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What is drainage of the pleural cavity? Spontaneous pneumothorax

Suction drainage is a fundamental intervention in the chest cavity. If this intervention is carried out carefully, then the possibility of postoperative complications is reduced to a minimum, and many serious, life-threatening diseases will be healed. If drainage is used incorrectly, recovery will not occur and septic complications may develop. The drainage-suction apparatus consists of a drainage tube, which is inserted into the pleural cavity, and a suction system connected to the drainage. The number of suction systems used is very large.

Suction tube

For suction drainage of the pleural cavity, various rubber and synthetic tubes are used.

For the most commonly used drainage, a rubber tube about 40 cm long with several side holes at the end is used. This tube is placed along the lung (from the base to the apex) and passed over the diaphragm from the pleural cavity to the outside. The drainage is attached to the skin with a knotted U-shaped suture. When the suction drain is removed, the threads are tied again, thereby sealing the hole in the chest. A three-barrel suction catheter (Viereck) is advantageous, allowing free passage of the tube inserted inside.

Insertion of suction drainage

In the chest between the two pleural layers, intrapleural pressure is lower than atmospheric pressure. If air or liquid gets between the pleural layers, then the normal physiological state can only be restored by long-term suction drainage. A closed drainage system is used to suction pleural fluid for recurrent pneumothorax and to treat empyema. This drainage is now usually inserted into the intercostal space through a trocar. The thickness of the drainage tube is determined in accordance with the consistency of the substance being sucked out (air, as well as watery fluid or serous, fibrinous, bloody, purulent fluid).

On the drainage, mark with paint or thread the place to which it will be inserted. The size of the trocar must correspond to the size of the drainage. It is advisable to have at least three trocars of different sizes with suitable tubes of 5, 8 and 12 mm in diameter. Before inserting the trocar, you must make sure that the selected drainage tube passes through it easily.

The site of the skin incision is filtered with novocaine to the pleura. A test puncture in the designated area makes sure that the desired air or liquid is really there. The assistant gives the patient the necessary position: the patient must sit and lean on the highly raised operating table so that the puncture area protrudes as much as possible and the selected intercostal space is, if possible, expanded. A scalpel is used to cut the skin over an area slightly larger than the size of the trocar. Then the trocar is inserted with a strong movement along the upper edge of the rib into the pleural cavity. After removal of the trocar, unimpeded release of fluid or free entry and exit of air indicates its correct insertion. Drainage is performed and the trocar tube is removed. If you are not convinced that the drainage is in the right place, you should, in order to prevent the trocar from puncturing the lung, heart or large vessel, perform the puncture again, taking all measures to localize it under X-ray control.

Before closing each thoracotomy hole, drainage is introduced into the pleural cavity, which is brought out above the diaphragm through a separate hole in the intercostal space. Through a hole about 1-2 cm in size, a forceps is inserted into the pleural cavity under the control of the eyes and under the protection of the left hand to ensure the correct position of the drainage from the inside. The drainage is pulled through the chest wall with a forceps from the inside to the outside. Pay attention to the fact that the drainage section, free from holes, is at least 5 cm in the chest cavity. If the fixation of the drainage to the skin is broken, then it slips out, and the first side hole appears outside the pleural cavity above the skin. In this case, the closed system turns into an open one, suction becomes ineffective, and pneumothorax often occurs.

Suction systems

There are so-called individual (“bed side”) and centralized suction systems. The suction action due to the hydrostatic effect can be obtained by a tube lowered under water, a water or gas pumping device (in this case the action is based on the valve effect) or an electric pump. Both individual and central systems must ensure individual regulation. If the release of air from the lung is insignificant, then due to its simplicity, the Biilau drainage system is still successfully used today, which can be sufficient to straighten the lung. A glass tube immersed under water (disinfectant solution) is equipped with a valve made from a finger cut off from a rubber glove, which prevents reverse suction. The Biilau system uses the physical law of communicating vessels to move bottles under the bed to create a suction effect.

The Fricar air pump best meets modern requirements. This device can work for many days without interruption and without heating up. The strength of the suction effect can be precisely adjusted.

Central suction devices are triggered by an oxygen canister system or a powerful suction pump. The system of outgoing tubes, if necessary, supplies hospital departments located on different floors. Depending on the need, the required number of hospital beds can be connected. An oxygen-powered system has the advantage that the suction and supply of oxygen to individual hospital beds is provided by the same tubing system. The suction effect is provided by a valve tube mounted along the oxygen flow. In this case, however, the effect produced by the central suction pump is not achieved.

Individual adjustment can be carried out using a dosimeter tap connected to a well-functioning pressure gauge, or through the so-called. three bottle system. The latter can be easily prepared by yourself. This system also has the advantage that it can easily and reliably create a very low suction effect (from 10 to 20 cm of water column). It is rarely possible to achieve such low pressure values ​​using factory pressure gauges.

Indications for suction drainage

Spontaneous and traumatic pneumothorax, hemothorax

Spontaneous pneumothorax occurs at a young age, more often as a result of rupture of single pulmonary alveoli in the apex of the lung, in older people - as a consequence of rupture of alveolar vesicles with diffuse emphysema. Due to the fact that the number of patients with emphysema is constantly increasing, the number of cases of spontaneous pneumothorax is becoming more frequent. The same applies to traffic accidents that result in closed injuries in the chest cavity, which often occur with pneumothorax or hemothorax.

Correctly performed pleural puncture for spontaneous pneumothorax is practically safe, and its benefits can hardly be disputed. If the flow of air from the damaged lung is completely stopped and the perforation site is closed, then it may be possible to completely remove the air that created the pneumothorax with a simple closed puncture. If pneumothorax recurs after puncture (even repeated), then drainage with long-term suction should be used. Recurrence of pneumothorax, even after prolonged drainage with suction, can only be reliably eliminated by surgery.

Traumatic pneumothorax most often results from rib fractures. When a rib fragment injures the lung, most often a significant amount of air comes out of it, and a tension pneumothorax occurs. At the same time, subcutaneous or even mediastinal emphysema may occur. Spontaneous pneumothorax can also occur when the pulmonary alveoli rupture or due to blunt force on an emphysematous lung. Therefore, in patients with pulmonary emphysema, chest injuries are often associated with the occurrence of pneumothorax, often severe tension pneumothorax. The principles of treatment for spontaneous and traumatic pneumothorax are the same.

If clinical symptoms indicate tension pneumothorax (severe respiratory failure, subcutaneous emphysema, mediastinal shift), then drainage of the pleural cavity should be performed immediately. If these symptoms are not present, then a closed puncture is performed and the air is sucked out. After this, the needle is left inserted into the pleural cavity, and its nozzle is connected to a pressure gauge and the pressure in the pleural cavity is determined (whether it is higher or lower than atmospheric). If the pressure in the pleural cavity is indicated by the pressure gauge needle in the positive direction, it means that air continues to be released into the pleural cavity, and, therefore, drainage is necessary. This issue can, of course, be resolved by X-ray examination. If there is a total pneumothorax, then drains are inserted in two different places. One of them runs along the posterior axillary line above the diaphragm in the VII-VIII intercostal space, the other is inserted along the midclavicular line between the 1st and 2nd ribs. In our experience, drainage inserted under the collarbone performs the task of straightening the apex of the lung better.

In case of encapsulated limited pneumothorax, drainage should be inserted locally, under X-ray control after a test puncture.

Empyema of the pleura

Pleural empyema is a disease for which treatment with suction from the pleural cavity is absolutely indicated.

