Ngamanye amaxesha kufanelekile ukuzibuza ukuba ingaba izinto esizivayo, esizibonayo kunye nesizivayo ziyafana na njengoko besicinga ukuba zinjalo. UGqr Alan Garner uye wajonga kwizivamvo zakho xa ungena esifubeni kwaye uyazibuza ukuba ingaba konke kuthe tye na njengoko sithanda ukucinga?

Masiqale esi sithuba ngokuchaza kwasekuqaleni ukuba oku kumalunga namanxeba esifuba. Ukuba ayisiyiyo le nto ubuyicinga ngoko lixesha lokujonga kwenye indawo.

Into endifuna ukuyixubusha kukuxilongwa kweklinikhi ye-tension pneumothorax kwintsimi. Isizathu sengxoxo kukuba ndikholelwa ukuba indlela yokuxilongwa ngokugqithisileyo. Xa ndandisebenza e-UK kwiminyaka emi-6 eyadlulayo kwakubonakala ngathi uxinezeleko lufunyaniswa rhoqo kwaye isizathu esinikiweyo yayisisandi njengoko babesaphula i-pleura nge-forceps. Njengoko isigulana sasinoxinzelelo olulungileyo lomoya ngelo xesha ngoko isandi kufuneka sibe ngumoya ophuma ngaphandle kwendawo ye-pleural njengoko uxinzelelo lwabo lwe-intrathoracic lwalulungile kuwo wonke umjikelo wokuphefumla?

Khumbula ukuba asinakuthembela njani kwizandi ezibandakanyekayo kuvavanyo lweklinikhi kwindawo ye-prehospital ngenxa yokuba abathembekanga kakhulu? Kaloku bendixelelwa ukuba lo usoloko enyanisile. 'Soloko' ligama elikhulu kwezamayeza

Ndikwayazi nokuba imeko enye apho isigulana esinenxeba elinye lokudubuleka kwi-epigastric kwisixhobo esinesantya esisezantsi saye safakwa kwithoracostomi yomnwe wamacala amabini. Inkcazo ngelo xesha kukuba ugqirha we-prehospital, ngokungathandabuzekiyo wangena kuyo yonke into ngokuthembeka, wathi ngexesha le-thoracostomies bafumana i-pneumothorax kwelinye icala kunye noxinzelelo kwelinye.

Nangona kunjalo kumfanekiso kunye notyando iprojekti yabuyela ngqo kwi-pancreas kwaye akukho ndawo ikufuphi ne-hemithorax okanye i-diaphragm. Ngokwenene ukwenzakala kuphela okuchongiweyo kuyo nayiphi na indawo yesifuba yayingamanxeba ethoracostomy ngokwawo. Kwakhona isigulane esifakwe kwi-intubated ngoko ke uxinzelelo lwe-intrathoracic kufuneka lube lulungile? Ukuba umphunga wawuvakala uphantsi ngoko kufuneka ibe yipneumothorax? Kwaye ukuba bekukho isandi ekwaphuleni i-pleura, kufanele ukuba kukho ukuxinana?

Kucacile kwityala lesibini imiqondiso yayilahlekisa ngoku kwenzeka ntoni apha? Masibeke ecaleni okwesibini imingeni yokuxilongwa kokuqala kwe-pneumothorax kwaye sigxininise kwimvakalelo ngomnwe kunye nesandi ezindlebeni. Ngaba kunokwenzeka ukuba obunye bobungqina esiye sikhokele ekukholelweni busixelela ukuba sijongene ne-pneumothorax inokulahlekisa amagqirha anamava, aqeqeshwe kakuhle?

Ukuntywila ngaphakathi

Mhlawumbi ndenze i-chest drains ezimbalwa kunezona zininzi. Ngokuyinxenye oko kungenxa yeminyaka engaphezulu kwe-20 kwisithuba se-prehospital kodwa mhlawumbi ndenze nangakumbi xa ndandingumbhalisi 25 kunyaka ophelileyo. Ndichithe iinyanga ze-6 ndisebenzela oogqirha abambalwa bokuphefumla kwaye ndibeka iidreyini ezininzi (ikakhulukazi ngenxa ye-effusions embi) kwizigulane ezingazange zibe ne-pneumothorax ngaphambi kokuba ndiqalise. Kwakuqhelekile ukuva ingxolo njengoko i-pleura yaphulwa njengoko umoya wawungena ngaphakathi.

Ngokucacileyo kufuneka sibuyele kwifiziyoloji ukuze sibone ukuba yintoni eqhuba ukuhamba komoya nokuba ungene okanye uphume kumngxunya esiwenzileyo ukufumanisa ukuba isandi esisivayo ngumoya ongena ngaphakathi, okanye umoya ophumayo.

