Spontaneous pneumothorax. Diagnosis and treatment of spontaneous pneumothorax Treatment of spontaneous pneumothorax recommendations

Pneumothorax is the penetration of air into the pleural cavity, which causes partial (incomplete) or absolute collapse of the lung, the tightness of which is broken. Pathology can be one- or two-sided, traumatic etiology or spontaneously occurring. The causes of the disease are different. With pure pneumothorax, only air accumulates. If blood exudate occurs, a special form of pathological condition develops, called hemopneumothorax. In the presence of pus, the condition of pyopneumothorax occurs. For diagnostics the most informative method is an x-ray on which the changes will be clearly visible. Treatment is required immediately. Timely delivery primary care reduces the risk of death.

Causal factors of the disease

Depending on the causes of pneumothorax, the type of injury and the course of the disease, it is customary to divide the disease into several types.

The most common classification:

• Closed pneumothorax - the pleural cavity does not communicate with the external environment, the amount of air penetrated inside is stable, does not depend on respiratory acts
• Open pneumothorax - there is a connection between the cavity and the surrounding space, as a result of which air “walks” (enters/exits)
• Valvular pneumothorax - there is a progressive increase in the volume of gases, since at the moment of exhalation the connection of the visceral cavity with the external environment decreases due to the displacement of nearby tissues, a kind of valve is formed that closes the defect and prevents the evacuation of air to the outside
• Spontaneous (sudden, spontaneous) pneumothorax is a consequence of an unexpected, not associated with trauma or medical manipulation, accumulation of gases in the visceral pleura
• Tension pneumothorax resembles a closed one, from which it differs in a higher gas pressure in the pleural sac, expressed in displacement of the anatomical structures of the mediastinum.

There are two main types of valve pneumothorax depending on the location of the valve. The classification refers to internal pneumothorax (the valve is located in the lung itself, the pleura communicates with the external environment through bronchial branches) and external valve pneumothorax (the valve is located in the wound).

Spontaneously, these types of pathologies stop working when, at the peak of inspiration, the pressure in the pleural cavity reaches the environmental pressure. In this case, inside the pleura, such pressure at the outlet may exceed atmospheric pressure - a tension pneumothorax occurs, which is considered a consequence of valvular pneumothorax.

The following pathologies and causes contribute to the development of spontaneous (unexpected) pneumothorax:

• Bullous lesion of lung tissue
• Pulmonary obstruction, cystic fibrosis, asthma
• Tuberculosis, pneumocystis inflammation of the respiratory organ (pneumonia)
• Tuberous sclerosis
• Pulmonary fibrosis
• Wegener's granulomatosis, sarcoidosis
• Rheumatoid arthritis, spondylitis
• Chest oncology
• Endometriosis thoracic
• Systemic sclerosis.

Spontaneous (sudden) pneumothorax occurs more often against the background of excessive straining or excessive physical activity. There is a sharp jump in intrapulmonary pressure, which creates favorable conditions for the development of the disease. Spontaneous primary pneumothorax occurs in a category of patients in whom pulmonary pathologies have not previously been recorded. Tall, thin, young people are more susceptible to the disease. The pathological process of the lung turns out to be a consequence of active smoking and hereditary predisposition. Pathology develops either in a state of calm or during physical overload. Probable Causes this problem - flying at height, water jumping.

Spontaneous secondary pneumothorax is seen in patients suffering from pulmonary pathologies. Occurs when infected with Pneumocystis jiroveci, defects in the pulmonary parenchyma. Diagnosed more often in older people.

Traumatic pneumothorax is another type of pathology. It is preceded by closed injuries chest cavity(lung rupture due to injury, destruction of lung tissue by bone fragments of the ribs), penetrating wounds. Such a wound can be a gunshot, stab or cut.

The causes of iatrogenic pneumothorax, which is the result of various diagnostic and therapeutic procedures on the lungs, are as follows:

• Puncture of the pleural cavity
• Installation of venous catheters
• Endoscopy, pleural tissue biopsies performed through the bronchi
• Injury sustained during pulmonary ventilation.

Previously, a specific method of treating cavernous pulmonary tuberculosis was used - “therapeutic” pneumothorax. In this case, air was deliberately introduced under the pleura to cause the lung to collapse.

Symptomatic picture

The depth of severity of symptoms directly depends on the degree of pulmonary collapse, compression of the anatomical structures of the mediastinum, the severity of lung collapse, and the compensatory ability of the body. The victim may experience slight shortness of breath while running or walking quickly.

If the volume of gases accumulated in the lung space is large, then the disease manifests itself as severe chest pain, serious respiratory failure, and cardiac dysfunction.

In its standard form, the disease is classified as an emergency critical condition requiring immediate medical correction.
Classic signs of pneumothorax:

If the open form of the disease has developed, there is the passage of air and the release of a foamy substance through the wound surface located on the chest. With a small volume of free gaseous substances, latent, sluggish symptoms may be observed, while the pain syndrome is not intense. Traumatic pneumothorax tends to manifest itself as air spreading into the space between the muscles and under the skin, which is why symptoms of subcutaneous emphysema arise - a “crunch” determined by palpation, an increase in the size of the soft tissues. Tension pneumothorax is characterized by swelling of the chest.

Diagnosis of the disease

To confirm/exclude pathology, the most informative method is radiography of the OGK. The image helps to detect the absence of lung tissue in the space between the collapsed whole organ, its lobe and the parietal pleura. The procedure is performed at the moment of inhalation, preferably with the patient's body in a vertical position.

Volumetric pneumothorax is characterized by such a change on X-ray as displacement of organs located in the mediastinal region, the trachea. The size of a pneumothorax is measured as a percentage of the volume of the part of the chest that is filled with air. This indicator also helps evaluate the x-ray.

The data provided by the x-ray is confirmed by thoracoscopy.

In order to detect pulmonary compression syndrome, puncture of the pleural cavity is performed. With pneumothorax, gases enter under pressure. In situations where the fistula in the lung has been sealed, air is evacuated with difficulty, and the lung can expand. Hemopneumothorax and hemothorax demonstrate the same symptoms as occur with non-purulent inflammation of the pleura.

An x-ray helps in differentiating injuries. Pleural puncture involves further examination of the obtained fluid samples in the laboratory.

When making a primary diagnosis, the patient’s complaints, as well as the following facts, are taken into account:

• Examination (obvious symptoms - cyanosis, blanching of the dermis and mucous membranes, etc.)
• Percussion or “tapping” (boxed sound, low, loud)
• Auscultation or “listening” (weakness of breathing on the side of the injury; in severe situations, the effect of a “silent” lung is observed).

Laboratory research does not have an informative, autonomous value for pneumothorax. It is carried out to assess subsequent complications and the general condition of the body.

Therapeutic measures

Sealed bandage

In case of spontaneous pneumothorax, urgent pre-medical treatment is required, since any delay is fraught with dangerous consequences, even death. First aid for pneumothorax can be provided even by a person without medical education. Necessary:

• Try to calm the victim
• Ensure oxygen supply to the room
• Call an ambulance immediately
• Apply a sealed bandage (use pure polyethylene, cellophane, cotton wool, gauze) - if there is room for open pneumothorax.

Prompt assistance saves the patient’s life.

Thoracic surgeons are qualified to treat pneumothorax; emergency hospitalization is indicated.

Oxygenation must be given before x-rays are taken. This will help speed up pleural reabsorption of air and relieve symptoms.

Treatment depends on the type of disease (X-rays help determine it). Expectant conservative treatment is allowed for minimal, strictly limited pneumothorax: the victim is provided with absolute rest and pain relief.

The x-ray shows the accumulation of clear gas. The pleural cavity is drained with easy aspiration in case of significant air accumulations. The procedure involves the following algorithm:

• Providing anesthesia
• Place the patient in a sitting position
• Choosing a place for drainage (as a rule, this is the 2nd intercostal space in front or the area under which the largest gas accumulations are expected)
• Insertion of a special small-caliber needle into a selected point with layer-by-layer impregnation of tissues with novocaine solution 0.5 in an amount of 20 ml
• Skin incision
• Introduction of a trocar, consisting of a pointed rod and tube, into the pleural cavity
• Installation of a drainage system and connection of the Bobrov apt.

Initially, spontaneous aspiration is allowed; if it is ineffective, active aspiration must be done. For this purpose, the installed mechanism is connected to the vacuum aspirator.

Traumatic pneumothorax and its symptoms are eliminated by immediate surgical intervention under general anesthesia. Treatment involves the following algorithm of measures:

• Suturing an existing tissue defect
• Emergency stop of pulmonary hemorrhage
• Step-by-step wound suturing
• Drainage of the pleural cavity.

In case of sudden recurrent pneumothorax, thoracoscopy should be done in order to identify the causative factor of the pathology. A puncture is made in the chest, through which the cavity is examined. The presence of bullae is an indication for endoscopic surgery. Surgical implementation is indicated in cases where the desired result is not achieved after conservative treatment.

It is important

In cases of illness, timely provision of quality care plays an important role - both at the pre-medical stage and in the hospital. The outcome of the disease, further treatment and the likelihood of developing complications that can result from closed pneumothorax or its other varieties will depend on this:

• Exudative pleurisy
• Empyema
• Lung stiffness
• Anemia, etc.

People who have a history of valvular pneumothorax, its other types and surgical intervention for this reason should avoid parachute jumping, diving, and air travel for at least two weeks in order to prevent relapse.

Although there are no specific methods of prevention for pneumothorax, the likelihood of its development is significantly reduced by timely treatment of a variety of pulmonary pathologies, smoking cessation. It is recommended to spend more time in the fresh air and perform respiratory exercises.

PROJECT

Working group for the preparation of the text of clinical recommendations:

Prof. , Associate Professor (Department of Thoracic Surgery of the Russian medical academy postgraduate education, Moscow).

Societies: National Thoracic Section of the Russian Society of Surgeons, Association of Thoracic Surgeons of Russia

Composition of the expert committee: Prof. (St. Petersburg), prof. (Moscow), prof. (Samara), prof. (Moscow), corresponding member. RAMS, prof. (Krasnodar), prof. (Kazan), prof. (Moscow), prof. (Saint Petersburg)

Foreign experts: prof. Stephen Cassivi (Rochester, USA), Academician of the Russian Academy of Medical Sciences, prof. Gilbert Massard (Strasbourg, France), prof. Enrico Ruffini (Torino, Italy), prof. Gonzalo Varela (Salamanca, Spain)

Edited by: Academician of the Russian Academy of Medical Sciences, professor

Introduction: Perhaps, none of the urgent pulmonary diseases has caused as much discussion about surgical tactics as spontaneous pneumothorax - from a purely conservative approach to prophylactic bilateral resections of the apical segments of the lungs.

It should be recognized that after any method of treatment spontaneous pneumothorax relapses are possible. According to the summary data of the world literature, the number of relapses during drainage is 30 - 36% (M. Almind, 1989; P. Andrived, 1995; F. Rodrigues Panadero, 1997); with pleurodesis 8 - 13% (M. Almind, 1989; S. Boutin, 1995; C. Khawand, 1995); with lung resection 4 – 8% (1997; H. P. Becker, 1997); with lung resection in combination with pleurodesis or pleurectomy 1.5 - 2% (1997; 2000; D. M. Donahue, 1993).

Etiology and pathogenesis: It should be noted that most often “spontaneous” pneumothorax is secondary - simply, due to a number of circumstances, the primary disease, the complication of which was pneumothorax, remained undiagnosed. Pneumothorax is a common complication a number of diseases, some of them are presented in Table 1.

Considering this far from complete list of diseases, we have to admit that most of them are never diagnosed in emergency surgical care. Therefore, when assessing the effectiveness of surgical treatment from the point of view of the possibility of avoiding postoperative relapses, one should clearly understand that, almost always, pneumothorax is not an independent disease, but a manifestation of other, much more complex pathological processes in the lung tissue and, first of all, pulmonary emphysema .

