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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
2、性氣胸，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),Spontaneous Primary pneumothorax Secondary pneumothorax Airway and pulmonary disease(COPD,asthma)Interstitial disease(Pulmonary fibrosis)Infection(TB.)Neoplastic Catamenial(Endometriosis)
3、Iatrogenic Post-Traumatic,Early complication Prolonged air leakage Non re-expansion of the lung Bilaterality Hemothorax Tension Complete pneumothoraxPotential hazard Occupational hazard Absence of medical facilities in isolated areas Associated single bulla PsychologicalSecond Episode Ipsilateral re
4、currence Contralateral recurrence after a first pneumothorax,Surgical indication for primary spontaneous pneumothorax,Spontaneous Pneumothorax-Definition&Factors,Definition Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleuraFactors determining gas reab
5、sorptionDiffusion properties of the gasesPressure gradientsArea of contactPermeability of pleural surface,Spontaneous Pneumothorax-Clinical investigation,Signs and symptomsSudden onset chest painShortness of breathingCoughDiagnosisCXRAuscultationDifferential diagnosisSkin foldGiant bulla,Treatment O
6、ptions for Pneumothorax,ObservationNeedle aspirationPercutaneous catheter to drainageWater seal Pleur-evac typeHeimlich valveTube thoracostomyWater seal Pleur-evac typeHeimlich valveTube thoracostomy with instillation of pleural irritantVideo-assisted thoracoscopic surgeryThoracotomy,Indications for
7、 Surgical Intervention,Second episodePersistent air leakage for greater than 7-10 daysFirst episode with unexpanded,“trapped”lungHistory of contralateral pneumothoraxBilateral pneumothoraxOccupational risk(driver,airplane pilot,living ina remote area)Large bullaLarge undrained hemothoraxFirst episod
8、e in a patient with one lungFirst episode in a patient with severely compromised pulmonary function,Recurrence of Primary Spontaneous Pneumothorax,Therapy Recurrence(%)Expectant 30Aspiration 20-50Chest tube drainage 20-30Pleurodesis(tetracycline)25Pleurodesis(talc)7Surgery 2,Complication of Pneumoth
9、orax,Tension pneumothoraxRe-expansion pulmonary edemaPersistent air leakHemothorax(less than 5%)Pneumomediastinum,Removal of Chest Tube,IndicationsNo fluctuation in the fluid column of the tube(complete lung reexpansion or tube occlusion)Daily fluid drainage 100ml in 24 hoursAir leakage has stoppedP
10、roper timing(controversy)Spontaneous pneumothorax after tube thoracostomyremoval tube within 6 hours of reexpansion-25%collapse,Tube Thoracostomy(Chest Intubation),Indication of Chest Intubation,Drain pleural fluid or air promote lung expansion1.Pneumothorax2.Hydrothorax3.Hemothorax4.Chylothorax5.Py
11、othorax6.Post-thoracotomy etc.,Apparatus of Chest Tube Drainage,1.Underwater sealed bottle:Separate from atmosphere2.Collecting bottle:Decrease resistance of drainage3.Negative pressure suction:Promote lung expansion,Procedure of Chest Intubation,1.Local anesthesia,confirm location2.Skin incision at
12、 selected area3.Dissect into pleural cavity thru a subcutaneous tunnel4.Deloculate in pleural cavity5.Insert tube posteriorly and laterally6.Close incision wound,fixed the tube7.Connect tube to underwater sealed bottle(or with negative pressure suction),Attention In Chest Tube Insertion,Attention Pr
13、event occurrence1.Thru thoracostomy wound Underlying organ injury palpate the underlying structure(supra-or infra-diaphragm)2.Avoid trocar intubation(exceptLung or other organ injury emergency)3.Keep tube in good directionChest pain,great vessel erosion4.Avoid intubation thru posteriorPain,unable in
14、 supine chest wall5.Avoid to suture&close Air leakage thoracostomy wound too looseSkin necrosis,pain or too tight,Attention in Massive Subcutaneous(Mediastinal)Emphysema,1.Keep airway patent(even endotracheal tube)2.CXR3.Insert chest tube in pneumothorax or suspicious side4.Connect tube to negative
15、pressure suction immediately5.Close thoracostomy wd slightly loose6.Insert another tube if no improvement7.Low O2 nasocannula8.Determine the cause&treat underlying disease9.Remove tube after complete subsidence,When to Remove Chest Tube?,Criteria:1.No air leakage 2.Drained fluid 50 c.c./day 3.Clear
16、serosanguineous color of fluid 4.Full expansion of lung in CXRClear sterile fluid remove directlyTurbid,infected fluid withdraw progressively open drain,Attention in Chest Tube Care(I),Attention Prevent occurrenceFix chest tube firmlyTube moving&contaminationDont clamp tube duringTension pneumothora
17、x transportation in presence of air leakageDont use negative pressure suctionAbrupt mediastinal shift,after pneumonectomy venous return decrease,deathDont apply negative suction Reexpansion pulmonary edeme immediately after intubation for cases with large volume or long duration of pneumothorax,hydr
18、o-pyothorax,Attention in Chest Tube Care(II),Attention Prevent occurrenceDont lift up tube aboveBack flow contamination thoracostomy woundUse collecting bottle and elevateBack flow contamination the connecting tube between 2Lung collapse bottles in big residual pleural space or massive air leakage,A
19、ttention in Thoracotomy with Lung Resection(I),Attention Prevent occurrenceSuture ligated or close pulmonary Slip out,bleeding vessel with staplerMake adequate length in bronchialStump broken stumpCover bronchial stump with Bronchopleural fistula surrounding tissue,especially in pneumonectomyPre-operative anti-TB or anti-fungal Disease flare up drug(at least 2 wks)for suspicious TB or fungal diseases,
