The closed pheumothorax – the partial or full fall of a lung caused by hit of air in a pleural cavity; at the same time the pleural cavity is not reported with the external environment, and the amount of gas at breath does not increase. It is shown by breast pain on the party of defeat, feeling of shortage of air, pallor and cyanosis of integuments, aspiration of the patient to reach the compelled position, existence of hypodermic emphysema. The diagnosis of the closed pheumothorax is confirmed auskultativno and radiological. The medical help includes anesthesia, a kislorodoterapiya, carrying out a pleural puncture or drainage.
The closed pheumothorax
The closed pheumothorax is characterized by availability of free gas in a pleural cavity in the absence of its message with atmospheric air. By origin can be spontaneous or traumatic; idiopathic (to primary - arising without the visible reasons) or symptomatic (secondary - developing against the background of other pulmonary pathology). On lung collapse degree in pulmonology distinguish small, or limited (fall of a lung on 1/3 volumes), average (fall on 1/2 volumes) and total pheumothorax (fall of a lung more than on a half). In comparison with other forms (open, valvate), the closed pheumothorax has more favorable current. At the same time, bilateral total or intense pheumothorax at not rendering the timely help can result in critical respiratory insufficiency and a lethal outcome.
The reasons of the closed pheumothorax
In most cases leads a rupture to developing of the closed pheumothorax subplevralno of the located air cysts at a bullous pulmonary disease. On the second place on the frequency of the reasons chronic bronchopulmonary diseases are called: HOBL, bronkhoektatichesky disease, bronchial asthma, tuberculosis, staphylococcal destruction of a lung, pneumosclerosis, , malformations of lungs, etc. In these cases there is an anguish of pleural unions or single alveoluses. The anguish of bulls or solderings can be provoked by the physical tension, a natuzhivaniye, cough or just forced breath, however quite often arises at rest.
Traumatic pheumothorax, as a rule, is a consequence of the closed injury of the thorax which is followed by a fracture of edges, a rupture of a lung. Sometimes carry the yatrogenny closed pheumothorax developing at violation of a technique of carrying out a pleural puncture, transthoracic tonkoigolny biopsy of a pleura, a transbronchial biopsy of a lung, statement of a subclavial catheter to the same group; a barotrauma at IVL, warm and pulmonary resuscitation. Imposing of the artificial closed pheumothorax (an operational kollapsoterapiya) is used as a way of treatment of kavernozny tuberculosis of lungs.
Contribute to development of pathology: prematurity (an underdevelopment of a pleura, cellulose of a sredosteniye, connecting fabric, bronkho-alveolar ways), addiction to smoking, soyedinitelnotkanny a dysplasia, the burdened heredity.
At the closed pheumothorax air is included into a pleural cavity at the time of a trauma or small damage. In the absence of the valvate mechanism defect in pulmonary fabric is quickly closed, the amount of air in a pleural cavity does not increase, pressure in it does not exceed atmospheric, flotation of a sredosteniye is absent. The intense pheumothorax which is a complication of valvate pheumothorax on the mechanism can be considered as closed. In the beginning there is a forward forcing of air in a pleural cavity via the wound channel in a chest wall (external valvate pheumothorax) or the injured large bronchial tubes (internal valvate pheumothorax). In process of increase in amount of air and pressure in a pleural cavity wound defect is fallen down that development of intense pheumothorax marks. In this case dislocation of structures of a sredosteniye, sdavleny VPV, zhizneugrozhayushchy disorders of breath and blood circulation is observed.
Symptoms of the closed pheumothorax
The clinic of the closed pheumothorax is defined by the painful phenomena, respiratory insufficiency and violation of blood circulation which expressiveness depends on air volume in a pleural cavity. The disease most often demonstrates suddenly, unexpectedly for the patient, however in 20% of cases the atypical, erased beginning is noted. In the presence of a small amount of air the clinical symptomatology does not develop, and limited pheumothorax comes to light at planned passing of fluorography.