Table 1. Lung diseases and systemic diseases, which are a common cause of secondary pneumothorax

Respiratory diseases	Chronic obstructive pulmonary disease
Cystic fibrosis
Interstitial lung diseases	Sarcoidosis
Idiopathic pulmonary fibrosis
Histiocytosis X
Lymphangioleiomyomatosis
Infectious lung diseases	Pneumonia Pneumocystis carinii
Systemic connective tissue diseases
Ankylosing spondylitis
Polymyositis/dermatomyositis
Systemic scleroderma
Marfan syndrome
Ehlers–Danlos syndrome
Other	Endometriosis

Currently, the problems of studying the etiology and methods of treating spontaneous pneumothorax are inextricably linked with lung diseases that cause bullous emphysema. Bullous pulmonary emphysema is the cause of spontaneous pneumothorax in 71–95% of cases.

According to the WHO definition, pulmonary emphysema is “an anatomical change in the lungs, characterized by pathological expansion of the air spaces located distal to the terminal bronchioles and accompanied by destructive changes in the alveolar walls.” There are primary emphysema, which develops in the lungs that do not have any other pathology and is an independent nosological form, as well as secondary, complicating diseases that cause bronchial obstruction, such as chronic bronchitis, bronchial asthma and chronic obstructive pulmonary disease.

Over the past 20 years, a number of scientific papers have appeared on the genetically determined nature of emphysema and spontaneous pneumothorax, caused by hereditary deficiency of elastase inhibitors, such as alpha-1-antitrypsin and alpha-2-macroglobulin. In this case, destruction of the elastic framework of the lung occurs due to excessive accumulation of proteolytic enzymes, which are produced mainly by neutrophils and alveolar macrophages, and enzymatic disintegration of interalveolar septa occurs, fusion of individual alveoli into larger bullous formations.

In secondary emphysema, chronic inflammatory diseases of the bronchi play an important role, the most common of which is chronic obstructive bronchitis. In addition to disturbances in bronchial obstruction, inflammatory changes in the wall of small bronchi, extending to the respiratory bronchioles and alveoli, are of significant importance. In this case, obstruction occurs in the bronchioles and smallest bronchi with a valve effect in the form of local bronchospasm, accumulation of viscous secretion or stenosis. If the bronchial patency at the above level is disrupted, the pores of Conn'a expand and flatten, which leads to a slow accumulation of air, constant stretching of the alveoli, atrophy of the partitions between them, and thin-walled tense air cavities arise that can reach gigantic sizes. The formation of such cavities is a characteristic sign of bullous emphysema; air cavities, the wall of which is the visceral pleura, are called blebs, and in cases where the wall is represented by overstretched lung parenchyma - bullae.

Spontaneous pneumothorax can be caused not only by rupture of the wall of the bleb or bulla. In 1976, H. Suzuki proved the presence of micropores with a diameter of 10 microns in the bulla wall, which can cause spontaneous pneumothorax without rupture of the bullae. More rare causes of spontaneous pneumothorax are rupture of the lung parenchyma by adhesions (in 3–5% of patients) and perforation of congenital lung cysts (in 1–3%).

Prevalence. In general, the incidence of pneumothorax ranges from 7.4 to 18 cases per 100 thousand people per year among men and from 1.2 to 6 cases per 100 thousand women per year. According to data obtained during a general medical examination of the population of the USSR, pneumothorax was diagnosed in 0.3% of all pulmonary patients who applied to medical institutions.

Clinical picture pneumothorax is quite typical: the patient complains of arching pain, often radiating to the shoulder, shortness of breath, and a constant dry cough. A physical examination reveals a lag in breathing of half the chest, sometimes widening of the intercostal spaces, tympanitis, weakened breathing, weakening voice tremors and increased conduction of heart sounds.

Diagnosis of pneumothorax, in the case of a typical clinical picture, is not difficult, however, it should be remembered that a hidden and erased clinical picture occurs in more than 20% of cases. These patients have moderate pain of a radiculoneuritic or anginal nature without characteristic pulmonary symptoms and, often, they are unsuccessfully “treated” for ischemic disease, intercostal neuralgia, osteochondrosis and similar diseases. This emphasizes the obligatory X-ray examination for ANY complaints of chest pain.

Diagnostics: The diagnosis of pneumothorax is finally established radiologically. It is mandatory to take radiographs in frontal and lateral projections, and in doubtful cases, an additional expiratory X-ray in direct projection. The main X-ray symptoms are visualization of the outlined edge of the collapsed lung, displacement of the mediastinum, change in the position of the diaphragm, emphasizing the structure of the ribs and cartilage against the background of air in the pleural cavity. When assessing radiographs, it is necessary to remember the possibility of limited pneumothorax, which, as a rule, has an apical, paramediastinal or supradiaphragmatic localization. In these cases, it is necessary to perform inspiratory and expiratory radiographs, the comparison of which provides complete information about the presence of limited pneumothorax. An important task x-ray examination is to assess the condition of the lung parenchyma, both the affected and the opposite lung.

The best of the radiological methods, which provides complete information about the condition of the lung parenchyma, interstitial lung diseases, the location and volume of pneumothorax, the presence and location of pleural adhesions, is spiral computed tomography.

In addition to x-ray examination, the examination standard includes clinical tests blood and urine, biochemical blood test, determination of blood group and Rh factor, as well as determination of the gas composition and acid-base state of the blood. A study of pulmonary function in pneumothorax is not advisable; it should be performed after the elimination of pneumothorax.

Differential diagnosis: pneumothorax should be differentiated from giant bullae, destructive processes in the lungs, dislocation of hollow organs from abdominal cavity into the pleural space.

Classification: To resolve issues of surgical tactics for spontaneous pneumothorax, its classification is necessary, reflecting those aspects that are important for making tactical decisions. The combined classification is presented in Table 2.

table 2. Classification of spontaneous pneumothorax

By etiology:	Caused by primary bullous pulmonary emphysema
Caused by primary diffuse pulmonary emphysema
Caused by respiratory disease
Caused by interstitial lung disease
Summoned systemic disease
Caused by avulsion of the pleural commissure
By frequency of education:	Primary
Recurrent
By mechanism:	Closed
Valve
According to the degree of lung collapse:	Apical (up to 1/6 volume)
Small (up to 1/3 volume)
Medium (up to ½ volume)
Large (over ½ volume)
Total (lung completely collapsed)
For complications:	Uncomplicated
Tense
Respiratory failure
Soft tissue emphysema
Pneumomediastinum
Hemopneumothorax
Hydropneumothorax
Pyopneumothorax
Rigid

General principles of treatment. All patients with pneumothorax should be urgently hospitalized in surgical, and, if possible, in thoracic surgical hospitals.

In world practice, two consensus documents are used on the diagnosis and treatment of patients with spontaneous pneumothorax: the British Thoracic Society manual and the American College of Chest Physicians manual. Despite some differences in approaches to patient management, these guidelines use the general principle of gradually increasing the invasiveness of the intervention and propose similar stages of treatment, which include:

Dynamic observation and oxygen therapy

· Pleural puncture

Drainage of the pleural cavity

Closed chemical pleurodesis

· Surgery

The fundamental points for determining surgical tactics for pneumothorax are: the presence of respiratory and, even to a greater extent, hemodynamic disorders, the frequency of formation, the degree of lung collapse and the etiology of pneumothorax. In all cases, it is necessary before surgery to clarify the nature of changes in the pulmonary parenchyma using all possible methods, preferably spiral computed tomography (SCT).

Emergency surgical care for spontaneous pneumothorax should be aimed, first of all, at decompressing the pleural cavity and preventing respiratory and circulatory disorders, and only then at performing radical surgery.

Principles for choosing surgical tactics for spontaneous pneumothorax

The general principles for choosing surgical tactics when providing emergency care for spontaneous pneumothorax, depending on the volume and frequency of pneumothorax formation, are as follows.

Dynamic observation: o It is possible to limit ourselves only to observation without air evacuation with isolated apical pneumothorax in patients without severe dyspnea or with spontaneous pneumothorax of small volume (less than 15%). The resolution rate of pneumothorax is 1.25% of the hemithorax volume in 24 hours. Thus, a 15% volume pneumothorax will require approximately 8–12 days to completely resolve.

Pleural punctures with aspiration: indicated for patients under 50 years of age with the first episode of spontaneous pneumothorax with a volume of 15–30% without severe dyspnea. The puncture is performed using a needle or, preferably, a thin stylet catheter. A typical place for puncture is the 2nd intercostal space along the midclavicular line; however, the puncture point should be determined only after a polypositional X-ray examination, which allows us to clarify the localization of adhesions and largest clusters air. Aspiration is carried out using a syringe; after the air evacuation is completed, the needle or catheter is removed. It is important to remember that if the first puncture is ineffective, repeated attempts at aspiration are successful in no more than one third of cases.

Drainage of the pleural cavity: indicated for pneumothorax volume more than 30%, for recurrent pneumothorax, for puncture failure, in patients with dyspnea and in patients over 50 years of age. The key points of correct installation of drainage are: mandatory polypositional x-ray examination before drainage and monitoring the position of the drainage with its correction as necessary after manipulation. It is advisable to perform drainage using a stylet catheter, which is inserted at the point indicated by fluoroscopy (in the absence of adhesions - in the 2nd intercostal space along the midclavicular line), aspiration is carried out using a pleuroaspirator with a vacuum of 5 to 25 cm of water. Art. Drainage of the pleural cavity leads to expansion of the lung in 84–97%.

The question of the advisability of emergency thoracoscopy for spontaneous pneumothorax without preliminary drainage, expansion of the lung and examination of the condition of the lung tissue is debatable.

Performing a one-stage radical operation “ex tempore” is possible for bullous emphysema localized within one lobe and for pneumothorax caused by separation of the pleural commissure. However, the use of such tactics is dangerous because during a thoracoscopic examination one can, unexpectedly, discover that the cause of pneumothorax is widespread diffuse emphysema, or cystic hypoplasia, or one of the interstitial lung diseases, or, even worse, that the pneumothorax developed as a result of a rupture lung cavity or abscess. Obviously, any of these situations will require a completely different surgical procedure, for which the surgeon, anesthesiologist and, most importantly, the patient may not be prepared.

Surgical tactics for spontaneous pneumothorax are as follows. After a physical and polypositional X-ray examination, which allows one to assess the degree of lung collapse, the presence of adhesions, fluid, and mediastinal displacement, it is necessary to perform a puncture or drainage of the pleural cavity.

At the first episode of pneumothorax an attempt at conservative treatment is possible - puncture or drainage of the pleural cavity. If the treatment is effective, SCT should be performed, and if bullae, emphysema and interstitial lung diseases are detected, elective surgery should be recommended. If there are no changes in the lung parenchyma that are subject to surgical treatment, then we can limit ourselves to conservative treatment, recommending that the patient adhere to a regimen of physical activity and SCT monitoring once a year. An exception is made for professional indications - patients carrying out their work in changing conditions. external pressure; in these cases, it is advisable to perform a preventive operation - thoracoscopic pleurectomy. This treatment is especially indicated for pilots, paratroopers, divers and musicians who play wind instruments.

If drainage does not lead to expansion of the lung and air flow through the drains continues for 72–120 hours, urgent thoracoscopic surgery is indicated.

If pneumothorax recurs, as a rule, surgery is indicated, however, it is always preferable to first perform drainage of the pleural cavity, achieve expansion of the lung, then perform a CT scan, assess the condition of the lung tissue, paying special attention to signs of diffuse emphysema, COPD and processes of destruction of lung tissue; and the operation should be performed in an emergency-delayed manner.

Surgical procedures for spontaneous pneumothorax.

Drainage of the pleural cavity in spontaneous pneumothorax. The first surgical treatment for pneumothorax is decompression of the pleural cavity using its drainage. There are so many erroneous opinions associated with this simplest surgical procedure that it rightfully ranks first among the “myths of emergency thoracic surgery.”

The usual point for drainage is the 2nd intercostal space along the midclavicular line. This is true only for large and total pneumothorax in the absence of adhesions in the pleural cavity. Often, as a result of previously suffered diseases of the pleura and lungs, minor injuries, it is in the projection of the 2nd rib that the most pronounced adhesive process is formed. Attempting “standard” chest drainage will result in lung injury or hemothorax.

The correct tactic is a mandatory polypositional X-ray examination - fluoroscopy or radiography in two projections and determining the optimal drainage point.

The next common mistake is the opinion that in order to avoid damage to the lung, drainage should be inserted exclusively “bluntly” - using a clamp and certainly along the upper edge of the rib. Installation of a stylet catheter or drainage through a trocar is much less traumatic, and if the technique is followed, the risk of iatrogenic damage is less than with drainage using a clamp. As for possible damage to the intercostal artery during drainage, it should be remembered that only on the anterior surface of the chest wall is it hidden in the rib groove, and on the posterior and posterolateral surfaces the artery passes through the middle of the intercostal space.

