pneumothorax in children
Introduction
Introduction to Pediatric Pneumothorax Pneumothorax refers to the accumulation of gas in the pleural cavity. If pus is present at the same time, it is called pyopneumothorax. The etiology and clinical manifestations are similar, so the combined description can be seen from premature infants to older children. Can be spontaneous pneumothorax or secondary to disease, trauma or surgery. basic knowledge Sickness ratio: 0.0001% Susceptible people: children Mode of infection: non-infectious Complications: shock tension pneumothorax
Cause
Pediatric pneumothorax
Penetrating or non-penetrating trauma (25%):
Penetrating or non-penetrating trauma, due to bronchial or alveolar rupture, children with chest trauma often occur in car accidents or fall from high places, trauma with rib fractures and penetrating injuries, involving the visceral pleura with blood chest.
Swallowing corrosive drugs (15%):
Swallowing corrosive drugs can cause esophageal ulceration to allow air to escape into the chest cavity. For example, a flap mechanism is formed at the bronchial rupture. Air can be sucked into the chest cavity and cannot be discharged, forming a tension pneumothorax. During the whole respiratory cycle, the pressure in the thoracic cavity is higher than atmospheric pressure. It has a great influence on cardiopulmonary function, not only severe ventilatory dysfunction, but also decreased blood flow caused by positive pressure to the mediastinum and venous return. Due to severe hypoxia and shock, tension pneumothorax is a serious acute illness in children, and should be diagnosed immediately. Treatment, the common causes of pneumothorax are shown in Table 1, pneumothorax secondary to empyema, known as pus pneumothorax, mostly after Staphylococcus aureus infection.
Various punctures (10%):
When various punctures such as pleural puncture or pulmonary puncture, the needle is too deep when acupuncture can cause pneumothorax.
After surgery (10%):
Bronchopleural fistula can be associated with pneumothorax. When the tracheotomy is performed, if the site is too low to break through the chest wall.
Mechanical ventilation (15%):
Mechanical ventilation, especially terminal positive pressure, is more likely to cause pneumothorax than intermittent positive pressure. Those with extensive alveolar damage and severely reduced lung compliance are most likely to have pneumothorax with artificial mechanical ventilation, while air enters the mediastinum to cause mediastinal emphysema and subcutaneous. Emphysema, severe cases combined with abdominal or pericardial gas.
Severe obstruction of the respiratory tract (5%):
When the respiratory tract is severely obstructed (such as neonatal asphyxia, whooping cough, airway foreign body inhalation, asthma, etc.), it can also cause pneumothorax in the lung tissue.
Pulmonary infection (5%):
Pneumothorax secondary to pulmonary infection, the most common for Staphylococcus aureus pneumonia, followed by Gram-negative bacilli pneumonia, but also secondary to lung abscess, lung gangrene, are due to infection caused by lung tissue necrosis through the visceral layer Pneumothorax or pneumothorax occurs in the pleura.
Diffuse lung lesions (10%):
Secondary to lung diffuse lesions, such as miliary tuberculosis, cavitary tuberculosis, Langhans cell histiocytosis and congenital pulmonary cysts, Beijing Children's Hospital has seen a case of congenital intestinal pneumon cyst (gastric duplication) Due to ulceration, it is connected to the lungs and pleura, causing bilateral pneumothorax. Occasionally, pneumothorax occurs in malignant tumors, such as malignant lymphoma, osteosarcoma in children, and tuberculosis.
When the pleural cavity and the outside atmosphere have traffic such as thoracic trauma or surgery, air through the parietal pleura into the chest, and any cause of alveolar rupture or bronchopleural palsy, air from the airway or alveoli into the pleural cavity can cause pneumothorax .
Spontaneous pneumothorax: The cause is unknown. It is more common in young and older children. It is easy to relapse. There are reports of high recurrence rate. About 1/3 to 1/2 patients have spontaneous pneumothorax on the same side, and may be familial.
Pathogenesis
Perennial pressure increase in the lungs causes neonatal alveolar rupture; elderly children with cheese-like lesions on the lung surface, tumor-induced lung tissue necrosis, liquefaction and other factors can cause alveolar rupture, the formation of bronchopleural fistula and pneumothorax, chest wall penetration Trauma and thoracic surgery damage, causing pneumothorax, due to a large number of or continuous gas leakage, increased pressure in the pleural cavity, such as when the pressure exceeds atmospheric pressure, it is called "tensional pneumothorax", at this time the affected side of the lung is stressed The trapped side, while the contralateral lung is over-expanded, leading to a series of serious consequences.
Prevention
Pediatric pneumothorax prevention
Pneumothorax is mostly secondary, and should be actively treated for primary diseases. For example, the common complications of staphylococcal pneumonia are empyema, pneumothorax, and pus and chest. It should be actively prevented. In artificial ventilation of CPAP, attention should be paid to prevent the occurrence of this disease. Infants and young children should avoid contact with patients with respiratory infections as much as possible. The epidemic season is less than public places. Children should be diagnosed with early diagnosis and treatment, and children's planned immunization, especially measles live vaccine and Baibai broken mixture preparation. Injection to reduce the incidence of secondary pneumonia, actively promote breastfeeding, prevent rickets, malnutrition, etc., promote outdoor activities, more sun, cultivate good diet and hygiene habits, children are not too thick or too thin, baby Do not over-tighten, usually open the window every day to change the air, to strengthen the health care and care of premature and weak children (including children with congenital heart disease).