Buyela kwizinto ezisisiseko

Uxinzelelo lweTranspulmonary yithambeka yoxinzelelo eqhuba umoya oqhelekileyo. Ngumahluko phakathi kwe uxinzelelo lwe-alveolar kwaye i uxinzelelo lwe-intrapleural kwi imiphunga.

P_tp =P_alv -Up_ip. Apho uP_tp luxinzelelo lwe-transpulmonary, P_alv luxinzelelo lwe-alveolar, kunye ne-P_ip luxinzelelo lwe-intrapleural.

(Ukuba ungathanda okungaphezulu kobu UBomi obubalaseleyo kwiNdlela eKhawulezayo inoxinzelelo lwe-transpulmonary Apha.)

Kwakhona kuye kwavela ukuba unokufumana umbono kaGoogle wencwadi yakudala kaJohn West kwifiziyoloji yokuphefumla. Thatha umzuzwana uhambe uyonwabele Umfanekiso 4-9 kwiphepha 59 . 

Ungabona kwiphaneli B (bendiyithetha, hamba kwaye ujonge) ukuba uxinzelelo lwe-intrapleural luyohluka phakathi kwe -5 kunye -8 cmH.₂O kwinqanaba eliphakathi kwemiphunga ngexesha lokuphefumla okuqhelekileyo. Ihlala i-negative kwaye loo nto ibangelwa kukubuyela kwe-elastiki yokuphefumula okuchaswa ludonga lwesifuba. Alibi kangako kwimimandla exhomekeke emiphungeni (ukunciphisa ubungakanani be-alveolar) kunye ne-negative ngakumbi kwi-apex (ukwandisa ubungakanani be-alveolar).

Masidibanise Umoya

Kwimeko ye-pneumothorax encinci umoya kwi-pleural space yenza ukuba uxinzelelo lwe-intrapleural lube luncinci kwaye umahluko woxinzelelo lokuqhuba umoya wokungena umoya uyancipha. Ukuba i-pneumothorax ivuleke ngokupheleleyo emoyeni njengenxeba elivulekileyo le-thoracostomy uxinzelelo lwe-intrapleural lulingana noxinzelelo lwe-atmospheric, i-elastic recoil ye-lung ibangela ukuwa okupheleleyo kunye nokungena komoya ngokunyuka kwesifuba akunakwenzeka - uxinzelelo olufanelekileyo lomoya kufuneka lusetyenziswe.

Asiyomeko ye-pneumothorax eyona nto indikhathazayo. Ukuba i-hypoxic okanye i-hypotensive kwaye isigulane sine-pneumothorax isifuba kufuneka sithotywe - i-no-brainer epheleleyo. Umbuzo kukuba kutheni oogqirha abalungileyo behlisa izifuba eziqhelekileyo kwaye becinga ukuba kukho i-pneumothorax okanye uxinzelelo xa bekungekho? Ngaba iphysiology isikhokelela apho?

Onesigulane

Okokuqala masithathele ingqalelo isigulana esingafakwanga ngokuphefumla okuqhelekileyo kwaye akukho pneumothorax. Le yimeko yezigulana ezinemibhobho eyingozi endandiyifakela idreyini kwiminyaka eyadlulayo. Apha uxinzelelo lwe-alveolar alunakuze lube ngaphezu kwe-cmH₂O okanye ezimbini ezilungileyo okanye ezimbi. Uxinzelelo lwe-intrapleural nangona kunjalo -5 ukuya -8 cmH₂O. Ke ngoko, akukhathaliseki nokuba wesiphi isigaba sokuphefumla owaphula i-pleura, i-gradient yoxinzelelo phakathi kwe-pleural space kunye ne-atmosfera i-negative kwaye umoya uya kungena ngokukhawuleza.

I-gradient inkulu ngokuphefumlelwa xa uxinzelelo lwe-alveolar lungalunganga (kwaye ke ngoko uxinzelelo lulonke lujikeleze -8 cmH₂O) kunye ne-negative encinci ngexesha lokuphelelwa kwexesha xa ifana ne-5 cmH₂O. Nangona kunjalo ihlala ingalunganga. Ayinamsebenzi nokuba yeyiphi indawo yomjikelo wokuphefumla owaphula i-pleura, umoya uya kuqukuqela kwindawo yepleural kwaye i-elastic recoil yomphunga iya kuyiqhuba ukuba iwe. Ukuba usiva ingxolo njengoko bendihlala ndisenza, kubetha umoya, inxeba eliqhelekileyo lokufunxa esifubeni. Enye iatrogenic.

