胸腔急症气胸.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,胸腔急症氣胸,1.,氣胸(Pneumothorax):,是氣體在胸腔內引起肺萎陷。若引起縱,隔偏移及壓迫到對側的肺稱之為高張性氣胸,(tension,pneumothorax),，常因使用的人工呼吸器壓力過大而引起，或是,肺氣腫的水泡、肺囊腫破裂而造成。,胸腔外科黃文傑醫師,診斷:i.理學檢查:患側的呼吸音減弱，心音偏向對側。有時頸部有捻,髮音(crepitus)。ii.胸部X光:患側呈現高透光性，而且沒有支氣管的顯影。旁邊,或甚至對側的肺葉萎陷。縱隔及心臟向對側偏移。,治療:無症狀或僅有輕微的呼吸窘迫，可在病房作嚴密的看護，這種,單純性氣胸有三分之二在五至七天內自癒而無須手術。,若有嚴重的呼吸困難及高張性氣胸，則應立即採取行動。以靜,脈注射用之套管針，由,前胸第二肋間或腋窩中線第五或第六,肋間插入,，接上水下引流瓶，先解除呼吸困難。然後再改用,胸管插入，等肺完全擴張沒漏氣後24-48小時再拔除。,手術(肺氣泡切除術、肋膜沾粘術),Spontaneous,Primary pneumothorax,Secondary pneumothorax,Airway and pulmonary disease(COPD,asthma),Interstitial disease(Pulmonary fibrosis),Infection(TB.),Neoplastic,Catamenial,(Endometriosis),Iatrogenic,Post-Traumatic,Spontaneous Pneumothorax,-Definition&Factors,Definition,Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleura,Factors determining gas reabsorption,Diffusion properties of the gases,Pressure gradients,Area of contact,Permeability of pleural surface,Spontaneous Pneumothorax,-Clinical investigation,Signs and symptoms,Sudden onset chest pain,Shortness of breathing,Cough,Diagnosis,CXR,Auscultation,Differential diagnosis,Skin fold,Giant bulla,Treatment Options for Pneumothorax,Observation,Needle aspiration,Percutaneous catheter to drainage,Water seal Pleur-evac type,Heimlich valve,Tube thoracostomy,Water seal Pleur-evac type,Heimlich valve,Tube thoracostomy with instillation of pleural irritant,Video-assisted thoracoscopic surgery,Thoracotomy,Indications for Surgical Intervention,Second episode,Persistent air leakage for greater than 7-10 days,First episode with unexpanded,“trapped”lung,History of contralateral pneumothorax,Bilateral pneumothorax,Occupational risk,(driver,airplane pilot,living ina remote area),Large bulla,Large undrained hemothorax,First episode in a patient with one lung,First episode in a patient with severely compromised pulmonary function,Recurrence of Primary Spontaneous Pneumothorax,Therapy Recurrence(%),Expectant 30,Aspiration 20-50,Chest tube drainage 20-30,Pleurodesis(tetracycline)25,Pleurodesis(talc)7,Surgery 2,Complication of Pneumothorax,Tension pneumothorax,Re-expansion pulmonary edema,Persistent air leak,Hemothorax(less than 5%),Pneumomediastinum,Removal of Chest Tube,Indications,No fluctuation in the fluid column of the tube(complete lung reexpansion or tube occlusion),Daily fluid drainage 100ml in 24 hours,Air leakage has stopped,Proper timing(controversy),Spontaneous pneumothorax after tube thoracostomy,removal tube within 6 hours of reexpansion-25%collapse,Tube Thoracostomy,(Chest Intubation),Indication of Chest Intubation,Drain pleural fluid or air,promote lung expansion,1.Pneumothorax,2.Hydrothorax,3.Hemothorax,4.Chylothorax,5.Pyothorax,6.Post-thoracotomy etc.,Apparatus of Chest Tube Drainage,1.Underwater sealed bottle:,Separate from atmosphere,2.Collecting bottle:,Decrease resistance of drainage,3.Negative pressure suction:,Promote lung expansion,Procedure of Chest Intubation,1.Local anesthesia,confirm location,2.Skin incision at selected area,3.Dissect into pleural cavity thru a subcutaneous tunnel,4.Deloculate in pleural cavity,5.Insert tube posteriorly and laterally,6.Close incision wound,fixed the tube,7.Connect tube to underwater sealed bottle(or with negative pressure suction),Attention In Chest Tube Insertion,Attention Prevent occurrence,1.Thru thoracostomy wound Underlying organ injury,palpate the underlying structure(supra-or infra-diaphragm),2.Avoid trocar intubation(exceptLung or other organ injury,emergency),3.Keep tube in good directionChest pain,great vessel erosion,4.Avoid intubation thru posteriorPain,unable in supine,chest wall,5.Avoid to suture&close Air leakage,thoracostomy wound too looseSkin necrosis,pain,or too tight,Attention in Massive Subcutaneous(Mediastinal)Emphysema,1.Keep airway patent(even endotracheal tube),2.CXR,3.Insert chest tube in pneumothorax or suspicious side,4.Connect tube to negative pressure suction immediately,5.Close thoracostomy wd slightly loose,6.Insert another tube if no improvement,7.Low O,2,nasocannula,8.Determine the cause&treat underlying disease,9.Remove tube after complete subsidence,When to Remove Chest Tube?,Criteria:,1.No air leakage,2.Drained fluid 50 c.c./day,3.Clear serosanguineous color of fluid,4.Full expansion of lung in CXR,Clear sterile fluid remove directly,Turbid,infected fluid withdraw progressively,open drain,Attention in Chest Tube Care(I),Attention Prevent occurrence,Fix chest tube firmly,Tube moving&contamination,Dont clamp tube during,Tension pneumothorax,transportation in presence of,air leakage,Dont use negative pressure suction,Abrupt mediastinal shift,after pneumonectomy,venous return decrease,death,Dont apply negative suction,Reexpansion pulmonary,edeme,immediately after intubation for,cases with large volume or long,duration of pneumothorax,hydro-,pyothorax,Attention in Chest Tube Care(II),Attention Prevent occurrence,Dont lift up tube aboveBack flow contamination,thoracostomy wound,Use collecting bottle and elevateBack flow contamination,the connecting tube between 2Lung collapse,bottles in big residual pleural,space or massive air leakage,Attention in Thoracotomy with Lung Resection(I),Attention Prevent occurrence,Suture ligated or close pulmonary Slip out,bleeding,vessel with stapler,Make adequate length in bronchialStump broken,stump,Cover bronchial stump with Bronchopleural fistula,surrounding tissue,especially in,pneumonectomy,Pre-operative anti-TB or anti-fungal Disease flare up,drug(at least 2 wks)for suspicious,TB or fungal diseases,