Overview of pneumothorax
Rupture of pleura due to disease, the pleural cavity communicates with the atmosphere, and airflow enters the pleural cavity to form pleural cavity pneumothorax, which is called pneumothorax. Spontaneous pneumothorax in the elderly is mostly secondary to lung or pleural lesions, which is commonly caused by chronic obstructive pulmonary emphysema or diffuse pulmonary fibrosis with pulmonary hernias, and pneumothorax occurs when pulmonary hernias rupture due to a sharp rise in intrapulmonary pressure. Spontaneous pneumothorax in the elderly is also seen in staphylococcus aureus, anaerobic bacteria or gram-negative bacilli caused by suppurative pneumonia and ulceration to the pleural cavity, that is, the occurrence of purulent pneumothorax; lung cancer or tuberculosis cavity erosion of the pleura can also occur in the pneumothorax.
Etiology
The pleural cavity is a closed cavity between the dirty-wall pleura. It is a negative pressure cavity due to the elastic retraction force of the lungs. When the pressure in the alveoli rises sharply due to some triggering factor, the diseased lung-pleura ruptures, and the pleural cavity is connected to the atmosphere, so the airflow flows into the chest cavity and forms a spontaneous pneumothorax. Spontaneous pneumothorax in the elderly is mostly secondary, due to some patients’ lung tissue has been adhered to the wall pleura, lung tissue rupture when pneumothorax formation, fistula or fine bronchopleural fistula can not be closed with lung compression, resulting in the fistula continues to open, and become “open pneumothorax”; some patients due to bronchial stenosis, semi-obstruction and the formation of valve-like, so that air enters the chest during inspiration. In some patients, due to bronchial stenosis and semi-obstruction, a valve-like shape is formed, so that air enters the chest cavity during inspiration, and the pressure in the chest cavity can be more than 20cmH2O, which becomes “tension pneumothorax”. Elderly pneumothorax is often difficult to heal, recurrent pneumothorax and limited pneumothorax are more common.
Symptoms
The clinical manifestations of spontaneous pneumothorax in the elderly are often atypical and are often masked by the primary disease. About one fourth of the cases start slowly and worsen gradually, mainly manifesting as aggravation of dyspnea which is difficult to be explained by the primary disease; some of the cases have no clear triggers to find, manifesting as sudden or rapidly aggravating chest tightness and shortness of breath; some of the cases are characterized by sudden and significant shortness of breath, chest tightness, panic, and dyspnea after a severe coughing fit. Other common symptoms include cough, cyanosis and inability to lie down. The clinical manifestations of massive pneumothorax or tension pneumothorax sometimes resemble pulmonary infarction or myocardial infarction, which can be characterized by chest tightness, chest pain, dyspnea, panic, sweating, pallor, and restlessness at an early stage; respiratory failure can also be induced on the basis of chronic obstructive pulmonary emphysema. When lung compression is more than 30%, the trachea is shifted to the healthy side, the affected side of the chest is puffed up, respiratory movement is weakened, there is a tympanic sound on percussion, the cardiac turbid tone boundary disappears or the hepatic turbid tone boundary moves downward, and the respiratory sound and speech tremor are weakened or disappeared. In some elderly patients, it resembles an asthma-like attack, and rales can be heard in the lungs along with severe dyspnea.
Examination
1. Laboratory tests
Thoracic gas analysis: the use of thoracic gas PaO2, PaCO2 and PaO2/PaCO2 ratio of three indicators, to determine the type of pneumothorax has a certain significance.
2. Other auxiliary examinations
(1) X-ray examination is the most reliable method to diagnose pneumothorax, which can show the degree of lung atrophy, the presence or absence of pleural adhesion, mediastinal displacement and pleural effusion.
(2) CT examination is more sensitive to the diagnosis of small amount of gas in the chest cavity.
(3) Plethysmography This method can clarify the surface of pleura, and it is easy to define the cause of pneumothorax.
