Secondary spontaneous pneumothorax is a more serious condition than the primary, since it causes a reduction in les of pulmonary function in patients with pre-existing violation le of pulmonary function.
Frequency
The frequency of secondary pneumothorax is the same as the primary. In a study conducted in Olmsted County , pcs. Minnesota, the annual rate for men is 6.3 / 100,000, for women — 2.0 / 100,000 [1]. If these data are extrapolated to the entire US population, the number of new cases of secondary spontaneous pneumothorax annually around 7,500 compared with 8,600 new cases of primary spontaneous pneumonia motoraksa.
Etiological factors
Spontaneous pneumothorax may develop in patients with a time of personal lung diseases. Secondary spontaneous pneumonia motoraks most often occurs in patients with chronic obstructive pulmonary disease. Thus, of the 34 patients with Auto ary spontaneous pneumothorax in 20 cases pneumothorax was caused by chronic obstructive pulmonary disease lay FIR in 7 – TB, 2 – sarcoidosis and 1- tuberculosilicosis in 1 – lung fibrosis and still 1 – metastatiche skim defeat pleura . Other diseases include asthma, scleroderma, histiocytosis X, tuberous glued onto, interstitial pneumonia, limfoangiomiomatoz , xanthomatosis , liver cirrhosis, the syndrome Marfan , idiopathic pulmonary hemosiderosis , pulmonary infarction, rheumatoid Zabolev Nia, echinococcosis, berylliosis . Spontaneous pneumothorax hour that develops in cystic fibrosis. Luck and colleagues MESSAGE schili that of 144 patients with cystic fibrosis, whose age was older than 10 years, secondary spontaneous pneumothorax was observed in 12.5% of cases.
Clinical picture
The clinical course of secondary spontaneous pneumothorax is much harder than the primary. The majority of patients with WTO ary spontaneous pneumothorax shortness of breath [33], which is not the severity of the Avis of pneumothorax size . In one series of observations, all 57 patients with chronic obstructive pulmonary disease complained of difficult Noah breathing, and 42 (74%) – pain in the chest on the side of pneumatic thorax . In addition, 5 patients had cyanosis and 4 had hypotension.
In patients with lung diseases, pneumothorax often has severe consequences. Because they reserve a lung. already reduced, partial or complete loss of lung function mo Jette pose a threat to the life of the patient. In a group of 18 patients , in which the admission to the hospital was determined gas composition of blood, the mean PaO2 composition lyala 48 mm Hg. Art., and the average Paco2 – 58 mm Hg. Art. Secondary spontaneous pneumothorax is often lethal ICs move. Analysis of three sets of observations in which the total number of cases was 120, showed that 16% of them had a lethal ny outcome . In three cases, death occurred outside zapno, before they enter the drain pipe in the other three. cases, the cause of death was respiratory failure, which developed in the first 24 hours of treatment, in three cases – dy respiratory failure, but at a later date, and in three cases – massive gastrointestinal bleeding. Ty severity of the disease and high mortality rates require at nyatiya all possible measures to prevent a recurrence.
These physical examination. Physical obsledo vanie with secondary spontaneous pneumothorax less helpful in establishing the diagnosis than with primary spontaneous pneumonia motorakse. In such patients, an overstretching of the lungs is already observed , the tactile detectable voice tremor is reduced ,. percussion giperrezonantna , breath sounds over both le Gotschna margins strengthened. Accordingly, the development in pain Nogopneumothorax differences between the two sides of the lungs may not be explicit. The probability of pneumothorax should be borne in mind in any patient with chronic Obst ruktivnym lung disease, which is observed on Rastanshortness of breath, especially if it is accompanied given chest pain.
As in the cases of primary spontaneous pneumothorax, diag ERA Secondary spontaneous pneumothorax is set based on chest x-ray.
In patients with chronic obstructive pulmonary diseases, the radiographic picture of pneumothorax will be changed due to the loss of elastic tension and the presence of obstruction in the lungs. In the absence of adhesions collapse unaffected otde fishing light is more pronounced than the diseased portions of the lungs, where there are bulls and emphysema. In addition, the smoothing of the lung is also incomplete due to a decrease in elastic thrust.
The diagnosis of pneumothorax is established on the basis of identifying the line of the visceral pleura. In some cases, the detection of this line on the radiograph is difficult, as the transparency of the lung increases and it is difficult to distinguish the pneumothorax from the emphysematous lung by the X-ray picture. Not rarely, during the initial radiological examination of a patient, pneumothorax remains undetected . In addition, spontaneous pneumothorax should be distinguished from large thin-walled bulls containing air. In pneumothorax, the pleural line usually has a convex shape towards the lateral chest wall, while in the case of a large bull, the apparent pleural line usually has a concave shape in the same direction. Differential diagnosis is facilitated by tomography . Such differentiation is necessary because thoracostomy and the introduction of drainage are required only for pneumothorax.
In some cases, secondary spontaneous pneumothorax may develop in patients with primary lung cancer and about struction bronchus. Since the introduction of drainage contraindicated but bronchial obstruction, it is necessary to recognize the pathology of radiological signs. When on lichii complete collapse of the lung should determine whether there is air in the bronchograms easy. When an endobronchial struction air bronchograms will not, in all the Drew GIH cases, it will be present . In the absence of air on the bronchogram Before the introduction of drainage, the patient should make a bronchoscopy.
