Spontaneous pneumothorax in the elderly
Introduction
Introduction to spontaneous pneumothorax in the elderly Spontaneous pneumothorax: The pleura is ruptured due to lesions, the pleural cavity communicates with the atmosphere, and the airflow enters the pleural cavity to form pleural effusion, which is called pneumothorax. The elderly spontaneous pneumothorax is often secondary to lung or pleural lesions, usually COPD. Or diffuse pulmonary fibrosis disease complicated with pulmonary bullae, when the intrapulmonary pressure rises sharply, the bullous rupture occurs, that is, pneumothorax occurs. Spontaneous pneumothorax in the elderly is also seen in S. aureus, anaerobic or Gram-negative bacilli causing suppurative pneumonia and rupture into the pleural cavity, that is, pus pylori, lung cancer or tuberculosis can also cause pneumothorax when the pleura is eroded. basic knowledge The proportion of illness: 0.002% Susceptible people: the elderly Mode of infection: non-infectious Complications: pleural effusion pneumonia lung abscess blood pneumothorax mediastinal emphysema arrhythmia
Cause
Spontaneous pneumothorax in the elderly
Causes:
The pleural cavity is a closed cavity between the visceral-wall pleura. Due to the elastic retractive force of the lung, it is a negative pressure chamber [-0.290.49kPa(-3.5cmH2O)], when some cause causes alveolar pressure When the temperature rises sharply, the lung-pleural rupture of the lesion ruptures, the pleural cavity communicates with the atmosphere, and the airflow flows into the chest cavity to form a spontaneous pneumothorax. The spontaneous pneumothorax in the elderly is mostly secondary, because some patients have lung tissue and walls. Pleural adhesion, pulmonary tissue rupture, or bronchial pleural stenosis can not be closed with lung compression, resulting in continuous opening of the pupil, close to zero pleural pressure, and become an "open pneumothorax"; some patients have bronchoconstriction Semi-blocking and forming a flap, so that the air enters the chest during inhalation, and is still left here when exhaling. The chest pressure can exceed 1.96 kPa (20 cmH2O), becoming a "tensional pneumothorax"; due to the above reasons, it is often difficult for the elderly pneumothorax. Healing, re-venting the chest, localized pneumothorax is more common, but the simple closed pneumothorax is less.
Pathogenesis:
Except for pneumothorax injury or diagnosis and treatment for artificial pneumothorax, they are called spontaneous pneumothorax. Most of the spontaneous pneumothorax is caused by rupture of subpleural emphysema, and it is also seen in the subpleural lesion or cavity collapse, tear of pleural adhesion, etc. Subpleural emphysema can be congenital or acquired; the former is congenital elastic fiber dysplasia, alveolar wall elasticity declines, and forms a large pulmonary sac after expansion, more common in elongated males, no obvious X-ray examination of the lungs Disease, the latter is more common in obstructive emphysema or post-inflammatory fibrous lesions, bronchioles are semi-occlusive, distorted, resulting in a valve mechanism to form emphysema, swelling of the emphysema bubble due to nutrition, circulatory disorders Degenerative degeneration, causing rupture when coughing or increased intrapulmonary pressure.
Prevention
Spontaneous pneumothorax prevention in the elderly
The key to the prevention of pneumothorax in the elderly is to actively prevent and treat the primary diseases, especially COPD and respiratory tract infections. For the elderly with pulmonary bullae, especially those with a history of pneumothorax, the stool should be kept open, avoid contact with respiratory irritants, avoid fatigue and weight-bearing. Pleural pleural adhesions are the main method to prevent recurrence.
Complication
Spontaneous pneumothorax complications in the elderly Complications pleural effusion pneumonia lung abscess blood gas chest mediastinal emphysema arrhythmia
The complication of senile pneumothorax is much more common than that of young and middle-aged people. They not only aggravate the condition, but also cause death.
Pleural effusion
The incidence rate is 30% to 40%, which occurs more than 3 to 5 days after the onset of pneumothorax. The amount is usually not much. The effusion not only aggravates the lung collapse, but also develops the pneumothorax for the open pneumothorax.
