Closed pneumothorax is a partial or complete collapse of the lung caused by air entering the pleural cavity; at the same time, the pleural cavity does not communicate with the external environment, and the amount of gas during breathing does not increase. It is manifested by chest pain on the side of the lesion, a feeling of lack of air, pallor and cyanosis of the skin, the desire of the patient to take a forced position, the presence of subcutaneous emphysema. The diagnosis of closed pneumothorax is confirmed auscultatively and radiologically. Medical care includes anesthesia, oxygen therapy, pleural puncture or drainage.
Closed pneumothorax is characterized by the presence of free gas in the pleural cavity in the absence of its communication with atmospheric air. By origin, it can be spontaneous or traumatic; idiopathic (primary – arising for no apparent reason) or symptomatic (secondary – developing against the background of another pulmonary pathology).
According to the degree of lung collapse in pulmonology, there are small or limited (lung decline by 1/3 volume), medium (decline by 1/2 volume) and total pneumothorax (lung decline by more than half). Compared with other forms (open, valvular), closed pneumothorax has a more favorable course. At the same time, bilateral total or intense pneumothorax with failure to provide timely assistance can lead to critical respiratory failure and death.
Causes of closed pneumothorax
- Bullous lung disease. In most cases, the rupture of subpleurally located air cysts in bullous emphysema leads to the appearance of a closed pneumothorax.
- Chronic bronchopulmonary diseases: COPD, bronchiectatic disease, bronchial asthma, tuberculosis, staphylococcal lung destruction, pneumosclerosis, cystic fibrosis, lung malformations, etc. In these cases, there is a rupture of pleural junctions or single alveoli. Tearing of bullae or adhesions can be provoked by physical exertion, straining, coughing or simply forced breathing, however, it often occurs at rest.
Traumatic pneumothorax, as a rule, is a consequence of a closed chest injury, accompanied by a fracture of the ribs, a rupture of the lung. The same group sometimes includes iatrogenic closed pneumothorax, which develops in violation of the methods of pleural puncture, transthoracic fine needle biopsy of the pleura, transbronchial lung biopsy, subclavian catheter placement; barotrauma during ventilation, cardiopulmonary resuscitation. The imposition of an artificial closed pneumothorax (surgical collapse therapy) is used as a method of treating cavernous pulmonary tuberculosis.
Predispose to the development of pathology: prematurity (underdevelopment of the pleura, mediastinal fiber, connective tissue, broncho-alveolar tract), addiction to smoking, connective tissue dysplasia, burdened heredity.
With a closed pneumothorax, air enters the pleural cavity at the time of injury or damage to the lung. In the absence of a valve mechanism, the defect in the lung tissue closes quickly, the amount of air in the pleural cavity does not increase, the pressure in it does not exceed atmospheric, there is no mediastinal flotation.
A strained pneumothorax, which is a complication of a valvular pneumothorax, can be considered closed by its mechanism. Initially, there is a progressive injection of air into the pleural cavity through the wound channel in the chest wall (external valvular pneumothorax) or damaged large bronchi (internal valvular pneumothorax). As the amount of air and pressure in the pleural cavity increases, the wound defect subsides, which marks the development of a tense pneumothorax. In this case, there is a dislocation of mediastinal structures, compression of ERW, life-threatening respiratory and circulatory disorders.
Closed pneumothorax symptoms
The clinic of closed pneumothorax is determined by pain, respiratory insufficiency and circulatory disorders, the severity of which depends on the volume of air in the pleural cavity. The disease most often manifests suddenly, unexpectedly for the patient, but in 20% of cases there is an atypical, erased onset. In the presence of a small amount of air, clinical symptoms do not develop, and a limited pneumothorax is detected during routine fluorography.
In the case of medium or total closed pneumothorax, sharp stabbing pains appear in the chest, radiating into the neck and arm. There is shortness of breath, dry cough, a feeling of lack of air, tachycardia, lip cyanosis, arterial hypotension. The patient is sitting with his hands on the bed, his face is covered with cold sweat. Subcutaneous emphysema spreads through the soft tissues of the face, neck, and trunk due to the ingress of air into the subcutaneous tissue.
With a strained pneumothorax, the patient’s condition is severe or extremely severe. The patient is restless, feels a sense of fear due to a feeling of suffocation, greedily gasps for air. The heart rate increases, the skin becomes cyanotic, a collaptoid state may develop. The described symptoms are associated with a complete collapse of the lung and a displacement of the mediastinum to the healthy side. In the absence of emergency care, a tense pneumothorax can lead to asphyxia and acute cardiovascular insufficiency.
A closed pneumothorax may be suspected by a pulmonologist based on the clinical picture and auscultative data, and finally confirmed by the results of X-ray diagnostics. During examination, smoothing of intercostal spaces, lagging of half of the chest on the side of the lesion during breathing is determined; during ascultation – weakening or absence of respiratory noises; with percussion – tympanitis; with palpation of soft tissues with phenomena of subcutaneous emphysema – a characteristic crunch.
With the help of lung x-ray, it is possible to detect the accumulation of free gas between the collapsed part of the lung and the parietal pleura (with total pneumothorax, a complete collapse of the lung with simultaneous displacement of the mediastinum to the healthy side). The final confirmation of the diagnosis is the receipt of air during thoracocentesis. The immediate causes of closed pneumothorax are clarified after receiving chest CT data or during diagnostic thoracoscopy.
The closed pneumothorax should be differentiated from:
- relaxation of the diaphragm dome
- uncomplicated lung cysts
- lung atelectasis
- of lobar emphysema
- hernias of the esophagus
- myocardial infarction, etc.
This may require a clarifying diagnosis (bronchography, angiopulmonography, CT of the lungs, stomach radiography, etc.).
Closed pneumothorax treatment
A small amount of air in the pleural cavity, which does not give symptoms, can dissolve on its own. However, to exclude the progression of a closed pneumothorax, X-ray monitoring is necessary. In clinically significant cases, hospitalization of the patient in the department of thoracic surgery or traumatology and immediate provision of qualified care is required. During transportation to the clinic, the patient should be anesthetized, given a semi-sitting position, provided with inhalation of moistened oxygen, with arterial hypotension, vasotonic agents should be administered.
Subsequent treatment of a closed pneumothorax can be performed by a conditionally conservative or operative method. The first method involves a pleural puncture with simultaneous evacuation of air or drainage of the pleural cavity with the imposition of drainage by Bulau or an electric vacuum device of active aspiration. A typical place for the installation of drainage is the intercostal space II along the sredneklyuchny line.
In case of ineffectiveness of the puncture-drainage method or repeated relapses of a closed pneumothorax, thorax-surgical or open intervention is performed with the aim of eliminating the root cause of the pathology. To prevent repeated cases of the disease, pleurodesis is carried out, leading to the formation of splices between the pleural leaves and obliteration of the pleural fissure.
The prognosis of a closed pneumothorax is closely related to its root cause. It is noted that idiopathic pneumothorax proceeds more favorably than symptomatic. The most dangerous are tense and bilateral pneumothorax, leading to respiratory and cardiovascular insufficiency.
The conditions complicating closed pneumothorax include relapse of the disease, pleurisy, pleural empyema, intrapleural bleeding, the formation of the so-called rigid lung. With an unexplained or known, but unresolved cause of a closed pneumothorax, relapses for 3 years are observed in half of cases, after the elimination of the cause – only in 5%.