Isigulana seSibini

Andiqondi ukuba umntu unokuba nengxaki ngezinto ukuza kuthi ga ngoku. Ngoko ke masiqhubele phambili kwisigulane esingenayo i-pneumothorax. Ndiza kucinga apha ukuba akukho kuxhathisa kwindlela yomoya kwisigulana sethu somonzakalo (oku akuthethi ukuba abanaso isifo se-pulmonary obstructive pulmonary, i-anaphylaxis kumachiza okungeniswa onike wona okanye ihlwili ehleli kwi-bronchus enkulu. /ETT) njengoko isenza ukuba ingxoxo ibe lula ukucinga ukuba ukuxhathisa kuncinci (akunamsebenzi ngokwe-Daleks) kunye noxinzelelo olubonayo kwigeyiji ye-ventilator ubukhulu becala idluliselwa ngqo kwi-alveoli.

Ukujonga i-equation yethu yoxinzelelo lwe-transpulmonary, ngaphandle kokuba uxinzelelo lwe-airway kwaye ngenxa yoko uxinzelelo lwe-alveolar luphezulu kune-5 cmH.₂O ke i-gradient ngexesha uvula i-pleura ithetha ukuba umoya uya ukungena umgodi wepleural. (Ukuba banokuxhathisa okubalulekileyo kwendlela yomoya oku kunokwenzeka ngoxinzelelo oluphezulu lomoya).

Yiba nebala leliso elikhawulezayo ngeli xesha itshati yoxinzelelo lwevolume eqhelekileyo ejikelezayo yokungenisa umoya engenazo i-PEEP (kunye nebhegi ezizikhuphayo iya kubonelela ngendlela efanayo nangona iguquguqukayo ngakumbi). Kwaye ngabom andinayo i-PEEP kule tshathi. I-PEEP ayinakwenzeka ukuba ibe yinto yokuqala esiyifikelelayo kwisigulane se-hypotensive trauma esisanda kufakwa kuyo apho sixhalabile malunga nokuba kunokwenzeka ukuba kubekho i-pneumothorax.

Ngemiphunga eqhelekileyo uxinzelelo oluphezulu apha lunokuba malunga ne-20 cmH₂O. Yiyiphi inxalenye yomjikelezo opheleleyo wokuphefumla ingcinezelo yomoya (kwaye ngoko ke uxinzelelo lwe-alveolar kwisigulane sethu esinokumelana komoya ophantsi) kunokwenzeka ukuba sibe ngaphantsi kwe-5 cmH₂O? Ukuba i-ventilator yakho encinci ye-prehospital inomlinganiselo we-1: 2 I: E njengoko uninzi lusenza, ke impendulo uninzi lwayo.

Ngamanye amazwi, ngaphandle kokuba unePEEP ubuncinane be-5 cmH₂O nakwisigulane sakho esifakwe kwi-intubated uxinzelelo lwe-transpulmonary lubi kwisiqingatha esihle somjikelo wokuphefumla. Ebudeni bobuncinci besiqingatha somjikelo wokuphefumla, ukuba usiva ingxolo njengoko usaphula i-pleura uva umoya ubaleka. IN.

I-elastic recoil yomphunga sisizathu sokuba uve ukuba imiphunga iwile ngexesha ukhupha izinyanzelo kwaye ufake umnwe wakho ngaphandle ngaphandle kokuba une-PEEP odlala ngayo.

Ngoku anditsho ukuba akuzange kubekho ixesha apho umoya wawungangxamanga. Andicingi kakhulu ngegama elithi “rhoqo” kwezamayeza, uyakhumbula? Ndicebisa nje ukuba into esiyaziyo ngefiziyoloji inokuxoxa ukuba kukho ubuncinci umlinganiso oqinileyo wexesha apho i-gradient yoxinzelelo lwe-transpulmonary ingalunganga xa usaphula i-pleura, okuthetha ukuba kunokwenzeka ukuba kubekho umlinganiso olungileyo wamatyala apho. ezo "zithile" iimpawu zeklinikhi ziba zithembeke kancinci.

Ukubonisa oku kunye nomama wazo zonke iithoracotomies ezivulekileyo (kwi-cadaver) khangela le vidiyo.

I-cadaver ifakwe kwi-intubated, "i-generous" pleural decompression inxeba lenziwe, kwaye ekupheleni kwexesha ngalinye umphunga uwela phantsi ngaphandle kokuba i-PEEP isetyenziswe. Kwaye qaphela ukudilika kugqityiwe kukuphela kwexesha ngalinye.