(4) Thoracoscopy It is easy to find out the cause of pneumothorax, and observe whether there are cracks in the pleura of the dirty layer, whether there are lung blisters under the pleura, and whether there are adhesive bands in the thoracic cavity.
Diagnosis
The clinical manifestations of spontaneous pneumothorax in the elderly are very atypical, and it is easy to be misdiagnosed or missed because it is concealed by the primary disease. The possibility of pneumothorax should be considered when the following conditions occur in elderly patients:
1. sudden unexplained dyspnea, or sudden increase in shortness of breath on the basis of existing dyspnea, which cannot be explained by the primary disease.
2. Sudden onset of severe chest breathlessness with dyspnea, except myocardial infarction and pulmonary infarction.
3. Unexplained progressive deterioration of the condition, short-term panic, sweating, pallor or cyanosis, and/or impaired consciousness.
4. Sudden aggravation of wheezing symptoms, double or single lungs covered with rales, and all kinds of antispasmodic drugs, corticosteroids, oxygen therapy and antibiotic treatment is ineffective.
Rapidly or progressively worsening cyanosis. Elderly people, especially chronic obstructive pulmonary emphysema, pulmonary tuberculosis patients with the above conditions, accompanied by one side of the chest puffing, respiratory movement is weakened, percussion is drumming, tracheal displacement, pulmonary respiratory sounds and tremors weakened or even disappeared, can be initially diagnosed. If the condition permits, X-ray examination should be carried out in time to confirm the diagnosis and understand the degree of lung compression.
Differential diagnosis
1. Exacerbation of chronic obstructive pulmonary emphysema (COPE)
Closed pneumothorax secondary to chronic obstructive pulmonary emphysema and sometimes even open pneumothorax are often mistaken for exacerbation of chronic obstructive pulmonary emphysema. Shortness of breath is prominent in pneumothorax patients and tends to occur suddenly or worsen progressively, while cough and sputum are correspondingly mild; exacerbation of chronic obstructive pulmonary emphysema is often triggered by climate change, and upper respiratory tract infections are the precursors, which are highlighted by worsening of cough and sputum, and purulent sputum. The signs of pneumothorax are limited or unilateral, and asymmetric, while the signs of lung hyperinflation are diffuse and bilateral; the new tracheal displacement is a strong evidence of pneumothorax. x-ray examination and diagnostic puncture and pressure measurement by artificial pneumothorax machine if necessary can help to confirm the diagnosis.
2. Pneumothorax
A small number or limited pneumothorax sometimes needs to be differentiated from pulmonary herpes. The development of pulmonary pustules is very slow and the clinical manifestations are usually stable.
3. Pleural effusion
Elderly patients with pleural effusion also often present with chest pain and shortness of breath, but physical examination and X-ray are signs of effusion, which are different from pneumothorax.
4. Myocardial infarction, pulmonary infarction
Clinical manifestations of tension pneumothorax are sometimes similar to myocardial infarction and pulmonary infarction, both of which are characterized by sudden severe chest pain, shortness of breath, dyspnea, panic, pallor or cyanosis, profuse sweating, and irritability, etc. However, obvious signs of pleural effusion on the side of the affected side of tension pneumothorax and contralateral displacement of the trachea can help to distinguish tension pneumothorax, and the diagnosis can be confirmed by X-ray and diagnostic puncture of the artificial pneumothorax machine.
5. Bronchial asthma attack
Some elderly patients with pneumothorax present similarly to asthma-like attacks, with severe dyspnea and audible rales in the lungs. Signs of pneumothorax, ineffective antispasmodic agent-corticosteroid-oxygen therapy, dyspnea and rales disappeared after exhalation are different from asthma.
Complications
The complications of pneumothorax in the elderly are far more common than in the young and middle-aged, and they not only aggravate the condition, but also can lead to death in severe cases.
