MINISTRY OF HIGHER AND SPECIALIZED EDUCATION OF THE REPUBLIC OF
UZBEKISTAN
MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TEACHING OFFICE OF HIGHER EDUCATION AND SPECIALIZED MEDICINE
TASHKENT MEDICAL ACADEMY
Syndrome of Dyspnea on a thorax trauma, an acute bacterial destruction of
lungs complicated by the haemopneumothorax and pyopneumothorax.
(methodological manual)
TASHKENT-2012
MINISTRY OF HIGHER AND SPECIALIZED EDUCATION OF THE REPUBLIC OF
UZBEKISTAN
MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TEACHING OFFICE OF HIGHER EDUCATION AND SPECIALIZED MEDICINE
TASHKENT MEDICAL ACADEMY
Authors:
MD. Ph.D Yunusov I.I - Assistant Professor of Surgery for
GeneralPracitioners
MD Ph D Rustamoy A E - Assistant Professor of Surgery for
GeneralPracitioners
Reviewers:
Dadaev Sh. A.- Dr.,Prof. Head of the department of surgical diseases in field
surgery TashPMI .
Asrarov A.A.- Professor of Department of Hospital Surgery Faculty in TMA,
Honored Worker of Science the Republic of Uzbekistan.
TASHKENT-2012
[1]
ANNOTATION
For tutorial «Dyspnea syndrome on a thorax trauma, an acute bacterial destruction
of lungs complicated by the haemopneumothorax and pyopneumothorax» of
Yunusov I.I, associate professor of TMA surgical department for general
practitioners
In spite of improvement organization traumathological and pulmonologic service,
also widely using of antibacterial medicines, frequency of an acute bacterial
destructions of lungs remains by higher rate. By the way, remain impressions,
occurrence of an thorax trauma and lungs purulent diseases by the dyspnea
syndrome is increased. Russian scientific institute of pulmonology shows increased
quantity of purulent lung diseases in the world. Quantity such kind of patients
raises by 5 % annually and mortality is on the rise by 7-12% p.a. distinguished
features of these diseases are damaging vitally essential organs and systems,
rapidly development of severe disturbances and complications on these cases
requires urgent appropriate aide from the physicians. That is why creation of this
tutorial «dyspnea syndrome on a thorax trauma, an acute bacterial destruction of
lungs complicated by the haemo-pneumothorax and pyopneumothorax» is one of
important requirements nowadays.
The tutorial consists of 74 typed pages according to modern educational
technologies, by indications of topicality, anothomo-physiological dates, clinic and
laboratory instrumental investigations of this syndrome. By the originator of this
tutorial was developed diagnostic and treatment algorithm, also differential
diagnostic methods of dyspnea syndrome. On the basis of evidence-based medicine
there are general practitioners policy on rendering first aid, indications and
techniques of pleural puncture, pleural cavity drainage, operative introductions.
Originated diagnostic and treatment algorithms of «cough», «expectoration»
«blood spitting» syndromes are basic guides in studying of chest dyspnea
syndrome.
On this tutorial also by originator was payed attention to acquirement of practical
skills in diagnose of haemothorax and pneumothorax, fulfillment of pleural
puncture by unified standards.
Decision clinical tasks (12) and test packs (50) from this tutorial promotes
development of medical students and entry-level physicians clinical thoughts.
[2]
Dyspnea syndrome on a thorax trauma, an acute bacterial destruction of
lungs complicated by the haemopneumothorax and pyopneumothorax.
Shortness of breath - is respiratory distress syndrome, requiring additional tension during
inhalation and exhalation.
Degree of breathlessness:




I degree - occurrence after heavy physical exertion;
II degree - the emergence of post-secondary exercise;
III degree - after the appearance of mild exercise;
IV degree - the emergence during the holiday;
The main causes of shortness of breath:
 Heart disease:





Acute heart failure (occurs within a few hours);
Pulmonary embolism (occurs within 2-3 minutes);
A bundle of an aortic aneurysm (occurs in a few hours);
Cardiac tamponade (occurs in a few hours);
Cyocarditis, cardiomyopathy (occurs within a few days, weeks).
 Respiratory Diseases:
 Upper airway obstruction (occurs within minutes);
 Pneumothorax (occurs within 2-3 minutes);
MOTIVATION:
Treatment of injuries of the chest, complicated by hemo-pneumothorax is one of the most
important problems of modern medicine, owing to the increasing number of patients with this
pathology.
Despite improvements in the organization of trauma and pulmonology services and widespread
use of antibiotics, not a decrease in the number of patients. Moreover it seems that more often
began to appear chest injuries, and pulmonary suppuration syndrome of dyspnea. The features of
lung disease are injury to vital organs and body systems, the rapid development of severe
functional impairment and complications, and therefore the need for adequate emergency care.
Any modern physician must possess a complex of diagnostic methods to know the basic
principles of treatment of patients with injuries of the chest, and be able to provide the necessary
assistance in urgent situations.
By suppurative lung diseases include pulmonary abscess and gangrene, and they share the term
"acute pulmonary suppuration," "acute infectious destruction," "destructive pneumonitis." They
are among the most serious diseases are often life-threatening patient, characterized by necrosis
and subsequent purulent or putrid decay (degradation) of lung tissue as a result of exposure to
infectious pathogens.
[3]
Treatment of suppurative-destructive lung disease and its complications, and injuries of the
chest, complicated by hemopneumothorax is one of the most important problems of modern
medicine, owing to the increasing number of patients with this pathology.
Despite improvements in the organization of pulmonology service at the present stage of its
development and widespread use of antibiotics, not a decrease in the number of patients.
Moreover it seems that more often began to appear chest injuries, and pulmonary suppuration
syndrome of dyspnea. The features of lung disease are injury to vital organs and body systems,
the rapid development of severe functional impairment and complications, and therefore the need
for adequate emergency care. Any modern physician must possess a complex of diagnostic
methods, to know the basic principles of treatment of patients with purulent diseases of the
lungs, as well as be able to provide the necessary assistance in urgent situations.
Between the subject and intra-subject relations.
Resuscitation, clinical pharmacology, traumatology.
Anatomy, regional anatomy, operative surgery, anesthesiology and resuscitation, clinical
pharmacology, traumatology.
Anatomy:
Chest or thoracic cavity consists of a
bone skeleton, ribs and spine. The ribs
movably connected to the spine. At
the bottom of thoracic cavity ends
domed muscular partition - the
diaphragm.
The ribs are interconnected muscles
and actively participate in the process
of respiration. Lungs are covered with
visceral pleura (Pleura pulmonalis or
visceralis), and the inside of the snug
against the chest cavity. Thoracic
cavity is also covered with a thin film
of mucus - (Pleura parietalis)-wall or
parietal pleura. Liquid layer, which is
in the narrow gap between two serous
membranes, prevents friction during
the motion of light, and promotes
strong adhesion to the visceral pleura
costal pleura. Thus the lungs are suspended in the chest and follow the movements of the chest,
and vice versa, the chest should be supple-powered light during expiration.
Lung, pulmo, - paired organ, surrounded by the right and left pleural sacs, occupies a large part
of the chest cavity. Remaining between the two pleural sacs space bounded by the front chest,
back - the spine and bottom - tendinous part of the diaphragm, and turned to the top of the
apertura thoracis superior, called the mediastinum, mediastinum.
Conditional frontal plane passing through the trachea and the roots of the lungs, mediastinum is
divided into front and back, mediastinum anterius et posterius. In the anterior mediastinum are,
[4]
thymus, heart, pericardium with, the large vessels of the heart and phrenic nerve and blood
vessels. In the posterior mediastinum occur: trachea, esophagus, aorta, unpaired and paired
semicontinuous vein, the vagus nerves, sympathetic trunks and the thoracic lymph duct. Each,
right and left lung has the shape of a truncated cone, the tip of the lung, apex pulmonis, pointing
up into the region of supraclavicular fossa, base of lung, basis pulmonis, rests on the diaphragm.
The right lung is broader than the left, but slightly shorter. The left lung in the lower front edge
has a heart, a clipping of the left lung, incisura cardiaca pulmonis sinistri - a place fit heart.
Light is made up of shares: right - one of the three left - of the two. Accordingly, in the left lung,
there is one oblique slit, fissura obliqua, - a deep fissure that divides it into upper and lower
lobes, lobus superior et lobus inferior. The right lung has two interlobar fissure, of which the
upper is called a horizontal slit (right lung), fissura horizontals (pulmonis dextri). These grooves
divide it into three shares: upper, middle and bottom, lobus superior, lobus medius et lobus
inferior. Sulcus between the lobes of the left lung is projected on the chest as the line connecting
the spinous process of thoracic vertebra III front end of Part VI of the bone ribs. Furrows are
projected share of the right lung to the chest as follows: the upper interlobar cleft, as the
boundary between the upper and middle lobes, consistent course of IV edge of the axillary line,
linea axillaris, to the sternum.
[5]
The lower gap, as the boundary between the middle and lower lobes in front and the upper and
lower back, passes through the line connecting the spinous process of thoracic vertebra W VI rib
cartilage liners (mid-clavicular) line, linea mamillaris (medioclavicularis). The lungs are
following surfaces: Ribs, facies costalis, diaphragmatic, facies diaphragmatica, interlobar, facies
interlobares, the medial surface, facies medialis, which distinguish the vertebral portion, pars
vertebralis, mediastinal portion, pars mediastinalis, and heartfelt "impression, impressio cardiaca.
Rib lung surface is convex, and often bears the imprints of ribs. On the concave surface of the
lung mediastinal a bay shaped depression, called a gateway to lung, hilus pulmonum,-place entry
in the pulmonary lung and bronchial arteries, bronchi and nerves, and the exit of pulmonary and
bronchial veins and lymphatic vessels. The relationship of these structures in both lungs are not
the same gate. At the gate of the right lung upper front position is occupied by bronchus,
lowback - veins, average - an artery. At the gate of the right lung upper front position is occupied
by an artery-vein lowback, average - bronchus. The set of all these structures (blood vessels,
lymph nodes, nerves, and bronchi), performing light gate is the root of the lung, radix pulmonis.
Places transition surfaces of light into one another are called edges.
[6]
Light has two edges:
1. the bottom edge, margo inferior and
2. cutting edge, margo anterior.
In the lower part of the front edge of the left lung has cardiac notch, incisura cardiaca. The color
of light in the childhood of pale pink, with later years he became a slate-blue with stripes and
spots. Lung tissue in the normal state of elastic and cut finely porous. Lung parenchyma consists
of a system of pneumatic tubes branching (bronchi and their branches, bronchioles, alveoli) and
branching of blood vessels (arteries and veins), lymphatic vessels and nerves. All these
formations are linked together by connective tissue.
