What is ectopic rhythm? Atrial rhythm on ECG in a child. What happens with ectopic heart rhythm

Indications: pneumothorax, hemothorax, hemopneumothorax.

To eliminate pneumothorax in the 2nd intercostal space along the midclavicular line, an elastic tube with a diameter of 0.5 cm is inserted into the pleural cavity through a trocar (pleural drainage according to Petrov).

The distal end of the drainage tube is immersed in an antiseptic solution or active aspiration is performed at a vacuum of 30-40 mm Hg. The criterion for correct installation of drainage is the release of air bubbles through the tube.

The main mistakes that occur when installing pleural drainage according to Petrov:

1. The drainage tube is inserted into the pleural cavity to a great depth. In this case, the tube bends, curls up and does not perform drainage function. To avoid this, it is necessary to insert the drainage tube to a depth of 2-3 cm from the last hole.

There should not be very many side holes on the tube - up to 3. If it is difficult for the doctor to determine the depth of insertion of the drainage, it is necessary to put a mark on the drainage tube.

2. Inadequate fixation of the drainage tube. The drainage completely comes out of the pleural cavity or falls out partially. In the latter situation, the lateral openings end up in the subcutaneous tissue with the development of subcutaneous emphysema. If the side opening is above the skin, atmospheric air is sucked into the pleural cavity. with the occurrence of lung collapse. The drainage tube must be fixed to the skin of the chest wall with two silk threads at each edge of the wound.

If the ligature on the drainage tube is tightened too tightly, it becomes compressed until the lumen is completely compressed. It is necessary to cut off the ligature and re-fix the drainage tube. In open pneumothorax, the chest wall must be sealed before inserting a chest tube.

The next day after installing the drainage, a control fluoroscopy (graphy) is performed. chest. When the lung is fully expanded and there is no air passage through the pleural drainage, the drainage tube is removed on the 4th day. In this case, X-ray control is required. There are no clear criteria for the duration of drainage of the pleural cavity for pneumothorax. The drainage must be maintained until the lung is completely expanded. In case of pathology of the lung tissue, this delays for 2-3 weeks.

P For intractable conservative tension pneumothorax, thoracotomy is indicated.

Drainage of the pleural cavity for hemothorax

The main goal: timely and adequate removal of blood from the pleural cavity and expansion of the lung. To do this, install pleural drainage according to Bulau.

Technique: under local anesthesia, a puncture of soft tissue is made with a scalpel in the 7-8 intercostal space along the midaxillary line, focusing on top edge underlying rib. A drainage tube with a diameter of 1-1.5 cm with several side holes is inserted into the pleural cavity using a forceps or a trocar with a diameter of more than 1.5 cm. The tube is fixed to the edges of the skin wound with two sutures. The lower end of the tube with a valve is lowered into a bottle of antiseptic or to a vacuum system for active aspiration.

Blood from the pleural cavity must be collected for reinfusion.

Mistakes when installing pleural drainage according to Bulau:

1. Use a tube with a diameter of less than 8 mm for drainage. The thin drainage tube becomes clogged with blood clots and does not function.

2. Use soft rubber tubes for drainage. Such tubes are deformed and compressed by the ligature and the tissues of the chest wall. Silicone and PVC tubes must be used.

3. Leaving the end of the drainage tube too long in the pleural cavity. The proximal end of the tube is located in the upper parts of the pleural cavity and does not drain the lower parts where the blood is located. It is necessary to tighten the drainage tube a few centimeters.

4. Errors in fixing the drainage tube to the skin (described in detail in the pneumothorax section).

Drainage of the pleural cavity is indicated only for moderate and large hemothorax. For small hemothorax, pleural puncture is performed.

After installation of pleural drainage according to Bulau, dynamic monitoring is necessary.

At the same time, the amount of blood released through the drainage is determined and further treatment tactics are determined. The main task of the doctor is to determine: does intrapleural bleeding continue or has it stopped? To diagnose ongoing intrapleural bleeding, the following are used: clinical picture, the amount of blood through the pleural drainage, the Rouvilois-Grégoire test - intensive flow of blood through the drainage, which quickly coagulates, against the background of clinical anemia. The presence of ongoing intrapleural bleeding is an indication for thoracotomy. If the bleeding has stopped, a control X-ray of the chest is performed the next day after the installation of pleural drainage. The drainage tube is removed no earlier than 4 days, when the lung is fully expanded and there is no discharge through the drainage.

The presence of pneumothorax and moderate hemothorax is an indication for double drainage of the pleural cavity (in the 2nd and 7th intercostal spaces).

Pneumothorax is divided into spontaneous (not associated with trauma or any obvious cause), traumatic and iatrogenic. Primary spontaneous pneumothorax occurs in the absence of clinically significant pulmonary pathology; secondary spontaneous pneumothorax is a complication of existing pulmonary pathology.

Iatrogenic pneumothorax occurs as a result of a complication of a therapeutic or diagnostic intervention. Traumatic pneumothorax is a consequence of penetrating or blunt trauma to the chest, in which air can enter the pleural cavity from a ruptured lung tissue or chest wall defect. In this review we will examine spontaneous pneumothorax.