In case of an average or the total closed pheumothorax there are sharp pricking breast pains irradiating in a neck and a hand. There is short wind, dry cough, feeling of shortage of air, tachycardia, cyanosis of lips, arterial hypotonia. The patient sits, leaning hands on a bed, the face is covered cold then. On soft facial tissues, necks, trunks extend the hypodermic emphysema caused by hit of air in hypodermic cellulose.
At intense pheumothorax condition of the patient heavy or extremely heavy. The patient is uneasy, has sensation of fear because of feeling of suffocation, greedy catches a mouth air. ChSS increases, integuments get cyanotic coloring, the kollaptoidny state can develop. The described symptomatology is connected with a full collapse of a lung and shift of a sredosteniye in the healthy party. In the absence of emergency aid intense pheumothorax can lead to asphyxia and sharp cardiovascular insufficiency.
Diagnosis of the closed pheumothorax
The closed pheumothorax can be suspected by the pulmonologist on the basis of a clinical picture and auskultativny data, and is finally confirmed with results of a rentgendiagnostika. At survey smoothing of intercostal intervals, lag of a half of a thorax on the party of defeat at breath is defined; at an askultation - easing or lack of respiratory noise; at percussion – timpanit; at a palpation of soft fabrics with the phenomena of hypodermic emphysema - a characteristic crunch.
By means of a X-ray analysis of lungs it is possible to reveal a congestion of free gas between a kollabirovanny part of a lung and a parietal pleura (at total pheumothorax – a full collapse of a lung with the simultaneous shift of a sredosteniye in the healthy party). As final confirmation of the diagnosis serves receiving air at a torakotsenteza. Immediate causes of the closed pheumothorax are specified after data acquisition of KT of a thorax or in the course of carrying out a diagnostic torakoskopiya.
It is necessary to differentiate the closed pheumothorax from a relaxation of a dome of a diaphragm, uncomplicated cysts of a lung, an atelektaz of a lung, lobarny emphysema, hernia of a gullet, a gemotoraks, a hilotoraks, a myocardial infarction, etc. For this purpose the specifying diagnostics can be required (a bronchography, an angiopulmonografiya, KT of lungs, a stomach X-ray analysis, etc.).
Treatment of the closed pheumothorax
The small amount of air in a pleural cavity which is not giving symptoms can independently resolve. However radiological control is necessary for an exception of progressing of the closed pheumothorax. In clinically significant cases hospitalization of the patient in office of thoracic surgery or traumatology and immediate rendering the qualified help is required. When transporting in clinic it is necessary to anesthetize the patient, to give him a semi-sitting position, to provide inhalations of the moistened oxygen, at arterial hypotonia to enter vazotonichesky means.
The subsequent treatment of the closed pheumothorax can be made by conditionally conservative or operational method. The first method assumes carrying out a pleural puncture with one-stage evacuation of air or drainage of a pleural cavity with imposing of a drainage across Byulau or the electrovacuum device of active aspiration. The typical place for installation of a drainage is the II mezhreberye on the sredneklyuchichny line.
In case of inefficiency of a punktsionno-drainage method or a numerous recurrence of the closed pheumothorax the toraksokospichesky or open intervention pursuing the aim of elimination of the prime cause of pathology is made. For prevention of repeated cases it is carried out , leading to formation of unions between leaves of a pleura and an obliteration of a pleural crack.
The forecast and prevention of the closed pheumothorax
The forecast and prevention of the closed pheumothorax are closely connected with its prime cause. It is noticed that idiopathic pheumothorax proceeds more favorably, than symptomatic. Are the most dangerous intense and bilateral pheumothorax, resulting in respiratory and cardiovascular insufficiency.
The disease recurrence, pleurisy, empiyema of a pleura, intra pleural bleeding, formation of a so-called rigidny lung belong to number of the states complicating the closed pheumothorax. At the obscure or known, but not removed cause of the closed pheumothorax a recurrence for 3 years is observed in half of cases, after elimination of the reason – only in 5%.