vanishing as well as existing

胸腔急症~氣胸  胸腔外科~黃文傑醫師

1.氣胸( Pneumothorax):是氣體在胸腔內引起肺萎陷。若引起縱   

隔偏移及壓迫到對側的肺稱之為高張性氣胸(tension

pneumothorax)，常因使用的人工呼吸器壓力過大而引起，或是

肺氣腫的水泡、肺囊腫破裂而造成。

胸腔外科~黃文傑醫師

 診斷 :  
i.理學檢查: 患側的呼吸音減弱，心音偏向對側。有時頸部有捻

髮音(crepitus)。  
ii.胸部X光: 患側呈現高透光性，而且沒有支氣管的顯影。旁邊

或甚至對側的肺葉萎陷。縱隔及心臟向對側偏移。

治療 : 無症狀或僅有輕微的呼吸窘迫，可在病房作嚴密的看護，這種

單純性氣胸有三分之二在五至七天內自癒而無須手術。

若有嚴重的呼吸困難及高張性氣胸，則應立即採取行動。以靜

脈注射用之套管針，由前胸第二肋間或腋窩中線第五或第六

肋間插入，接上水下引流瓶，先解除呼吸困難。然後再改用

胸管插入，等肺完全擴張沒漏氣後24-48小時再拔除。

手術(肺氣泡切除術、肋膜沾粘術) 

• Spontaneous  自發性?
  

Primary pneumothorax

Secondary pneumothorax

Airway and pulmonary disease (COPD, asthma)

Interstitial disease (Pulmonary fibrosis)

Infection ( TB..)這應該是肺結核

Neoplastic

Catamenial ( Endometriosis)

• Iatrogenic
• Post-Traumatic

• Early complication

Prolonged air leakage

Non re-expansion of the lung

Bilaterality

Hemothorax

Tension

Complete pneumothorax

• Potential hazard

Occupational hazard

Absence of medical facilities in isolated areas

Associated single bulla

Psychological

• Second Episode

Ipsilateral recurrence

Contralateral recurrence after a first pneumothorax

  Surgical indication for primary spontaneous pneumothorax

Spontaneous Pneumothorax 
-Definition & Factors 自發性氣胸的定義和起因

• Definition

Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleura

• Factors determining gas reabsorption
  • Diffusion properties of the gases
  • Pressure gradients
  • Area of contact
  • Permeability of pleural surface

Spontaneous Pneumothorax 
-Clinical investigation 臨床調查

• Signs and symptoms
  • Sudden onset chest pain
  • Shortness of breathing
  • Cough
• Diagnosis
  • CXR
  • Auscultation
• Differential diagnosis
  • Skin fold
  • Giant bulla

Treatment Options for Pneumothorax 

• Observation
• Needle aspiration
• Percutaneous catheter to drainage
  • Water seal Pleur-evac type
  • Heimlich valve
• Tube thoracostomy
  • Water seal Pleur-evac type
  • Heimlich valve
• Tube thoracostomy with instillation of pleural irritant
• Video-assisted thoracoscopic surgery
• Thoracotomy

Indications for Surgical Intervention 

• Second episode
• Persistent air leakage for greater than 7-10 days
• First episode with unexpanded, “trapped” lung
• History of contralateral pneumothorax
• Bilateral pneumothorax
• Occupational risk (driver, airplane pilot, living ina remote area)
• Large bulla
• Large undrained hemothorax
• First episode in a patient with one lung
• First episode in a patient with severely compromised pulmonary function

Recurrence of Primary Spontaneous Pneumothorax  

• Therapy Recurrence (%)
  • Expectant 30
  • Aspiration 20-50
  • Chest tube drainage 20-30
  • Pleurodesis (tetracycline) 25
  • Pleurodesis (talc) 7
  • Surgery 2

Complication of Pneumothorax 

• Tension pneumothorax
• Re-expansion pulmonary edema
• Persistent air leak
• Hemothorax (less than 5%)
• Pneumomediastinum

