Tension pneumothorax

Introduction to tension pneumothorax Tension pneumothorax refers to a large lung bubble rupture or a large and deep lung laceration or bronchial rupture. The rupture communicates with the pleural cavity and forms a one-way valve, also known as a high-pressure pneumothorax. When inhaling, the air enters the pleural cavity from the rupture, and when the breath is closed, the valve is closed, the air in the cavity cannot be discharged, the pressure in the pleural cavity is continuously increased, the lung is pressed to gradually collapse, and the mediastinum is pushed to the healthy side. Squeezing the healthy lungs creates severe obstacles to respiratory and circulatory function. If the high-pressure air in the pleural cavity is squeezed into the mediastinum, it spreads to the subcutaneous tissue, forming subcutaneous emphysema at the neck, face, chest, etc. basic knowledge The proportion of illness: 0.003% Susceptible people: no specific population Mode of infection: non-infectious Complications: pleural effusion

Tension pneumothorax

(1) Causes of the disease

Tension pneumothorax refers to the pleural cavity of the pleural cavity. The pleural cavity pressure is reduced, the valve is open, and the gas enters. When the pleural cavity is raised during exhalation, the valve is closed and the gas cannot be discharged. The traumatic pneumothorax of the lung, bronchus, chest wall injury wound can be a single-channel valve, the pleural rupture of spontaneous pneumothorax can also form such a flap.

(two) pathogenesis

As the gas continues to enter the pleural cavity and cannot be expelled, the pressure in the pleural cavity continues to rise, causing the following changes:

1 The affected side lung was completely compressed and collapsed, thus completely losing ventilation and ventilation function.

2 The mediastinum continues to shift to the healthy side, and the mediastinal displacement distorts the large blood vessels connected to the heart, affecting the flow of blood to the heart.

3 The lung part of the healthy side is oppressed, affecting the ventilation and ventilation function of the healthy side lung.

When the intrapleural pressure increases to a certain extent, the gas enters the mediastinum or chest wall through the parietal pleural or mediastinal pleura, resulting in mediastinal emphysema or ipsilateral emphysema of the affected chest, head, face and neck. Subcutaneous emphysema marks the pleural cavity. The degree of gas accumulation can also reduce the pressure in the pleural cavity. If the treatment is not timely, the gas exchange will be severely restricted, the venous return will be blocked, the cardiac output will decrease, the tissue will be hypoxic, the patient will have a full thoracic, and the breathing will be severe. Difficulties, bun and shock.

Tension pneumothorax prevention

The key to the prevention of tension pneumothorax is to improve the health, that is, to strengthen nutrition and pay attention to rest; the second exercise is necessary, but it is necessary to pay attention to avoiding suffocation during exercise and try not to do anaerobic exercise, such as sprinting. Heavy objects, etc.

Tension pneumothorax complications Complications pleural effusion

Spontaneous pneumothorax, especially pleural rupture in the short-term non-healing or treatment is not prone to pleural effusion; long-term non-healing can form pleural bronchospasm; severe thoracic infection or lung abscess into the chest can produce pus pneumothorax; pleural adhesion tear Or cancer infiltration and ulceration can occur blood pneumothorax; mediastinal emphysema is a serious complication of pneumothorax, mostly due to high-pressure pneumothorax gas sputum lungs, vascular sheath or peri-bronchial space through the hilar into the mediastinum, more often in the left Lateral pneumothorax, severe examination of the internal organs of the mediastinum can cause respiratory and circulatory failure.

Tension pneumothorax symptoms Common symptoms Subcutaneous emphysema Post-sternal pain Painful breathing Difficult chest tightness Abdominal abnormal breathing Chest pain Heart suffocation

1. Difficulty breathing: Patients have difficulty breathing during pneumothorax, the severity of which is related to the course of the attack, the type of pneumothorax, the degree of compression of the lungs and the original state of pulmonary function. Patients with tension pneumothorax may have significant breathing. Difficult, unilateral closed pneumothorax, in young patients with normal respiratory function, no obvious difficulty in breathing, even if the lung is compressed >80%, can only be a little chest tightness during activities, and in chronic obstructive pulmonary disease In elderly patients with emphysema, the lungs are slightly compressed and have obvious dyspnea. The acute pneumothorax may have more obvious symptoms, while the chronic pneumothorax and the healthy lung may be compensatory and the clinical symptoms may be milder.

2. Chest pain: Sudden sharp tingling and knife cut pain often occur at the time of pneumothorax. It is not related to the sudden rupture of the bullae and the degree of compression of the lung. It may be related to the increase of pressure in the pleural cavity and the involvement of the parietal pleura. The pain is not certain, it can be confined to the chest, but also to the shoulder, back, upper abdomen, when there is obvious mediastinal emphysema, there may be sustained post-sternal pain, pain is the most common complaint of pneumothorax patients, and in mild pneumothorax When, it may be the only symptom.