The right lung
upper lobe
1. apical
2. back
3. front
SEGMENTS OF LUNGS
The left lung
upper lobe
1-2. Apex-posterior
3. front
4. The top reed
5. The bottom reed
Middle lobe
4. lateral
5. mesial
The lower proportion
6. apical
7. The medial basal
8. The anterior basal
9. lateral basal
10. posterior basal
The lower proportion
6. apical
7. None
8. The anterior basal
9. lateral basal
10. posterior basal
[7]
In Fig. 1. Bronchopulmonary segments:
a - the front view, b - back view.
Numbers indicate the segments
[8]
In Fig. 2. Bronchopulmonary segments:
в - an edge surface of the right lung,
г - an edge surface of the left lung,
д - the medial surface of the left lung,
e - the medial surface of the right lung,
ГБ - the main bronchus,
ЛА - the pulmonary artery,
ЛВ - lung Vienna
Blood supply to the lungs by pulmonary and bronchial vessels. Pulmonary vessels are
pulmonary circulation and primarily a function of gas exchange between blood and air, bronchial
vessels provide nutrition and light belong to the systemic circulation. Between these two systems
are sufficiently pronounced anastomoses. The right and left pulmonary arteries are branches of
the pulmonary trunk. Pulmonary arteries in the lungs are divided into equity and then segmental
branch. The smallest branch of the pulmonary arteries form a network of capillaries, Entangling
alveoli (respiratory capillaries).
[9]
Scheme of the division of pulmonary arteries
1 - pulmonary trunk;
2 - right pulmonary artery;
3 - left pulmonary artery;
4 - front trunk of pulmonary artery;
5 - Upper trunk of the pulmonary artery;
6, 7 - basal artery of the pyramid;
8, 9 - interlobar trunk;
A1-10 - segmental artery
In the right lung upper pulmonary vein of Vienna formed the upper and middle lobes, the lower from the veins of the lower lobe. In the left lung, upper and lower pulmonary vein formed by
confluence of intrapulmonary veins, respectively, the upper and lower lobes. The upper and
lower pulmonary veins of both lungs flow into the left atrium.
[10]
Scheme of formation of the pulmonary veins.
1 - upper pulmonary Vienna;
2 - lower pulmonary Vienna
Bronchial branches diverging from the back surface of the aorta, usually at the boundary
between the arc and the beginning of the descending aorta. The total number of bronchial arteries
often is 4 (2 for each lung), but can range from 2 to 6. In addition to the branches of the
bronchial blood supply to the lung and esophageal participate pericardial arteries in bronchial
arterial network formed by peribronchial, giving the arterioles and capillaries, the capillaries
connecting the pulmonary arteries.
The lymphatic system of the lung. Beginning of the lymph lungs are superficial and deep
network of lymphatic capillaries. The surface network is located in the visceral pleura. The deep
capillary network in the connective tissue within the lung lobes, interlobular septa in, in the
submucosa of bronchial walls, around the intrapulmonary blood vessels and bronchi, followed by
the gate of the lung. Regional lymph nodes in the mediastinum and lung anatomical
nomenclature of the International merged into the following groups, which correspond to the
stages of regional metastasis in lung cancer. Group I, including the pulmonary lymph nodes
along the segmental bronchi - the 1st stage of metastasis; II group - bronchopulmonary lymph
nodes, localized along the bronchi equity - 2nd stage of metastasis; Group III - lymph nodes that
lie along the main bronchi and pulmonary vessels near the upper and lower traheobronhial-term,
as well as lymph nodes, located at the lower wall of the azygos vein - third stage of regional
metastasis; IV group - paratracheal, prevenous, predaortocatodous , preperidicaldias and
paraesophageal lymph nodes - stage 4 metastatic lesions.
By D. A. Zhdanov, a close relationship exists between pulmonary lymph nodes, mediastinum,
and neck.
[11]
Lymph nodes of the lung.
1 - pulmonary lymph nodes;
2 - bronchopulmonary lymph nodes;
3 - the lower tracheobronchial (bifurcation) lymph nodes;
4 - the upper tracheobronchial lymph nodes;
5 - tracheal (paratracheal) lymph nodes;
6 - Rear lymph nodes;
7 - pulmonary ligament lymph nodes
The innervation of the lung. Autonomic nerves of the lungs are derived from the sympathetic
trunk of the border - the sympathetic innervation of the lungs and vagus nerve - parasympathetic
innervation.
Sympathetic nerves originate from the two lower cervical ganglia and five upper thoracic.
Of the vagus nerves are moving to a light at the intersection of the branches of the root of the
lung. Those and other nerves are directed to the lung tissue, accompanying bronchus, and lung
form two autonomic plexus - front and rear.
Anatomy and physiology of the respiratory system
Brief anatomical and physiological data.
Lungs - paired organ has the shape of a truncated cone. Between the lungs is the mediastinum.
Each lung is enclosed in a separate pleural sac formed by the visceral (covering the lung) and
[12]
parietal flooring inside the chest cavity leaves the pleura. Downwards from the root of these two
sheets of pleura combine to form the pulmonary ligament.
Parietal pleura consists of costal-sternum, diaphragm and mediastinal parts, forms the dome of
the pleura, stood at 3-4 cm above the clavicle, between the sheets of pleura formed sinuses
(edge-diafral, interlobar).
departments parietal pleura
[13]
The right lung oblique and horizontal fissure is divided into 3 shares (upper, middle, bottom),
and the left lung oblique groove on the 2 lobes (upper, lower).
In 1958, Congress of Anatomists adopted a segmental classification of pulmonary distinguished
10 segments in the right (3 apical, anterior, posterior in the upper lobe, 2 in the medial lateral
middle lobe, 5 in the lower lobe), and 8 segments in the left lung (4 - in the upper lobe, because
the apical and posterior segments, and 4 are combined in the lower lobe).
Segmentation of bronchi
The structure of the bronchial tree: a cylinder covered with ciliated epithelium, bronchial 1.2.3order term, respir.
Perfusion a.pulmonalis (upper - lobar, descending, mid-lobar) and a bronchialis. Vienna, top,
bottom. Innervation - Mr. vagus and sympathetic.
Lung function - breathing (breath - contraction of the diaphragm and m \ p muscles, breathelastic light reduction), that is, gas exchange, where oxygen is absorbed by the erythrocytes of air
and produces carbon dioxide. Alveolar area of 100 m2. The pressure in the well. 14-16 mm Hg
pulmonalis.
О2
СО2
В выдыхаемом воздухе
17%
больше
В атмосферном воздухе
22%
Меньше
Normally involved in respiration 1 \ 5 part 4 \ 5 is in the physiological state of atelectasis.
[14]
Gas exchange is due to the difference between the partial pressure.
Breathing: 1) the mechanics of breathing (inhalation, exhalation), the diffusion of gases, blood
flow in the pulmonary capillaries - external respiration (determined spirography), 2) transport
function of blood, and 3) internal (tissue) respiration, gas exchange between blood and tissues.
Methods of examination of patients.
External respiration-spirography study, tidal volume 500 - 800 sm.3, minute volume of
respiration (MOU) = respiratory rate (12-16 per min.) X stomach. the volume., ie, 8-10 liters.
VC - 3500-5000 ml residual volume and respiratory reserve - 1500 cm 3, the additional volume
of 2000 cm 3. The total volume of the respiratory tract of 5.5 - 6 liters.
FEV 1 - Forced volume of respiration.
FEV 1 - Tiffno sample - must be at least 70%
CRO 2 (coefficient of O) for at least 34-40 (calculate).
HBO - the absorption of O% (determined biochemically).
When the question of biloba ectomy and pneumonitis ectomy performed separately spirography,
ie turning off one light on and off blood flow and pressure are measured as well. pulmonalis:
- With increased blood pressure in 30-50% of the operation involves great risk.
- If the pressure is over 50% of surgery is contraindicated because develops after surgery right
ventricular failure.
- Analysis of sputum pot. sowing.
- The study of immunological reactivity.
- When the AP-graphy, in the capillary phase of drawing clear at pnevmoskleroze as combined
capillaries.
- BA-graphy.
The structure of the lung studied:
- X-ray (Skopje, engraving, Multiaxis, sighting, tomography KT)
- Endoscopy - bronchoscopy (stenosis, stiffness, redness, bumps, rashes)
- Bronchography.
- Plevrography - thoracoscopy.
- Media angina spectroscopy - cavography.
- Radioisotope scanning of xenon.
Respiratory problem - providing vital organs of oxygen and release into the environment of
carbon dioxide as the end product of metabolism. As a result, the role played by the lungs in the
process of gas exchange and lung are an important regulator in the acid-alkaline balance. Thus,
when oxygen deficiency occurs peroxidation of blood and thus the metabolism in cells - a
process that occurs in advanced stages of the lung in this pathology.
Respiratory tract, especially the nose, and serve for heating, humidifying and purifying inhaled
air.
Airways
Respiratory tract - the path of air from the mouth and nasal openings to the pulmonary vesicles
(alveoli). Airways are located outside the chest cavity (thoracic outside) and the chest cavity
(thoracic inside). For respiratory tract, located outside the thoracic cavity include the mouth,
nosopharynx and oropharynx, larynx, and trachea. The trachea divides into two bronchial trunk,
[15]
leading to the left and right lung. Hence, the bronchi branch into three right, left - two equity
bronchus, because the right lung has three left - two lobes. They depart from the segmental
bronchi, which supply smaller areas of the lungs (segments).
After a further 22 single division (the branching bronchial tree), bronchus terminal flows into the
pulmonary vesicles (alveoli). They consist of a thin cell layer, under which are the blood vessels
(capillaries) through which gas exchange occurs. Large and small bronchi are lined with mucous
membrane, covered with cilia (setae), which are absent in the terminal bronchi and in alveoli.
to content
The structure of the wall: bronchus, bronchiole, alveolus
(bronchial cells with cilia, muscles, bronchial lymph node, cartilage)
The bronchi are surrounded by a layer of muscle and cartilage rings are stabilized, preventing the
decay of the bronchi during exhalation. And only "after the 12th division (this is already
bronchioles) - no cartilage. With the help of bronchial muscles may contract (eg, asthma) or
expand (drugs that stimulate breathing, the effects of adrenaline in the sense of joy).
