ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170
The release of a new revision (ICD-11) is planned by WHO in 2017-2018.
With changes and additions from WHO.
Processing and translation of changes © mkb-10.com
Pneumothorax - presence of air in pleural cavity, caused by a wound of the chest wall or lung with damage to one of the branches of the bronchus.
Code by international classification diseases ICD-10:
Classification and etiology
By etiology: traumatic, spontaneous, artificial Traumatic Closed injury chest: damage to the lung by rib fragments, rupture of the lung or bronchus due to increased intrapulmonary pressure when the vocal cords are closed at the time of injury Open chest injury: penetrating wounds Iatrogenic injuries: injury to the lung during an attempt at catheterization subclavian vein, acupuncture of the stellate ganglion, blockade of the intercostal nerve, pleural puncture Spontaneous Nonspecific: rupture of bullae, cysts, rupture of the lung by adhesions, as a result of a regional increase in intra-alveolar pressure (in combination with mediastinal emphysema), pulmonary endometriosis, rupture of a lung abscess into the pleural cavity (pyopneumothorax), spontaneous rupture of the esophagus Tuberculous: rupture of the cavern, rupture of caseous foci Artificial pneumothorax is applied for therapeutic purposes in pulmonary tuberculosis, for diagnostic purposes - for thoracoscopy, for differential diagnosis of formations of the chest wall.
Classification by pathophysiological mechanism Closed pneumothorax - after gas penetrates into the pleural cavity, its flow stops, intrapleural pressure is usually negative Open pneumothorax - the presence of an opening in the chest wall (including the parietal pleura), freely communicating with external environment Valvular pneumothorax is a progressive accumulation of air in the pleural cavity. Air enters from a small hole in the lung tissue at the moment of inhalation, and at the moment of exhalation, finding no outlet, it remains in the pleural cavity. In the final stage of development, valvular pneumothorax becomes tense when the pressure in the pleural cavity becomes higher than in the adjacent lung and vessels. Valvular pneumothorax is characterized by a triad: positive intrapleural pressure, persistent displacement of the mediastinum to the opposite side, acute respiratory failure
Risk factors Trauma (broken rib, torn bronchus, perforation of the esophagus) Playing wind instruments Vigorous or prolonged physical activity High-altitude flights Diving COPD (especially emphysema) Pneumoconiosis Tuberculosis Lung tumors Lung abscesses Cystic fibrosis Subpleural pneumonia caused by Pneumocystis carini (in patients with AIDS Intubation) ation trachea with mechanical ventilation Hereditary defects in the development of collagen structures (Marfan, Ehlers-Danlos syndromes).
Pathological physiology Compression of the lung Displacement of the mediastinal organs to the opposite side (with tension pneumothorax) Shunting of unoxygenated blood from the collapsed lung into the systemic circulation Formation of serous exudate (irritation of the pleura) Subcutaneous emphysema Closed pneumothorax is benign: air from the pleural cavity resolves independently after 6–12 days Chest wounds with open pneumothorax are severe. Under the influence of continuous fluctuations in intrapleural pressure, oscillation (floating) of the mediastinum occurs, leading to the development of shock. So-called paradoxical breathing may occur when, when exhaling, air does not exit through the trachea, but is blown into the collapsed other lung, from where carbon dioxide-saturated air, when inhaled, flows back into the only breathing lung, sharply worsening blood oxygenation and causing hypercapnia.
Clinical picture Chest pain - sudden, aggravated by breathing, coughing or chest movements; shortness of breath With an open pneumothorax, the wounded person lies on the side of the injury, tightly pressing the wound. When examining the wound, a noise of air suction is heard. Foamy blood may be released from the wound Subcutaneous emphysema, especially pronounced with closed and valvular pneumothorax General condition is severe, the face is pale with a cyanotic tint, breathing is labored, rapid, superficial Movements of the chest are asymmetrical Tympanic percussion sound Auscultation - weakening of breathing Hemodynamic disturbances, especially pronounced during intense pneumothorax - weak fast pulse, arterial hypotension, swelling of the neck veins. In uncomplicated nonspecific spontaneous pneumothorax, the condition of patients is usually compensated.
Laboratory pH tests<7,35 paО2 <80 мм рт.ст paCО2 >45 mmHg
Special studies - chest x-ray Presence of air along the periphery of the chest. The well-defined root and edge indicate the location of the collapsed lung. The mediastinum, especially with a significant pneumothorax, is shifted to the opposite side. A minor pneumothorax may not be noticed on a regular survey image (at the height of inspiration). It is necessary to take a picture at the height of exhalation. In patients receiving mechanical ventilation for a long time, the first sign of pneumothorax may be pneumomediastinum.
Differential diagnosis Hemothorax Effusion pleurisy Asphyxia Pericarditis MI PE Diaphragmatic hernia Dissecting aneurysm of the thoracic aorta Giant cysts and bullae of the lungs Unipulmonary emphysema (McLeod syndrome) Lobar emphysema.
TREATMENT Immediate hospitalization in the surgical department. Closed pneumothorax is benign and gradually resolves. As a therapeutic measure, pleural puncture is sometimes necessary for air aspiration Massive nonspecific spontaneous pneumothorax: diagnostic thoracoscopy, drainage of the pleural cavity. Indications for surgery: ongoing bleeding (spontaneous pneumothorax), ineffective drainage, chronic pneumothorax, recurrent pneumothorax, large bullae or cysts, lung tumors. The purpose of the operation: elimination of the cause of pneumothorax, obliteration of the pleural cavity to prevent relapse. Thoracoscopic operations are possible Open pneumothorax The first aid at the scene of the incident is an airtight (occlusive) bandage, which temporarily turns an open pneumothorax into a closed one and reduces mediastinal flotation. The simplest occlusive dressing consists of several layers of gauze, heavily soaked in Vaseline, on top of which compress paper or oilcloth is applied Surgical treatment of the wound, thoracotomy, lung revision Drainage of the pleural cavity Valve pneumothorax Decompression of the pleural cavity using drainage Damage to the chest wall - suturing the defect, evacuating air from pleural cavity Damage to pulmonary structures - constant drainage for several days. In some cases, occlusion of the affected bronchus during bronchoscopy is indicated.
Complications Shock lung syndrome Pyopneumothorax Bronchopleural fistulas requiring surgical treatment.
1.Restore respiratory function and improve the patient's condition.
2. Maintain optimal respiratory function and prevent possible complications
J 93 spontaneous pneumothorax
Definition: spontaneous pneumothorax - pathological condition, characterize-
accumulation of air between the visceral and parietal pleura, not associated with
mechanical lung damage or chest as a result of trauma or
Depending on the type of pneumothorax, there are:
1. Open pneumothorax.
2. Closed pneumothorax.
With an open pneumothorax, there is communication between the pleural cavity and the lumen
bronchus and, therefore, with atmospheric air. On inspiration, air enters the pleura
cavity, and on exhalation it leaves it through a defect in the visceral pleura. At the same time
the lung collapses and is switched off from breathing (lung collapse).
With a closed pneumothorax, air enters the pleural cavity and causes
severe partial and complete collapse of the lung, subsequently losing connection with the atmosphere
spheral air and does not cause a threatening condition.
With valvular pneumothorax, air freely enters the pleural space during inspiration.
cavity, but its exit is difficult due to the presence of a valve mechanism.