Before drainage, it is correct to perform a puncture of the pleural cavity with a thin needle or, even better, a Veress needle at the point of intended installation of drainage, using aspiration to control the advancement of the needle in the soft tissues. After the needle penetrates the pleural cavity, without pushing it deeply, you should describe a circle in the air with the needle cannula. The same circle describes the end of the needle in the pleural cavity, and you can get a distinct sensation of resistance or “scratching”, which indicates fixation of the lung to the site of intended drainage. If the pleural cavity is free, you should, by aspirating air, make sure that the needle is in the pleural cavity, fix the direction of the injection and mark on the needle the depth to which the trocar should be inserted. It is necessary to make an incision corresponding to the trocar, apply a suture capturing the muscle layer through the middle of the incision (this will eliminate the need to suture the wound after removing the drainage) and insert a stylet catheter or trocar into the pleural cavity to a given depth.

An elastic tube with a diameter of 5–7 mm is inserted through the trocar. The main mistakes that occur when installing pleural drainage:

1. The drainage tube is inserted deep into the pleural cavity. Correctly insert it to a depth of 2 - 3 cm from the last hole.

2. unreliable fixation of the drainage, in which case it completely comes out of the pleural cavity or falls out partially. In the latter case, the lateral openings end up in the subcutaneous tissue and subcutaneous emphysema develops.

A common misconception is that it is necessary to install a thick drainage for tension pneumothorax, since “thin drainages cannot cope with the release of air.” In fact, failures of fine drainage are more often associated with poor manipulation techniques.

After drainage, air aspiration should be established. Here we encounter polar opposite opinions: some surgeons advocate Bülau drainage, others advocate aspiration with maximum vacuum, and still others indicate specific vacuum numbers. The truth is in the middle: aspiration should be carried out with the minimum vacuum at which the lung is completely expanded. The method for choosing the optimal vacuum is as follows: under fluoroscopy control, we reduce the vacuum to the level when the lung begins to collapse, after which we increase the vacuum by 3–5 cm of water. Art. The most convenient device for aspiration is the OH-D Univac (FTO "Cascade"). When complete expansion of the lung is achieved, there is no passage of air for 24 hours and fluid intake is less than 100-150 ml, the drainage is removed. There is no exact timing for drainage removal; aspiration should be carried out until the lung is completely expanded. X-ray monitoring of lung expansion is performed daily. If air flow from the pleural cavity ceases within 12 hours, the drainage is closed for 24 hours and then an x-ray is taken. If the lung remains expanded, the drainage is removed. In case of repeated lung collapse, active aspiration is continued. If air discharge continues for hours, drainage should be considered ineffective and indications for thoracoscopic surgery should be given.

Pleurodesis. If it is impossible for any reason to perform radical surgery, after drainage, pleurodesis can be performed to obliterate the pleural cavity - the injection of a drug that causes aseptic inflammation and adhesions. For chemical pleurodesis, you can use fine talc powder, a solution of tetracycline or bleomycin.

The most powerful sclerosing agent is talc. You can often hear the opinion that talc is carcinogenic and should not be used for pleurodesis. This is because some types of talc contain asbestos, which is a carcinogen. Conducted by C. Boutine et al. , P. Lange et al. , K. Viskum et al. and the Lyon International Agency for Research on Cancer, a study of 35 years of results from the use of asbestos-free chemically pure talc, did not establish a single case of the development of a tumor of the pleura or lung. The talc pleurodesis technique is quite labor-intensive and requires spraying 3 - 4.5 grams of talc using a special sprayer introduced through a trocar before draining the pleural cavity.

It is important to remember that talc does not cause an adhesive process, but granulomatous inflammation, which results in the fusion of the parenchyma of the mantle zone of the lung with the deep layers of the chest wall. Previously performed talc pleurodesis causes extreme difficulties for any subsequent surgical intervention on the breast organs. That is why indications for talc pleurodesis should be strictly limited to only those cases (senile age, severe concomitant diseases, inoperable tumors) when the likelihood that the patient will subsequently require surgery in the obliterated pleural cavity is minimal.

The next most effective drugs for pleurodesis are antibiotics of the tetracycline and bleomycin group. Tetracycline should be administered at a dose of 20–40 mg/kg; if necessary, the procedure can be repeated the next day. Bleomycin is administered at a dose of 100 mg on the first day and, if necessary, pleurodesis of bleomycin 200 mg is repeated on subsequent days. Due to the severity of pain during pleurodesis with tetracycline and bleomycin, it is necessary to dilute these drugs in 2% lidocaine and be sure to premedicate with narcotic analgesics. The method of pleurodesis with these antibiotics is quite simple. After drainage, the drug is administered through a drain, which is clamped for 1 - 2 hours, or, with constant air release, passive aspiration is carried out according to Bulau. During this time, the patient must constantly change body position to evenly distribute the solution over the entire surface of the pleura.

The choice of surgical tactics for spontaneous pneumothorax from the perspective of evidence-based medicine.

The British Society of Thoracic Surgeons Guidelines, 2010 summarized the results of level 1 and 2 evidence, based on which it was concluded that pulmonary resection in combination with pleurectomy is the technique that provides the lowest percentage of relapses (~ 1 %). Thoracoscopic resection and pleurectomy are comparable in recurrence rate to open surgery, but are more preferable in terms of pain, duration of rehabilitation and hospitalization, and restoration of external respiratory function.

Operations for spontaneous pneumothorax.

Thus, thoracoscopy is the operation of choice for spontaneous pneumothorax, differing favorably from thoracotomy in its low morbidity, light current postoperative period, quick rehabilitation of the patient and good cosmetic results.

Thoracoscopic examination for spontaneous pneumothorax has 3 main goals: diagnosis of the disease that caused the pneumothorax, assessment of the severity of emphysematous changes in the parenchyma, and search for the source of air intake.

Thoracoscopic examination allows not only to visualize changes in lung tissue characteristic of a particular disease, but also, if necessary, to obtain biopsy material for morphological verification of the diagnosis.

To assess the severity of emphysematous changes in the parenchyma, it is most advisable to use the P. C. Antony classification:

· type 1 - a single subpleural bladder less than 1 cm in diameter;

· type 2 - more than one subpleural bladder located within one lobe of the lung;

· Type 3 - more than one subpleural bladder located in different lobes of the lung.

· type 1 - a single thin-walled cavity more than one cm in diameter;

· Type 2 – one or more bullae in combination with a bleb, located within one lobe;

· Type 3 – combined (diffuse and bullous) emphysema, damage to several lobes.

A thorough assessment of the severity of emphysematous changes makes it possible to predict with a high degree of probability the risk of recurrent pneumothorax and make an informed decision about the need to perform an operation aimed at obliterating the pleural cavity.

The success of the operation depends to the greatest extent on whether the source of air supply was found and eliminated. The frequently held opinion that with thoracotomy it is easier to detect the source of air intake is only partly true. Indeed, under conditions of one-lung ventilation, necessary for thoracoscopy, the ruptured bulla collapses, and finding it becomes a difficult task.

Many researchers (2000; 2000) note that regardless of the inspection method, in 6–8% of cases of spontaneous pneumothorax the source of air intake cannot be detected. As a rule, these cases are associated with the entry of air through the micropores of an unruptured bulla or occur when a thin pleural adhesion is torn off. According to our data, it is possible to identify the source of air intake during thoracoscopy in 93.7%, and during thoracotomy - in 91.2% of cases. This is due to better visualization during thoracoscopy due to the use of a video system and an 8-fold magnification of the image.

To detect the source of air intake, the following technique is advisable. Pour 250–300 ml of sterile solution into the pleural cavity. The surgeon presses all suspicious areas one by one with an endoscopic retractor, immersing them in liquid. It is not advisable to use endoscopic clamps for this, since, while fixing the lung, they can block the flow of air to the ruptured bulla, and, in addition, the retractor creates the necessary volume for examination when turned on lung ventilation. The anesthesiologist connects the open bronchial canal of the endotracheal tube to the Ambu bag and, at the surgeon’s command, takes a small breath. As a rule, with a thorough sequential inspection of the lung, it is possible to detect the source of air intake. As soon as you can see a chain of bubbles rising from the surface of the lung, you should, carefully manipulating the retractor, turn the lung so that the source of air intake is as close as possible to the surface of the sterile solution. Without removing the lung from under the liquid, it is necessary to grasp its defect with an atraumatic clamp and make sure that the air supply has stopped. After this, the pleural cavity is drained and suturing of the defect or lung resection begins.

If, despite a thorough inspection, the source of air intake could not be detected, it is necessary not only to eliminate the existing undamaged bullae and blebs, but also, in mandatory, create conditions for obliteration of the pleural cavity - perform pleurodesis or endoscopic parietal pleurectomy.

Pleurodesis during thoracoscopy is performed by applying a sclerosing agent - talc, tetracycline solution or bleomycin - to the parietal pleura. The advantages of pleurodesis under the control of a thoracoscope are the ability to treat the entire surface of the pleura with a sclerosing agent and the painlessness of the procedure.

Mechanical pleurodesis can be performed using special thoracoscopic instruments for abrasion of the pleura or, in a simpler and effective option– pieces of sterilized metal sponge, used in everyday life for washing dishes. Mechanical pleurodesis, performed by wiping the pleura with tuffers, is ineffective due to their rapid wetting, and cannot be recommended for use.

Physical methods of pleurodesis also give good results; they are simple and very reliable. Among them, it should be noted the treatment of the parietal pleura with electrocoagulation - in this case, it is more advisable to use coagulation through a gauze ball moistened with saline solution; This method of pleurodesis is characterized by a larger area of ​​influence on the pleura with a smaller depth of current penetration. The most convenient and in effective ways physical pleurodesis is the destruction of the parietal pleura using an argon plasma coagulator or ultrasound generator.

A radical operation for obliteration of the pleural cavity is endoscopic pleurectomy. This operation should be performed according to the following procedure. Using a long endoscopic needle, saline solution is injected subpleurally into the intercostal spaces from the apex of the lung to the level of the posterior sinus. Along the spine at the level of the costovertebral joints, the parietal pleura is dissected along its entire length using an electrosurgical hook. Then the pleura is dissected along the lowest intercostal space at the level of the posterior phrenic sinus. The corner of the pleural flap is grabbed with a clamp, the pleural flap is peeled off from the chest wall using measured traction. The pleura detached in this way is cut off with scissors and removed through a thoracoport. Hemostasis is carried out using a ball electrode. Preliminary hydraulic preparation of the pleura makes the operation easier and safer.

If there is an obvious source of air intake, in order to select the optimal volume of surgery, it is necessary to correctly assess the changes in the lung tissue identified during the audit. To assess the results of thoracoscopic revision of the pleural cavity and select the type of operation, the classification described above by P. C. Antony is most successful.

For type 1 and 2 bleb, it is possible to perform electrocoagulation, suturing the lung defect, or performing lung resection within healthy tissue. Electrocoagulation of the bleb is the simplest and, if the technique is carefully followed, the most reliable operation. Before coagulating the surface of the bleb, it is necessary to carefully coagulate its base. If not large sizes bleb, you can grab the lung tissue underneath with a clamp and carry out coagulation through the clamp. For larger sizes, it is necessary to carefully coagulate the lung tissue along the border of the bleb with a ball electrode. After coagulation of the underlying lung tissue, the coagulation of the bleb itself begins, and one should strive to ensure that the wall of the bleb is “welded” to the underlying lung tissue, using a non-contact coagulation mode for this. Ligation using a Raeder loop, advocated by many authors, should be considered risky, since the ligature may slip off during lung reexpansion. Suturing with the EndoStitch device or manual endoscopic suture is much more reliable. The suture must be placed 0.5 cm below the base of the bleb and the lung tissue must be tied on both sides, after which the bleb can be coagulated or cut off.