Removal of Chest Tube 

• Indications
  • No fluctuation in the fluid column of the tube (complete lung reexpansion or tube occlusion)
  • Daily fluid drainage <100ml in 24 hours
  • Air leakage has stopped
• Proper timing (controversy)
  • Spontaneous pneumothorax after tube thoracostomy
    • removal tube within 6 hours of reexpansion--25% collapse

• Tube Thoracostomy

( Chest Intubation)

Indication of Chest Intubation 

Drain pleural fluid or air

promote lung expansion

1. Pneumothorax

2. Hydrothorax

3. Hemothorax

4. Chylothorax

5. Pyothorax

6. Post-thoracotomy etc. 

Apparatus of Chest Tube Drainage 

1. Underwater sealed bottle:

Separate from atmosphere

2. Collecting bottle:

Decrease resistance of drainage

3. Negative pressure suction:

Promote lung expansion

Procedure of Chest Intubation 

1. Local anesthesia, confirm location

2. Skin incision at selected area

3. Dissect into pleural cavity thru a subcutaneous tunnel

4. Deloculate in pleural cavity

5. Insert tube posteriorly and laterally

6. Close incision wound, fixed the tube

7. Connect tube to underwater sealed bottle (or with negative pressure suction)

Attention In Chest Tube Insertion 

Attention  Prevent occurrence

1. Thru thoracostomy wound  Underlying organ injury

palpate the underlying structure (supra-or infra-diaphragm)

2. Avoid trocar intubation (except Lung or other organ injury

emergency)

3. Keep tube in good direction Chest pain, great vessel erosion

4. Avoid intubation thru posterior Pain, unable in supine

chest wall

5. Avoid to suture & close  Air leakage

thoracostomy wound too loose  Skin necrosis, pain

or too tight

Attention in Massive Subcutaneous (Mediastinal) Emphysema 

1. Keep airway patent (even endotracheal tube)

2. CXR

3. Insert chest tube in pneumothorax or suspicious side

4. Connect tube to negative pressure suction immediately

5. Close thoracostomy w’d slightly loose

6. Insert another tube if no improvement

7. Low O_² nasocannula

8. Determine the cause & treat underlying disease

9. Remove tube after complete subsidence

When to Remove Chest Tube ?  

Criteria:

  1. No air leakage

 2. Drained fluid < 50 c.c./day

 3. Clear serosanguineous color of fluid

 4. Full expansion of lung in CXR

• Clear sterile fluid remove directly
• Turbid, infected fluid withdraw progressively

open drain

Attention in Chest Tube Care (I) 

Attention  Prevent occurrence

• Fix chest tube firmly Tube moving & contamination
• Don’t clamp tube during Tension pneumothorax

transportation in presence of

air leakage

• Don’t use negative pressure suction Abrupt mediastinal shift,

after pneumonectomy  venous return decrease, death

• Don’t apply negative suction  Reexpansion pulmonary edeme immediately after intubation for

cases with large volume or long

duration of pneumothorax, hydro-

pyothorax

Attention in Chest Tube Care (II) 

Attention  Prevent occurrence

• Don’t lift up tube above Back flow contamination

thoracostomy wound 

• Use collecting bottle and elevate Back flow contamination

the connecting tube between 2 Lung collapse

bottles in big residual pleural

space or massive air leakage

Attention in Thoracotomy with Lung Resection (I) 

Attention  Prevent occurrence

• Suture ligated or close pulmonary  Slip out, bleeding

vessel with stapler

• Make adequate length in bronchial Stump broken

stump

• Cover bronchial stump with  Bronchopleural fistula

surrounding tissue, especially in 

pneumonectomy

• Pre-operative anti-TB or anti-fungal  Disease flare up

drug (at least 2 wks) for suspicious

TB or fungal diseases

http://www.mmh.org.tw/taitam/csc/download/pneumo.ppt