Complication
Pediatric pneumothorax complications Complications, shock, tension, pneumothorax
This disease is often secondary to various lung diseases, severe cases can occur with low cardiac output shock, tension pneumothorax and tension pneumothorax crisis; pust pneumothorax can develop adhesive pleurisy.
Symptom
Pediatric pneumothorax symptoms Common symptoms Chest pain Breathing difficulties Breathing sounds weakened Blood hypoxia Persistent cough breath Abnormal children crying Uneasy face bruising Acute respiratory distress syndrome Shock
The symptoms of pneumothorax and the onset of illness, the amount of gas in the chest, the size of the original lung lesions, the type of pneumothorax, etc., generally speaking, the pneumothorax is mostly sudden, the symptoms are more dangerous, pneumothorax symptoms and signs according to the amount of air in the chest and Whether it is different in tension, it is suddenly worsened on the basis of the original disease, and the breathing is accelerated and distressed. Because of the nervousness of children with hypoxia, the incidence of pneumothorax in infants is more acute, and most of them suddenly have difficulty breathing during the course of pneumonia. Localized pneumothorax can be asymptomatic. Only X-ray examination can be found. If the range of pneumothorax is large, it can cause chest pain, persistent cough, cyanosis and bruising. The breathing is weakened, the chest sounds and the sick side breath sounds weaken or disappear. Wait, if you use two coins to fight on the back, auscultation on the chest can smell the empty voice, if the bronchospasm continues to exist, the breath sounds can be empty, a large amount of gas in the chest, especially for tension pneumothorax. It can be seen that the intercostal space is full, the diaphragm is moved down, the trachea and the heart are all moved to the healthy side, and the shortness of breath is aggravated, the blood is severely deficient, the pulse is very small, and the blood pressure is lowered. The occurrence of low heart rate shock is a crisis caused by tension pneumothorax. The symptoms of pneumothorax and pneumothorax are basically similar, but there are obvious symptoms of poisoning, and the fever is higher. If the pus is thin, it is auscultation. Shake the upper part of the child, you can hear the sound of water, but if the pleura has adhesions, this disease is not easy to see.
Examine
Pediatric pneumothorax examination
Because most of the pneumothorax is caused by infection, the white blood cells are higher, and the pus and chest is more prominent. The chest radiograph can find a small amount of gas without clinical symptoms. If the gas volume is more, the lungs of the affected side are compressed. The mediastinum and the heart move to the healthy side. The pus and pectoral chest can be seen with pus level. When the position changes, the perspective is more obvious. The X-ray and lateral fluoroscopy and filming can help diagnose the lung edge of the collapsed lung line. The lung tissue of the atelectasis is pushed to the hilar to form a mass, the pneumothorax part is overly transparent, and no lung texture is seen. However, in the neonatal pneumothorax, the lung tissue can be pushed to the front and the posterior anterior position. The chest line is not visible, or there is a little pneumothorax image on the outer lung line only at the tip of the lung, and the pneumothorax is a transparent curved shadow with a convex outward surface. Outside the translucent curved round edge, a dense collapsed lung shadow can be seen. Tension When the pneumothorax is seen, the trachea and heart are pushed to the healthy side, and the transverse movement is moved downward.
Diagnosis
Diagnosis and diagnosis of pneumothorax in children
diagnosis
According to the typical symptoms and signs of clinical diagnosis is not difficult, and then combined with X-ray examination to confirm the diagnosis, neonatal pneumothorax is sometimes difficult to diagnose, using the light transmission method can be found to increase the transmission of the affected side to assist in diagnosis.
Differential diagnosis
Pneumothorax should be differentiated from bullous bullae, lobar emphysema, congenital gas-filled pulmonary cyst or transverse diaphragm.
First, bronchial asthma and obstructive emphysema
There are shortness of breath and difficulty breathing, and the signs are similar to spontaneous pneumothorax, but emphysema dyspnea is a long-term slow increase. Patients with bronchial asthma have many years of recurrent asthma. When asthma and emphysema patients have sudden increase in breathing difficulties and chest pain, the possibility of complicated pneumothorax should be considered. X-ray examination can be used for identification.
Second, acute myocardial infarction
Patients also have acute chest pain, chest tightness, and even breathing difficulties, shock and other clinical manifestations, but often have a history of hypertension, atherosclerosis, coronary heart disease. Signs, electrocardiogram and chest X-ray are helpful for diagnosis.
Third, pulmonary embolism
Chest pain, dyspnea and purpura are similar to the clinical manifestations of spontaneous pneumothorax, but patients often have hemoptysis and hypothermia, and often have lower extremity or pelvic embolic phlebitis, fractures, severe heart disease, atrial fibrillation, etc., or occur in Elderly patients who have been bedridden for a long time. Physical examination and X-ray examination are helpful for identification.
Fourth, pulmonary bullae
Pulmonary bullae located in the peripheral part of the lung is sometimes mistaken for pneumothorax under the X-ray. Pulmonary bullae may be formed due to congenital development, or a tension cyst or giant cavity may be formed due to obstruction of the intrabronchial valve. The onset is slow, the air is not severe, and the chest is seen from different angles. The bullae or bronchial source can be seen. The cyst is a round or oval translucent area, and there is no line of pneumothorax at the edge of the bullae. The blister has a small strip of texture, which is a remnant of the pulmonary lobules or blood vessels. The bullae are inflated to the surrounding area, and the lungs are pressed toward the apical region, the rib angle and the palpebral angle, while the pneumothorax is the light-transmitting belt on the outer side of the chest, in which no lung pattern is visible. The pressure inside the bullae was similar to that of atmospheric pressure. After pumping, the volume of the bullae did not change significantly.
