《2010BTS指南：自发性气胸的管理》内容预览

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The term ‘pneumothorax’ was ?rst coined by Itardand then Laennec in 1803 and 1819 respectively,1and refers to air in the pleural cavity (ie, inter-spersed between the lung and the chest wall). Atthat time, most cases of pneumothorax weresecondary to tuberculosis, although some wererecognised as occurring in otherwise healthypatients (‘pneumothorax simple’). This classi?ca-tion has endured subsequently, with the ?rstmodern desc**tion of pneumothorax occurring inhealthy people (primary spontaneous pneumo-thorax, PSP) being that of Kj?rgaard2in 1932. It isa signi?cant global health problem, with a reportedincidence of 18e28/100 000 cases per annum formen and 1.2e6/100 000 for women.

Secondary pneumothorax (SSP) is associatedwith underlying lung disease, in distinction to PSP,although tuberculosis is no longer the commonestunderlying lung disease in the developed world. Theconsequences of a pneumothorax in patients withpre-existing lung disease are signi?cantly greater,and the management is potentially more dif?cult.Combined hospital admission rates for PSP and SSPin the UK have been reported as 16.7/100 000 formen and 5.8/100 000 for women, with corre-sponding mortality rates of 1.26/million and 0.62/million per annum between 1991 and 1995.

With regard to the aetiology of pneumothorax,anatomical abnormalities have been demonstrated,even in the absence of overt underlying lungdisease. Subpleural blebs and bullae are found at thelung apices at thoracoscopy and on CT scanning inup to 90% of cases of PSP,5 6and are thought toplay a role. More recent auto?uorescence studies7have revealed pleural porosities in adjacent areasthat were invisible with white light. Small airwaysobstruction, mediated by an in?ux of in?ammatorycells, often characterises pneumothorax and maybecome manifest in the smaller airways at an earlierstage with ‘emphysema-like changes’ (ELCs).8Smoking has been implicated in this aetiologicalpathway, the smoking habit being associated witha 12% risk of developing pneumothorax in healthysmoking men compared with 0.1% in non-smokers.

Patients with PSP tend to be taller thancontrol patients.10 11The gradient of negativepleural pressure increases from the lung base to theapex, so that alveoli at the lung apex in tall indi-viduals are subject to signi?cantly greaterdistending pressure than those at the base of thelung, and the vectors in theory predispose to thedevelopment of apical subpleural blebs.

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