1.Spontaneous pneumothorax
Including primary pneumothorax and secondary pneumothorax, primary pneumothorax mostly has no underlying lung disease, about 90% of the operated cases have subpleural lung and pulmonary bullae (bullae), and some of them can have positive findings on CT or chest X-ray.
2.Diagnosis of spontaneous pneumothorax
It mainly relies on symptoms, signs and X-ray examination. General chest X-ray can clarify the diagnosis and can evaluate the degree of lung compression. Chest CT can detect some occult pneumothorax that cannot be detected by chest X-ray and can better evaluate the lung condition.
3.Treatment of spontaneous pneumothorax
3.1 Simple observation
For a small amount of asymptomatic pneumothorax (<20%), it can be observed, and simple oxygenation is beneficial to the absorption of pneumothorax.
3.2 Thoracentesis
In 2003, the British Thoracic Society (BTS) recommended thoracentesis as the first-line treatment for primary pneumothorax, but for secondary pneumothorax thoracentesis alone may have little effect. For secondary pneumothorax with significant symptoms and age >50 years, thoracentesis is not suitable.
3.3 Closed thoracic drainage
If thoracentesis cannot significantly reduce pulmonary compression and relieve symptoms, closed chest drainage should be performed promptly; for secondary pneumothorax with obvious symptoms and pulmonary compression >20%, closed chest drainage is preferred; if there is still air leakage or the lung cannot be reopened after 48 hours, add negative pressure suction at -12 to -20 MH2O. chemical pleural fixation via closed chest drainage is mainly used for refractory patients who cannot tolerate or refractory patients who are unwilling to undergo surgical treatment.
3.4 Surgical treatment
3.4.1 Early surgical intervention (3-5 days) is the treatment of choice for cases with persistent pulmonary air leak and failure to reopen the lungs.
3.4.2 Indications for first-stage surgery.
① Recurrent ipsilateral pneumothorax;
② first-episode contralateral pneumothorax
③ Bilateral spontaneous pneumothorax
④ Spontaneous hemopneumothorax
⑤ Special occupations: divers, pilots, long-term field work
3.4.3 Purpose of surgical treatment: to deal with pulmonary pneumothorax and pulmonary rupture; to promote pleural adhesions
3.4.4 Choice of surgical modality: The choice of surgical treatment for pneumothorax includes full thoracoscopic surgery, thoracoscopic-assisted small incision, small incision open-chest surgery and traditional open-chest surgery. Due to the development of minimally invasive surgical techniques and surgical instruments, thoracoscopic surgery can treat more than 80% of pneumothorax and a part of hemopneumothorax.
3.4.5 The main ways to promote pleural adhesions include: pleural exfoliation, physical inflammatory reaction caused by pleural friction, and inflammatory reaction formed by various chemicals. Pleural exfoliation has the most definite effect, but it is less commonly used at present due to the large trauma and bleeding.
4.Management of complications
Complications of spontaneous pneumothorax mainly include tension pneumothorax, mediastinal emphysema and hemothorax. Tension pneumothorax is a life-threatening complication, and the main principle of treatment is to immediately relieve the high pressure in the chest cavity, and then perform closed drainage of the chest cavity after the situation is slightly stable. If the mediastinal emphysema affects the circulation, mediastinal decompression should be performed first, and then closed drainage should be performed.
5.Discharge and follow-up
For patients with simple observation, they should come to the hospital for review 2 weeks after stabilization; patients treated by thoracentesis should be discharged only 24-48 hours after stabilization;
Most patients should avoid air travel for 6 weeks; diving is absolutely contraindicated before undergoing radical surgery.