For type 1 and 2 bullae, endoscopic suturing of the underlying parenchyma or lung resection using an endostapler should be performed. Coagulation of bullae should not be used. If a single bulla ruptures no more than 3 cm in size, the lung tissue supporting the bulla can be sutured using a hand suture or the EndoStitch device. In the presence of multiple bullae or blebs localized in one lobe of the lung, if single giant bullae are ruptured, an atypical resection of the lung should be performed within healthy tissue using an endoscopic stapler. More often, for bullae, it is necessary to perform marginal resection, less often - wedge-shaped. When wedge-shaped resection of the 1st and 2nd segments, it is necessary to mobilize the interlobar groove as much as possible and perform the resection by sequentially applying a stapler from the root to the periphery of the lung along the border of healthy tissues.

Endoscopic lobectomy should be performed for cystic hypoplasia of the lung lobe. This operation is much more technically difficult and can only be recommended to surgeons with extensive experience in thoracoscopic surgery. To make endoscopic lobectomy easier and more convenient, before proceeding to the treatment of the elements of the root lobe, you can open the cysts using endoscopic scissors with coagulation. Of course, before this it is necessary to ensure the adequacy of separate intubation. After opening the cysts, the lobe collapses, providing optimal conditions manipulations at the root of the lung. Endoscopic isolation of the lobar artery and vein, as in traditional surgery, must be performed in accordance with the “golden rule of Overhold”, first treating the visible anterior, then the lateral and only then the posterior wall of the vessel. To isolate the posterior wall of the vessel, it is convenient to use the EndoMiniRetract tool. It is easier to suture selected lobar vessels using the EndoGIA II Universal or Echelon Flex device with a white cassette. In this case, it is technically easier to bring it under the vessel “upside down,” i.e., not with a cassette, but with the thinner mating part of the apparatus downward. You can ligate the vessels using ligatures with tying an extracorporeal knot. The bronchus should be sutured and crossed using a stapler with a blue or green cassette. Removing a lung lobe from the pleural cavity with cystic hypoplasia, as a rule, does not cause difficulties and can be performed through an extended trocar injection.

Endoscopic anatomical resection of the lung is technically complex and requires a large number of expensive consumables. Video-assisted lobectomy from a mini-access does not have these disadvantages, and the course of the postoperative period does not differ from that of endoscopic lobectomy. In addition, mini-thoracotomy allows for palpable inspection of the lung and easy removal of the resected lobe.

The technique for performing video-assisted lobectomy was developed in detail and introduced into clinical practice by T. J. Kirby. The technique is as follows. The optical system is inserted into the 7-8 intercostal space along the anterior axillary line and a thorough visual inspection of the lung is performed. The next thoracoport is installed in the 8-9 intercostal space along the posterior axillary line. The lobe is isolated from the adhesions and the pulmonary ligament is destroyed. Then the intercostal space is determined, the most convenient for manipulations on the root of the lobe, and a mini-thoracotomy 4-5 cm long is performed along it, through which standard surgical instruments are passed - scissors, a pulmonary clamp and dissectors. The intersection of vessels is carried out using the UDO-38 apparatus, with mandatory additional ligation of the central stump of the vessel. The bronchus is carefully isolated from the surrounding tissue and lymph nodes, then sutured with a UDO-38 device and transected. The proximal end of the bronchus is additionally sutured with an atraumatic thread. The separation of interlobar fissures is carried out by electrocoagulation or, if they are poorly expressed, by a UDO stapler. Be sure to control hemostasis and aerostasis and complete the operation by draining the pleural cavity with two drains.

The most difficult question is surgery spontaneous pneumothorax with widespread combined (bullous and diffuse) emphysema. Emphysematous lung tissue is extremely easily damaged during any surgical procedure. When it is captured with atraumatic clamps and sutures are applied, more and more new sources of massive air release arise. In addition, a lung that does not collapse when turned off from ventilation creates great difficulties when performing thoracoscopy.

When performing operations for spontaneous pneumothorax in patients with widespread combined emphysema, the following operating principles should be observed.

1. It is preferable to perform anatomical resection of the lung - lobectomy. As a rule, atypical resection in these patients in the postoperative period is complicated by significant and prolonged air discharge and, accordingly, the risk of developing pleural empyema increases.

2. Even if there is an obvious source of air entry, the operation to eliminate it should be supplemented with thoracoscopic pleurectomy. Emphysematous lung tissue is not only easily damaged during surgical manipulations, but also has a tendency to spontaneous rupture during cough impulse or active aspiration.

3. Attempts to simply suturing a rupture of emphysematous pulmonary tissue are, as a rule, futile, since each suture becomes a new and very strong source of air entry. In this regard, preference should be given to modern stitching machines that use cassettes with gaskets - for example, Duet TRS, or sutures using gaskets. Both synthetic materials, for example, Gore-Tex, and free flaps of biological tissue, for example, a pleural flap, can be used as a gasket. Good results are obtained by strengthening the seam with an application of Tahocomb plate or BioGlue glue.

When applying sutures to emphysematous lung tissue, the following technique can be used: the edges of the rupture of the lung tissue are treated using an argon plasma coagulator, and a sufficiently strong coagulation scab is formed through which the sutures are applied. Good results are obtained by the method of seamless resection of emphysematous lung tissue using the LigaSure device.

Thus, surgical treatment of spontaneous pneumothorax is a complex and multifaceted problem. Often, experienced surgeons call spontaneous pneumothorax “thoracic appendicitis”, implying that this is the simplest operation of all performed for lung diseases. This definition is doubly true - just as appendectomy can be both the simplest and one of the most complex operations in abdominal surgery, also a banal pneumothorax can create difficult problems to overcome during a seemingly simple operation.

The described surgical tactics, based on an analysis of the results of a number of leading thoracic surgery clinics and extensive collective experience in performing operations, both in very simple and in very complex cases of pneumothorax, make it possible to make thoracoscopic surgery simple and reliable, and to significantly reduce the number of complications and relapses.

LITERATURE.

1. Ahmed of small approaches in the correction of spontaneous pneumothorax // Diss... Cand.-M., 2000.-102 p.

2. Perelman problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16.

3. Yasnogorodsky intrathoracic interventions // Diss... doc., M., 200 p.

4. Almind M., Lange P., Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis // Thorax.- 1989.- Vol. 44.- No. 8.- P.

5. Boutin C., Viallat J., Aelony Y. Practical thoracoscopy / New York, Berlin, Heidelberg: Springer-Verlag. - 199p.

6. British Thoracic Society Pleural Disease Guideline 2010 //Thorax.- 2010.- vol. 65, Aug.- suppl. 2.- ii 18 – ii 31.

7. Kocaturk C., Gunluoglu M., Dicer I., Bedirahan M. Pleurodesis versus pleurectomy in case of primary spontaneous pneumothorax // Turkish J. of Thoracic and Cardiovasc. Surg.- 2011.- vol. 20, N 3.- P. 558-562.

8. Ikeda M. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax, with special reference to the operative indication considered from its contralateral occurrence rate // Nippon Kyobi Geka. Gakhai Zasshi.- 1985.- V.14.- No. 3.- P.

9. Up Huh, Yeong-Dae Kim, Yeong Su Cho et al. The effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion // Korean J. of Thoracic and Cardiovasc. Surg.- 2012.- vol. 45, N 5.- P. 316-319.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other spontaneous pneumothorax (J93.1), Spontaneous tension pneumothorax (J93.0)

Thoracic surgery

general information

Short description

Approved by the minutes of the meeting
Expert commission on health development issues of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Spontaneous pneumothorax is a pathological condition characterized by the accumulation of air between the visceral and parietal pleura, not associated with mechanical damage to the lung or chest as a result of injury or medical manipulation, infectious or tumor destruction of lung tissue. .

I. INTRODUCTORY PART

Protocol name: Spontaneous pneumothorax
Protocol code:

ICD-10 code:
J 93 spontaneous pneumothorax
J 93.0 spontaneous tension pneumothorax
J 93.1 other spontaneous pneumothorax

Abbreviations used in the protocol:
BPD - bullous lung disease
BEL - bullous pulmonary emphysema
IHD - coronary pulmonary disease
CT - computed tomography
SP - spontaneous pneumothorax,
CFG OGK - digital fluorography of the chest organs,
ECG - electrocardiogram,
VATS - video-assisted thoracoscopic surgery

Date of development of the protocol: year 2013
Patient category: adult patients with pneumothorax
Protocol users: Thoracic surgeons, pulmonologists, therapists, cardiologists, phthisiatricians and oncologists in hospitals and outpatient clinics.

Note: This protocol uses the following classes of recommendations and levels of evidence:

Level of evidence		Description
1++		High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias.
1+		Well-performed meta-analyses, systematic reviews of RCTs, or RCTs with low risk of bias.
1?		Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias.
2++		High-quality systematic reviews, case-control or cohort studies, or high-quality case studies control or cohort studies with a very low risk of data bias or chance and a high probability that the association is causal y.
2+		Well-performed case-control or cohort studies with low risk of bias data, or chance, and the average probability that the relationship is causal.
2?		Case-control or high-risk cohort studies bias, data error or chance and significant risk m that the connection is not causal.
3		Non-analytical studies such as case reports and case series.
4		Expert opinion.
Level of recommendation
A	At least 1 meta-analysis, systematic review, or RCT classified as 1++ and directly applicable to the target population; or systematic review, RCT, or body of evidence consisting primarily of studies classified as 1+ directly applicable to the target group ne population and demonstrating overall homogeneity of results.
B	Body of evidence, including studies classified as 2++ directly applicable to the target population and demonstrating overall homogeneity of results or extrapolation Evidence from studies classified as 1++ or 1+.
C	Body of evidence, including research studies classified as 2+ directly applicable to the target population and demonstrating overall homogeneity of results or extra polished evidence from studies classified as 2++.
D	Level of evidence 3 or 4 or extrapolated evidence from studies classified as 2+.

Classification

Clinical classification:
- Primary (idiopathic) pneumothorax
- Secondary (symptomatic) pneumothorax
- Catamenial (menstrual) pneumothorax

Primary (idiopathic) pneumothorax persists in the ratio of 5:100 thousand people: among men 7.4:100 thousand, among women 1.2:100 thousand of the population, it occurs most often in people of working age from 20-40 years.
Secondary (symptomatic) pneumothorax is: among men 6.3:100 thousand, among women 2.0:100 thousand of the population, covers a wider age range and is often one of the manifestations of pulmonary tuberculosis.
Catamenial (Menstrual) pneumothorax is a rare form of pneumothorax that occurs in women. More than 230 cases of catamenial pneumothorax have been described worldwide.

Depending on the type of pneumothorax, there are :
- Open pneumothorax.
- Closed pneumothorax.
- Tension (valve) pneumothorax.

With an open pneumothorax, there is a connection between the pleural cavity and the lumen of the bronchus and, therefore, with atmospheric air. On inhalation, air enters the pleural cavity, and on exhalation it leaves it through a defect in the visceral pleura. In this case, the lung collapses and is switched off from breathing (lung collapse).
With a closed pneumothorax, air that has entered the pleural cavity and caused partial and complete collapse of the lung subsequently loses contact with atmospheric air and does not cause a threatening condition.
With valve pneumothorax, air freely enters the pleural cavity during inspiration, but its exit is difficult due to the presence of a valve mechanism.
According to their prevalence, they are divided into: total and partial pneumothorax.
Depending on the presence of complications: uncomplicated and complicated (bleeding, pleurisy, mediastinal emphysema).

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic:
1. History taking
2. Inspection, auscultation and percussion of the chest
3. General blood test
4. General urine test
5. Biochemical blood tests
6. Blood for blood type and Rh factor
7. Blood coagulogram
8. Microreaction
9. Blood test for hepatitis and HIV
10. Feces on worm eggs
11. ECG
12. Radiography in two projections

Additional:
1. Computed tomography of the chest organs in spiral mode
2. Fiberoptic bronchoscopy
3. Consultations with specialists (according to indications)

Diagnostic tactics at the outpatient (prehospital) stage:
- If sudden (spontaneous) pain appears in the chest and suspicion of SP occurs, a chest x-ray (in anterior and lateral projections) is indicated.
- If it is impossible to carry out radiography, it is necessary to send the patient to a surgical hospital.

