In the treatment of patients with pneumothorax SETTING need to build a degree of collapse of the lung. The volume of the lung and hemithorax is approximately proportional to the cube of their diameters. Thus, the degree of collapse can be determined by measuring the average diameter of the lung and Hemithorax , raising these values to a cube and finding their ratio. For example, the average diameter of the hemithorax is 10 cm, and the distance between the lung and the chest wall is 4 cm. Therefore, the ratio of diameters per cubic meter 63: 103 will be 22%. This means that pneumonia motoraks takes about 80% volume, although at first glance it does not look so extensive.
Recurrent pneumothorax
A patient with primary spontaneous pneumothorax has a risk of its recurrence. Gobbel and coworkers in over 6 years of watching the 119 patients with spontaneous pneumothorax. It was found that of 110 patients who had not produ Dehn thoracotomy pneumothorax during the first relapse pneumothorax on the same side was observed in 57 (52%) pain GOVERNMENTAL. If thoracotomy was not done, the frequency of the 2nd and 3rd retsi diva is respectively 62 and 83%. Seremetis on the basis of a short follow-up period indicated that the recurrence rate after the first spontaneous pneumothorax was 41%. Larrien et al reported that, out of 63 patients treated with the drainage method alone, relapses were observed in 23% of cases within one year after pneumothorax . According to Gobbel et al. , The average time between the first and second pneumothorax was 2.3 years, and according to Sere-metis , the average interval between relapses was 17 months.
Treatment
In the treatment of patients with primary spontaneous pneumothorax, there are two objectives: 1) removing air from the pleural cavity; 2) reducing the likelihood of relapse. If about air sachivanie from the alveoli into the pleural cavity otsutst exists, then, for the reasons outlined in Chapter 2, air will dissolve. However, spontaneous resolution prois walks slowly. Kircher and Swartzel calculated that kazh Dyje 24 h absorbed 1.25% by volume hemithorax . That’s why mu to complete resorption air occupying 15% Ob EMA hemithorax required 12 days. .Nesomnenno, introduction of a large amount of oxygen will increase the rate of dissolving Nia air in the pleural cavity . Because of the low resorption speed air all patients have to toryh pneumothorax occupies more than 15% hemithorax , shown by draining torakostomii .
Thoracostomy and drainage. Most patients with lane the Primary spontaneous pneumothorax shown drainage IU Tod torakostomii since it provides fast withdrawn of air from the pleural cavity. Drainage should be introduced into the uppermost part of the pleural cavity, where residual air is collected. General rules drainage outlined in chapter 24. Drainage method torakostomii is effectiveness tive in removing air from the pleural cavity when the drainage has been entered correctly. In a group of 81 patient millet air Chivanov elk in only 3 patients (4%) . The average duration of hospitalization of patients in this group was only 4 days (from 3 to 6 days). While it may seem that the introduced drain, providing irritating to the pleura will partly contribute pleurodesis and reduce the likelihood of time relapse Vitia, data analysis showed that the incidence of recurrent pneumothorax same, regardless of the first, if used in the treatment of only bed rest or torakostomiya and drainage .
Thoracotomy. If the air seepage does not stop or is not easily cracked down after 5 days after the start of the draenei tion method torakostomii should consider an open thoracotomy with suturing of bulls in the apical regions of the lungs and pleura scarification. Thoracotomy, not only allows you to not slow to solve the problem, but also reduce the likelihood of relapse. Data Compare 4 different screenings observations INDICATES that of 108 patients who underwent torakoto mia about spontaneous pneumothorax, only one patient experienced a relapse on the same side , In another series of observations of 362 patients who had you polyene pleurectomy of parietal pleura, relapse was observed only in 2 of 310 patients followed for an average 41/2 years ; It presents data on low mortality and a small number of complications after surgery : from 362 SLE teas thoracotomy this series of observations was only one death, and the average hospital stay was only 6 days. When pleural scarification is used There are various methods: from removal of the visceral and parietal pleura to simple rubbing of the pleura with a dry sponge. All these methods are quite effective [8], but since rubbing with a dry sponge is less traumatic than removing the pleura and does not affect the quality of the thoracotomy, this is the method of choice.