1. Primary - without clinically obvious lung diseases (limited bulb
beneficial emphysema due to a1-antitrypsin deficiency, Marfan syndrome). More often
occurs in tall young men. Smoking increases the risk by 22 times.
2. Secondary – due to lung diseases.
Depending on the presence of complications: uncomplicated, complicated (bleeding)
pleurisy, mediastinal emphysema).
Risk factors: pulmonary tuberculosis, congenital polycystic disease, bronchiectasis
illness, suppurative lung diseases, chronic obstructive pulmonary disease, as-
matic status, AIDS, malignant tumors, smoking
The clinical picture of any type of pneumothorax depends on the volume and speed
air entering the pleural cavity. Disease in typical case manifests itself
the appearance of spontaneous short-term, lasting only a few minutes,
severe pain in one half of the chest; later they can either
disappear completely, or take on a dull character. Often the victim with great precision
This may indicate the time of onset of pain.
Sharp pain in the corresponding half of the chest radiating to the neck,
hand, worse with deep inspiration, coughing and movement;
Change in skin color (pallor, cyanosis);
Cold clammy sweat;
Forced position (half-sitting, leaning towards the lesion, or lying down)
on the sore side).
The intercostal spaces are widened, breathing movements on the affected area
rona are limited or absent;
The affected half of the chest lags behind during breathing, percussion determining
there is tympanitis, lower limit the lungs do not shift during breathing, the displacement is determined
reduction of the mediastinum and heart to the healthy side and prolapse of the liver in right-sided
or gastric prolapse with left-sided pneumothorax;
Auscultation reveals a significant weakening or absence of breathing
loud noises on the affected side and their amplification over the healthy lung.
With pronounced displacement of the mediastinum and kinks of the vessels flowing into the cavities
heart and leading to increased pressure in the superior vena cava, swelling is noted
Possible mediastinal shift clinical sign deviation of the trachea in health
If there is intramediastinal damage to the bronchus, emphysema develops
mediastinum without tension pneumothorax and intrapleural bleeding.
If the parietal pleura is damaged, air can escape into the subcutaneous cell.
chat, resulting in the formation of subcutaneous emphysema. The air quickly spreads
spreads along the subcutaneous fat to the chest, neck, anterior abdominal face
wall, etc., and after a few hours makes the person unrecognizable. On palpation of the
In the area of subcutaneous emphysema, a characteristic “snow crunch” is felt - crepitus.
The greatest danger is posed by tense emphysema of the mediastinum, which
occurs when the trachea and large bronchi rupture. It leads to disruption of outflow
blood from the vena cava system, stagnation in big circle blood circulation - extrapericar-
Dial cardiac tamponade
List of basic and additional diagnostic measures:
1. Evaluation general condition and vital functions: consciousness, breathing (participation
venous, superficial), blood circulation.
2. Visual assessment: assessment of the constitution (asthenic), forced position
(sedentary or semi-sedentary), skin pale, covered in cold sweat and/or
3. Pulse examination, measurement of heart rate, arterial
pressure (tachycardia, arterial hypotension).
4. Examination of the chest: widening of the intercostal spaces, lag in
breathing of the affected half of the chest, swelling and pulsation of the neck veins, air
Possible subcutaneous emphysema.
5. Palpation and percussion: weakening or absence of vocal tremors for a while
female side, tympanic sound (with accumulation of fluid in the pleural cavity in
lower sections dullness is determined), displacement of the apical impulse area and
borders of cardiac dullness in the healthy direction.
6. Auscultation: weakening or absence of breathing on the affected side.
Tactics of medical care:
In case of loss of consciousness, cessation of blood circulation and/or breathing, cardiac
no-pulmonary resuscitation, but only after preliminary pleural decompression;
Correction of hypoxia – oxygen therapy;
With rapidly growing mediastinal emphysema, transverse
make a small incision in the skin and platysma in the area of the jugular notch (about 2 cm), carefully insert
index finger into the retrosternal space, install drainage and fix
Pain relief - non-narcotic analgesics:
Ketorolac 30 mg (1 ml) intravenously slowly or intramuscularly;
For severe pain, narcotic analgesics:
Morphine 1% 1 ml diluted with 0.9% sodium chloride solution to 20 ml administered intravenously
4-10 ml (or 2-5 mg) in small fractions every 5-15 minutes until the pain syn-
droma and shortness of breath, or until the appearance side effects(arterial hypotension, depression
shortness of breath, vomiting);
For tension pneumothorax, a pleural puncture is performed;
If bronchospasm develops, salbutamol 2.5 mg via nebulizer for 5-10
Monitoring hemodynamic parameters and blood oxygen saturation, maintaining
List of essential medications:
1. *Morphine 1% 1ml, amp
2. *Oxygen for inhalation
3.*Salbutamol 3 mg, sky
List of additional medications:
1. *Ketorolac 30 mg - 1 ml, amp
2. *Sodium chloride 0.9% - 5.0 ml, amp
Indications for hospitalization: All patients with pneumothorax are subject to immediate
hospitalization in the thoracic surgery department or intensive care unit. Transport
testing in a sitting position or with the head end raised.
Indicators of the effectiveness of medical care: stabilization of condition
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What is the ICD-10 code for pneumothorax? ICD-10 is the international classification of diseases in the 10th revision, which contains all diseases and is used throughout the world. Pneumothorax is a pathology of the lungs, which has code J93, included in the X-class of this classifier of diseases, which takes into account all diseases of the respiratory system. And this international classification contains not only disease codes, but also complications after certain diseases and medical procedures.
As for pneumothorax itself, a similar pathology is found in the pleural cavity of the lungs with the accumulation of gases or air. It has a rather complex description of its types and mechanism of occurrence. Moreover, the international classification of pneumothorax does not indicate the types that exist in medicine, but only generalized codes. In medical practice, pathology is divided by type into open, closed and valvular, that is, it differs precisely in form. In the classification of pneumothorax, there are 4 codes, of which only one is accurately designated in the form of spontaneous tension pneumothorax. The remaining three codes have imprecise wording.
As already noted, pneumothorax occurs in three types - closed, open and valve. The closed form of this disease differs from others in that with it some amount of gas entering the pleural cavity does not increase. This form of pneumothorax is considered the easiest, since due to the lack of communication with the external environment, the likelihood of spontaneous resorption of accumulated air increases.
With open pneumothorax the situation is completely different. With this form, communication with the external environment is open and due to this a pressure arises that is equal to atmospheric pressure. As a result of this, the lung collapses due to the lack of negative pressure in the pleural cavity. It stops participating in breathing, there is no gas exchange, and oxygen does not enter the blood.
The valve form of pneumothorax is detected when a valve structure is formed in which air enters the pleural cavity in only one direction. It can come from the environment or from the lung with increasing pressure with each breathing movement. This type of pneumothorax is the most dangerous due to the fact that when the lung is turned off from breathing, the nerve endings of the pleura are usually irritated and pleuropulmonary shock develops. Against this background, compression of large vessels occurs, as the mediastinal organs are displaced and their function is disrupted.
