Pneumothorax

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Classification according to ICD-10
J93.0 Spontaneous tension pneumothorax
J93.1 Other spontaneous pneumothorax
J93.2 Iatrogenic pneumothorax
J93.8 Other pneumothorax
S27.0 Pneumothorax, traumatic
ICD-10 online (WHO version 2019)

The pneumothorax (from ancient Greek πνεῦμα pneuma "air", and θώραξ thoracic "rib cage"; the translated Sauerbruch with "air chest" word "pneumothorax" was introduced by the British surgeon William Hewson in the 18th century in medical jargon he will. Pneu called .) is a most acutely occurring, life-threatening, depending on the severity of the medical condition in which air in the pleural cavity (the pleural cavity) between the two pleural passes, and thus the extent of a lung , or both lungs hindered, so that it for breathing is not or is only limited To be available.

A pneumothorax can only develop in mammals (except in proboscis ), since only they have a pleural space.

The characteristics range from minimal amounts of air in the pleural space, which are barely noticed by the patient, to a collapsed lung, to tension pneumothorax , in which the function of both lungs and the cardiovascular function can be drastically restricted. A tension pneumothorax must be assumed to be an acute danger to life.

causes

Spontaneous pneumothorax left
(right in the picture)
Chest X-ray lying down: Pneumothorax after placement of a central venous catheter

A distinction is made between two forms of pneumothorax based on their origin.

The spontaneous occurs every third patients without apparent cause. It often affects young, slim men between the ages of around 15 and 35 years. Smokers are often affected after a more or less violent cough and are carriers of bullous pulmonary emphysema , congenitally due to an α 1 -antitrypsin deficiency or acquired by a chronic obstructive pulmonary disease . The causes of the occasional spontaneous pneumothorax in newborns are unknown.

The traumatic pneumothorax always arises from a direct or indirect injury to the chest and its organs. The following mechanisms are typical:

  • Injury to the lungs due to inwardly tapering rib fractures
  • Stab and gunshot wounds with opening of the chest cavity or injury to the lungs
  • Excessive squeezing of the chest (pinching, rolling over) causes damage and weakening of the lung tissue
  • Barotrauma : extreme, sudden change in pressure in the lungs when flying and diving or iatrogenically in the context of positive pressure ventilation
  • iatrogenic (= caused by medical intervention) injury of the lungs or chest wall, for example by failure puncture the subclavian vein or regional anesthesia as the infraclavicular plexus as well as in 0.6 to 6% of all punctures a pleural effusion .

In the past, according to a method introduced by Carlo Forlanini in 1882 , a pneumothorax was also artificially applied as a therapeutic method, especially for pulmonary tuberculosis (therapeutic pneumothorax, artificial pneumothorax, artificial pneumothorax). This procedure, made internationally known by John Benjamin Murphy and Ludolph Brauer , was initially replaced by thoracoplasty and abandoned entirely after the development of effective antibiotics .

Because of the risk of pneumothorax as a life-threatening complication, open chest surgery was generally not performed until the late 19th century. The surgical treatment of chest injuries only became safer with the introduction of the siphon drainage system, originally intended to remove accumulations of pus within the pleura, by the internist Gotthard Bülau .

Pathogenesis

With every pneumothorax, air enters the pleural space . This is the space between the inner lining of the chest wall (pleura parietalis) and the outer skin of the lungs (pleura visceralis). The pleural space normally holds the lungs slidably on the inner wall of the chest due to the prevailing negative pressure (similar to two panes of glass that are held together by a drop of water but can be moved against each other). If air penetrates this gap, which is normally evacuated, the elastic lung tissue follows its internal tension and collapses. There are two cases:

  • When the pneumothorax is closed, there is no external injury to the thorax with opening of the thoracic cavity. The air enters the pleural space from the bronchi and lung tissue.
  • With an open pneumothorax , air can enter through an open chest wall injury.

When there is a connection between the inside of the chest and the surrounding air, a complete pneumothorax of the affected side usually results . H. the entire lung on one side is no longer able to take part in breathing. Pre- existing adhesions between the parietal pleura (the pleura on the chest wall) and the visceral pleura (the pleura covering the lungs) can prevent total lung collapse. Such adhesions can result, for example, from previous pleurisy , surgical interventions on the lungs or, if desired, for therapeutic purposes ( pleurodesis ).

A tension pneumothorax (see below), in which a valve mechanism continues to strengthen the pneumothorax, is particularly serious .

Symptoms

The individual complaints of the patient are very different: They range from a slight urge to cough to an existential feeling of suffocation. Rapid breathing ( tachypnea ) despite physical rest is a first symptom, often associated with pulling in the tips of the lungs when inhaling deeply. In addition, there is often a feeling of pressure or pain (sometimes occurring at intervals) in the chest area, which can radiate to the arms, head or back. If there is severe shortness of breath, the skin is bluish-gray, which suggests a lack of oxygen in the blood ( cyanosis ). Sometimes an emphysema of the skin can be palpated: If you press lightly on the skin you can feel a crackling or crunching sound, as if you were compressing snow. With hydropneumothorax there is also an exudate in the pleural space. In the case of traumatic pneumothorax, skin emphysema can occasionally be felt.

diagnosis

The most important thing is to even think about a pneumothorax if you have unclear breathlessness .