Diagnostic tactics in a general surgical hospital.
The main goal of diagnostics in a surgical hospital is to establish an accurate diagnosis and determine therapeutic and surgical tactics.
- X-ray of the chest organs in frontal and lateral projections during exhalation (direct observation, lateral projection on the side of pneumothorax);
- CT scan of the chest in a spiral mode (additionally, according to indications);
It is recommended to use computed tomography for differential diagnosis pneumothorax and bullous emphysema, if there is a suspicion of improper placement of drainage and in cases where the interpretation of a chest X-ray is difficult due to the presence of subcutaneous emphysema (level C).

Diagnostic tactics in the thoracic department.
To determine the cause of spontaneous pneumothorax, it is recommended to perform a CT examination of the thoracic segment and, based on its results, make a decision on planned surgical treatment.

Diagnostic criteria
SP in most cases occurs at a young age and is characterized by a relapsing course.
The reasons for SP may be:
1. Pulmonary emphysema, most often bullous (71-95%)
2. COPD
3. Cystic fibrosis
4. Bronchial asthma
5. Rheumatoid arthritis
6. Ankylosing spondylitis
7. Dermatomyositis
8. Systemic scleroderma
9. Marfan syndrome
10. Ehlers-Danlos syndrome
11. Idiopathic pulmonary fibrosis
12. Sarcoidosis
13. Histiocytosis X
14. Lymphangioleiomyomatosis
15. Pulmonary endometriosis

Complaints and anamnesis:
In the classic version, the joint venture begins with the appearance of:
- sudden pain in the chest,
- non-productive cough,
- shortness of breath.
In 15 - 21% of cases, pneumothorax is asymptomatic or with a blurred clinical picture without characteristic complaints of respiratory failure. .

Physical examination:
The main signs of pneumothorax during an objective examination of the patient are:
- forced position, pale skin, cold sweat and/or cyanosis
- expansion of the intercostal spaces, lag in breathing of the affected half of the chest, swelling and pulsation of the neck veins, subcutaneous emphysema is possible.
- upon percussion, weakening or absence of vocal tremor on the affected side, tympanic sound (with the accumulation of fluid in the pleural cavity in the lower parts, dullness is determined), displacement of the area of ​​the apical impulse and the boundaries of cardiac dullness to the healthy side.
- weakening of breathing upon auscultation
In the process of diagnosis and selection of treatment tactics, complicated forms of spontaneous pneumothorax require a special approach:
- tension pneumothorax
- hemothorax, ongoing intrapleural bleeding
- bilateral pneumothorax
- pneumomediastinum.

Laboratory research: not informative

Instrumental studies:
- X-ray of the chest organs in frontal and lateral projections on exhalation (direct view, lateral projection on the side of pneumothorax): a collapsed lung is determined, the presence of free air; :
- ECG (for the purpose of differential diagnosis with ischemic heart disease);
- CT scan of the chest in a spiral mode: CT picture of pneumothorax, bullous changes. :

Indications for consultation with specialists:
Specialists of a different profile - in the presence of corresponding concomitant pathology or in case of secondary and recurrent pneumothorax during planned hospitalization.
Anesthesiologist: to determine the type of anesthesia if surgical intervention is necessary, as well as to coordinate the tactics of managing the preoperative period.
Resuscitator: to determine indications for treating a patient in an intensive care unit, to coordinate the tactics of managing a patient with SP.

Differential diagnosis

Differential diagnosis:

Nosologies	Characteristic syndromes or symptoms	Differentiation test
IHD	Acute pain behind the sternum, squeezing in nature, radiating to the left upper limb. There may be a history of angina or the presence of risk factors (smoking, arterial hypertension, diabetes mellitus, obesity).	ECG - signs of ischemia (ST segment isoline, T wave inversion, left bundle branch block)
Lower lobe pneumonia	Productive cough with fever, auscultation - bronchial breathing, crepitating rales, dullness on percussion.	X-ray - darkening in the lower parts of the lung on the affected side.

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Treatment

Treatment goals: Complete expansion of the lung on the side of the pneumothorax.

Treatment tactics

Non-drug treatment
Diet: table No. 15, bed rest during hospitalization.

Drug treatment
Antibiotic therapy is not the main conservative treatment method. Its main purpose is preventive and for complicated forms of SP. The duration of therapy in the postoperative period depends on the characteristics clinical course. In complicated cases, it can be prolonged according to indications. No symptoms of fever for 24 hours, normal indicators leukocytes in the blood are criteria for stopping antibiotic therapy.

Other treatments

Surgical intervention

Treatment tactics at the outpatient (prehospital) stage
In case of tension pneumothorax, puncture or drainage is indicated on the side of the pneumothorax in the II intercostal space along the midclavicular line or along the lateral surface of the chest in the III-VII intercostal space for the purpose of decompression of the pleural cavity

Treatment tactics in a general surgical hospital
"Minor surgery" - Drainage of the pleural cavity: The pleural cavity should be drained with drainage with a diameter of at least 14 Fr -18 Fr with active aspiration with a vacuum of 20-40 cm of water. Art. or according to Bulau. (level B)
Active aspiration of the pleural cavity using vacuum aspirators (stationary and portable).

To decide on further management tactics, an examination by a thoracic surgeon is necessary.

N/B! SP with ongoing intrapleural bleeding, tension pneumothorax against the background of a drained pleural cavity is an indication for emergency or urgent surgery. After elimination of complications, pleural induction is required. Anti-relapse surgery is not recommended for patients with uncomplicated course of SP in a non-specialized surgical hospital.

Treatment tactics in the thoracic department
- when a patient is admitted to the thoracic department after an X-ray examination, if it is impossible to perform an urgent CT scan, a diagnostic thoracoscopy is performed. Depending on changes in the pleural cavity, the procedure can be completed by draining the pleural cavity or performing anti-relapse surgical treatment.
- if a patient with SP is transferred from another medical institution with an already drained pleural cavity, it is necessary to assess the adequacy of the drainage function. If the drainage is functioning adequately and diagnostic thoracoscopy has been performed in another medical institution, repeated drainage is not required, and the decision on the need for anti-relapse surgery is made based on the established cause of SP.
- if air flow through the drains continues for 72 hours, thoracoscopic surgery or video-assisted mini-thoracotomy is also indicated. The extent of surgery depends on the specific intraoperative finding.
- in case of relapse of SP, it is necessary to drain the pleural cavity, achieving expansion of the lung. Surgical treatment should be carried out in a delayed or planned manner.

N/B! Anti-relapse treatment is surgery in the chest cavity to identify and eliminate the cause of pneumothorax, as well as induce pleura in one way or another to prevent recurrence of pneumothorax.

After any method of treating spontaneous pneumothorax, conservative or surgical, relapses are possible.

N/B! If the patient refuses hospitalization, the patient and his relatives should be warned about possible consequences. The situation must be documented by an appropriate entry in the medical record and medical history.

It is preferable to perform anti-relapse surgery in a low-traumatic manner using video-assisted thoracoscopic technology or video-assisted technology (VATS). (level C). If technical difficulties are expected during thoracoscopy, surgery from a thoracotomy or sternotomy approach is possible. .
For patients who need anti-relapse treatment, but have contraindications to surgical treatment, pleural induction and pleurodesis using chemical sclerosants introduced into the drainage or through a trocar are possible.

The purpose of surgical intervention for SP:
1. Inspection of the lung and pleural cavity with elimination of the source of air intake by:
- resection of bullae
- dressings of bullae
- suturing of broncho-pleural fistula
- coagulation bullae
- excision, suturing or stitching of other bullae that do not contain a defect
- pleurectomy
- pleurodesis
- economical resection of the lobe
Regardless of the presence or absence of bullous changes, a biopsy of the lung tissue is necessary.

N/B! The volume and method of surgical treatment is determined by the severity and nature of changes in the lung and pleural cavity, the presence of complications, the age and functional state of the patient. Surgical tactics may change intraoperatively.

Preventive actions: There is no special prevention of SP.

Further management
In the postoperative period, the pleural cavity is drained by one or more drainages, depending on the type and volume of surgery. Drains with a diameter of at least 12 Fr. In the early postoperative period, active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is indicated. Art. (level D).
To control the expansion of the lung, a dynamic X-ray examination is performed. The amount is determined by the thoracic surgeon according to indications individually for each patient.
The criteria for the possibility of removing pleural drainage are: complete expansion of the lung according to X-ray examination, no air flow through the drainage for 24 hours, and discharge through the pleural drainage of less than 150 ml/day.
Before removal of chest tubes, patients are advised to receive prophylactic antibiotic therapy.
Discharge in an uncomplicated postoperative period is possible after removal of the pleural drainage, with mandatory X-ray monitoring before discharge.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- complete expansion of the lung, determined radiographically;
- cessation of air flow through the pleural drainage for 24 hours.
Despite the mandatory implementation of all points of the protocol, there must be a personalized and individual approach to each patient based on the actual clinical situation.

Groups of drugs according to ATC used in treatment

Hospitalization

Indications for hospitalization
Emergency hospitalization with an x-ray confirmed diagnosis of SP.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. J. Rivas de Andres, MJimenez Lopez, L. Molins Lopez – Rodd, A. Perez Trullen, J. Torres Lanzase. Recommendations of the Spanish Society of Pulmonology and Thoracis Surgery (SEPAR). Guidelines for the diagnosis and treatment of spontaneous pneumothorax. Ach. Bronconeumol. 2008; 44(8): 437-448. 2. Avilova O.M., Getman V.G., Makarov A.V. Thoracoscopy in emergency thoracic surgery. Kyiv. “Healthy, I” 1986 - 128 p. 3. Akhmed D.Yu. Surgery of small accesses in the correction of spontaneous pneumothorax // Diss... Cand.-M., 2000.-102 p. 4. Bisenkov L.N. Thoracic surgery. Guide for doctors. Saint Petersburg. "ELBI-SPB".2004-928s.ill. 5. Perelman M.I. Current problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16. 6. Katz D.S., Mas K.R., Groskin S.A. Secrets of radiology. Saint Petersburg. 2003 7. Kolos A.I., Rakishev G.B., Takabaev A.K. Current issues in thoracic surgery. Educational and methodological manual. Almaty “Alash” 2006.-147p. 8. Kuzin M.I., Adamyan A.A., Todua F.I. and others. The importance of computed tomography in thoracic surgery // Thoracic and cardiovascular surgery. – 2002. - No. 4. – pp. 49-54. 9. Pakhomov G.A., Khayamov R.Ya. Tactics of treatment of bullae, emphysema, complicated by spontaneous pneumothorax // Materials of the XIV International Congress on Pulmonology. – M., 2004. – P. 303. 10. Putov N.V., Fedoseev G.B. Guide to Pulmonology. – L., 1978. – 385 p. 11. Chukhrienko D.P., Danilenko M.V., Bondarenko V.A., Bely I.S. Spontaneous (pathological) pneumothorax. M. Medicine. 1973 - 296 pp. 12. Yasnogorodsky O.O. Video-assisted intrathoracic interventions // Diss...doct., M., 2000. - 182 p.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers:
Takabaev A.K. - Candidate of Medical Sciences, thoracic surgeon, Associate Professor of the Department of Surgical Diseases No. 2 of the FNPRiDO JSC "Astana Medical University".

Reviewers:
Turgunov E.M. - Doctor of Medical Sciences, Professor, surgeon of the highest qualification category, Head of the Department of Surgical Diseases No. 2 of the RSE at the Karaganda State medical University» Ministry of Health of the Republic of Kazakhstan, independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.

Disclosure of no conflict of interest: There is no conflict of interest.

Indication of the conditions for reviewing the protocol: The protocol is subject to revision once every 3 years, or when new proven data on the surgical treatment of pneumothorax becomes available.

Attached files

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Other spontaneous pneumothorax (J93.1)

Thoracic surgery, Surgery

general information

Short description

Definition:

Spontaneous pneumothorax (SP) is a syndrome characterized by the accumulation of air in the pleural cavity, not associated with lung injury and medical manipulations.

ICD 10 code: J93.1

Prevention:
Induction of pleurodesis, that is, the formation of adhesions in the pleural cavity, reduces the risk of recurrent pneumothorax [A].
Quitting smoking reduces both the risk of developing pneumothorax and the risk of its recurrence [ C].

Screening:
Screening is not applicable for primary pneumothorax.
For secondary - it is aimed at identifying diseases that provoke the development of spontaneous pneumothorax.

