Pneumothorax

Introduction Pneumothorax refers to the pathophysiological condition caused by rupture of the visceral pleura and gas into the pleural cavity leading to pleural effusion without trauma or human factors. No obvious lesions in the lungs are formed by subpleural emphysema and rupture. They are called idiopathic pneumothorax; those secondary to chronic obstructive pulmonary tuberculosis and other pleural and pulmonary diseases are called secondary pneumothorax. According to pathophysiological changes, it is divided into three categories: closed (simple), open (traffic) and tensile (high pressure). At this time, the pressure in the thoracic cavity rises, and even the negative pressure becomes a positive pressure, so that the lungs are compressed, and the blood flow to the heart is yin, resulting in different degrees of lung and heart dysfunction. In recent years, scholars at home and abroad have conducted in-depth research on its etiology, pathogenesis and diagnosis and treatment methods, and made some progress.

Cause

1. Traumatic pneumothorax: common chest trauma, including sharp stab wounds and bullets, penetrating rib fractures, staggering lungs, and diagnosis, lung injury during therapeutic medical operations, such as acupuncture and lung biopsy, artificial Pneumothorax, etc.

2, secondary pneumothorax: for the bronchopulmonary disease into the chest to form a pneumothorax. Such as chronic bronchitis, pneumoconiosis, bronchial asthma and other obstructive pulmonary diseases, pulmonary interstitial fibrosis, cellular lung and bronchial lung cancer partially occluded airway, resulting in bubble emphysema and pulmonary bullae, and close to the pleura Suppurative pneumonia, lung abscess, tuberculous cavity, pulmonary fungal disease, congenital pulmonary cyst and so on.

3, idiopathic pneumothorax: refers to the usual history of no respiratory disease, but there may be large lungs under the pleura, once the rupture of the pneumothorax is called idiopathic pneumothorax. More common in young and thin young men.

4, chronic pneumothorax: refers to the chest after 2 months, there is no full re-expansion. The reasons are: a poorly absorbed encapsulated liquid pneumothorax, a pneumothorax formed by a pulmonary bullous or congenital bronchogenic cyst, and an airway obstruction or atrophic lung with a pneumothorax with a thicker mechanism of the envelope obstructing lung recruitment.

mechanism:

Except for pneumothorax injury or artificial pneumothorax, it is called spontaneous pneumothorax. Spontaneous pneumothorax is mostly caused by rupture of subpleural emphysema, and also seen in subpleural lesions or cavity collapse, tearing of pleural adhesions. Subpleural emphysema can be congenital or acquired; the former is congenital elastic fiber dysplasia, alveolar wall elasticity declines, and forms a large pulmonary sac after expansion, more common in elongated males, no obvious X-ray examination of the lungs Disease, the latter is more common on obstructive emphysema or post-inflammatory fibrous lesions. The thin-branched gas negotiates semi-occlusion, distorts, produces a valve mechanism to form emphysema, and enlarges the emphysema bubble due to nutrition, circulation Destructive and degenerative, causing rupture when coughing or increased intrapulmonary pressure.

an examination

Physical examination

With the different types of pneumothorax, the degree of dyspnea is not equal. Hours of closed pneumothorax often have no difficulty in breathing. Tension pneumothorax has cyanosis, forced position and significant difficulty in breathing. Typical pneumothorax signs have full thoracic and rib tone on the affected side. Gap bulging, tracheal and apical beat to health shift, respiratory movement reduced or disappeared, percussion is drum sound, tactile tremor and respiratory sound weakened or disappeared, right pneumothorax when liver dullness is down, left pneumothorax Unclear boundaries, when you have less air, you can hear the "beep" sound that is consistent with the dirty beat.

Device inspection

1. X-ray examination: It is the most reliable method for diagnosing pneumothorax. Can show the degree of lung atrophy, with or without pleural adhesions, mediastinal shift and pleural effusion. The pneumothorax side has enhanced transparency, no lungs, lung atrophy in the lungs, and a clear thin strip of lungs at the junction of the pneumothorax. The mediastinum can be displaced to the healthy side, especially the tension pneumothorax; a small amount of pneumothorax occupies the tip of the lung. , the lung tip tissue is pressed to the hilum; if there is a liquid pneumothorax, the liquid level is seen.

2, CT: sensitive to the diagnosis of a small amount of gas in the chest. For recurrent pneumothorax, patients with chronic pneumothorax observed whether there were pneumothorax lesions on the edge of the lungs, such as pulmonary vesicles, pleural band adhesions, lungs being pulled, and the ruptures were not easy to close. Pneumothorax is basically characterized by a very low-density gas shadow in the pleural cavity, accompanied by varying degrees of compression and atrophy changes in the lung tissue.

