Pneumothorax J93.9

Itard was the first to describe the term pneumothorax in 1803. This term was then coined by Laennec in 1819 as air accumulation in the pleural cavity. At that time, pneumothorax occurred almost exclusively in tuberculosis patients.

The first description of a primary spontaneous pneumothorax without previous diseases was given by Kjaergaard in 1932.

Etiologically a distinction is made between:

- primary (spontaneous) pneumonia: here a rupture of max. 1-2 cm large pleural bubbles occurs, preferably in the apical segment and mostly of bubbles located directly under the pleura.

- Secondary pneumonia: affects patients with a wide variety of pre-existing lung diseases

- traumatic tyre: caused by rib fracture, chest trauma, etc.

- iatrogenic pneumonia: especially after subclavian catheterization, pleural puncture, hyperbaric ventilation, thoracic surgery, transbronchial biopsy and very rarely, but described, in slim patients due to paravertebral wheals

- Tension pneumonia: occurs more frequently in ventilated patients, but also in secondary or traumatic pneumonia

The primary pneumothorax occurs up to 6 times more frequently in younger men than in women. The incidence is about 9 /100.000. The recurrence rate is between about 30 % - 50 %, depending on the literature. Mostly smokers are affected, which suggests the suspicion of a subclinical lung disease. However, this type of pneumothorax can also occur in previously lung-healthy non-smokers.

The secondary pneumothorax occurs significantly more frequently (about 5 times as often). Here too, men are affected more often than women.

The tension pneumothorax is a rare clinical picture and accounts for only about 3% of the pneumothorax.

The mortality rate for pneumothorax as a whole is 0.03 % for people under 45 years of age and then increases significantly. In 90 year olds it is over 16 %.

As soon as air enters the pleural space, the physiological negative pressure of the pleural space is released and lung collapse occurs. The resulting sudden decrease in perfusion in the collapsed lung is compensated within a few seconds by the Euler-Liljestrand reflex and reaches a plateau after only 15 minutes. For this reason, the patient often does not have hypoxaemia when arriving at the clinic, but rather compensatory hyperventilation. Depending on the genesis of the disease, the clinical picture is partially different. The following symptoms usually occur together:

- stabbing pain on the affected side of the thorax

- Dyspnea

- often tachypnea

- irritation of the throat

- respiratory asymmetric thoracic motion

- sometimes also a very mild course in young and/or previously lung healthy patients

Secondary 1dary spontaneous

The secondary spontaneous neoplasm, which occurs in patients with a wide variety of pre-existing lung diseases, is much more threatening in terms of symptoms, since these patients lack the pulmonary reserve capacity that healthy people with healthy lungs have.

Iatrogenic or post-traumatic pneumonia:

- Possibly skin emphysema on the affected side of the thorax

Voltage tire:

Tension pneumonia is a rarely occurring disease. Due to the valve mechanism, air enters the pleural space with every breath and cannot escape during expiration. This leads to an increase in pressure in the pleural space, which in turn displaces the mediastinum to the healthy side. This causes compression of the healthy side of the lung and impedes venous return. As a result, the CVD increases and the CVS decreases.

The following symptoms are characteristic:

- dramatic clinical picture

- sometimes within minutes or hours worst shortage of air

- Cyanosis

- Tachycardia

- Skin emphysema on the affected side

- Signs of upper influence accumulation

- often shock symptoms

- ZVD increases

- HZV decreases

Anamnesis: in particular, ask for information on previous tyres, timely medical interventions, chest trauma, existing lung diseases, etc.

Auscultation: Absent or reduced sound of breathing on the affected side (not or barely auscultable in patients with pre-existing lung diseases, especially emphysema).

Sonography: Sonography is equivalent to X-ray imaging of a tyre, and even superior in the diagnosis of an occult tyre. However, the extent of the tyre and lung collapse cannot be estimated by sonography. Note: The sonography should be performed in the supine position with the sonoscope head above the MCL at the highest point of the chest.

If a pneumonia is present, neither lung slippage in the B-mode nor the so-called seashore sign in the M-mode can be detected. Instead, horizontal skylines, so-called barcode sign or stratosphere sign, can be displayed. These typically occur in patients with pneumothorax.

The so-called lung point in the M-mode, i.e. the transition of the lung adjacent to the thoracic wall and the beginning of the tire, is of particular importance in the ultrasound diagnosis of the tire. The lung point has a specificity of 98% to even 100% (depending on the literature). However, since this point cannot always be represented, the sensitivity is significantly lower.

