胸腔急症~气胸

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1、胸腔急症氣胸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

2、，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)SpontaneousPrimarypneumothoraxSecondarypneumothoraxAirwayandpulmonarydisease(COPD,asthma)Interstitialdisease(Pulmonaryfibrosis)Infection(TB.)NeoplasticCatamenial(Endometriosis)IatrogenicPost-

3、TraumaticEarlycomplicationProlongedairleakageNonre-expansionofthelungBilateralityHemothoraxTensionCompletepneumothoraxPotentialhazardOccupationalhazardAbsenceofmedicalfacilitiesinisolatedareasAssociatedsinglebullaPsychologicalSecondEpisodeIpsilateralrecurrenceContralateralrecurrenceafterafirstpneumo

4、thoraxSurgicalindicationforprimaryspontaneouspneumothoraxSpontaneousPneumothorax-Definition&Factors DefinitionAccumulationofintrapleuralairastheresultofabreakineitherthevisceralorparietalpleura Factorsdetermininggasreabsorption Diffusionpropertiesofthegases Pressuregradients Areaofcontact Permeabili

5、tyofpleuralsurfaceSpontaneousPneumothorax-Clinicalinvestigation Signsandsymptoms Suddenonsetchestpain Shortnessofbreathing Cough Diagnosis CXR Auscultation Differentialdiagnosis Skinfold GiantbullaTreatmentOptionsforPneumothorax Observation Needleaspiration Percutaneouscathetertodrainage WatersealPl

6、eur-evactype Heimlichvalve Tubethoracostomy WatersealPleur-evactype Heimlichvalve Tubethoracostomywithinstillationofpleuralirritant Video-assistedthoracoscopicsurgery ThoracotomyIndicationsforSurgicalIntervention Secondepisode Persistentairleakageforgreaterthan7-10days Firstepisodewithunexpanded,“tr

7、apped”lung Historyofcontralateralpneumothorax Bilateralpneumothorax Occupationalrisk(driver,airplanepilot,livinginaremotearea)Largebulla Largeundrainedhemothorax Firstepisodeinapatientwithonelung FirstepisodeinapatientwithseverelycompromisedpulmonaryfunctionRecurrenceofPrimarySpontaneousPneumothorax

8、 TherapyRecurrence(%)Expectant30 Aspiration20-50 Chesttubedrainage20-30 Pleurodesis(tetracycline)25 Pleurodesis(talc)7 Surgery2ComplicationofPneumothorax Tensionpneumothorax Re-expansionpulmonaryedema Persistentairleak Hemothorax(lessthan5%)PneumomediastinumRemovalofChestTube Indications Nofluctuati

9、oninthefluidcolumnofthetube(completelungreexpansionortubeocclusion)Dailyfluiddrainage100mlin24hours Airleakagehasstopped Propertiming(controversy)Spontaneouspneumothoraxaftertubethoracostomy removaltubewithin6hoursofreexpansion-25%collapse TubeThoracostomy(ChestIntubation)IndicationofChestIntubation

10、Drainpleuralfluidorairpromotelungexpansion1.Pneumothorax2.Hydrothorax3.Hemothorax4.Chylothorax5.Pyothorax6.Post-thoracotomyetc.ApparatusofChestTubeDrainage1.Underwatersealedbottle:Separatefromatmosphere2.Collectingbottle:Decreaseresistanceofdrainage3.Negativepressuresuction:PromotelungexpansionProce

11、dureofChestIntubation1.Localanesthesia,confirmlocation2.Skinincisionatselectedarea3.Dissectintopleuralcavitythruasubcutaneoustunnel4.Deloculateinpleuralcavity5.Inserttubeposteriorlyandlaterally6.Closeincisionwound,fixedthetube7.Connecttubetounderwatersealedbottle(orwithnegativepressuresuction)Attent

12、ionInChestTubeInsertionAttentionPreventoccurrence1.ThruthoracostomywoundUnderlyingorganinjurypalpatetheunderlyingstructure(supra-orinfra-diaphragm)2.Avoidtrocarintubation(exceptLungorotherorganinjuryemergency)3.KeeptubeingooddirectionChestpain,greatvesselerosion4.AvoidintubationthruposteriorPain,una

13、bleinsupinechestwall5.Avoidtosuture&closeAirleakagethoracostomywoundtoolooseSkinnecrosis,painortootightAttentioninMassiveSubcutaneous(Mediastinal)Emphysema1.Keepairwaypatent(evenendotrachealtube)2.CXR3.Insertchesttubeinpneumothoraxorsuspiciousside4.Connecttubetonegativepressuresuctionimmediately5.Cl

14、osethoracostomywdslightlyloose6.Insertanothertubeifnoimprovement7.LowO2nasocannula8.Determinethecause&treatunderlyingdisease9.RemovetubeaftercompletesubsidenceWhentoRemoveChestTube?Criteria:1.Noairleakage2.Drainedfluid50c.c./day3.Clearserosanguineouscoloroffluid4.FullexpansionoflunginCXR Clearsteril

15、efluidremovedirectly Turbid,infectedfluidwithdrawprogressivelyopendrainAttentioninChestTubeCare(I)AttentionPreventoccurrence FixchesttubefirmlyTubemoving&contamination DontclamptubeduringTensionpneumothoraxtransportationinpresenceofairleakage DontusenegativepressuresuctionAbruptmediastinalshift,afte

16、rpneumonectomyvenousreturndecrease,death DontapplynegativesuctionReexpansionpulmonaryedemeimmediatelyafterintubationforcaseswithlargevolumeorlongdurationofpneumothorax,hydro-pyothoraxAttentioninChestTubeCare(II)AttentionPreventoccurrence DontliftuptubeaboveBackflowcontaminationthoracostomywound Usec

17、ollectingbottleandelevateBackflowcontaminationtheconnectingtubebetween2LungcollapsebottlesinbigresidualpleuralspaceormassiveairleakageAttentioninThoracotomywithLungResection(I)AttentionPreventoccurrence SutureligatedorclosepulmonarySlipout,bleedingvesselwithstapler MakeadequatelengthinbronchialStumpbrokenstump CoverbronchialstumpwithBronchopleuralfistulasurroundingtissue,especiallyinpneumonectomy Pre-operativeanti-TBoranti-fungalDiseaseflareupdrug(atleast2wks)forsuspiciousTBorfungaldiseases