3, pleural angiography: This method can understand the condition of the pleural surface, easy to identify the cause of pneumothorax, when the compression area of the lung is 30% ~ 40%, it is appropriate to perform angiography, the lung vesicles appear as single or multiple within the contour of the lung Cystic low density shadow; pleural rupture manifests as bubbling or spraying, especially when the patient coughs, this sign is more obvious due to increased intrapulmonary pressure.

4, thoracoscopy: flexible operation, up to the interlobular fissure, lung tip, hilar, almost sliding blind area, to observe the visceral pleural rupture, subpleural with or without pulmonary vesicles and no adhesions in the chest.

5, chest gas analysis: the use of pleural gas PAO, PACO and PAO ratio of three indicators, to determine the type of pneumothorax has a certain significance.

Differential diagnosis

Differential diagnosis

1, liquid gas chest: pleural cavity and effusion at the same time called liquid pneumothorax. Imaging findings: There is a liquid dense shadow in the lower part of the chest, the liquid surface is horizontal, the gas is translucent above the liquid level, the affected lung is compressed to varying degrees; the wide, narrow, high and low vision air of the liquid pleural fluid And the amount of liquid varies, the liquid level is always parallel to the ground when the patient's position changes. Encapsulated liquid pneumothorax is more common in the lateral wall of the thoracic cavity. There is a translucent gas shadow and liquid level on the upper part of the shadow of the wrapped pectoral effusion, which is not connected with other pleural cavity. Multi-atrial fluid pneumothorax is caused by pleural adhesions. There are many liquid levels with different heights. It can be seen that the liquid level is close to the chest wall.

2, tension pneumothorax: the wound on the chest wall, lung, bronchus or esophagus is a one-way valve, traffic with the pleural cavity, the valve is open when inhaling, the air enters the pleural cavity, the valve is closed when exhaling, the air can not be The pleural cavity is discharged, so with the respiration, the pressure in the pleural cavity of the injured side is continuously increased, so that the tension of the pneumothorax is formed over the atmospheric pressure, which is also called the pneumothorax or the pneumothorax.

(1) Chest signs: The thoracic uplift of the affected side, the respiratory movement is weakened, the intercostal space is widened, the percussive side of the affected side is drum sounded, and the auscultation side is weak or disappears. On the left pneumothorax and mediastinal emphysema, a high-pitched rough murmur that is consistent with the heart beat can be heard on the left sternal border. The Hamman sign (mediastinal emphysema syndrome) may hit the gas in the left pleural cavity when the heart beats. Gas is related to the mediastinum. When the tension pneumothorax is combined with subcutaneous emphysema, the front chest wall and the head and face can be touched.

(2) The trachea and heart are displaced to the healthy side, especially in the case of tension pneumothorax.

(3) Increased respiratory rate, cyanosis of the lips, more common in tension pneumothorax. According to the history, clinical manifestations and X-ray chest X-ray examination is easier to diagnose, but also according to the thoracic puncture see high pressure gas to push the needle core outward to further confirm the diagnosis.

3, shortness of breath: shortness of breath, gas is not taken up, mostly caused by lack of oxygen, emotional stress. Dyspnea is an important symptom of respiratory insufficiency. It is subjectively characterized by insufficient air or breathing, and objectively manifested as changes in respiratory rate, depth, and rhythm. There is a gas sign in the chest, the chest on the affected side is raised, the breathing movement and tremor are weakened, the percussion is excessive reverberation or drum sound, and the auscultation breath sound is weakened or disappeared.

Medical history

In the case of chest trauma or invasive diagnosis, if there is difficulty in breathing after treatment, a traumatic pneumothorax should be suspected. Spontaneous pneumothorax may occur after coughing, holding your breath or exerting force. Most patients suddenly get sick, and chest pain and breathing difficulties occur rapidly. A small number of onsets are slow, and the symptoms are also mild. After the onset, only the chest is painful, and breathing difficulties often occur after a few hours. The severity of the symptoms is related to the age and the health of the original lung. For example, young people with previous pulmonary function can only show mild dyspnea, while the elderly with emphysema reduce the lung capacity by 10%. Significant breathing difficulties can occur. The symptoms and pneumothorax of the pneumothorax are markedly difficult to breathe. The symptoms of pneumothorax are related to the onset of illness, the amount of gas, clinical type, lung compression and primary lung disease.

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