自发性气胸的诊治策略课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,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,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,）,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,）,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的不同,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“健康”男青年,可能与肺组织生长发育落后有关,90%,患者肺尖部有胸膜下肺大疱,继发性,（,SSP,）,存在基础肺部疾病，老年人多见,COPD,继发气胸，死亡率明显升高,Donahue DM,et al.,Chest,1993.,Videm V,et al.,Eur J respire Dis,1987,.,吸烟对气胸的影响,吸烟者气胸风险明显增高,12%,VS,0.1%,可能与小气道炎症有关,BTS,推荐,Strong emphasis should be placed on,smoking cessation,to minimise the risk of,recurrence.(D),Bense L,et al.,Chest,1987.,MacDuff A,et al.,Thorax,2010.,医源性气胸,（,Iatrogenic pneumothorax,）,Britten S,et al.,Injury,1996.,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，,SaO,2,90%,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.,Chest,2001.,胸片吸气相,or,呼气相？,一项回顾性队列研究：,Druda D,et al.,Emerg Med J,2009.,呼气相气胸压缩率增,多,9%,纳入,44,例病人，,49,次,SP,发作,使用,Collins,方法计算压缩率,气胸压缩率,(%),=4.2+4.7(A+B+C),A=,胸腔顶到肺尖的距离,B=,上部中点到肺的距离,C=,下部中点到肺的距离,长度单位均为,cm,Collins method,Collins CD,et al.,Am J Roentgenol,1995.,后前位胸片,Standard 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.,Thorax,2010.,BTS,推荐吸气相胸片,气胸的大小,（,size of pneumothorax,）,计算法,Collins,方法,估算法,侧胸壁至肺边缘,1cm,，约,25%,；,侧胸壁至肺边缘,2cm,，约,50%,，即为大量；,从肺尖至胸腔顶部距离,3cm,为大量，,3cm,为小量。,MacDuff A,et al.,Thorax,2010.,Baumann MH,et al.,Chest,2001.,气胸大小的估算法,MacDuff A,et al.,Thorax,2010.,ACCP a3cm?,BTS b2cm?,左肺门高于右肺门,RPA,成人气管分叉在,T,5,-T,6,肺动脉是肺门最主要成分,右肺动脉顺着右主支气管,前下方,入肺，左肺动脉跨过左主支气管,后上方,入肺,一般左肺门比右肺门高,0.75-3cm,，约半个椎体,LPA,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,推荐,In defining a management strategy,the size of a PTX is,less important,than the degree of clinical compromise.(D),Breathlessness indicates the need for active intervention as well as supportive treatment.(D),Kelly AM,Druda D.,Resp Med,2008.,MacDuff A,et al.,Thorax,2010.,自发性气胸,如为双侧或血流动力学不稳定，即行胸腔插管,年龄,50,岁,&,大量吸烟史,有潜在肺部疾病,原发性气胸,继发性气胸,是,否,距离,2cm,和,/,或,气促,距离,=1-2cm,抽气,16-18G,2.5L,成功,2cm&,气促改善,考虑出院,2-4wks,门诊复查,入院,氧疗,+,观察,成功,1cm,是,是,否,是,抽气,16-18G,2cm,和,/,或,气促,否,是,是,否,否,Flowchart of,management of SP,保守治疗,BTS,推荐,Observation is the treatment of choice for small PSP without signicant breathlessness.(B),Selected asymptomatic patients with a large PSP 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,胸腔气体主要成分为氮气,氧疗提高血液氧分压，降低氮气分压，增加梯度,MacDuff A,et al.,Thorax,2010.,Kelly AM,et al.,Emerg Med J,2006.,ACCP,反对细针穿刺,found simple aspiration to be appropriate,rarely,in any clinical circumstance,BTS,推荐,Needle(14-16 G)aspiration is,as effective as,large-bore(20 F)chest drains and may be associated with reduced hospitalisation and length of stay.(A),Needle aspiration,should not be repeated,unless there were technical difculties.(B),Following failed NA,small-bore(14 F),chest drain insertion is recommended.(A),Large-bore chest drains are,not needed,for pneumothorax.(D),Baumann MH,et al.,Chest,2001.,MacDuff A,et al.,Thorax,2010.,细针穿刺,or,胸腔插管,？,危险三角,&,安全三角,口角平面以上面静脉常无静脉瓣,面静脉可经多条静脉与 海绵窦交通,肌肉较为薄弱,血管、神经束少，手术损伤较小,腰大肌肌前缘,胸大肌外缘,乳头水平线,腋窝,BTS,推荐,Suction should,not be routinely,employed.(B),Caution is required because of the risk of RPO.(B),High-volume low-pressure suction systems(-10-20 cmH,2,O)are recommended.(C),MacDuff A,et al.,Thorax,2010.,Chest drain,不需常规负压吸引,气胸与皮下气肿,胸水,Chest tube,肺大疱,气胸,R,L,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,拔管前需常规夹管吗？,ACCP,不建议,53%of panel members,would never clamp,a chest tube to detect the presence of an air leak.,The remaining panel members would clamp the chest tube approximately 4h.,BTS,未提及,国内,多主张,夹管,第,7,版,内科学,：夹管,24-48h,夹管后应密切观察病情,如有气促，应立即开放引流,Baumann MH,et al.,Chest,2001.,MacDuff A,et al.,Thorax,2010.,拔管在 吸气末,or,呼气末？,吸气末：,肺复张程度最大，胸腔间隙最小,呼气末：,胸腔内负压最小，与大气压力差最小,BTS,与,ACCP,皆未提及,Baumann MH,et al.,Chest,2001.,MacDuff A,et al.,Thorax,2010.,吸气末负压最大,呼气末负压最小,Intrapleural pressure:,Always negative compared with the atmosphere(-3.4-8 cmH,2,O),Recurrent PTX EI,8%EE 6%,p,=1.0,气胸与航空,航空的风险：,气压的高低变化,空中缺乏医疗救助,There is,no evidence,that air travel precipitates PTX recurrence.,Air travel should be avoided,until full resolution,.(C),MacDuff A,et al.,Thorax,2010.,Lippert HL,et al.,Eur Resp J,1991.,Cumulative freedom,from PTX recurrence in relation to pre-existing lung disease,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.,Thorax,2010.,Thanks,广州帽峰山天湖,