The principle of treatment of empyema does not depend on the causative agent of the disease. It consists of gluing the pleural layers and eliminating the empyema cavity through early drainage and suction of fluid. Treatment with suction from the pleural cavity is combined with targeted local chemotherapy, based on the identification of the pathogen and its resistance to the drugs used. Most empyemas result from infection of the exudate. In this case, incorrect and insufficient suction from the pleural cavity plays a certain role. In cases where pockets with delimited fluid form in the pleural cavity, their complete emptying becomes increasingly difficult, more difficult, and infection is more likely. In such cases, complete recovery can only be ensured by surgery.

Suction treatment may fail for two reasons: one is the presence of pleural cords, the other is a bronchopleural fistula.

Pleural moorings are often the result of insufficient emptying of the pleural cavity. When moorings have already formed in the pleural cavity and the walls of the empyema cavity are thickened, there is little chance of eliminating the empyema by suctioning the fluid. The ability to expand the lung in this case is also very controversial. In this case, drainage with suction is a preparatory measure before the inevitable operation. Radical surgery (decortication) is performed only after the patient’s general condition has improved by washing the pleural cavity and targeted antibiotic therapy.

Bronchopleural fistula reduces the effectiveness of suction and thereby the prospect of lung expansion. In cases where there is a large bronchial fistula and its closure is contraindicated (for example, a rupture of the cavity, tumor disintegration, rupture of a cystic, emphysematous lung that has lost its elasticity), success cannot be expected from the use of suction. On the other hand, suction can also be used in cases where surgery is indicated. In elderly patients, with low general resistance and the possibility of severe complications, surgery becomes impossible. Then all that remains is to leave the patient with permanent drainage.

In case of chronic pleural empyema, drainage should be inserted into the pleural cavity at its lowest point. Large-diameter drains are used so that the thick liquid does not close the lumen and it is easy to wash the pleural cavity. Often, in the area where the drainage will be introduced, a rib resection (2-3 cm) is performed.

Postoperative suction from the pleural cavity

In order to remove fluid that accumulates after thoracotomy from the pleural cavity and maintain normal intrapleural pressure, a suction drain should be available.

If during pleural operations and mediastinal, transthoracic interventions on the esophagus, stomach, heart and large vessels there was no damage to the lung, then the chest can be closed with the introduction of one perforated drainage into the pleural cavity. Drainage is carried out above the diaphragm along the midaxillary line with its pleural end installed at the level of the apex of the lung.

Two drains are inserted into the pleural cavity if the lung was damaged during separation of adhesions, as well as after resection or excision of lung tissue. In such cases, one of the drains is inserted along the anterior and the second along the posterior axillary line. The use of a third drainage may be considered relatively appropriate when it is brought to the site of anastomosis of the esophagus or bronchus or when thoracoplasty is performed in combination with lung resection (for suction from the subscapular space).

After removing the lung, one drain with a diameter of 12-15 mm is inserted into the pleural cavity and placed in the lower part of the cavity so that a piece of drainage 10-12 cm long is equipped with 2-3 side holes. Active suction through this drain is prohibited.

After median sternotomy, a drainage is inserted retrosternally and its second end is brought out in the epigastrium.

Intensity and duration of suction

The intensity of suction through drainage from the pleural cavity depends on the cause of the disease, the condition of the lung and the nature of the operation. The flow of air from the lung into the pleural cavity is of decisive importance. If this occurs, then more air should be sucked out of the pleural cavity per unit time than is supplied there. Only in this way can gluing of the pleural layers be achieved. In practice, however, this is often not feasible. If the connection of the bronchus with the pleural cavity is significant (for example, in the case of a bronchial fistula), then intensive suction cannot achieve the goal. If you increase the suction force, then at the same time the patient will experience increased respiratory failure due to “air theft” from the tidal volume. Despite this, the lung will not be able to expand. In such cases, surgery is inevitable.

When the lung is damaged or after lung surgery, air most often escapes from a hole the size of a pinprick. In this case, specialized suction is indicated. In children and adolescents, due to the fact that their lung parenchyma is healthy and not affected by fibrosis and emphysema, it does not matter with what force the suction is performed. It doesn’t matter whether they suction with an intensity of 25 cm of water. Art. or simple underwater drainage, the lung will expand within 24-48 hours. The drainage can be removed after 48-72 hours. This is the advantage of elastic tissue capable of lung retraction in young patients. With emphysematous lung in an elderly person, the situation is different. The pinprick holes become gaping holes in the lung because the surrounding tissue is unable to contract. If you try to reduce the flow of air coming from the damaged lung by increasing the intensity of suction, you can easily get a paradoxical effect. The flow of air from the lung will increase. Small holes, due to prolonged suction, stabilize and turn into fistulas.

What to do in such cases? Begin gentle suction from the pleural cavity (5-6 cm of water) and pay attention to ensure that tension pneumothorax does not occur. Thanks to this, the resulting fibrin seals small holes in the lung. Within 24 hours, a decrease in air leakage from the damaged lung begins to be detected. The intensity of suction can be increased slightly. On the fourth day you can already suction with an intensity of 10 cm of water. Art., if no unforeseen complications arise, then the drainage can be removed on day 4-5.

The same principles are followed when treating spontaneous and traumatic pneumothorax with suction.

If there is a significant intake of air from the emphysematous lung, they begin to carefully perform suction with a gradual increase in its intensity. If, after many days of treatment with suction, the release of air from the lung does not stop, then it is recommended to immediately undertake surgery, without waiting for the development of infection in the pleural cavity. If suction from the pleural cavity continues for more than a week, the development of infection becomes real.

In cases where the patient does not undergo surgery due to low general resistance, suction from the pleural cavity remains to be continued. Prolonged and specialized suction under the guise of drug treatment may be more or less effective. The pleural layers are glued together completely or partially. Only small limited cavities remain that do not lead to complications. The drain can be removed.

In the treatment of pleural empyema, long-term use of suction drainage is a common method. The empyema cavity gradually becomes smaller and smaller, the amount of fluid decreases, and in the end it can become bacteriologically sterile. If the daily amount of fluid extracted from the pleural cavity does not exceed 10-15 ml, then the suction is stopped, the drainage is shortened, but left until the residual cavity is completely closed.

S.N.Avdeev Federal State Institution Research Institute of Pulmonology of the Ministry of Health and Social Development of the Russian Federation, Moscow

Treatment goals: Resolution of pneumothorax; Prevention of repeated pneumothoraxes (relapses).

Treatment tactics for pneumothorax:

Currently, there are two known consensus documents on the diagnosis and treatment of patients with spontaneous pneumothorax - the British Thoracic Society (BTS) guide and the American College of Chest Physicians (ACCP) guide.

Despite some differences in approaches to patient management, these guidelines suggest similar stages of patient treatment, which include:

  • observation and oxygen therapy;
  • simple aspiration;
  • installation of a drainage tube;
  • chemical pleurodesis;
  • surgical treatment.

All patients with pneumothorax should be hospitalized in a hospital.

Observation and oxygen therapy

It is recommended to limit ourselves to observation only (i.e. without performing procedures aimed at evacuating air) for small-volume PSP (less than 15% or when the distance between the lung and the chest wall is less than 2 cm) in patients without severe dyspnea, with VSP (with a distance between lung and chest wall less than 1 cm or with isolated apical pneumothorax), also in patients without severe dyspnea.

The resolution rate of pneumothorax is 1.25% of the hemothorax volume within 24 hours. Thus, a 15% pneumothorax volume will require approximately 8–12 days to completely resolve.

