Pneumothorax

Causes

The pneumothorax is either spontaneous or traumatic. When it occurs at a patient without known identifiable disease, it is known as “primary education”; if the patient presents a disease under unclaimed in connection with the pneumothorax, it is then known as “secondary”. It is supported by the consumption of the tobacco, one of the stakes of the treatment will be to stop this nicotinic impregnation.

Spontaneous pneumothoraxes

I.e. without subjacent pulmonary pathology, and occurring then mainly at the young, large people and longilignes, sometimes following a violent effort.

Primary educations

The Incidence is of 6-7 for: 100,000 at the men and of 1-2 for: 100,000 among women.

At the top of the lung of the cells can break and let air collect itself under the visceral plèvre forming what one calls a “bleb”. When this bleb breaks creates for itself a pneumothorax. These blebs is often localized at the top of the higher lobe or the top of the higher segment of the lower lobe.

It is the most frequent origin among young people.

Secondaries

Obstructive chronic broncho-pneumonopathy (BPCO)

At the time of this emphysémateuse disease, the destruction of alveolar walls occurs creating the spaces filled of air within the lung which are called bubbles (or bulleuse Dystrophie). The pneumothorax is usually caused by the rupture of one of these bubbles.

It is the most frequent origin at the people of more than 15 years.

The infectious illness

Syndrome of Immunodéficience Acquired: they are usually due to pneumopathies with Pneumocystis carinii. But of the infections with cytomegalovirus and mycobacteries are also found as well as syndromes of Kaposi;
Tuberculosis;
All bacterial, mycosic and parasitic infections being able to create holes in the lung.

Tumors

Any rupture of a malignant lesion located in the lung can cause a pneumothorax.

Cataménial

In fact pneumothoraxes occur in the 48-72 hours after occurred of the rules. The majority are located on the right. They repeat sometimes during several years before being diagnosed.

Genetic cause

Mucoviscidose, disease of Marfan, syndrome of Ehler-Danlos

Others

Sarcoidosis, histiocytose X, lymphangioleïomyomatose…
Diseases of system and autoimmune.

Traumatic pneumothoraxes

The air passes then by effraction of the lung towards the plèvre, the latter being able to be injured by direct wound or a fracture of coasts.

Iatrogenic

I.e. like complication of an medical act, during the effraction of the plèvre and the lung by a needle during the installation of a central venous Way by catheterization of the veins subclavians, or more rarely during a assisted Ventilation badly regulated or under strong pressures.

Noniatrogenic

Traumas thoracic closed or with penetrating wound (knife, firearm).

Therapeutic pneumothorax

The therapeutic pneumothorax consists in voluntarily causing a pneumothorax with an aim of curing a disease. It was the case of the Tuberculose, which one treated in this manner until the Années 1950.

Diagnosis

According to the importance, it can appear by simple a thoracic Douleur isolated, with or without breathlessness (Dyspnée) or result in a table of acute respiratory distress.

With the examination

the murmur vésiculaire (noise of breathing such as it is heard with the Stéthoscope) classically is decreased or abolished on a side.
the percussion on the side of the thorax reaches watch a tympanism (hollow noise).
With the inspection, one can note an immobility of the thorax on the side reached.

Complementary examinations

The pulmonary Radiographie of face makes it possible to make, in general, the diagnosis, in the form of a clearness of a top with visualization of a fine convex edging upwards, corresponding to the retracted lung. In the difficult cases, one can make use of a Radiographie taken in expiry. The simultaneous presence of épanchement liquid gives the aspect of horizontal rectilinear level hydroaeric characteristic.

Physiopathology

In normal weather, the lung adheres to the thoracic wall by the existence of a negative pressure between the two layers of the plèvre. Following the irruption of air in pleural space, the lung is taken off of the wall and retracted in the thorax in area hilaire (on the level of the hile of the lung). The consequence is that the ventilation of the east coast decreased to see null.

The symptoms depend on the degree of depression of the lung and the respiratory function on the patient. The lung while subsiding affects the capacity of the patient to be breathed, it can thus have difficulty in breathe (dyspnea) with the effort or rest. The plèvre is richly innervé, the patient can thus have badly and cough.

First aid

He requires a catch of load in urgency to judge his importance and conduit of his treatment.

The setting under Oxygène can be useful if it is badly tolerated, possibly guided by the measurement of the blood saturation out of oxygen (SaO2).

The serious forms can require a monitoring of the vital constants

Although the Radiologie always does not detect the pneumothoraxes, the first line of care requires radio operator of face in inspiration then in expiry if the inspiratory stereotype is noncontributive, even a Tomodensitométrie (scanner) if pathological lung. It can sometimes prove to be necessary to carry out a thoracic radiology of profile.

Treatment

It is adapted to the symptomatology, extended from the pneumothorax and the state of the lung under unclaimed.

The treatment can be sometimes medical about it, but its final payment will be often only surgical. The treatment considered will depend on the severity of the symptoms and the disease under unclaimed.

The spontaneous pneumothorax of low abundance cures spontaneously into 2 or 3 weeks. Antalgic S and rest are prescribed.

Preserving treatment

It is the simple monitoring of the patient and his pneumothorax.

It is based on the observation which the pleural cavity reabsorbs spontaneously the air at the rate of 1,25% of the volume of the hémithorax per day. It often requires an initial hospitalization of 24:00, then the patient can turn over to his residence while being followed regularly.

It is reserved for the pneumothoraxes of low volume among asymptomatic patients. The risk occurred of a complication (compressive pneumothorax). The need for a prolonged brought closer monitoring is also a disadvantage.

