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Artificial pneumothorax
Last reviewed: 23.04.2024
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Artificial pneumothorax is the introduction of air into the pleural cavity, leading to the collapse of the affected lung.
Prior to the discovery of specific chemopreparations, artificial pneumothorax was considered the most effective method of treating patients with destructive forms of pulmonary tuberculosis.
Indications for artificial pneumothorax
When establishing indications for the imposition of artificial pneumothorax, a strictly individual approach is necessary. In each case, not only the stage of the process, the prevalence and nature of the lungs' lesion, but also the general condition of the patient, his age and other factors are taken into account.
The main indications for the application of artificial pneumothorax:
- multiple drug resistance of mycobacterium tuberculosis:
- intolerance or hypersensitivity of patients to anti-TB drugs:
- Some concomitant diseases or conditions that limit the conduct of adequate chemotherapy in full in the required time.
Artificial pneumothorax is also indicated for patients who underwent a 3-month course of chemotherapy, with uncovered caverns and cavities in infiltrative, focal, cavernous and limited hematogenically disseminated pulmonary tuberculosis in the decay phase. With widespread dissemination, the imposition of artificial pneumothorax can lead to exacerbation of the process and pneumo pleura.
According to the currently approved standards, the treatment of pulmonary tuberculosis is carried out in stages. The tasks of artificial pneumothorax at each stage of treatment are different.
Indications for its use at the 1 st stage (in the intensive phase of chemotherapy in patients with newly diagnosed lung tuberculosis):
- impossibility of full chemotherapy due to drug resistance of mycobacterium tuberculosis or the presence of limiting treatment side effects:
- no regression of the disease after the intensive phase of treatment.
The purpose of using artificial pneumothorax at the 1 st stage is complete cure of the patient as soon as possible without the use of surgical methods. Pneumothorax can be applied for 1-3 months after the start of chemotherapy. The duration of collapse is 3-6 months.
At the 2nd stage (with the prolongation of the intensive phase of chemotherapy to 4-12 months) this type of collapse therapy can be used as an additional method:
- in newly diagnosed patients with advanced tuberculosis who had no indications for the use of artificial pneumothorax during the intensive phase of treatment, but after the chemotherapeutic treatment a positive effect was achieved (reduction of the severity of the process, reduction of the destruction cavities, partial resolution of inflammatory infiltration);
- in newly diagnosed patients who developed secondary resistance to anti-tuberculosis drugs against a background of inferior therapy.
The use of artificial pneumothorax at the second stage is an attempt to achieve complete cure of the patient or the stage of preparation for surgery. Pneumothorax is applied after 4-12 months from the beginning of chemotherapy. The duration of collapse therapy is up to 12 months.
At the 3rd stage (more than 12 months from the beginning of chemotherapy), after several ineffective, inadequate or interrupted treatment courses with the development of multiple drug resistance with the presence of formed caverns, the main goal of using pneumothorax is to prepare the patient for surgical treatment. Artificial pneumothorax in these patients is imposed after 12-24 months from the beginning of chemotherapy. The duration of collapse therapy is up to 12 months
Sometimes artificial pneumothorax is imposed on urgent or vital indications (with severe repeated pulmonary hemorrhages that do not yield to other methods of treatment).
The localization of the process is important. Pneumothorax is often applied when localization of cavities of destruction or caverns in the apical, posterior and anterior segments of the lung. In order to achieve maximum effect, one-sided artificial pneumothorax is more often used.
The application of this method to bilateral lung lesions is justified. The imposition of pneumothorax on the side of a larger lesion contributes to the stabilization of the tuberculosis process on the opposite side and the reverse development of the available in the second light changes. In bilateral trials, artificial pneumothorax is sometimes used on the side of a lesser lesion in the context of preparing the patient for an operation on the opposite lung. In the presence of localized processes in both lungs, pneumothorax is sometimes applied from both sides simultaneously or sequentially to achieve the maximum effect of complex treatment. Such patients need a thorough examination to assess the status of the functions of the respiratory and cardiovascular systems. Apply a second pneumothorax recommended after 1-2 weeks after the application of the first. The question of the order of formation of the gas bubble is decided individually in each case. More often the treatment with pneumothorax starts from the side of greater damage.
