自发性气胸的诊治策略46727.ppt

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1、袖手旁观袖手旁观 还是还是 动手插管动手插管气胸气胸(q xin)(q xin)(q xin)(q xin)诊疗的策略及细节诊疗的策略及细节2022年2月28日星期一第一页，共三十二页。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？疑心气胸拍胸片，吸气相还是(hi shi)呼气相？气胸压缩率如何估算？大量/小量？问题(wnt)1-7第二页，共三十二页。氧疗为什么能够加快气胸的吸收？何谓“危险三角/“平安三角？胸腔闭式引流需要常规负压吸引吗？如何(rh)尽量防止皮下气肿的产生？拔除胸管前必

2、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(wnt)8-14第三页，共三十二页。交通交通(jiotng)(jiotng)性性气胸气胸(q xin)(q xin)闭合性闭合性张力性张力性气胸(q xin)(q xin)的临床分类 根据破口情况及胸腔压力的不同第四页，共三十二页。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(q xin)(q xin)的病因学分类 第五页，共三十二页。自发性气胸(q xin)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

3、肺大疱 继发性SSP存在根底肺部疾病，老年人多见COPD继发气胸，死亡率明显(mngxin)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.第六页，共三十二页。吸烟(x yn)(x yn)对气胸的影响吸烟者气胸风险明显增高12%VSVS 0.1%可能与小气可能与小气(xio qi)(xio qi)道炎症有关道炎症有关BTS推荐 Strong emphasis should be pla

4、ced on Strong emphasis should be placed on smoking smoking cessationcessation to minimise the risk of to minimise the risk of recurrence.(D)recurrence.(D)Bense L,et al.Chest 1987.Bense L,et al.Chest 1987.MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第七页，共三十二页。医源性气胸(q xin)Iatrogenic pneumot

5、horaxBritten S,et al.Britten S,et al.InjuryInjury 1996.1996.第八页，共三十二页。稳定型气胸(q xin)(q xin)呼吸频率24次/分心率=60-120次/分血压正常(zhngchng)(zhngchng)吸入空气，SaO290%两次呼吸间说话成句不能同时满足(mnz)(mnz)以上5项者，即为不稳定型Baumann MH,et al.Baumann MH,et al.ChestChest 2001.2001.第九页，共三十二页。胸片吸气(x q)(x q)相 or 呼气相？一项回忆性队列(duli)研究：Druda D,et al

6、.Emerg Med J 2022.Druda D,et al.Emerg Med J 2022.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(nr)(nr)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第十页，共三十二页。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=上部中点上部中点(zhn din)(zhn din)到肺的距到肺的距离离C=C=下

7、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cmCollins 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第十一页，共三十二页。Standard erect chest x-rays in inspiration are recommended for the initial diagnosis of pneumothorax,rather than expiratory films.(A)CT scanning is

8、recommended for uncertain or complex cases.(D)MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.BTS推荐(tujin)(tujin)吸气相胸片第十二页，共三十二页。气胸(q xin)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(dling)(dling)；从肺尖至胸腔从肺尖至胸腔顶顶部距离部距离3c

9、m3cm为为大量，大量，3cm3cm为为小量。小量。MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.Baumann MH,et al.Chest 2001.Baumann MH,et al.Chest 2001.第十三页，共三十二页。气胸(q xin)(q xin)大小的估算法MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.ACCP a3cm?ACCP a3cm?BTS b2cm?BTS b2cm?第十四页，共三十二页。左肺门高于右肺门RPARPA 成人成人(chng

10、 rn)(chng rn)气管分叉在气管分叉在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第十五页，共三十二页。应重视(zhngsh)临床病症BTS、BSP及ACCP比较，一致性仅47%判断为大量气胸(q xin)者：BTS 10%BSP 47%ACCP 49%BTS推荐In defining a management strateg

11、y,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 2022.Kelly AM,Druda D.Resp Med 2022.MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第十六页，共三十二

12、页。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(jl)(jl)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(jl)(jl)=1-2cm=1-2cm抽气抽气抽气抽气(chu(chu q

13、)q)16-18G16-18G2.5L2.5L成功成功成功成功2cm&2cm&气气气气促改善促改善促改善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第十七页，共三十二页。保守(boshu)(

14、boshu)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 may be Selected asymptomatic patients with a large PSP m

