What disease is pneumothorax? How serious is it? How to treat it?

Pleural cavity is composed of pleural wall layer and visceral layer, which is a closed potential cavity without air. Pleura is damaged for any reason, and air enters the pleural cavity, which is called pneumothorax. At this time, the pressure in pleural cavity rises, even the negative pressure becomes positive pressure, which makes the lungs compressed, and the blood flow of venous return to the heart is blocked, resulting in different degrees of pulmonary and cardiac dysfunction. The most common pneumothorax is the rupture of lung tissue and visceral pleura caused by lung diseases, or the spontaneous rupture of bullae and tiny bubbles near the lung surface, and the air in the lungs and bronchi escapes into the pleural cavity, which is called spontaneous pneumothorax. First, exhaust treatment According to the symptoms, signs and X-ray findings, you can judge what type of pneumothorax it is, whether it needs immediate exhaust treatment, and if it needs exhaust, what method is appropriate. (1) Closed pneumothorax When the volume of pneumothorax is less than 20% of the volume of the side chest cavity, the gas can be absorbed by itself within 2-3 weeks, and there is no need to pump air, but the change of pneumothorax volume should be observed dynamically. When the air volume is large, it can be pumped once a day or every other day, and the pumping time should not exceed 1L until most of the lungs expand, and the remaining pneumothorax can be absorbed by itself. (2) Hypertensive pneumothorax is serious and life-threatening, so it must be exhausted as soon as possible. Pneumothorax box can be used to measure pressure and exhaust simultaneously. In case of emergency, the sterile needle is inserted into the pleural cavity from the affected intercostal space, so that the high positive pressure pneumothorax can be discharged automatically and the symptoms can be alleviated. In case of emergency, a large syringe can be connected with three switches to pump air, or a pin can be inserted through the chest wall, and the end of the needle is connected with a water seal bottle for drainage, so that the high-pressure gas can be discharged in one direction. You can also use a thick injection needle to tie a rubber finger cuff at its tail, cut a small slit at the end of the finger cuff, and insert it into the pneumothorax for temporary and simple exhaust, so that high-pressure gas can be exhausted through the small slit. When the intrathoracic pressure drops to negative pressure, the cuff will collapse, the small cracks will be closed, and the outside air cannot enter the pleural cavity. In order to exhaust air effectively and continuously, a sealed water-sealed bottle for thoracic drainage is usually installed. The intubation site is usually taken from the second intercostal space outside the clavicle midline or the fourth to fifth intercostal space in the axillary front line. If it is a localized pneumothorax, or if it is necessary to drain pleural effusion, it is necessary to select a suitable part for intubation and exhaust drainage under X-ray fluoroscopy. Before installation, measure the pressure at the selected position with a pneumothorax box to know the type of pneumothorax, then make a skin incision of 1.5-2cm in parallel along the upper edge of the rib under local anesthesia, puncture the pleural cavity with a trocar, take out the needle core, and insert the sterile hose into the thoracic cavity through the cannula. Generally, a large catheter or silicone tube is selected, and a duckbill-shaped opening is cut at its front end, and one or two side holes are cut to facilitate drainage. Alternatively, after skin incision, the intercostal tissue can be blunted to the pleura, and then the catheter can be directly sent into the pleural cavity by penetrating the pleura. After the catheter is fixed, put the other end of the catheter under the water surface of the water-sealed bottle 1-2 cm, so as to keep the pressure in the pleural cavity below 1-2cmH2O. If the gas accumulated in the pleural cavity exceeds this positive pressure, the gas will escape from the water surface through the catheter. 1-2 days later, the patient did not feel short of breath. When the lungs are completely dilated by fluoroscopy or radiography, the catheter can be removed. Sometimes, although bubbles appear on the water surface, the patient's shortness of breath cannot be alleviated. It may be because the catheter is not smooth enough or partially slips out of the pleural cavity. If the catheter is blocked, it should be replaced. If this kind of water-sealed bottle drainage still can't heal the pleural breach and the lung can't dilate for a long time according to fluoroscopy, we can choose to intubate at another part of the chest wall, or add a negative pressure suction closed drainage device at the original unobstructed drainage tube end. Because the vacuum cleaner may generate excessive negative pressure, the negative pressure should not exceed -0.8 to-1.2 kPa (-8 to-12 H2O) when using the pressure regulating bottle. If the negative pressure exceeds this limit, the indoor air will enter the pressure regulating bottle through the pressure regulating tube, so that the negative pressure on the patient's chest will not be higher than -0.8 to-1.2 kPa (-8 to). When closed negative pressure suction is adopted, the aspirator should be started continuously, but if the lung does not dilate after 12 hours, the reason should be found. If there are no bubbles and the lungs are completely dilated, the drainage tube can be clamped to stop negative pressure suction and observed for 2-3 days. If the pneumothorax has not recurred, the drainage tube can be pulled out and the surgical incision can be covered with vaseline gauze immediately to prevent outside air from entering. If the bottle is not sealed, it should be placed under the patient's chest (such as under the patient's bed) to prevent the water in the bottle from flowing back to the