notes by
dr Claudio Italiano
It is a rather frequent pathology, has an age distribution that knows no fragmentation so it is so frequent in young as in adults, especially if the latter is affected by COPD or by degenerative diseases of epithelia, such as boiled emphysema. Pneumothorax is defined as the presence of air between the two pleural sheets, the parietal and the visceral ones. Between the two pleural sheets there is a small quantity of physiological liquid in normal; in pathological conditions, either by effusion or by pneumothorax, the lungs are compressed, crushed.
- Spontaneous pnx (primitive and secondary)
- Traumatic Pnx
- iatrogenic Pnx
Main differences between these three types:
-
Spontaneous PNX arises spontaneously, without an obvious cause. In the case of
the primitive, the cause is a pnx in which there is a presence of microbubbles
on the surface of the lung. It is a fairly common condition in male subjects (ratio
4: 1 male females), especially if they are long-limbed subjects, who do sports.
It may occur due to a congenital condition, due to the presence of bubbles or
micro blebs, micro bubbles on the surface of the lung, which due to an increased
pressure inside them for sudden efforts or for less serious efforts, such as
lacing the shoes, can determine the breaking of these bubbles and then a
spontaneous pneumothorax.
The secondary spontaneous PNX is due to airway diseases. In bronchial asthma,
given the difficulty in breathing, there is an increase in endoalveolar pressure.
In barotrauma, a pressure injury in general can increase the endoalveolar
pressure and may cause bubbles to break if they are present. In cystic fibrosis,
the pulmonary structures of the septa are destroyed and there is evidence of
large cysts in the lung parenchyma, thus a condition that reduces resistance and
the structural capacity of the lung.
COPD, pneumonia, tuberculosis, primitive neoplasms, such as bronchogenic carcinoma; lung metastases, which can often lead to an emo-pneumothorax, because the metastases are highly vascularized and if they break, they cause wall lesions and bleeding inside the pleural cavity. Interstitial diseases, such as sarcoidosis, pulmonary fibrosis, rheumatoid arthritis cause pneumothorax. A characteristic form of endometriosis is the shape of the thorax, so in women, even if the ratio between men and women is 4: 1, the woman can be affected by pneumothorax caused by endometriosis; this form is called "catamenial pneumothorax", due to endometrial islands at the level of the pleural cavity. This abnormal tissue, the uterine tissue, responds to hormones.
If a certain force acts on the lungs, the bronchi, the
esophagus and the chest wall, as happens in a traffic accident, or due to a
fight, a gunshot wound. In these cases, the traumatism can cause a pulmonary
wall breach because it is the energy of the trauma or the kinetic for the recoil
or else it will affect one of these mediastinal and pulmonary structures.
The Iatrogen PNX is determined for operations on the heart and / or lung or for
diagnostic-therapeutic maneuvers performed on the patient. Pneumocentesis,
transparietal needle biopsy, procedures related to the cannulation of central
vessels, such as subclavian (more frequent are methods that can pierce the
pleura at the apex and give a pneuomotorace, or worse yet, being a vessel, an
emo-pneumothorax) . In other cases, even the placement of a cardiac device can
be complicated with a PNXCLASSIFICAZIONE TORACOSCOPICA
Classification of Vanderschueren, Poumon Coeur 1981
I - no endoscopic changes
II - Pleural adhesions
III - blebs or bullae less than 2 cm
IV - bullae greater than 2 cm
The pnx is classified in:
• Open
• Closed
• Hypertensive or "valve"
The open Pneumothorax is caused by a breach in the chest wall, so when inhaling
the air enters, it takes up most of the pleural cavity during exhalation, as
there is an open penetrating wound, which connects the atmosphere and pleural
cavity, the air is fed back out and the conditions are restored. The situation
is repeated at every breath, but if we want it is the least severe form, it does
not produce respiratory failure.
The closed Pneumothorax is determined by the breaking of a bubble on the
pulmonary parenchyma, but then closes on itself, so the patient inhales, the air
enters, the bubble breaks but then closes, and the lung tends to expand in a
manner limited due to the presence of air in the pleural cavity.
Hypertensive pneumothorax is the most dangerous condition. It is due to a
penetrating wound in the chest: air enters during inspiration, but can not
escape during exhalation. After each breath, air will accumulate in the pleural
cavity. This condition causes the mediastinal shift, that is to say a
displacement of the mediastinum and therefore of the organs it contains, with an
important consequence of cardiogenic shock.
It is characterized by a characteristic pain with sudden onset, piercing, like a
stab wound, which simulates the condition of myocardial infarction or of an
aneurysm that dissects, with which conditions must be diagnosed differential.
There is a feeling of tension on the chest wall, as if something pulled or tore
off the wall fabrics; the pleura is richly innervated and inevitably its
collapse stimulates the receptors and pain is due to this reason. The patient
has cough. The lung does not expand as it should, there may be in the more
advanced stages a respiratory failure, with cyanosis, especially it is a
subcyanosis, at the level of the lips. Subcutaneous emphysema may also be
present; the air from the inside of the pleural cavity discovers the
pneumo-thoracic fascia, the muscular layers are undone, up to the subcutaneous
tissue, and palpatoryly, at the neck and chest, the subcutaneous emphysema will
be appreciated (presence of air bubbles in the subcutis and pressing it
appreciates what is called the crackling of fresh snow).
They are characterized by:
- Persistent air loss
- Hypertensive pneumothorax
- pulmonary edema
- re-expansion
- pneumomediastinum
- hemothorax
- bilateral pneumothorax
The first maneuver to be performed is the restoration of the condition of the
pleural cavity, positioning a drainage that sucks air and / or liquid. This way
the pnx is solved, but it is not said that this is definitive solution, because
maybe the bubbles are broken and still goes out air. In these cases, persistent
pnx is spoken. When a pnx manifests itself, a collapsed structure of the lung is
also created, atelectasic, with a vascular stasis. Circulation continues
regularly but the vessels have lost their physiological structure. When the lung
re-expands, especially if it has been collapsed for a long time, these vessels
can be stretched and we risk breaking. Or you can have alveolar edema, as there
is a sudden "reopening" of the circulation. Then a condition called a
re-expansion pulmonary edema is determined. Therefore we must be careful in
order to restore the condition of the lung progressively, to avoid both an
ex-vacuous problem, edema, and, especially if it is a neoplastic situation, a
problem of lung rupture. The pnx can break the mediatinic pleura, if important.
And then the air can make its way into the mediatino (virtual space between the
two visceral pleura) around the esophagus, trachea, to the structures of the
neck. There can then be bilateral pnx, caused for example by trauma, such as
traffic accidents, in which a double opening of the thoracic cavity occurs.
The anamnesis and the semeiology allow to make diagnoses, in most cases. There are a number of elements (accidents, beatings, ...) that directs us on the possible development of pnx. So the E.O. chest is the easiest exam to do. In fact, at inspection there could be asymmetry of the two haemitors, with interest mainly of one of the two. At palpation there is a reduction of f.v.t., to percussion, unlike the pleural effusion, there will be a hyper-hypertensive sound. Also in the physiological case we have a tympanism, in the clear lung sound. But in the pnx there will be an amplification of the sound, for the amplification carried out by the same pleural cavity. To make radiological diagnosis, a standard chest X-ray is sufficient, but we also do CT because, both with spontaneous pnx and with traumatized PC, CT is essential for two reasons: in the case of trauma, the PC is a complex case to evaluate, since it is almost always a poly-traumatized (necessary multidisciplinary approach); - we identify well the air (black), its location, if it had made its way between the various layers. If the medistine pleura are broken, everything is surrounded by air.
Pneumology