Logama nje i-thoracostomy inkulu ngokwaneleyo ukuba inxibelelane ngokukhululekileyo nomoya (kwaye ukuba uthembela kwindlela evulekileyo “yomnwe” endaweni yokufaka umbhobho kufuneka ibe nkulu okanye ingaphinda icinezele), xa ubeka i-drain yakho. umnwe phakathi ngexesha lokuphelelwa kwexesha umphunga uya kuwa ngaphandle kokuba kukho isixa esifanelekileyo se-PEEP eqhekezayo izinto ezivuleke ngokumangalisayo.

Iya kudilika nokuba ibisele iphambi kokuba wenze isilonda okanye yenzekile na njengoko usasaza izinyanzelo kwaye wenza umngxuma wokunxibelelana. Ixesha eliphakathi kokwenza umngxuma kunye nokufumana loo mvakalelo yokunyuka komphunga okanye umphunga phantsi ngomnwe lixesha elaneleyo lokuba umphunga uwele phantsi. Kubonakala ngathi olu phawu oluthile lweklinikhi alukuxeleli nto malunga nemeko yokudlala phambi kokuba inxeba lenziwe.

Ke ingxolo inokuba yinkohliso kwaye uve umphunga owileyo kuthetha nje ukuba imiphunga iye yabuya umva njengoko kuvulwe i-pleura. Ngaba ungaqinisekisa nokuba sesiphi isigaba somjikelo wokuphefumla isigulana ebesikuso xa ubusenza loo mngxuma? Ngaphandle kokuba ubune-5 cmH ubuncinane₂O (kwaye mhlawumbi nangaphezulu) PEEP ngexesha wophule i-pleura akukho nanye kwezi mpawu engathethi nto.

Ngoku kuthweni?

Kwakhona, andizithethi izinto ezinje ngo “rhoqo” okanye “ungaze”. Into endiyicebisayo kukuba kusenokuba ngwevu kakhulu malunga nezi mpawu zeklinikhi kunokuba kubonakala ngathi kunjalo.

Ngoko uyazi njani ukuba babene-pneumothorax? Kum lonto iphantse yahlala yi-ultrasound ngoku. Andazi ukuba ndilawule njani kwi-15 yeminyaka eyi-20+ yokhathalelo lwangaphambi kwesibhedlele ngaphandle komnye. Ngamanye amaxesha ngokuqinisekileyo ukuskena kuyalingana kwaye kufuneka ufowune ngokusekwe kwiimpawu ozibonayo kunye nemeko yesigulana kodwa ndifumanisa ukuba oku kunqabile kakhulu ngeprobe elungileyo yelinear ephezulu.

Ngokubhekiselele kwingxwabangxwaba uphawu yiphysiology engaqhelekanga, ngakumbi uxinzelelo lwegazi. Ukuba i-decompressing isifuba ilungisa i-physiology ngoko babenoxinzelelo. Ukuba akunjalo ke babenepneumothorax elula - okanye bangabikho kwaphela. Ngenxa yokuba ingxolo oyivileyo xa usaphula i-pleura isenokuba ngumoya ongena okanye ophumayo kwisakhiwo, ukuva ingxolo akuncedi nangayiphi na indlela. Ngaba u-Elvis wayekhe waba kwisakhiwo?

amanqaku:

Ndibe noGqr uBlair Munford okrelekrele uphonononga imfumba yefiziyoloji apha ukuze ndiqiniseke ukuba iyahambelana.

Emva kwekhonkco kwi-LITFL bit kuxinzelelo lwe-transpulmonary kwakhona? Emva koko hamba ngasekunene Apha.

Kwaye umsebenzi wobugcisa kaJohn West (kakuhle ubuncinci iphepha elikhankanyiweyo). Apha.

Loo mfanekiso kaNahni ngeendlebe ezinkulu wathunyelwa kwi Commons Creative inxalenye yeflickr ka-Allan Henderson kwaye ayitshintshwanga apha.

Owu, kwaye ukuba ubungayazi eyona nto imangalisayo kaJohn West, inkwenkwe yase-Adelaide yenze okulungileyo, irekhode yonke lecture series yakhe ukuba uhambe kwaye ubukele. Kuba xa ukwi-80s yakho mhlawumbi uya kuba negalelo kwimfundo yezonyango ngolo hlobo, akunjalo?

Funda kwakhona:

I-Tracheal Intubation: Nini, njani kwaye kutheni uyenza i-Airway yomoya engeyiyo eyomonde

Yintoni i-Tachypnoea eThutyanayo yoSana olusandul' ukuzalwa, okanye i-Neonatal Wet Lung Syndrome?

umthombo:

Inqwelomoya yokukhathalela i-Collettive