I. Spontaneous pneumothorax
Spontaneous pneumothorax can be divided into primary and secondary according to the cause and clinical manifestations, among which secondary spontaneous pneumothorax mostly occurs in men over 45 years old, often accompanied by chronic obstructive pulmonary disease (COPD) or tuberculosis lung disease, and can also be secondary to other lung diseases such as bronchopulmonary carcinoma, while primary spontaneous pneumothorax refers to the spontaneous formation of pneumothorax without associated lung disease, and it is generally believed that The primary spontaneous pneumothorax refers to the spontaneous formation of pneumothorax without associated lung disease, which is now widely believed to be caused mainly by large pulmonary alveoli (bullae).
Primary spontaneous pneumothorax and pulmonary alveoli
Primary spontaneous pneumothorax is mostly seen in healthy young adult males, 5-10/100,000, relatively speaking, it is more common in long and lean people, and more likely to occur in flat chested people, considering that the lung tissue of long and lean patients grows rapidly, causing local ischemia of the lung and the formation of large alveoli at the lung tip, which are easily dilated under the action of external triggers (strenuous exercise, heavy impact, vigorous coughing, sneezing, forceful defecation or rapid changes in external air pressure). The pneumothorax is easily caused by the rupture of the expanded alveoli under the action of external triggers (violent exercise, heavy impact, vigorous coughing, sneezing, forceful defecation or rapid changes in external air pressure).
Clinical manifestations and diagnosis
Spontaneous pneumothorax due to pulmonary alveoli is mostly seen on the right side, 10% of them occur bilaterally, and in most cases, they occur one after another. 25% of spontaneously healed patients will have ipsilateral recurrence within 2 years, and after the second recurrence, the chance of the third one will be more than 50%. The clinical presentation is closely related to the degree of pulmonary atrophy, with most patients presenting with acute chest pain and/or dyspnea, which may be accompanied by a dry cough that is easily tolerated as it subsides after a few hours. The most meaningful examination is upright frontal and lateral chest radiographs, in addition CT can often accurately show the number, size and location of small pulmonary alveoli, which is helpful to decide the treatment plan.
Fourth, non-surgical treatment
The purpose and principle of treatment is to reopen the atrophied lung tissue, restore lung function and prevent its recurrence, but it should be clear that surgical treatment cannot change the pathological changes of the lung tissue itself. The non-surgical treatment includes observation, puncture and aspiration and closed drainage of the chest cavity.
1.Observation
Patients who are usually healthy and asymptomatic, with lung atrophy less than 20% and chest X-ray not suggesting increased pneumothorax, can be observed and wait for self-healing and absorption of pneumothorax. To ensure that no complications occur, patients must stay in the hospital for 24-48 hours for observation and review chest X-ray every 5-7 days after discharge until the pneumothorax completely disappears, and if the lung does not reopen in 7-10 days, there is a need for puncture and aspiration or closed drainage.
2.Puncture suction and closed chest drainage
For patients with more than 30%, medium or large amount of pneumothorax, puncture suction or closed chest drainage is recommended, because puncture suction requires several operations to have certain effect, so most of the clinical practice takes closed chest drainage as the main treatment, as long as the drainage tube is properly positioned, the lung can be rapidly reopened, and most patients can stop air leakage within 48 hours.
V. Surgical treatment
If there is still a large amount of air leakage after closed chest drainage and the lung still cannot be completely expanded and reopened, surgical treatment is required, and the main indications for surgical treatment are as follows
1, the first episode of pneumothorax accompanied by a pneumothorax lasting more than 3 days with poor lung expansion.
2, hemopneumothorax.
3.Bilateral or tension pneumothorax.
At present, the operation mostly takes a minimally invasive method, i.e. thoracoscopic alveolar resection and suture, and the operation port is mostly one or two incisions less than 1cm, and the thoracoscope and the operation instrument are placed respectively. At present, the application of single-hole technology is mature, which reduces the operation trauma even more, and the ruptured alveoli or the visible alveoli that have not yet ruptured should be removed, ligated or sutured as much as possible. At present, the mechanical suture method is mostly adopted under the thoracoscope, that is, the use of disposable cutting closures combined with the nail bin to excise and anastomose the alveoli, the mechanical method is less traumatic than the manual excision and suture method, the operation time is shorter, the recurrence rate of pneumothorax is low, and the overall effect of healing is satisfactory, according to the literature, the recurrence rate of pneumothorax after mechanical closure can be reduced to less than 5%.
VI. Perioperative and postoperative recovery exercises
Pneumothorax will be left with chest drains after surgery, because of the intraoperative thoracoscopic operation and postoperative drainage tube compression of the intercostal nerve, it will cause more obvious pain after surgery, and the pain will cause the patient to refuse deep inspiration and cough up sputum, which will affect the postoperative exercise of whistle function and increase the possibility of postoperative complications such as sputum blockage, pulmonary atelectasis and even pneumonia, or seriously affect the prognosis, so it is necessary to give pain pump or symptomatic pain management after surgery, and it is more necessary to Patients need to adjust their mentality and increase their confidence and patience in fighting against pain and disease. Generally, the drainage tube can be removed when the postoperative drainage is less than 100ml/day (most of them are within 3 days), and the patient can be discharged after good wound healing and satisfactory CT review (about 10 days after surgery).
Review CT within 1 month after discharge, avoid strenuous exercise for 3 months, including jogging and heavy lifting, avoid vigorous coughing, sneezing and prolonged breath-holding, quit smoking and drinking, avoid staying up late, eat more high-fiber and high-protein foods to facilitate smooth bowel movements, avoid excessive use of abdominal pressure for bowel movements, use lubricants such as corkage if necessary, and suggest resting in silence throughout the process, combined with deep whistling exercises and slow walking.
Finally, even surgical treatment cannot correct the pathological changes formed in the lung itself, so large pulmonary alveolar tissue may still develop in the patient, which in turn may form a new pneumothorax, or the residual alveoli may rupture to form a recurrent pneumothorax.