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STRAINED PNEUMOTHORAX

It arises in injury of trachea, large bronchi, multiple ruptures of pulmonary parenchyma. Pathogenesis:

1. A pain syndrome sharply limits movements of the chest, aggravates ventilation and leads to shock.

2. Floatation of mediastinum leads to a decrease of venous return and formation of small ventricular ejection syndrome.

3. In inspiration, C0₂ saturated air from the collapsed lung is carried away with a stream of fresh atmospheric air into the healthy lung. In expiration, the air from the healthy lung partially enters the collapsed lung.

Clinical picture

There are pain in the chest and tachypnea (shallow). Skin cyanosis, cold sweat, tachycardia, arterial hypotension are determined. The affected half of the chest lags behind or does not take part in the act of respiration. The subcutaneous emphysema is also noted. Patient's breathing is not auscultated, but while percussion a bandbox sound is determined. Boundaries of cardiac dullness are shifted to the healthy side.

With each inspiration patient's general state is being progressively aggravated.

Intensive therapy

The principal task is elimination of pneumothorax and control of pain syndrome.

1. Puncture and drainage of pleural cavity are carried out with active aspiration of air from it.

2. Analgesia. Regional anesthesia is used, more rarely narcotic analgetics (they inhibit respiratory center).

3. Antishock therapy.

Status asthmaticus. It is a grave, patient's life threatening complication of bronchial asthma (a state of growing bronchial obstruction in which disorders of gas exchange and respiration are progressing, traditional medicamentous

methods of treatment become ineffective, secondary changes of hemodynamics and psychoemotional disorders develop).

Diagnosis of status asthmaticus is established on the basis of the following symptoms:

1. Duration of bronchial asthma attack (from a few hours to several days and weeks) with short lucid intervals.

2. Ineffectiveness of adrenomimetic agents.

3. Syndrome of "silent lung".

4. Diffuse cyanosis.

5. Disorders (depression) of consciousness.
Pathogenesis of obstructive syndrome.

1. Hypersecretion of mucus, dyscrinism and obturation of bronchi.

2. Bronchospasm.

3. Inflammatory (chronic inflammation) edema of mucous membrane of the bronchi.

4. Hypoxemia-hypercapnia, spasm of pulmonary vessels.

5. Acute right ventricular failure.

6. General dehydration.

7. Pachyemia, polycytemia, microcirculatory disorder.

8. DIC-syndrome.

Knowledge of the basic elements of obstructive syndrome is necessary for carrying out pathogenetic intensive therapy and respiratory support.

3 stages are distinguished in the course of status asthmaticus (Yurenev).

1 stage — is that of subcompensation: attacks of asphyxia become more
frequent, pronounced tachypnea, sonorous, sibilant rales are heard at a distance,
psychoemotional excitation, insignificant cyanosis, dryness of skin, decrease
of sputum discharge.

There are dry rales in auscultation of the lungs. "Mottling" of percussion sound (areas of tympanitis are alternated with the areas of dullness) is defined on percussion. AP is up to 180/130 mm Hg, HR — up to 140 beats per min. Pa0₂ — 70-60 mm Hg, PaC0₂ — 35^5 mm Hg.

2 stage is that of decompensation with pronounced pulmonary obstruction:
cough decreases, discharge of sputum stops, tachypnea is intensified.

Cutaneous coverings are grey-cyanotic with subsequent development of diffuse cyanosis.

There is a syndrome of "silent lung" on auscultation of the lungs. On percussion a symptom of emphysema (tympanitis) disappears — a sign of atelectasis of alveoli.

Pulse is rapid and thready. AP — arterial hypotension. Pa0₂ — 59-50 mm Hg, PaC0₂ — 50-70 mm Hg.

3 stage is hypercapnic coma: bradypnea develops on the background of the
"silent lung" syndrome. Consciousness — coma. Diffuse cyanosis. There is

the "silent lung" syndrome upon auscultation. Excursion of the lungs is absent. AP— hypoxic collapse. HR — tachycardia, arrhythmia, pulse is thready.

This stage is estimated as preagony, and quite often as agony.

Treatment of status asthmaticus.

1. Dilution and evacuation of sputum (infusion therapy — 3000-3500 ml/day. Under CVP control; bronchoscopy or sanitation of tracheobronchial tree through the intubation tube with active tapping massage.

2. Removal of bronchospasm and inflammatory edema from bronchial mucous membrane (prednisolon up to 1000 mg/day, calcium blockers — verapamil, epidural anesthesia, fluothane narcosis, euphilline).

3. Correction of respiratory hypoxemia (inhalation of 30-50% 0₂ mixture at the rate of 5 1/min. A respiratory support — traditional APV with inspiratory pause and inspiration/expiration ratio— 1:1.5— 1:1, PPEE — 7-10 mm water column and more). Indications for APV are:

1. Appearance of coma precursors (sleepiness, mental confusion);

2. Addition of growing on hypercapnea (Pa0₂ — 50 mm Hg, PaC0₂ — 70 mm Hg) to hypoxemia.

3. Inefficiency of all other measures.

4. Correction of disturbed microcirculation and DIC-syndrome
(rheopoliglucin, trental, heparin or fraxiparine).

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