内科学教学课件：英文气胸

pneumothorax气胸anatomical

structure(解剖结构)壁层胸膜（parietal

pleura）脏层胸膜(visceral

pleura)胸膜腔(pleural

cavity)

ahermeticcavity(密闭)

noair3～15mlliquids

anegative

pressure(呼气末-5~-3mmHg；吸气末-10~-5mmHg)anatomical

structure(解剖结构)characteristic

Pneumothoraxisthepresenceofgasinthepleuralspace.Definitionofpneumothorax气体胸膜腔胸膜腔积气状态Thefailureofrespirationrestrictive

ventilatory

disorderventilation/perfusionratio↓Circulationdisorder

disturbvenousreflux

Heart:FV↓、SV↓HypoxemiaHR↑BP↓ShockPathophysiologyofpneumothorax气胸的病理生理表现

Pathogenesis发病机制

Thefractureofparietal

pleura

Thefractureofvisceral

pleuraInfectionofaerogen(产气菌感染)1.AccordingtothepathogenesisThefractureofvisceral

pleuraPrimarySpontaneousPneumothoraxSecondarySpontaneousPneumothoraxClassificationofpneumothoraxTraumaticPneumothoraxIatrogenicPneumothoraxThefractureofvisceral/parietal

pleuraThefractureofvisceral/parietal

pleuraSpontaneousPneumothorax★WhethertherearedefinitelungdiseasesaccordingtothechestX-rayThefractureofvisceral

pleuraPrimarySecondary

自发性气胸（SpontaneousPneumothorax）：Pneumothraxwithouttrauma

oranthropogenicfactors.Primaryspontaneouspneumothorax:Usuallyduetoruptureofapicalpleuralblebs,smallcysticspacesthatliewithinorimmediatelyunderthevisceralpleura.Secondaryspontaneouspneumothorax:Secondaryspontaneouspneumothoracesareduetopre-existinglungdiseases(likechronicobstructivepulmonarydisease).SpontaneousPneumothorax1.AccordingtothepathogenesisClassificationofpneumothorax2、clinicalclassification（★重点掌握）闭合性（单纯性）气胸（Closurepneumothorax）交通性（开放性）气胸（Unclosurepneumothorax）★张力性（高压性）气胸（Tensionpneumothorax

）Classificationofpneumothorax闭合性气胸ClosurepneumothoraxClassificationofpneumothorax1.Smallcrevasse2.Thecrevassehealedquickly3.Relativelylowpressure

in

the

chestUnclosurepneumothoraxClassificationofpneumothorax1.Crevasseopenned

persistently2.Airflowsintothepleuraspaceandbacktolungtissuethroughthecrevassefredomly张力性气胸Tensionpneumothorax

Classificationofpneumothorax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（clinical

manifestation）Inducingcauses:Classicalsymptom:intense

activity,lifting,fiercecoughchestpain,

dyspnea,coughThedegreeofdyspneadependson呼吸困难的程度取决于：

Thebasiclungfunctionofthepatients

Whetherthegenerationofpneumothraxissloworfast

Theamount

of

gas

andthepressureinthepleural

space

Tensionpneumothorax

Severrespiratoryfailureandshock.Orthopnea,restless,sweating.

Case1Case2临床表现（clinical

manifestation）Case1

Ayoungmanwithnorespiratorydiseasebefore.Symptom：SlightchestpainandnodyspneaChestX-ray:middle-largeamountofpneumothrax

AnoldmanwithCOPDSeverdyspnea，Orthopnea，cyanosis，RR:40~50/minNeedoxygen

therapy

ChestCTCase2

ClinicalsignInspection：Tracheashifttouninjured

side,fullchestoftheinjuredsidePalpation:deceasedvocalfremitus/chestexpansionoftheinjuredside,

(subcutaneous

emphysema)subcutaneouscrepitationPercussion：hyper-esonance/tympanyAusculation：decreasedofrespiratorysoundoftheinjuredside.临床表现（clinical

manifestation）RadiologytestChestX–rayCT-scan压缩肺组织无肺纹理区（积气带）RadiologytestChestX–rayCT-scan压缩肺组织无肺纹理区（积气带）1.Minimal

pneumothorax;2.Findthediseaseinlung;3.Findtheblebs

of

lung.(发现潜在的肺大疱)Diagnosisanddifferentialdiagnosis

Typicalsyndrome(chestpaininearlystage，dyspnea，caugh,inducingcauses)

Classicalsign(Inspection,palpation,percussion,auscultation)

ChestX-ray——

Toestablish

the

diagnosis

DiagnosticthoracocentesisDiagnosis(★重点掌握)AECOPDandAsthma：

1）PatientswithAECOPDoracuteexacerbationofasthmacan

alsohavethesyndromesofdyspnea.2）Differential

points:Posthistory,recurrent

shortofbreath,allergenAcute

myocardial

infarction1）History，angina，Physicalexaminationnopulmonarysigns

2）ECG、MyocardialenzymespulmonaryembolismhighriskfactorofDVT、D-dimer、CTPADifferentialdiagnosisDiagnosisanddifferentialdiagnosisTreatments(★重点掌握)Principle：

Todischargetheretentiveair，Topromotethehealingofcrevasse，Topromotethepulmonaryre-expansion，reduce

recurrenceTherapeutic

measuresConservativetreatment(保守治疗)★

Airexhausting：Thoracentesis,Closeddrainageofpleuralcavity,suctiondrainage

pleurodesis（胸膜固定术）

Surgery

TreatmentoftheprimarydiseaseConservativetreatment保守治疗Indication：Invasionfirsttime,noseveresymptoms,mildclosurepneumothrax（<20%）restinbed，analgesic，keep

your

bowels

open.Oxygentherapy（FiO2≥40%）TreatmentofprimarydiseasePayattentiontoreexaminethechest-X-ray2-3daysAirexhausting排气治疗胸腔穿刺抽气Thoracentesis胸腔闭式引流Closeddrainageofpleuralcavity负压吸引闭式引流suctiondrainage紧急时，消毒针插入直接排气EmergencyDiagnosticThoracentesis

Thoracentesis

Indication:lung

collapse>10%，Patientwithoutdyspnea，Closurepneumothrax;emergencyfortensionpneumothorax

Location：midclavicular

line,2ndICS

Volume：＜1000mlforthe1sttime

Indication：

pooreffectafterthoracentesis

Tension/Unclosuepneumothrax

hemopneumothoraxRecurrentpneumothoraxSomeclosurepneumothoraxwithseveresymptomCloseddrainageofpleuralcavity胸腔闭式引流1-2cm标本瓶水封瓶调压瓶suctiondrainage(负压吸引闭式引流)接胸膜腔吸引机Indication：NoeffectafterCloseddrainageofpleuralcavityIndicationforextubation(拔管指征)：Airbubblesneverappearinthewater-sealedbottlefromthoracictube.After1-2daysreexaminethechestX-rayanddeterminethefullyre-expansionoflung.(未见气泡冒出1~2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。CloseddrainageofpleuralcavityPleurodesis（胸膜固定术）Methods：

IntrapleuralinjectionofsterilizedTalc(灭菌滑石粉)orCorynebacteriumParvumVaccine（短小棒状杆菌菌苗）,inordertoinduceanasepticinflammation

andpromotingtheadhesionofparietal

pleuraandvis