3. Irritant cough: occasional irritating cough in spontaneous pneumothorax.

4. Other symptoms: When pneumothorax combined with blood pneumothorax, if the amount of bleeding is high, the patient will have palpitations, low blood pressure, cold limbs, etc. When the tension pneumothorax is used, the affected lung is extremely oppressed, and the mediastinum is also displaced to the healthy side. In addition to high dyspnea, clinically, there will be cyanosis, blood pressure, and even suffocation, shock, combined with subcutaneous emphysema, the patient's chest, face swelling, mediastinal shift can cause heart, large blood vessel displacement, large vein distortion , affecting blood reflux, the appearance of systemic stasis, such as venous anger.

5. Common signs

(1) Chest signs: the thoracic uplift of the affected side, the respiratory movement is weakened, the intercostal space is widened, the affected side of the chest is percussed with a drum sound, the auscultation side is weak or disappears, and the left pneumothorax and mediastinal emphysema are on the left sternal border. A high-pitched, coarse murmur that is audible to the heart beat, called the Hamman sign (mediastinal emphysema syndrome), may be related to the gas in the left pleural cavity and the gas in the mediastinum when the heart beats. Tension pneumothorax with subcutaneous emphysema It can touch the hair on the front chest wall and the head and face.

(2) The trachea, the heart shifts to the healthy side, especially in the tension pneumothorax.

(3) Increased respiratory rate, cyanosis of the lips, more common in tension pneumothorax.

Tension pneumothorax examination

1.X-ray performance

Chest radiograph is the most reliable method for diagnosing pneumothorax. It can show the degree of lung collapse, lung condition, presence or absence of pleural adhesions, pleural effusion and mediastinal shift. The pleural cavity shows a uniform translucent area without lung texture on the chest image. The inner side of the air belt is a curved linear lung edge parallel to the chest wall. A small amount of gas is often confined to the upper part of the chest cavity and is often covered by the bone. At this time, the patient exhales deeply, and the collapsed lung is further reduced and the density is increased. It forms a sharper contrast with the exposed air-transparent area, which shows the pneumothorax. When the pneumothorax is large, the affected lung is compressed, and the lung gathers in the hilar area. Some patients can see the lung tip on the chest X-ray. Pulmonary bullae; in the presence of blood pneumothorax, the liquid-vapor plane is visible; when there is an adhesive band in the chest, the collapsed lung loses its uniform compression to the hilum, showing irregular compression or lung on the chest X-ray. The compression margin is lobulated; the ipsilateral diaphragm is obviously moved down, the trachea, and the heart are displaced to the healthy side; when mediastinal emphysema is combined, the mediastinum and subcutaneous gas are visible.

According to the X-ray image, the degree of compression of the lungs after pneumothorax can be roughly calculated, which has certain guiding significance for clinical treatment of pneumothorax. Kircher proposed a simple calculation method:

According to the above formula, it can be estimated that when the width of the gas-filled zone is equivalent to 1/4 of the width of the thoracic side of the affected side, the lung is compressed by about 35%; when the width of the gas-filled zone in the chest is equivalent to 1/3 of the width of the affected thorax, the lung is Compression is 50%; when the width of the gas in the chest is equivalent to 1/2 of the width of the thoracic side of the affected side, the lung is compressed by 65%. According to the amount of pneumothorax, the pneumothorax can be divided into 3 categories: a small amount of pneumothorax (<20%) , medium volume pneumothorax (20% to 40%), a large number of pneumothorax (> 40%).

In the clinic, pneumothorax is sometimes difficult to identify. For example, a chest radiograph taken by a portable radio camera in an emergency or traumatic position in a supine or semi-recumbent position may obscure the pneumothorax sign, especially in the apex of the lung or the lateral area of the lung field. It does not show signs of pneumothorax; due to pleural disease, chest trauma or multiple pleural adhesions caused by previous surgery can be characterized as localized pneumothorax, which is easily confused with bullous bullae or bullous emphysema.

2. Chest CT scan

Can clearly show the extent of pleural effusion and the amount of gas, the degree of compression of the lungs, in some patients can see the presence of lung bullae, and chest CT can also show how much pleural effusion, especially for the pole Pneumothorax with a small amount of gas and a localized pneumothorax mainly located in the anterior middle pleural cavity are easily missed on the X-ray image, while CT has no weakness in image overlap, which can confirm the diagnosis.

Diagnostic diagnosis of tension pneumothorax

1. Pulmonary bullae: Pulmonary bullae are slow onset and have a long course of disease; while pneumothorax is often onset and has a short history. X-ray examination of the bullae is a circular or elliptical translucent area, located in the lung field, there is still a small strip of texture inside; and the pneumothorax is a strip-like shadow, located in the chest of the lung field. Pulmonary bullae in the peripheral part of the lung is easily misdiagnosed as pneumothorax, and the bullae line on the chest radiograph is concave toward the lateral chest wall; and the convex surface of the pneumothorax often faces the lateral chest wall, and chest CT is helpful for differential diagnosis. After a long period of observation, the size of the lung bullae rarely changed, while the shape of the pneumothorax gradually changed and eventually disappeared.

2. Acute myocardial infarction: clinical manifestations similar to pneumothorax, such as acute chest pain, chest tightness, dyspnea, shock and other clinical manifestations, but patients often have coronary heart disease, history of hypertension, heart sounds and rhythm changes, no gas chest signs, ECG Or chest X-ray examination helps identify.

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