胸腔急症气胸

1、胸腔急症气胸诊断 : i.理学检查: 患侧的呼吸音减弱，心音偏向对侧。有时颈部有捻 发音(crepitus)。 ii.胸部X光: 患侧呈现高透光性，而且没有支气管的显影。旁边 或甚至对侧的肺叶萎陷。纵隔及心脏向对侧偏移。 治疗 : 无症状或仅有轻微的呼吸窘迫，可在病房作严密的看护，这种 单纯性气胸有三分之二在五至七天内自愈而无须手术。 若有严重的呼吸困难及高张性气胸，则应立即采取行动。以静 脉注射用之套管针，由前胸第二肋间或腋窝中线第五或第六 肋间插入，接上水下引流瓶，先解除呼吸困难。然后再改用 胸管插入，等肺完全扩张没漏气后24-48小时再拔除。 手术(肺气泡切除术、肋膜沾粘术) Spont

2、aneous Primary pneumothorax Secondary pneumothorax Airway and pulmonary disease (COPD, asthma) Interstitial disease (Pulmonary fibrosis) Infection ( TB.) Neoplastic Catamenial ( Endometriosis) Iatrogenic Post-Traumatic Early complication Prolonged air leakage Non re-expansion of the lung Bilateralit

3、y Hemothorax Tension Complete pneumothoraxPotential hazard Occupational hazard Absence of medical facilities in isolated areas Associated single bulla PsychologicalSecond Episode Ipsilateral recurrence Contralateral recurrence after a first pneumothorax Surgical indication for primary spontaneous pn

4、eumothoraxSpontaneous Pneumothorax-Definition & FactorsDefinition Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleuraFactors determining gas reabsorptionDiffusion properties of the gasesPressure gradientsArea of contactPermeability of pleural surfaceSp

5、ontaneous Pneumothorax-Clinical investigationSigns and symptomsSudden onset chest painShortness of breathingCoughDiagnosisCXRAuscultationDifferential diagnosisSkin foldGiant bullaTreatment Options for PneumothoraxObservationNeedle aspirationPercutaneous catheter to drainageWater seal Pleur-evac type

6、Heimlich valveTube thoracostomyWater seal Pleur-evac typeHeimlich valveTube thoracostomy with instillation of pleural irritantVideo-assisted thoracoscopic surgeryThoracotomyIndications for Surgical InterventionSecond episodePersistent air leakage for greater than 7-10 daysFirst episode with unexpand

7、ed, “trapped” lungHistory of contralateral pneumothoraxBilateral pneumothoraxOccupational risk (driver, airplane pilot, living ina remote area)Large bullaLarge undrained hemothoraxFirst episode in a patient with one lungFirst episode in a patient with severely compromised pulmonary function Recurren

8、ce of Primary Spontaneous Pneumothorax Therapy Recurrence (%)Expectant 30Aspiration 20-50Chest tube drainage 20-30Pleurodesis (tetracycline) 25Pleurodesis (talc) 7Surgery 2 Complication of PneumothoraxTension pneumothoraxRe-expansion pulmonary edemaPersistent air leakHemothorax (less than 5%)Pneumom

9、ediastinumRemoval of Chest TubeIndicationsNo fluctuation in the fluid column of the tube (complete lung reexpansion or tube occlusion)Daily fluid drainage 100ml in 24 hoursAir leakage has stoppedProper timing (controversy)Spontaneous pneumothorax after tube thoracostomyremoval tube within 6 hours of

10、 reexpansion-25% collapse Tube Thoracostomy ( Chest Intubation)Indication of Chest IntubationDrain pleural fluid or air promote lung expansion1. Pneumothorax2. Hydrothorax3. Hemothorax4. Chylothorax5. Pyothorax6. Post-thoracotomy etc.Apparatus of Chest Tube Drainage1. Underwater sealed bottle: Separ

11、ate from atmosphere2. Collecting bottle: Decrease resistance of drainage3. Negative pressure suction: Promote lung expansionProcedure of Chest Intubation1. Local anesthesia, confirm location2. Skin incision at selected area3. Dissect into pleural cavity thru a subcutaneous tunnel4. Deloculate in ple

12、ural cavity5. Insert tube posteriorly and laterally6. Close incision wound, fixed the tube7. Connect tube to underwater sealed bottle (or with negative pressure suction)Attention In Chest Tube Insertion Attention Prevent occurrence1. Thru thoracostomy wound Underlying organ injury palpate the underl

13、ying structure(supra-or infra-diaphragm)2. Avoid trocar intubation (exceptLung or other organ injury emergency)3. 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 to

14、o looseSkin necrosis, pain or too tightAttention in Massive Subcutaneous (Mediastinal) Emphysema1. Keep airway 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.

15、 Insert another tube if no improvement7. Low O2 nasocannula8. Determine the cause & treat underlying disease9. 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 i

16、n CXRClear sterile fluid remove directlyTurbid, infected fluid withdraw progressively open drainAttention in Chest Tube Care (I) Attention Prevent occurrenceFix chest tube firmlyTube moving & contaminationDont cl tube duringTension pneumothorax transportation in presence of air leakageDont use negat

17、ive pressure suctionAbrupt mediastinal shift, after pneumonectomy venous return decrease, deathDont 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) Attentio

18、n 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 Slip out, b