[16]
From the bronchus to the pulmonary vesicles (by Netter)
Small airways in the lung run out the bubbles. The small empty bags
shaped honeycomb or pellets with a diameter of 0.1 to 0.3 mm, coated
with a surfactant (surfactant). Together with the elastic fibers
surrounding the alveoli, it prevents the decay of the tissue.
to content
About two months after giving birth the alveoli functionally developed enough. New alveoli of the lungs most
intensively formed about three years. After that stops the formation of new alveoli, only increases in size until it
reaches the chest of the final volume.
[17]
The capillary system of arteries
and veins surrounding the alveoli
(the Cegla)
• pulmonary artery (the blood,
poor O2)
• bronchiole
• Pulmonary Vienna (blood,
intense O2)
Alveoli of the lungs are covered with very fine
blood vessels (capillaries). Oxygen is inhaled
with the air in the alveoli is absorbed by red
blood cells, carbon dioxide goes from the
blood into the alveoli.
Thoracic cavity during inhalation
[18]
Elastic lung tissue has the property to decline, while the chest is more inclined to, to remain in the breath.
Breath is due to the fact that the respiratory muscles elevates and expands the chest, the diaphragm
descends, when it should be overcome elastic resistance of the chest and lungs.
When the flow of air during inhalation and exhalation through a system of pipes of different diameters
airway resistance occurs, the so-called counter current of air. Thus, the breath - this is an active process.
Inspiratory airway pressure there is lower than atmospheric pressure. Because of this air can pass into the
respiratory tract. Exhalation occurs because lung expansion during inspiration compressed. Consequently, when
breathing at rest breath active, exhale - a passive process.
During an exhalation from the lungs up the compression pressure in the bronchi and alveoli compared with
atmospheric pressure and the air rushes out.
The main breathing muscle - the diaphragm. It moves down towards the belly, like a piston reciprocating movement
inside the vehicle and extends in the lungs. The motion of the diaphragm is shown in the figure given above. When
you exhale the diaphragm moves up. When stress or strong breath exhalation (eg, FET) supports expiration
abdominal muscles. When breathing at rest in adults 2 / 3 of air is pumped into the lungs and diaphragm, only 1 / 3 the rib cage.
Overview of guidelines:
1. The essence of the syndrome: chest pain, shortness of breath, coughing, coughing up blood.
2. The severity of these syndromes in chest trauma
3. Diagnosis and differential. diagnostics. injuries of the chest, complicated pneumothorax and hemothorax.
4. Clinical management of patients, indications for surgery.
5. Complications of chest trauma and emergency care with their help
Theoretical part:
Damage to the breast are classified as severe injuries peacetime and wartime. They are characterized by high
mortality at the scene and a relatively favorable prognosis if timely delivered to the victim to hospital. C In practical
terms, all the damage the breast can be divided into two groups that differ in mechanism of injury, pathogenesis,
clinical presentation and treatment methods: 1) open chest injury, and 2) closed chest injury.
By understanding trauma of the chest open or closed injury or wall of the chest.
The following types of chest injuries: open and closed, with damage to bones or without, with damage to internal
organs, and without it.
Classification of trauma surgery (by EA Wagner).
1. Closed chest injuries
A. without damage to internal organs
- Without damage to the rib cage (abrasions and contusions of the chest wall)
- With damage to the rib cage:
1. fractures of the ribs: single, multiple, unilateral, bilateral, double (floating);
2.perelomy sternum.
B. the damage of internal organs
- Without damage to the rib cage
- Corruption rib cage
2. Open chest injury
A Non-penetrative
[19]
B. Penetrating
- Stab-incised
- gunshot
- blind
- through
- one-sided
- Bilateral
- Multiple
- Conjunction
- With pneumothorax
- With hemothorax
- With pneumohemothorax
- Without damage to internal organs
- With damage to internal organs
3. Thoracoabdominal injuries
- Corruption of the breast
- With damage to abdominal organs
- With organ damage
- Retroperitoneal
- Associated injuries
Floating fractures
[20]
The mechanism of formation of the front doors with injury of the heart
Frequency and characteristics of damage the chest. During the Great Patriotic War of 1941-1945. frequency of
breast lesions ranged from 5% to 12% with respect to all affected, depending on the nature of the fighting and the
[21]
removal of their c battlefield. The overall mortality among the wounded in the chest at that time was 13%. The
structure of sanitary losses of modern war chest injuries share rose slightly, due to early delivery injured to hospital..
In recent decades, significant progress against the background of Thoracic Surgery, Anesthesiology and Critical
Care Medicine has been steadily declining number of adverse outcomes in breast lesions, and mortality at the
present time does not exceed 3.5-6%.
In peacetime, dominated by private injuries, which occur 5-6 times more often than open (Wagner, EA, 1981).
Attention is called to increase the number of closed thoracic injuries in local armed conflicts in the use of explosive
mines and weapons (Bisenkov L.N, 1993, Nechaev E.A, 1994).
Closed chest injuries are caused by the impact of the blast wave, shock in the chest wall, squeezing the body of solid
objects, falls, etc. According to the severity of chest injuries covered may vary from relatively light (bruises and soft
tissue hematoma, local discontinuities of the muscles without damaging the edge frame) to severe - the injury of
intrathoracic organs and multiple fractures of the ribs. Especially difficult the multiple double (two lines)
"fenestrated" rib fractures, in which part of the chest wall becomes a paradoxical mobility. A so-called edge-valve: a
moment of inspiration "valve" in contrast to the rest frame of the chest wall sinks, and when exhaling - bulges. The
more and more mobile "flap" that expression of disorders of respiratory function and blood circulation.
Damage to internal organs (lungs, heart, great vessels, trachea, bronchi) can occur as a result of their injuries
fragments of ribs, and regardless of the violation of the integrity of the skeleton. The mechanism of damage during
compression of the important role belongs to a sudden sharp rise in pressure in the airway and the organs containing
fluid.
When exposed to a shock wave or a heavy object causing a severe impact on the chest wall a peculiar kind of injury
- injury of the heart or the lung, significantly aggravating for traumatic illness, especially when combined injuries.
Injuries can be penetrating the chest, if accompanied by a violation of the integrity of the parietal pleura, and nonpenetrative, if the pleura is intact.
When a nonpenetrating wound damaged the soft tissue of the chest wall, often without rib fractures. They belong to
the category of light and flow, usually without serious complications.
Penetrating chest injuries are more dangerous to the victims in connection with possible damage to intrathoracic
organs and development of internal bleeding, mediastinal emphysema, increasing cardiopulmonary diseases.
Stab wounds are typically characterized by a small area of damage. More often it is the blind wound without fracture
of the chest.
Gunshot wounds of the chest (gunshot, fragmentation) are characterized by high severity and extent of. Injuring
projectile has a damaging effect on the organs and tissues of force not only direct but also a side impact. At the same
time revealed the destruction of tissue structures, located both on the move and away from the wound channel.
Application of wounding projectiles with a displaced center of gravity leads to multiple injuries due to the
complexity of the trajectory of motion of the projectile in the body tissues. Violation of regional circulation and
microcirculation in the wound helps in extensive areas of primary development of tissue necrosis significant number
of septic complications.
Open and closed chest injury is often complicated by pneumothorax or hemothorax. Most often caused by air
pockets in the pleural cavity is combined with the inside of pleural hemorrhage.
Pneumothorax - air pockets in the pleural cavity. The development of pneumothorax with subsequent accumulation
of blood or fluid in the pleural cavity can occur due to trauma, as well as a breakthrough in the pleural cavity
emphysematous bullae, abscess or cyst of the lung, bronchial wall destruction during the decay of the tumor or
tuberculosis, and others focus Pneumothorax may be the result of not sealing seams surgical wound or differences in
their festering. Finally, it can be created artificially with a diagnostic or therapeutic purposes.
[22]
The causes of pneumothorax and traumatic emphysema: 1 - tracheal rupture 2 - break of mediawall pleura,
3-gap bronchus, 4-gap lung and visceral pleura.
Classification of the etiological basis of pneumothorax
• Tuberculosis - TB breakthrough due to the cavity
• Idiopathic spontaneous pneumothorax - on the grounds of "vesicular" emphysematous changes in lung tissue
• Pneumothorax - the breakout of inflammatory suppurative destructive changes in lung tissue
• Pneumothorax - the breakout of congenital bronchogenic cysts
• Traumatic - as a consequence of the closed and open chest injury
• Iatrogenic - physician for manipulation / puncture the pleural cavity, subclavian vein catheterization, etc.
• Artificial / diagnostic or therapeutic
• By the nature of communication with the external environment distinguish closed and open pneumothorax as a
special form of release valve and air block.
• An open pneumothorax. In an open pneumothorax is a free report pleural cavity with the ambient air. Compression
of light by atmospheric air (collapsed lung) on the side of pneumothorax causes the development of the so-called
paradoxical breathing. When inhaling air into the lungs of the healthy side falls not only from the external
environment, but also on the side of the lung injury in exhaled air of healthy lung from a slight fall on the side of
injury, some fanning him.
[23]
Pneumothorax
Closed post-traumatic pneumothorax
Open pneumothorax
• Valve pneumothorax. Occurs when a form of the wound channel or lung injury, when the air enters the pleural
cavity, but leave it not be, because the wound channel is covered with an exhalation tissue edges of the wound of the
chest wall (with the outer valve pneumothorax), or tissue of the lung (pneumothorax in the internal valve ) As a
result, accumulates in the pleural cavity air pressure in it gradually increases, which leads to the development of
stress pneumothorax, accompanied by compression of the lung, mediastinum veins, mediastinum shift to the healthy
side, severe respiratory distress and hemodynamic.
[24]
Right-hydropneumothorax.
Radiographs of the chest in total (complete) left-sided pneumothorax: the transparency of the left half of the chest is
increased, pulmonary picture is missing, mediastinum adherent to the shadow completely collaborate lung (arrow).
Spontaneous pneumothorax.
Spontaneous pneumothorax is defined as a syndrome of acute respiratory failure resulting from visceral pleura
rupture and subsequent impairment of respiratory function of the lung. Causes spontaneous pneumothorax is the
rupture of visceral pleura against various chronic respiratory diseases that were not previously diagnosed: bullous
form of emphysema, at least - lung abscess, and rarely - a decaying lung tumor or esophagus.
There are 3 types of spontaneous pneumothorax:
• 1. Open .
• 2. Closed.
• 3. Tense (Valve).
Emergency care for spontaneous Pneumathorx. required is relatively rare.
