treatment of spontaneous pneumothorax. Ach. Bronconeumol. 2008; 44(8): 437-448. 2. Avilova O.M., Getman V.G., Makarov A.V. Thoracoscopy in emergency thoracic surgery. Kyiv. “Healthy, I” 1986 - 128 p. 3. Akhmed D.Yu. Surgery of small accesses in the correction of spontaneous pneumothorax // Diss... Cand.-M., 2000.-102 p. 4. Bisenkov L.N. Thoracic surgery. Guide for doctors. St. Petersburg. "ELBI-SPB".2004-928s.ill. 5. Perelman M.I. Current problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16. 6. Katz D.S., Mas K.R., Groskin S.A. Secrets of radiology. Saint Petersburg. 2003 7. Kolos A.I., Rakishev G.B., Takabaev A.K. Current issues in thoracic surgery. Educational and methodological manual. Almaty “Alash” 2006.-147p. 8. Kuzin M.I., Adamyan A.A., Todua F.I. and others. The importance of computed tomography in thoracic surgery // Thoracic and cardiovascular surgery. – 2002. - No. 4. – pp. 49-54. 9. Pakhomov G.A., Khayamov R.Ya. Tactics of treatment of bullae, emphysema, complicated by spontaneous pneumothorax // Materials of the XIV International Congress on Pulmonology. – M., 2004. – P. 303. 10. Putov N.V., Fedoseev G.B. Guide to Pulmonology. – L., 1978. – 385 p. 11. Chukhrienko D.P., Danilenko M.V., Bondarenko V.A., Bely I.S. Spontaneous (pathological) pneumothorax. M. Medicine. 1973 - 296 pp. 12. Yasnogorodsky O.O. Video-assisted intrathoracic interventions // Diss...doct., M., 2000. - 182 p.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers:
Takabaev A.K. - Candidate of Medical Sciences, thoracic surgeon, Associate Professor of the Department of Surgical Diseases No. 2 of the FNPRiDO JSC "Astana Medical University".

Reviewers:
Turgunov E.M. - Doctor of Medical Sciences, professor, surgeon of the highest qualification category, head of the Department of Surgical Diseases No. 2 of the RSE at the Karaganda State Medical University of the Ministry of Health of the Republic of Kazakhstan, independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.

Disclosure of no conflict of interest: There is no conflict of interest.

Indication of the conditions for reviewing the protocol: The protocol is subject to revision once every 3 years, or when new proven data on the surgical treatment of pneumothorax becomes available.

Attached files

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