Relapses
Data on the frequency of relapses of secondary spontaneous pnevmoto Rax much less than primary spontaneous pnevmoto Rax. The most complete information regarding the cases of chro -ethnic obstructive pulmonary disease, is contained in Mr. boat Dines and colleagues . In this series of observations at the Mayo Clinic for a ten-year period included 57 patients with pnevmotorak catfish. In 22 (39%) of them, primary spontaneous pneumothorax was observed earlier, and in 38 cases, relapses were recorded at the Mayo Clinic. From these data, it is possible ETS clude that relapses occurred in 50% of cases. Luck et al . It showed that patients with cystic fibrosis frequency re tsidivov is 50%, if the treatment is carried out only by torakostomii and drainage.
Treatment
The goal of treatment of secondary spontaneous pneumothorax as primary spontaneous pneumothorax is excretion WHO spirit from the pleural cavity and reducing the likelihood retsidivirovapiya . Performing these tasks is more important for patients with secondary spontaneous pneumothorax. Primary spontaneous ny pneumothorax, as well as its recurrence, mainly presents no wish to set up a threat to the life of the patient. In the case of a secondary spontaneous pneumothorax, the mortality rate exceeds 15%, and the relapse is often lethal before they enter the drainage. According Dines and colleagues , three (5%) of 57 pain GOVERNMENTAL with pneumothorax caused by chronic obstructive pulmonary disease, died before they were able to enter the nucleus nazh. According to Boat et al. , Of 15 patients with cystic fibrosis, three (20%) died of pneumothorax before they were given drainage .
Drainage by thoracostomy . SLU almost all teas treatment of patients with secondary spontaneous pneumothorax should begin with the implementation torakostomii and administration drains Ms. Even with a small pneumothorax, its elimination can give a quick improvement in the patient’s condition. After 24 h after torakostomii and administration improve drainage typically occurs of the gas composition of the arterial blood [34]. In the case of respiratory tion failure requiring artificial (mechanical drainage, it is necessary to introduce drainage, since during ventilation there is a possibility of an increase in the size of the pneumothorax. However, when the secondary pneumothorax thoraco stomy and drainage administering less effective. In primary spontaneous pneumothorax in three days after the start of draining Bani usually observed unfolding light and termination of air supply. In the case of secondary pneumonia spontaneous motoraksa caused by chronic obstructive Zabolev Niemi light, smoothing lung occurs after an average of 5 days . In one of observing 29% of patients with chro nical obstructive pulmonary disease required the introduction of more than one drainage, in another series of observations 35% of patients knstoznym fibrosis took the Introduction of multiple drainage. In accordance with the data obtained GOVERNMENTAL number of authors , approximately 20% of patients with secondary spontaneous pneumothorax light remains neraspravlennym and air flow continues for more than 7 days.
Patients with secondary spontaneous pneumothorax recom mended to conduct as follows. After diagnosis, the patient should enter the drainage, if he does not have obstruction of the bronchus. If easily dealt and stop the flow of air in the pleural cavity through the drainage tube trail is to introduce sclerosing agent, to reduce the likelihood of relapse. As already indicated, tetracycline is the preferred sclerosing agent. If after 5 days is not easily cracked down or stopped will do of air, these patients also need to enter into stubble ral cavity tetracycline. Although some authors may argue that as a result of the introduction of tetracycline on vistse tral pleura may occur inflammatory Mooring line, which can then expand to a stop light and hinder the implementation of surgery, we in our practice with such cases are not met.
Thoracotomy. If a few days after the tete ratsiklina is not easily cracked down or stopped Postup Lenie air, should consider thoracotomy for the purpose of suturing or removing bull. Undoubtedly, such a pain GOVERNMENTAL often has severe primary lung disease, in which the performance of thoracotomy is associated with risk. In chronic obstructive pulmonary disease and cystic fibrosis, the mortality rate after thoracotomy is about 10%. In general we can say that the tyazhe Leia primary lung disease, especially in the longer trail em ‘postpone the execution of thoracotomy. In some patients, the lung and the termination of air flow is observed only a few weeks after performing thoracostomy and the introduction of drainage .
Secondary pneumothorax, complicated tuberculosis. From cases of secondary spontaneous pneumothorax complicating the course of pulmonary tuberculosis should be considered separately. From the number of patients hospitalized for pulmonary tuberculosis, pneumothorax develops in 1-3% of cases . In a group of 28 patients 11 patients produced repeated ny thoracentesis with aspirating pleural fluid, one temporarily watching their condition. Seven (64%) of these II patients died. Other 17 patients were treated with the use of drainage, “out of their number, only one death was observed (6%). Duration of drainage method thoracostomy ranged from 5 days to 6 months and averaged 50 days . It can be concluded from these data that the patients with pneumothorax caused by tuberculosis parenhi We are easily shown thoracostomy. One to be kept in mind that the drainage can be lengthy. In general thoracotomy should not be made as long as the patient does not get TB Tera Pius for at least 6 weeks .