2. Puss chest
Secondary to S. aureus, anaerobic or Gram-negative bacilli cause suppurative pneumonia, or lung abscess, or pneumonia pneumonia easily combined with pus.
3. Blood pneumothorax
Pneumothorax causes tearing of blood vessels in the pleural adhesion zone, and its severity is related to the size of the torn blood vessel. Small bleeding can be automatically stopped with the contraction of the blood vessels and the contraction of the endothelium; the large blood-thoracic chest is abrupt. Chest pain, chest tightness, shortness of breath, as well as dizziness, palpitation, pale, cold skin, blood pressure and other signs of hemorrhagic shock, X-ray examination showed fluid level, thoracic puncture for whole blood.
4. Chronic pneumatic chest
In some elderly patients with pneumothorax, the pleural rupture cannot be closed with compression due to the underlying lesions; it is difficult to heal by forming bronchial pleural sputum; the lungs can not be re-inflated if the bronchial stenosis or occlusion; the pleural thickening of the visceral layer makes the lungs unable to fully re-expand, The pneumothorax lasted for more than 3 months.
5. Mediastinal emphysema
More complicated by tension pneumothorax, no significant symptoms when the gas volume is low; if the gas volume is high and rapid occurs, there will be circulatory-respiratory failure, the condition is extremely sinister, physical examination can be seen with cyanosis, jugular vein engorgement, heart beat can not be paralyzed, heart sounds Reduced or disappeared, often accompanied by subcutaneous emphysema (local swelling, palpation with a sense of snow, auscultation with sputum pronunciation), X-ray chest showed a translucent band on both sides of the mediastinum with a line of shadows.
6. Respiratory failure
This is a common complication of the elderly pneumothorax secondary to COPD.
Circulatory failure
More complicated by tension pneumothorax.
8. Heart failure
More common in elderly patients with severe heart disease, hypoxemia caused by pneumothorax, infection, increased oxygen consumption by respiratory exercise, arrhythmia and other causes can induce heart failure.
Symptom
Spontaneous pneumothorax symptoms in the elderly Common symptoms Irritability, pale face, difficulty breathing, supine dyspnea, hypoxemia, palpitation, wheezing, dysfunction, chest tightness, chest pain
The clinical manifestations of spontaneous pneumothorax in the elderly are often atypical, often concealed by the primary disease. About one-fourth of the cases have a slow onset and gradually worsen. The main manifestations are the difficulty in explaining the difficulty of the primary disease, and the incidence of some cases is not Clear incentives can be found, manifested as sudden or rapid aggravation of chest tightness and shortness of breath, 40% to 60% of cases with severe cough, sudden acute shortness of breath, chest tightness, palpitation and difficulty breathing, a small number of elderly patients can also exercise due to physical activity Defecation, sneezing, weight-bearing and other reasons, chest pain, especially the typical sudden pain of pneumothorax is rare, other common symptoms are cough, cyanosis and not lying, cough can be irritating dry cough, but also due to the underlying disease Cough, a large number of pneumothorax or tension pneumothorax clinical manifestations sometimes resemble pulmonary infarction or myocardial infarction, early chest tightness, chest pain, difficulty breathing, palpitation, sweating, pale, irritability; can also be induced on the basis of COPD Respiratory failure, a small amount of pneumothorax when the signs are not obvious; when the lung compression is more than 30%, the trachea shifts to the healthy side, the affected side of the thoracic bulging, respiratory movement is weak, percussion Drum sound, the heart sounds disappeared or the liver voiced down, the breath sounds and tremors weakened or disappeared, which is sometimes confused with emphysema. Some elderly patients are similar to asthma-like episodes, and the lungs can be heard with severe breathing difficulties. Wheezing, such patients with severe emphysema, pulmonary insufficiency, and pleural adhesions and multiple compartments separated, such patients after the pneumothorax drainage, shortness of breath and wheezing quickly disappeared.
Pulmonary function test: Usually, the pneumothorax may have limited ventilation damage (lung volume and decreased lung capacity) when compressed more than 20%. The elderly pneumothorax often has severe lungs when the lung compression is less than 20% due to the presence of underlying diseases. Dysfunction, clinically suspected of having a pneumothorax is not suitable for pulmonary function tests for forced breathing, so as not to cause the disease to deteriorate.