All patients, even with a normal arterial blood gas composition, are advised to administer oxygen (BTS recommends 10 l/min through a mask, but a positive effect is also observed when oxygen is administered through nasal cannulas), since oxygen therapy can speed up the resolution of pneumothorax by 4–6 times.

Oxygen therapy leads to denitrogenation of the blood, which in turn increases the absorption of nitrogen (the main part of the air) from the pleural cavity and accelerates the resolution of pneumothorax. The administration of oxygen is absolutely indicated for patients with hypoxemia, which can occur with tension pneumothorax even in patients without underlying pulmonary pathology.

In patients with COPD and other chronic lung diseases, blood gas monitoring is necessary when prescribing oxygen, as hypercapnia may increase.

In case of severe pain, analgesics are prescribed, including narcotic ones; in the absence of pain control with narcotic analgesics, an epidural or intercostal blockade is possible.

Classification of pneumothorax

Spontaneous pneumothorax

  • Primary
  • Secondary

Traumatic

  • Due to penetrating chest injury
  • Due to blunt chest trauma

Iatrogenic

  • Due to transthoracic needle aspiration
  • Due to placement of a subclavian catheter
  • Due to thoracentesis or pleural biopsy
  • Due to barotrauma

The most common causes of VSP

  • Respiratory diseases
  • Cystic fibrosis
  • Severe exacerbation of bronchial asthma
  • Infectious lung diseases
  • Pneumonia Pneumocystis carinii
  • Tuberculosis
  • Abscess pneumonia (anaerobes, staphylococcus)
  • Interstitial lung diseases
  • Sarcoidosis
  • Idiopathic pulmonary fibrosis
  • Histiocytosis X
  • Lymphangioleiomyomatosis
  • Systemic connective tissue diseases
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Polymyositis/dermatomyositis
  • Systemic scleroderma
  • Marfan syndrome
  • Ehlers–Danlos syndrome
  • Tumors
  • Lung cancer
  • Sarcoma

Simple aspiration

Simple aspiration (pleural puncture with aspiration) is indicated for patients with PSP of more than 15%; patients with VSP (with a distance between the lung and the chest wall of less than 2 cm) without severe dyspnea, under 50 years of age.

Simple aspiration is carried out using a needle or, preferably, a catheter, which is inserted into the 2nd intercostal space along the midclavicular line, aspiration is carried out using a large syringe (50 ml), after completion of air evacuation, the needle or catheter is removed. Some experts recommend leaving the catheter in place for 4 hours after completing suction.

If the first attempt at aspiration fails (the patient's complaints persist) and evacuation is less than 2.5 liters, repeated attempts at aspiration can be successful in a third of cases.

If after aspiration of 4 liters of air there is no increase in resistance in the system, then presumably there is persistence of the pathological message and the installation of a drainage tube is indicated for such a patient.

Simple aspiration leads to expansion of the lung in 59–83% with PSP and in 33–67% with VSP. According to a randomized controlled trial by Noppen et al., which included 60 patients with new-onset PSP, the immediate success of simple aspiration and drainage of the pleural cavity was 59 and 64%, respectively (p = 0.9), after 7 days - 93 and 85% (p =0.4), and the number of relapses during the 1st year was 26 and 27%, respectively (p=0.9).

However, despite the similar effectiveness of the two methods, simple aspiration had important advantages: fewer patients were hospitalized (the study was carried out in an emergency department): 52 versus 100% in the drainage group (p<0,0001).

The randomized controlled trial of BTS in patients with spontaneous pneumothorax compared the effectiveness of simple aspiration (35 patients) and drainage of the pleural cavity (38 patients).

Simple aspiration was effective in 80% of patients; none of the patients in this group subsequently required thoracotomy, but the duration of hospitalization in these patients was significantly shorter compared to patients in the drainage group (on average 3.2 and 5.3 days, p =0.005), and the procedure was less painful compared to the installation of a drainage tube.

In another randomized study by Andrivert et al., which included 61 patients with new-onset PSP, the effectiveness of drainage was higher than with simple aspiration (93 vs. 67%, p = 0.01).

Drainage of the pleural cavity (using a drainage tube)

Installation of a drainage tube is indicated: if simple aspiration fails in patients with PSP; with relapse of PSP; with VSP (with a distance between the lung and the chest wall of more than 2 cm) in patients with dyspnea and over 50 years of age.

Choosing the correct size of drainage tube is very important because the diameter of the tube, and to a lesser extent its length, determines the flow rate through the tube.

Patients with a bronchopleural fistula may have a “leak” flow of about 16 L/min, and provide flow at a standard pressure of 10 cmH2O. Art. tubes with a diameter of at least 20 F can.

For patients with PSP and stable patients with VSP who are not scheduled for mechanical ventilation, placement of 16–22 F tubes is recommended. In patients with pneumothorax that developed during mechanical ventilation, the risk of developing a bronchopleural fistula or progression of pneumothorax to tension pneumothorax is very high; large-diameter tubes are recommended for them (28 –36 F).

In patients with traumatic pneumothorax, due to the frequent association with hemothorax, the choice of large-bore tubes (28–36 F) is also recommended.

Small gauge tubes (10-14 F) are as effective as large gauge tubes (20-24 F).

Installation of a drainage tube is a more painful procedure compared to pleural punctures and is associated with complications such as penetration into the lungs, heart, stomach, large vessels, infections of the pleural cavity, and subcutaneous emphysema.

During the installation of a drainage tube, it is necessary to carry out intrapleural administration of local anesthetics (1% lidocaine 20–25 ml).

Drainage of the pleural cavity leads to expansion of the lung in 84–97%.

The use of suction (a source of negative pressure) is not necessary when draining the pleural cavity. In a randomized controlled trial of 53 patients with spontaneous pneumothorax, So and Yu found no benefit when using suction systems.

Minami et al. found that attaching a unidirectional valve (Heimlich type) to the drainage tube allows for expansion of the lung in 77% of patients with spontaneous pneumothorax.

Currently, the most accepted technique is to connect a drainage tube to a “water lock”; there is no data on the advantage of a Heimlich valve over a “water lock”.

Early use of suction after chest tube placement, especially in patients with PSP that occurred several days ago, can lead to the development of reexpansion pulmonary edema.

The cause of this edema is increased permeability of the pulmonary capillaries. Clinically, reexpansion pulmonary edema is manifested by coughing and increased shortness of breath or the appearance of chest congestion after insertion of a drainage tube. On a chest x-ray, signs of edema may be visible not only in the affected lung, but also on the opposite side.

The prevalence of reexpansion pulmonary edema when using suction can reach 14%, and its risk is significantly higher with the development of pneumothorax for more than 3 days, complete collapse of the lungs, and young patients (up to 30 years). Mortality with reexpansion pulmonary edema, according to a study by Mafhood et al., which included 53 patients, can reach 19%.

When air bubbles are released, clamping (clamping) of the drainage tube is unacceptable, since such an action can lead to the development of tension pneumothorax.

There is no consensus on the need to clamp the tube when air loss stops. Opponents of the method fear the development of repeated pulmonary collapse, and supporters talk about the possibility of detecting a small “leak” of air, which the “air lock” cannot detect.

The drainage tube is removed 24 hours after air has stopped flowing through it, if, according to a chest x-ray, expansion of the lung has been achieved.