Classification

Classifications

Table 1. Classification of spontaneous pneumothorax

By etiology:
1. Primary is a pneumothorax that occurs without obvious causes in previously healthy individuals.	Caused by primary bullous pulmonary emphysema
	Caused by primary diffuse pulmonary emphysema
	Caused by avulsion of the pleural commissure
2. Secondary- pneumothorax occurring against the background of existing progressive pulmonary pathology.	Caused by respiratory tract disease (see Table 2)
	Caused by interstitial lung disease (see Table 2)
	Caused by systemic disease (see Table 2)
	Catamenial (recurrent SP associated with menstruation and occurring within 24 hours before their onset or in the next 72 hours)
	For ARDS in patients on mechanical ventilation
By frequency of education:	First episode
	Relapse
By mechanism:	Closed
	Valve
According to the degree of lung collapse:	Apical (up to 1/6 of the volume - a strip of air located in the dome of the pleural cavity above the collarbone)
	Small (up to 1/3 of the volume - a strip of air no more than 2 cm paracostally)
	Medium (up to ½ volume - air strip 2-4 cm paracostally)
	Large (over ½ volume - air strip more than 4 cm paracostal)
	Total (lung completely collapsed)
	Limited (with adhesions in the pleural cavity)
On the side:	One-sided (right-sided, left-sided)
	Bilateral
	Pneumothorax of a single lung
For complications:	Uncomplicated
	Tense
	Respiratory failure
	Soft tissue emphysema
	Pneumomediastinum
	Hemopneumothorax
	Hydropneumothorax
	Pyopneumothorax
	Rigid

Table 2. The most common causes of secondary pneumothorax

Note: The accumulation of air in the pleural cavity resulting from rupture of cavities of destruction of lung tissue (in tuberculosis, abscess pneumonia and cavitary lung cancer) should not be classified as secondary pneumothorax, since in these cases acute pleural empyema develops.

Diagnostics

Diagnostics:

Diagnosis of SP is based on the clinical manifestations of the disease, objective and radiological examination data.

In the clinical picture, the main place is occupied by: pain in the chest on the side of the pneumothorax, often radiating to the shoulder, shortness of breath, dry cough.

Rare complaints - usually appear in complicated forms of SP. Changes in voice timbre, difficulty swallowing, an increase in the size of the neck and chest occur with pneumomediastinum and subcutaneous emphysema. With hemopneumothorax, the manifestations of acute blood loss come to the fore: weakness, dizziness, orthostatic collapse. Palpitations and a feeling of interruptions in the heart (arrhythmia) are characteristic of tension pneumothorax. Late complications of pneumothorax (pleurisy, empyema) lead to the patient developing symptoms of intoxication and fever.

With secondary SP, even if it is small in volume, there is a more pronounced clinical symptoms, in contrast to the primary joint venture [D].

An objective examination reveals a lag in breathing of half the chest, sometimes widening of the intercostal spaces, a tympanic tone during percussion, weakening of breathing and weakening of vocal tremor on the side of the pneumothorax.

For tension pneumothorax clinical manifestations more pronounced [D].

It is mandatory to take radiographs in frontal and lateral projections during inspiration, which are sufficient to make a diagnosis of pneumothorax [A]. In doubtful cases, it is necessary to take an additional expiratory photograph in a direct projection.

The main radiological symptoms of SP are:

• absence of a pulmonary pattern in the peripheral parts of the corresponding hemithorax;
• visualization of the outlined edge of the collapsed lung;

With severe lung collapse, additional radiological symptoms may be detected:

• shadow of a collapsed lung;
• symptom of deep furrows (in lying patients);
• mediastinal shift;
• changing the position of the diaphragm.

When assessing radiographs, it is necessary to remember the possibility of limited pneumothorax, which, as a rule, has an apical, paramediastinal or supradiaphragmatic localization. In these cases, it is necessary to perform inspiratory and expiratory radiographs, the comparison of which provides complete information about the presence of limited pneumothorax.
An important task of x-ray examination is to assess the condition of the lung parenchyma, both the affected and the opposite lung.

When assessing radiographs, pneumothorax should be differentiated from giant bullae, destructive processes in the lungs, and dislocation of hollow organs from the abdominal cavity to the pleural cavity.

Before draining the pleural cavity, it is necessary to perform radiography in 2 projections or polypositional fluoroscopy to determine the optimal drainage point [D].

Spiral computed tomography (SCT) of the chest plays a major role in determining the causes of pneumothorax and differential diagnosis of SP with other pathologies. SCT should be performed after drainage of the pleural cavity and the maximum possible expansion of the lung. With SCT they evaluate following signs: the presence or absence of changes in the pulmonary parenchyma, such as infiltration, disseminated process, interstitial changes; unilateral or bilateral bullous changes; diffuse emphysema.
Indicators of laboratory tests in cases of uncomplicated spontaneous pneumothorax, as a rule, are not changed.

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Treatment

Treatment:
All patients with pneumothorax should be urgently hospitalized in thoracic surgical hospitals, and if impossible, in emergency surgical hospitals.

Treatment goals for spontaneous pneumothorax:

• expansion of the lung;
• cessation of air flow into the pleural cavity;
• prevention of disease relapse;

The fundamental points for determining surgical tactics for pneumothorax are: the presence of respiratory and, even to a greater extent, hemodynamic disorders, the frequency of formation, the degree of lung collapse and the etiology of pneumothorax. In all cases, it is necessary to clarify the nature of changes in the pulmonary parenchyma before surgery using all possible methods, preferably SCT.
Emergency surgical care for spontaneous pneumothorax should be aimed, first of all, at decompressing the pleural cavity and preventing respiratory and circulatory disorders, and only then at performing radical surgery.
Tension pneumothorax occurs in cases where a defect in the lung functions as a valve, while an increase in intrapleural pressure leads to a total collapse of the lung, a progressive decrease in alveolar ventilation on the affected side, and then on the healthy side, pronounced shunting of the blood flow, as well as a shift of the mediastinum to the healthy side side, leading to a decrease in stroke volume of blood circulation up to extrapericardial cardiac tamponade.

Treatment methods for spontaneous pneumothorax:

• conservative - dynamic observation;
• pleural puncture;
• drainage of the pleural cavity;
• chemical pleurodesis through pleural drainage;
• surgical intervention.

1. Dynamic observation
Conservative treatment involves clinical and radiological monitoring, in combination with a protective regimen, pain relief, oxygen therapy and, if indicated, preventive antibacterial therapy.
Observation, as the method of choice, is recommended for small, non-strained primary SP occurring without respiratory failure [ B].
For small apical or limited pneumothorax, the risk of pleural puncture exceeds its therapeutic value [ D]. Air from the pleural cavity is resorbed at a rate of about 1.25% of the volume of the hemithorax in 24 hours, and oxygen inhalation increases the rate of air resorption from the pleural cavity by 4 times.

2. Pleural puncture
Indicated for patients under 50 years of age with the first episode of spontaneous pneumothorax with a volume of 15 - 30% without severe dyspnea. The puncture is performed using a needle or, preferably, a thin stylet catheter. A typical place for puncture is the 2nd intercostal space along the midclavicular line or the 3rd - 4th intercostal space along the midaxillary line, however, the puncture point should be determined only after a polypositional x-ray examination, which makes it possible to clarify the localization of adhesions and the largest accumulations of air. It is important to remember that if the first puncture is ineffective, repeated attempts at aspiration are successful in no more than one third of cases [B].
If the lung does not expand after pleural puncture, drainage of the pleural cavity is recommended. [A].

3. Drainage of the pleural cavity
Drainage of the pleural cavity is indicated when pleural puncture is ineffective; with large SP, with secondary SP, in patients with respiratory failure, and in patients over 50 years of age [B].
Drainage should be installed at a point selected based on the results of the x-ray examination. In the absence of adhesions, drainage is performed in the 3rd - 4th intercostal space along the mid-axillary line or in the 2nd intercostal space along the midclavicular line.
The most common methods of drainage of the pleural cavity for pneumothorax are stylet and trocar. You can also install drainage through a guidewire (Seldinger technique) or using a clamp. The procedure for drainage of the pleural cavity is performed under aseptic conditions in dressing room or operating room.
The drainage is inserted to a depth of 2 - 3 cm from the last hole (inserting the tube too deeply will not allow it to function adequately, and the location of the holes in the soft tissues can lead to the development of tissue emphysema) and is securely fixed with skin sutures. Immediately after drainage, the drainage is lowered to the bottom of a jar with an antiseptic solution (Bulau drainage) and subsequently connected to a pleuroaspirator. The pleural cavity is carried out using active aspiration with individual selection of vacuum until air discharge stops. It should be taken into account that with prolonged lung collapse before hospitalization, the risk of developing reperfusion pulmonary edema after its expansion increases. [D].

Diagnostic thoracoscopy (DT), performed during drainage.
If it is impossible to perform SCT urgently, to identify the cause of pneumothorax and determine further tactics, it is advisable to perform diagnostic thoracoscopy during drainage. It should be taken into account that DT does not provide a complete opportunity to identify intrapulmonary changes.
The operation is performed under local anesthesia on the side of the pneumothorax, with the patient lying on the healthy side. The location for installing the thoracoport is selected based on the results of an X-ray examination. In patients with complete lung collapse, a thoracoport is installed in the 4th or 5th intercostal space along the mid-axillary line.
The pleural cavity is sequentially inspected (the presence of exudate, blood, adhesions), the lung is examined (blebs, bullae, fibrosis, infiltrative, focal changes), and in women the diaphragm is specifically assessed (scars, through defects, pigment spots). Macroscopic changes in the pulmonary parenchyma and pleural cavity identified during DT should be assessed according to the classification of Vanderschuren R. (1981) and Boutin C. (1991).

Classification of morphological types detected in the pleural cavity and pulmonary parenchyma in patients with spontaneous pneumothorax
(Vanderschuren R. 1981, Boutin C. 1991).
Type I - absence of visual pathology.
Type II - the presence of pleural adhesions in the absence of changes in the lung parenchyma.
Type III - small subpleural bullae less than 2 cm in diameter.
Type IV - large bullae, more than 2 cm in diameter.

The operation is completed by draining the pleural cavity. The pleural cavity is maintained under active aspiration until air discharge stops. Active aspiration with a vacuum of 10-20 cm of water column is considered optimal. [ B]. However, the most beneficial is aspiration with the minimum vacuum at which the lung fully expands. The method for choosing the optimal vacuum is as follows: under fluoroscopy control, we reduce the vacuum to the level when the lung begins to collapse, after which we increase the vacuum by 3 - 5 cm of water. Art. When complete expansion of the lung is achieved, there is no passage of air for 24 hours and fluid intake is less than 100-150 ml, the drainage is removed. There is no exact timing for drainage removal; aspiration should be carried out until the lung is completely expanded. X-ray monitoring of lung expansion is performed daily. If air flow from the pleural cavity ceases within 12 hours, the drainage is closed for 24 hours and then an x-ray is taken. If the lung remains expanded, the drainage is removed. The next day after removal of the drainage, it is necessary to perform a control x-ray of the chest to confirm the elimination of pneumothorax.
If, despite drainage, the lung does not expand and the flow of air through the drainage continues for more than 3 days, urgent surgical treatment is indicated.

4. Chemical pleurodesis
Chemical pleurodesis is a procedure in which substances are introduced into the pleural cavity, leading to aseptic inflammation and the formation of adhesions between the visceral and parietal layers of the pleura, which leads to obliteration of the pleural cavity.
Chemical pleurodesis is used when it is impossible for some reason to perform radical surgery. [B].
The most powerful sclerosing agent is talc; its introduction into the pleural cavity is rarely accompanied by the development of respiratory distress syndrome and pleural empyema [ A] . Studies of 35 years of results from the use of asbestos-free chemically pure talc have proven that it is not carcinogenic [ A]. The talc pleurodesis technique is quite labor-intensive and requires spraying 3-5 grams of talc using a special sprayer introduced through a trocar before draining the pleural cavity.
It is important to remember that talc does not cause an adhesive process, but granulomatous inflammation, as a result of which the parenchyma of the mantle zone of the lung fuses with the deep layers of the chest wall, which causes extreme difficulties for subsequent surgical intervention. Therefore, indications for talc pleurodesis should be strictly limited to only those cases (senile age, severe concomitant diseases) when the likelihood that subsequent surgery in the obliterated pleural cavity will be required is minimal.
The next most effective drugs for pleurodesis are antibiotics of the tetracycline group (doxycycline) and bleomycin. Doxycycline should be administered at a dose of 20 - 40 mg/kg, if necessary, the procedure can be repeated the next day. Bleomycin is administered at a dose of 100 mg on the first day and, if necessary, pleurodesis of bleomycin 200 mg is repeated on subsequent days. Due to the severity of pain during pleurodesis with tetracycline and bleomycin, it is necessary to dilute these drugs in 2% lidocaine and be sure to premedicate with narcotic analgesics [WITH]. After drainage, the drug is administered through a drain, which is clamped for 1 - 2 hours, or, with constant air release, passive aspiration is carried out according to Bulau. During this time, the patient must constantly change body position to evenly distribute the solution over the entire surface of the pleura.
When the lung is not expanded, chemical pleurodesis through pleural drainage is ineffective, since the layers of the pleura do not touch and adhesions do not form. In addition, in this situation, the risk of developing pleural empyema increases.
Although other substances are used in clinical practice: sodium bicarbonate solution, povidone iodine, ethanol, 40% glucose solution, etc., it should be remembered that there is no evidence of the effectiveness of these drugs.

