Hemopneumothorax is the simultaneous presence of hemorrhagic effusion and free gas in the pleural cavity. Hemopneumothorax is manifested by both signs of bleeding (pallor of the skin, tachycardia, decreased blood pressure) and symptoms of respiratory failure (shallow rapid breathing, cyanosis, chest pain, etc.). In order to detect hemopneumothorax, lung radiography and pleural puncture are performed. Treatment can be either conditionally conservative (drainage of the pleural cavity), or active, surgical (thoracoscopy or thoracotomy with elimination of hemopneumothorax).
ICD 10
S27.2 Traumatic hemopneumothorax
Meaning
Hemopneumothorax is a pathological condition that develops when blood and air enter the pleural cavity due to damage to blood vessels, lung tissue or bronchi. Hemopneumothorax is more common in men, usually young and middle-aged. According to the etiology, hemopneumothorax is divided into spontaneous (extremely rare), traumatic and iatrogenic. In turn, traumatic hemopneumothorax may be with the presence or absence of an open wound in the thoracic cavity. Just like isolated hemothorax and pneumothorax, this condition in surgical pulmonology is urgent and requires an emergency medical response.
Causes
The producing causes differ depending on the conditions in which hemopneumothorax has developed. Thus, spontaneous hemopneumothorax is usually a consequence of rupture of subpleurally located air cysts in bullous lung disease. In addition, a rupture of pleural junctions or pulmonary arterioles may be detected.
Traumatic hemopneumothorax is based on penetrating or blunt trauma of the chest, received in road accidents, falling from a height, stab and gunshot wounds, beating, chest compression, etc. Such injuries are often accompanied by a fracture of the ribs, collarbone or sternum, bruising or rupture of the lung, as well as injury to intercostal, internal thoracic and other vessels. Iatrogenic hemopneumothorax occurs due to the fault of medical personnel, for example, in violation of the technique of performing catheterization of central veins, pleural biopsy, thoracocentesis, drainage of the pleural cavity.
Symptoms
By volume, there are small (accumulation of blood and air in the pleural sinuses), medium (blood and gas levels reach the angle of the scapula), large (blood and gas levels reach the middle of the scapula) and total hemopneumothorax. Clinical manifestations of hemopneumothorax are largely determined by the amount of hemorrhagic exudate and gas in the pleural cavity.
Small hemopneumothorax is not accompanied by significant respiratory and hemodynamic disorders and active complaints. With a more massive pathological process, chest pains occur, breathing becomes difficult, frequent and superficial, the skin becomes pale. There is a decrease in blood pressure, a frequent pulse of weak filling. With sudden bleeding, hypovolemic shock develops, accompanied by weakness, dizziness, and impaired consciousness.
Hemopneumothorax, caused by a violation of the integrity of the pulmonary parenchyma, is accompanied by hemoptysis, subcutaneous emphysema, shortness of breath, cyanosis. In severe cases, pleuropulmonary shock may develop. A sharp displacement of the heart and large vessels leads to a violation of hemodynamics and the development of cardiovascular insufficiency; a complete collapse of the lung leads to respiratory failure and asphyxia.
With hemopneumothorax with the presence of an open wound in the thoracic cavity, a syndrome of cardiopulmonary disorders occurs, characterized by paradoxical breathing, “flotation” of the mediastinum, hypoxemia, increased pressure in the small circle of blood circulation. In this case, dyspnea, tachycardia, arterial hypotension are expressed, chest pains increase with each breath. With the long-term existence of hemopneumothorax, conditions are created for infection of the pleural contents and the development of pleural empyema.
Diagnostics
Characteristic clinical symptoms in combination with physical data and an indication in the anamnesis of a recent chest injury or intrapleural intervention allow a thoracic surgeon or traumatologist to suspect hemopneumothorax already at the initial examination of the patient. The affected side lags behind (or does not participate at all) in the act of breathing; vesicular breathing is not heard over the affected area, a dull sound is detected during percussion.
The most valuable diagnostic tools at the stage of primary detection of hemopneumothorax are radiation imaging methods (radiography and lung fluoroscopy). To determine the nature of the fluid, an ultrasound of the pleural cavity is informative. These methods allow not only to detect the presence of air and fluid in the pleural cavity, but also to estimate their volume. The final confirmation of the X-ray data is the receipt of hemorrhagic exudate and air during diagnostic thoracocentesis.
Treatment
First aid may consist in wound PHO, the supply of moistened oxygen, if necessary, the application of a sealing bandage, the introduction of painkillers, and cardiovascular agents. Modern tactics in relation to hemopneumothorax provides for the rapid removal of blood and gas from the pleural cavity and the achievement of lung expansion. For this purpose, they resort to drainage of the pleural cavity with active aspiration of the contents through drainage using an electric pump. Enzyme preparations can be injected into the pleural cavity to dissolve blood clots and fibrin.
Indications for thoracotomy are lung injury, coagulated hemothorax, ongoing intrapleural bleeding, ineffectiveness of conditionally conservative tactics. Ligation or coagulation of the bleeding vessel can be performed during thoracoscopy or pleuroscopy. Elimination of hemopneumothorax and straightening of the lung in the first 3-5 days contribute to the prevention of pleural empyema and restoration of lung function in full.
Prognosis and prevention
With timely provision of the necessary amount of medical care (drainage, stopping bleeding, conducting antishock therapy, etc.), the prognosis is favorable. In cases where hemopneumothorax is caused by polytrauma, the outcome is determined by the totality and severity of the injuries received. Prevention of hemopneumothorax is closely related to injury prevention, mandatory X-ray examination of patients with chest trauma and polytrauma, elimination of the source of bleeding and air discharge into the pleural cavity. In order to prevent the development of iatrogenic hemopneumothorax, it is necessary to observe the technique of invasive interventions on the thoracic cavity.