Chemical pleurodesis

One of the main objectives in the treatment of pneumothorax is to prevent repeated pneumothorax (relapses), however, neither simple aspiration nor drainage of the pleural cavity can reduce the number of relapses.

Chemical pleurodesis is a procedure in which substances are introduced into the pleural cavity, leading to aseptic inflammation and adhesion of the visceral and parietal layers of the pleura, which leads to obliteration of the pleural cavity.

Chemical pleurodesis is indicated for: patients with the first and subsequent VSP and patients with the second and subsequent PSP, since this procedure helps prevent the occurrence of recurrent pneumothorax.

Chemical pleurodesis is usually performed by injecting doxycycline (500 mg in 50 ml saline) or a talc suspension (5 g in 50 ml saline) through a drainage tube.

Before the procedure, adequate intrapleural anesthesia is necessary - at least 25 ml of a 1% lidocaine solution.

After administration of the sclerosing agent, the drainage tube is closed for 1 hour.

The number of relapses after the introduction of tetracyclines is 9–25%, and after the introduction of talc - 8%. Of particular concern are the complications that can occur when talc is administered into the pleural cavity: acute respiratory distress syndrome (ARDS), empyema, acute respiratory failure.

The development of ARDS may be associated with a high dose of talc (more than 5 g), as well as with the size of the talc particles (smaller particles undergo systemic absorption with subsequent development of a systemic inflammatory response). It is characteristic that cases of ARDS after the administration of talc have been reported mainly in the USA, where the particle size of natural talc is much smaller than in Europe.

Transforming growth factor and silver nitrate are currently considered promising candidates as sclerotic agents.

Surgical treatment of pneumothorax

The objectives of surgical treatment of pneumothorax are:

  1. resection of bullae and subpleural vesicles (blebs), suturing of lung tissue defects;
  2. performing pleurodesis.

Indications for surgical intervention are:

  • lack of expansion of the lung after drainage for 5–7 days;
  • bilateral spontaneous pneumothorax;
  • contralateral pneumothorax;
  • spontaneous hemopneumothorax;
  • recurrence of pneumothorax after chemical pleurodesis;
  • pneumothorax in people of certain professions (related to flying, diving).

All surgical interventions can be divided into two types: video-assisted thoracoscopy (VAT) and open thoracotomy.

In many centers, VAT is the main surgical method for treating pneumothorax, which is associated with the advantages of the method compared to open thoracotomy: reduction in operation and drainage time, reduction in the number of postoperative complications and the need for analgesics, reduction in hospitalization time for patients, less pronounced gas exchange disorders.

According to a meta-analysis by Schramel et al., the number of recurrences of pneumothorax after VAT (total number of patients 805) is 4%, which is comparable to the number of relapses after conventional thoracotomy (total number of patients 977) - 1.5%. In general, the effectiveness of pleurodesis performed during surgical interventions is superior to the effectiveness of chemical pleurodesis performed during drainage of the pleural cavity.

Urgent events

For tension pneumothorax, immediate thoracentesis is indicated (using a needle or cannula for venipuncture no shorter than 4.5 cm, in the 2nd intercostal space along the midclavicular line), even if it is impossible to confirm the diagnosis using radiography.

Patient education

  • After discharge from the hospital, the patient should avoid physical activity for 2–4 weeks and air travel for 2 weeks.
  • The patient should be advised to avoid changes in barometric pressure (parachuting, diving).
  • The patient should be advised to quit smoking.

Forecast

Mortality from pneumothorax is low, often higher with secondary pneumothorax.

In HIV-infected patients, in-hospital mortality is 25%, and the average survival after pneumothorax is 3 months. Mortality in patients with cystic fibrosis with unilateral pneumothorax is 4%, with bilateral pneumothorax - 25%. In patients with COPD, when pneumothorax develops, the risk of death increases 3.5 times and averages 5%.

1

Drainage of the pleural cavity is one of the necessary methods of treating surgical diseases of the thoracic cavity. Placement of an intrapleural drain is often the first and main step in the treatment of pneumothorax, hemothorax, and pleural effusion. Errors and systematic misconceptions in such treatment often cost the patient’s life, therefore, in order to improve treatment results and the quality of life of patients, it is necessary to conduct new research, study the respiratory mechanics of a patient with surgical pathology of the chest organs and installed pleural drainage. The history of drainage of the pleural cavity generally reflects the history of all surgery, since discoveries in one area of ​​surgery are inextricably linked with expanding understanding of problems in another area, in particular in thoracic surgery. In the domestic literature there are practically no publications devoted to drainage of the pleural cavity in a historical aspect. This article discusses the main types of drainage of the pleural cavity, described in the past and present, and how they were formed over time.

drainage

pleural cavity

thoracostomy

thoracentesis

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Treatment of surgical diseases of the chest cavity is impossible to imagine without intrapleural drainage. Placement of an intrapleural drain is often the first and main step in the treatment of pneumothorax, hemothorax, and pleural effusion syndrome. This seemingly simple manipulation, at the same time, requires the correct implementation of surgical technique and the creation of an operative approach that is adequate to the existing pathology and anatomy of the individual patient. Despite the fact that today this skill is considered one of the most frequently performed procedures for surgeons, issues related to the installation technique and management of patients with pleural drainage in the postoperative period are still controversial. However, errors and systematic errors when installing drainage into the pleural cavity and managing it in the postoperative period often cost the patient’s life. Therefore, it is still relevant to determine design requirements for drainage and a method for removing exudate, creating a vacuum in a closed drainage system and the pleural cavity, which in turn makes it necessary to conduct new research, study the respiratory mechanics of a patient with surgical pathology of the chest organs and installed pleural drainage .

We can conditionally divide the types of drainage of the pleural cavity according to the methods of creating conditions for the outflow of fluid and air: open, valve, passive-gravity using a “water lock”, aspiration with the creation of active aspiration and combined.

The earliest known scientific description of the use of drainage of the pleural cavity in the treatment of surgical diseases of the chest organs belongs to Hippocrates. This is described in his writings on the treatment of "empyema". Hippocrates proposed using tin tubes for this purpose, not only for outflow, but also for washing the cavity with heated wine and oil.

The open method of draining the pleural cavity would seem to have, for the most part, historical significance. However, to date, thoracostomy and pleurostomy remain one of the successful options for organ-preserving staged surgical treatment of suppurative diseases. For a long time, thoracostomy was the only method of treating non-expandable lungs. The first description of drainage of the pleural cavity by creating an opening in the chest is given by Mitchell in Medicine in the Crusades during the first crusades. To evacuate pus from the pleural cavity after a chest injury, thoracentesis using a spear was used without installing a drainage tube into the wound canal. Currently, open drainage of the pleural cavity is found in a limited form of pleurostomy using the methods of Eloesser (1935), in its modification from Symbas (1970), and pleurostomy according to Clagett (1971). In this case, it is important to see the difference in terminology in domestic and Western medical literature. “Pleurostomy” or “thoracostoma” most often in the understanding of domestic surgeons represents what in the West is called open window thoracostomy, namely the formation of a fairly wide non-physiological communication between the environment and the pleural or residual cavity through the chest wall with resection of one or more ribs to form access to the cavity for the purpose of sanitation. Pleurostomy or thoracostomy involves surgical access to the pleural cavity for the purpose of its sanitation. In our time of development of high-tech medical care, namely the advent of mechanical ventilation, fibrinolytics for intracavitary administration and minimally invasive interventions (videothoracoscopy), the formation of a pleurostomy has a narrow range of indications: chronic pleural empyema with or without the presence of bronchopleural communications in the absence of effectiveness of closed drainage in case of insufficiency in the patient physiological reserves for radical surgical intervention in the scope of decortication, lung resection, pleurectomy.