5. Use of endobronchial valves and obturators
If air discharge continues and it is impossible to expand the lung, one of the methods is bronchoscopy with the installation of an endobronchial valve or obturator. The valve is installed for 10-14 days using both a rigid bronchoscope under anesthesia and a fiberoptic bronchoscope under local anesthesia.
In most cases, a valve or obturator allows the defect to be sealed and leads to expansion of the lung.

6. Surgical treatment

Indications and contraindications
Indications for emergency and urgent surgery:
1. hemopneumothorax;
2. tension pneumothorax with ineffective drainage.
3. continued release of air when it is impossible to expand the lung
4. continued air release for more than 72 hours with the lung expanded

Indications for planned surgical treatment:
1. recurrent, including contralateral pneumothorax;
2. bilateral pneumothorax;
3. the first episode of pneumothorax when bullae or adhesions are detected (II-IV type of changes according to Vanderschuren R. and Boutin C.);
4. endometriosis-dependent pneumothorax;
5. suspicion of secondary pneumothorax. The operation is of a therapeutic and diagnostic nature;
6. professional and social indications - patients whose work or hobbies are associated with changes in blood pressure respiratory tract(pilots, parachutists, divers and musicians playing wind instruments).
7. rigid pneumothorax

Basic principles of surgical treatment of spontaneous pneumothorax
Surgical tactics for spontaneous pneumothorax are as follows. After a physical and polypositional X-ray examination, which allows one to assess the degree of lung collapse, the presence of adhesions, fluid, and mediastinal displacement, it is necessary to perform a puncture or drainage of the pleural cavity.
At the first episode of pneumothorax an attempt at conservative treatment is possible - puncture or drainage of the pleural cavity. If the treatment is effective, SCT should be performed, and if bullae, emphysema and interstitial lung diseases are detected, elective surgery should be recommended. If there are no changes in the lung parenchyma that are subject to surgical treatment, then we can limit ourselves to conservative treatment, recommending that the patient adhere to a regimen of physical activity and SCT monitoring once a year. If drainage does not lead to expansion of the lung and air flow through the drains continues for 72 hours, urgent surgery is indicated.

If pneumothorax recurs surgery is indicated, however, it is always preferable to first perform drainage of the pleural cavity, achieve expansion of the lung, then perform a CT scan, assess the condition of the lung tissue, paying special attention to signs of diffuse emphysema, COPD, interstitial diseases and processes of destruction of lung tissue; and perform the operation as planned. The preferred approach is thoracoscopic. The exceptions remain rare cases of complicated pneumothorax (continuing massive intrapleural bleeding, fixed lung collapse), intolerance to one-lung ventilation.
Surgical techniques for the surgical treatment of pneumothorax can be divided into three stages:
audit,
surgery on a modified area of ​​the lung,
obliteration of the pleural cavity.

Revision technique for spontaneous pneumothorax
Thoracoscopic examination allows not only to visualize changes in lung tissue characteristic of a particular disease, but also, if necessary, to obtain biopsy material for morphological verification of the diagnosis. To assess the severity of emphysematous changes in the parenchyma, it is most advisable to use the R. Vanderschuren classification. A thorough assessment of the severity of emphysematous changes makes it possible to predict the risk of recurrent pneumothorax and make an informed decision about the type of operation aimed at obliterating the pleural cavity.
The success of the operation depends to the greatest extent on whether the source of air supply was found and eliminated. The frequently held opinion that with thoracotomy it is easier to detect the source of air intake is only partly true. According to a number of studies, the source of air intake cannot be detected in 6 - 8% of cases of spontaneous pneumothorax.
As a rule, these cases are associated with the entry of air through the micropores of an unruptured bulla or occur when a thin pleural adhesion is torn off.
To detect the source of air intake, the following technique is advisable. Pour 250 - 300 ml of sterile solution into the pleural cavity. The surgeon presses all suspicious areas one by one with an endoscopic retractor, immersing them in liquid. The anesthesiologist connects the open bronchial canal of the endotracheal tube to the Ambu bag and, at the surgeon’s command, takes a small breath. As a rule, with a thorough sequential inspection of the lung, it is possible to detect the source of air intake. As soon as you can see a chain of bubbles rising from the surface of the lung, you should, carefully manipulating the retractor, turn the lung so that the source of air intake is as close as possible to the surface of the sterile solution. Without removing the lung from under the liquid, it is necessary to grasp its defect with an atraumatic clamp and make sure that the air supply has stopped. After this, the pleural cavity is drained and suturing of the defect or lung resection begins. If, despite a thorough inspection, the source of air intake could not be detected, it is necessary not only to eliminate the existing intact bullae and blebs, but also, without fail, to create conditions for obliteration of the pleural cavity - to perform pleurodesis or endoscopic parietal pleurectomy.

Pulmonary stage of the operation
The operation of choice is resection of the altered area of ​​the lung (marginal, wedge-shaped), which is performed using endoscopic staplers that ensure the formation of a reliable hermetically sealed mechanical suture.
In some cases, the following interventions may be performed:
1. Electrocoagulation of blebs
2. Opening and suturing of bullae
3. Plication of bullae without opening
4. Anatomical lung resection

For blebs, electrocoagulation can be performed, the lung defect can be sutured, or the lung can be resected within healthy tissue. Electrocoagulation of the bleb is the simplest and, with careful adherence to the technique, reliable operation. Before coagulating the surface of the bleb, it is necessary to carefully coagulate its base. After coagulation of the underlying lung tissue, the coagulation of the bleb itself begins, and one should strive to ensure that the wall of the bleb is “welded” to the underlying lung tissue, using a non-contact coagulation mode for this. Ligation using a Raeder loop, advocated by many authors, should be considered risky, since the ligature may slip off during lung reexpansion. Suturing with the EndoStitch device or manual endoscopic suture is much more reliable. The suture must be placed 0.5 cm below the base of the bleb and the lung tissue must be tied on both sides, after which the bleb can be coagulated or cut off.
For bullae, endoscopic suturing of the underlying parenchyma or lung resection using an endostapler should be performed. Coagulation of bullae cannot be used. If a single bulla ruptures no more than 3 cm in size, the lung tissue supporting the bulla can be sutured using a hand suture or the EndoStitch device. In the presence of multiple bullae or blebs localized in one lobe of the lung, if single giant bullae are ruptured, an atypical resection of the lung should be performed within healthy tissue using an endoscopic stapler. More often with bullae it is necessary to perform marginal resection, less often - wedge-shaped. When wedge-shaped resection of the 1st and 2nd segments, it is necessary to mobilize the interlobar groove as much as possible and perform the resection by sequentially applying a stapler from the root to the periphery of the lung along the border of healthy tissues.
Indications for endoscopic lobectomy in patients with SP are extremely limited; it should be performed for cystic hypoplasia of the lung lobe. This operation is much more technically difficult and can only be recommended to surgeons with extensive experience in thoracoscopic surgery. To make endoscopic lobectomy easier, you can open the cysts using endoscopic scissors with coagulation before proceeding to the treatment of the root lobe elements. After opening the cysts, the lobe collapses, providing optimal conditions for manipulation at the root of the lung. Endoscopic isolation of the lobar artery and vein, as in traditional surgery, must be performed in accordance with the “golden rule of Overhold”, first treating the visible anterior, then the lateral and only then the posterior wall of the vessel. It is easier to suture selected lobar vessels using the EndoGIA II Universal or Echelon Flex device with a white cassette. In this case, it is technically easier to bring it under the vessel “upside down”, i.e. not a cassette, but a thinner mating part of the device downwards. The bronchus should be sutured and crossed using a stapler with a blue or green cassette. Removing a lobe of the lung from the pleural cavity with cystic hypoplasia, as a rule, does not cause difficulties and can be performed through an extended trocar injection.
Endoscopic anatomical resection of the lung is technically complex and requires a large number of expensive consumables. Video-assisted lobectomy from a mini-access does not have these disadvantages, and the course of the postoperative period does not differ from that of endoscopic lobectomy.
The technique for performing video-assisted lobectomy was developed in detail and introduced into clinical practice by T.J. Kirby. The technique is as follows. The optical system is inserted into the 7-8 intercostal space along the anterior axillary line and a thorough visual inspection of the lung is performed. The next thoracoport is installed in the 8-9 intercostal space along the posterior axillary line. The lobe is isolated from the adhesions and the pulmonary ligament is destroyed. Then the intercostal space is determined, the most convenient for manipulations on the root of the lobe, and a mini-thoracotomy 4-5 cm long is performed along it, through which standard surgical instruments are passed - scissors, a pulmonary clamp and dissectors. The intersection of vessels is carried out using the UDO-38 apparatus, with mandatory additional ligation of the central stump of the vessel. The bronchus is carefully isolated from the surrounding tissue and lymph nodes, then sutured with a UDO-38 device and transected.
Particular technical difficulties are presented by pneumothorax caused by diffuse emphysema. Attempts to simply suturing a rupture of emphysematous pulmonary tissue are, as a rule, futile, since each suture becomes a new and very strong source of air entry. In this regard, preference should be given to modern stitching machines that use cassettes with gaskets - or sutures using gaskets.
Both synthetic materials, for example, Gore-Tex, and free flaps of biological tissue, for example, a pleural flap, can be used as a gasket. Good results are obtained by strengthening the seam with an application of Tahocomb plate or BioGlue glue.

Obliteration of the pleural cavity
In the British Society of Thoracic Surgeons Guidelines, 2010. [ A] The results of studies of the 1st and 2nd level of evidence are summarized, on the basis of which it was concluded that pulmonary resection in combination with pleurectomy is a technique that provides the lowest percentage of relapses (~ 1%). Thoracoscopic resection and pleurectomy are comparable in recurrence rate to open surgery, but are more preferable in terms of pain, duration of rehabilitation and hospitalization, and restoration of external respiratory function.

Methods of obliteration of the pleural cavity
Chemical pleurodesis during thoracoscopy is performed by applying a sclerosing agent - talc, tetracycline solution or bleomycin - to the parietal pleura. The advantages of pleurodesis under the control of a thoracoscope are the ability to treat the entire surface of the pleura with a sclerosing agent and the painlessness of the procedure.
You can perform mechanical pleurodesis using special thoracoscopic instruments for abrading the pleura or, in a simpler and more effective version, pieces of sterilized metal sponge used in everyday life for washing dishes. Mechanical pleurodesis, performed by wiping the pleura with tuffers, is ineffective due to their rapid wetting, and cannot be recommended for use.
Physical methods of pleurodesis also give good results; they are simple and very reliable. Among them, it should be noted the treatment of the parietal pleura with electrocoagulation - in this case, it is more advisable to use coagulation through a gauze ball moistened with saline solution; This method of pleurodesis is characterized by a larger area of ​​influence on the pleura with a smaller depth of current penetration. The most convenient and effective methods of physical pleurodesis are the destruction of the parietal pleura using an argon plasma coagulator or an ultrasonic generator.
A radical operation for obliteration of the pleural cavity is endoscopic pleurectomy. This operation should be performed according to the following procedure. Using a long needle, saline solution is injected subpleurally into the intercostal spaces from the apex of the lung to the level of the posterior sinus. Along the spine at the level of the costovertebral joints, the parietal pleura is dissected along its entire length using an electrosurgical hook. Then the pleura is dissected along the lowest intercostal space at the level of the posterior phrenic sinus. The corner of the pleural flap is grasped with a clamp, and the pleural flap is peeled off from the chest wall. The pleura detached in this way is cut off with scissors and removed through a thoracoport. Hemostasis is carried out using a ball electrode. Preliminary hydraulic preparation of the pleura makes the operation easier and safer.