• Acute chest pain is removed by introducing analgesics
• 2-3 ml of 1% solution or promedola 1 ml of 2% solution omnopone subcutaneously, 1-2 ml of 50% solution
intramuscularly analgene
• With the increasing incidence of shortness of breath and blood pressure shows an urgent pleural puncture and
aspiration of air.
• hemothorax - accumulation of blood in the pleural cavity, mainly occurs after injury to the pulmonary, intercostal
or internal mammary arteries.
Classification of hemothorax by P.A Kupriyanov
Depending on the amount of sequestered blood are distinguished:
Small - accumulation of blood in the costophrenic sinus / 250 -300 ml
Average - the level of blood to the lower corner of scapula / 1 l ;
Great - to 2-rib and above / near total and total.
Clotted hemothorax
1. Uninfected 2. Infected
Types of hemothorax
[25]
Depending on the nature of the communication pleural cavity with the external environment distinguish indoor,
outdoor and valvular pneumothorax. All of them are found in open injuries, when disrupted the integrity of the skin
and parietal pleura.
Closed pneumothorax
formed when the wound hole in the soft tissues of the chest and lungs is rapidly closing as a result of displacement
of tissues and their traumatic edema, further air through it into the pleural cavity is not received. The volume of air
that has entered the pleural cavity, can be large or very small, almost not determined by the usual methods of
research.
Open pneumothorax
If the wound is gaping chest wall, then there is always a chain of adverse anatomical and functional changes.
Inspiratory portion of the air entering the pleural cavity, compresses the lung, yielding hollow of the heart and veins,
strongly pushes the mediastinum to the healthy side, and the diaphragm downward. When you exhale air is pushed
out of the pleural cavity: a light, devoid of elastic recoil of the chest, partially straightened. Appears paradoxical
breathing, in which to breathe in the healthy lung falls of air saturated with carbon dioxide gas from the affected
lung, and as you exhale, he rushes in the opposite direction. As a result of gas exchange in off not only easy on the
side of the injury, but significantly decreases the efficiency of the respiratory function of the healthy lung, greatly
disturbed the general and pulmonary hemodynamics, hypoxemia develops, in conjunction with stimulation of nerve
structures in mediastinum its flotation leads to an increase in functional disorders.
Pneumothorax valve.
Distinct respiratory and circulatory disorders also appear in valvular pneumothorax. C every breath the air on the
side of injury is injected into the pleural cavity through the wound of the chest wall or a bronchus, lung squeezing
more and pushing the mediastinum as a result of the valve mechanism can not go outside. Thus, there is within the
pleural compression, quickly leading to severe respiratory and cardiovascular failure.
Hemothorax is a consequence of vascular injury of the chest wall (intercostal, internal mammary, etc.), and lung.
Less commonly detected dangerous wounds of the heart, aorta, and pulmonary veins hollow. Depending on the
number of streamed into the pleural cavity blood differentiate small (in the pleural sinuses), middle (to the level of
the angle of the scapula) and a large hemothorax (Kupriyanov P.A, 1946). By the time of the inspection as the
victim bleeding may stop and go. Disorders of gas exchange and cardiac activity depends on the volume of blood
loss and the degree of lung collapse on the affected side.
[26]
With closed chest injuries involving broken ribs, their fragments can be inserted into the lung tissue, breaking it. In
such cases, a closed valve or hemopneumothorax and ripped through the parietal pleura air is distributed in cellular
spaces of the chest wall (subcutaneous emphysema).
The clinical picture and diagnosis. Diagnosis of closed injuries and injuries to the chest is often hampered by the
severity of the victims and the dynamics of clinical manifestations caused by the growth of pathological changes, so
it's important to know the mechanism of injury, time elapsed since the injury and the nature of the pre-hospital care.
Damage to the breast are a number of common diagnostic features:
- The pain of varying intensity on the side of injury, aggravated by breathing, coughing, changing body position,
often with a sharp restriction of respiratory movements, especially when damage to the skeleton;
- Shortness of breath and difficulty breathing, is also aggravated by movement, which, together with the pain causes
the patient to take a forced position of the body;
- Different on the severity of hemodynamic changes;
- Haemoptysis of varying intensity and duration;
- Emphysema in the tissues of the chest wall, mediastinum, and related fields;
- Shift of mediastinum to the opposite side of the place of injury;
- Other Physical changes.
Some of them are marked by the absolute majority of victims (pain, shortness of breath), while others are much rarer
(emphysema, hemoptysis).
Essential in assessing the status of the victim, even in emergency care, always has a systematic physical
examination, including inspection, palpation, percussion, auscultation, the study of the nature and location of
wounds, etc. On this basis and in the absence of other research methods are often unable to determine the feature
damage and take immediate therapeutic measures. The data obtained serve as a basis for selecting the type and
sequence of improved diagnostic techniques.
In emergency situations, to detect pneumothorax and hemo pneumothorax, ongoing bleeding or hemodynamic
pericardium is a useful therapeutic and diagnostic puncture. Methodically executed correctly, it can easily establish
the presence of air or blood in the pleural cavity and pericardium, and if necessary - to remove them.
The widespread use of laboratory tests for gunshot wounds of the chest, no doubt, improve the quality of their
diagnosis and helps in the selection of a rational treatment strategy. In particular, the study results of general blood
analysis, determination of hemoglobin and hematocrit provide an opportunity to objectively assess the degree of
anemia and to identify the signs of the ongoing internal bleeding.
Despite the relatively high information content of physical examination, the primary role in clarifying the nature of
the defeat belongs to the ray method study, implementation of which should be compulsory for all damage to the
chest. A promising method of substantially complementary to other studies, is the sound echolocation. C it can be
used to determine the thickness of the pleura, the contents of the pleural cavity, the mobility of light and airiness,
foreign bodies, to X-rays.
A specific value to determine the characteristics of trauma have chest thoracoscopy, bronchoscopy, esophagoscopy,
which, however, are not always leading to the diagnosis of intrathoracic lesions.
Symptomatology in a closed chest injury depends on the severity of damage the chest wall, the severity of associated
air-and hemothorax, the degree and extent of damage to the lung, heart, bronchial tubes and other organs.
With a relatively small bruises breast clinical picture tends to be mild. The main complaint is the pain of victims of
injury, aggravated by deep breathing and movement.
In cases of more serious injuries usually, there are marked disturbances of general condition. Severe pain in the area
of injury, forced position of the victim, multiple abrasions and subcutaneous hemorrhages, wounds of the chest wall,
do not penetrate into the pleural cavity, marked dyspnea, cyanosis, rapid heart rate and weakening, strain the chest,
paradoxical motion of its individual fragments or lagging while breathing one way or other half of the show closed
the severity of injury. Physical examination provides an additional basis for diagnosis. Palpation of the chest reveals
subcutaneous emphysema, place rib fractures, to determine the intensity of voice tremor. A short-percussion sound
indicates the presence of hemothorax or atelectasis of the lung. Tympanitis characteristic of pneumothorax.
Percussion is also possible to establish the boundaries of the lungs, heart, mediastinal shift, and so on, and on
auscultation of the lack of or reduced breathing.
On plain film reveals fractures of the skeleton chest, the presence of free gas and fluid in the pleural cavity,
mediastinal shift, aperture, collapse or atelectasis of the lung, mediastinal emphysema, and other symptoms.
[27]
Symptoms of Breast nonpenetrating wound depends on the nature and extent of damage. In the case of the blind,
cross-or tangential wounds of the chest wall common condition usually suffers little, respiratory and cardiovascular
disorders are expressed only slightly.
It is important to remember that in the tangential wounds of the chest as a result of side impact wounding projectile
may have severe bruising and internal organs, above all, heart and lungs.
Penetrating wounds in the chest during the Great Patriotic War of 1941-1945. were noted in 42.5% of patients with
thoracic trauma. Close to these figures appear in the statistical reports subsequent wars.
Penetrating chest wounds are usually accompanied by damage to internal organs, primarily the lungs, heart and
major blood vessels, etc. Quite often and combined injuries, damaged at the same time when other areas of the body.
These types of injuries are different severity and high mortality, despite the timely provision of medical care.
Diagnosis of open chest injuries perforating wound does not cause serious difficulties. Comparison of inlet and
outlet of the wound channel creates a view of the possible movement of the projectile wounding and involvement in
the pathological process of various organs. When the blind wounds diagnosis can be difficult.
In general, clinical breast penetrating wounds depends primarily on the nature of the destruction of intrathoracic
organs and the massiveness of haemothorax and pneumothorax.
Closed pneumothorax is a common manifestation of closed injuries and penetrating wounds chest. Its magnitude
depends on the nature of lung injury. In case of injury of the surface of the respiratory parenchyma often small
pneumothorax, and collaborated lung to 1/3-1/4 of its volume. By the time of receipt of the victim to a hospital
respiratory disorders arising from injury, remain small, shortness of breath is noticeable only during physical
exertion.
X-rays, respectively, are determined by areas affected side of enlightenment in the form of higher or lower zone,
devoid of the pulmonary pattern. Easy collaborated , the mediastinum is shifted in the opposite direction.
When injury of lung tissue or blood vessels of the chest wall, mediastinum, rarely, the clinical picture depends on
the magnitude of blood loss and the amount of blood accumulated in the pleural cavity.
Small hemothorax show little clinical evidence. Abnormalities in the cardiovascular and respiratory systems are
minimal and short-lived or non-existent.
In the middle and especially the large hemothorax clinical picture is more severe: victims complain of general
weakness, pain in the chest, shortness of breath.
An objective study revealed signs of respiratory failure and hemodynamic disorders (cyanosis, pale skin, cold sweat,
shortness of breath, light and rapid pulse, drop in blood pressure). For percussion show signs of fluid buildup in the
corresponding pleural cavity.
Radiographically defined homogeneous intense shadowing of most or even the entire lung and mediastinal shift to
the opposite side of the wound (Fig.). Reducing the number of red blood cells, hemoglobin and hematocrit reflect
the bleeding body.
If you puncture the pleural space evacuated 1 liter of blood or more, and often it is stored again. In cases of ongoing
bleeding received blood clot at the puncture, as no time to undergo fibrinolysis impact of the pleura. Open
pneumothorax, identified in the Great Patriotic War, about a third of the wounded (33.2%), differed significantly
even when the weight of a relatively small damage of the lung. The frequency of shock at such casualties reached
50-55%.
The victims are excited, scared, suffering from sharp pain in the wound and painful cough. Without occlusive
dressings on the wound tends to close a gaping chest wall defect by hand.
