[History taking
1, predisposing factors: chronic obstructive pulmonary emphysema, subpleural herpes, caseous pneumonia, lung abscess, bronchopulmonary carcinoma and other lung parenchymal lesions breaking into the pleural cavity, when using continuous positive pressure artificial mechanical ventilation suction pressure is too high; there are also people with no obvious previous lung lesions.
2.Causes.
Most have no obvious causative factors.
Holding heavy objects and other forceful movements.
Laughter or violent coughing.
3, symptoms.
Chest pain.
Difficulty in breathing.
Coughing.
Cyanosis.
Vomiting, unconsciousness or shock.
[Physical examination].
1.Tracheal (and heart) displacement.
2.Thorax fullness.
3.Reduced respiratory movement.
4.Tactile fibrillation is diminished or absent.
5.Drum sound on percussion.
6.Reduced or absent breath sounds.
Auxiliary examination
1.Chest x-ray examination.
2.Pulmonary pressure measurement.
3.Thoracoscopy.
Diagnostic points
1.Medical history.
Before the occurrence of pneumothorax, there may be violent cough or forceful movements such as holding heavy objects, but most of them have no obvious cause.
The onset of pneumothorax is rapid, with sudden chest pain, shortness of breath and irritating cough.
If the onset is slow, the symptoms of chest pain and cough are not obvious, or even no conscious symptoms, which are only found during chest X-ray.
Tension pneumothorax can cause severe respiratory and circulatory dysfunction with cyanosis and deficiency, and in severe cases, unconsciousness and shock.
2. Physical signs.
The affected side of the chest is full and the respiratory movement is weakened.
The affected side has a drum sound on percussion.
Affected side fibrillation and respiratory sounds are diminished or disappeared.
The pneumothorax, mediastinum and heart are shifted to the healthy side in case of massive pneumothorax.
In the case of left-sided pneumothorax or mediastinal emphysema, there is Hamman’s sign on auscultation.
3.Device examination.
Chest X-ray examination: increased translucency at the pneumothorax site without lung texture. The lung tissue is compressed toward the hilum. At the edge of the atrophied lung, the dirty pleura shows a slender hairline shadow.
Thoracic pressure measurement: the type of pneumothorax can be identified.
Thoracoscopic examination: it can peep into the pleura for rupture, adhesion and suprapleural pulmonary blister.
[Differential diagnosis
1.Acute myocardial infarction.
2, pulmonary embolism.
3, obstructive emphysema and emphysematous pneumothorax.
Treatment principles
1, exhaust treatment: timely exhaustion, so that the lung early reopening. Lung atrophy greater than 20%, can be pumped once a day or every other day, each pumping to not more than 800ml is appropriate.
Ventilation methods are.
Simple venting method: In critical condition, without special equipment, a 100 ml syringe can be used to puncture the second intercostal space in the midclavicular line of the affected side. Or use a thick injection needle, tie a rubber finger sleeve on its tail, and cut a small mouth at the end of the finger sleeve, and insert it into the chest cavity to ventilate.
Artificial pneumothorax chest pumping: the intra-thoracic pressure can be measured first to determine the amount of pumping, generally pumping until the intrathoracic pressure to maintain negative pressure.
Water-sealed bottle closed drainage: mainly used for open pneumothorax and high-pressure pneumothorax. When the drainage tube is no longer exhausted and the lung is fully expanded, the drainage tube is clamped and can be removed after 1 day of observation without changes.
Negative pressure suction water seal bottle closed drainage: Applicable to high-pressure pneumothorax, open pneumothorax and liquid pneumothorax. A pressure regulating bottle is installed in the exhaust pipe of the water seal bottle to regulate the negative pressure. The lower end of the pressure regulating tube is 8-12cm away from the water surface, and the water seal bottle should be placed at a place lower than the patient’s chest cavity to avoid the backflow of the water inside the bottle into the chest cavity.
2, recurrent pneumothorax treatment: in addition to water seal bottle drainage or negative pressure exhaust, pleural adhesions can be performed when the lung is about to be fully reopened. Use 50% grape 40ml + 2% procaine 4ml + antibiotics (tetracycline 0.5g) intra-thoracic injection through the drainage tube and rotate the body position, every 2 to 3 days to give the drug until no air bubbles escape. 20% sterilized talcum powder suspension 10ml intra-thoracic injection. Multiple recurrence can also be surgical.
3, the treatment of hemopneumothorax: suction and drainage, or for low intercostal incision water seal bottle closed drainage. When internal treatment is ineffective, dissection of the chest surgery to stop the bleeding.
4, the treatment of chronic pneumothorax: the persistence of bronchopleural fistula, pneumothorax maintained for more than 3 months, called chronic pneumothorax. Dissection and surgical treatment can be performed.
5, treatment of mediastinal emphysema: timely treatment of pneumothorax, inhalation of 95% oxygen to increase the concentration of oxygen in the mediastinum, accelerate the absorption of mediastinal and subcutaneous emphysema. If the condition is serious, the upper and lower vena cava compression signs can be punctured or skin incision can be made to ventilate the upper sternal fossa.
Efficacy standards
1.Cure: clinical symptoms such as chest pain, cough, dyspnea disappeared, pneumothorax signs disappeared; X-ray examination showed that the lungs were completely reopened and all complications were cured.
2.Improved: clinical symptoms are obviously improved or disappeared, pneumothorax signs basically disappeared; X-ray examination shows that the lung is largely reopened, lung atrophy is less than 20%.
3.Not cured: those who do not meet the above criteria, or those who have bronchopleural fistula.
Discharge criteria]
Anyone who achieves clinical cure or improvement of relatively stable condition can be discharged.