15、ay be managed by observation alone.(A)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(chng fn)(chng fn)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.Thorax 2022.MacDuff A,et al.Thorax 2022.Kelly AM,et al.Emerg Med J 2006.Kelly AM,et al.Emerg Med

16、J 2006.第十八页，共三十二页。ACCP反对细针穿刺(chunc)(chunc)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-bor

17、e(20 F)chest large-bore(20 F)chest drains and may be associated with reduced hospitalisation and length of drains and may be associated with reduced hospitalisation and length of stay.(A)stay.(A)Needle aspiration Needle aspiration should not be repeated should not be repeated unless there were techn

18、ical unless there were technical difficulties.(B)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 p

19、neumothorax.(D)for pneumothorax.(D)Baumann MH,et al.Chest 2001.Baumann MH,et al.Chest 2001.MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.细针穿刺(chunc)(chunc)or 胸腔插管？第十九页，共三十二页。危险三角(snjio)&平安三角 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 海绵海绵(himin)(himin)窦交通窦交通 肌肉较为薄弱肌肉较为薄弱 血管、神血管、神经经束

20、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第二十页，共三十二页。BTS推荐(tujin)(tujin)Suction should Suction should not be routinely not be routinely employed.(B)employed.(B)Caution is required because of the risk of Caution is required because of the risk of RPO.(B)RPO.(B)Hig

21、h-volume low-pressure suction systems(-10-High-volume low-pressure suction systems(-10-20 cmH20 cmH2 2O)are recommended.(C)O)are recommended.(C)MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.Chest drain不需常规负压(f y)(f y)吸引第二十一页，共三十二页。气胸(q xin)(q xin)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

22、大疱气胸气胸气胸气胸R RL L第二十二页，共三十二页。尽量防止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(tngchng)(tngchng)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，如机械通气，检查检查并并调节调节有关参数有关参数CXR/CT评价引流管位置及胸肺情况 第二十三页，共三十二页。拔管前需常规(chnggu)(chnggu)夹管吗？ACCP不建议53%of panel members would never clamp a chest tube to detect the presence

23、of an air leak.The remaining panel members would clamp the chest tube approximately 4h.BTS未提及(t j)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.Baumann MH,et al.Chest 2001.MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第二十四页，共三十二页。拔管在 吸气(x q)(x q)末 or 呼气末？吸气末：肺复

24、肺复张张程度最大，胸腔程度最大，胸腔间间隙隙(jin x)(jin x)最小最小呼气末：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.Baumann MH,et al.Chest 2001.MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第二十五页，共三十二页。吸气吸气吸气吸气(x q)(x q)末末末末负压负压最大最大最大最大呼气呼气呼气呼气(h q)(h q)末末末末负压负压最小最小最小最小Intrapleural pressure:Intrapleural

25、pressure:Always negative compared with the atmosphereAlways negative compared with the atmosphere(-3.4-8 cmH(-3.4-8 cmH2 2O)O)第二十六页，共三十二页。Recurrent PTX EI 8%EE 6%p=1.0第二十七页，共三十二页。气胸(q xin)(q xin)与航空航空的风险：气压的上下变化(binhu)空中缺乏医疗救助There is no evidence that air travel precipitates PTX recurrence.Air trave

26、l should be avoided until full resolution.(C)MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第二十八页，共三十二页。Lippert 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 disease第二十九页，共三十二页。小结(xioji)(xioji)与展望指南间存在差异及争议，

27、有待统一近10年来高质量研究甚少，进展不大2022年BTS流程图简明扼要，有助于临床医生对气胸(q xin)诊治的掌握MacDuff A,et al.Thorax 2022.MacDuff A,et al.Thorax 2022.第三十页，共三十二页。Thanks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第三十一页，共三十二页。内容(nirng)总结袖手旁观 还是 动手插管气胸诊疗的策略及细节。袖手旁观 还是 动手插管气胸诊疗的策略及细节。何谓稳定型/不稳定型气胸。疑心气胸拍胸片，吸气相还是呼气相。拔管应该在吸气末/呼气末。气胸压缩率(%)=4.2+4.7(A+B+C)。口角平面(pngmin)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。胸腔内负压最小，与大气压力差最小。广州帽峰山天湖第三十二页，共三十二页。