In the overall clinical picture is clearly dominated by respiratory distress. Cyanosis of the skin, cold sweat, shortness
of breath severe, lowering blood pressure, rapid pulse and low indicate the severity of the wounded man. Inspection
of the gaping wound chest, communicating with the pleural cavity through which air passes from the noise in both
directions, provides a basis for establishing the final diagnosis. If you cough shock or change of body position can
pour out frothy blood.
Physical signs pneumothorax is defined with an almost complete collapse of the lung and mediastinal shift to the
opposite side. In the majority of cases can be identified and haemothorax, expressed to a greater or lesser degree.
X-rays detected by hemopneumothorax collapsed lung, mediastinal shift to the opposite side and a horizontal fluid
level. Establish the nature of bone lesions, the localization of foreign bodies.
Almost always, these victims can be found marked changes in the blood (anemia): a significant decrease in
hemoglobin, hematocrit and red blood cell count.
Wounds and injuries covered his chest with valvular pneumothorax occur in small groups (1-2%) of the total
number of victims, but differ in significant weight of functional changes. In these cases, the survey observed most of
[28]
the symptoms that occur with other types of penetrating wounds chest. During the inspection of the victims, along
with signs of hypoxia and hemodynamic disorders striking pronounced increasing subcutaneous emphysema of the
chest wall, often extending to the neck, head, legs, stomach.
Physical signs revealed pneumothorax with mediastinal shift sharp in the opposite direction.
Radiographically detected collapsed lung, a low dome of the diaphragm and the location of a dramatic shift in the
mediastinum intact side. The wounded with valvular pneumothorax requires emergency surgery, without which they
would quickly die due to progression of respiratory and cardiovascular disorders.
In cases of mediastinal emphysema is very dangerous subcutaneous airbag, first appears on the neck, the jugular
notch in the field, and thence distributed symmetrically on both sides of the body.
The clinical picture of lung injuries depends mainly on the amount of damage to the respiratory parenchyma. In
limited lesions of the lung symptoms is weak. Hemodynamic and respiratory function are preserved at the level of
compensatory reserves. In patients with extensive intrapulmonary hematomas, often with significant hemo - and
pneumothorax occur more noticeable disturbances of respiration and circulation. The state suffered heavy. They
slowed down, struggling to answer questions and complaining of severe, sometimes excruciating pain in his chest. A
characteristic sign is hemoptysis. On examination, attention is drawn to the sharp apnea - to 44-46 in 1 min. Blood
pressure decreased, heart rate speeded. Auscultatory there is a weakening heart sounds, pulmonary respiration and
the presence of many different-sized rales in the lungs.
Radiographically visible light in homogeneous areas of focal and infiltrative changes, holding a share or two.
Open and closed injuries of mediastinum (heart, great vessels, trachea and main bronchi, esophagus, etc.) we have
classified the most difficult. Victims often die at the scene due to severe primary disorders of blood circulation and
respiration.
Only
the
timely
delivery
of
required
surgery
can
expect
a
favorable
[29]
outcome
Causes of respiratory failure in closed chest Injurious tions: 1 - the pain of broken ribs and rupture of the parietal
pleura, 2 - "costal valve" 3 - break light, 4 - hemathorax 5 - pneumothorax, 6 - lung atelectasis, and 7-damaged
diaphragm 8 - "shock lung", 9 - bronchial obstructions due to congestion in their sputum and blood, bronchospasm,
10 - break the bronchi, 11 - laryngeal spasm, 12 - the central respiratory disorders.
The basic principles of surgical care. Improving treatment outcomes of patients with chest injury depends on the
definition of organizational support for assistance at all stages of medical evacuation. Conducted at the scene, during
transport and later in a hospital activities should always be pathogenetically substantiated, aimed at reducing the
period of acute functional impairment and possible rapid removal of wounded from the shock.
In general, a landmark treatment of patients with chest injuries is as follows. At the scene (in the lesion focus) on the
chest wound impose protective aseptic dressing. Produce a stop external bleeding pressure bandage. In an open
pneumothorax chest gaping wound is sealed occlusive dressing. In cases of asphyxia cleanse the mouth of blood,
mucus and foreign bodies, according to testimony resort to artificial respiration using the S-shaped duct. All victims
injected analgesics, cardiac drugs and carry them on stretchers, preferably in a position half-sitting.
When stress pneumothorax pleural puncture with a thick needle (like Dufour) in the second intercostal space in mid
clavicular line, with its fixation to the skin patch. To the free end of the needle stick rubber valve, made of surgical
glove finger. If necessary, resort to artificial or assisted ventilation.
In cold weather, the victim should be taxed and hot-water bottles wrapped in a blanket. If there are signs of bleeding
and fall in blood pressure for health spend infusion therapy (polyglucine, saline solutions, glucose), which however
should not prevent the transportation of wounded.
[30]
After rendering first medical aid wounded in the chest is always in need of an emergency evacuation to hospital.
The overall schematic diagram of treatment of patients with lesions in the breast surgical hospital includes:
- Early and full drainage of the pleural cavity;
- Replenishment of blood loss;
- The effective maintenance of the airway;
- Elimination of pain;
- Seal and stabilize the chest wall;
- Antimicrobial and supportive therapy.
Clinical experience suggests that in both groups of patients with chest injuries, while maintaining a principled
scheme to help them have their own characteristics.
In the treatment of almost all the victims, in addition to drainage of the pleural cavity, shows the assignment of
painkillers, antibiotics, oxygen therapy and breathing exercises. In this case the use of non-narcotic analgesics in
conjunction with intercostal or paravertebral novocaine blockade provides a completely satisfactory anesthesia.
In most cases, penetrating wounds requires primary breast debridement. It consists of a fiber dissection of the tissue
through the wound channel, excision of devitalized and contaminated sites, subcutaneous fat, fascia, and especially
the muscles, resection of the damaged edges, removing blood and clots, streamed, foreign bodies ensuring thorough
haemostasis. When cutting and blind wounds without ragged edges, where the diameter of the inlet does not exceed
2-2.5 cm, there is an open pneumothorax and injury of large vessels, surgical treatment can not perform, limiting
toilet wounds.
Victim with a closed pneumothorax in general good condition produce more puncture or drain the pleural cavity a
thin plastic tube with a diameter of 0.5-0.6 cm in the second intercostal space in mid clavicular line, followed by
active aspiration vacuum system with a constant negative pressure of 30-40 mm of water. of Art. (Figure). During
the active aspiration to achieve a constant airway, timely elimination of atelectasis, often preventing complete
unfolding of the lung. According to testimony perform surgical wound care, analgesics administered, appointed
breathing exercises. The need for a wide thoracotomy in this group of wounded is usually absent.
In cases hem thorax and hem pneumothorax particular treatment largely depends on the severity of the wounded
and the volume of blood loss. General is required thoracostomy drainage widely translucent tubes diameter 14-15
cm
Drainage of pleural cavity technique. In seventh - eighth intercostal space on the middle axillary line anesthetized
soft tissue 2% solution of trimekaina. Scalpel pierce the veils of intercostal space, focusing on the upper edge of the
underlying edge to avoid damage to the intercostal nerves and blood vessels. Prepared widely translucent prepared
tube with an additional cut through the side hole capture curved clamp or forceps and inserted through the incision
into the pleural cavity after removal of a scalpel. Edge of skin wounds beside a drain stitch seam fixing and fix them
up. The outer end of the tube fitted with a valve is lowered into the vessel with an antiseptic solution. Often, patients
with hem pneumothorax to remove air and more rapid and reliable lung distention must install a second phone on
the system for blood transfusion (5-6 mm in diameter). It is administered by trocar in the second intercostal space on
mid clavicular line and connected to a water-jet or electric suction.
I wounded with a small hemothorax at low and short-term respiratory and circulatory disorders therapeutic measures
include puncture or drainage of the pleural cavity widely translucent tubes, the appointment of painkillers,
antibiotics and breathing exercises. Infusion therapy is carried out in a volume of 500-800 ml. There is usually no
need for surgical treatment and skin wounds that are well healed under a scab.
In cases of secondary and especially large hemothorax using more advanced level of assistance. In addition to the
drainage of the pleural cavity, aggressively remove the contents of the airways due to excessive accumulation of
frequent secret in the tracheobronchial tree and is widely used inhalation of humidified oxygen, thus improving, the
oxygenation of blood. If signs of heart failure prescribed cardiac glycosides and steroid hormones, simultaneously
administered bronchodilators and antihistamines. Of particular importance in the treatment of patients with acute
blood loss should be given to evaluation of the testimony and the volume of ITT. Clinical experience suggests that
most of the affected hemothorax with an average need of intravenous fluids mainly of plasma replacement fluids,
less blood, only the day of admission. It is advisable to use salt solutions, 5% glucose solution, low molecular
weight dextran (total liquids 1300-1500 ml).
[31]
With a large volume of hemothorax with blood loss 1000-1500 ml of infusion-transfusion facilities with complex
respiratory therapy are particularly important.
The day of admission to each victim poured 2000-2500 ml of fluids, including blood transfusions required.
Intravenous injection of plasma replacement fluids is necessary and in the next 2-3 days (total 4500-5500 ml)
A very important and effective treatment for the victims is a reinfusion of blood from the pleural cavity, successfully
used in field and clinical conditions in the latter decades.
Blood reinfusion technique. Pre-harvest sterile vials graded volume 500-1000 ml, which immediately before the
blood sample is added preservative (1000 IU heparin and 10 ml of 4% sodium citrate in 500 ml of blood). Blood is
collected into vials using vacuum systems or entering them on drainage by gravity through the filter. Transfusions
start immediately without any pre-trial and research.
In 8-10% of affected medium and large hemothorax is necessary in a wide thoracotomy. In the first hours and days
after injury in 55-60% of them are an indication for surgery is ongoing intrapleural bleeding. In the later periods of
intervention is the cause of clotted hemothorax, persistent collapsed lung or pleural empyema.
The volume of surgical care for the wounded to open pneumothorax depends on the size and nature of the damage.
Most of the victims in urgent need of prompt closure of the wound of the chest wall defect and certainly draining the
pleural cavity, the main task of which is a complete smoothing of the lung. To reduce the duration of functional
impairment and possible rapid removal of wounded from the shock in order preoperative always justified by shortterm (within 40-60 min) antishock therapy. It is aimed at combating pain, respiratory failure and replenishment of
blood loss. Preoperative therapeutic measures should include control of the tightness of the pleural cavity, the
introduction of analgesics, the implementation of the intercostal, paravertebral subpleural and novocaine blockades,
the effective maintenance of airway, inhalation of humidified oxygen, replenishing blood loss, the introduction of
cardiac, bronchodilators, steroid hormones. Drain the pleural cavity widely translucent tubing is required prior to
surgery, not after debridement chest.