The age of the patient is of some importance. If necessary, artificial pneumothorax is used both in elderly patients and in adolescence.
Currently, along with medical indications, there are indications of social and epidemiological. Given the high cost of drugs in the reserve series for the treatment of forms of multidrug-resistant tuberculosis, it is advisable to expand the indications for the use of artificial pneumothorax. The imposition of pneumothorax usually leads to a cessation of the release of mycobacterium tuberculosis in a short time, the patient ceases to be dangerous to others.
Mechanism of therapeutic action of artificial pneumothorax
The use of artificial pneumothorax in the treatment of pulmonary tuberculosis is possible due to the presence of elastic properties of the lung. Reduction of elastic traction and partial collapse of the lung lead to the collapse of the walls and the closure of caverns or cavities of destruction. With hypotensive artificial pneumothorax with a lung collapse of 1/3 volume and negative intrapleural pressure, the amplitude of respiratory movements decreases, the affected area of the lung is in a state of relative rest, while it participates in gas exchange. Increased pressure in the pleural cavity leads to redistribution of blood flow and mixing of the active perfusion zone from the lower parts of the lungs to the upper ones. This helps to improve the delivery of medications to the areas of greatest lung damage. Artificial pneumothorax leads to the development of lymphostasis, slows the absorption of toxins, enhances phagocytosis, stimulates fibrosis and encapsulates the foci, and also stimulates reparative processes, resorption of infiltrative-inflammatory changes, healing of cavities of decay with the formation of linear or stellate scars in their place. At the heart of the therapeutic action of pneumothorax lie other neuro-reflex and humoral mechanisms.
The method of artificial pneumothorax
There are more than 200 different modifications of devices for applying artificial pneumothorax. The principle of the majority of them is based on the law of communicating vessels: fluid from one vessel enters the other and pushes out air, which, entering the pleural cavity, forms a gas bubble.
For daily use, the APP-01 is recommended. It consists of two communicating containers (500 ml each), which are marked with fissions to determine the volume of air (gas meter). They are connected to each other and to the pleural cavity through a three-way valve. The movement of fluid from one container to another leads to the expulsion of air into the cavity of the pleura.
A necessary part of any apparatus for applying artificial pneumothorax is a water manometer. It allows the doctor to determine the location of the needle (in the cavity of the pleura, in the lung, in the blood vessel) and the pressure in the pleural cavity before the introduction of the gas, during its administration and after the end of the manipulation.
The pressure in the pleural cavity during inspiration is normal from -6 to -9 cm of water, during exhalation - from -6 to -4 cm of water. After the application of pneumothorax and the formation of a gas bubble, the lung should be collapsed by less than 1/3 of the volume, while it can participate in the act of breathing. After the introduction of air, the pressure in the pleural cavity rises, but it should remain negative: -4 to -5 cm of water. On inspiration and from -2 to -3 cm of water. On exhalation.
If, during the application of pneumothorax, the needle is inserted into the lung or into the lumen of the bronchus, the manometer records the positive pressure. When the needle pierces the needle, blood enters. If the needle is inserted into the soft tissues of the chest wall, there is no pressure fluctuation.
The process of treatment of tuberculosis by the application of artificial pneumothorax consists of several stages:
- formation of a gas bubble;
- maintenance of artificial pneumothorax using permanent insufflation;
- the termination of insufflation and the elimination of artificial pneumothorax.
To superimpose pneumothorax, the patient is placed on a healthy side, the skin is treated with a 5% solution of iodine alcohol or 70% ethanol. The thoracic wall is pierced in the third, fourth or fifth intercostal space by the middle axillary line with a special needle with a mandrel. After the puncture of the intrathoracic fascia and the parietal pleura, the mandril is removed, the needle is attached to the manometer, and the location of the needle is determined.
