A. Causes
1, traumatic pneumothorax is common in a variety of chest trauma, including sharp-edged stab wounds and gunshot penetrating wounds rib fracture end misalignment stab wounds lung, as well as diagnostic, therapeutic lung injury during medical operations, such as acupuncture puncture lung biopsy, artificial pneumothorax, etc.
2, secondary pneumothorax for bronchopulmonary disorders broken into the chest cavity to form a pneumothorax. Such as chronic bronchitis, pneumoconiosis, obstructive pulmonary disorders caused by bronchial asthma, interstitial fibrosis, cellular lung and bronchopulmonary carcinoma partially occluding the airway, resulting in vesicular emphysema and pulmonary alveoli, as well as septic pneumonia near the pleura, lung abscess, tuberculous cavity, pulmonary fungal disease, congenital pulmonary cysts, etc.
3, idiopathic pneumothorax refers to the usual history of no respiratory disease, but there can be large pulmonary alveoli under the pleura, once ruptured to form a pneumothorax is called idiopathic pneumothorax. Most often seen in lean and long body type of male young adults.
4, chronic pneumothorax refers to the pneumothorax after 2 months without full reopening. The reasons for this are: the absorption difficulty of the encapsulated liquid pneumothorax, not easy to heal bronchial negotiation pleural fistula, pulmonary alveoli or congenital bronchial cysts formed by the pneumothorax, and the airway obstruction or atrophy of the lung connected with the pneumothorax covered with a thicker mechanized envelope to prevent lung reopening.
Pathogenesis
Pneumothorax is called spontaneous pneumothorax except for traumatic injury or artificial pneumothorax for diagnosis and treatment. Spontaneous pneumothorax is mostly caused by the rupture of subpleural pneumothorax bubbles, but also by the collapse of subpleural lesions or cavities and tearing of pleural adhesion bands. Subpleural emphysema bubble can be congenital or acquired; the former is congenital elastic fiber dysplasia, alveolar wall elasticity decreases, expanding to form large pulmonary alveoli, mostly seen in lean and long men, no obvious disease on lung X-ray, the latter is more common on the basis of obstructive emphysema or post-inflammatory fibrous lesions, fine bronchial negotiation semi-obstructed, distorted, producing live valve mechanism and forming emphysema bubble, distended emphysema bubble due to The distended pneumothorax bubble degenerates due to nutrition and circulatory disorders, so that it ruptures when coughing or intrapulmonary pressure increases.
Second, how to diagnose pneumothorax
1.Medical history
Traumatic pneumothorax should be suspected in cases of chest trauma or invasive diagnosis and dyspnea after therapeutic operation. Spontaneous pneumothorax can occur after severe coughing, breath-holding or exertion, and most patients have sudden onset and rapid onset of chest pain and dyspnea, while a few have a slow onset and light self-conscious symptoms, and only feel vague chest pain after onset, often with gradual onset of dyspnea after several hours. The severity of symptoms is related to age and original lung health status, such as young people with previous lung function parties may only show mild dyspnea, while elderly people with original emphysema can have significant dyspnea when the lung volume is reduced by 10%. The symptoms of pneumothorax are associated with a rapid onset of significant dyspnea. The symptoms of pneumothorax are related to the urgency of the onset, the amount of air volume, the clinical type, the degree of lung compression and the primary lung disease.
2.Physical examination
With different types of chest, the degree of dyspnea caused varies, hourly closed pneumothorax is often without dyspnea, while multiple tension pneumothorax has cyanosis, forced position and significant dyspnea, typical signs of pneumothorax include fullness of the affected side of the thorax, rib tone gap expansion, deviation of the trachea and apical pulsation to the healthy side, reduction or disappearance of respiratory movement, drum sound on percussion, diminished or disappearance of palpation fibrillation and breath sounds, in the case of right pneumothorax, liver In the case of right pneumothorax, the faintest sound is heard in the left pneumothorax, and in the case of left pneumothorax, the heart border is not clearly percussive, and the “splintering” sound consistent with the dirty beating can be heard when the air volume is small.
3.Common examination
(1) X-ray examination is the most reliable method to diagnose pneumothorax, which can show the degree of lung atrophy, the presence of pleural adhesions, mediastinal displacement and pleural effusion. Pneumothorax side transparency enhancement, no lung reasoning, lung atrophy in the lung, and pneumothorax junction with a clear thin strip of lung margin, mediastinum can be displaced to the healthy side, especially tension pneumothorax is more significant; a small amount of pneumothorax is occupying the apical part of the lung, so that the apical lung tissue pressure to the lung door; if there is liquid pneumothorax, then see the liquid plane.
(2), CT is more sensitive to the diagnosis of a small amount of gas in the chest cavity. For recurrent pneumothorax and chronic pneumothorax, observe whether there are lesions causing pneumothorax at the edge of the lung, such as large pulmonary alveoli, pleural band adhesions, lung being stretched and fissures not easily closed, etc. The basic manifestation of pneumothorax is the appearance of extremely low-density gas shadow in the pleural cavity, accompanied by different degrees of compression and atrophy changes of lung tissue.
Third, how to prevent
1.Postoperative bed rest should be in a comfortable and quiet environment.
2.Avoid exertion and breath-holding action, keep the bowels unobstructed, and effective measures should be taken if the bowels are not relieved for more than 2 days.
3.Patients should quit smoking, usually pay attention to nutrition, intake of adequate protein, vitamins, not picky, not partial food, appropriate into the coarse cellulose food, in order to enhance the body resistance.
4.Do not do pulling action and contouring chest exercise for 3 to 6 months after pneumothorax discharge to prevent inducing pneumothorax.
5.Prevent upper respiratory tract infection and avoid violent coughing.
IV. Treatment of pneumothorax
1, general treatment: all types of pneumothorax patients should be bed rest, restrict activities, lung compression < 30% without suction, can give cough, analgesic symptomatic treatment, the presence of infection should be selected according to the situation of the corresponding antibiotics, more can be absorbed.
2.Thoracic decompression.
(1) closed pneumothorax, lung compression <20%, simple bed rest leisure pneumothorax can be self-absorption, lung compression >20% symptoms should be thoracentesis pumping 1/1 ~ 2d times, each time 600 ~ 800ml is appropriate. (2) open pneumothorax, the application of closed chest drainage exhaust, the lung still can not reopen, can be added with negative pressure continuous suction. (3) Tension pneumothorax, the condition is more critical must be exhausted as soon as possible to reduce pressure, while preparing to immediately perform closed chest drainage or negative pressure continuous suction.
3.Surgical treatment.
For the active treatment of internal medicine lung still can not reopen, then need to consider surgery. Surgical treatment is divided into three types: the first; traditional open-heart surgery, traumatic, the effect is sure, slow recovery. It is rarely used now. The second one is the television thoracoscopic surgery, which is performed through two or three small holes into the chest cavity, which is less traumatic and can also achieve the purpose of ligating the fistula in the lung, with fast recovery and cosmetic effects. This type of minimally invasive surgery has long been performed in our department. The success rate is about 98%. The third type, da Vinci robotic surgery, is a newly introduced procedure, which is accurate and less traumatic, but more expensive and more used abroad. A good idea for the radical treatment of refractory pneumothorax: complete closure of the pleural cavity; otherwise, there is a possibility of recurrence even after surgery.