(内科学课件）15.英文气胸课件-许瑞

pneumothoraxpneumothoraxpneumothoraxpneumothorax 气气气气 胸胸胸胸 重庆医科大学附属第二医院 呼吸内科 许瑞 讲师 anatomical structure(anatomical structure(anatomical structure(anatomical structure(解剖结构解剖结构解剖结构解剖结构) ) ) ) 壁层胸膜（ parietal pleura） 脏层胸膜 (visceral pleura) 胸膜腔 (pleural cavity ) a hermetic cavity(密闭 ) no air 3 15ml liquids a negative pressure (呼气末-5-3mmHg； 吸气末-10-5mmHg) anatomical structure(anatomical structure(anatomical structure(anatomical structure(解剖结构解剖结构解剖结构解剖结构 ) ) ) ) characteristic Pneumothorax is the presence of gas in the pleural space. Definition of Definition of Definition of Definition of pneumothoraxpneumothoraxpneumothoraxpneumothorax 气气 体体 胸膜腔胸膜腔 胸膜腔积气状态胸膜腔积气状态 The failure of respiration restrictive ventilatory disorder ventilation/perfusion ratio Circulation disorder disturb venous reflux Heart: FV、SV Hypo xemia HR BP Shock PathophysiologyPathophysiologyPathophysiologyPathophysiology of of of of pneumothoraxpneumothoraxpneumothoraxpneumothorax 气胸的病理生理表现气胸的病理生理表现气胸的病理生理表现气胸的病理生理表现 Pathogenesis Pathogenesis Pathogenesis Pathogenesis 发病机制发病机制发病机制发病机制 The fracture of parietal pleura The fracture of visceral pleura Infection of aerogen(产气菌感染) 1. According to the pathogenesis The fracture of visceral pleura Primary Spontaneous Pneumothorax Secondary Spontaneous Pneumothorax Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax Traumatic Pneumothorax Iatrogenic Pneumothorax The fracture of visceral/ parietal pleura The fracture of visceral/ parietal pleura Spontaneous Pneumothorax Whether there are definite lung diseases according to the chest X-ray The fracture of visceral pleura Primary Secondary 自发性气胸自发性气胸（ Spontaneous Pneumothorax ）：Pneumothrax without trauma or anthropogenic factors. Primary spontaneous pneumothorax: Usually due to rupture of apical pleural blebs, small cystic spaces that lie within or immediately under the visceral pleura. Secondary spontaneous pneumothorax: Secondary spontaneous pneumothoraces are due to pre-existing lung diseases (like chronic obstructive pulmonary disease) . Spontaneous Pneumothorax 1. According to the pathogenesis Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax 2、 clinical classification （重点掌握） 闭合性（单纯性）气胸（Closure pneumothorax） 交通性（开放性）气胸（Unclosure pneumothorax） 张力性（高压性）气胸（Tension pneumothorax ） Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax 闭合性气胸 Closure pneumothorax Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax 1.Small crevasse 2. The crevasse healed quickly 3. Relatively low pressure in the chest Unclosure pneumothorax Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax 1.Crevasse openned persistently 2. Air flows into the pleura space and back to lung tissue through the crevasse fredomly 张力性气胸 Tension pneumothorax Classification of Classification of Classification of Classification of pneumothoraxpneumothoraxpneumothoraxpneumothorax 临床分类比较临床分类比较临床分类比较临床分类比较 破裂口 胸腔内压 纵隔移位 呼吸循环 影响 闭合性 小小破口 自行闭合 接近大气 压 无轻 交通性 持续开放 自由出入 =大气压不明显轻 张力性 单向活瓣 只进不出 明显严重 临床表现（临床表现（临床表现（临床表现（clinical manifestationclinical manifestationclinical manifestationclinical manifestation） Inducing causes: Inducing causes: Classical symptom: Classical symptom: intense activity, lifting, fierce cough chest pain, dyspnea, cough The degree of The degree of dyspneadyspnea depends on depends on呼吸困难的程度取呼吸困难的程度取 决于：决于： The basic lung function of the patients Whether the generation of pneumothrax is slow or fast The amount of gas and the pressure in the pleural space Tension pneumothorax Sever respiratory failure and shock. Orthopnea, restless, sweating. Case1Case2 临床表现（临床表现（临床表现（临床表现（clinical manifestationclinical manifestationclinical manifestationclinical manifestation） Case 1 Case 1 Case 1 Case 1 A young man with no respiratory disease before. Symptom：Slight chest pain and no dyspnea Chest X-ray: middle-large amount of pneumothrax An old man with COPD Sever dyspnea， Orthopnea，cyanosis，RR: 4050 /min Need oxygen therapy Chest CT Case 2 Case 2 Case 2 Case 2 Clinical sign Inspection：Trachea shift to uninjured side, full chest of the injured side Palpation: deceased vocal fremitus/chest expansion of the injured side, (subcutaneous emphysema) subcutaneous crepitation Percussion：hyper-esonance/tympany Ausculation：decreased of respiratory sound of the injured side. 