1. Pleural effusion
Most of them appear 3-5 days after the onset of pneumothorax, and the amount is usually small. The accumulation of fluid not only aggravates pulmonary atrophy, but also tends to develop into septic pneumothorax in open pneumothorax.
2. Septic pneumothorax
Pneumothorax secondary to pyogenic pneumonia or lung abscess or caseous pneumonia caused by Aureus, anaerobic bacteria or gram-negative bacilli is easy to be combined with septic pneumothorax.
3. Hemopneumothorax
Pneumothorax is caused by tearing of blood vessels in the pleural adhesion zone. The severity of the disease is related to the size of the torn blood vessel.
4. Mediastinal emphysema
Mostly complicate with tension pneumothorax.
5. Respiratory failure
This is a very common complication of pneumothorax in the elderly secondary to chronic obstructive pulmonary emphysema.
6. Circulatory failure
This is a common complication of tension pneumothorax.
7. Heart failure
Most common in elderly pneumothorax patients with severe heart disease. Heart failure can be induced by hypoxemia caused by pneumothorax, infection, increased oxygen consumption by respiratory exercise and cardiac arrhythmia.
Treatment
The aim is to eliminate the pneumoperitoneum, relieve the symptoms, promote pulmonary re-tension and prevent recurrence.
1. General therapy
Absolute bed rest, less speech, cough suppressant for those with severe cough, sedative for those with agitation, laxative for those with constipation. Reduce pulmonary activity and prevent the rise of intra-alveolar pressure, in order to facilitate the healing of the rupture and the absorption of gas. Actively treat the primary disease.
2. Exhaustion therapy
Exsufflation therapy should be used on the basis of general therapy for patients with moderate or severe diseases.
(1) Artificial pneumothorax machine pumping method The patient takes the sitting position or supine position.
(2) Closed drainage with water-seal bottle The same puncture point is used as above, and the drainage tube is inserted with a trocar or surgical incision. The drainage tube is fixed on the chest wall to prevent it from coming out, and the outer end of the tube is connected with a water-seal bottle. Closed drainage is also divided into two types: continuous positive pressure and continuous negative pressure exhaust.
3. Pleural adhesion surgery
If the above treatment is ineffective or recurrent pneumothorax without significant pleural hypertrophy, pleural adhesion surgery should be performed.
4. Thoracoscopic pneumothorax surgery
Thoracoscopic direct vision can determine the lesion site, nature, scope, small fissure or bronchopleural fistula can be used electrocoagulation or laser treatment to make the breach closed, if necessary, local spray adhesive to promote its healing; larger pulmonary herpes will be resected under the microscope, and multiple pulmonary herpes can not be resected can be sprayed with adhesive under direct vision.
5. Open heart surgery
In addition to primary diseases requiring surgery (e.g. lung cancer, etc.), significant pleural hypertrophy, massive hemopneumothorax, bilateral pneumothorax, inability or pleural adhesion surgery – thoracoscopic pneumothorax surgery failure, it is advisable to use open thoracotomy with caution.
Prognosis
The recurrence rate of spontaneous pneumothorax in the elderly is high, and the morbidity and mortality rate is proportional to the degree of lung compression. The prognosis of those with advanced age, severe underlying lesions, tension pneumothorax, and comorbidities is dire. Due to the underlying lesions, severe dyspnea often occurs when the proportion of lung compression is not large. Whether or not closed drainage is performed in a timely manner will greatly affect the prognosis.
Prevention
The key to preventing pneumothorax in the elderly is to actively prevent and treat primary diseases, especially chronic obstructive pulmonary emphysema and respiratory tract infections. Elderly people with pulmonary pustules, especially those with a history of pneumothorax, should keep their bowels clear, avoid contact with respiratory irritants, and avoid exertion and weight-bearing. Pleural adhesion surgery is the main method to prevent recurrence in those with recurrent pneumothorax.