Removal of exudate by puncture of the pleural cavity through the intercostal space with a thick hollow needle was proposed by Boerhaave in 1873. He successfully performed it for penetrating chest wounds.

The first possibility of using the water-seal principle was described by Playfair in 1873, who successfully used it in the treatment of acute pleural empyema in a child using transthoracic installation of drainage into the pleural cavity. The essence of the water lock is that a tube from the patient (proximal) is lowered into the container through a sealed lid on one side almost to the bottom of the vessel, while there is an additional tube (distal) that passes through the lid, but does not reach the bottom, but barely extends down from the lid. At the bottom of the vessel there is a small amount of aseptic non-alcohol solution (3-5 cm above the bottom), the proximal tube with its end is below the surface of the liquid. Drainage is carried out under the influence of gravity, so the vessel with a water lock should always be located below the chest relative to the horizon. Due to the law of communicating vessels, liquid from the upper vessel (pleural cavity) will flow into the lower one (container with a water lock). When positive pressure appears in the pleural cavity (for example, when coughing, forced exhalation), air comes out through the distal tube, and when inhaling (increasing vacuum in the pleural cavity), air cannot get back in due to the force of attraction, which does not allow the solution to let air back in.

In 1875, Gotthard Bülau not only introduced into practice the still used method of draining the pleural cavity with a water lock, but also drew attention to the great danger of respiratory complications associated with drainage of pleural empyema in the form of an open pneumothorax, although most surgeons of that time associated high mortality with this disease with manifestations of the infectious process in the lung itself. He proved the effectiveness of active aspiration of pathological contents from the pleural cavity to expand the lung in order to restore its function even before the discovery of x-rays and widespread x-ray diagnostics.

During the influenza epidemic in 1918, the frequency of complications of pneumonia in the form of recurrent exudative pleurisy and acute pleural empyema increased significantly. The main treatment method for these complications at that time remained surgical resection of the rib with the installation of pleural drainage without the use of a water lock and active aspiration (Fig. 1). This undoubtedly led to high mortality, with death often occurring within the first 30 minutes after access was created (up to 30%). The reason for this was the lack of understanding of respiratory mechanics, namely, what happens in the pleural cavity under normal conditions and pathology.

By and large, the principles of treatment of pleural empyema during this epidemic differed little from those used at the end of the 19th century. But it is worth noting that if earlier successful surgical treatment of chronic pleural empyema was due to the formed shell of the visceral pleura and adhesions with the chest wall, which did not allow the lung to collapse, then in 1918 empyema against the background of pneumonia developed rapidly over several days and was acute, adhesion they simply didn’t have time to form. In this regard, at the beginning of 1918, a surgical commission on the treatment of pleural empyema (Empyema Commission) was created in the United States. The result of her work was the substantiation of the need to prevent the entry of atmospheric air into the pleural cavity and maintain a vacuum in it. Graham, an American surgeon, a member of this commission, was the first to identify and substantiate the relationship between the mortality of patients with drained pleural empyema and the activity of the adhesive process in the pleural cavity. He associated greater survival in patients with empyema caused by pneumococcus compared with patients with the same disease caused by hemolytic streptococcus. In the first case, pleural adhesions form earlier, which prevents the collapse of the lung during drainage of the pleural cavity and the subsequent compression of the superior vena cava and a decrease in tidal volume, which leads to death. In this case, the use of active aspiration was reduced to the use of a conventional syringe. However, as a result of the work of this commission, mortality after drainage was reduced from 30% to 4.3%.

Rice. 1. Drainage of the pleural cavity for empyema during the influenza epidemic in 1918 (materials of the commission on the treatment of pleural empyema)

The use of closed drainage of the pleural cavity, as well as the use of active aspiration in the postoperative period after resection operations on the lungs, was introduced thanks to Lilienthal and Brunn in 1929.

It is worth noting that the method of using a water lock for drainage of the pleural cavity and aspiration was not widely used for the treatment of penetrating wounds and closed chest injuries, which did not lead to a decrease in mortality among victims and wounded during the world wars. Thus, even during the Second World War and the Korean War, in most cases with gunshot wounds of the chest, removal of blood and air from the pleural cavity was used using thoracentesis through a needle using aspiration. So, one patient could undergo 60 pleural punctures in 2 months! . Drainage through the installation of an intrapleural drainage tube with a water lock continued to be used only in the formation of pleural empyema after the addition of a secondary infection at the site of lung injury or the introduction of foreign bodies.

Closed drainage of the pleural cavity using silicone tubular drainage and a sealed suction system for injuries to the chest organs has become routine practice only since the late 50s of the 20th century. Thus, Maloney, in a study on the conservative treatment of hemothorax (traumatic and postoperative), proved that thoracentesis with installation of a catheter with a diameter of 13-14 Fr into the pleural cavity gives results comparable to surgical lung decortication.

Over time, approaches to the use of a water lock in drainage of the pleural cavity have changed. If Bülau proposed using only one glass bottle, combining a water lock and a container for collecting exudate, then later two- and three-component systems appeared (Fig. 2). The reason for this was the development of anesthesiology and the creation of effective ventilators that make it possible to perform resection operations on the lungs, after which, as is known, there is a high probability of prolonged release of air, and the phenomenon of bubbling is possible and the contents of the container are thrown directly into the vacuum source, after which a release is possible contents outside the system, which in itself can lead to the elimination of the water lock. The two-can system consists of two glass or plastic containers connected in series to the drainage of the pleural system, to each other and to a vacuum source, if any. In this case, the first jar after drainage is empty and is necessary for collecting exudate; the second jar already contains a water lock. The three-vessel system was introduced by Deknatel in 1967 and features an additional can (at the distal end of the system) which is necessary to control the vacuum. This is done as follows: the jar also has a proximal end connected by a pipe to the jar with a water lock, and a distal end connected to a vacuum source; in addition, in the sealed lid there is another solid glass or plastic tube, lowered at one end almost to the bottom of the vessel , while others are open to the atmosphere. There is also liquid at the bottom of the vessel, but its level can be controlled through the middle dense tube; as the volume of liquid in the vessel increases, the level of vacuum in the system decreases accordingly. The disadvantages of all these systems are their strict dependence on gravity. Such a system cannot only be raised above chest level, but also tilted, which undoubtedly limits the patient’s mobility. With a massive air discharge, the “bubbling” phenomenon has a fairly loud sound, which is very annoying for patients and prevents them from resting.

Rice. 2. Systems for drainage of the pleural cavity with a water lock:

A - one-component, B - two-component, C - three-component

To eliminate these disadvantages, the three-component system is currently produced in the body of one device, which is undoubtedly convenient, but increases the cost of this device. Such a device is, for example, Atrium (Oasis, USA). In this case, the first (“proximal vessel”) has a rectangular shape, stands on the narrow side and is divided into 4 chambers that communicate with each other in the upper section. The second chamber (water lock) is connected to the first in its lower part from the distal end and, just like in the classic version, requires filling with liquid. The third chamber (“distal”) is similar in structure to the classic version, located above the second and also requires filling with liquid. All cameras are located in one transparent housing, which makes it easy to determine the volume of removed exudate and the presence of air discharge.

