Traumatic pneumothorax

Traumatic pneumothorax occurs in injuries of the chest. Traumatic pneumothorax can be external or internal, is open or closed. Outer pneumothorax is called open if the air when the breath is drawn in through a wound in the pleural cavity, and when exhaling out again. When closed, P. the quantity of air, simultaneously released into the pleura, then remains stable. Finally, if the air in each breath sucked in the pleural cavity, but when exhaling out of it goes out, P. called valve. This Isthmus is usually the case when internal P., but occurs when the outer.
Every penetrating wound of the thorax is accompanied by entering into the pleural cavity of a number of air. However, an indoor P. not always detected clinically, and the final diagnosis is only at an early x-ray. Open pneumothorax can turn into a closed, if the wound of the chest wall was covered fabrics, and the flow of air in the pleural cavity stopped. If the air through the wound of the chest wall or bronchus comes with inspiration in the pleural cavity, and when exhaling the wound is covered fabrics like a valve, the pressure in the cavity of the pleura is gradually increasing, leading to the total collapse of the lung and large mediastinal shift. Outdoor P. can be a double, if one of the pleural cavity has two wounds (C. I. Kolesov). Bilateral P. may occur as the result of injury both pleural cavities, and because of the simultaneous failure of one half of the chest wall and mediastinum.
Pathological physiology traumatic pneumothorax depends on the degree and nature of damage. When you open P., if the value of wound apertures larger than the diameter of the main bronchus, is developing the so-called wide open P., which comes a collapsed lung, mediastinal shift towards intact pleural cavity, leading to gross violations of the mechanism of respiratory and cardiovascular activities. At a wide-open P. the pressure in the pleural cavity is approaching naturally (by C. B. Dmitriev, the norm - from 30 to 45 cm of water. Art.).
In addition to a number of reflex impacts associated with cooling pleural cavity, inflection and rotation of large vessels of the heart, a violation sufficient outflow in the system hollow vein (especially in right P.) and other smaller total respiratory surface. Mediastinum not only offset in the undamaged side, but there are fluctuations (flotation), sharply reduced diaphragm excursion, and there is a paradoxical breathing - pumping air, saturated with carbon dioxide, from stavshego easy healthy. In the small circle of blood come disorders associated with difficulty passing blood in collaborando lung. The depth of inhalation falls to 200 ml (M. N. Anichkov). All this leads to a marked disruption of gas exchange.
Pathophysiological changes in the closed pneumothorax expressed less sharply and depend mainly on the number penetrated into the pleural cavity of the air and the degree of spadenia easy. This may decrease pulmonary ventilation, not lead, as a rule, to heavy breathing disorders.
The most severe form of traumatic P. is a valve, which come deep violations of the mechanism of breathing.
The clinical picture traumatic pneumothorax depends on the nature of the damage. When closed, P. develop moderately severe shortness of breath (see), cyanosis (see), tachycardia (see). Percussion chest is defined sound box, and auscultation - decreased breath.
The clinical picture of the open P. characterized by severe condition, accompanied circulatory disorders and pronounced breathing disorders. The severity of the condition depends on the development of shock (see), which was named pleuropulmonary because of differences in the pathogenesis of shock trauma other localizations. Based pleuropulmonary shock is the irritation of many receptors of parietal and visceral pleura.
During examination of the patient with an open pneumothorax in the wounds of the chest wall (if the wound channel narrow) with inspiration may be heard "sucking" the sound associated with the penetration of air in the pleural cavity. When exhaling and coughing, on the contrary, the air is pushed from the pleural cavity, often with frothy blood, as the result of injury, almost as a rule, develops and hemothorax (see). In the case of a large defect chest wall air penetrates into the pleural cavity without noise. When a small skin wound (gunshot wound, injury to the chest wall any sharp instrument or atomcom ribs and so forth), you need to make a careful palpation for detecting broken ribs, subcutaneous emphysema (see). Palpation in the area of the pectoralis major muscle and shoulder blades represents a significant challenge, and determine fractured ribs are very difficult. Subcutaneous emphysema is a very important symptom indicating the need for surgical intervention discontinued when the suction of air. The increase in subcutaneous emphysema indicates damage the lung, and especially fast-growing and spreading emphysema typical valve pneumothorax (C. L. Libov). To set the degree of damage to the lung before surgery is very difficult. Main symptoms of lung serve hemoptysis, significant emphysema and hemothorax. However, emphysema and hemothorax may occur in the open pneumothorax without damage to the lung.
At gunshot wounds of the chest may develop secondary P., which occurs a few days after the injury and is the result of infectious complications of the bullet wounds to the chest. In the result purulent fusion of soft tissue or blood clots, clog the wound channel at the time of injury, from the pleural cavity of the pouring out of the accumulated fluid, air penetrates into the pleural cavity and develops a picture of the open P. Second coming P. should be distinguished from secondary opened P., which develops as a result of discrepancies wounds after the liquidation of open P. (stitching wounds of the chest). The reasons again opened on can be wound infection or technical errors during the primary surgical treatment of wounds.
The clinical picture valve pneumothorax is characterized by rapidly increasing disorder of respiratory and cardiovascular activities with severe shortness of breath, pronounced cyanosis, tachycardia. Percussion is defined sound box on the affected side, borders cardiac dullness significantly biased towards intact pleural cavity. One of the leading symptoms valve P. - rapid progressive subcutaneous emphysema, which in a short period of time can reach extreme levels. If in the next few hours after the injury has not been provided surgical assistance, subcutaneous emphysema can spread throughout the body. The person of the victim takes the form of inflated air balloon; the eyes, mouth, nostrils turned into a narrow slit.
Treatment depends on the type of pneumothorax. Indoor P. with a small amount of air in the pleural cavity special treatment is not required, as usual conservative measures (rest, medical treatment) for several days lead to resorption of air from the pleural cavity.
In the case of a complete collapse of the lung required puncture pleural cavity with a maximum suction of air to the full unfolding of the lung. Puncture should be done in VI-VIII intercostal space on the posterior axillary line under local infiltration anaesthesia (0.25-0.5% solution novokaina). To prevent penetration of air in the pleural cavity during the puncture should be used needle planted with rubber tube, which pinch clip. For pumping can be used device for imposing artificial P. or Janet's syringe.
When you open the pneumothorax necessary urgent measures. First aid is to prevent future admission of air in the pleural cavity, which can be accomplished by imposing so-called occluzionna bandages from strips of adhesive tape or impermeable fabric (for example, the shell individual bandage). You must enter painkillers, anti-tetanus serum (1500 AE), and at very contaminated wounds and protivomigrenoznoe. To transport the victim to the hospital better in a semi-sitting position and oxygen inhalation. At the first medical aid must be made cervical vagosimpatical procaine blockade (see Blockade procaine).