Gas, like air, can enter the pleural cavity from the outside or from other organs. As a rule, this occurs due to an open injury to the chest, a closed lung injury, or when emphysematous blisters rupture. Even minimal trauma can rupture these blisters (bullas), for example, with a very strong cough, spontaneous pneumothorax can develop. But this does not necessarily lead to the development of pathology. Pneumothorax can occur as a secondary phenomenon due to a lung disease that destroys the integrity of its tissues. Pneumothorax is manifested by the following symptoms:
At the same time, the patient may experience panic fear. During examination, the doctor always notes, against the background of sharp painful sensations in the chest area, that the patient is breathing rapidly due to lack of air. In addition to pallor of the skin, cyanosis may also be present, in particular this applies to the skin on the face. Further, upon examination, as a rule, very weak auscultatory breathing is detected from the side of the damaged lung; the percussion sound has a boxy tint. Subcutaneous emphysema can often be detected.
If a person develops spontaneous pneumothorax, then it is necessary to urgently consult a doctor for qualified help. But when this is not available in the near future, in some cases you can provide first aid to the patient yourself. For example, with an open pneumothorax, it is urgent to apply a sealed occlusive dressing to the wound. This should prevent further air from entering the lung. Oilcloth material or plastic film may be suitable for this. In extreme cases, a bandage can be made from cotton wool and gauze. An excellent option would be to apply a valve bandage when the material is secured on three sides in a U-shape. But this is if we are talking about first aid in conditions where qualified assistance is not available.
Traditionally, treatment of pneumothorax will be aimed at suctioning air from the pleural cavity and restoring the necessary pressure in the lung.
If the pneumothorax is closed, then puncture aspiration of air is performed. When this is not enough, it means that air enters from the lung tissue and sealed drainage is required in the pleural cavity. For open pneumothorax, the same procedures are performed, but only after surgery to remove the wound. If unruptured air bullae are found, they are usually removed along with the area of the lung where they formed to prevent spontaneous pneumothorax from occurring.
Causes, symptoms and treatment of fluid (water) in the lungs
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How is an occlusive dressing applied to the chest for open pneumothorax?
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RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan (Order No. 764)
Protocol code: E-021 "Spontaneous pneumothorax"
Profile: emergency medical services
With an open pneumothorax, there is a connection between the pleural cavity and the lumen of the bronchus and, therefore, with atmospheric air. On inhalation, air enters the pleural cavity, and on exhalation it leaves it through a defect in the visceral pleura. In this case, the lung collapses and is switched off from breathing (lung collapse).
With a closed pneumothorax, air that has entered the pleural cavity and caused partial and complete collapse of the lung subsequently loses contact with atmospheric air and does not cause a threatening condition.
With valve pneumothorax, air freely enters the pleural cavity during inspiration, but its exit is difficult due to the presence of a valve mechanism.
1. Primary - without clinically obvious lung diseases (limited bullous emphysema with a1-antitrypsin deficiency, Marfan syndrome). More common in tall young men. Smoking increases the risk by 22 times.
2. Secondary - against the background of lung diseases.
By prevalence: total, partial.
Depending on the presence of complications: uncomplicated, complicated (bleeding, pleurisy, mediastinal emphysema).
Suppurative lung diseases;
Chronic obstructive pulmonary disease;
Characteristic symptoms spontaneous pneumothorax:
An objective clinical examination reveals:
With a pronounced displacement of the mediastinum and kinks of the vessels flowing into the cavities of the heart and leading to an increase in pressure in the superior vena cava, swelling of the jugular veins is noted.
There may be a shift of the mediastinum with a clinical sign of deviation of the trachea to the healthy side.
If there is intramediastinal damage to the bronchus, then mediastinal emphysema develops without tension pneumothorax and intrapleural bleeding.
If the parietal pleura is damaged, air can escape into the subcutaneous tissue, resulting in the formation of subcutaneous emphysema. The air quickly spreads through the subcutaneous fat to the chest, neck, face, anterior abdominal wall, etc., and after a few hours makes the person unrecognizable. When palpating the area of subcutaneous emphysema, a characteristic “snow crunch” is felt - crepitus.
The greatest danger is posed by tense emphysema of the mediastinum, which occurs when the trachea and large bronchi are ruptured. It leads to disruption of the outflow of blood from the vena cava system, stagnation in the systemic circulation - extrapericardial cardiac tamponade.
Pneumothorax (the name is based on the Greek pneuma - air and thorax - chest) is a change in which gas accumulates in the pleural cavity, and as a result, collapse of the lung tissue, compression of the blood vessels of the mediastinum, displacement of the mediastinum, prolapse of the diaphragm, due to all these changes occur in the respiratory and circulatory functions. Air entering the pleural cavity provokes an increase in intrapleural pressure, leading to the collapse of the whole lung or part of it, another name for this condition: partial or complete collapse of the lung.
The picture shows - Pneumothorax
Classification is carried out on the basis of the following characteristics: etiology, mechanism of damage, distribution of lung collapse and duration of the disease.
According to the etiology of the disease, the following types and causes of each individual type are distinguished:
It is the most common in clinical practice and is always secondary to pulmonary or pleural pathology.
Occurs in relatively healthy people without previous underlying pulmonary diseases and in the absence of a precipitating event. However, many patients diagnosed with primary pneumothorax have pulmonary disease, such as pleural bullae, that are discovered later on CT scans. This type occurs due to air being sucked through a weakened area of the lung. Patients with the primary spontaneous form are usually men under 40 years of age, with a tall, thin build.
⚠️ Smoking increases the risk of disease. Sometimes it is provoked by a sharp change in intrapleural pressure in pilots, parachutists at high altitudes, in divers, and divers when immersed in water.
Occurs in patients with a wide range of lung diseases (chronic obstructive pulmonary disease, bronchial asthma, cystic fibrosis of the lungs, cancer, pneumonia, etc.). These diseases change the normal structure of the lungs, and air enters the pleural cavity through stretched and damaged alveoli.
The usual cause of the development of this form is blunt or penetrating trauma that ruptures the visceral and parietal layers of the pleura (for example, contusion of the chest during a fall, collision, fractures of the ribs and sternum, injuries from road traffic accidents, stab injuries, etc.).
Develops as a result of damage to the pleura, penetration of air into the pleural cavity due to diagnostic or therapeutic intervention. This pathology occurs in 1–2% of children in the first year of life; a higher incidence rate is observed in newborns with neonatal respiratory distress syndrome during artificial ventilation.
Open. When the form is open, atmospheric air moves from the pleural cavity unhindered. Communication between the pleural cavity and the respiratory tract can lead to the development of a bronchopleural fistula.
Closed. It develops when air enters the pleural cavity through a defect during inhalation, but becomes trapped there as the defect becomes occluded after some time.
Valve. Occurs when air is able to enter the pleural space during inspiration, but is unable to escape during expiration because the opening is blocked by part of the bulla, lung, or wound that functions as a valve. This condition requires emergency medical attention. The air pressure continues to gradually increase, and further collapse of the lung leads to a displacement of the mediastinum and disruption of the main veins leading to the heart.
At this stage it is usually called "tense" due to the increasing positive pressure. Tense appearance is rare but may have a potentially unfavorable outcome and if suspected, immediate chest decompression is required.
👨⚕️ According to the distribution of lung collapse, localized and generalized are distinguished, according to duration - acute and chronic.
Symptoms of pneumothorax depend on its type and extent of spread. Often the small spontaneous form is asymptomatic. Patients with secondary spontaneous disease may have more severe clinical symptoms and complications from comorbidities.