Currently relevant is the use of systems for the so-called dry drainage of the pleural cavity (dry suction), such as Pleur-evac (Sahara, USA). In this case, instead of a water lock on the line after the assembly container, there is a one-way valve that opens towards the source or atmosphere, thereby preventing air from entering back into the pleural cavity. Such a device is less dependent on gravity, since there is no need to keep it constantly in a vertical position to avoid “splashing” of the water lock.

With “dry aspiration”, modifications of the aspiration mode, such as those presented in the Croteau patent, are also possible. The aspirator operates in two modes. The first mode is a constant vacuum level, adjustable as needed to a certain value in various clinical situations. The second mode, with a higher level of vacuum, begins to work when the pressure changes between the distal and proximal sections of the drainage tube, in which two pressure sensors are respectively installed, for example, by more than 20 mm of water. Art. (this parameter is configurable). This helps eliminate drainage obstruction and improve its function in the future. Also, with this method, the described aspirator is capable of independently counting the frequency of respiratory movements and giving a signal (including an audio signal) to medical personnel if it changes significantly. The disadvantage of this method is the lack of association with the act of breathing, which can cause an erroneous determination of an emergency situation when the lung is sucked in at full expansion during inspiration.

One of the simplest methods for draining the pleural cavity is the Heimlich valve method using his invention (Heilmich valve or flutter valve), patented in 1965. This device is a rubber valve enclosed in a cylindrical container that has two outlets: to the outer end of the chest tube and to the environment or container (Fig. 3). A rubber cylindrical valve is placed on the proximal end "from the drain". When inhaling, the rubber valve collapses due to suction through the drainage, preventing air from flowing back into the pleural cavity. When you exhale, air from the pleural cavity comes out due to the pressure created by the respiratory muscles on the chest cavity and opening the valve petals. The advantages of this method are ease of use, the possibility of use at the prehospital stage, the mobility of the wounded patient, the possibility of use even with prolonged air release, the possibility of use without a liquid container for spontaneous pneumothorax, while the distal end of the device can always be attached to the container. The device can be rationally used as an opportunity for outpatient treatment of thoracic patients. According to Lai, in case of spontaneous pneumothorax in case of expansion of the lung after installation of a small-diameter drainage tube (8 Fr) with a Heimlich valve, patients can be discharged for outpatient treatment under dynamic observation 24-72 hours after the procedure. The limitations of using the Heimlich valve are associated with the inability to evacuate fluid in larger volumes than during drainage of spontaneous pneumothorax, and the difficulty of taking into account the volume of air and exudate discharge. The only drawback that can lead to death with the use of the Heimlich valve is the development of tension pneumothorax when the valve is incorrectly installed in the pleural drainage with the distal end, which is why each product has a special marking.

Rice. 3. Heimlich valve

Despite these disadvantages, the Heimlich valve continues to be used in practical medicine not only for drainage of pneumothorax, but even for the treatment of pleural empyema, in which exudation per day can reach a volume of up to 400-500 ml. In such cases, the Pneumostat device (Atrium, USA) is used, which is a Heimlich valve connected on the proximal side to pleural drainage, and on the distal side to a small transparent vessel that has a hole for draining fluid.

One of the options for the outflow and collection of exudate from the pleural cavity is flutter bags with a valve that opens towards the container bag, which prevents the contents from being thrown back into the drainage. The advantage in this case is the convenience of packaging the container, which is of no small importance for outpatient treatment and patient mobility. However, these bags are not applicable in cases where the patient needs to maintain a constant negative pressure above the physiological modulus in the pleural cavity, including when air is released and with viscous exudate, such as pus.

Lang et al. conducted a meta-analysis of studies that compared the results of treatment after resection of lung groups using active aspiration and without it, showed that the routine use of aspiration in the postoperative period has no advantages over gravity drainage, except in cases where air discharge through the drainage is maintained for more than 24 hours and with a non-expandable lung for more than 3 days.

A non-expandable lung, undoubtedly, in most cases requires longer treatment than during normal reparative processes in the pleural cavity and in the postoperative period. Treatment of such patients is costly, since, in addition to drug treatment, constant monitoring of the drainage system and dynamic X-ray monitoring are required, which often requires treatment in a specialized hospital and causes long-term disability. The use of advanced technologies in the field of monitoring the pleural cavity makes it possible to predict, promptly diagnose and prevent many postoperative complications.

Recording data on the dynamics of the process of drainage of the pleural cavity on digital media was one of the first to offer Dernevik. The DigiVent drainage system he studied includes two sensors (pressure and flow), which makes it possible to record the amount of discharge, the volume of air discharge through the drainage, and also records data on changes in vacuum specified by the system operator. Early detection of massive air discharge, according to the author, contributes to the timely decision by the doctor to change the patient’s management tactics, reduce the time for taking corrective treatment measures and, accordingly, improve the quality of life and the possibility of early discharge of the patient from the hospital. Determining air leakage quantitatively allows us to determine the dynamics of the process, which is also important in changing the management tactics of such patients. A meta-analysis of six multicenter studies conducted by Cerfolio, in which patients after pulmonary resection were divided into two groups with analog and digital drainage systems, confirms the effectiveness of the latter, since in the study groups drainage was removed earlier in the postoperative period.

It is worth noting that the digital devices themselves, with their ability to dynamically change the vacuum applied to the pleural cavity, despite the early detection of air release, are not able to significantly affect the inflammatory process in the pleura and cannot reduce or increase exudation. This was described in a study by De Waele comparing two groups of patients who had undergone pulmonary resection for lung cancer. In the first group, the postoperative period included the use of the “analog” Atrium drainage system, in the second group, the Thopaz digital drainage system (Medela, USA). There were no significant differences between the groups in the volume and persistence of exudation in the postoperative period, while significantly less air discharge persisted in the group with a digital device.

Currently, the most commonly used digital devices are Atmos, Atrium and Thopaz, which also determine changes in intrapleural pressure and quantitative air release. The use of these devices allows for safe clinical studies with pleural manometry analysis, which can also be considered an advantage of using such a technique.

Outpatient thoracic surgery is actively developing in many medical centers around the world. Currently, it has become technically possible to manage thoracic patients with drainage of the pleural cavity with reliable monitoring of the processes occurring in the pleural cavity, including taking into account the discharge, the volume of air discharge, and the pressure in the pleural cavity. Thus, in a study by Laureano Molins et al. 300 outpatients who underwent various endosurgical interventions (lung biopsy, mediastinoscopy, bilateral sympathectomy) took part. The study used devices for drainage of the pleural cavity with digital control, which made it possible to predict possible complications earlier and develop the necessary tactics.

Thus, despite significant improvements in technology, surgical instrumentation, and understanding of the physiology and pathology of the respiratory system, the use of pleural drainage to evacuate pathological contents remains the main way of managing thoracic surgical patients. However, the evolution of understanding the need for drainage and its methods makes it possible to reveal the features of the physiology and pathophysiology of the pleura and lung, which makes it possible to respond in a timely manner to changes in these organs and change medical tactics. Undoubtedly, new technologies and evidence-based medicine make it possible to more accurately formulate the diagnosis and indications for drainage. The use of digital drainage systems in outpatient surgery will reduce treatment costs, reliably determine the dynamics of pleural repair, and speed up making the right decision. At the same time, the study of intrapleural pressure and its changes, as well as the dependence of changes in the composition of the exudate in the dynamics of the disease, is still relevant, which opens up wide scope for further research in thoracic surgery.

