Overview of pneumothorax Pneumothorax refers to the accumulation of gas in pleural cavity. It can be seen from premature babies to children. It can be spontaneous pneumothorax or secondary to disease, trauma or after surgery. Etiology and Pathogenesis When the pleural cavity is connected with the external atmosphere, such as chest trauma or surgery, air enters the thoracic cavity through parietal pleura, and alveolar rupture or bronchopleural fistula caused by any reason, air escapes from the airway or alveoli and enters the pleural cavity, which can cause pneumothorax. Spontaneous pneumothorax, the cause of which is unknown, is more common in young and elderly children and easy to recur. It is reported that the recurrence rate is high, and about 1/3- 1/2 patients have spontaneous pneumothorax again. I can be a family member. Secondary pneumothorax mostly occurs in the following situations: ① penetrating or non-penetrating trauma caused by bronchial or alveolar rupture. Children's chest injuries often occur in car accidents or falling from high places. Trauma of rib fracture and penetrating injury involving visceral pleura are often accompanied by hemothorax. ② All kinds of puncture, such as pleural puncture or lung puncture, can cause pneumothorax if the needle is inserted too deeply. ③ Postoperative bronchopleural fistula with pneumothorax may occur. ④ During tracheotomy, if the position is too low to pierce the chest wall. ⑤ Mechanical ventilation, especially terminal positive pressure, is more likely to cause pneumothorax than intermittent positive pressure. In recent years, it has become more and more common to use mechanical breathing to rescue neonatal respiratory distress syndrome and other lung diseases abroad, so the number of neonatal pneumothorax has also increased. Those newborns with extensive alveolar damage and severe decline in lung compliance are most likely to be complicated with pneumothorax with artificial mechanical ventilation. At the same time, air entering the mediastinum causes mediastinal emphysema and subcutaneous emphysema, and severe cases are accompanied by pneumoperitoneum or pericardium. ⑥ Severe airway obstruction (such as neonatal asphyxia, whooping cough, foreign body inhalation in airway, asthma, etc.). ) can also cause pneumothorax due to rupture of lung tissue. All landowners pneumothorax secondary to lung infection, the most common is staphylococcus aureus pneumonia, followed by gram-negative bacilli pneumonia. It can also be secondary to lung abscess and gangrene, both caused by infection, such as lung tissue necrosis, visceral pleural perforation and pneumothorax or empyema. (8) Secondary to diffuse lung diseases, such as miliary pulmonary tuberculosis (Figure 20-20), cavitary pulmonary tuberculosis, Langerhans histiocytosis and congenital pulmonary cyst's disease. Beijing Children's Hospital has admitted a case of congenital enterogenous pulmonary cyst (gastric duplication)/kloc-0, which is bilateral pneumothorax caused by ulcer communicating with lung and pleura (Figure 24-25). Pet-name ruby occasionally pneumothorax complicated with malignant tumor such as malignant lymphoma, osteosarcoma in children, tuberculosis, etc. Attending swallowing corrosive drugs can cause esophageal ulcers and air escaping into the chest. For example, the mechanism of valve formation at the bronchial fissure, air can be inhaled into the chest cavity but not discharged, leading to tension pneumothorax. During the whole respiratory cycle, the pressure in the chest cavity is higher than atmospheric pressure, which has a great influence on cardiopulmonary function. Not only is there a serious ventilation disorder, but also the blood flow of venous return to the heart decreases because the positive pressure reaches the mediastinum. Due to severe hypoxia and shock, tension pneumothorax in children is a serious emergency, which should be diagnosed and treated correctly immediately. Clinical manifestations The symptoms and signs of pneumothorax vary according to the amount of gas in the chest cavity and whether it is tense or not. Most of them are suddenly aggravated on the basis of the original disease, breathing faster, looking embarrassed, and the child's expression is frightened because of lack of oxygen. The incidence of pneumothorax in infants is more acute and serious, and dyspnea occurs suddenly during the course of pneumonia. A small number of localized pneumothorax can be completely asymptomatic and can only be found by X-ray examination. If the pneumothorax is large, it can cause chest pain, persistent cough, asphyxia and cyanosis, and there will be weakened