기흉 pneumothorax
1. pathophysicology
normal negative pressure : -5mmHg~8mmHg
visceral pleura의 break가 있으면 생김
Tension pneumothorax의 intrathoracic pressure는 15~20mmHg 증가된다.
2. clinical feature
sudden onset of dyspnea, ipsilateral, pleuritic chest pain.
Sinus tachycardia, ipsilateral decreased breath sounds, hyperresonance, absent tactile fremitus
tension pneumothorax - tracheal deviation, hyperresonance, hypotension, profound dyspnea
3. 진단
1) Chest xray PA+lat (pain방향)
+ 설수 없는 환자의 경우 Deep sulcus sign을 본다.
The deep sulcus sign on a supine chest radiograph raises suspicion of a pneumothorax.
The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign.
ddx. large bullae : 둥근 모양, single lobe / 기흉은 pleural line이 chest wall과 평행, multiple lobe
** apex에서 <3cm, hillum level에서 <2cm이면 small pneumothorax
2) US - traumatic 에서 본다.
comet tail, sliding sign, seashore
3) Chest CT
ddx. pulmonary belb : not visible on chest x-rays, but may be seen on the lung windows of CTs
Pulmonary blebs are small subpleural thin-walled air-containing spaces, not larger than 1 or 2 cm in diameter (with the precise limit varying by source). Their walls are less than 1 mm thick. If they rupture, they allow air to escape into the pleural space resulting in a spontaneous pneumothorax.
3. Treatment
# option : oxygen, observation, needle or catheter aspiration (either single or sequential aspirations), tube thoracostomy (either small-size or standard chest tube)
1) Oxygen : pleural air 흡수를 빠르게 함.
Recommended oxygen dosing ranges from 3 L/min by nasal cannula to 10 L/min by mask.
Monitor for hypercapnia in patients with chronic obstructive pulmonary disease.
2) Observation : small, stable pneumothorace인 경우
첫번째 발생 + spontaneous + <20% 기흉시 obser가 주로 이루어진다.
4시간 이상 관찰(우리는 6시간 함) + O2 -> Chest AP f/u
3) Aspiration or tube thoracostomy : 재발확률이 높을 경우
기저질환, Large(>2cm), with air leak, 기흉의 증가를 견딜 수 없는 경우(poor cardiopulmonary reserve)
- 14gauge needle / 2, 4th intercostal space 뼈 위를 따라서 / mid clavicular line (medial로 가면 mediastinal vessel injury)
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Chest xray PA+lat (pain방향) / O2 3L NP -> CTD insertion 필요한 경우 LAB 나가기 -> CTD
CTD 필요 없는 경우 no medi f/u