ITT continues during operation, while a large hemorrhage and severe condition of wounded - in the postoperative
period.
Open stitching technique of pneumothorax. Operations carried out in the open pneumotorax under general
anesthesia ventilator c.
Skin incision and subcutaneous wound extends in both directions parallel to the edges. Excised nonviable, filled
with blood or contaminated pieces of tissue, fascia and muscle are removed bone fragments and foreign bodies.
Subperiosteal resecting the ends of broken ribs. Damaged intercostal vessels were ligated. Then, layer by layer
sutures in the muscle, completely sealing the pleural cavity. The operation was complete novocaine blockade of the
intercostal nerves.
Stitching of large chest wall defects, especially on the front surface, often presents considerable difficulties. Achieve
the goal in these cases by mobilizing tissue from the intersection, but not removal of several higher-and lower edges,
plastic free or muscular layer of the dome of the diaphragm adding to the edges of the treated wounds.
Application of this technique allows to obtain good results in 80-85% of casualties. Thoracotomy at the stage of
providing quality health care is carried out with continued bleeding inside the pleural and massive damage to the
lung. The need for them does not exceed 5-10%.
Victims with valve pneumothorax also need for urgent reanimation care. For decompression and removal of
mediastinal drain bias pleural cavity in the seventh intercostal tubes of large diameter. According to testimony
conducting fluid therapy, prescribed medications. For the full unfolding of the lung is almost always requires the
additional introduction of a thin tube into the second intercostal space, followed by active aspiration. However,
securely fix valve mechanism only drainage of the pleural cavity can be only in rare cases, and ongoing activities are
essentially a preparatory stage for the necessary in such situations thoracotomy.
Treatment of closed injuries chest. When bruised chest enough of analgesics (analgin, baralgin) in combination
with intercostal or subpleural novocaine blockade. When isolated rib fractures in the fracture site is administered 80100 mL of 0.25% solution of novocaine, with multiple injuries and perform retrosternal paravertebral blockade.
In cases of severe complications of closed chest injury for the correction of respiratory and cardiovascular disorders
spend the whole complex, as set out above.
Surgical treatment of a floating rib "valve" begins with a full anesthetic sites of fracture alcohol-procaine segmental
blockades in conjunction with the appointment of non-narcotic analgesics and antihistamines. Very useful for
epidural block with the introduction of fractional epidural space of highly active anesthetics (lidocaine, trimecaine).
[32]
External fixation rib "valve" produced by bullet forceps (stretching over blocks to a special frame), a special plate
with multiple perforations or extrafocal osteosynthesis fracture site. In extreme cases, particularly if associated
trauma, rib "flap" is temporarily fixed with the help of mechanical ventilation (internal pneumatic stabilization).
After normalization of the respiratory and circulatory produce one of the above operations.
In cases of mediastinal emphysema increasingly tense shows its drainage.
Under local anesthesia, novocaine perform transverse skin incision of 3-4 cm in length just above the handle of the
sternum. Cut through the skin, subcutaneous tissue, superficial and 2nd fascia neck. Finger are boundaryponeurothic
space and penetrating the sternum for possible deeper tissue carefully stratify the mediastinum along the trachea. To
sum up the place of damaged drain tube connecting it to a vacuum device.
Treatment of cardiac injury in general is similar to the intensive care of acute coronary insufficiency or myocardial
infarction. It includes the removal of pain, the purpose of cardiac glycosides, antihistamines, drugs that improve
coronary circulation and normalizing metabolism in the myocardium. According to the testimony administered
antiarrhythmic and diuretics. Required fluid resuscitation is performed under the control of CVP. In the contusion of
the heart with a predilection for hypotension of a wide thoracotomy, except for emergency operations should be
possible delayed until stabilization of the heart.
Treatment of lung injury include the following activities. Carefully remove mucus from the tracheobronchial tree.
Injected painkillers, antibiotics and inhalation of humidified oxygen is carried out through nasal catheters. If
necessary, drain the pleural cavity, conduct blood reinfusion and provide smoothing of the lung. When the volume
of circulating plasma deficit under control for CVP spend ITT, giving preference to protein preparations (albumin, a
protein) and antiplatelet (reopolyglucin). To reduce the permeability of the alveolar-capillary membrane is
administered steroid hormones, vitamins C, P, and antihistamines. In order to enhance myocardial contractility
prescribed cardiac glycosides, while reducing pulmonary hypertension bronchodilators (aminophylline) and
diuretics. Many times during the day used inhalation of 5% solution of sodium bicarbonate with proteolytic enzymes
to produce the testimony of remedial bronchoscopy. With the rapid growth of respiratory disorders go on
mechanical ventilation, duration of which may be 5-7 days or more.
Clinical experience of recent decades has convincingly shown that successful treatment for most patients with breast
lesions using a set of possible therapeutic measures, which are based on antishock therapy and drainage of the
pleural cavity.
Wide thoracotomy should be performed only on strict indications, not more than 10-15% of cases. This is due to the
upcoming often spontaneously stop bleeding from the lung parenchyma, especially when wounds are located far
from the root, and high regenerative properties of lung tissue.
Treatment of hemothorax
Treatment of patients with hemothorax is possible only in thoracic compartment. Therapeutic measures consist in
the aspiration of blood streamed. For all types of hemothorax must first be satisfied: stopped or continued bleeding.
This involves puncture of the pleural cavity in the lower regions of hemothorax and conducted test-Ruvilua Gregoire
/ if ongoing bleeding, blood clot from the pleural cavity and forms a clot.
Puncture
Thoracostomy / two at hemopneumothorax /
if the passive aspiration of 2 hours is allocated
500-600 ml of blood, monitoring of patients stopped and displayed
thoracotomy / principle of Sanders / * with continued bleeding
* with clotted infected
Reinfusion of blood during an average hemothorax
[33]
Indications for thoracotomy. Distinguish urgent, immediate and deferred transactions.
Urgent thoracotomy are shown:
1) to carry out resuscitation (cardiac arrest, rapidly rising valvular pneumothorax, profuse bleeding, intrapleural);
2) injury of the heart and large vessels (when you need to quickly resolve life-threatening disorder).
Urgent thoracotomy performed during the first days after injury. They are shown in the following cases:
1) ongoing intrapleural bleeding and blood loss 300 mL / h or more;
2) uncropped valvular pneumothorax;
3) Open pneumothorax with massive damage to the lung;
4) damage to the esophagus;
5) suspected injury of the heart and aorta.
Deferred thoracotomy produced after 3-5 days after injury and later. They are shown at:
1) clotted hemothorax infected,
2) persistently renewing pneumothorax with collapse of the lung;
3) large (greater than 1 cm) foreign bodies in the lung and pleura;
4) recurrent cardiac tamponade;
5) The threat of profuse pulmonary hemorrhage;
6) pleural empyema.
The pooled data indicate that the number of urgent thoracotomy is related to the number of immediate and deferred
approximately as 1:3. At the same time their number grows depending on speed of delivery of the victims to
hospital.
Common questions of operational art. Thoracotomy is performed under general anesthesia with endotracheal
mechanical ventilation.
Thoracotomic incision is scheduled based on the data X-ray examination, the localization of the entrance and exit
wound openings clinical disease. The greatest scope for the operation the surgeon in all parts of the pleural cavity
provides lateral thoracotomy. It allows not only examine in detail the front and rear sections of the lung, heart,
mediastinum and diaphragm, but also to carry out any intervention on the intrathoracic organs.
After opening the pleural cavity with continued bleeding, you must install the source. In cases of bleeding from the
damaged intercostal arteries central and peripheral ends of the stitch and tie them with silk ligatures. Bleeding from
the wounds of the root vascular lung temporarily stop the finger pressing, followed by suturing of the wound defect.
Accumulated in the pleural cavity of liquid blood is collected in specially prepared bottles with a stabilizer. Further
surgical approach depends on the nature of intrathoracic lesions.
[34]
Not cut the wound with a light, but only very sparingly excised nonviable tissue. Conduct a thorough hemostasis, all
visible gaping ligated bronchi. Minor blemishes easily remove individual interrupted sutures on thin filaments round
atraumatic needles. With torn and cross-sections of peripheral lung injuries following boundary or wedge resection
using the apparatus UKL-60 and UKL-40. If the devices do not, then use hand stitching. In cases of significant
damage lung lobectomy or pneumonectomy performed.
The indication to remove the lobe of the lung is extensive destruction of, damage to the bronchus aerating share
without the possibility of the bronchoplastic operations, signs of venous plethora in significant damage and ligation
of common vein. After lobectomy is mandatory check and complete unfolding of the light leakage under high
pressure.
Pneumonectomy is indicated for extensive destruction of the lung, damage to the root element of a violation of
aeration and circulation, which can not be removed during the operation, the volume of non-conformity remains
after a partial resection of the intact lung tissue volume of the pleural cavity.
All interventions in the intrathoracic organs finish washing the pleural cavity, resection of the sharp edges of the
fragments, required drainage of the pleural cavity, novocaine blockade of the intercostal nerves. Layers are sewn
cloth chest wall. Rounding out the operation of the surgical treatment of the entrance and exit wound openings chest.
After thoracic operations transportable wounded in the chest for 7-8 days, if the evacuation is carried out by road.
The term transportable can be shortened to 2-3 days for evacuation by air.
In the postoperative period, carry out activities aimed at filling the volume of circulating plasma, maintaining a
weakened heart and adequate ventilation, prevention and treatment of complications. Therapy includes antibiotics in
maximal doses, analgesics, cardiac glycosides, bronchodilators, antihistamines, oxygen therapy, infusion means.
The most common complications of breast lesions are pneumonia, empyema, abscess wounds of the chest wall,
clotted hemothorax. Their number has been steadily declining during the early delivery of the victims and carrying
out complex pathogenesis based treatment.
For better absorption of the topics are new teaching technologies: methods of "lots"
"Round table", and "academic controversy."
Using the "lottery"
Students are removed from the boxes and answer quiz questions without preparation.
One student's lawyer points out the positive and the other student, "the prosecutor" negatives response.
Using the "round table":
Embarks on a circle with a piece of paper assignments. Each student writes his answer sheet and transfer to another.
Responses should not be repeated. All write down their answers, followed by discussion: the wrong answers crossed
out the number of right - assessing students' knowledge.
Examples:
-type of injuries of the chest
- Provide a diagnostic algorithm apnea syndrome
-identify the tactics of GPs with chest injuries.
