自发性气胸的诊治策略课件

袖手旁观 还是 动手插管气胸诊疗的策略及细节2011年2月28日星期一袖手旁观 还是 动手插管气胸诊疗的策略及细节2011年2原发性自发性气胸好发于哪类人群？吸烟对气胸有无影响？怎样影响？在座各位有没读过中国气胸诊治指南？医源性气胸最常见于什么临床操作？何谓稳定型/不稳定型气胸？怀疑气胸拍胸片，吸气相还是呼气相？气胸压缩率如何估算？大量/小量？问题（1-7）原发性自发性气胸好发于哪类人群？问题（1-7）氧疗为什么能够加快气胸的吸收？何谓“危险三角”/“安全三角”？胸腔闭式引流需要常规负压吸引吗？如何尽量避免皮下气肿的产生？拔除胸管前必须夹管吗？拔管应该在吸气末/呼气末？气胸痊愈者，多久可以坐飞机？问题（8-14）氧疗为什么能够加快气胸的吸收？问题（8-14）交通性交通性气胸气胸闭合性闭合性张力性张力性气胸的临床分类 根据破口情况及胸腔压力的不同交通性气胸闭合性张力性气胸的临床分类 根据破口情况及胸腔压力自发性自发性气胸气胸创伤性创伤性医源性医源性原发性原发性继发性继发性气胸的病因学分类 自发性气胸创伤性医源性原发性继发性气胸的病因学分类 自发性气胸（spontaneous pneumothorax，SP）原发性（PSP）多见于瘦高多见于瘦高“健康健康”男青年男青年可能与肺组织生长发育落后有关可能与肺组织生长发育落后有关90%90%患者肺尖部有胸膜下肺大疱患者肺尖部有胸膜下肺大疱 继发性（SSP）存在基存在基础础肺部疾病，老年人多肺部疾病，老年人多见见COPDCOPD继发继发气胸，死亡率明气胸，死亡率明显显升高升高 Donahue DM,et al.Donahue DM,et al.ChestChest 1993.1993.Videm VVidem V,et al.et al.Eur J respire DisEur J respire Dis 1987 1987.自发性气胸（spontaneous pneumothora吸烟对气胸的影响吸烟者气胸风险明显增高12%12%VSVS 0.1%0.1%可能与小气道炎症有关可能与小气道炎症有关BTS推荐 Strong emphasis should be placed on Strong emphasis should be placed on smoking cessationsmoking cessation to minimise the risk of to minimise the risk of recurrence.(D)recurrence.(D)Bense L,et al.Bense L,et al.ChestChest 1987.1987.MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.吸烟对气胸的影响吸烟者气胸风险明显增高Bense L,et医源性气胸（Iatrogenic pneumothorax）Britten S,et al.Britten S,et al.InjuryInjury 1996.1996.医源性气胸（Iatrogenic pneumothorax稳定型气胸呼吸频率24次/分心率=60-120次/分血压正常吸入空气，SaO290%两次呼吸间说话成句不能同时满足以上5项者，即为不稳定型Baumann MH,et al.Baumann MH,et al.ChestChest 2001.2001.稳定型气胸呼吸频率24次/分不能同时满足以上5项者，即为不胸片吸气相 or 呼气相？一项回顾性队列研究：Druda D,et al.Druda D,et al.Emerg Med J Emerg Med J 2009.2009.呼气相气胸压缩率增呼气相气胸压缩率增多多9%纳入纳入纳入纳入4444例病人，例病人，例病人，例病人，4949次次次次SPSP发作发作发作发作使用使用使用使用CollinsCollins方法计算压缩率方法计算压缩率方法计算压缩率方法计算压缩率胸片吸气相 or 呼气相？一项回顾性队列研究：Druda D气胸气胸压缩压缩率率(%)(%)=4.2+4.7(A+B+C)=4.2+4.7(A+B+C)A=A=胸腔胸腔顶顶到肺尖的距离到肺尖的距离B=B=上部中点到肺的距离上部中点到肺的距离C=C=下部中点到肺的距离下部中点到肺的距离长长度度单单位均位均为为cmcmCollins methodCollins CD,et al.Collins CD,et al.Am J Roentgenol Am J Roentgenol 1995.1995.后前位胸片后前位胸片后前位胸片后前位胸片气胸压缩率(%)=4.2+4.7(A+B+C)ColliStandard erect chest x-rays in inspiration are recommended for the initial diagnosis of pneumothorax,rather than expiratory films.(A)CT scanning is recommended for uncertain or complex cases.(D)MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.BTS推荐吸气相胸片Standard erect chest x-rays in气胸的大小（size of pneumothorax）计算法 CollinsCollins方法方法估算法侧侧胸壁至肺胸壁至肺边缘边缘1cm1cm，约约25%25%；侧侧胸壁至肺胸壁至肺边缘边缘2cm2cm，约约50%50%，即，即为为大量；大量；从肺尖至胸腔从肺尖至胸腔顶顶部距离部距离3cm3cm为为大量，大量，3cm3cm为为小量。小量。MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.Baumann MH,et al.Baumann MH,et al.Chest Chest 2001.2001.气胸的大小（size of pneumothorax）计算气胸大小的估算法MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.ACCP a3cm?ACCP a3cm?BTS b2cm?BTS b2cm?