Features of surgical tactics for pneumothorax in patients with extragenital endometriosis
In women with SP, the cause of the disease may be extragenital endometriosis, which includes endometrial implants on the diaphragm, parietal and visceral pleura, as well as in lung tissue. During surgery, if damage to the diaphragm is detected (fenestration and/or implantation of the endometrium), it is recommended to use resection of its tendon part or suturing of defects, plication of the diaphragm or plastic surgery with a synthetic polypropylene mesh, supplemented by costal pleurectomy. Most authors [ B] consider it necessary to carry out hormonal therapy (danazol or gonadotropin-releasing hormone), the purpose of which is to suppress menstrual function and prevent recurrence of pneumothorax after surgery.

Postoperative treatment in uncomplicated cases
1. The pleural cavity is drained with two drains with a diameter of 6-8 mm. In the early postoperative period, active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is indicated. Art.
2. To control the expansion of the lung, a dynamic X-ray examination is performed.
3. The criteria for the possibility of removing pleural drainage are: complete expansion of the lung according to X-ray examination, absence of air and exudate through the drainage within 24 hours.
4. Discharge in an uncomplicated postoperative period is possible one day after removal of the pleural drainage, with mandatory X-ray monitoring before discharge.

Tactics of examination and treatment of patients with SP depending on the category of medical institution.

1. Organization of diagnostic and treatment care at the prehospital stage:
1. Any pain in the chest requires the targeted exclusion of spontaneous pneumothorax using radiography of the chest organs in two projections; if this study is impossible, the patient must be immediately referred to a surgical hospital.
2. In cases of tension pneumothorax, decompression of the pleural cavity is indicated by puncture or drainage on the side of the pneumothorax in the 2nd intercostal space along the midclavicular line.

2. Diagnostic and therapeutic tactics in a non-specialized surgical hospital.
The task of the diagnostic stage in a surgical hospital is to clarify the diagnosis and determine further treatment tactics. Particular attention should be paid to identifying patients with complicated forms of spontaneous pneumothorax.

1. Laboratory research:
general analysis blood and urine, blood group and Rh factor.
2. Hardware research:
- it is mandatory to perform a chest x-ray in two projections (frontal and lateral projection from the side of the suspected pneumothorax);
- ECG.
3. An established diagnosis of spontaneous pneumothorax is an indication for drainage.
4. Active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is advisable. Art.
5. Complicated spontaneous pneumothorax (with signs of ongoing intrapleural bleeding, tension pneumothorax against the background of a drained pleural cavity) is an indication for emergency surgery through a thoracotomy approach. After the elimination of complications, obliteration of the pleural cavity is mandatory.

7. The inability to perform SCT or diagnostic thoracoscopy, recurrent pneumothorax, detection of secondary changes in the lung tissue, continued release of air and/or non-expansion of the lung for 3-4 days, as well as the presence of late complications (pleural empyema, persistent lung collapse) are indications for consultation thoracic surgeon, referral or transfer of the patient to a specialized hospital.
8. Performing anti-relapse surgical intervention in patients with uncomplicated spontaneous pneumothorax in a non-specialized surgical hospital is not recommended.

3. Diagnostic and therapeutic tactics in a specialized (thoracic) hospital.

1. Laboratory research.
- general blood and urine analysis, biochemical blood test (total protein, blood sugar, prothrombin), blood group and Rh factor.
2. Hardware research:
- SCT is mandatory, if not possible, chest x-ray in two projections (frontal and lateral projection from the side of the suspected pneumothorax) or polypositional fluoroscopy;
- ECG.
3. If a patient with spontaneous pneumothorax was transferred from another hospital with an already drained pleural cavity, it is necessary to assess the adequacy of the drainage function. If the pleural drainage is not functioning adequately, it is advisable to perform diagnostic thoracoscopy and re-drainage of the pleural cavity. If the drainage is functioning adequately, re-drainage is not required, and the decision on the need for anti-relapse surgery is made on the basis of examination data.
4. The pleural cavity is drained, and active aspiration of air from the pleural cavity with a vacuum of 20-40 cm of water is advisable. Art.
5. Complicated spontaneous pneumothorax (with signs of ongoing intrapleural bleeding, tension pneumothorax against the background of a drained pleural cavity) is an indication for emergency surgery. After elimination of complications, induction of pleurodesis is required.
6. The criteria for removal of pleural drainage are: complete expansion of the lung according to X-ray examination, no air flow through the drainage within 24 hours and no discharge through the pleural drainage.

Mistakes and difficulties in treating SP:

Errors and difficulties of drainage:
1. The drainage tube is inserted deep into the pleural cavity and is bent, which is why it cannot evacuate accumulated air and straighten the lung.
2. Unreliable fixation of the drainage, with it partially or completely coming out of the pleural cavity.
3. Against the background of active aspiration, massive air discharge persists and respiratory failure increases. Surgery is indicated.

Management of the long-term postoperative period:
After discharge from the hospital, the patient should avoid physical activity for 4 weeks.
During the 1st month, the patient should be advised to avoid changes in barometric pressure (parachute jumping, diving, air travel).
The patient should be advised to quit smoking.
Observation by a pulmonologist and examination of external respiration function after 3 months are indicated.

Forecast:
Mortality from pneumothorax is low, and is more often observed with secondary pneumothorax. In HIV-infected patients, in-hospital mortality due to the development of pneumothorax is 25%. 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 is 5%.

Conclusion:
Thus, surgical treatment of spontaneous pneumothorax is a complex and multifaceted problem. Often, experienced surgeons call spontaneous pneumothorax “thoracic appendicitis,” implying that this is the simplest operation performed for lung diseases. This definition is doubly true - just as appendectomy can be both the simplest and one of the most complex operations in abdominal surgery, also a banal pneumothorax can create difficult problems to overcome during a seemingly simple operation.
The described surgical tactics, based on an analysis of the results of a number of leading thoracic surgery clinics and extensive collective experience in performing operations, both in very simple and in very complex cases of pneumothorax, make it possible to make thoracoscopic surgery simple and reliable, and to significantly reduce the number of complications and relapses.

Information

Sources and literature

1. Clinical recommendations of the Russian Society of Surgeons
   1. 1. Bisenkov L.N. Thoracic surgery. Guide for doctors. – St. Petersburg: ELBI-SPb, 2004. – 927 p. 2. Varlamov V.V., Levashov Yu.N., Smirnov V.M., Egorov V.I. New way non-operative pleurodesis in patients with spontaneous pneumothorax // Vestn.khir. - 1990. - No. 5. - P.151-153. 3. Porkhanov V.A., Mova V.S. Thoracoscopy in the treatment of bullous pulmonary emphysema complicated by pneumothorax // Chest and heart. vascular surgery. - 1996. - No. 5. - pp. 47-49. 4. Pichurov A.A., Orzheshkovsky O.V., Petrunkin A.M. et al. Spontaneous pneumothorax - analysis of 1489 cases // Vetn. Surgery named after I.I.Grekova. – 2013. – Volume 172. – P. 82-88. 5. Perelman M.I. Current problems of thoracic surgery // Annals of Surgery.-1997.-No.3.-P.9-16. 6. Seagal E.I., Zhestkov K.G., Burmistrov M.V., Pikin O.V. Thoracoscopic surgery. “House of Books”, Moscow, 2012.- 351 p. 7. Filatova A.S., Grinberg L.M. Spontaneous pneumothorax - etiopathogenesis, pathomorphology (literature review) // Ural. honey. magazine - 2008. - No. 13. - P. 82-88. 8. Chuchalin A.G. Pulmonology. National leadership. Brief edition. GEOTAR-Media. 2013. 800s. 9. Yablonsky P.K., Atyukov M.A., Pishchik V.G., Bulyanitsa A.L. The choice of treatment tactics and the possibility of predicting relapses in patients with the first episode of spontaneous pneumothorax // Medicine XXI century - 2005. - No. 1. – P.38-45. 10. Almind M., Lange P., Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis // Thorax.- 1989.- Vol. 44.- No. 8.- P. 627 - 630. 11. Baumann M.H., Strange C., Heffner J.E., et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement // Chest. - 2001. - Vol. 119. - No. 2. - P. 590–602. 12. Boutin C., Viallat J., Aelony Y. Practical thoracoscopy / New York, Berlin, Heidelberg: Springer-Verlag. - 1991. - 107 p. 13. British Thoracic Society Pleural Disease Guideline, 2010 //Thorax.- 2010.- vol. 65, Aug.- suppl. 2.- 18 –31. 14. Kelly A.M., Weldon D., Tsang A.Y.L., et al. Comparison between two methods for estimating pneumothorax size from chest x-rays // Respir. Med. – 2006. – Vol. 100. – P. 1356-9. 15. Kocaturk C., Gunluoglu M., Dicer I., Bedirahan M. Pleurodesis versus pleurectomy in case of primary spontaneous pneumothorax // Turkish J. of Thoracic and Cardiovasc. Surg.- 2011.- vol. 20, N 3.- P. 558-562. 16. Ikeda M. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax, with special reference to the operative indication considered from its contralateral occurrence rate // Nippon Kyobi Geka. Gakhai Zasshi.- 1985.- V.14.- No. 3.- P.277 - 282. 17. MacDuff A., Arnold A., Harvey J. et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 // Thorax. – 2010. - Vol. 65. - Suppl. 2. – P. ii18-ii31. 18. Miller W.C., Toon R., Palat H., et al. Experimental pulmonary edema following reexpansion of pneumothorax // Am. Rev. Respira. Dis. – 1973. – Vol. 108. – P. 664-6. 19. Noppen M., Alexander P., Driesen P. et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study // Am. J. Respira. Crit. Care. Med. - 2002. - Vol. 165. - No. 9. - P. 1240-1244. 20. Noppen M., Schramel F. Pneumothorax // European Respiratory Monograph. - 2002. - Vol. 07. - No. 22. - P. 279-296. 21. Pearson F.G. Thoracic Surgery. - Philadelphia, Pennsylvania: Churchill Livigstone, 2002. - 1900c. 22. Rivas J. J., López M. F. J., López-Rodó L. M. et al. Guidelines for the diagnosis and treatment of spontaneous pneumothorax / Spanish Society of Pulmonology and Thoracic Surgery // Arch. Bronconeumol. - 2008. - Vol. 44. - No. 8. - P. 437-448. 23. Sahn S.A., Heffner J.E. Spontaneous pneumothorax // N. Engl. J. Med. - 2000. - Vol. 342. - No. 12. - P. 868-874. 24. Shields T.W. General Thoracic Surgery. - New York: Williams@Wilkins, 2000. - 2435c. 25. Up Huh, Yeong-Dae Kim, Yeong Su Cho et al. The effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion // Korean J. of Thoracic and Cardiovasc. Surg.- 2012.- vol. 45, N 5.- P. 316-319.

Information

Working group for the preparation of the text of clinical recommendations:

Prof. K.G.Zhestkov, Associate Professor B.G.Barsky (Department of Thoracic Surgery, Russian Medical Academy of Postgraduate Education, Moscow), Ph.D. M.A. Atyukov (Center for Intensive Pulmonology and Thoracic Surgery, St. Petersburg State Budgetary Healthcare Institution “GMPB No. 2”, St. Petersburg).

Composition of the expert committee: Prof. A.L. Akopov (St. Petersburg), prof. E.A.Korymasov (Samara), prof. V.D.Parshin (Moscow), corresponding member. RAMS, prof. V.A. Porkhanov (Krasnodar), prof. E.I.Sigal (Kazan), prof. A.Yu. Razumovsky (Moscow), prof. P.K. Yablonsky (St. Petersburg), prof. Stephen Cassivi (Rochester, USA), Academician of the Russian Academy of Medical Sciences, prof. Gilbert Massard (Strasbourg, France), prof. Enrico Ruffini (Torino, Italy), prof. Gonzalo Varela (Salamanca, Spain)

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