内科学课件气胸

DefinitionDefinition The The accumulation accumulation of of air air in in the the pleural pleural space space with secondary lung collapse.with secondary lung collapse. Spontaneous Spontaneous pneumothoraxpneumothorax, , which which occurs occurs without trauma or obvious causewithout trauma or obvious cause Traumatic Traumatic pneumothoraxpneumothorax (iatrogenic), (iatrogenic), which which occurs occurs as as a a result result of of direct direct trauma trauma to to the chest.the chest. Spontaneous pneumothoraxSpontaneous pneumothorax Spontaneous Spontaneous pneumothoraxpneumothorax is by far the commonest form is by far the commonest form in clinical practice and is always secondary to in clinical practice and is always secondary to pulmonary or pleural abnormality. pulmonary or pleural abnormality. This may be congenital or due to acute or chronic acquired This may be congenital or due to acute or chronic acquired disease.disease. ClassificationClassification 1.1. Primary spontaneous (idiopathic) pneumothorax Primary spontaneous (idiopathic) pneumothorax which occurs in healthy persons which occurs in healthy persons 2.2. Secondary spontaneousSecondary spontaneous pneumothorax pneumothorax which occurs in persons with diseases that which occurs in persons with diseases that affect the lung affect the lung AetiologyAetiology 1.1. Primary spontaneous pneumothorax (idiopathic)Primary spontaneous pneumothorax (idiopathic) 2.2. Defined as a Defined as a pneumothoraxpneumothorax occurring in patients occurring in patients without obvious pulmonary disease clinically or on chest without obvious pulmonary disease clinically or on chest X-ray, although chest CT usually reveals X-ray, although chest CT usually reveals subapicalsubapical blebs and blebs and bullaebullae. . 2. 2. Secondary spontaneous pneumothoraxSecondary spontaneous pneumothorax Defined as a pneumothorax occurring in patients with Defined as a pneumothorax occurring in patients with underlying lung disease underlying lung disease Clinical Clinical typestypes 1. 1. Closed pneumothoraxClosed pneumothorax There is no movement of air takes place because the There is no movement of air takes place because the hole through which air entered has been sealed off. hole through which air entered has been sealed off. Clinical Clinical typestypes 2. Open pneumothorax2. Open pneumothorax The air moves freely in and out of the pleural space The air moves freely in and out of the pleural space during respiration. during respiration. Clinical Clinical typestypes 3. 3. Tension pneumothorax (Tension pneumothorax (valvularvalvular pneumothorax) pneumothorax) A one-way valve is created where air enters pleural A one-way valve is created where air enters pleural space in inspiration but cannot exit in expirationspace in inspiration but cannot exit in expiration Clinical featuresClinical features 1. 1. SymtomsSymtoms Strenuous activity, unilateral chest pain and Strenuous activity, unilateral chest pain and dyspnoeadyspnoea. . The clinical manifestations of pneumothorax The clinical manifestations of pneumothorax depend on its size, type, and the healthy depend on its size, type, and the healthy condition of patients lung. condition of patients lung. Clinical featuresClinical features 2.2. Physical signsPhysical signs 3.3. Signs of air accumulation in the thoraxSigns of air accumulation in the thorax decreased expansion of the involved decreased expansion of the involved hemithoraxhemithorax decreased decreased fremitusfremitus tympanitictympanitic percussion percussion decreased breath sounds on the involved sidedecreased breath sounds on the involved side Radiographic appearancesRadiographic appearances Sharply defined lung edge separated from the bony Sharply defined lung edge separated from the bony cage by a clear zone devoid of lung markingscage by a clear zone devoid of lung markings , , and and there may be there may be mediastinalmediastinal shift to the opposite side. shift to the opposite side. Diagnosis and differential diagnosisDiagnosis and differential diagnosis DiagnosisDiagnosis Sudden onset with chest pain and Sudden onset with chest pain and dyspnoeadyspnoea Physical signs of pneumothoraxPhysical signs of pneumothorax Radiographic appearancesRadiographic appearances Diagnostic aspiration by needle Diagnostic aspiration by needle Diagnosis and differential diagnosisDiagnosis and differential diagnosis Differential diagnosisDifferential diagnosis 1. 1. Chronic obstructive emphysema and Chronic obstructive emphysema and large emphysematous large emphysematous bullaebullae 2. 2. Bronchial asthmaBronchial asthma 3. 3. Acute myocardial infarctionAcute myocardial infarction 4. 4. Pulmonary embolism or infarctionPulmonary embolism or infarction TherapyTherapy The The basic tenetsbasic tenets of therapy of therapy to evacuate the spaceto evacuate the space to achieve closure of the leak to achieve closure of the leak to assess the risk of recurrence or ensure to assess the risk of recurrence or ensure some means of reducing this risk. some means of reducing this risk. TherapyTherapy 1.1. Observation (conservative treatment)Observation (conservative treatment) 2.2. Asymptomatic patients with a small Asymptomatic patients with a small 3.3. ( (20 per cent20 per cent) unilateral ) unilateral pneumothoraxpneumothorax. . 2.2. Aspiration Aspiration by needle or catheterby needle or catheter 3.3. Closed Closed pneumothoraxpneumothorax with collapsed lung with collapsed lung more than 20% and accompanied by dyspnoea. more than 20% and accompanied by dyspnoea. Emergency treatment for tension Emergency treatment for tension pneumothoraxpneumothorax to relieve symptoms. to relieve symptoms. TherapyTherapy 3. Chest tube drainage (long-term aspiration)3. Chest tube drainage (long-term aspiration) Insertion of a chest tube into the pleural space attached to Insertion of a chest tube into the pleural space attached to water seal (closed) chamber for continual removal of the water seal (closed) chamber for continual removal of the interpleuralinterpleural gas. gas. Chest tube drainage systemChest tube drainage system Three bottle chest tube drainage systemThree bottle chest tube drainage system SuctionSuction PatientPatient Fluid collection Fluid collection chamberchamber Water sealWater seal chamberchamber ManometerManometer chamberchamber TherapyTherapy 4. Operative therapy4. Operative therapy ( (ThoracotomyThoracotomy or Thoracoscopy) or Thoracoscopy) ThoracotomyThoracotomy The most effective in assuring expansion of the lung with The most effective in assuring expansion of the lung with the lowestthe lowest recurrence rate. recurrence rate. Indication: Indication: Failure to Failure to reexpandreexpand the collapsed lung with tube drainage the collapsed lung with tube drainage Recurrence of the Recurrence of the peumothoraxpeumothorax HaemopneumothoraxHaemopneumothorax TherapyTherapy 4. Operative therapy4. Operative therapy ( (ThoracotomyThoracotomy or Thoracoscopy) or Thoracoscopy) ThoracoscopyThoracoscopy (Video-Assisted (Video-Assisted ThoracoscopicThoracoscopic Surgery VATS) Surgery VATS) Less invasive surgeryLess invasive surgery and more acceptable by the and more acc