气胸大小的估算法MacDuff A,et al.Thor左肺门高于右肺门RPARPA 成人气管分叉在成人气管分叉在T T5 5-T-T6 6肺肺动动脉是肺脉是肺门门最主要成分最主要成分右肺右肺动动脉脉顺顺着右主支气管着右主支气管前下方前下方入肺，左肺入肺，左肺动动脉跨脉跨过过左主支气管左主支气管后上方后上方入肺入肺一般左肺一般左肺门门比右肺比右肺门门高高0.75-3cm0.75-3cm，约约半个椎体半个椎体LPALPA左肺门高于右肺门RPA 成人气管分叉在T5-T6LPA应重视临床症状BTS、BSP及ACCP比较，一致性仅47%判断为大量气胸者：BTS 10%BSP 47%ACCP 49%BTS 10%BSP 47%ACCP 49%BTS推荐 In defining a management strategy,the size of a In defining a management strategy,the size of a PTX is PTX is less important less important than the degree of clinical than the degree of clinical compromise.(D)compromise.(D)Breathlessness indicates the need for active Breathlessness indicates the need for active intervention as well as supportive treatment.(D)intervention as well as supportive treatment.(D)Kelly AM,Druda D.Kelly AM,Druda D.Resp Med Resp Med 2008.2008.MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.应重视临床症状BTS、BSP及ACCP比较，一致性仅47%自发性气胸自发性气胸自发性气胸自发性气胸如为双侧或血流动力学不稳定，即行胸腔插管如为双侧或血流动力学不稳定，即行胸腔插管如为双侧或血流动力学不稳定，即行胸腔插管如为双侧或血流动力学不稳定，即行胸腔插管年龄年龄年龄年龄5050岁岁岁岁&大量吸烟史大量吸烟史大量吸烟史大量吸烟史有潜在肺部疾病有潜在肺部疾病有潜在肺部疾病有潜在肺部疾病原发性气胸原发性气胸原发性气胸原发性气胸继发性气胸继发性气胸继发性气胸继发性气胸是是是是否否否否距离距离距离距离2cm2cm和和和和/或或或或气促气促气促气促距离距离距离距离=1-2cm=1-2cm抽气抽气抽气抽气16-18G16-18G2.5L2.5L成功成功成功成功2cm&2cm&气促改善气促改善气促改善气促改善考虑出院考虑出院考虑出院考虑出院2-4wks2-4wks门诊复查门诊复查门诊复查门诊复查入院入院入院入院氧疗氧疗氧疗氧疗+观察观察观察观察成功成功成功成功1cm1cm是是是是是是是是否否否否是是是是抽气抽气抽气抽气16-18G16-18G2.5L2cm2cm和和和和/或或或或气促气促气促气促否否否否是是是是是是是是否否否否否否否否Flowchart of Flowchart of management of SPmanagement of SP自发性气胸年龄50岁&大量吸烟史原发性气胸继发性气胸是否距保守治疗BTS推荐 Observation is the treatment of choice for small Observation is the treatment of choice for small PSP without significant breathlessness.(B)PSP without significant breathlessness.(B)Selected asymptomatic patients with a large PSP Selected asymptomatic patients with a large PSP may be managed by observation alone.(A)may be managed by observation alone.(A)气胸吸收率1.25-2.2%，平均1.5%/天氧疗可促进气胸吸收 胸腔气体主要成分胸腔气体主要成分为为氮气氮气 氧氧疗疗提高血液氧分提高血液氧分压压，降低氮气分，降低氮气分压压，增加梯度，增加梯度 MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.Kelly AM,et al.Kelly AM,et al.Emerg Med J Emerg Med J 2006.2006.保守治疗BTS推荐 MacDuff A,et al.ThACCP反对细针穿刺 found simple aspiration to be appropriate found simple aspiration to be appropriate rarelyrarely in any clinical in any clinical circumstancecircumstanceBTS推荐 Needle(14-16 G)aspiration is Needle(14-16 G)aspiration is as effective as as effective as large-bore(20 large-bore(20 F)chest drains and may be associated with reduced F)chest drains and may be associated with reduced hospitalisation and length of stay.(A)hospitalisation and length of stay.(A)Needle aspiration Needle aspiration should not be repeated should not be repeated unless there were unless there were technical difficulties.(B)technical difficulties.(B)Following failed NA,Following failed NA,small-bore(14 F)small-bore(14 F)chest drain insertion is chest drain insertion is recommended.(A)recommended.(A)Large-bore chest drains are Large-bore chest drains are not needed not needed for pneumothorax.