breathing, chest percussion drum sound and breathing sound on the affected side weakened or disappeared. If you hit two coins on your back, you can hear the empty sound when you auscultate on your chest. If the bronchial fistula persists, the breathing sound will become hollow. A large number of pneumothorax, especially tension pneumothorax, can be seen that the intercostal space is filled, the diaphragm moves down, the trachea and heart are pushed to the healthy side, and at the same time, shortness of breath is aggravated, resulting in severe hypoxia, extremely small pulse, decreased blood pressure and low cardiac output shock, all of which are crises caused by tension pneumothorax. It is not difficult to diagnose and differentiate according to typical symptoms and signs. X-ray fluoroscopy and X-ray photography are helpful for diagnosis. It can be seen that the atrophic lung edge is the pneumothorax line, and the compressed atelectasis lung tissue is pushed to the hilum in groups. Pneumothorax is partly transparent without any lung texture, but in newborns, pneumothorax can be located in the front and inside, pushing lung tissue to the back. No pneumothorax line can be seen in the frontal radiograph, or only a few pneumothorax images can be seen at the lung apex. The pneumothorax is a transparent arc shadow with its surface protruding outward, and a dense collapsed lung shadow can be seen outside the edge of the transparent arc circle. Tension pneumothorax shows that the trachea and heart are pushed to the healthy side and the diaphragm moves down (Figure 24-26). It is sometimes difficult to diagnose neonatal pneumothorax, and the increase of transmittance of the affected side can be detected by light transmission method to assist the diagnosis. Pneumothorax should be differentiated from pulmonary bulla, lobar emphysema, congenital pulmonary cyst with air or diaphragmatic hernia. Please refer to the special chapter of this disease. The treatment shows that small pneumothorax, such as pneumothorax accounting for less than 20% of the chest volume, will automatically absorb air after untreated 1 ~ 2 months. Large volume pneumothorax can absorb pure oxygen 1 ~ 2 hours, which will increase the oxygen gradient difference between pleural cavity and blood, which is beneficial to the absorption of pneumothorax. When a large number of pneumothorax causes dyspnea, first aid should be performed by thoracic puncture and then closed drainage should be adopted. For tension pneumothorax, if the general closed drainage is still ineffective, continuous thoracic suction drainage can be performed. When there is bronchopleural fistula, air should not be sucked out too frequently to make the fistula heal as soon as possible. The prognosis shows that the prognosis depends on whether there are bronchopleural fistula and tension pneumothorax. Limited to local pneumothorax, air can be absorbed gradually. A large number of pneumothorax can generally be cured if it can be diagnosed and treated correctly in time, but tension pneumothorax is a critical disease, and improper treatment will lead to death. Pneumothorax complicated with bronchopleural fistula can last for a long time or complicated with empyema, and the prognosis is poor. Pneumothorax is a common medical emergency. When the pleura ruptures due to pathological changes or trauma, gas enters the pleural cavity to form pneumothorax. Although the gender distribution is different due to different etiology, there are more men than women (5∶ 1), which can be seen at any age. According to the pathogenesis, pneumothorax can be divided into the following types: 1, post-traumatic pneumothorax: caused by stabbing the chest with a sharp instrument; 2. Primary pneumothorax: Pneumothorax of healthy people without obvious lung lesions is more common in young adults aged 20-40, especially men; 3. Secondary pneumothorax: pneumothorax secondary to various lung diseases, such as chronic bronchitis, emphysema, tuberculosis and lung cancer. According to the pathological structure, pneumothorax can be divided into the following types: 1, closed pneumothorax (simple pneumothorax): the lung is compressed by the gas in the pleural cavity, the breach is closed, and there is no leakage; 2. Open pneumothorax: In fact, it is a bronchopleural fistula, the breach is always open, and the pressure remains unchanged after pumping. This type of pneumothorax is rare, and mediastinal oscillation occurs during respiratory circulation, which seriously affects the physiology of respiratory circulation; 3. Tension pneumothorax (high pressure pneumothorax): A one-way valve is formed