胸腔急症气胸 ppt课件

1、胸腔急症氣胸1.氣胸( Pneumothorax):是氣體在胸腔內引起肺萎陷。假设引起縱 隔偏移及壓迫到對側的肺稱之為高張性氣胸(tension pneumothorax)，常因运用的人工呼吸器壓力過大而引起，或是 肺氣腫的水泡、肺囊腫破裂而呵斥。 胸腔外科黃文傑醫師診斷 : i.理學檢查: 患側的呼吸音減弱，心音偏向對側。有時頸部有捻 髮音(crepitus)。 ii.胸部X光: 患側呈現高透光性，而且沒有支氣管的顯影。旁邊 或甚至對側的肺葉萎陷。縱隔及心臟向對側偏移。 治療 : 無症狀或僅有輕微的呼吸窘迫，可在病房作嚴密的看護，這種 單純性氣胸有三分之二在五至七天內自癒而無須手術。 假设有

2、嚴重的呼吸困難及高張性氣胸，則應立刻採取行動。以靜 脈注射用之套管針，由前胸第二肋間或腋窩中線第五或第六 肋間插入，接上水下引流瓶，先解除呼吸困難。然後再改用 胸管插入，等肺完全擴張沒漏氣後24-48小時再拔除。 手術(肺氣泡切除術、肋膜沾粘術) Spontaneous Primary pneumothorax Secondary pneumothorax Airway and pulmonary disease (COPD, asthma) Interstitial disease (Pulmonary fibrosis) Infection ( TB.) Neoplastic Catame

3、nial ( Endometriosis) Iatrogenic Post-Traumatic Early complication Prolonged air leakage Non re-expansion of the lung Bilaterality Hemothorax Tension Complete pneumothoraxPotential hazard Occupational hazard Absence of medical facilities in isolated areas Associated single bulla PsychologicalSecond

4、Episode Ipsilateral recurrence Contralateral recurrence after a first pneumothorax Surgical indication for primary spontaneous pneumothoraxSpontaneous Pneumothorax-Definition & Factors Definition Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleura

5、Factors determining gas reabsorption Diffusion properties of the gases Pressure gradients Area of contact Permeability of pleural surfaceSpontaneous Pneumothorax-Clinical investigation Signs and symptoms Sudden onset chest pain Shortness of breathing Cough Diagnosis CXR Auscultation Differential dia

6、gnosis Skin fold Giant bullaTreatment Options for Pneumothorax Observation Needle aspiration Percutaneous catheter to drainage Water seal Pleur-evac type Heimlich valve Tube thoracostomy Water seal Pleur-evac type Heimlich valve Tube thoracostomy with instillation of pleural irritant Video-assisted

7、thoracoscopic surgery ThoracotomyIndications for Surgical Intervention Second episode Persistent air leakage for greater than 7-10 days First episode with unexpanded, “trapped lung History of contralateral pneumothorax Bilateral pneumothorax Occupational risk (driver, airplane pilot, living ina remo

8、te area) Large bulla Large undrained hemothorax First episode in a patient with one lung First episode in a patient with severely compromised pulmonary function Recurrence of Primary Spontaneous Pneumothorax Therapy Recurrence (%) Expectant 30 Aspiration 20-50 Chest tube drainage 20-30 Pleurodesis (

9、tetracycline) 25 Pleurodesis (talc) 7 Surgery 2 Complication of Pneumothorax Tension pneumothorax Re-expansion pulmonary edema Persistent air leak Hemothorax (less than 5%) PneumomediastinumRemoval of Chest Tube Indications No fluctuation in the fluid column of the tube (complete lung reexpansion or

10、 tube occlusion) Daily fluid drainage 100ml in 24 hours Air leakage has stopped Proper timing (controversy) Spontaneous pneumothorax after tube thoracostomy removal tube within 6 hours of reexpansion-25% collapse Tube Thoracostomy ( Chest Intubation)Indication of Chest IntubationDrain pleural fluid

11、or air promote lung expansion1. Pneumothorax2. Hydrothorax3. Hemothorax4. Chylothorax5. Pyothorax6. Post-thoracotomy etc.Apparatus of Chest Tube Drainage1. Underwater sealed bottle: Separate from atmosphere2. Collecting bottle: Decrease resistance of drainage3. Negative pressure suction: Promote lun

12、g expansionProcedure of Chest Intubation1. Local anesthesia, confirm location2. Skin incision at selected area3. Dissect into pleural cavity thru a subcutaneous tunnel4. Deloculate in pleural cavity5. Insert tube posteriorly and laterally6. Close incision wound, fixed the tube7. Connect tube to unde

13、rwater sealed bottle (or with negative pressure suction)Attention In Chest Tube Insertion Attention Prevent occurrence1. Thru thoracostomy wound Underlying organ injury palpate the underlying structure(supra-or infra-diaphragm)2. Avoid trocar intubation (exceptLung or other organ injury emergency)3.

14、 Keep tube in good directionChest pain, great vessel erosion4. Avoid intubation thru posteriorPain, unable in supine chest wall5. Avoid to suture & close Air leakage thoracostomy wound too looseSkin necrosis, pain or too tightAttention in Massive Subcutaneous (Mediastinal) Emphysema1. Keep airwa

15、y patent (even endotracheal tube)2. CXR3. Insert chest tube in pneumothorax or suspicious side4. Connect tube to negative pressure suction immediately5. Close thoracostomy wd slightly loose6. Insert another tube if no improvement7. Low O2 nasocannula8. Determine the cause & treat underlying dise

16、ase9. Remove tube after complete subsidenceWhen to Remove Chest Tube ? Criteria: 1. No air leakage 2. Drained fluid 50 c.c./day 3. Clear serosanguineous color of fluid 4. Full expansion of lung in CXRClear sterile fluid remove directlyTurbid, infected fluid withdraw progressively open drainAttention

17、 in Chest Tube Care (I) Attention Prevent occurrenceFix chest tube firmlyTube moving & contaminationDont clamp tube duringTension pneumothorax transportation in presence of air leakageDont use negative pressure suctionAbrupt mediastinal shift, after pneumonectomy venous return decrease, deathDon

18、t apply negative suction Reexpansion pulmonary edeme immediately after intubation for cases with large volume or long duration of pneumothorax, hydro- pyothoraxAttention in Chest Tube Care (II) Attention Prevent occurrenceDont lift up tube aboveBack flow contamination thoracostomy woundUse collecting bottle and elevateBack flow contamination the connecting tube between 2Lung collapse bottles in big residual pleural space or massive air leakage Attention in Thoracotomy with Lung Resection (I) Attention Prevent occurrenceSuture ligated or close pulmonary S