The exsufflation with the needle

It is a question of evacuating the air with a small catheter connected to an aspiration of air. The method is simple, but if the escape is not healed the pneumothorax can repeat. Its disadvantage is thus its low level of success from 20 to 50%. The risk of infection exists, this intervention must be realized in medium medicalized in rigorous rules of aseptie. It is, of course, in the same way for the thoracic drainage which remains often the most practiced intervention.

The thoracic drainage

It is the most used technique and most effective of first intention. It consists in placing a thoracic drain in aspiration in the pleural cavity. It ensures D expansion of the lung and supports the cicatrization.

An escape of air prolonged (more than 4-7 days) will require a surgery. If the patient presents an anesthetic high-risk a prolonged drainage can be considered possibly accompanied by a pleurodèse.

The pleurodèse

It is a question “of sticking” the 2 plèvres (parietal and visceral) one against the other by creating a strong inflammatory reaction. This reaction east generally creates by injecting into the pleural cavity an irritating substance like talc, tétracyclines or injection of blood autologist.

The rates of repetition are high of about 20 to 40%.

The majority of the surgeons are reticent with respect to this method especially among young patients. To become foreign bodies left in the plèvre is not completely elucidated, and young people having made a pneumothorax will be able to require a thoracotomy later on.

Surgery

Its principal goal is to avoid the repetitions. To avoid the short-term repetitions the pulmonary lesions (blebs, bubbles) are réséquées surgically by using mechanical staplers. The coagulation of the blebs and bubbles, by laser or electric lancet, if it makes it possible to control the escapes of air and the bleedings, nevertheless is sullied with a rate of repetition going up to 25%.

The medium-term repetitions are prevented by carrying out the obliteration of the pleural cavity with a principle similar to the pleurodèse. The means used are mainly the pleurectomy (ablation of the parietal plèvre) and mechanical pleural abrasion (the plèvre is rubbed with a plug). Irritating substances are used by certain in a complementary way like talc, iodized alcohol, or the tétracyclines.

The choice of the way initially is usually done between the video-assisted thoracoscopy and a small thoracotomy.

The rate of repetition is weak, after surgery it is in general lower than 2%.

Indications

the surgery is proposed with any repeating pneumothorax dice the first repetition.
the first episode of pneumothorax can profit from a surgery in the following indications:

the absence of D expansion of the lung in spite of a drainage led well
the escape of air prolonged
compressive pneumothorax: It should be prevented that the patient repeats by making a new compressive pneumothorax which would put its life in danger if it were far from any medical structure
the bilateral pneumothorax: It should be prevented that the patient repeats by making a new bilateral pneumothorax which also would put its life in danger to him if it were far from any medical structure
the hémothorax unsolved by the thoracic drainage: The intervention is necessary to put an end to the bleeding
Grosse single bubble: The bubble compresses the adjacent lung which is thus not used with its normal capacity, it must thus be removed
Certaines professions as fighter pilot, plunger underwater professional, sporting high level: The repetition of the pneumothorax during the exercise of their profession represents a vital risk for these patients.

Before the intervention

the consultation and the opinion of the anesthetist is obligatory and essential.
the bronchial fibroscopy is interesting to exclude an endobronchial, cancerous lesion at nicotinic patients, or being able to prevent the D-expansion of the lung.
the thoracic scanner makes it possible to take stock of the blebs and the bubbles of the 2 lungs, to detect a possible pulmonary tumor and to know the state of the lung under unclaimed.

Complications

They can be of occurred immediate, resistance to the treatment or occur after the treatment.

Occurred immediate

Compressive pneumothorax

It is a complication serious, untreated it perhaps quickly mortal. It occurs in 2 to 3% of the cases. The air which returns in the pleural cavity to the inspiration cannot any more leave there to the expiry usually on a mechanism of non-return valve. The pressure increases in the plèvre compressing the lung (distress respiratory) and the heart (cardiovascular distress).

Bilateral pneumothorax

It occurs in a simultaneous way at 1% of the pneumothoraxes and requires an emergency treatment by a thoracic drainage in aspiration of both cavity pleural.

The hémothorax

Sometimes adherences developed between the pleural and parietal plèvre. At the time of the pneumothorax if one of them tears, it can bleed in the pleural cavity, it is the hémothorax.

The pneumo médiastin

The air of the pneumothorax will dissect fabrics of the médiastin.

Resistance to the treatment

When they are drained the majority of the escapes of air are dried up in 2 days. In spite of an adequate drainage the lung can not D-expendre or the escape can persist more than 7 days.

Occurred after treatment

Even if it is classified among the complications, the repetition, whereas there no was surgical treatment, is not strictly speaking a complication but rather one of the aspects of normal” or usual evolution the “of the natural history of the pneumothorax.

The risk of repetition of the side pneumothorax homo (on the same side) is of 20% to 2 years after a first episode and of more than 50% after the second episode and increases further after the third episode.

The risk of pneumothorax controlatéral is of 12%.

History

Jean Itard, a student of Rene Laennec, for the first time identified a pneumothorax in 1803, and Laennec itself described the clinical image of it supplements in 1819.

References

Laennec RTH. Treated mediate sounding and diseases of the lungs and heart. Share II. Paris, 1819.
J. Deslaurier, Mr. Beaulieu, J. - P. Despres. Transaxillary thoracothomy for the treatment off spontaneous pneumothorax , Annals off Thoracic Surgery , 1980; 30: 35
SR Hazelrigg, RJ Landreneau, MJ Mack. Thoracoscopic stapled resection for spontaneous pneumothorax . Newspaper oh Thoracic and Cardiovascular Surgery , 1993; 105: 389
Paape K, Fry WA. Spontaneous pneumothorax. Chest Surgery Clinics off North America . 1994; 4: 517
Compeau C, Johnston Mr. Pneumothorax. in " Key Topics in Thoracic Surgery" Glass fragment AG, Johnston MR., Bios Scientific Publishers

See too

Urgentologie

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