  • During the inspection , a “dragging” (limited breathing excursions) of the diseased side can be seen.
  • The intercostal spaces are widened, lengthened, possibly also bulging.
  • When listening to the lungs with a stethoscope , the breathing sound is weakened or canceled.
  • The bronchophony is also weakened. Even the fremitus is weakened or eliminated.
  • During percussion (tapping the chest) a loud, hollow ( tympanic ) knocking sound, a so-called box tone, is noticeable. However, the percussion should always be done in side-by-side comparison (in this case with the other half of the chest).
  • A significant pneumothorax can be reliably identified in the chest x-ray (x-ray of the lungs).
  • Diagnosis by ultrasound is a newer method, it is fast, reliable and, for a small pneumothorax (mantle pneumothorax), more sensitive than x-rays. In the case of pneumothorax, the M-mode shows the barcode symbol , whereas the seashore symbol can be seen with normal findings .
CT series of a pneumothorax
  • The more complex computed tomography (CT), which shows other accompanying injuries or illnesses, is also safe.

Tension pneumothorax

A left-sided tension pneumothorax before (above) and after (below) placement of a chest drain. The shift of the mediastinum towards the healthy side can be clearly seen.

A tension pneumothorax is particularly serious , in which an injury to the lungs or chest wall creates a lip valve that draws more air into the pleural space with each breath , without letting it escape during exhalation. As a result, the pressure in the affected chest cavity increases, compresses the lungs, thereby further restricting breathing, shifting the middle membrane to the opposite side and, by distorting and compressing the vena cava, impedes the return of blood to the heart, so that a critical drop in blood pressure up to the cardiovascular system Standstill can result. One finds

  • all symptoms of the "simple" pneumothorax, further increasing dyspnoea and further circulatory decline, whereby
  • the breathing movement of the chest is asymmetrical, the chest is upright on the affected side and hardly sinks when exhaling,
  • bulging neck veins and increased peripheral venous pressure (venous congestion) indicate increased pressure in the chest cavity.
  • If a patient with severe shortness of breath does not recover after intubation and ventilation , tension pneumothorax should always be considered.
  • Tension pneumothorax is an important differential diagnosis of unclear circulatory shock .
  • A tension pneumothorax can be assumed on the x-ray if the mediastinum is shifted to the healthy side.

treatment

A minor pneumothorax, for example a mantle pneumothorax, can remain undetected and often does not need any therapy, as the body clears the air itself over time. A possible oxygen deficit can be remedied by oxygen insufflation. The therapy of choice for a more extensive pneumothorax is a tube through which the air that has penetrated is sucked out again ( chest drainage ). This drainage is usually inserted below the middle of the clavicle (medioclavicular) in the second or third intercostal space with the incision direction upwards and laterally ( cranio -lateral ) ( Monaldi drainage ). The drain can be left open with a valve, the so-called Heimlich valve, or connected to negative pressure to allow the lungs to gradually re-expand . Up to now (as of 2006) there have been no prospective comparative studies between different procedures and only a few on different surgical methods.

If the pneumothorax is traumatic and there are other injuries, for example rib fractures, hemothorax (blood in the pleural space), a Bülau drainage must be applied, i.e. in the middle to rear axillary line at the level of the lower shoulder blade tip (5th to 6th intercostal space ) in order to be able to drain fluids (blood, effusion).

Air travel ability

Air travel after treated pneumothorax, thoracic surgery or punctures should be undertaken after three weeks at the earliest. After that, complications during the flight are possible, but very rare.

literature

Web links

Commons : Pneumothorax  - Collection of pictures, videos and audio files

Individual evidence

  1. ↑ Ferdinand Sauerbruch : That was my life. Kindler & Schiermeyer, Bad Wörishofen 1951; Licensed edition for Bertelsmann Lesering, Gütersloh 1956, pp. 41–45.
  2. ↑ Andrew L. Banyai: Is "spontaneous pneumothorax" really spontaneous?  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. @1@ 2Template: Toter Link / journal.publications.chestnet.org   In: Dis. Chest. Volume 56, No. 6, December 1969, p. 487.
  3. ^ John B. West: Why doesn't the elephant have a pleural space? In: News in Physiological Sciences. Volume 17, 2002, pp. 47-50, doi : 10.1152 / nips.01374.2001 .
  4. ^ Rüdiger Meyer: Spontaneous Pneumothorax. Chest drainage has no clear advantages in younger patients. In: Deutsches Ärzteblatt. Volume 117, Issue 10, March 6, 2020, p. B 435.
  5. ^ H. Matthys, W. Seeger: Clinical Pneumology . Springer, Heidelberg 2008, ISBN 3-540-37682-8 , pp. 581 .
  6. ↑ Berthold Jany, Tobias Welte: Pleural effusion in adults - causes, diagnosis and therapy. In: Deutsches Ärzteblatt. Volume 116, No. 21, (May) 2019, pp. 377-385, here: p. 381.
  7. ↑ Joachim Frey : Pneumothorax. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 734-738, here: p. 734.
  8. ↑ Christoph Weißer: Pneumothorax. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. Walter de Gruyter, Berlin and New York 2005, ISBN 3-11-015714-4 , p. 1171.
  9. ↑ Pulmonologists on the Net - Pneumothorax. German Society for Pneumology and Respiratory Medicine (DGP), Federal Association of Pneumologists e. V. (BdP), accessed on January 25, 2013 .
  10. ↑ Journal of Trauma 2004, http://www.jtrauma.com/
  11. ↑ Treatment of the pneumothorax. In: The surgeon. July 2007, 78, pp. 655-668, accessed April 3, 2010.
  12. ↑ Pneumothorax: Clinic, Diagnosis and Treatment. In: The pulmonologist. July 2008, 5, pp. 239–246, accessed April 3, 2010.
  13. ↑ Treatment options of spontaneous pneumothorax. In: Indian J Chest Dis Allied Sci. Volume 48, No. 3, July-September 2006, pp. 191-200, PMID 18610677 , accessed April 3, 2010.
  14. ↑ Xiaowen Hu et al .: Air Travel and Pneumothorax. In: Chest. Volume 145, No. 4, 2014, pp. 688-694. doi : 10.1378 / chest.13-2363