Typically, patients experience severe pain that has an acute onset. Chest pain occurs in approximately 90% of patients with the primary spontaneous form. The pain is sharp and can lead to a feeling of tightness in the affected part of the chest. At the same time, pain and shortness of breath are observed in more than 60% of patients.
Other symptoms include:
The skin may become pale or bluish (cyanosis) due to decreased oxygen levels in the blood.
With a tense form, you may experience:
Pneumothorax of the right lung can cause a downward displacement of the lower edge of the liver. When the left lung is affected, popping sounds are heard with heart contractions. The side of the chest with pneumothorax becomes larger compared to the opposite side.
Studying the medical history and examining the patient remain the main diagnostic methods. An assessment of clinical manifestations and physical data is sufficient to make a preliminary diagnosis.
On examination, there is a deviation of the trachea and apex impulse to the side opposite the lesion, and an increase in resonance during percussion. When listening to the lung with a stethoscope or phonendoscope, there is an absence or decrease in breathing sounds during inspiration.
A chest x-ray can confirm the diagnosis. Chest X-rays taken from different angles provide additional information about the extent of the disease and its possible causes. On radiographs, it is classically seen as an area of “missing” pulmonary pattern between the rib cage skeleton and the margin of the lungs. In some cases, a computed tomography (CT) scan may be needed to provide more detailed images. Data from these studies are the basis for drawing up a treatment plan.
The doctor can also confirm the clinical diagnosis by performing the following procedure: insert a needle into the pleural cavity through the second anterior intercostal space and remove the plunger from the syringe; in the case of a tension pneumothorax, air immediately escapes through the liquid in the syringe.
👩⚕️ Conducted differential diagnosis with the following diseases: myocardial infarction, pulmonary embolism, pulmonary infarction, perforation of a gastric ulcer, pneumopericardium.
Treatment of pneumothorax, similar to the symptoms, depends on the classification of the disease: remove air from the pleural cavity, reduce pressure on the lungs, which will allow them to expand, and prevent relapses of the disease.
If the type of disease is minor, observation tactics are used until the air is completely absorbed. In this case, the period of expansion of the lungs can range from several days to several weeks; oxygen therapy is used as additional treatment.
If the disease has a large area affected, a closed drainage tube will be required, through which air is continuously removed from the chest cavity. In the absence of communication between the pleural cavity, lungs and respiratory tract, air is absorbed at the rate of 1.25% of the total radiographic volume of the half chest per day.
When carrying out therapy, it is also necessary to ensure cleanliness respiratory tract, maintain ventilation if, despite treatment, ventilation remains impaired, use controlled ventilation (using an endotracheal tube or tracheostomy).
Surgical treatment is used in patients with repeated episodes (relapses). The surgeon may use surgical options such as thoracoscopy, electrocoagulation, laser coagulation, resection of bullae or pleura, and open thoracotomy.
The following consequences may develop after surgery to treat pneumothorax:
prof. Avdeev Sergey Nikolaevich (Moscow),
prof. Vizel Alexander Andreevich (Kazan)
Epidemiology
The incidence of primary spontaneous pneumothorax (PSP) is 7.4–18 cases per 100 thousand people per year among men and 1.2–6 cases per 100 thousand people per year among women. PSP is more common in tall, thin boys and men 10–30 years old, rarely in people over 40 years old.
The incidence of secondary spontaneous pneumothorax (SSP) is 6.3 cases per 100 thousand people per year among men and 2.0 cases per 100 thousand people per year among women. VSP is most common in patients with COPD (26 cases per 100 thousand people per year), mainly at the age of 60–65 years. Among patients infected with HIV, SSP develops in 2–6% of cases, of which in 80% against the background of Pneumocystis pneumonia. VSP is a common (incidence 6–20%) and potentially life-threatening complication (mortality 4–25%) of cystic fibrosis. In some rare lung diseases belonging to the cystic group, the incidence of VSP is extremely high: up to 25% in histiocytosis X (eosinophilic granuloma) and up to 80% in lymphangioleiomyomatosis. The frequency of pneumothorax in tuberculosis is currently low and amounts to only 1.5%.
Pneumothorax occurs in 5% of all patients with multiple injuries, in 40–50% of patients with chest injuries, including blunt injuries. A characteristic feature of traumatic pneumothorax is its frequent combination with hemothorax (up to 20%), as well as the difficulty of diagnosing it using chest radiography; CT can detect up to 40% of so-called “occult” or hidden pneumothorax.
The incidence of iatrogenic pneumothorax depends on the type of diagnostic procedures performed: with transthoracic needle aspiration - 15-37%; during catheterization of central veins (especially subclavian) – 1-10%; with thoracentesis – 5-20%; with pleural biopsy - 10%; with transbronchial lung biopsy – 1-2%; during mechanical ventilation 5-15%.
PreventionPrimary prevention
Classification
All pneumothoraxes can be divided into spontaneous(not associated with any obvious reason), traumatic(associated with direct and indirect chest trauma) and iatrogenic(related to medical interventions). In turn, spontaneous pneumothoraxes are divided into primary(arising without background pulmonary pathology) and secondary(arising against the background of lung diseases, see table).
Spontaneous pneumothorax:
The most common causes of secondary spontaneous pneumothorax
| Respiratory diseases |
| COPD |
| Cystic fibrosis |
| Severe exacerbation of bronchial asthma |
| Infectious lung diseases |
| Pneumonia ^ Pneumocystis carinii |
| Tuberculosis |
| Abscess pneumonia (anaerobes, staphylococci) |
| Interstitial lung diseases |
| Sarcoidosis |
| Idiopathic pulmonary fibrosis |
| Histiocytosis X |
| Lymphangioleiomyomatosis |
| Systemic connective tissue diseases |
| Rheumatoid arthritis |
| Ankylosing spondylitis |
| Polymyositis/dermatomyositis |
| Systemic scleroderma |
| Marfan syndrome |
| Ehlers–Danlos syndrome |
| Tumors |
| Lung cancer |
| Sarcoma |
Diagnosis
History, complaints and physical examination.
The acute onset of the disease is usually not associated with physical activity.
^ Leading complaints- chest pain and shortness of breath.
The pain is often described by patients as “sharp, piercing, dagger-like”, intensifies during inspiration, and can radiate to the shoulder of the affected side.
The severity of shortness of breath is associated with the size of the pneumothorax; with secondary pneumothorax, as a rule, more severe shortness of breath is observed, which is associated with a decrease in respiratory reserve in such patients.
Less commonly, a dry cough, sweating, general weakness, and anxiety may occur.
Symptoms of the disease most often subside 24 hours after the onset of the disease, even in the absence of therapy and maintaining the same volume of pneumothorax.
Physical signs:
Tachycardia (more than 135 min -1), hypotension, paradoxical pulsus, distended jugular veins and cyanosis are signs of tension pneumothorax.
Possible subcutaneous emphysema.
Survey The patient should include questions about smoking history, episodes of pneumothorax and the presence of lung diseases (COPD, asthma, etc.), HIV, Marfan disease, Ehlers-Danlos syndrome D .
^ Laboratory researchTo confirm the diagnosis, it is necessary to conduct a chest x-ray (the optimal projection is anteroposterior, with the patient in an upright position).