Etiological classification of pneumothorax

Spontaneous

Primary: no evidence of lung pathology
Secondary: complication of an already diagnosed lung disease

Traumatic

Due to penetrating chest trauma
Due to blunt chest trauma

Iatrogenic

After puncture of the pleural cavity
After central venous catheterization
After thoracentesis and pleural biopsy
Due to barotrauma

Primary spontaneous pneumothorax

Epidemiology

Primary spontaneous pneumothorax occurs with an incidence of 1 to 18 cases per 100,000 population per year (depending on gender). It usually appears in tall, thin young people between the ages of 10 and 30, and rarely occurs in people over 40 years of age. Cigarette smoking increases the risk of pneumothorax by approximately 20 times (depending on the number of cigarettes smoked).

Pathophysiology

Although patients with primary spontaneous pneumothorax do not have clinically obvious pulmonary pathology, subpleural bullae are detected during videothoracoscopy in 76-100% of such patients, and with open thoracotomy they are detected in 100% of patients. In the contralateral lung, bullae are found in 79-96% of patients.

Computed tomography of the chest reveals bullae in 89% of patients with primary spontaneous pneumothorax, compared with a 20% incidence of bullae in similarly healthy people of the same age group with the same amount of cigarette consumption. Even among nonsmokers with a history of pneumothorax, bullae are found in 81%.

The mechanism of formation of bullae remains unclear. Perhaps they arise due to the degradation of the elastic fibers of the lungs, which is caused by the activation of neutrophils and macrophages caused by smoking.

This leads to an imbalance between proteases and antiproteases and the oxidation and antioxidant system. After the formation of the bulla, inflammatory oscillation of small respiratory tract, as a result of which intra-alveolar pressure increases and air begins to penetrate into the pulmonary interstitium.

Then the air moves towards root of the lung, causing mediastinal emphysema, with increasing pressure in the mediastinum, the mediastinal parietal pleura ruptures and pneumothorax occurs.

Histological analysis and electron microscopy of tissue obtained during surgery usually do not reveal a defect in the tissue of the bulla itself. In most patients with such pneumothorax, standard chest radiographs do not show pleural effusion. Increased intrapleural pressure due to pneumothorax prevents fluid from leaking into the pleural cavity.

Large primary spontaneous pneumothorax leads to a sharp decrease in the vital capacity of the lungs and an increase in the alveolar-arterial oxygen gradient, resulting in hypoxemia of varying severity. Hypoxemia is the result of a violation of the ventilation-perfusion relationship and the appearance of a right-to-left shunt; the severity of these disorders depends on the size of the pneumothorax. Since gas exchange in the lungs is usually not impaired, hypercapnia does not develop.

Clinical picture

Most cases of primary spontaneous pneumothorax occurs at rest. Almost all patients complain of chest pain from pneumothorax and acute shortness of breath. The intensity of the pain can vary from minimal to very severe, most often described as sharp and later as aching or dull. Symptoms usually resolve within 24 hours, even if the pneumothorax remains untreated or does not resolve.

In patients with a small pneumothorax (occupying less than 15% of the volume of the hemithorax), physical symptoms are usually absent. Most often they experience tachycardia. If the volume of the pneumothorax is larger, there may be a decrease in chest excursion on the painful side, a percussion sound with a boxy tint, a weakening of vocal tremor and a sharp weakening or complete absence of breath sounds on the painful side.

Tachycardia greater than 135 beats per minute, hypotension, or cyanosis suggest tension pneumothorax. Arterial blood gas measurements usually indicate an increased alveolar-arterial gradient and acute respiratory alkalosis.

Diagnostics

The diagnosis of primary spontaneous pneumothorax is made based on the history and identification of the free edge of the lung (that is, a thin line of visceral pleura becomes visible) on a plain chest radiograph taken while sitting or standing. Fluoroscopy or expiratory radiography can help identify small pneumothorax, especially apical pneumothorax, but should not be performed in the department. intensive care not always possible.

Probability of relapse

The average recurrence rate for primary spontaneous pneumothorax is 30 percent. In most cases, relapse occurs within the first six months after the first episode.

Radiologically, fibrosis of the lung tissue is determined, patients have an asthenic build, young age, smoke - all these factors are called independent risk factors for pneumothorax. In contrast, detection of bullae on computed x-ray tomography or thoracoscopy during the first episode cannot be considered a risk factor.

Secondary spontaneous pneumothorax

In contrast to the benign clinical course of primary spontaneous pneumothorax, secondary spontaneous pneumothorax can often be life-threatening, since in these patients the underlying disease is some kind of pulmonary pathology, so their cardiac reserves are vascular system limited.

Causes of secondary spontaneous pneumothorax

Pathology of the respiratory tract:

Chronic obstructive pulmonary disease
Asthmatic status

Infectious diseases:

Pneumocystis pneumonia
Necrotizing pneumonitis (caused by anaerobic, gram-negative flora or staphylococci) - in Russian literature this condition is called abscess pneumonia (translator's note)

In Russia, such a common disease as tuberculosis cannot be discounted (translator's note)

Interstitial lung diseases:

Idiopathic pneumosclerosis
Wegener's granulomatosis
Lymphangioleiomyomatosis
Tuberous sclerosis

Connective tissue diseases:

Rheumatoid arthritis(more often leads to pyopneumothorax)
Ankyllizing spondylitis
Polymyositis and dermatomyositis
Marfan syndrome

Malignant neoplasms:

Lung cancer
Breast endometriosis (so-called menstrual pneumothorax)

(all of the above are in descending order of frequency)

Chronic obstructive pulmonary disease and Pneumocystis pneumonia, a disease associated with HIV infection, are the most common causes of secondary spontaneous pneumothorax in Western countries.