Using the "Academic debate"
The group is divided into two smaller subgroups. Each subgroup is proposed consultations: physician - patient. In
each subgroup a student parses the positive aspects of advice - "lawyer" and the other examines the negative
moments advice - "Attorney".
Results of the "lawyer" and "prosecutor" are reported and discussed as a group.
Discussion regarding AT ADMISSION PATIENTS: 1. Clinic and diagnostics pneumotharax.2. Clinic and
diagnostics gemotoraksa.3. Clinic and diagnostics pneumoempyema.
Abscess and gangrene of the LUNG
Classification of chronic suppurative Lung
Malformations, among which are the most common lung hypoplasia, lung sequestration, cysts of the lung, acquired
the disease
- Outcomes of acute destructive and inflammatory processes: Mts. abscess, cyst
- Bronchiectasis: primary, secondary
[35]
Classification of chronic suppurative Lung







In the presence of complications:
Hemoptysis, pulmonary hemorrhage
metastatic abscess
Aspiration pneumonia
Empyema, pneumoempyema
bronchopleural fistula
sepsis
amyloidosis of the body
Lung abscess - a limited pyo-destructive process, accompanied by the formation of single or multiple purulent
cavities in the lung tissue.
Gangrene of the lung - a widespread purulent-necrotic process in the lung tissue that has no clear boundaries.
By the appearance of distinguished bronchogenic (aspiration,
postpneumoempyema and obstructive), thromboembolic (microbial and
aseptic) and post-traumatic types of lung abscess.
Abscess and gangrene of the lung - a qualitatively different pathological
processes.
If an abscess is a pus-limited destructive process in the lung tissue.
Limitation of the inflammatory focus and transition ichorization to fester
show pronounced defensive reactions, while widespread gangrene is the
result of progressive necrosis as a result of the weak reactivity or complete
areactivity body.
Among patients with more men aged 30-35 years, women suffer 6-7 times
less, which is associated with features of productive activities of men,
more common among them are alcohol abuse and smoking, leading to a violation of the drainage function of the
upper respiratory tract.
The etiology and pathogenesis: key factors in the development of abscesses and gangrene airless of the lung tissue
(due to obstruction bronchus, atelectasis and inflammation) disorders of blood circulation in it, a direct effect of
toxins on the airless lung tissue with impaired circulation.
Distinguish bronchopulmonary, haematogenously-embolic, lymphogenous and traumatic way of lung abscesses and
gangrene.
Bronchopulmonary way. One of the most common causes of abscesses and gangrene is a violation of the patency
of the segmental bronchi and equity due to their release to the lumen of the infected material from the oropharynx.
In the unconscious (due to alcohol intoxication, after surgery) for serious infectious diseases ciliary function of
bronchial epithelium is broken, the cough reflex is suppressed and infected material (food particles, tartar, saliva)
can be recorded in the bronchi as much time as necessary for the development of atelectasis and inflammation in the
corresponding portion of the lung. Typically, in these cases, abscesses are located in the posterior segments (II, VI)
and more often in the right lung.
Similar conditions arise in the bronchus obstruction of the tumor, foreign body, narrowing its lumen scar
(obstructive abscesses). Removal of foreign body and restore patency of the bronchus in these cases often lead to a
rapid cure the patient. Metapneumonic abscesses occur in 1.2-1.5% of patients with pneumonia. Their development
is favored by lowering the reactivity of the body, pronounced disturbances of ventilation and circulation of the lung,
often caused by previous lung disease, the inadequate treatment of pulmonary process.
Haematogenously-embolic path. In this way develop 7 - 9% of lung abscess.
Of infection in the lungs is due to the transfer of infected blood flow emboli from extrapulmonary foci of infection
in septicopyemic, osteomyelitis, suppurative thrombophlebitis, and others infected emboli block the vessels of the
lungs - pulmonary infarction develops, which is subject to purulent fusion. Abscesses with haematogenouslyembolic origin, usually localized in the lower lobes, and they are numerous.
[36]
Lymphogenous way of developing lung abscesses and gangrene is rare. Drift infection in the lungs is possible with
angina, mediastinitis, subdiaphragmatic abscess, etc.
Abscesses and gangrene of traumatic origin are the result of closed chest injuries with damage to lung tissue and
penetrating wounds.
Pathological anatomy: a moment of abscess formation in the lung tissue against the background of the
morphological changes characteristic of pneumonia, there is one or more areas of necrosis. Under the influence of
bacterial proteases is purulent fusion of necrotic masses - a cavity filled with pus. The destruction of the wall of a
bronchus in the zone of necrosis, determines supply of pus in the bronchial tree. Further morphological changes
determined by the state of reactivity patient, drainage of abscess, and the terms of its size, the course of
inflammation in the surrounding lung tissue. When single pyogenic abscess cavity quickly relieved of pus, its walls
gradually cleared of necrotic masses and covered with granulations, an abscess formed on the spot or scar
epithelium lined the narrow cavity. For large poorly draining cavities, prolonged purulent fusion of necrotic tissue,
the presence of inflammation in the surrounding parts of the lung cavity release from necrotic masses is slow in the
wall of an abscess is formed by dense scar tissue that prevents healing.
Chronic abscess is formed.
Multiple abscesses are usually preceded by widespread inflammation in the lung. Against this background, several
sections of lung tissue necrosis. Areas of necrosis are purulent fusion at different times, the breakthrough of ulcers in
the bronchial tree does not occur simultaneously.
When multiple abscesses are the outcome of the acute period of the formation of several bubbles surrounded by a
thick membrane of necrotic and granulation tissue. Between lung tissue abscesses does not recover its normal
structure.
For lung gangrene is characterized by limited changes of lung tissue from healthy. Land mortify tissue without sharp
boundaries becomes softened lung tissue of dark color, which also goes without clear boundaries in healthy tissue.
Clinic and diagnostics:
With typical forms of the disease occurring in the clinical picture can be separated into two periods: 1) prior to the
opening of the abscess into the bronchus, 2) the period after the opening of the bronchus.
Абсцесс легкого с уровнем жидкости
Абсцесс легкого с уровнем жидкости
Clinic
[37]
Абсцесс легкого с уровнем жидкости
I. phase of a "closed" lung abscess - lasts 6-8 days, then break into the bronchi
• hyperthermia
• intoxication
• dry cough
II. phase of the "open" lung abscess - with 8-9 days of onset
• purulent sputum or putrid t º C reduction and toxicity
The character of sputum lung abscess
The disease usually begins with symptoms typical of pneumonia: a fever, pain in the side with a deep breath and
cough. Physical examination reveals gap in respiration of the chest, corresponding to the affected parts of the lungs,
tenderness, here defined shortening of percussion sound.
The x-ray and CT scan seen larger or smaller sizes of dense shade. Following initial treatment, pneumonia is not
allowed and gets dragged. The high temperature is accompanied by chills and drenching sweat. Sometimes patients
say bad breath. In the study reveal high blood leukocytosis, an abrupt shift formula of white blood to the left.
These physical examinations vary in comparison with the first period. As the release of abscess cavity of pus and
resolution of perifocal inflammation disappears zone shortening percussion sound. In the presence of a large cavity,
free from pus, and above it may be determined by tympanic sound, more distinctly detectable, if the patient opens
his mouth percussion. With significant amounts of abscess listened amphoratic breath over the cavity and mixed
wet rales, predominantly in the adjacent regions of the lung.
X-ray examination after emptying abscess cavity defined, sometimes with the liquid level. At first, she has fuzzy
contours due to perifocal inflammation. As the evacuation of abscess and remitting inflammatory process around the
boundary of abscess become clearer.
If there is a blockage of the holes leading to the bronchus, the body temperature rises again. With good drainage
condition gradually improved, and recovery occurs.
More severe the multiple abscesses of the lung. Usually they are metapneumothic and occur against a background
of inflammatory infiltration of large areas of lung tissue. The breakthrough single from an abscess in the bronchial
tree does not lead to a substantial decrease toxicity and improve the patient's condition, as in the lung tissue remain
foci of necrosis and the purulent fusion. Heavier state develops purulent bronchitis with copious foul-smelling
sputum. Physical examination determines the delay in breathing chest on the affected side, dullness on percussion,
respectively, one or two lobes of the lung; auscultatory - a lot of rattles of all sizes.
X-ray study reveals the first extensive blackout in the lung, as emptying the contents of pustules on a background
dimming become visible cavities with fluid levels. Recovery of the sick, as a rule, does not occur.
The disease progresses. Develop pulmonary heart disease, stasis in the pulmonary circulation, degenerative changes
in parenchymal organs. All this leads quickly to death.
Gangrene is the most severe form of purulent lesions of the lung. Absorption of products ichorization formed by
gangrene of the lung, and bacterial toxins leads to a rare intoxication patients. In the early lung gangrene starting
gins to separate a lot of stinking frothy sputum, which has the form "meat slops" because of admixture of blood from
the pulmonary vessels. The process usually involves the pleura, which leads to the development of putrid empyema
or pneumoempyema. In the study of patient attention is drawn to severe shortness of breath, anemia, cyanosis, a
significant shortening of the area of percussion sound over the affected lung, heard on auscultation of rales many
[38]
different calibers. Radiographically detected extensive blackout in the lung, which increases with each passing day.
Before the advent of antibiotics, patients with gangrene of the lung usually died within the first days of illness.
CLINICAL PRESENTATION
1. SIGNS OF CHRONIC INTOXICATION: weakness, sweating, low-grade fever periodical
2. Chronic recurrent inflammation in the airways
3. Bronchial obstruction and chronic respiratory failure
4. Signs of pulmonary hypertension and "PULMONARY" heart
COMPLAINTS:
- Cough (82.5%)
- Weakness (82.5%)
- Sputum (67.5%)
- Pain in the affected side (67.4%)
- An increase in temperature (56.5%)
- Shortness of breath (48.6%)
- Hemoptysis (42%)
Physical DATA
 Pale skin, and weight loss
 "Watch glasses" and "drumsticks"
 Lagging the affected side when breathing
 Dullness of percussion on the affected side
 Attenuation breathing amphoratic breath, bronchial breathing, or wheezing shade
METHODS
 Fluoroscopy, radiography, tomography
 Computed tomography (spiral, in the mode of angiography)
 Magnetic Resonance Imaging
 bronchography
 Angiography: angio pulmonography, bronchial arteriography
 PBS
Differential diagnosis of lung abscess, cancer, gangrene, lung cysts, cavernous tuberculosis.