Bibliographic link

Khasanov A.R. DRAINAGE OF THE PLEURAL CAVITY. PAST AND PRESENT // Modern problems of science and education. – 2017. – No. 6.;
URL: http://science-education.ru/ru/article/view?id=27332 (access date: 12/12/2019). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

Figure 20

Indications: open and valve pneumothorax, medium and large hemothorax, hemopneumothorax.

To eliminate pneumothorax in the 2nd intercostal space along the midclavicular line, an elastic tube with a diameter of 0.5 - 1 cm is inserted into the pleural cavity through a trocar (pleural drainage according to Petrov). The distal end of the drainage tube is immersed in an antiseptic solution or active aspiration is performed at a vacuum of 30-40 mm. rt. Art. The criterion for correct installation of drainage is the release of air bubbles through the tube.

The main mistakes that occur when installing pleural drainage according to Petrov:

1) the drainage tube is inserted into the pleural cavity to a great depth. In this case, the tube bends, curls up and does not perform a drainage function. To avoid this, it is necessary to insert the drainage tube to a depth of 2-3 cm from the last hole.

There should not be very many side holes on the tube - 1-2. If it is difficult for the doctor to determine the depth of insertion of the drainage, it is necessary to place a mark on the drainage tube.

2) inadequate fixation of the drainage tube. The drainage completely comes out of the pleural cavity or falls out partially. In the latter situation, the lateral openings end up in the subcutaneous tissue with the development of subcutaneous emphysema. If the side opening is above the skin, atmospheric air is sucked into the pleural cavity. with the occurrence of lung collapse. The drainage tube must be fixed to the skin of the chest wall with two silk threads at each edge of the wound.

If the ligature on the drainage tube is tightened too tightly, it becomes compressed until the lumen is completely compressed. It is necessary to cut off the ligature and re-fix the drainage tube. In open pneumothorax, the chest wall must be sealed before inserting a chest tube.

The next day after installing the drainage, a control x-ray is performed.

x-ray (graphy) of the chest. When the lungs are fully expanded and there is no passage of air through the pleural drainage, the drainage tube is removed on the 4th day. In this case, X-ray control is required. There are no clear criteria for the duration of drainage of the pleural cavity for pneumothorax. The drainage must be maintained until the lung is completely expanded. In case of pathology of the lung tissue, this delays for 2-3 weeks.

For intractable conservative tension pneumothorax, thoracotomy is indicated.

Drainage of the pleural cavity for hemothorax.

The main goal: timely and adequate removal of blood from the pleural cavity and expansion of the lung. To do this, install pleural drainage according to Bulau.

Technique: under local anesthesia, a puncture of soft tissue with a scalpel is made in the 7th-8th intercostal space along the midaxillary line, focusing on the upper edge of the underlying rib. A drainage tube with a diameter of 1-1.5 cm with several side holes is inserted into the pleural cavity using a forceps or a trocar with a diameter of more than 1.5 cm. The tube is fixed to the edges of the skin wound with two sutures. The lower end of the tube with a valve is lowered into a bottle of antiseptic or to a vacuum system for active aspiration.

Blood from the pleural cavity must be collected for reinfusion.

Mistakes when installing pleural drainage according to Bulau:

1) use a tube with a diameter of less than 8mm for drainage. The thin drainage tube becomes clogged with blood clots and does not function;

2) use of soft rubber tubes for drainage. Such tubes are deformed and compressed by the ligature and the tissues of the chest wall. Silicone and PVC tubes must be used.

3) leaving the end of the drainage tube too long in the pleural cavity. The proximal end of the tube is located in the upper parts of the pleural cavity and does not drain the lower parts where the blood is located. It is necessary to tighten the drainage tube a few cm.

4) errors in fixing the drainage tube to the skin (described in detail in the pneumothorax section).

Drainage of the pleural cavity is indicated only for moderate and large hemothorax. For small hemothorax, pleural puncture is performed.

After installation of pleural drainage according to Bulau, dynamic monitoring is necessary.

At the same time, the amount of blood released through the drainage is determined and further treatment tactics are determined. The main task of the doctor is to determine: does intrapleural bleeding continue, or has it stopped? To diagnose ongoing intrapleural bleeding, use: the clinic, the amount of blood through the pleural drainage, the Ruvilois-Gregoire test. - intensive flow of blood through the drainage, which quickly coagulates, against the background of clinical anemia. The presence of ongoing intrapleural bleeding is an indication for thoracotomy. If the bleeding has stopped, a control X-ray of the chest is performed the next day after the installation of pleural drainage. The drainage tube is removed no earlier than 4 days, when the lung is fully expanded and there is no discharge through the drainage.

The presence of pneumothorax and moderate hemothorax is an indication for double drainage of the pleural cavity (in the 2nd and 7th intercostal spaces).

Removing drainage from the pleural cavity. A gauze pad measuring 10 x 10 cm or a napkin folded in several layers is generously moistened on one side with vaseline ointment or gel (A). Remove the bandage and remove the stitches. With one hand, firmly press the pad to the drainage exit site, and with the other hand, grab the drainage (B). While the patient is performing the Valsalva maneuver, the drainage tube is quickly, but without jerking, removed without stopping the pressure on the pad. At the end of the procedure, the pad is fixed with adhesive tape (B). If the drainage tube has been in the pleural cavity for more than 48 hours, air may enter through the wound canal. In this case, increase the amount of Vaseline ointment and apply a sealed bandage (made of non-porous material) over the pad. The bandage is not removed until the wound channel has healed. Do not pinch or remove drains that recently supplied air. This can lead to life-threatening tension pneumothorax. If a large amount of blood flows through the drainage, the drainage tube must be clamped and the patient transferred to the operating room.

Three-can drainage system.( Top drawing) The bottle is connected through a tube to the centralized vacuum distribution; air flows freely through the tube into this bottle. The amount of negative pressure in the bottle A is regulated by the length of the underwater part of the tube b (in this case, 20 cm). Thus, bottle A serves to regulate the negative pressure, which is transmitted through the tube to the bottle B through the tube to bottle B. Bottle B serves as a water seal. Air can enter it from a bottle B through a tube only by overcoming the resistance of a two-centimeter column of liquid. Bottle B is designed to collect fluid aspirated from the pleural cavity. The negative pressure, under the influence of which liquid from the pleural cavity enters the bottle through the tube, in this case is 18 cm of water. Art. This pressure is usually sufficient to ensure effective drainage. The three-can system allows you to maintain negative pressure in the pleural cavity at a constant level, regardless of the amount of discharge through the drainage. If air is separated from the pleural cavity through the drainage, bubbles appear in the bottle. ( Bottom picture) The principle of a three-can drainage system is the basis of many commercially available aspirators (for example, Plevrevac, Toradrain). In these devices, all three “bottles” are combined into one block, the sections of which, designated by the letters A, BiV, correspond to bottles A, BiV in the upper figure

The term “spontaneous pneumothorax” (SP) (as opposed to the term “traumatic pneumothorax”) was first proposed by A. Hard in 1803. SP is diagnosed in 5-7 people per 100 thousand population per year. Patients with SP make up 12% of all hospitalized patients with acute diseases of the chest organs. Non-traumatic SP can occur due to various diseases, as well as during medical manipulations (iatrogenic pneumothorax (IP)) (Tables 1, 2). Mortality in severe clinical forms of pneumothorax reaches from 1.3 to 10.4%.

