经胸腔镜手术与开胸手术在治疗自发性气胸的效果

目的探讨胸腔镜手术与开胸手术在治疗自发性气胸的不同效果。方法将我科自发性气胸210例分为两组,其中应用胸腔镜115例为VATS组,同期开胸手术治疗自发性气胸95例为开胸组。比较两组术中切口长度、出血量、手术时间等,术后引流管拔管时间,患者的体温,应用镇静剂情况,住院天数,住院费用等。结果两组除住院费用无统计学意义（P〉0.05）外,其余各项观察指标都有统计学意义。结论从VATS组手术与开胸手术在治疗自发性气胸各个方面效果看,具有切口小、出血量少、手术时间短、恢复快等优点,值得推广。     

Transbronchoscopic selective bronchial occlusion for intractable pneumothorax

Background and objective: The aim of this study was to evaluate the efficacy, complications and safety of the application of transbronchoscopic balloon detection (TBD) and selective bronchial occlusion (SBO) to intractable pneumothorax. Methods: Forty patients with pneumothorax, who had experienced more than 7 days of chest tube drainage without closure of the pleural fistula, underwent TBD and SBO. In 10 patients, oxygenation and pulse rates were recorded. A thoracic CT scan was performed 10 days after SBO. Results: The bronchi leading to the pleural fistula were located by TBD in 34 of 40 patients (85%). The air leakages ceased after the first occlusion in 30 patients, and five of these 30 patients underwent a second occlusion due to recurrence of pneumothorax 72 h after the first occlusion. In three of these patients, air leakages ceased after the second occlusion, while the remaining two patients underwent thoracoscopy. In total, 28 of 40 patients (70%) were cured using SBO. During TBD/SBO, the lowest SaO2 was 89.0 ± 2.8%, the mean SaO2 was 93.4 ± 2. 6% and the percentage of time during the procedure that SaO2 was <90% was 10.7 ± 17.5%. Ten days after SBO, thoracic CT scans were performed on 10 patients and no obstructive atelectasis was detected in any patient. Conclusions: These results indicate that TBD and SBO are safe and effective procedures for treating patients with intractable pneumothorax.     

Pneumothorax and insertion of a chest drain

A pneumothorax occurs when the visceral or parietal pleura is breached and air enters the pleural space. This leads to loss of the negative intrapleural pressure and lung collapse. Pneumothoraces may be classified into ‘simple’, ‘tension’ or ‘open’ according to the underlying pathophysiology. A chest radiograph is essential in diagnosis and management. Tension pneumothorax is a medical emergency, relieved initially with needle thoracentesis, but treated definitively with a chest drain. The latter is inserted in all cases where aspiration is unsuccessful in controlling symptoms in a simple pneumothorax. A thoracic surgical opinion should be sought if there is persistent air leak from the drain or the lung fails to re-expand after three days.A chest drain is used to drain air, blood, fluid or pus from the pleural space. Proper attention should be paid to patient preparation, which should include full asepsis, appropriate patient positioning, and application of National Patient Safety Agency recommendations. A chest drain is usually inserted under local anaesthesia in the ‘safe triangle’ in the lateral chest wall using blunt dissection. The drains should not be clamped in cases of pneumothorax, and the drainage bottle should always be kept below the level of the patient’s chest.     

Outpatient Management of Primary Spontaneous Pneumothorax in the Emergency Department of a Community Hospital Using a Small-bore Catheter and a Heimlich Valve

Objectives: The objective was to assess the effectiveness of a small-bore catheter (8F) connected to a one-way Heimlich valve in the emergency department (ED)-based outpatient management of primary spontaneous pneumothorax (PSP). Methods: The authors conducted a structured chart audit in a retrospective case series of patients with PSP who were treated with a small-bore (8F) catheter and a Heimlich valve who were seen in the ED of a community hospital between April 2000 and March 2005. To be eligible, patients had to be available for a telephone interview. Main outcomes were success of treatment (sustained, complete lung reexpansion), admission, and surgical intervention rates. Secondary outcomes included number of chest x-rays (CXRs), number of visits to the ED, treatment duration, complications, and recurrence rates. Results: The authors identified 62 discrete episodes of PSP in 50 patients, with a mean (±standard deviation [SD]) age of 25.5 ± 10.5 years (range = 14–53 years). In 50 of 62 episodes (81%, 95% confidence interval [CI] = 70.8% to 90.5%), patients were discharged directly from the ED. Patients were admitted to the hospital at some point for treatment in 27/62 episodes (43.5%, 95% CI = 31.2% to 55.9%). Surgery was performed for acute treatment failure in 17 episodes. Ultimately, 19 patients, who accounted for 21 of 62 episodes (33.9%, 95% CI = 22.1% to 45.6%), had surgery at some point in the study. Mean (±SD) time to admission for those patients initially discharged from the ED was 2.9 (±2.01) days (95% CI = 1.9 to 3.8 days). There were no serious complications from treatment; the minor complication rate (misplacement or dislodging of the chest tube) was 22.6% (95% CI = 12.2% to 33.0%). No association was found between the size of pneumothorax and treatment failure. Conclusions: This study suggests that the initial management of PSP with a small-bore catheter and Heimlich valve can easily be performed by emergency physicians in the community hospital setting and appears safe. A larger study systematically comparing this approach with alternative therapies is needed.     