临床表现（临床表现（临床表现（临床表现（clinical manifestationclinical manifestationclinical manifestationclinical manifestation） Radiology testRadiology testRadiology testRadiology test Chest X ray CT-scan 压缩肺压缩肺 组织组织 无肺纹无肺纹 理区（理区（ 积气带积气带 ） Radiology testRadiology testRadiology testRadiology test Chest X ray CT-scan 压缩肺压缩肺 组织组织 无肺纹无肺纹 理区（理区（ 积气带积气带 ） 1.Minimal pneumothorax; 2. Find the disease in lung; 3. Find the blebs of lung. (发现潜在的肺大疱) Diagnosis and differential diagnosisDiagnosis and differential diagnosisDiagnosis and differential diagnosisDiagnosis and differential diagnosis Typical syndrome (chest pain in early stage，dyspnea，caugh, inducing causes) Classical sign (Inspection, palpation, percussion, auscultation) Chest X-ray To establish the diagnosis Diagnostic thoracocentesis Diagnosis (重点掌握) AECOPD and Asthma： 1）Patients with AECOPD or acute exacerbation of asthma can also have the syndromes of dyspnea. 2）Differential points: Post history, recurrent short of breath, allergen Acute myocardial infarction 1）History， angina，Physical examination no pulmonary signs 2）ECG、 Myocardial enzymes pulmonary embolism high risk factor of DVT 、D-dimer、CTPA Differential diagnosis Diagnosis and differential diagnosisDiagnosis and differential diagnosisDiagnosis and differential diagnosisDiagnosis and differential diagnosis Treatments (Treatments (Treatments (Treatments (重点掌握重点掌握重点掌握重点掌握) ) ) ) Principle ： To discharge the retentive air，To promote the healing of crevasse，To promote the pulmonary re-expansion， reduce recurrence Therapeutic measures Conservative treatment (保守治疗) Air exhausting： Thoracentesis , Closed drainage of pleural cavity, suction drainage pleurodesis（胸膜固定术） Surgery Treatment of the primary disease Conservative treatmentConservative treatmentConservative treatmentConservative treatment保守治疗保守治疗保守治疗保守治疗 Indication：Invasion first time, no severe symptoms, mild closure pneumothrax（10%，Patient without dyspnea，Closure pneumothrax; emergency for tension pneumothorax Location： midclavicular line, 2nd ICS Volume： 1000ml for the 1st time Indication： poor effect after thoracentesis Tension/Unclosue pneumothrax hemopneumothorax Recurrent pneumothorax Some closure pneumothorax with severe symptom Closed drainage of pleural cavityClosed drainage of pleural cavityClosed drainage of pleural cavityClosed drainage of pleural cavity 胸腔闭式引流胸腔闭式引流胸腔闭式引流胸腔闭式引流 1-2cm 标本瓶 水封瓶 调压瓶 suction drainage(suction drainage(suction drainage(suction drainage(负压吸引闭式引流负压吸引闭式引流负压吸引闭式引流负压吸引闭式引流) ) ) ) 接胸膜腔 吸引机 Indication： No effect after Closed drainage of pleural cavity Indication for extubation(拔管指征)：Air bubbles never appear in the water-sealed bottle from thoracic tube. After 1-2 days reexamine the chest X-ray and determine the fully re-expansion of lung. (未见气泡冒出12天后，症状好转，呼 吸音恢复，经透视或胸片证实肺已复张) 如无气泡冒出，患者症状缓解不明显，应考虑为导 管不通畅，或部分滑出胸膜腔，需及时更换导管或 其他处理。 Closed drainage of pleural cavityClosed drainage of pleural cavityClosed drainage of pleural cavityClosed drainage of pleural cavity PleurodesisPleurodesisPleurodesisPleurodesis（胸膜固定术）（胸膜固定术）（胸膜固定术）（胸膜固定术） Methods： Intrapleural injection of sterilized Talc(灭菌滑石粉 ) or Corynebacterium Parvum Vaccine （短小棒状杆 菌菌苗）, in order to induce an aseptic inflammation a