Arterial blood gas examination: In patients with acute pneumothorax, due to ineffective perfusion of collapsed lung tissue, right-to-left shunt occurs and hypoxemia occurs. Later, due to decreased blood flow in the collapsed lung, hypoxemia may be relieved. Young and middle-aged people generally have hypoxemia when the lungs are compressed by 20% to 30%. The elderly pneumothorax often produces hypoxemia when mild lung compression occurs.
X-ray examination: the typical X-ray of the pneumothorax is a spherical shadow of the lung to the hilar collapse. The gas often gathers on the outside of the thoracic cavity or the tip of the lung. This part has increased translucentness, no lung pattern, and the pneumothorax extends to the lower part of the lung. The angle shows sharpness. When a small amount of pneumothorax is concentrated on the tip of the lung, it is easy to be covered by the clavicle. At this time, the X-ray signs of deep gas phase are helpful for diagnosis. Some elderly patients with pneumothorax appear to be "limited" due to pleural adhesion. Sexual pneumothorax, the accumulation of gas shadow may be covered by the lungs or mediastinum, you need to turn the body position to see the fluoroscopy.
Examine
Spontaneous pneumothorax examination in the elderly
Chest gas analysis: the use of chest gas PaO2, PaCO2 and PaO2 / PaCO2 ratio of three indicators, has a certain significance for judging the type of pneumothorax, PaO2 5.33kPa (40mmHg) in the chest of closed pneumothorax, PaCO2 often > 5.33kPa, PaO2 / PaCO2 >1; open pneumothorax PaO2 often >13.33kPa (100mmHg), PaCO2<5.33kPa, PaO2/PaCO2<0.4; tension type pneumothorax PaO2 often >5.33kPa, PaCO2<5.33kPa, PaO2/PaCO2>0.4, but <1.
X-ray inspection
It is the most reliable method for diagnosing pneumothorax. It can show the degree of lung atrophy, presence or absence of pleural adhesions, mediastinal shift and pleural effusion, enhanced transparency on the pneumothorax, no lung texture, lung atrophy in the hilar, and pneumothorax. Clear thin strip of lung edge, mediastinum can be displaced to the healthy side, especially tension pneumothorax; a small amount of pneumothorax occupies the tip of the lung, so that the tip of the lung is pressed against the hilum; if there is a liquid pneumothorax, see the liquid level.
2.CT
It is sensitive to the diagnosis of a small amount of gas in the thoracic cavity. For recurrent pneumothorax and chronic pneumothorax, it is observed whether there are pneumothorax lesions on the edge of the lung, such as pulmonary bullae, pleural band adhesion, lung traction, and the opening is not easy to close. The basic manifestation is a very low-density gas shadow in the pleural cavity, accompanied by varying degrees of compression and atrophy changes in the lung tissue.
3. Pleural angiography
This method can understand the condition of the pleural surface, and it is easy to clarify the cause of pneumothorax. When the compression area of the lung is 30% to 40%, it is appropriate to perform angiography, and the large pulmonary sac appears as a single or multiple capsular low-density shadows within the contour of the lung; The pleural rupture manifests as a bubbling spray, especially when the patient coughs, and this sign is more pronounced due to increased intrapulmonary pressure.
4. Thoracoscopy
It is easier to find the cause of pneumothorax, flexible operation, up to interlobular lobes, apex of the lung, hilar, almost no blind zone, observation of visceral pleural rupture, presence or absence of pulmonary blister and no adhesion in the thoracic cavity .
Diagnosis
Diagnosis and diagnosis of spontaneous pneumothorax in the elderly
Diagnostic criteria
The clinical manifestations of spontaneous pneumothorax in the elderly are very atypical, easily misdiagnosed or missed by the primary disease. Elderly patients should consider the possibility of pneumothorax in the following situations:
1 sudden unexplained dyspnea, or sudden increase in shortness of breath on the basis of the original dyspnea, can not be explained with the primary disease.