Radiographic sign of pneumothorax- visualization of a thin line of visceral pleura (less than 1 mm), separated from the chest (Fig. 1).
^
Secondary spontaneous pneumothorax on the right in a patient with Pneumocystis pneumonia
A common finding with pneumothorax is a shift of the mediastinum to the opposite side. Since the mediastinum is not a fixed structure, even a small pneumothorax can lead to displacement of the heart, trachea and other elements of the mediastinum, so contralateral shift of the mediastinum is neither a sign of the severity of the pneumothorax nor a sign of tension pneumothorax.
About 10–20% of pneumothoraxes are accompanied by the appearance of a small pleural effusion(within the sinus), and in the absence of straightening of the pneumothorax, the amount of fluid may increase.
In the absence of signs of pneumothorax according to the radiograph in the anteroposterior projection, but in the presence of clinical data in favor of pneumothorax, radiographs in the lateral position or lateral position on the side are indicated ( decubitus lateralis), which allows confirming the diagnosis in an additional 14% of cases WITH .
Some guidelines recommend that in difficult cases, radiography be performed not only at the height of inspiration, but also at the end of expiration. However, as recent studies have shown, expiratory films have no advantages over conventional inspiratory films. Moreover, vigorous exhalation can significantly aggravate the condition of a patient with pneumothorax and even lead to asphyxia, especially with tension and bilateral pneumothorax. That's why X-ray at expiratory height is not recommended for the diagnosis of pneumothorax WITH .
^ Radiological sign of pneumothorax in a patient in a horizontal position (usually during mechanical ventilation) - a sign of a deep sulcus sigh, white arrows.
Deepening of the costophrenic angle, which is especially noticeable when compared with the opposite side (Fig. 2.).
^
Pneumothorax in a patient during mechanical ventilation
For diagnosing small pneumothoraxes, CT is a more reliable method compared to radiography. The sensitivity of CT in detecting pneumothorax after transthoracic lung biopsy is 1.6 times higher.
CT is indicated to determine the cause of secondary spontaneous pneumothorax (bullous emphysema, cysts, ILD, etc.), in the differential diagnosis of large emphysematous bullae and pneumothorax WITH .
^ Recurrent pneumothorax
Relapses, i.e. the development of repeated pneumothorax after a primary pneumothorax is one of important aspects management of patients. Relapses, as a rule, do not complicate the course of traumatic and iatrogenic pneumothorax. According to an analysis of literature data, the relapse rate 1–10 years after undergoing PSP ranges from 16 to 52%, averaging 30%. The majority of relapses occur in the first 0.5–2 years after the first episode of pneumothorax.
After recurrent pneumothorax, the likelihood of subsequent relapses progressively increases: 62% after the 2nd episode and 83% after the 3rd pneumothorax.
In one of the largest studies, which included 229 patients with VSP, the relapse rate was 43%.
The main risk factors for the development of relapses in patients with spontaneous pneumothorax (both with PSP and SSP) are the presence pulmonary fibrosis, age over 60 years, tall stature and low nutritional status of patients. The presence of subpleural bullae is not a risk factor for relapse.
Differential diagnosis
VSP is in most cases a complication and not the main diagnosis. In this regard, the duration of temporary disability is associated with the primary disease.
Examples of constructing a diagnosis
Primary (idiopathic) spontaneous pneumothorax, closed. DN-0.
Fibrous-cavernous pulmonary tuberculosis in the phase of infiltration and seeding, 1B, MBT (+). Spontaneous valvular pneumothorax, recurrent. Condition after application of active drainage. DN-1.
Treatment
Treatment Goals:
^ Treatment tactics. Currently, there are two known consensus documents on the diagnosis and treatment of patients with spontaneous pneumothorax - the British Thoracic Society manual (2003) and the American College of Chest Physicians manual (2001).
Despite some differences in approaches to patient management, these guidelines suggest similar stages of patient treatment: observation and oxygen therapy, simple aspiration, installation of a drainage tube, chemical pleurodesis, surgical treatment.
Doctor general practice must be able to diagnose PSP and VSP and ensure timely transportation and hospitalization of the patient in a large city to a specialized institution with pulmonology and thoracic departments (in the conditions of a central district hospital - the central district hospital).
Further management includes
Oxygen therapy;
Simple aspiration;
Drainage of the pleural cavity;
Chemical pleurodesis;
If indicated, surgical treatment of pneumothorax;
Urgent events
For tension pneumothorax it is indicated immediate tracocentesis(using a needle or cannula for venipuncture no shorter than 4.5 cm, in the 2nd intercostal space along the midclavicular line), even if it is impossible to confirm the diagnosis using radiography WITH .
Patient education
If there are difficulties in interpreting chest x-ray data, consultation with a specialist in x-ray methods is indicated.
Consultation with a pulmonologist (or specialist intensive care) and a thoracic surgeon are necessary: when performing invasive procedures (installation of a drainage tube), determining indications for pleurodesis, additional measures (thoracoscopy, etc.).
Further management
Consultation with a pulmonologist 7–10 days after discharge from the hospital (if tuberculosis is present, transfer to an anti-tuberculosis facility).
Forecast
Mortality from pneumothorax is low and is more often observed with secondary pneumothorax. In HIV-infected patients, in-hospital mortality with the development of pneumothorax is 25%, and the average survival after pneumothorax is 3 months. Mortality in patients with cystic fibrosis with unilateral pneumothorax is 4%, with bilateral pneumothorax 25%). U patients with COPD with the development of pneumothorax, the risk of death increases 3.5 times and is 5%.
Sarcoidosis
^
Author: prof. Wiesel Alexander Andreevich (Kazan)
Sarcoidosis - systemic and relatively benign granulomatosis of unknown etiology, characterized by the accumulation of activated T-lymphocytes (CD4+) and mononuclear phagocytes, the formation of non-secreting epithelioid cell non-caseifying granulomas. Intrathoracic manifestations of this disease predominate; damage to all organs and systems except the adrenal gland has been described.
ICD-10: D86 Sarcoidosis; D86.0 Pulmonary sarcoidosis; D86.1 Sarcoidosis lymph nodes; D86.2 Sarcoidosis of the lungs with sarcoidosis of the lymph nodes; D86.3 Sarcoidosis of the skin; D86.8 Sarcoidosis of other specified and combined localizations; Iridocyclitis in sarcoidosis +(H22.1*); Multiple paralysis cranial nerves for sarcoidosis +(G53.2*); Sarcoid: arthropathy +(M14.8*); myocarditis +(I41.8*); myositis +(M63.3*); D86.9 Sarcoidosis, unspecified.
^
An example of a diagnosis formulation
Sarcoidosis of intrathoracic lymph nodes and lungs, acute course, Löfgren's syndrome. Stage II. DN-0. Sarcoidosis of the skin, papular form.
Epidemiology
Newly identified cases are most often registered at the age of 20–50 years with a peak at 30–39 years, 2/3 of patients are women. The incidence of sarcoidosis in Russia is 3.0 per 100,000 population. Prevalence of sarcoidosis in different countries and different ethnic groups ranges from 5 to 100 per 100 thousand population. Sarcoidosis is less common in childhood and in the elderly. Intrathoracic lesions are rare in children under 4 years of age. Cases of familial sarcoidosis have been reported. The likelihood of sarcoidosis and the severity of its course are associated with HLA histocompatibility genes; genes of ACE, tumor necrosis factor, vitamin D receptors, etc.