The likelihood of secondary spontaneous pneumothorax increases in the presence of chronic obstructive pulmonary disease, in patients with a forced expiratory volume in 1 second (FEV1) less than 1 liter or a forced vital capacity (FVC) less than 40% of predicted. Spontaneous pneumothorax develops in 2-6% of HIV-infected people, and in 80% of cases - in patients with Pneumocystis pneumonia. This is very dangerous complication, accompanied by high mortality.

Pneumothorax complicates the course of eosinophilic granulomatosis in 25% of cases. Lymphangiomyomatosis is a disease characterized by the proliferation of smooth muscle cells in the lymphatic vessels that affects women of reproductive age.

Pneumothorax occurs in more than 80% of patients with lymphagiomyomatosis and may be the first manifestation of the disease. In interstitial lung diseases, it is very difficult to treat pneumothorax, since the lung, which has poor extensibility, expands with great difficulty.

Pneumothorax associated with menstruation usually occurs in women aged 30 to 40 years with a history of pelvic endometriosis. This menstrual pneumothorax usually occurs on the left and appears in the first 72 hours from the onset of menstruation.

Although this is an uncommon condition, it is very important to recognize it on time, since only a thorough analysis of the history can help in diagnosis, this eliminates further expensive studies and allows timely initiation of hormonal treatment, which, if ineffective, is supplemented with pleurodesis. Since the probability of relapse even with hormonal therapy is 50%, pleurodesis can be performed immediately after diagnosis.

Epidemiology

The incidence of secondary spontaneous pneumothorax is approximately equal to that of primary spontaneous pneumothorax - from 2 to 6 cases per 100,000 people per year. It most often occurs at an older age (60 to 65 years) than primary spontaneous pneumothorax, which corresponds to the peak incidence of chronic lung disease in the general population. In patients with chronic nonspecific lung diseases, the incidence of secondary pneumothorax is 26 per 100,000 per year.

Pathophysiology

When intra-alveolar pressure exceeds the pressure in the pulmonary interstitium, which can be observed in chronic obstructive pulmonary diseases, during coughing the alveoli rupture and air penetrates the interstitium and passes to the hilum of the lung, causing mediastinal emphysema; if the rupture occurs close to the hilum, it ruptures and parietal pleura, and air ends up in the pleural cavity.

An alternative mechanism for the development of pneumothorax is lung necrosis, for example, with Pneumocystis pneumonia.

Clinical manifestations

In patients with pulmonary pathology with pneumothorax, shortness of breath always appears, even if there is little air in the pleural cavity. Most patients also have pain on the affected side. Hypotension and hypoxemia may also occur, sometimes significant and life-threatening.

These do not go away on their own, unlike primary spontaneous pneumothorax, which often resolves on its own. Patients often experience hypercapnia, with the partial pressure of carbon dioxide in arterial blood exceeding 50 mmHg. Physical symptoms can be scant and may be masked by symptoms inherent in existing pulmonary pathology, especially in patients with obstructive pulmonary diseases.

In a patient with chronic nonspecific pulmonary disease, pneumothorax should always be suspected if he or she develops unexplained shortness of breath, especially in combination with unilateral chest pain.

Diagnostics

Chest x-rays of patients with bullous emphysema may show giant bullae that sometimes appear similar to pneumothorax.

You can distinguish them from each other as follows: you need to look for a thin strip of visceral pleura, which in pneumothorax runs parallel to the chest wall; the outer contour of the bulla will follow the chest wall. If the diagnosis remains unclear, then perform computed tomography chest organs, since in case of pneumothorax, drainage of the pleural cavity is mandatory.

Relapse

The recurrence rate of spontaneous pneumothorax ranges from 39 to 47 percent.

Treatment

Treatment of pneumothorax consists of evacuating air from the pleural cavity and preventing recurrence. For small-volume pneumothorax, you can limit yourself to observation; you can aspirate air through the catheter and remove it immediately. The optimal treatment for pneumothorax is drainage of the pleural cavity.

To prevent relapses, carry out surgical intervention on the lung either through a thoracoscopic approach or by thoracotomy. The choice of access depends on the volume of pneumothorax, severity clinical manifestations, the presence of persistent air leak into the pleural cavity, and whether the pneumothorax is primary or secondary.

Lung expansion

With primary spontaneous pneumothorax of small volume (less than 15% of hemithorax), symptoms may be minimal. Inhalation of oxygen accelerates the resorption of air in the pleural cavity four times (when breathing normal air, air is reabsorbed at a rate of 2% per day).

Most doctors hospitalize patients, even if the volume of pneumothorax is small, although if it is a primary spontaneous pneumothorax in a young person without concomitant pathology, then after a day the patient can be sent home, but only if he can quickly get to the hospital.

Primary spontaneous pneumothorax of significant volume (more than 15% of the volume of hemothorax) or progressive pneumothorax can be managed as follows: either aspiration of air through an ordinary large-diameter intravenous catheter, or drainage of the pleural cavity.

Simple aspiration of air from the pleural cavity is effective in 70% of patients with primary spontaneous pneumothorax of moderate volume. If the patient is over 50 years of age or is aspirating more than 2.5 liters of air, this method will most likely fail.

If everything is in order, that is, six hours after aspiration there is no air in the pleural cavity, then the patient can be discharged the next day, but only if his condition is stable and he can quickly get to the hospital if necessary. If the lung does not expand after aspiration through the catheter, then the catheter is connected to a single-lumen Helmich valve or underwater traction and used as a drainage tube.

In case of primary spontaneous pneumothorax, drainage of the pleural cavity can also be performed, and the drainage is left for a day or more. Since air leakage in this case is usually minimal, thin drainage (7-14 F) can be used. The catheter is connected to a single-lumen Helmich valve (which allows the patient to move) or to an underwater traction.