Relapse prevention. If the patient your primary Foot spontaneous pneumothorax should take measures to pre dotvrascheniyu its recurrence. If the initial treatment is draining method torakostomii or passive observation Deniafor the condition of the patient, the likelihood of relapse wa exceeds 50% . As already mentioned, torakoto mia with suturing subpleural bullae apical part lay someone and scarification pleura effective in preventing re tsidivov, but this operation is a serious hirur physical intervention. Because the primary spontaneous pneumothorax is rarely fatal, and if we take into account the fact that 50% of patients do not relapse, the thoracotomy in the first pneumothorax re mended only in cases where there is a constant Noah leakage of air or light is not straightened. In the treatment of first -onset pneumothorax to create a pleurodesis and prevent relapse after a pleural drainage hydrochloric cavity administered dec ary substances including quinacrine , talc , olive oil and tetracycline . Apparently, these substances are effective. Larrien and coworkers , 20 patients were administered with pneumothorax drainage akri hin. Of these patients, relapse was observed only in 1 case (5%). The authors recommend the introduction through the drainage of acryca in all patients with pneumothorax. However, quinacrine for parenteral administration currently does not produ ditsya. Nandi used aerosol talcum in the pleural cavity in 24 patients; there were no relapses during the observation period from 2 to 24 months . Some authors are high It was coupled assumption that talc can be contaminated asbes volume. In one of the works, a case of lung adenocarcinoma was reported in a patient after 2 g of ode after talcosis . These fears are most unjust, if we take into account the data of the Committee on Research Britan tion Thoracic Association, who reviewed individual results of 210 cases of pleurodesis with talc or kaolin iodinated made from 14 to 40 years ago. Analysis proved that among these patients have not been cases of mesothelioma and the incidence of lung cancer has not increased. However, the use of aerosol talc has not found quite widespread neniya as a sclerosing agent that is likely. ” can be explained by the difficulties associated with its dispersion.
Tetracycline . As a sclerosing substance recom mended use tetracycline. Sahn and Good in studies SRI shown in rats that intrapleural administration wall ratsiklina in a large dose (35 mg / kg) is more effective nym means pleurodesis than hydrochloric acid, quinacrine (10 mg / kg), nitrogen mustard, bleomycin or sodium oxide , Control studies determine the effectiveness of intrapleural use of tetracycline and the study of long-term results have not been conducted, although some authors consider this drug effective . Tetracycline recommends etsya used at a dose of 20 mg / kg t. E. The same way as with malignant ohm pleural effusion . Administered tetratsik ling recommended immediately after straightening lung while the patient should be placed in such position that the wall ratsiklin fed into separated apical pleural cavity Data obtained in animal experiments and clinic , indicate that the penetration of air into the pleural cavity is not a contraindication to the introduction of tetracycline. It has been reported that at OD Foot patient with a collapsed lung after 15 days after the Introduction there was a rapid unfolding of lung Nia . Currently we are introducing tetracycline into the pleural cavity. (20 mg / kg), most patients with primary spontaneous pneumonia motoraksom. We believe that tetracycline does not provide for any side-action in the long term, as they are not observed with the introduction of talc or silver nitrate .
So, the majority of patients with primary spontaneous pneumonia motoraksom must first make drainage method torakostomii . In the first case of pneumothorax, it is necessary to consider the introduction into the pleural cavity of tetracycline in order to reduce the likelihood of relapse. If air continues to flow into the pleural cavity for several days and the lung does not expand, then the patient should certainly have a thoracotomy with suturing of the pleural bladders in the apical sections of the lung and scarification of the pleura. If the patient has relapsed on the ipsilateral side, tetracycline should be injected, if this has not been done before. If tetracycline was already up den, thoracotomy must be performed.