Pneumothorax

Pneumothorax ( altgr. πνεῦμα pneumatic " air" and θώραξ thorax " chest ") is a mostly acute onset, life-threatening depending on the severity of disease, passes from the air into the pleural space and thus the expansion of a lung or both lungs disabled, so this for not breathing or only limited available. The severity ranges from minimal amounts of air that are hardly noticed by the patient, a lung collapse up to tension pneumothorax, in which both lungs and cardiovascular function can be drastically reduced. In a tension pneumothorax must be considered from an acute danger to life.

Causes

Due to the emergence of three forms of pneumothorax can be distinguished:

The spontaneous pneumothorax occurs without apparent cause. It often affects young, slim men between 15 and 35 years of age .. are affected by smoking often a more or less violent coughing and support of a bullous emphysema, congenital, caused by an α1 -antitrypsin deficiency or acquired by chronic obstructive lung disease. Reasons for the occasional spontaneous pneumothorax in neonates are not known.

The traumatic pneumothorax is always formed by a direct or indirect injury of the thorax and its organs. The following mechanisms are typical:

• Violation of the lung by pike inward rib fractures
• Stab and gunshot wounds with opening the chest cavity or injury of the lung
• Severe contusion of the chest ( pinching, rolling over ), causes damage and weakening of lung tissue
• Barotrauma: extreme, sudden change in pressure of the lungs when flying and diving or iatrogenic under a positive pressure ventilation
• Iatrogenic ( = action by medical -related ) injury of the lung or chest wall, for example by faulty puncture of the subclavian vein or regional anesthesia as the infraclavicular plexus block.

The therapeutic pneumothorax: History of artificial pneumothorax is known as a method of therapy in pulmonary tuberculosis. This method was abandoned after the development of effective antibiotics again.

Pathogenesis

Each time air enters the pleural cavity pneumothorax. This is the space between the inner lining of the chest wall ( parietal pleura ) and the outer skin of the lung ( visceral pleura ). The pleural space normally holds by the prevailing therein under pressure (so-called hydrostatic pressure) the lung displacement on the inner chest wall (similar to two pieces of glass which are held together by a drop of water, but can be shifted against each other ). Air enters this gap a which is normally evacuated, followed by the elastic lung tissue of its internal tension and collapses. We distinguish the

• Closed pneumothorax, in which no external injury of the chest with opening the chest cavity exists, and thus the air from the bronchi and lung tissue from entering the pleural space from the
• Open pneumothorax, in which the air can enter through an open chest wall injury.

When a connection between the interior of the chest and the ambient air is, usually arises a Komplettpneumothorax the affected side, i.e., the entire lung of a page is no longer able to participate in the breathing. Pre-existing adhesions between the parietal pleura ( the chest wall side pleura ) and the visceral pleura ( the pleura covering the lungs), however, can prevent the total collapse of the lung. Such bonds, for example, by previous pleurisy, caused surgery to the lungs or even desirable for therapeutic purposes ( pleurodesis ).

Particularly serious is a tension pneumothorax (see below), in which a valve mechanism the pneumothorax still further strengthened.

Symptoms

The individual complaints of the patient are very different, ranging from low to cough up an existential suffocation. Rapid breathing ( tachypnea ), despite physical rest is a first symptom often associated with drawing in the apex of the lungs when taking deep breaths. Sometimes be added to a feeling of pressure or pain (sometimes at intervals occurring ) in the chest area that may radiate to the arms, head or back. Case of severe shortness of breath shows a bluish gray skin color, which suggests a lack of oxygen in the blood ( cyanosis). Sometimes a subcutaneous emphysema is palpable: With light pressure on the skin makes you feel a crackle or a crunch, as if one were to compress the snow. Since one side is worse ventilated, resulting asymmetric breathing movements. The chest does not expand evenly. When listening with the stethoscope no or only very quiet breath sounds are audible on the relevant page.

Diagnosis

The most important thing is to think at all to a pneumothorax is unclear shortness of breath.

• While listening to the lungs via stethoscope, the sound of breathing is reduced or canceled.
• In the percussion ( tapping the chest ) is a hollow knocking sound, called a shaft Elton falls on. However, the percussion should always be done in the side comparison (in this case, with the other half of the thorax ).
• The chest radiograph ( chest X-ray ), a significant pneumothorax is certainly recognizable.
• The diagnosis by ultrasound is a newer method, quickly, reliably and for a small pneumothorax ( Mantelpneumothorax ) more sensitive than X-ray. In pneumothorax the M-mode shows the barcode characters, whereas in normal finding the Seashore character is seen.
• What is certain is also the more elaborate computed tomography ( CT), which reveals more associated injuries or diseases.

Tension pneumothorax

Particularly serious is a tension pneumothorax, in which a lip valve is caused by injury to the lung or chest wall, the more air in the pleural cavity moves with every breath without letting it escape during exhalation. This increases the pressure in the affected chest cavity, compressing the lung, thus compromising breathing is more, the mediastinum shifts to the opposite side and hampered by distortion and compression of the vena cava blood return to the heart, so that a critical drop in blood pressure or even heart and circulatory may result standstill. One finds

• All the symptoms of the "simple" pneumothorax, further increasing shortness of breath and other circulatory depression, with
• The respiratory movement of the chest is asymmetrical, the chest on the affected side tall and hardly lowers at expiration,
• Bulging neck veins and increased peripheral venous pressure point (venous cava ) to an increased pressure in the chest cavity.
• Recovering a patient with severe dyspnoea after intubation and ventilation not, is always to think of a tension pneumothorax.
• The tension pneumothorax is an important differential diagnosis of unclear circulatory shock.
• In the radiograph is to start from a tension pneumothorax if the mediastinum is shifted to the healthy side.

Treatment

A small pneumothorax, such as a Mantelpneumothorax can remain undetected and often does not need treatment because the body over time eliminates the invading air itself. A possible oxygen deficiency can be corrected by oxygen insufflation. Treatment of choice for a broader pneumothorax is a tube through which the permeated air is sucked back ( thoracic drainage ). This drainage is mostly below the center of the collarbone ( medioklavikulär ) in the second or third intercostal space with random upward and sideways ( craniolateral ) introduced ( Monaldi drainage ). The drain can be provided with a valve, called the Heimlich valve left open or connected to negative pressure in order to achieve a gradual re- expansion of the lung. Until now (2006 ) there are no prospective studies comparing different approaches and only a few different surgical methods.

If the pneumothorax caused traumatic and are more injuries, such as rib fractures, hemothorax (blood in the pleural space ), then a Bülau drainage must be created, that is in the mid to posterior axillary line at the level of the lower tip of the scapula ( 5th-6th intercostal ) to be derived fluids (blood, effusion) can.