Surgical treatment is the primary processing of wounds and wound closure of the chest wall. The surgery is performed under local infiltration anaesthesia, or under endotracheal anesthesia with the use of muscle relaxants and controlled breathing. General anesthesia is more rational, as endotracheal anesthesia provides a complete ventilation of the lungs, which is particularly important when the lung damage; in addition, with the anesthesia, you can suck blood and mucus from the Airways. After excision of the wound edges, including muscles, impose a two-, three -, nodal kathoey seam at the pleura, muscles (Fig. 1) and the fascia. Skin leave unembroidered or impose rare silk sutures. When symptoms of lung necessary revision of the pleural cavity, which produce a wide thoracotomy (see). The nature of the incision depends on the location of the wound and directions of the wound channels. At small stripes of light produce closure of the lung, in case of more extensive damage - segmentectomy, a lobectomy (see Light, surgery). The surgery is completed the introduction of permanent drainage in the VIII-IX intercostal space on the posterior axillary line. Drainage is connected to a device for permanent aspiration at a slight negative pressure or establish underwater valve drain on N. N. Petrov (see Drainage). In the case of large defects of the chest wall may be applied plastic flap on the leg muscles, the periosteum rib flap of the diaphragm at the bottom (Fig. 2), pneumopulse - sewing light or chest wall, or to the medial pleura.
In valvular pneumothorax necessary emergency measures, as a sharp increase of intrapleural pressure can very quickly lead to severe respiratory failure and death. First aid, in addition to General measures include a biopsy of the pleura. With extensive subcutaneous emphysema also required puncture subcutaneous tissue several thick needle, including in the neck (mediastinal emphysema). Surgical treatment of external valve P. involves excision of the wounds of the chest wall and impose on it a deaf seam. When the internal valve pneumothorax shown thoracotomy and wound closure of the lung. If the condition does not allow thoracotomy, as palliative measures can be taken drainage of the pleural cavity active and constant aspiration for 5-7 days. In two-way valve P. necessary drainage both pleural cavities with a constant active aspiration for 7-8 days. If it is impossible to have an active aspiration used underwater drainage valve. In the postoperative period to combat hypoxia necessary inhalation humidified oxygen through nasal catheter or mask), and the appointment of broad-spectrum antibiotics and sulfa drugs.

Fig. 1. Operation the suturing wounds in the open pneumothorax: 1 - the first row of stitches in the pleura with muscles; 2 - second row of stitches on the muscles.
Fig. 2. The closure of the defect chest wall with open pneumothorax with flap of the diaphragm.