It is forbidden to introduce gas in the absence of pressure fluctuations synchronous with respiratory movements or in the absence of confidence in that. That the needle is in the free pleural cavity. The absence of pressure fluctuations can be caused by occluding the needle with tissues or blood. In such cases, the needle should be cleaned with a mandrel and the position of the needle changed. A stable negative pressure in the pleural cavity, which varies with the respiratory phase, indicates the correct position of the needle in the pleural cavity. In the initial formation of a gas bubble, 200-300 ml of air are injected, while for repeated ones - 400-500 ml. The protocol records the initial and final readings of the manometer, as well as the amount of air introduced. The record is made in the form of a fraction: in the numerator indicate the pressure during inspiration, in the denominator - the pressure on the exhalation. Example: IP dex (-12) / (-8); 300 ml (-6) / (-4).
During the first 10 days after the application of artificial pneumothorax, insufflation is carried out at intervals of 2-3 days, after the formation of the gas bubble and collapse of the lung, the intervals between insufflation are increased to 5-7 days, and the amount of injected gas to 400-500 ml.
After applying pneumothorax it is necessary to evaluate its effectiveness, the desirability of continuing treatment and the possibility of correction. These questions are resolved within 4-8 weeks from the moment of superimposition of pneumothorax. Optimum pulmonary collapse is considered to be a minimal decrease in lung volume, in which pneumothorax provides the necessary therapeutic effect.
Variants of the formed artificial pneumothorax
Complete hypotensive pneumothorax - the lung is evenly collapsed by 1/3 of the volume, intrapleural pressure on inspiration (-4) - (-3) cm of water, on exhalation (-3) - (-2) cm of water. Indicators are saved.
Full hypertensive pneumothorax - the lung is evenly collapsed by 1/2 volume or more, intrapleural pressure is positive, the lung does not participate in breathing. Used to stop bleeding.
Selective-positive pneumothorax - collapse of the affected lungs, intrapleural pressure (-4) - (-3) cm of water. During inspiration. (-3) - (-2) cm of water. During exhalation, the affected areas of the lung are straightened, participate in breathing.
Selective-negative pneumothorax - the collapse of healthy lungs without falling off the affected areas, sprained caverns, the threat of a rupture. Requires surgical correction.
Factors affecting the result of artificial pneumothorax
The main reason for the ineffectiveness of artificial pneumothorax is pleural adhesions and adhesions that impede the complete collapse of the affected areas of the lung and the healing of caverns. Spikes are formed in the majority (up to 80%) of patients with pulmonary tuberculosis. Distinguish the following types of pleural fusion: ribbon-like, fan-shaped, funnel-shaped, planar. Modern surgical technologies with the use of videotorakoscopy can effectively and safely separate such fusion. Contraindication to videotorakoscopy - extensive (more than two segments) tight fusion of the lung with a difficult wall (separation of adhesions is technically difficult).
Videotoracoscopic correction of artificial pneumothorax is performed under anesthesia. A necessary condition for the operation is a separate intubation of the bronchi with the "shutdown" of the operated lung from the ventilation. In some cases, instead of "turning off" the lung can be used ventilation. In the pleural cavity, a videotoracoscope is inserted and a thorough revision of the lung is performed. Bracing and adhesions are separated by means of special tools (coagulators, dissec- tors, scissors). The operation is completed by installing drainage (per day) to control hemostasis and aerostasis. The effectiveness of correction of artificial pneumothorax is monitored by CT or X-ray examination.
[8], [9], [10], [11], [12], [13], [14],
Collapsotherapy
Four main methods are used in the treatment of pulmonary tuberculosis: anti-tuberculosis chemotherapy, correction of homeostasis (regimen, diet, symptomatic treatment), collapse therapy and surgical treatment. Collapsotherapy - treatment by creating artificial pneumothorax or artificial pneumoperitoneum.
In recent years, the effectiveness of treatment with modern chemotherapeutic drugs has declined because of the emergence of multidrug-resistant strains of mycobacteria, so in some cases the treatment strategy needs to be reviewed. With intolerance to antituberculosis drugs and multiple drug resistance of TB pathogens, the role of collapsotherapy increases. In some cases, collapse therapy is the only method of treatment, sometimes it allows you to prepare a patient for a surgical operation. In modern conditions, one should also take into account the economic factor: the methods of collapsotherapy are available, inexpensive and effective.
