Spontaneous pneumothorax is a pathological condition that is characterized by a sudden violation of the integrity of the pleura. In this case, air enters from the lung tissue into the pleural region. The appearance of spontaneous pneumothorax can be marked by acute pain in the chest, and in addition, patients have shortness of breath, tachycardia, pallor of the skin, acrocyanosis, subcutaneous emphysema and a desire to take a forced position.
As part of the initial diagnosis of this disease, a chest x-ray and diagnostic pleural puncture are performed. In order to establish the causes of spontaneous pneumothorax (ICD J93.1.), The patient must undergo an in-depth examination, for example, computed tomography or thoracoscopy. The process of treating spontaneous pneumothorax involves the drainage of the pleural region with air evacuation along with video-assisted thoracoscopic or open surgery, which involves the removal of bullae, lung resection, and so on.
The causes of spontaneous pneumothorax will be considered in this article.
What it is?
Under this condition in pulmonology is understood spontaneous pneumothorax, which is not associated with trauma or iatrogenic diagnostic and treatment intervention. The disease, according to statistics, often occurs in men, prevailing among people of working age, which determines not only the medical, but also the social significance of the problem. In the traumatic and iatrogenic form of spontaneous pneumothorax, the causal relationship between the disease and external influence is clearly monitored, which may include various chest injuries, pleural cavity puncture, venous catheterization, pleural biopsy or barotrauma. But in case of spontaneous pneumothorax, there is no such conditionality. In this regard, the choice of adequate diagnosis and treatment tactics seems to be the subject of increased attention from pulmonologists, TB specialists and thoracic surgeons.
Classification
According to the etiological principle, the primary and secondary forms of spontaneous pneumothorax are distinguished (ICD code J93.1.). The primary type is spoken against the background of a lack of information about clinically significant pulmonary pathology. The emergence of a secondary spontaneous form occurs as a result of concomitant lung diseases.
Partial and total spontaneous pneumothorax are distinguished depending on the collapse of the lung. In partial, the lung falls by one third of the original volume, and in the total - more than half.
According to the level of compensation for respiratory and hemodynamic disorders that accompany pathology, the following three phases of pathological changes are distinguished:
- Persistent compensation phase.
- Unstable compensation phase.
- Inadequate compensation phase.
The persistent compensation phase is observed after spontaneous partial volume pneumothorax. It is noted by the absence of signs of respiratory and heart failure. The level of unstable compensation is accompanied by the development of tachycardia, and in addition, shortness of breath during physical exertion is not excluded, along with a significant decrease in external respiration. The decompensation phase manifests itself by the presence of dyspnea at rest, while severe tachycardia, microcirculatory disorders and hypoxemia are also observed.
Development reasons
The primary form of spontaneous pneumothorax can develop in individuals who do not have a clinically diagnosed lung disease. But when performing videothoracoscopy or thoracotomy in this category of patients, seventy percent of cases reveal emphysematous bullae located subpleurally. A mutual relationship between the frequency of spontaneous pneumothorax and the constitutional category of patients is noted. Thus, given this factor, the described pathology most often occurs among thin and tall young people. It is also worth noting that smoking increases the risk of an ailment up to twenty times. What else are the causes of spontaneous pneumothorax?
Secondary form
A secondary form of pathology can form against the background of a wide range of lung pathologies, for example, this is possible with bronchial asthma, pneumonia, tuberculosis, rheumatoid arthritis, scleroderma, ankylosing spondylitis, malignant neoplasms and so on. If a lung abscess enters the pleural region, pyopneumothorax usually develops.
The more rare varieties of spontaneous pneumothorax include menstrual and neonatal. Menstrual pneumothorax is associated with breast endometriosis and can develop in young women in the first two days after the onset of menstruation. Help with spontaneous pneumothorax should be timely.
The likelihood of recurrence of menstrual pneumothorax, even within the conservative treatment of endometriosis, is about fifty percent, therefore, immediately after establishing a diagnosis, pleurodesis is performed to prevent a second ailment.
Neonatal pneumothorax
Neonatal pneumothorax is a spontaneous form that occurs in newborns. This type of pathology occurs in two percent of children, most often it is observed in boys. This disease may be due to the problem of lung expansion or the presence of respiratory syndrome. In addition, the cause of spontaneous pneumothorax may be a rupture of lung tissue, malformations of the organ, and the like.
Pathogenesis
The severity of a structural change depends on the time that has passed since the onset of the ailment. In addition, it depends on the presence of an initial pathological disorder in the lung and pleura. No less influential is the dynamics of the inflammatory process in the pleural region.
Against the background of spontaneous pneumothorax, there is a pulmonary-pleural message, which determines the penetration and accumulation of air in the pleural region. Partial or complete collapse of the lungs may also be observed.
The inflammatory process develops in the pleura four hours after spontaneous pneumothorax. It is characterized by the presence of hyperemia, injection of pleural vessels and the formation of a certain amount of exudate. Over the course of five days, puffiness of the pleura may increase, mainly this occurs at the site of its contact with the air. There is also an increase in the amount of effusion along with prolapse of fibrin onto the pleural surface. The progression of inflammation can be accompanied by the growth of granulations, and, in addition, fibrotic transformation of precipitated fibrin occurs. A collapsed lung is fixed in a tense state, so it becomes unable to straighten out. In case of infection, pleural empyema may develop over time. It is not excluded the formation of a bronchopleural fistula, which will support the course of pleural empyema.
Symptoms of pathology
The nature of the clinical symptoms of this pathology distinguishes between a typical form of spontaneous pneumothorax and latent. Typical spontaneous can pass with moderate or violent manifestations.