at the breach, which opens when inhaling and closes when air enters the lungs, so that air cannot escape. The pressure in pleural cavity gradually increases, which can be reduced for a short time after aspiration and then increased again soon. This type is a medical emergency, which can cause serious respiratory and circulatory dysfunction, even hypoxia and shock. Primary pneumothorax is usually caused by congenital pulmonary tissue hypoplasia, pulmonary bullae or subpleural pulmonary bullae, and the lesion is often located at the tip of the lung. Secondary pneumothorax is caused by primary pulmonary lesions, the rupture of subpleural pulmonary bullae or the direct damage to pleura caused by the lesions themselves. Spontaneous pneumothorax is mostly unilateral, with only about 65,438+00% on both sides, while the probability of secondary pneumothorax on both sides is very high. Patients often have sudden chest pain after pneumothorax, which is sharp and persistent stabbing pain or knife cutting pain. Inhalation is aggravated, mostly in the chest and armpit, and can radiate to the shoulders, back and upper abdomen, thus causing dyspnea. Its severity is closely related to the speed and type of pneumothorax, the degree of lung atrophy and the basic function of lung. Unilateral closed pneumothorax, especially young people with normal lung function, can have no obvious dyspnea, even 80-90% of the lungs are compressed or feel a little short of breath when moving and going upstairs, while tension pneumothorax or original obstructive emphysema. Irritating dry cough is caused by gas stimulating pleura, which is mostly not serious, has no sputum or occasionally has a small amount of bloodshot sputum, which may come from broken lung. If chest pain or dyspnea suddenly occurs, you should go to the hospital for X-ray examination immediately. On the chest radiograph, there is a pneumothorax in the pleural cavity without lung texture, and there is a curved linear lung compression edge on the inside, which can be diagnosed as pneumothorax. But other emergencies have similar manifestations, such as acute myocardial infarction, acute pulmonary embolism, pulmonary bullae, acute abdomen and so on. If X-ray examination shows no signs of pneumothorax, further examination should be done immediately to clarify the cause, such as electrocardiogram. The treatment of pneumothorax is as follows: 1. General reason: All kinds of pneumothorax patients should stay in bed and limit their activities. When the lung compression is less than 20%, there is no need to suck it out, and symptomatic treatment can be given to relieve cough and pain. When there is infection, appropriate antibiotics should be selected as appropriate. 2. Treatment of acute pneumothorax: The key to emergency treatment of pneumothorax is evacuation and decompression to promote early expansion. Suction: For closed pneumothorax with lung compression > 20%, especially emphysema patients with poor lung function, suction is the primary measure to quickly relieve dyspnea. Suction method: simple method: suction with syringe, suitable for first aid and convenient for patients to transport. Closed drainage: suitable for tension pneumothorax. No bubbles escape from the water-sealed bottle, and the liquid level in the glass tube no longer fluctuates. When the chest X-ray confirms that the lungs have expanded, you can extubate. Continuous negative pressure suction: bubbles still escape after more than one week of closed drainage, indicating that the breach has not healed, and negative pressure suction should be added to facilitate lung recruitment. 3. Surgical treatment: Proper surgical treatment can not only accelerate the cure of pneumothorax and help the lungs recover as soon as possible, but also accurately understand the basic lesions of spontaneous pneumothorax, so as to take reliable radical measures to prevent recurrence. Surgical indications: open pneumothorax: surgical resection of adhesion around the crevasse and repair of pleural fistula; Chronic pneumothorax: Pneumothorax that has been treated by negative pressure suction in internal medicine for more than 3 months, and the breach has not healed. 