Prevention
Screening
In countries with widespread preventive radiation examinations (usually through TB services), intrathoracic forms of the disease are detected even at preclinical stages (up to 60% of all newly diagnosed). Upon referral, patients with articular syndrome, erythema nodosum, neurological pathology, and arrhythmias are identified. Sarcoidosis is most often diagnosed by TB specialists, pulmonologists, oncologists, rheumatologists, dermatologists, and general practitioners.
Classification
According to the course: acute, subacute, chronic. In accordance with intrathoracic X-ray changes, sarcoidosis is divided into stages.
^ 0 . There are no changes on the chest x-ray.
I. Hilar lymphadenopathy. The lung parenchyma is not changed.
II. Lymphadenopathy of the roots of the lungs and mediastinum. Pathological changes lung parenchyma.
III. Pathology of the pulmonary parenchyma without lymphadenopathy.
IV. Irreversible pulmonary fibrosis.
Extrathoracic manifestations of sarcoidosis (damage to the eyes, skin, bones, etc.) are described separately.
Diagnostics
History and physical examination
Sarcoidosis is a “diagnosis of exclusion” followed by histological confirmation.
Anamnesis. When collecting an anamnesis, it is necessary to establish the presence of signs of arthritis (with damage to the ankles, small joints of the arms and legs), erythema nodosum, decreased vision, and the timing of the last preventive radiation examination.
Inspection. Erythema nodosum and skin sarcoidosis are detected in the form of purple dense plaques; manifestations on the face - lupus pernio(“lupus pernio”) - often combined with bone damage and chronic progressive lung damage.
In acute cases (usually radiation stages I–II) it is characteristic Löfgren's syndrome(up to 30%): fever, bilateral hilar lymphadenopathy, polyarthralgia and erythema nodosum (Löfgren's syndrome in 80% of cases involves spontaneous remission without hormonal therapy); much less often Heerfordt–Waldenström syndrome: fever, enlarged parotid lymph nodes, anterior uveitis and paralysis facial nerve(Bell's palsy, a sign of benign sarcoidosis).
At chronic course(usually radiation stages II–IV) manifestations are variable.
Complaints: fatigue, weakness, fatigue (up to 90%), nonproductive cough, discomfort and pain in the chest, joint pain, decreased vision, mixed or inspiratory shortness of breath, palpitations.
^ Physical examination : pulmonary manifestations are scanty and atypical ( hard breathing, dry wheezing), expansion of the percussion boundaries of the mediastinum; an increase in the percussion determined size of the liver and spleen. Facial nerve paralysis, peripheral neuropathies. Arrhythmias that occurred without previous pathology cardiovascular system(cardiac arrest in sarcoidosis, as a cause of sudden death).
^ Laboratory and instrumental studies
Blood. Conduct clinical analysis blood, biochemical research. In peripheral blood: leukopenia, lymphopenia, increased ESR, hypergammaglobulinemia, hypercalciuria, hypercalcemia; increased concentration of ACE in blood serum and lavage fluid.
^ Lavage liquid : CD4/CD8 lymphocyte ratio greater than 3.5 (sensitivity 53%, specificity 94%). When detected and with each exacerbation, sputum or lavage fluid must be examined for Mycobacterium tuberculosis (at least 3 samples).
^ Kveim-Siltzbach test : intradermal injection of a pasteurized suspension of the spleen affected by sarcoidosis. A biopsy of the papule that forms at the injection site after 4–6 weeks reveals characteristic granulomas. There is no standard Ag Kveim.
^ Instrumental data
Radiography chest organs is necessary at the detection stage, HRCT - at the stage of primary and dynamic examination is carried out to identify the main radiation syndromes: hilar lymphadenopathy, ground glass symptom, pulmonary dissemination syndrome, local shadows, fibrosis and bullae, pleural consolidation. X-ray of the hands: bones cystic formations. HRCT of organs abdominal cavity: hepato- and/or splenomegaly.
^ Respiratory function test : on early stages distal obstruction syndrome bronchial tree[decrease in instantaneous volumetric velocity - MOS 50 and MOS 75], later decrease in VC, TEL and diffusion capacity of the lungs - DLco.
ECG. The ECG shows rhythm and conduction disturbances. At initial examination: ECG monitoring according to Holter, MRI examination and for sarcoidosis of the central nervous system, liver, heart - identification of foci, clusters of granulomas.
Bronchoscopy. Bronchoscopy reveals bronchial compression syndromes and dilatation of the carina.
Biopsy. Transbronchial or transthoracic video-thoracoscopic biopsy of the lungs or hilar lymph nodes, biopsy of the skin, liver, peripheral lymph nodes reveals characteristicgranulomas: discrete, compact, non-caseifying epithelioid cell granuloma, consisting of highly differentiated mononuclear (mononuclear) phagocytes (epithelioid and giant cells) and lymphocytes. Giant cells may contain cytoplasmic inclusions (asteroid bodies and Schaumann bodies). The central part of the granuloma consists predominantly of CD4+ lymphocytes, while CD8+ lymphocytes are present in the peripheral zone.
^ Differential diagnosis
The differential diagnosis of sarcoidosis until the moment of histological verification is based on the exclusion of other diseases, the list of which is determined by the predominant localization of the process.
When the central nervous system is affected, the differential diagnosis is made with tumor lesions and brain tuberculomas, which are similar to “sarcoids” - clusters of granulomas that form foci on HRCT and MRI scans.
Sarcoidosis is included in the list of differential diagnostic diseases for sudden death syndrome (sarcoidosis of the heart), metrorrhagia (sarcoidosis of the uterus), seminomas (sarcoidosis of the testicle and appendages), and galactorrhea unknown origin(pituitary sarcoidosis).
^ Indications for consultation with other specialists :
^ Approximate terms of temporary disability
In most cases, uncomplicated sarcoidosis does not impair the ability to work. A certificate of incapacity for work can be issued for a period of intensive diagnostics for further examination and biopsy (up to 1 month). In case of a chronic progressive course, with multiple organ damage, in each case, ability to work and disability are determined individually during a medical and social examination.
^ Treatment
Goal of treatment- prevention and elimination of conditions that threaten the health and life of the patient, depending on the predominant localization of sarcoidosis. Causal therapy has not been developed.
^ Indications for hospitalization : short-term hospitalization during the initial examination for invasive diagnostics (biopsy); severe violations external respiration, failure of organs and systems of II degree of severity and higher; selection of treatment for resistance to treatment in outpatient setting.
^ Non-drug treatment (regime, diet). It is recommended to improve the lifestyle and workplace, eliminate stress, and avoid hyperinsolation. Unloading diet therapy is used in Russia for the 1st and 2nd radiological stages of pulmonary sarcoidosis (its immunocorrective effect, stimulation of the adrenal cortex and antioxidant effect are noted). It is possible to combine it with hormonal treatment.
^ Drug treatment
indicated only for patients with initially severe and/or progressive respiratory failure, damage to the eyes, heart, nervous system, failure of organs and systems of II degree of severity and higher. In other cases, after diagnosis, outpatient monitoring is recommended every 3–6 months with radiological and functional monitoring, with consultation of specialists in accordance with the location of the lesion. During this period, vitamin E is used orally (200–400 mg/day), for pain and joint syndrome - non-steroidal anti-inflammatory drugs (preferably long-acting).