Contraindications to artificial pneumothorax
There are general and particular contraindications to the imposition of artificial pneumothorax.
General contraindications:
- age over 60 years and under 10 years.
- respiratory insufficiency II-III degrees;
- chronic lung diseases (COPD, bronchial asthma);
- severe cardiovascular disease, circulatory disorders;
- Some neurological and mental diseases (epilepsy, schizophrenia, drug addiction).
The clinical form of the disease, the prevalence and localization of the process, the presence of complications determine particular contraindications. It is technically impossible or ineffective to apply artificial pneumothorax in the presence of pronounced pleuropinous fusion and the absence of a free pleural cavity, with the loss of pulmonary tissue by elastic properties as a result of inflammation with the development of fibrosis or cirrhosis. Such changes are revealed when:
- caseous pneumonia;
- disseminated disseminated pulmonary tuberculosis;
- fibro-cavernous tuberculosis:
- cirrhotic tuberculosis;
- exudative or adhesive tubercular pleurisy;
- tubercular pleural empyema;
- bronchial tuberculosis;
- tuberculosis.
The presence of caverns with dense fibrous walls, the localization of caverns in the basal parts of the lung, large (over 6 cm in diameter) blocked, subpleurally located caverns - contraindications to the imposition of artificial pneumothorax.
Complications of artificial pneumothorax
Complications associated with the imposition of an artificial pneumothorax
- traumatic lung injury (2-4%):
- subcutaneous or mediastinal emphysema (1-2%);
- Air embolism (less than 0.1%).
Puncture of the lung when applying artificial pneumothorax is a rather frequent complication. The most dangerous consequence of such damage is intense traumatic pneumothorax, often occurs in patients with severe emphysema and in some cases may require drainage of the pleural cavity. After puncturing the lung with a needle, patients notice hemoptysis, which usually occurs without special treatment.
Another complication, subcutaneous or mediastinal emphysema, develops as a result of the displacement of the needle and the ingress of gas into the deep layers of the chest wall, into the interstitial tissue of the lung or to the mediastinum. A small amount of air in soft tissues usually resolves itself. In some cases, pneumothorax is called "insatiable": despite the frequent introduction of large volumes of air, its rapid resorption occurs. However, in most cases, these patients manage to create a gas bubble of sufficient magnitude.
The most formidable complication is air embolism, caused by the ingress of gas into the blood vessels, requires a complex of resuscitation measures. The patient suddenly loses consciousness, breathing becomes hoarse or stops. With a massive intake of air in the system of a large circle of blood circulation. Especially in the coronary arteries or cerebral vessels, a fatal outcome may occur. The most effective method of treatment of massive air embolism is HBO.
[25], [26], [27], [28], [29], [30]
Complications of maintaining an artificial pneumothorax
- pneumocystitis (10-12%);
- rigid pneumothorax (5-7%);
- atelectasis (3-5%).
Pneumoplethritis develops with excessive introduction of gas or as a result of the entry into the pleural cavity of pathogenic microorganisms. To eliminate pleurisy evacuate fluid from the pleural cavity, use antibiotics in combination with glucocorticoids, reduce the frequency and volume of insufflation. With prolonged (more than 2-3 months) preservation of exudate, progression of the adhesion process with the formation of clotted pleurisy or empyema, treatment with pneumothorax should be interrupted.
A prolonged collapse of the lung tissue with irritation of the pleura with gas leads to a gradual loss of elasticity of the lung tissue and the development of pleura and lung sclerosis. Early signs of rigid pneumothorax: sinus pleurisy, limitation of mobility of the collapsed lung and thickening of the visceral pleura. When a small volume of air is introduced into the pleural cavity, the pressure gauge registers significant pressure fluctuations. In such cases, it is necessary to lengthen the intervals between insufflation and reduce the volume of the gas introduced.
The development of atelectasis is associated with either "bloating" or bronchitis, it is necessary to reduce the size of the gas bubble.