4. Pleural adhesion statement: Injecting sclerosing agent into pleural cavity will produce aseptic inflammation, cause pleural adhesion, block pleural cavity and prevent the recurrence of pneumothorax. The prognosis depends on the primary disease, lung function, pneumothorax type and whether there are complications. Early and timely treatment has a good prognosis, 90% closed pneumothorax can be cured, 5- 10% patients have no complications, 20% patients with hemopneumothorax and 50% patients with bilateral pneumothorax have poor lung function. "Pneumothorax", as its name implies, refers to air escaping into pleural cavity, causing lung compression. Normal lungs are covered with two pleura, and a closed pleural cavity is formed between the two pleura, in which a small amount of serous fluid plays a lubricating role. The pressure in the closed pleural cavity is lower than atmospheric pressure, which is helpful for alveolar expansion and air inhalation. When the lung tissue and pleura rupture, air enters the pleural cavity, which increases the pressure in the thoracic cavity, even becomes positive pressure, causing the lung to be compressed, which leads to the obstacle of lung gas exchange and venous blood returning to the heart. Symptoms include dyspnea, chest pain, cough and cyanosis. Spontaneous pneumothorax is caused by the rupture of lung and pleura (inner layer), or the lung lesion degenerates into pleural cavity, and air directly enters the thoracic cavity from the mouth, trachea and bronchus. This section does not discuss traumatic pneumothorax caused by chest trauma (including accidental needle stick injury, puncture and operation). (1) Etiology of spontaneous pneumothorax: (1) Emphysema caused by tuberculosis, chronic bronchitis, asthma and silicosis, and rupture of pulmonary bullae. (2) Lung abscess and lung cancer destroy pleural cavity. (3) Suddenly entering a low-pressure environment from a high-pressure environment, such as diving, aviation has no protective measures. (4) The etiology of some patients is unknown. (5) Inducing factors include puffing gas to extract heavy objects, strenuous exercise, coughing, sneezing, laughing, and choking caused by pungent smell (such as when frying peppers). (2) Clinical manifestations of spontaneous pneumothorax: The severity of pneumothorax symptoms depends on the speed of pneumothorax, air intake and the degree of lung diseases that cause pneumothorax. 1 Chest pain occurs suddenly and can radiate to shoulder, back, armpit and forearm. Chest pain on the side where pneumothorax occurs is aggravated when coughing and inhaling deeply. Dyspnea is related to the degree of lung compression. Young adults have no obvious lung lesions and good lung function. If one lung collapses less than 20%, there is no sign. Mild dyspnea occurs when 90% of one lung collapses. The original chronic lung disease, weakness, old age, lung compression is only 10%, and severe dyspnea may occur. Some patients also have progressive dyspnea. 3 Cough is mostly dry cough, and those with empyema cough up pus and phlegm. Shock mostly occurs in patients with tension pneumothorax (the fissure is valvular and air can only enter and exit), and the rescue is not delayed in time. In addition to the aggravation of dyspnea, patients also have cyanosis, excessive sweating, cold limbs, weak pulse and decreased blood pressure, which can lead to coma and death. X-ray examination can confirm the diagnosis. If you don't have X-ray equipment, you can observe the chest, and the breathing movement on one side of the pneumothorax is weakened, and a "whirring" drum sound is issued by pounding. (3) The mortality rate of rescue measures is high. (1) Take a quiet rest immediately after pneumothorax, and those who have oxygen at home can take oxygen. Those with mild symptoms do not need special treatment, so that the air entering the pleural cavity is slowly absorbed and the wound is gradually healed. But you have to go to the hospital to find out the cause and treat it. (2) Patients with severe dyspnea, cyanosis and chest pain cannot be delayed. It must be immediately sent to the nearest hospital for thoracic puncture and aspiration, and then continue to be closed for 24 ~ 72 hours until the pleural fissure is closed, the air in the pleural cavity cannot enter, the collapsed lung tissue expands again, and the ventilation function is restored. (3) Emergency and simple exhaust method: In the case of serious illness and no special equipment, you can use a needle used for injection at ordinary times to connect a syringe of 50 ~ 100 ml (used after disinfection) for thoracic puncture and exhaust. The puncture site is at the intersection of the second intercostal space and the clavicle midline on one side of pneumothorax. It is safer to insert the needle in the place where percussion is drums. When the needle pierces the chest cavity, air is immediately ejected from the needle to push the syringe needle plug, and the patient's breathing difficulty is quickly relieved after exhausting. Generally, exhaust 1000 ~ 2000 ml before other treatment.