In most situations, primary spontaneous pneumothorax can occur suddenly against the background of absolute health. In the first minutes of the disease, sharp stitching or constricting pain in the corresponding half of the chest can be noted. Along with this, shortness of breath appears. The severity of pain varies from mildly intense to extremely strong. The intensification of pain occurs when trying to take a deep breath, and, in addition, when coughing. Pain can spread to the neck, shoulders, arms, abdomen or lower back.
During the day, the pain syndrome, as a rule, decreases markedly or completely disappears. The pain can pass even if spontaneous pneumothorax (ICD 10 J93.1.) Is not resolved. A feeling of respiratory discomfort, along with a lack of air, appears only during physical exertion.
Against the backdrop of turbulent clinical manifestations of the pathology, a pain attack with dyspnea is extremely pronounced. Short-term fainting, pallor of the skin, and in addition, tachycardia may appear. Often in patients with this there is a feeling of fear. Patients try to spare themselves by restricting movement, taking a lying position. Often there is the development and progressive growth of subcutaneous emphysema along with crepitus in the neck, trunk and upper limbs.
In patients with a secondary form of spontaneous pneumothorax, due to the limited reserves of the cardiac system, the pathology is much more difficult. Complicated options include the development of a stressed form of pneumothorax along with hemothorax, reactive pleurisy, and bilateral lung collapse. The accumulation, and, in addition, the prolonged presence of infected sputum in the lung, leads to abscesses, the development of secondary bronchiectasis, and in addition to repeated episodes of aspiration pneumonia that can occur in a healthy lung. Complications of spontaneous pneumothorax, as a rule, develop in five percent of cases. They can pose a serious threat to the lives of patients.
Diagnosis of spontaneous pneumothorax
Examination of the chest can reveal a smooth relief of the intercostal space, and in addition, determine the limitations of the respiratory excursion. In addition, subcutaneous emphysema can be detected along with swelling and expansion of the neck veins. On the part of the collapsed lung, a weakening of voice trembling can be noted. With percussion, tympanitis can be observed, and with auscultation, there is a complete absence or significant attenuation of respiratory sounds. What are the main recommendations for spontaneous pneumothorax?
The primary attention in the diagnosis is given to radiation methods. Most often, chest radiography and fluoroscopy are used, which make it possible to estimate the amount of air in the pleural region along with the degree of lung decay depending on the location of spontaneous pneumothorax. A control x-ray study is carried out after medical manipulations, whether it is a puncture or drainage of the pleural cavity. An X-ray study makes it possible to evaluate the effectiveness of medical techniques. In the future, using high-resolution computed tomography, carried out along with magnetic resonance therapy of the lungs, it is possible to establish the cause of this pathology.
A highly informative technique that is used in the diagnosis of spontaneous pneumothorax is thoracoscopy. In the process of this study, specialists are able to determine subpleural bullae along with tumor or tuberculous changes in the pleura. In addition, a biopsy of the material for morphological studies is performed.
Spontaneous pneumothorax having a latent or erased course, it is necessary to be able to differentiate primarily from the presence of a bronchopulmonary cyst, and in addition, from the presence of a diaphragmatic hernia. In the latter case, the diagnosis of the esophagus helps a lot with the diagnosis.
Disease treatment
Consider the emergency care algorithm for spontaneous pneumothorax.
Therapy of the disease requires, first of all, carrying out the most rapid evacuation of air that has accumulated in the pleural cavity. The generally accepted standard in medicine is the transition from diagnostic tactics to therapeutic measures. Obtaining air as part of thoracocentesis serves as an indication for the drainage of the pleural cavity. Thus, pleural drainage is installed in the second intercostal space at the level of the midclavicular line, after which active aspiration is performed.
Improving bronchial patency along with the evacuation of viscous sputum greatly facilitate the task of straightening the lung. Patients undergo therapeutic bronchoscopy, tracheal aspiration, inhalation with mucolytics, respiratory gymnastics and oxygen therapy as part of the treatment of spontaneous pneumothorax.
In the event that no spreading of the lung occurs within five days, specialists proceed to the use of surgical tactics. It, as a rule, consists in performing thoracoscopic diathermocoagulation of adhesions and bullae. In addition, in the treatment of spontaneous pneumothorax, the elimination of bronchopleural fistulas along with the implementation of chemical pleurodesis can be carried out. With the development of recurrent pneumothorax, depending on its cause and condition of the tissues, an atypical regional lung resection, lobectomy, and in some cases pneumonectomy can be prescribed.
With spontaneous pneumothorax, emergency care should be provided in full.
The prognosis for patients with this pathology
In the presence of primary pneumothorax, prognoses are usually favorable. As practice shows, lung expansion can be achieved by minimally invasive methods. With the development of secondary spontaneous pneumothorax, relapses of the disease can develop in fifty percent of patients. Which requires mandatory elimination of the root causes, and in addition, involves the selection of more effective therapeutic tactics. Patients who have undergone spontaneous pneumothorax should always be under the strict supervision of a pulmonologist or thoracic surgeon.
Conclusion
Thus, spontaneous pneumothorax is an ailment caused by the penetration of air into the pleural region from the environment as a result of a violation of the surface integrity of the lung. This pathology is recorded mainly among men at a young age. In women, this disease occurs five times less often. First of all, with the development of spontaneous pneumothorax, people mainly complain of pain that occurs in the chest. In this case, patients may have difficulty breathing and a cough occurs, which, as a rule, is dry. In addition, there may be a decrease in exercise tolerance. A few days later, an increased body temperature may appear.
The diagnosis usually does not cause any difficulties for experienced professionals. To accurately confirm this disease, a chest x-ray is performed, which is performed in two projections. If necessary, surgery is performed, which is performed under general anesthesia.