Routine use of active aspiration (20 cmH2O pressure) does not have a significant impact on the outcome of the process. Underwater traction and active aspiration should be used in those patients where the use of the Helmich valve is ineffective or in those who have concomitant pathology of other organs and systems that reduces tolerance to recurrent pneumothorax.

Chest drainage is effective in 90% of cases in the first episode of pneumothorax, but this figure drops to 52% in the second episode and to 15% in the third. Indicators of failure of thin tube or catheter drainage are air leakage and accumulation of effusion in the pleural cavity.

In case of secondary spontaneous pneumothorax, drainage should be immediately performed with a thick tube (20 - 28 F), which is then connected to an underwater traction. The patient must remain in the hospital because he has a high risk of developing respiratory failure. Active suction is used in those patients who have a persistent air leak and the lung does not expand after underwater drainage.

Complications of pleural cavity drainage: pain at the drainage site, infection of the pleural cavity, improper placement of the drainage tube, bleeding and hypotension, as well as pulmonary edema after expansion.

Persistent air leak

Persistent air leak into the pleural cavity is more common with secondary pneumothorax. Seventy-five percent of cases of this complication in primary and 61% in secondary are resolved within a week of drainage, and for the complete disappearance of this complication in the case of primary pneumothorax, 15 days of drainage are needed.

For the first episode of primary spontaneous pneumothorax, surgery is usually not necessary. However, indications for it appear if the air leak persists even after seven days of drainage. On the seventh day, we usually discuss the possibility of surgical treatment with the patient and explain the advantages and disadvantages of this or that method, and talk about the risk of recurrence of pneumothorax without surgical treatment. Most patients agree to undergo surgery a week after drainage.

In the first episode of secondary spontaneous pneumothorax and persistent air leaks, indications for surgical treatment appear depending on the presence or absence of bullae on computed tomography scans of the chest. Unfortunately, in patients with persistent air leaks, chemical pleurodesis is not very effective.

Videothoracoscopic intervention allows you to examine the entire affected side and allows you to immediately perform pleurodesis and resection of bullous areas of the lung. The incidence of complications during video-assisted thoracoscopic intervention is higher in patients with secondary spontaneous pneumothorax than in patients with primary pneumothorax.

You can also perform a less invasive intervention, the so-called limited thoracotomy - access is carried out in the axillary region and allows you to preserve the pectoral muscles. In some patients with widespread bullous changes, a standard thoracotomy is required.

What can be done during videothoracoscopy:

Introduction of talc suspension
Dissection of pleural adhesions
Destruction of pleural overlays
Elimination of metastases with neo-yttrium laser, carbon dioxide laser, argon laser
Partial pleurectomy
Removal of bullae
Segmentectomy with a suturing device
Lung resection
Electrocoagulation
Sewing lung tissue
Pulmonectomy

Unfortunately, comparative effectiveness studies different types there is very little intervention. The recurrence rate of pneumothorax with video-assisted thoracoscopic intervention varies from 2 to 14% compared to 0-7% of recurrence with limited thoracotomy (most often with it the probability of recurrence does not exceed 1%). Explain more high percent recurrence after videothoracoscopy can be explained by the limited possibility of examining the apical parts of the lungs - where bullae occur most often.

Some, but not all, authors say that the duration of hospitalization, the need for postoperative drainage of the pleural cavity and the severity of pain syndrome less with video-assisted thoracoscopic surgery, although a formal cost-effectiveness analysis has not yet been performed.

Unfortunately, in 2-10% of patients with primary spontaneous pneumothorax and in about a third of patients with secondary spontaneous pneumothorax, it is necessary to switch to conventional thoracotomy due to technical difficulties.

Patients with severe concomitant pulmonary pathology may not tolerate video-assisted thoracoscopic intervention at all, since it requires an artificial pneumothorax. However, recent studies have shown that it is possible to perform such an intervention under local or epidural anesthesia without complete collapse of the lung, even in patients with respiratory pathology.

The choice of intervention to prevent recurrence of pneumothorax also depends on the qualifications of the surgeon.

Patients with HIV infection

The prognosis for patients with acquired immunodeficiency syndrome (AIDS) and pneumothorax cannot be called favorable, since their HIV infection has already advanced. Most of them die within three to six months after developing pneumothorax due to the progression of complications of AIDS. Therefore, the tactics for such a patient depend on the prognosis.

Since when draining the pleural cavity the risk of recurrent pneumothorax is high, even in the absence of air leakage it is recommended to administer sclerosing drugs through the drainage tube. Surgical resection of the lung parenchyma is only possible in patients with asymptomatic HIV infection. Often these patients have necrosis of the lung tissue, areas of which also need to be resected.

Once a patient with an equivocal or poor prognosis has been stabilized, it is best managed in an outpatient setting and a Helmich valve catheter may be left in the pleural space.

Prospects for solving the problem

The widespread use of minimally invasive interventions, that is, video-assisted thoracoscopic surgery, can significantly improve care for patients with spontaneous pneumothorax. Knowledge and understanding of risk factors for recurrence of primary spontaneous pneumothorax allows you to correctly determine the tactics preventive treatment. Studying the mechanism of action of sclerosing agents and developing new means for pleurodesis will significantly increase the effectiveness of this procedure.

During seven days of drainage, the patient continued to leak air into the pleural cavity, and CT scans revealed giant bullae. The patient underwent videothoracoscopy, resection of bullae in the apical sections and talcum powder pleurodesis. The air leak stopped and the drains were removed 3 days after surgery.