(D)for pneumothorax.(D)Baumann MH,et al.Baumann MH,et al.Chest Chest 2001.2001.MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.细针穿刺 or 胸腔插管？ACCP反对细针穿刺Baumann MH,et al.C危险三角&安全三角 口角平面以上面静脉常无静脉瓣口角平面以上面静脉常无静脉瓣 面静脉可经多条静脉与面静脉可经多条静脉与 海绵窦交通海绵窦交通 肌肉较为薄弱肌肉较为薄弱 血管、神血管、神经经束少，手束少，手术损伤较术损伤较小小腰大肌肌前腰大肌肌前腰大肌肌前腰大肌肌前缘缘胸大肌外胸大肌外胸大肌外胸大肌外缘缘乳乳乳乳头头水平水平水平水平线线腋腋腋腋窝窝危险三角&安全三角口角平面以上面静脉常无静脉瓣肌肉较为薄弱腰BTS推荐Suction should Suction should not be routinely not be routinely employed.employed.(B)(B)Caution is required because of the risk of Caution is required because of the risk of RPO.(B)RPO.(B)High-volume low-pressure suction High-volume low-pressure suction systems(-10-20 cmHsystems(-10-20 cmH2 2O)are O)are recommended.(C)recommended.(C)MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.Chest drain不需常规负压吸引MacDuff A,et al.Thorax 2010.气胸与皮下气肿胸水胸水胸水胸水Chest tubeChest tube肺大疱肺大疱肺大疱肺大疱气胸气胸气胸气胸R RL L气胸与皮下气肿胸水Chest tube肺大疱气胸RL尽量避免皮下气肿切口勿过大，1.5-2倍引流管直径缝合勿过浅，尽量全层缝合检查引流管深度，注意侧孔位置检查引流系统是否通畅是否为疾病本身因素所致如气促明显，应排除张力性气胸如机械通气，检查并调节有关参数CXR/CT评价引流管位置及胸肺情况 尽量避免皮下气肿切口勿过大，1.5-2倍引流管直径拔管前需常规夹管吗？ACCP不建议 53%of panel members 53%of panel members would never clamp would never clamp a a chest tube to detect the presence of an air leak.chest tube to detect the presence of an air leak.The remaining panel members would clamp the The remaining panel members would clamp the chest tube approximately 4h.chest tube approximately 4h.BTS未提及国内多主张夹管第第7 7版版内科学内科学：夹夹管管24-48h24-48h夹夹管后管后应应密切密切观观察病情察病情如有气促，如有气促，应应立即开放引流立即开放引流 Baumann MH,et al.Baumann MH,et al.Chest Chest 2001.2001.MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.拔管前需常规夹管吗？ACCP不建议Baumann MH,e拔管在 吸气末 or 呼气末？吸气末：肺复肺复张张程度最大，胸腔程度最大，胸腔间间隙最小隙最小呼气末：胸腔内胸腔内负压负压最小，与大气最小，与大气压压力差最小力差最小BTS与ACCP皆未提及 Baumann MH,et al.Baumann MH,et al.Chest Chest 2001.2001.MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.拔管在 吸气末 or 呼气末？吸气末：Baumann MH,吸气末吸气末吸气末吸气末负压负压最大最大最大最大呼气末呼气末呼气末呼气末负压负压最小最小最小最小Intrapleural pressure:Intrapleural pressure:Always negative compared with the atmosphereAlways negative compared with the atmosphere(-3.4-8 cmH(-3.4-8 cmH2 2O)O)吸气末负压最大呼气末负压最小Intrapleural preRecurrent PTX EI Recurrent PTX EI 8%EE 6%8%EE 6%p p=1.0=1.0Recurrent PTX EI 8%气胸与航空航空的风险：气气压压的高低的高低变变化化空中缺乏医空中缺乏医疗疗救助救助There is no evidence that air travel precipitates PTX recurrence.Air travel should be avoided until full resolution.(C)MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.气胸与航空航空的风险：MacDuff A,et al.TLippert HL,et al.Lippert HL,et al.Eur Resp J Eur Resp J 1991.1991.Cumulative freedom from PTX recurrence in relation to pre-existing lung diseaseLippert HL,et al.Eur Resp J 小结与展望指南间存在差异及争议，有待统一近10年来高质量研究甚少，进展不大2010年BTS流程图简明扼要，有助于临床医生对气胸诊治的掌握MacDuff A,et al.MacDuff A,et al.Thorax Thorax 2010.2010.小结与展望指南间存在差异及争议，有待统一MacDuff A,广州帽峰山天湖广州帽峰山天湖广州帽峰山天湖广州帽峰山天湖Thanks广州帽峰山天湖