1. 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 胸腔外科~黃文傑醫師
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。

4.  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)

5. Spontaneous
Primary pneumothorax
Secondary pneumothorax
Airway and pulmonary disease (COPD, asthma)
Interstitial disease (Pulmonary fibrosis)
Infection ( TB..)
Neoplastic
Catamenial ( Endometriosis)
Iatrogenic
Post-Traumatic

6. Surgical indication for primary spontaneous pneumothorax
Early complication
Prolonged air leakage
Non re-expansion of the lung
Bilaterality
Hemothorax
Tension
Complete pneumothorax
Potential hazard
Occupational hazard
Absence of medical facilities in isolated areas
Associated single bulla
Psychological
Second Episode
Ipsilateral recurrence
Contralateral recurrence after a first pneumothorax

8. Spontaneous Pneumothorax -Definition & Factors
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

9. Spontaneous Pneumothorax -Clinical investigation
Signs and symptoms
Sudden onset chest pain
Shortness of breathing
Cough
Diagnosis
CXR
Auscultation
Differential diagnosis
Skin fold
Giant bulla

10. Treatment Options for Pneumothorax
Observation
Needle aspiration
Percutaneous catheter to drainage
Water seal Pleur-evac type
Heimlich valve
Tube thoracostomy
Tube thoracostomy with instillation of pleural irritant
Video-assisted thoracoscopic surgery
Thoracotomy

11. 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

12. Recurrence of Primary Spontaneous Pneumothorax
Therapy Recurrence (%)
Expectant
Aspiration
Chest tube drainage
Pleurodesis (tetracycline)
Pleurodesis (talc)
Surgery

13. Complication of Pneumothorax
Tension pneumothorax
Re-expansion pulmonary edema
Persistent air leak
Hemothorax (less than 5%)
Pneumomediastinum

14. Removal of Chest Tube Indications Proper timing (controversy)
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

15. Tube Thoracostomy
( Chest Intubation)

16. 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.

17. 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

18. 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)

19. 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 (except Lung or other organ injury
emergency)
3. Keep tube in good direction Chest pain, great vessel erosion
4. Avoid intubation thru posterior Pain, unable in supine
chest wall
5. Avoid to suture & close Air leakage
thoracostomy wound too loose Skin necrosis, pain
or too tight

20. 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 w’d slightly loose
6. Insert another tube if no improvement
7. Low O2 nasocannula
8. Determine the cause & treat underlying disease
9. Remove tube after complete subsidence

21. 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

22. Attention in Chest Tube Care (I)
Attention Prevent occurrence
Fix chest tube firmly Tube moving & contamination
Don’t clamp tube during Tension pneumothorax
transportation in presence of
air leakage
Don’t use negative pressure suction Abrupt mediastinal shift,
after pneumonectomy venous return decrease, death
Don’t apply negative suction Reexpansion pulmonary edeme immediately after intubation for
cases with large volume or long
duration of pneumothorax, hydro-
pyothorax

23. Attention in Chest Tube Care (II)
Attention Prevent occurrence
Don’t lift up tube above Back flow contamination
thoracostomy wound
Use collecting bottle and elevate Back flow contamination
the connecting tube between 2 Lung collapse
bottles in big residual pleural
space or massive air leakage

24. 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 bronchial Stump 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