The goals of treatment for SP are resolution of pneumothorax (expansion of the lung) and prevention of recurrent pneumothorax (prevention of relapse). Naturally, the tactics for achieving these goals depend on the cause of pneumothorax, its volume and the general condition of the patient. Possible methods of treating pneumothorax (due to the actual evacuation of air from the pleural cavity) include:
- puncture of the pleural cavity with air aspiration;
- drainage of the pleural cavity according to Bulau;
- drainage of the pleural cavity with active aspiration.
Additional administration of drugs for medicinal pleurodesis is aimed at preventing relapse.
Open operations and video-assisted interventions are used for suturing large defects of lung tissue, resection of bullous areas of the lung, single large bullae, etc. In this case, additional mechanical, thermal, and chemical pleurodesis is possible. The effectiveness of pleurodesis performed during surgical interventions is superior to the effectiveness of pleurodesis performed during drainage of the pleural cavity.

The incidence of complications after traditional thoracotomy for SP can reach 10.4-20%, and mortality - 2.3-4.3%, which is associated with the development of complications in the postoperative period, such as pleural empyema, postoperative pneumonia, thromboembolism of the branches of the pulmonary artery .

In recent years, in specialized hospitals for SP, predominantly video-assisted operations have been performed, and among all thoracoscopic operations, video-assisted thoracoscopy (VTS) for SP accounts for about 45%. In many centers, video-assisted thoracoscopy is the primary surgical treatment for pneumothorax. The advantages of the method compared to open thoracotomy are obvious: reduction in operation and drainage time, reduction in the number of postoperative complications, less severe pain in the postoperative period, reduction in the total number of bed days. According to a multicenter study, the rate of recurrence of pneumothorax after VAT is 4%. Other authors note an even lower rate of relapse of SP after VTS treatment - 1.3%, and there are no complications inherent in standard thoracotomy. The incidence of PU development: with transthoracic fine-needle puncture biopsy - 15-37%, on average - 10%; during catheterization of central veins - 1-10%; with thoracentesis - 5-20%; with pleural biopsy - 10%; with transbronchial lung biopsy - 1-2%; during artificial ventilation - 5-15%.

Materials and methods
From 1970 to 2013, 882 patients were treated for pneumothorax in the department of thoracic surgery of City Clinical Hospital No. 61 (in 1970-1986 - 144 people, in 1987-1995 - 174, in 1996-2013 - 564) . Until 1987, the only method of treating pneumothorax accepted in the clinic was drainage of the pleural cavity with active aspiration. For active aspiration, various devices were used: from “OP-1” to the more modern “Elema-N PRO 1” and “Medela”.

Since 1987, in addition to drainage of the pleural cavity, drug pleurodesis began to be used. To carry it out, tetracycline (20 mg per 1 kg of patient’s body weight), morphocycline 0.3 g (daily dose), and more recently doxycycline (20 mg per 1 kg of patient’s body weight) were used. Medicinal pleurodesis was performed in both surgical and conservative treatment of pneumothorax. During surgical treatment, 0.8 g (maximum daily dose) of a solution of doxycycline in 50 ml of 0.9% NaCl was injected into the pleural cavity. In total, from 1987 to 2013, 250 medicinal pleurodeses were performed during the conservative treatment of pneumothorax. During the period from 1987 to 1995, only 2 operations were performed - atypical lung resections using the UDO, UO, and US staplers. The approach used during the operations was lateral thoracotomy. With the introduction of video endoscopic technologies (since 1996), surgical activity in the treatment of pneumothorax was 28.5%; over the past 3 years, this figure has increased to 61.7% with the development of pneumothorax in patients with bullous pulmonary disease. From 1996 to 2013, a total of 170 operations for pneumothorax were performed.

Endostaplers are used for VTS of atypical resection of bullous areas of lung tissue. In video-assisted operations from a mini-access, the most commonly used staplers are UDO-20 and UDO-30. Thermal surgical instruments were used for coagulation of bullous-fibrotic areas of the lungs and, to a greater extent, for coagulation of subpleural vesicles and thermal pleurodesis.
The operation of choice is VTS with atypical lung resection, coagulation of bullae with thermal surgical instruments, thermal pleurodestruction of the parietal pleura with the same instruments and medicinal pleurodesis with doxycycline solution.

Results and discussion
140 VTS operations were performed: 114 VTS + atypical lung resection (81.4%), 26 VTS + coagulation of bullae and/or depleurized areas of the lung (18.5%). Coagulation of bullae and blebs with a plasma flow has become the most effective. 36 patients underwent atypical lung resection from a mini-thoracotomy approach with video assistance and the use of UDO staplers. Traditional thoracotomy was used 8 times to perform atypical lung resection.

In recent years (2003-2013), 165 patients with JP were observed in the thoracic department of City Clinical Hospital No. 61, 94 patients were transferred from Moscow hospitals and 71 from other departments of the hospital. The main causes of PU were: catheterization of the central (mainly subclavian) vein and pleural puncture for hydrothorax of various origins, less often - barotrauma during artificial ventilation of the lungs, and even less often - during transthoracic or transbronchial puncture biopsy of the lung. The main reason for transfer to the department from other hospitals was recurrence of pneumothorax after short-term drainage of the pleural cavity: the drainage was removed on the first day (or immediately) after expansion of the lung, which required repeated (often multiple) drainage of the pleural cavity. Early removal of the drainage was explained by the fear of infection of the pleural cavity and the development of associated complications - pleural empyema.

Relapses during the treatment of SP using drainage and puncture of the pleural cavity were observed in 21.5% of cases; with drainage followed by medicinal pleurodesis - in 5.5%. There were no early relapses (after drainage without pleurodesis, recurrent pneumothorax developed in 4.9% of cases in the next 10 days after discharge). The only complication of drainage of the pleural cavity is subcutaneous emphysema. There were no complications associated with medicinal pleurodesis.

In accordance with national clinical guidelines for the diagnosis and treatment of SP, expectant management is acceptable if the volume of spontaneous limited apical pneumothorax is less than 15% in patients with no dyspnea. If such patients have bullous disease and there are no contraindications, relapse prevention will involve surgical treatment to the extent of resection of bullous areas of lung tissue. When the volume of pneumothorax is up to 30% in patients without severe dyspnea, a single pleural puncture with air aspiration can be performed. Prevention of relapse is achieved in the same way as in the previous case.
Drainage of the pleural cavity is indicated when the volume of pneumothorax is more than 30%, recurrent pneumothorax, ineffective puncture, in patients with dyspnea and patients over 50 years of age. Key points of correct placement of drainage: mandatory polypositional x-ray examination before drainage and monitoring the position of the drainage with its correction as necessary after manipulation.
However, the results of treatment of SP exclusively with punctures and drainage of the pleural cavity in patients with bullous disease cannot be considered satisfactory: recurrence of pneumothorax is observed in 20-45% of cases when treated with pleural punctures, in 12-18% after closed drainage of the pleural cavity. In this regard, at present, in the absence of contraindications to VTS, operations with marginal resection and thermal destruction of bullous areas of the lung are performed in all patients with bullous lung disease.
The operation is completed with medicinal pleurodesis with solutions of tetracycline antibiotics in order to obliterate the pleural cavity, which serves as the prevention of pneumothorax even if the bulla ruptures (Fig. 1-4).

UP, unlike SP, develops against the background of healthy lung tissue or changes in the lung parenchyma that are insufficient for spontaneous rupture of the lung, so UP is an indication only for conservative treatment. In this case, it is important that active aspiration continues until the lung is completely expanded, and for at least 5-7 days after expansion, until an adhesive process develops in the pleural cavity. When the lung is expanded, there is no danger of infection of the pleural cavity and the development of pleural empyema, since there is no actual cavity in the pleura.




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