2 sudden onset of severe chest pain with dyspnea, except for myocardial infarction and pulmonary infarction.
3 Unexplained disease progresses progressively, and in the short term, there is palpitation, sweating, pale or cyanosis, and/or people with consciousness disorders.
4 wheezing symptoms suddenly aggravated, lungs or single lungs full of wheezing, and various antispasmodic drugs, corticosteroids, oxygen therapy and antibiotic treatment are invalid.
5 rapid or progressive exacerbation of cyanosis, the elderly, especially COPD, tuberculosis patients with the above-mentioned situation, accompanied by a side of the thoracic bulging, respiratory movements weakened, percussion drum sound, tracheal shift, lung breath sounds and tremors weakened or even disappeared Initial diagnosis can be made. If the condition permits, X-ray examination should be performed in time to confirm the diagnosis and understand the degree of lung compression.
Clinically highly suspected pneumothorax and the condition is not allowed or can not be X-ray examination, you can use the artificial gas chest machine to carefully perform diagnostic puncture and pressure measurement in the affected area under the clavicle or the breath sound is obviously weakened. The gas chest machine pressure measurement can also distinguish Type of pneumothorax,
1 Closed pneumothorax: Before the exhaust, the intrapleural pressure in the pleural cavity is close to or slightly higher than the atmospheric pressure. After the exhaust, the pressure in the pleural cavity drops, and the pressure does not rise after the pumping is stopped. This type of pneumothorax compression is usually <25%.
2 open pneumothorax: the pleural pressure before and after venting is close to "0", this type of pneumothorax compression is usually about 50%.
3 tension pneumothorax: positive pressure in the chest before exhaust, often more than 1.96kPa (20cmH2O), the pressure drops after pumping, but the pressure rises rapidly after stopping pumping, this type of pneumothorax compression is often >75%, for a small amount or Localized pneumothorax, often requires deep suction, expiratory or multi-position X-ray examination.
Differential diagnosis
Spontaneous pneumothorax in the elderly must sometimes be differentiated from the following diseases:
1. COPD exacerbation period
Closed pneumothorax secondary to COPD, sometimes even open pneumothorax is often mistaken for the exacerbation of COPD, pneumothorax patients with shortness of breath, and mostly sudden or progressive exacerbations, while cough, cough is correspondingly lighter. The period of COPD exacerbation is often caused by climate change. The above feelings are the leading. The prominent manifestations are cough, cough, and purulent sputum. The gas accumulation sign is limited or unilateral, bilateral asymmetry, and the lung hyperinflation sign is diffuse. , bilateral. The newly emerged tracheal displacement is a powerful evidence for pneumothorax. X-ray examination and artificial pneumothorax diagnostic puncture and pressure measurement may help to confirm the diagnosis.
2. Bullous bullae
A small amount or localized pneumothorax sometimes needs to be differentiated from bullae, and the development of lung bullae is very slow, and the clinical manifestations are generally stable. Small streak shadows can still be seen in the area of increased brightness on the chest X-ray. Review the chest radiographs in the past. The change is not large; the size of the bullous shadow after the diagnostic puncture is unchanged and is different from the pneumothorax.
3. Pleural effusion
Older patients with pleural effusion also often present with chest pain and shortness of breath, but physical examination and X-ray examination are effusion signs and are not related to pneumothorax.
4. myocardial infarction,
Pulmonary infarction Tension pneumothorax clinical manifestations sometimes resemble myocardial infarction, pulmonary infarction, are manifested as sudden severe chest pain, shortness of breath, difficulty breathing, palpitation, pale or cyanosis, sweating, irritability, etc., but the tension pneumothorax is obvious The pleural effusion sign and the contralateral displacement of the trachea are helpful for identification. X-ray examination and artificial pneumothorax diagnostic puncture can be diagnosed.
5. Bronchial asthma attacks
Some elderly patients with pneumothorax are similar to asthmatic episodes. Severe dyspnea and snoring of the lungs, pleural effusion, ineffectiveness to antispasmodic-corticosteroid-oxygen therapy, difficulty breathing after breathing and wheezing Disappears and is different from asthma.