Drainage of the pleural cavity is one of the necessary methods of treating surgical diseases of the thoracic cavity. Placement of an intrapleural drain is often the first and main step in the treatment of pneumothorax, hemothorax, and pleural effusion. Errors and systematic misconceptions in such treatment often cost the patient’s life, therefore, in order to improve treatment results and the quality of life of patients, it is necessary to conduct new research, study the respiratory mechanics of a patient with surgical pathology of the chest organs and installed pleural drainage. The history of drainage of the pleural cavity generally reflects the history of all surgery, since discoveries in one area of surgery are inextricably linked with expanding understanding of problems in another area, in particular in thoracic surgery. In the domestic literature there are practically no publications devoted to drainage of the pleural cavity in a historical aspect. This article discusses the main types of drainage of the pleural cavity, described in the past and present, and how they were formed over time.

drainage

pleural cavity

thoracostomy

thoracentesis

1. Twenty-six years of experience with the modified Eloesser flap / V.H. Thourani // Ann. Thorac. Surg. – 2003. – Vol. 76, No. 2. – P. 401-405.

2. Chest Drainage Systems in Use / C. Zisis // Annals of Translational Medicine. - 2015. – Vol. 3. - 43 p.

3. Botianu P.V. Thoracomyoplasty in the Treatment of Empyema: Current Indications, Basic Principles, and Results / P.V. Botianu, M. Botianu // Pulmonary Medicine. - 2012. - Vol. 2012. doi:10.1155/2012/418514.

4. Monaghan S.F. Tube thoracostomy: the struggle to the “standard of care”/ S.F. Monaghan, K.G. Swan // Ann. Thorac. Surg. – 2008. – Vol. 86, No. 6. – P. 2019-2022.

5. Mohammed H.M. Chest tube care in critically ill patient: A comprehensive review // Egyptian Journal of Chest Diseases and Tuberculosis. - 2015. - Vol. 64, No. 4. - P. 849-855.

6. Chest Tubes: Generalities / F. Venuta // Thoracic Surgery Clinics. - 2017. - Vol. 27. - P. 1-5.

7. Chest drainage systems and methods. US 20130110057 A USA: A 61 M1 /0019 / Croteau J.; applicant and patentee James Croteau; stated 01/28/2011; published 05/02/2013.

8. Heimlich valve and pneumothorax / A. Gogakos // Annals of Translational Medicine. – 2015. – Vol. 3, No. 4. – P. 54.

9. Lai S.M. Outpatient treatment of primary spontaneous pneumothorax using a small-bore chest drain with a Heimlich valve: the experience of a Singapore emergency department / S.M. Lai, A.K. Tee // European Journal of Emergency Medicine. – 2012. – Vol. 19, No. 6. – P. 400–404.

10. Narasimhan A. Re-discovering the Heimlich valve: Old wine in a new bottle / A. Narasimhan, S. Ayyanathan, R. Krishnamoorthy // Lung India. - 2017. – Vol. 34, No. 1. - P. 70-72.

11. Joshi J.M. Ambulatory chest drainage // Indian J. Chest Dis. Allied Sci. – 2009. – Vol. 51, No. 4. – P. 225-231.

12. Initial experience with the world’s first digital drainage system. The benefits of recording air leaks with graphic representation / L. Dernevik // European Journal of Cardiothoracic Surgery. - 2007. – Vol. 31, No. 2. – P. 209-213.

13. Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection? - A prospective randomized trial / M. De Waele // Journal of Thoracic Disease. - 2017. - Vol 10. - P. 1598-1606.

14. Digital and Smart Chest Drainage Systems to Monitor Air Leaks: The Birth of a New Era? /R.J. Cerfolio // Thoracic Surgery Clinics. - 2010. - Vol. 20. - P. 413–420.

15. Outpatient thoracic surgical program in 300 patients: clinical results and economic impact / L. Molins // European Journal of Cardiothoracic Surgery. - 2007. - Vol. 29, No. 3. - P. 271-275.

Treatment of surgical diseases of the chest cavity is impossible to imagine without intrapleural drainage. Placement of an intrapleural drain is often the first and main step in the treatment of pneumothorax, hemothorax, and pleural effusion syndrome. This seemingly simple manipulation, at the same time, requires correct execution. surgical technique and creation operational access, adequate to the existing pathology and anatomy of an individual patient. Despite the fact that today this skill is considered one of the most frequently performed procedures for surgeons, issues related to the installation technique and management of patients with pleural drainage in the postoperative period are still controversial. However, errors and systematic errors when installing drainage into the pleural cavity and managing it in the postoperative period often cost the patient’s life. Therefore, it is still relevant to determine the design requirements for drainage and the method of removing exudate, creating a vacuum in a closed drainage system and the pleural cavity, which in turn makes necessary new research, studying the respiratory mechanics of a patient with surgical pathology of the chest organs and installed pleural drainage.

We can conditionally divide the types of drainage of the pleural cavity according to the methods of creating conditions for the outflow of fluid and air: open, valve, passive-gravity using a “water lock”, aspiration with the creation of active aspiration and combined.

The earliest known scientific description of the use of drainage of the pleural cavity in the treatment of surgical diseases of the chest organs belongs to Hippocrates. This is described in his writings on the treatment of "empyema". Hippocrates proposed using tin tubes for this purpose, not only for outflow, but also for washing the cavity with heated wine and oil.