For the spontaneous new:

- pulmonary embolism

- Myocardial infarction

- Pleuritis

- Pericarditis

- Early form of histiocytosis X (also called Langerhans cell histiocytosis)

Depending on the clinical symptoms are therapeutically possible:

- controlled waiting

- Oxygen administration

- Pleural drainage with or without suction

- thoracic surgical interventions

Pleural suction drainage: For this purpose the pleura is punctured in the 2nd ICR medioklavicularly at the upper (!) edge of the rib. Alternatively, the puncture can also be performed in the 4th ICR in the posterior axillary line. After an initial suction, a permanent suction with approx. 10 cm H²O is applied (if the suction is too strong, there is a risk of re-expansion edema). The drainage should be positioned so that the pleural cap is drained.

Primary spontaneous pneumonia: If the pneumonia is very small and the patient does not complain of shortness of breath, outpatient treatment is possible with the requirement that the patient should reappear immediately if the symptoms increase. A control examination should, however, be carried out within 24 hours in any case. It is then recommended to have a weekly X-ray overview to check the course of the disease. The complete resorption of a pneumothorax can take up to 6 weeks, or even longer in the case of persistent air leaks.

Selected patients with a larger pneumothorax can also be treated as outpatients after the application of a small lumen chest tube (8 - 14 CH). An appropriate aftercare programme with a weekly X-ray overview for control is required.

Otherwise, simple suction of the bladders under X-ray control is recommended at the first event. In order to allow the lungs to unfold again, the drain should be left in place with or without suction (then with a Heimlich valve) for 2-3 days. After this time about 80% of the lung should have expanded. If this is not the case, a renewed suction with a large catheter is recommended for another 3-4 days. If the lung is not able to expand even underneath, the patient must be presented to the surgeon.

In case of a recurrence on the same side, the patient should be referred to the surgeon immediately. In the case of a recurrence on the opposite side, it must be decided in each individual case whether it makes sense to try a drainage first or whether the patient should be presented to the surgeon immediately.

Secondary pneumothorax: In patients with a previously known fibrotic lung disease, the indication for surgical treatment is very cautious. Retrospective studies have shown that both the recurrence rate and mortality in such cases are significantly higher than, for example, in patients with previous COPD. It is therefore recommended that treatment with a drainage system be carried out.

Note: In potential patients for lung transplantation, pneumothorax is not rare. In this case the therapeutic procedure should always be closely coordinated with the transplant center, since pleurodesis increases the postoperative risk of death after transplantation. Otherwise, suction drainage is recommended for most patients with secondary pneumothorax. If the leak persists, the lung does not expand after three days of drainage, or there is a pneumothorax recurrence, the patient must be presented to the thoracic surgeon.

Traumatic/iatrogenic pneumothorax: A traumatic/iatrogenic pneumothorax is usually treated with a thoracic drainage. Exception: very small pneumothorax (up to one transverse finger). In this case, treatment may consist of pure observation with or without oxygen supply. If a haematopneumothorax is present, the patient should be presented to the thoracic surgeon. Other literature also recommends an initially conservative treatment. The patient should be given a drain in the upper half of the thorax to allow air to escape and another drain in the lower half of the thorax to allow blood to drain. If this procedure is not successful, a thoracic surgeon should be consulted.

Tension pneumothorax: This is an urgent medical emergency. The patient may die within a short time from insufficient heart volume or severe hypoxia due to the excess pressure in the pleural space. In an emergency (even if the preparations for diagnosis are too long), a large-calibre long cannula (20 G or 1 needle) should therefore be inserted through the 2nd ICR medioklavicularly into the pleural cavity without an attached syringe. Due to the venous congestion it can bleed unusually strongly, but the needle should still be advanced until the thoracic cavity is reached and air escapes. As soon as a quantity of approx. 50 - 100 ml/min of gas has been evacuated, this usually leads to immediate clinical stabilization. The cannula should be left in place until a pleural drainage can be placed.

In up to 50% of patients with primary spontaneous neurosis, recurrences occur in the first year. It is therefore recommended - if the patient is a smoker - to give up smoking urgently.

Diving should be avoided permanently. Only patients who have undergone an open surgical bilateral pneumectomy and in whom both the CT examination and the lung function show inconspicuous findings postoperatively can continue to practice this sport.

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