Löfgren's syndrome is not a direct indication for starting hormonal therapy. With obvious progression and the appearance of extrapulmonary lesions, treatment with corticosteroids begins.
Glucocorticoids
GKS B used at the rate of 0.5–1.0 mg/kg, or 20–40 mg per day per os for 2–3 months, then reduced to a maintenance dose of 5–15 mg per day, which continues to suppress inflammation, but is devoid of many toxic effects (another 6–9 months); patients should continue to receive treatment if hypercalcemia and hypercalciuria, disfiguring skin lesions persist, and there are manifestations of ocular sarcoidosis (use of systemic and local drugs), sarcoidosis of the heart, nervous system.
In case of relapses of sarcoidosis, which are especially likely 3–4 months after discontinuation of hormones, treatment is resumed according to the same regimens or “pulse therapy” is used with intravenous methylprednisolone 3 g per day for 3 days of acute relapse.
Along with prednisolone, it is possible to use urbazone, methylprednisolone, tetracycline with triamcinolone (polcortolone), dexamethasone, betamethasone in dosages equivalent to prednisolone (20–40 mg). At hormonal treatment They recommend protein- and potassium-containing diets, vitamins, diuretics, limiting fluid intake, table salt, and spicy foods. In addition, intermittent hormone therapy in the same doses every other day and even after 2 days has also proven its effectiveness. Intermittent use of steroids is also possible during the maintenance phase.
Only if oral corticosteroids are poorly tolerated, it is possible to use long-acting triamcinolone for intramuscular administration. For extrapulmonary sarcoidosis (without pulmonary involvement) of the eyes, nervous system, upper respiratory tract, 60–80 mg/day is prescribed for for a long time until obvious effect, and in case of sarcoidosis of peripheral lymph nodes, spleen, submandibular salivary glands- 20–30 mg.
Evidence base positive influence Hormonal therapy for more than two years does not prevent further progression of the disease. Systemic steroids significantly improve the condition of patients with stages II and III of moderate-severe and severe course, whereas in stage I there are no significant differences in comparison with untreated B .
^ Inhaled steroids C for sarcoidosis are under study (beclomethasone, budesonide, fluticasone), they are prescribed as first-line drugs either at the stage of withdrawal from systemic steroids, or in patients with intolerance to systemic steroids. Largest number observations relate to budesonide, which was used 2 times a day at 800 mcg or higher in patients with severe cough syndrome. The expediency of consistent and combined use systemic and inhaled corticosteroids for sarcoidosis stage II and higher.
^ Other forms of topical corticosteroids. For laryngeal sarcoidosis, local administration of corticosteroids is used. Hormonal ointments and creams are used for skin sarcoidosis, and for eye sarcoidosis, drops containing corticosteroids are used.
^ Antimalarial drugs B- 4-aminoquinolones chloroquine and hydroxychloroquine. Chloroquine is prescribed 0.25 g 2-3 times a day for 2-6 months. as monotherapy, in combination with sodium thiosulfate and with a reduced dose of GCS. Chloroquine is used for hypercalcemia, neurosarcoidosis, and chronic forms of pulmonary sarcoidosis. Hydroxychloroquine is used in a dose of 200 mg every other day for 9 months and is recommended for the treatment of sarcoidosis of the skin and bones, as well as hypercalcemia.
Methotrexate B- antagonist folic acid with anti-inflammatory and immunosuppressive properties, a cytotoxic agent that is quite widely used in the chronic course of sarcoidosis. It can be effective when various manifestations diseases, both in chronic sarcoidosis of the lungs and skin. Methotrexate is prescribed once a week orally or intramuscularly at a dose of 7.5–20 mg for 1–6 months and up to 2 years in patients with insufficient effect of corticosteroids or their intolerance. It is used independently or to reduce the dose of GCS.
Cyclosporine A B- an immunosuppressant that inhibits the reactions of cellular and humoral immunity T-lymphocyte-dependent - prevents the activation of lymphocytes by inhibiting the release of lymphokines. His positive effect manifests itself in cases where there is no alveolitis caused by CD4 lymphocytes. Used when refractory to systemic steroids.
Azathioprine C- a purine analogue, a cytostatic and immunosuppressant, azathioprine, blocks cell division as a result of competition with the natural purine bases of DNA and RNA. The drug is prescribed orally at a dose of 2–3 mg/kg/day, but not more than 250 mg per day, and can be used simultaneously with or without corticosteroids. The course of treatment can be up to 6 months followed by breaks of 3–4 months.
^ Cyclophosphamide, colchicine prescribed for steroid-refractory sarcoidosis.
Nonsteroidal anti-inflammatory drugs C are useful as symptomatic agents in the treatment of acute arthritis and myalgia in Löfgren's syndrome, but do not play any role in progressive pulmonary sarcoidosis.
^ Tumor necrosis factor . Effect on the formation and release of tumor necrosis factor 4 (TNF) is one of the treatment methods for sarcoidosis, since TNF plays a significant role in the formation of granulomas and the progression of sarcoidosis. Monoclonal antibodies are also used B against TNF (infliximab, enbrel, etanercept).
Pentoxifylline C used as a treatment for active pulmonary sarcoidosis together with hormones and independently, dosage 25 mg/kg per day for 6 months. A combination with vitamin E is advisable.
Antioxidants D . Vitamin E is used (200–500 mcg per day).
Extracorporeal treatment methods C
Providing the patient with accessible knowledge about sarcoidosis [that it is not tuberculosis, that it is not contagious; that this is not a tumor (the similarity with “sarcoma” alarms patients); that treatment is aimed at the effect, not the cause]. Explain to the patient that staying in anti-tuberculosis institutions is not indicated and is even dangerous (except for the period of diagnosis). It is important to avoid stress, eat a healthy diet, avoid hyperinsolation, and isolate yourself from infections. In some cases, the help of a psychotherapist is needed.
^ Further management
A patient with sarcoidosis is monitored by a general practitioner or pulmonologist, or a member of the sarcoidosis center. Isolation from infectious diseases is ensured (strict isolation is required when treating with corticosteroids and immunosuppressants). Newly diagnosed patients with active forms of sarcoidosis of any localization visit a doctor every 3 months during the first year, and every 6 months during the second year of observation. Duration of observation: at favorable course- 2 years. For exacerbations and relapses: the first year - every 3 months, the second year - every 6 months. The duration of observation for a recurrent course is 3 years or more. Persons with clinically cured sarcoidosis (inactive sarcoidosis): the first year of observation - once every 6 months, the second year of observation - once every 12 months. It is not recommended to deregister patients due to the undulating course of sarcoidosis. X-rays and tomograms are taken upon detection; subsequently 1 month after the start of treatment, then after 3, 6, 12 months during the first year of observation; during the second and third years - once every 6 months (in the absence of exacerbations).
ForecastRCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)
Other spontaneous pneumothorax (J93.1)
Spontaneous pneumothorax- a pathological condition characterized by the accumulation of air between the visceral and parietal pleura, not associated with mechanical damage to the lung or chest as a result of injury or medical manipulation.