The open method of drainage of the pleural cavity, it would seem, for the most part has historical meaning. However, to date, thoracostomy and pleurostomy remain one of the successful options for organ-preserving staged surgical treatment of suppurative diseases. For a long time, thoracostomy was the only method of treating non-expandable lungs. The first description of drainage of the pleural cavity by creating an opening in the chest is given by Mitchell in Medicine in the Crusades during the first crusades. To evacuate pus from the pleural cavity after a chest injury, thoracentesis using a spear was used without installing a drainage tube into the wound canal. Currently, open drainage of the pleural cavity is found in a limited form of pleurostomy using the methods of Eloesser (1935), in its modification from Symbas (1970), and pleurostomy according to Clagett (1971). In this case, it is important to see the difference in terminology in domestic and Western medical literature. “Pleurostomy” or “thoracostoma” most often in the understanding of domestic surgeons represents what in the West is called open window thoracostomy, namely the formation of a fairly wide non-physiological communication between the environment and the pleural or residual cavity through the chest wall with resection of one or more ribs to form access to the cavity for the purpose of sanitation. Pleurostomy or thoracostomy involves surgical access to the pleural cavity for the purpose of its sanitation. In our time of development of high-tech medical care, namely the advent of mechanical ventilation, fibrinolytics for intracavitary administration and minimally invasive interventions (videothoracoscopy), the formation of a pleurostomy has a narrow range of indications: chronic pleural empyema with or without the presence of bronchopleural messages in the absence of effectiveness of closed drainage in case of insufficiency in the patient physiological reserves for radical surgical intervention in the scope of decortication, lung resection, pleurectomy.

Removal of exudate by puncture of the pleural cavity through the intercostal space with a thick hollow needle was proposed by Boerhaave in 1873. He successfully performed it for penetrating chest wounds.

The first possibility of using the water-seal principle was described by Playfair in 1873, who successfully used it in the treatment of acute pleural empyema in a child using transthoracic installation of drainage into the pleural cavity. The essence of the water lock is that a tube from the patient (proximal) is lowered into the container through a sealed lid on one side almost to the bottom of the vessel, while there is an additional tube (distal) that passes through the lid, but does not reach the bottom, but barely extends down from the lid. At the bottom of the vessel is a small amount of aseptic non-alcohol solution (3-5 cm above the bottom), the proximal tube with its end located below the surface of the liquid. Drainage is carried out under the influence of gravity, so the vessel with a water lock should always be located below the chest relative to the horizon. Due to the law of communicating vessels, liquid from the upper vessel (pleural cavity) will flow into the lower one (container with a water lock). When positive pressure appears in the pleural cavity (for example, when coughing, forced exhalation), air comes out through the distal tube, and when inhaling (increasing vacuum in the pleural cavity), air cannot get back in due to the force of attraction, which does not allow the solution to let air back in.

In 1875, Gotthard Bülau not only introduced the still used method of draining the pleural cavity with a water lock, but also drew attention to great danger respiratory complications associated with drainage of pleural empyema in the form of open pneumothorax, although most surgeons of that time associated the high mortality rate in this disease with the manifestations infectious process in the easiest way. He proved the effectiveness of active aspiration of pathological contents from the pleural cavity to expand the lung in order to restore its function even before opening x-rays and widespread x-ray diagnostics.

During the influenza epidemic in 1918, the frequency of complications of pneumonia in the form of recurrent exudative pleurisy and acute pleural empyema increased significantly. The main treatment method for these complications at that time remained surgical resection ribs with installation of pleural drainage without using a water lock and active aspiration (Fig. 1). This undoubtedly led to high mortality, with death often occurring within the first 30 minutes after access was created (up to 30%). The reason for this was the lack of understanding of respiratory mechanics, namely, what happens in the pleural cavity under normal conditions and pathology.

By and large, the principles of treatment of pleural empyema during this epidemic differed little from those used at the end of the 19th century. But it is worth noting that if previously successful surgery chronic pleural empyema was caused by the formed shell of the visceral pleura and adhesions with the chest wall, which did not allow the lung to collapse, then in 1918, empyema against the background of pneumonia developed rapidly over several days and was acute, adhesion simply did not have time to form. In this regard, at the beginning of 1918, a surgical commission on the treatment of pleural empyema (Empyema Commission) was created in the United States. The result of her work was the substantiation of the need to prevent atmospheric air from entering the pleural cavity and maintaining a vacuum in it. Graham, an American surgeon, a member of this commission, was the first to identify and substantiate the relationship between the mortality of patients with drained pleural empyema and the activity of the adhesive process in the pleural cavity. He associated greater survival of patients with empyema caused by pneumococcus compared with patients with the same disease caused by hemolytic streptococcus. In the first case, pleural adhesions form earlier, which prevents the collapse of the lung during drainage of the pleural cavity and the subsequent compression of the superior vena cava and a decrease in tidal volume, which leads to death. In this case, the use of active aspiration was reduced to the use of a conventional syringe. Nevertheless, as a result of the work of this commission, mortality after drainage was reduced from 30% to 4.3%.

Rice. 1. Drainage of the pleural cavity for empyema during the influenza epidemic in 1918 (materials of the commission on the treatment of pleural empyema)

The use of closed drainage of the pleural cavity, as well as the use of active aspiration in the postoperative period after resection operations on the lungs, was introduced thanks to Lilienthal and Brunn in 1929.