Pneumothorax preceding pulmonary blastoma in a child

Serial plain radiographic, ultrasound and CT findings of an unusual case of pulmonary blastoma are described with a review of the literature.     

肺大泡自发性气胸手术麻醉处理：—附28例临床分析

目的：探讨肺大泡自发气胸病人在麻醉期间的危险性及预防措施，方法：为了预防麻醉诱导和维持期间的肺大泡破裂，本组麻醉诱导面罩吸氧应用法控制呼吸囊辅助通气和控制通气时，轻压呼吸囊，使胸廓略有起伏，血氧饱和度在基础状态下逐渐上升，同时监测气道压力，使气道压不超过20cmH2O(1.96kPa)，以SpO2平稳上升为手法控制呼吸囊的适宜程度，同时选用双腔管插管。结果：本组28例肺大泡自发性气胸在麻醉期间无1例出现麻醉期间肺大泡破裂。结论：对此类病人选用全麻快速诱导，双腔管插管，手法控制通气量，严密监测SpO2和气道压，可防止肺大泡破裂。     

胸腔镜下联合应用聚乙醇酸网片治疗原发性自发性气胸

目的 探讨胸腔镜下联合应用聚乙醇酸网片在治疗原发性自发性气胸中的临床价值.方法 在胸腔镜下使用切割缝合器对134例原发性自发性气胸行肺大疱切除139例次:补片组(96例次),在胸腔顶部壁层胸膜覆盖15 cmXl5 cm大小可吸收聚乙醇酸修补网片;对照组(43例次),仅行肺大疱切除.比较两组第一次手术后同侧复发次数.结果 补片组复发3例(3.2%),明显少于对照组的9例(20.9%)(P<0.01).结论 胸腔镜下使用聚乙醇酸修补网片覆盖胸腔顶部壁层胸膜可降低原发性自发性气胸术后复发率.     

单孔胸腔镜治疗自发性气胸

目的：探讨单孔胸腔镜治疗自发性气胸的可行性。方法回顾分析2010年7月～2013年7月114例单孔胸腔镜手术治疗自发性气胸的临床资料,均采用自制可弯曲双关节腔镜专用器械行单孔胸腔镜手术。结果手术均顺利完成,无中转开胸,未增加穿刺孔,无术后大出血等并发症。手术时间（42．4±11．4） min,术后胸管留置时间（1．8±0．4） d,术后住院时间（5．4±3．4）d。术后随访1～36个月,平均20个月,其中76例＞12个月,无切口感染、出血、积液、气胸复发等并发症。结论单孔胸腔镜手术治疗自发性气胸是安全、微创、可行的。     

张力性气胸野战救护装置的研制及其实验效果

目的设计制作张力性气胸（tension pneumothorax，TPT）野战救护装置并验证其对张力性气胸的救治效果。方法自行设计并制备张力性气胸野战救护装置，以犬为实验动物，将32只犬随机分为4组，每组8只，采用改进的Rutherford的张力性气胸动物模型制作方法制作张力性气胸动物模型，第1组不给予任何干预措施，第2组采取穿刺减压法，第3组采用胸腔闭式引流装置，第4组采用新装置治疗张力性气胸，在干预前及干预后0．5、1、3、6hN定指标：4-dp／dtmax、-dp／dtmax、LVSP、LVEDP、MAP、HR、RR、pH、PaO2、PaCO2、SaO2。结果模型制备成功后6h，第1组动物存活率为75％，其余3组存活率为100％。第2组的操作时间少于与第3、4组，第4组的操作时间少于第3组，差异均有统计学意义（P＜0．01）。干预后6h，第3组与第2组相比，除MAP、pH、PaCO2外，其余指标均与第2组比较，差异均有统计学意义（P＜0．05）；第4组与第2组相比，除HR、MAP、pH、PaCO2外，其余指标均与第2组比较，差异均有统计学意义（P＜0．05）。结论张力性气胸野战救护装置治疗张力性气胸的效果和临床常用的胸腔闭式引流装置无差别，且携带方便、操作简单、可用于自救互救、适合在野战复杂的环境及平时的院前急救中使用。