Purpose of the stage:
1. Restore respiratory function and improve the patient’s condition
2. Support optimal respiratory function and prevent possible complications
Code(s) according to ICD-10-10:
J 93 spontaneous pneumothorax
Depending on the type of pneumothorax, there are:
1. Open pneumothorax.
2. Closed pneumothorax.
With open pneumothorax there is a connection between the pleural cavity and the lumen of the bronchus and, therefore, with atmospheric air. On inhalation, air enters the pleural cavity, and on exhalation it leaves it through a defect in the visceral pleura. In this case, the lung collapses and is switched off from breathing (lung collapse).
With closed pneumothorax air that has entered the pleural cavity and caused partial and complete collapse of the lung subsequently loses contact with atmospheric air and does not cause a threatening condition.
With valvular pneumothorax During inhalation, air freely enters the pleural cavity, but its exit is difficult due to the presence of a valve mechanism.
By origin:
1. Primary- without clinically obvious lung diseases (limited bullous emphysema with a1-antitrypsin deficiency, Marfan syndrome). It is more common in tall young men 20-40 years old. Smoking increases the risk by 22 times.
2. Secondary- against the background of lung diseases.
By prevalence: total, partial.
Depending on the presence of complications: uncomplicated, complicated (bleeding, pleurisy, mediastinal emphysema).
Pulmonary tuberculosis;
- congenital polycystic disease;
- bronchiectasis;
- suppurative lung diseases;
- chronic obstructive pulmonary disease;
Asthmatic status;
- AIDS;
- malignant tumors;
- smoking.
Diagnostic criteria
The clinical picture of any type of pneumothorax depends on the volume and speed of air entering the pleural cavity. The disease in a typical case is manifested by the appearance of spontaneous short-term, lasting only a few minutes, acute pain in one of the halves of the chest; subsequently they can either disappear completely or take on a dull character. Often the victim can accurately indicate the time of onset of pain.
Characteristic symptoms of spontaneous pneumothorax:
Sharp pain in the corresponding half of the chest, radiating to the neck, arm, intensifying with a deep breath, coughing and movement;
Sudden shortness of breath;
Change in skin color (pallor, cyanosis);
Tachycardia;
Cold clammy sweat;
Decreased blood pressure;
Forced position (half-sitting, leaning towards the affected side, or lying on the affected side).
An objective clinical examination reveals:
The intercostal spaces are widened, respiratory movements on the affected side are limited or absent;
The affected half of the chest lags behind when breathing, tympanitis is determined by percussion, the lower border of the lungs does not shift during breathing, a displacement of the mediastinum and heart to the healthy side and prolapse of the liver in case of right-sided or prolapse of the stomach in case of left-sided pneumothorax are determined;
Auscultation reveals a significant weakening or absence of respiratory sounds on the affected side and their intensification over the healthy lung.
With a pronounced displacement of the mediastinum and kinks of the vessels flowing into the cavities of the heart and leading to an increase in pressure in the superior vena cava, swelling of the jugular veins is noted.
There may be a shift of the mediastinum with a clinical sign of deviation of the trachea to the healthy side.
If there is intramediastinal damage to the bronchus, then mediastinal emphysema develops without tension pneumothorax and intrapleural bleeding.
If the parietal pleura is damaged, air can escape into the subcutaneous tissue, resulting in the formation of subcutaneous emphysema. The air quickly spreads through the subcutaneous fat to the chest, neck, face, anterior abdominal wall, etc., and after a few hours makes the person unrecognizable. When palpating the area of subcutaneous emphysema, a characteristic “snow crunch” is felt - crepitus.
The greatest danger is posed by tense emphysema of the mediastinum, which occurs when the trachea and large bronchi are ruptured. It leads to disruption of the outflow of blood from the vena cava system, stagnation in the systemic circulation - extrapericardial cardiac tamponade.
List of basic and additional diagnostic measures:
1. Assessment of the general condition and vital functions - consciousness, breathing (rapid, superficial), blood circulation.
2. Visual assessment - assessment of the constitution (asthenic), forced position (sitting or semi-sitting), the skin is pale, covered in cold sweat and/or cyanosis.
3. Pulse examination, measurement of heart rate, blood pressure (tachycardia, arterial hypotension).
4. Examination of the chest - widening of the intercostal spaces, lag in breathing of the affected half of the chest, swelling and pulsation of the neck veins, subcutaneous emphysema is possible.
5. Palpation and percussion - weakening or absence of vocal tremor on the affected side, tympanic sound (with the accumulation of fluid in the pleural cavity in the lower parts, dullness is determined), displacement of the area of the apical impulse and the boundaries of cardiac dullness to the healthy side.
6. Auscultation - weakening or absence of breathing on the affected side.
Treatment abroad
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Tactics of medical care
Urgent Care:
1. In case of loss of consciousness, cessation of blood circulation and/or breathing, cardiopulmonary resuscitation, but only after preliminary pleural decompression.
2. Correction of hypoxia - oxygen therapy.
3. With rapidly growing mediastinal emphysema, a transverse incision should be made in the skin and platysma in the area of the jugular notch (about 2 cm), carefully insert the index finger into the retrosternal space, install a drainage and fix it to the skin.
4. Pain relief - non-narcotic analgesics:
Ketorolac 30 mg (1 ml) intravenously or intramuscularly.
5. For severe pain, narcotic analgesics:
Morphine 1% 1 ml diluted with 0.9% sodium chloride solution to 20 ml and administered intravenously in fractional doses of 4-10 ml (or 2-5 mg) every 5-15 minutes. until pain and shortness of breath are eliminated, or until side effects appear (hypotension, respiratory depression, vomiting).
6. In case of tension pneumothorax, a pleural puncture is performed.
7. If bronchospasm develops, salbutamol 2.5 mg via nebulizer for 5-10 minutes.
8. Monitoring hemodynamics and blood oxygen saturation, maintaining vital functions.
List of essential medications:
1. *Morphine 1% 1ml, amp.
2. *Oxygen for inhalation
3.*Salbutamol 3 mg, neb.
List of additional medications:
1. *Ketorolac 30 mg - 1 ml, amp.
2. *Sodium chloride 0.9% - 5.0 ml, amp.
Indications for hospitalization: all patients with pneumothorax are subject to immediate hospitalization in the thoracic surgery department or in the intensive care unit. Transport in a sitting position or with the head end elevated.
Indicators of the effectiveness of medical care: stabilization of the patient's condition.
* - drugs included in the list of essential (vital) medicines.
Head of the Department of Ambulance and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National medical university them. S.D. Asfendiyarova - Doctor of Medical Sciences, Professor Turlanov K.M.
Employees of the Department of Ambulance and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National Medical University named after. S.D. Asfendiyarova: candidate of medical sciences, associate professor Vodnev V.P.; Candidate of Medical Sciences, Associate Professor B.K. Dyusembayev; Candidate of Medical Sciences, Associate Professor Akhmetova G.D.; candidate of medical sciences, associate professor Bedelbaeva G.G.; Almukhambetov M.K.; Lozhkin A.A.; Madenov N.N.
Head of the department emergency medicine Almaty state institute advanced training for doctors - candidate of medical sciences, associate professor Rakhimbaev R.S.
Employees of the Department of Emergency Medicine of the Almaty State Institute for Advanced Medical Studies: Candidate of Medical Sciences, Associate Professor Silachev Yu.Ya.; Volkova N.V.; Khairulin R.Z.; Sedenko V.A.