It is worth noting that the method of using a water lock for drainage of the pleural cavity and aspiration is not widely used for the treatment of penetrating wounds and closed injuries chest, which did not lead to a decrease in mortality among victims and wounded during the world wars. Thus, even during the Second World War and the Korean War, in most cases with gunshot wounds of the chest, removal of blood and air from the pleural cavity was used using thoracentesis through a needle using aspiration. So, one patient could undergo 60 pleural punctures in 2 months! . Drainage by installing an intrapleural drainage tube with a water lock continued to be used only in the formation of pleural empyema after the addition of a secondary infection at the site of lung injury or the introduction of foreign bodies.

Closed drainage of the pleural cavity using silicone tubular drainage and a sealed suction system for injuries to the chest organs has become routine practice only since the late 50s of the 20th century. Thus, Maloney in a study about conservative treatment hemothorax (traumatic and postoperative) proved that thoracentesis with installation of a catheter with a diameter of 13-14 Fr into the pleural cavity gives results comparable to surgical lung decortication.

Over time, approaches to the use of a water lock in drainage of the pleural cavity have changed. If Bülau proposed using only one glass bottle, combining a water lock and a container for collecting exudate, then later two- and three-component systems appeared (Fig. 2). The reason for this was the development of anesthesiology and the creation of effective ventilators that make it possible to perform resection operations on the lungs, after which, as is known, there is a high probability of prolonged release of air, and the phenomenon of bubbling is possible and the contents of the container are thrown directly into the vacuum source, after which a release is possible contents outside the system, which in itself can lead to the elimination of the water lock. The two-can system consists of two glass or plastic containers connected in series to the drainage of the pleural system, to each other and to a vacuum source, if any. In this case, the first jar after drainage is empty and is necessary for collecting exudate; the second jar already contains a water lock. The three-vessel system was introduced by Deknatel in 1967 and features an additional can (at the distal end of the system) which is necessary to control the vacuum. This is done as follows: the jar also has a proximal end connected by a pipe to the jar with a water lock, and a distal end connected to a vacuum source; in addition, in the sealed lid there is another solid glass or plastic tube, lowered at one end almost to the bottom of the vessel , while others are open to the atmosphere. There is also liquid at the bottom of the vessel, but its level can be controlled through the middle dense tube; as the volume of liquid in the vessel increases, the level of vacuum in the system decreases accordingly. The disadvantages of all these systems are their strict dependence on gravity. Such a system cannot only be raised above chest level, but also tilted, which undoubtedly limits the patient’s mobility. With a massive air discharge, the “bubbling” phenomenon has a fairly loud sound, which is very annoying for patients and prevents them from resting.

Rice. 2. Systems for drainage of the pleural cavity with a water lock:

A - one-component, B - two-component, C - three-component

To eliminate these disadvantages, the three-component system is currently produced in the body of one device, which is undoubtedly convenient, but increases the cost of this device. Such a device is, for example, Atrium (Oasis, USA). In this case, the first (“proximal vessel”) has a rectangular shape, stands on the narrow side and is divided into 4 chambers communicating with each other in upper section. The second chamber (water lock) is connected to the first in its lower part from the distal end and, just like in the classic version, requires filling with liquid. The third chamber (“distal”) is similar in structure to the classic version, located above the second and also requires filling with liquid. All cameras are located in one transparent housing, which makes it easy to determine the volume of removed exudate and the presence of air discharge.

Currently relevant is the use of systems for the so-called dry drainage of the pleural cavity (dry suction), such as Pleur-evac (Sahara, USA). In this case, instead of a water lock on the line after the assembly container, there is a one-way valve that opens towards the source or atmosphere, thereby preventing air from entering back into the pleural cavity. Such a device is less dependent on gravity, since there is no need to keep it constantly in vertical position to avoid "splashing" of the water lock.

With “dry aspiration”, modifications of the aspiration mode are also possible, such as those presented in the Croteau patent. The aspirator operates in two modes. The first mode is a constant vacuum level, adjustable as needed to a certain value in various clinical situations. The second mode, with a higher level of vacuum, begins to work when the pressure changes between the distal and proximal sections of the drainage tube, in which two pressure sensors are respectively installed, for example, by more than 20 mm of water. Art. (this parameter is configurable). This helps eliminate drainage obstruction and improve its function in the future. Also, with this method, the described aspirator is capable of independently counting the frequency of respiratory movements and giving a signal (including sound) medical personnel with significant changes. The disadvantage of this method is the lack of association with the act of breathing, which can cause erroneous determination emergency situation when the lung is sucked in at full expansion while inhaling.

One of the simplest methods for draining the pleural cavity is the Heimlich valve method using his invention (Heilmich valve or flutter valve), patented in 1965. This device is a rubber valve enclosed in a cylindrical container that has two outlets: to the outer end of the chest tube and to the environment or container (Fig. 3). A rubber cylindrical valve is placed on the proximal end "from the drain". When inhaling, the rubber valve collapses due to suction through the drainage, preventing air from flowing back into the pleural cavity. When you exhale, air from the pleural cavity comes out due to the pressure created by the respiratory muscles on the chest cavity and opening the valve petals. The advantages of this method are ease of use, the possibility of application on prehospital stage, mobility of the wounded patient, possibility of use even with prolonged air release, possibility of use without a liquid container for spontaneous pneumothorax, while the distal end of the device can always be attached to the container. The device can be rationally used as an opportunity for outpatient treatment thoracic patients. According to Lai, in case of spontaneous pneumothorax in case of expansion of the lung after installation of a small-diameter drainage tube (8 Fr) with a Heimlich valve, patients can be discharged for outpatient treatment under dynamic observation 24-72 hours after the procedure. The limited use of the Heimlich valve is associated with the inability to evacuate fluid in larger volumes than during drainage of spontaneous pneumothorax, and the difficulty of taking into account the volume of air and exudate discharge. The only drawback that can lead to fatal outcome with the use of a Heimlich valve, the development of tension pneumothorax occurs when the valve is incorrectly installed in the pleural drainage with the distal end, which is why each product has a special marking.