chest. All kinds of intubation should be strictly disinfected in the process of drainage and exhaust to avoid infection. (3) Patients with a small amount of pneumothorax and no obvious dyspnea, after resting in bed and restricting their activities, or installing a water-sealed bottle for drainage, sometimes the pleural breach can be closed by itself and turned into a closed pneumothorax. If dyspnea is obvious, or patients with chronic obstructive pulmonary disease have pulmonary insufficiency, negative pressure suction can be tried. In the process of lung recruitment, the fissure will also close. If the rupture is large, or it continues to open due to pleural adhesion, and the patient's symptoms are obvious, and the simple exhaust measures do not work, the rupture can be observed by thoracoscope and closed by adhesion cautery. If there is no taboo, you can also consider opening the chest to repair the breach. Wiping parietal pleura with gauze during operation can promote postoperative pleural adhesion. If there are obvious lung lesions, lobectomy or segmental resection of the affected lung can be considered. Second, other treatment of spontaneous pneumothorax patients with lung atrophy, affecting gas exchange, forming a right-to-left shunt, blood oxygen saturation decreased, alveolar-arterial oxygen partial pressure increased. However, due to the decrease of blood flow in atrophic lung, the right-to-left shunt was corrected and the oxygen saturation recovered rapidly. Due to the existence of pneumothorax, restrictive ventilation dysfunction occurs, and lung volume such as vital capacity decreases, and respiratory failure may occur in severe cases. According to the patient's condition, give oxygen appropriately to treat the primary disease. Prevention and treatment of chest infection, antitussive and expectorant treatment, analgesia, rest and supportive treatment should also be paid attention to. For menstrual pneumothorax, in addition to exhaust treatment, drugs that inhibit ovarian function (such as progesterone) can be added to prevent ovulation. Third, complications and their management (1) Recurrent pneumothorax About13 pneumothorax can recur on the same side within 2-3 years. For recurrent pneumothorax. Pleural repair should be done for patients who can tolerate surgery; For those who can not tolerate thoracotomy, pleural adhesion treatment can be considered. Available binders include tetracycline powder for injection, sterilized refined talcum powder, 50% glucose, vitamin C, tracheitis vaccine, streptokinase, OK432 (Streptococcus preparation) and so on. Its mechanism of action is to produce aseptic allergic pleurisy through biological and physical and chemical stimulation, which makes the two pleura adhere and the pleural cavity atresia, thus achieving the purpose of preventing and treating pneumothorax. Before injecting adhesive into the chest cavity, there should be negative pressure suction closed drainage, and the lungs must be completely dilated. In order to avoid severe chest pain caused by drugs, appropriate lidocaine should be injected first, so that the patient can rotate his position to fully anesthetize the pleura, and the adhesive should be injected after 15-20 minutes. For example, 0.5- 1g tetracycline powder is dissolved in 100ml physiological saline, and then injected into the chest cavity through a drainage tube, so as to instruct the patient to repeatedly rotate the body position, so that the medicine is evenly coated on the pleura (especially the lung tip), and the tube is clamped for observation for 24 hours (if there are symptoms of pneumothorax, the tube can be opened at any time to exhaust), and the excess medicine in the chest cavity is sucked out. If you fail once, you can inject drugs repeatedly and observe for 2-3 days. (2) Purulent pneumothorax: necrotizing pneumonia, lung abscess and caseous pneumonia caused by Staphylococcus aureus, pneumonia, Pseudomonas aeruginosa, tuberculosis and various anaerobic bacteria may be complicated with purulent pneumothorax. The condition is critical, often forming bronchopleural fistula. Pathogens can be found in pus, and besides proper application of antibiotics (local and systemic), surgical treatment should also be considered according to specific conditions. (3) Hemopneumothorax Spontaneous pneumothorax with intrapleural hemorrhage is caused by rupture of blood vessels in pleural adhesion area. After the lungs are completely dilated, the bleeding can stop by itself. If bleeding continues, besides aspiration and proper blood transfusion, we should also consider thoracotomy and ligation of bleeding blood vessels. (4) mediastinal emphysema and subcutaneous emphysema After high-pressure pneumothorax is aspirated or closed drainage is installed, subcutaneous emphysema of chest wall can appear along pinhole or incision. The escaping gas also spreads to the subcutaneous layer of the abdominal wall and upper limbs. High-pressure gas enters the interstitial lung, along the vascular sheath, and enters the mediastinum through the hilum. Mediastinal gas can also enter the subcutaneous tissue of neck and chest and abdomen along fascia. On the X-ray film, the subcutaneous and mediastinal zona pellucida can be seen, and the great vessels in mediastinum are compressed. The patient felt pain behind the sternum, shortness of breath and cyanosis, decreased blood pressure, narrowed or disappeared the boundary of voiced heart sounds, and the heart sounds were far away, and a rough crack synchronized with the heartbeat could be heard in the mediastinum. Subcutaneous emphysema and mediastinal emphysema can be absorbed by themselves with the discharge and decompression of gas in pleural cavity. Inhalation of higher concentration of oxygen can increase the oxygen concentration in mediastinum, which is beneficial to the dissipation of emphysema. If the tension of mediastinal emphysema is too high, which affects breathing and circulation, puncture of suprasternal fossa or incision and exhaust can be done.