Rice. 3. Heimlich valve

Despite the indicated disadvantages, the Heimlich valve continues to be used in practical medicine not only for drainage of pneumothorax, but even for the treatment of pleural empyema, in which exudation per day can reach a volume of up to 400-500 ml. In such cases, the Pneumostat device (Atrium, USA) is used, which is a Heimlich valve connected on the proximal side to pleural drainage, and on the distal side to a small transparent vessel that has a hole for draining fluid.

One of the options for the outflow and collection of exudate from the pleural cavity is flutter bags with a valve that opens towards the container bag, which prevents the contents from being thrown back into the drainage. The advantage in this case is the convenience of packaging the container, which is of no small importance for outpatient treatment and patient mobility. However, these bags are not applicable in cases where the patient needs to maintain a constant negative pressure above the physiological modulus in the pleural cavity, including when air is released and with viscous exudate, such as pus.

Lang et al. conducted a meta-analysis of studies that compared the results of treatment after resection of lung groups using active aspiration and without it, showed that the routine use of aspiration in the postoperative period has no advantages over gravity drainage, except in cases where air discharge through the drainage is maintained for more than 24 hours and with a non-expandable lung for more than 3 days.

A non-expandable lung, undoubtedly, in most cases requires more long-term treatment than during normal reparative processes in the pleural cavity and in the postoperative period. Treatment of such patients is costly, since, in addition to drug treatment, constant monitoring of the drainage system and dynamic X-ray monitoring are required, which often requires treatment in a specialized hospital and causes long-term disability. The use of advanced technologies in the field of monitoring the pleural cavity makes it possible to predict, promptly diagnose and prevent many postoperative complications.

Recording data on the dynamics of the process of drainage of the pleural cavity on digital media was one of the first to offer Dernevik. The DigiVent drainage system he studied includes two sensors (pressure and flow), which makes it possible to record the amount of discharge, the volume of air discharge through the drainage, and also records data on changes in vacuum set by the system operator. Early detection of massive air discharge, according to the author, contributes to the timely decision by the doctor to change the patient’s management tactics, reduce the time for taking corrective treatment measures and, accordingly, improve the quality of life and the possibility of early discharge of the patient from the hospital. Determining air leakage quantitatively allows us to determine the dynamics of the process, which is also important in changing the management tactics of such patients. A meta-analysis of six multicenter studies conducted by Cerfolio, in which patients after pulmonary resection were divided into two groups with analog and digital drainage systems, confirms the effectiveness of the latter, since in the study groups drainage was removed earlier in the postoperative period.

It is worth noting that the digital devices themselves, with their ability to dynamically change the vacuum applied to the pleural cavity, despite early detection air discharge, are not able to significantly affect the inflammatory process in the pleura and cannot reduce or increase exudation. This was described in a study by De Waele comparing two groups of patients who underwent pulmonary resection for lung cancer. In the first group, the postoperative period included the use of the “analog” Atrium drainage system, in the second group - the Thopaz digital drainage system (Medela, USA). There were no significant differences between the groups in the volume and persistence of exudation in the postoperative period, while significantly less air discharge persisted in the group with a digital device.

Currently, the most commonly used digital devices are Atmos, Atrium and Thopaz, which also determine changes in intrapleural pressure and quantitative air release. The use of these devices allows for safe clinical researches with analysis of pleural manometry, which can also be considered an advantage of using this technique.

In many medical centers Ambulatory thoracic surgery is actively developing around the world. Currently, it has become technically possible to manage thoracic patients with drainage of the pleural cavity with reliable monitoring of the processes occurring in the pleural cavity, including taking into account the discharge, the volume of air discharge, and the pressure in the pleural cavity. Thus, in a study by Laureano Molins et al. 300 outpatients who underwent various endosurgical interventions (lung biopsy, mediastinoscopy, bilateral sympathectomy) took part. The study used devices for drainage of the pleural cavity with digital control, which made it possible to predict earlier possible complications and build the necessary tactics.

Thus, despite significant improvements in technology, surgical instrumentation, and understanding of the physiology and pathology of the respiratory system, the use of pleural drainage to evacuate pathological contents remains the main way of managing thoracic surgical patients. However, the evolution of understanding the need for drainage and its methods makes it possible to reveal the features of the physiology and pathophysiology of the pleura and lung, which makes it possible to respond in a timely manner to changes in these organs and change medical tactics. Undoubtedly, new technologies and evidence-based medicine allow us to more accurately formulate the diagnosis and indications for drainage. The use of digital drainage systems in outpatient surgery will reduce treatment costs, reliably determine the dynamics of pleural repair, and speed up making the right decision. At the same time, the study of intrapleural pressure and its changes, as well as the dependence of changes in the composition of the exudate in the dynamics of the disease, is still relevant, which opens up wide scope for further research in thoracic surgery.

Bibliographic link

Khasanov A.R. DRAINAGE OF THE PLEURAL CAVITY. PAST AND PRESENT // Modern problems of science and education. – 2017. – No. 6.;
URL: http://science-education.ru/ru/article/view?id=27332 (access date: 12/12/2019). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"