In the peripheral lung cancer has a round shadow jagged edges, defined path toward the roots of light, gives the
clinic pneumonia. The decay of cancer formed by cancerous cavity with jagged edges, at biopsy determined
abnormal cells.
• Uncomplicated cyst lung on a radiograph gives a rounded shadow with a smooth, thin edges. For the cyst is
characterized by eosinophilia, positive reactions and latex hemagglutination. If festering cysts are difficult to
distinguish from an abscess of the lungs. There will carefully collected history.
[39]
• Gangrene light shows the dire state of the patient, acrocyanosis, severe intoxication. Radiographically determined
uneven darkening 1-2 proportion lung lesions with destruction. Sputum offensive, in the form of "meat slops" from
the sequestration of lung tissue.
• Cavernous tuberculosis lung abscess differs from anamnestic data, the appearance of symptoms for 2-3 weeks in
the dissemination of dynamic X-ray study, the detection of tubercle bacilli in the sputum, positive tuberculin skin
test.
Clinic and diagnosis of pneumoempyema composed of pions and pneumothorax, purulent intoxication, signs of
respiratory failure. In the diagnosis plays an important role medical history, x-ray and pleural puncture.
Bronchiectasis
 Mild form: clinical symptoms in remission are minimal - cough, cough, phlegm moves in small quantities,
the mucous. With worsening - sputum is mucopurulent or purulent character, fever, wheezing occur.
Exacerbations are a once a year or several years.
 Moderate forms: acute, from 2-3 to 6-8 times a year, have dragged on, there are signs of chronic purulent
intoxication.
 Severe form: characterized by ongoing inflammation in the bronchial wall, with a gradual deterioration,
marked signs of chronic intoxication, respiratory and cardiovascular failure.
Clinic and diagnosis of abscess lung complications
Pneumoempyema developed an abscess at the break of light into the pleural cavity and is characterized by
shortness of breath, tachycardia, cyanosis of the skin and mucous membranes, chest pain (sometimes shocking), a
high temperature. Percussion dullness observed in the lower and upper parts of tympanitis in the affected side of the
chest, the X-ray shadow of the lower parts of the chest with a horizontal level and the absence of broncho-vascular
pattern in the upper part, the collapse of the lung.
[40]
Clinic aspiration lesions and lung abscess, the opposite is the same as in acute lung abscess.
Pulmonary hemorrhage is characterized by hemoptysis scarlet frothy blood in the aspiration - the phenomena of
respiratory distress, cyanosis, tachycardia, physical rales. For the diagnosis of prime importance are bronchoscopy
and bronchial arteriography.
Go to the chronic form of abscess is easily observed in the giant and multiple abscesses, inappropriate treatment of
patients, as well as when the abscess bursts into the bronchus in the upper pole (transition to the chronic form after 2
months from onset). The x-ray of light is determined by the circular shadow with horizontal level, pyogenic capsule
is thick, irregular in shape.
The differential diagnosis of acute pulmonary abscess is drawn from a peripheral lung cancer and cysts,
tuberculous cavities and gangrene of the lung.
Peripheral lung cancer has uneven borders, path to the root of the lungs, gives edge serous pneumonia, cancer in
the decay of the cavity has a thick irregular wall biopsy are abnormal cells.
Cyst of the lungs (uncomplicated) has a clear-wall boundary, with echinococcosis are positive reactions of latexhaemagglutination eosinophilia. If festering cysts - to distinguish them from the acute abscess is virtually
impossible.
Gangrene of the lung differentiated from weight general condition of patients, acrocyanosis, severe intoxication,
radiographically dimming 1.2 parts of light without a clear boundary from the adjacent healthy tissue, and pockets of
destruction. Sputum color of meat slops ichorosus smell, with sequestration of lung tissue.
Tuberculous cavity is distinguished from an abscess on the basis of history, x-rays. Studies in the dynamics of
(usually 2-3 weeks, there are signs of dissemination), the identification of Mycobacterium tuberculosis in sputum
(+) tuberculin tests.
Treatment:
PRINCIPLES OF TREATMENT




DRAINAGE suppurative focus
CORRECTION homeostasis and immunological reactivity
ANTIBACTERIAL THERAPY IN ACCORDANCE WITH THE SENSITIVITY
Detoxication THERAPY METHODS extracorporal detoxication (hemosorbtion using membrane
oxygenation, HBO, plasma, quantum oksihemotherapy)
DRAINAGE suppurative focus
Through the bronchial METHODS
-Postural drainage
- INHALATION
- Nasotracheabronchial catheterization
- MEDICAL bronchoscopy
- Micro Tracheostomy according to Kyun
- Extension Nasotracheabronchial catheterization
METHODS Transthoracic
- PUNCTURE
- Closed drainage
- OPEN DRAINAGE
Acute suppurative lung disease should be treated comprehensively, it is aimed at strengthening the resilience of the
body, improving the drainage of abscess, infection control, normalization of heart function, the function of internal
organs
1. Increase the body's resistance is achieved by: a) appropriate hygiene regime, b) enhanced nutrition of patients
with sputum lose large amounts of protein, primarily albumin. Total caloric intake should be 3500-4000. The diet
should be protein, for energy payback appropriate full parenteral and enteral (including tube) feeding.
2. Improving the drainage of the abscess may be achieved: a) the use of expectorants, and b) the introduction of the
bronchial tree of solutions of proteolytic enzymes, mucolytic funds in aerosol form by filling in the cavity of the
[41]
abscess through the bronchoscope, the puncture through the chest wall abscess in the case of subpleural its location
in ) the appointment of physiotherapy in combination with postural drainage (giving the patient a situation in which
the contents of the abscess will be flowing by gravity).
3. Rational antimicrobial therapy should be tailored sensitivity of flora, seeding of sputum. In the absence of data on
the sensitivity of flora appropriate to use broad-spectrum antibiotics (amino-glycosides, cephalosporins, etc.) in
combination with sulfonamides, metronidazole (trihopol).
In addition to administration of antibiotics intravenously, intramuscularly, or orally, it is necessary to enter them into
the bronchial tree or abscess cavity (in the form of aerosol, through the bronchoscope during bronchoscopy, the
cavity of the abscess at the puncture an abscess).
4. Normalization of the heart reaches the heart of the application.
For detoxification and improve microcirculation to use gemodez, reopoligljukin.
5. Of great importance is Immunocorrecting therapy. Repeated blood transfusions, plasma, the introduction of IgG
(gamma globulin), increase the therapeutic sera reactivity. It is promoted and some medications: levamisole,
thymosin, prodigiozan etc.
2. When staphylococcal destruction to the introduction of lipofundina or other fat emulsions used for parenteral
nutrition. Injected into the blood fat linked bacterial enzymes and reduces their destructive effect on lung tissue.
Surgical intervention is indicated in gangrene of the lung (pneumonitis or lobectomy) in acute abscess resort to it
when there are large pockets destruction of lung tissue in a satisfactory drainage. In these patients, perform onestage (in the presence of adhesions between the visceral and parietal pleura sheets) or Two of the moment (no
adhesions) pneumonopathy.
In recent years, these operations are performed less frequently, as good drainage of abscess can be achieved by using
a puncture through the chest wall, his introduction into the cavity of the abscess drainage with the trocar. b)
Subsequent aspiration of pus and the introduction of proteolytic enzymes and antibiotics are usually given a good
effect.
Conservative baking is futile in abscesses with a diameter of 6 cm thick capsule of an abscess is detected by the Xray examination of intoxication is not inferior to) complete the treatment in these cases we can recommend resection
of the lung during the acute stage.
Outcomes of acute lung abscess: 1) complete recovery which, together with the disappearance of clinical
symptoms and radiographic symptoms disappear lung abscess, 2) clinical improvement is characterized by the
complete disappearance of clinical manifestations of disease but the X in the lung revealed genealogic dry cavity 3)
clinical improvement to discharge the patient remains subfebral patient's body temperature selects a small amount
of mucopurulent sputum. Radiographically detected cavity with infiltration of lung tissue in her circle 4) without any
improvement in these patients without any remission of the acute form of the disease to a chronic intoxication
increases rapidly developing pulmonary heart disease degeneration of parenchymal organs 5) death.
The most severe complications in the acute stage often cause the death are: a) break the abscess into the pleural
cavity with the development of tension pneumothorax b) bleeding into the bronchial tree due to asphyxia, which can
come in), aspiration of pus in the unaffected parts of the bronchial tree and the development of new abscesses d)
formation of ulcers in distant organs most often in the brain.
Remedial measures determined by the nature of complications and) the development of stress pneumothorax
urgently needed thoracostomy b) for bleeding into the bronchial tree as emergency measures shows an urgent
intubation tube two luminal that helps prevent blood numb in the unaffected lung bronchi. In the future held
hemostatic therapy. If the conditions are suitable endovascular surgery - embolization of bronchial arteries of the
affected lung arrosion which frequently causes bleeding into the airways), the newly formed abscesses in the lung
treated in correspondence with the above principles of therapy lung abscess d) metastatic abscesses are treated by
the conventional scheme ( Early autopsy abscess rational antibiotic therapy immunotherapy, etc.).
Questions of tactics and treatment of GPs OIDL, complicated pneumoempyema dismantled by parsing the
treatment algorithms and decision of situational problems.
1.When lung abscess patients should be sent to the thoracic department for further examination and treatment.
The components of treatment:
- Balanced diet, rich in proteins, fats and vitamins
- Antibacterial treatment by intratracheal instillation of antibiotics and proteolytic enzymes.
- Therapeutic remedial bronchoscopy, postural drainage.
- blood transfusion
- Extracorporeal detoxification
[42]
- A / c infusion of 33% solution of ethyl alcohol and calcium supplementation
- Immunocorrection.
Used in this lesson, new teaching technologies: Method "lottery" method "round table" method of "doctor" and
"expert".
1. By the method of "dice" the students respond to the selected test questions.
Using the "round table":
2. Embarks on a circle with a piece of paper assignments. Each student writes his answer sheet and transfer to
another. Responses should not be repeated. All write down their answers, followed by discussion: the wrong
answers crossed out the number of right - assessing students' knowledge.
Examples:
a. The essence of the syndrome: chest pain, shortness of breath, coughing, coughing up blood.
b. The severity of these syndromes in suppurative lung diseases and injuries of the chest
c. Diagnosis and differential. diagnosis OIDL complicated pneumothorax and pneumoempyema.
Tactics, the treatment of patients, indications for surgery.
d. Complications OIDL and emergency care for them.
3. The method of "doctor" and "expert". The group is divided into subgroups by 2 people. In each subgroup shall be
appointed "physician" and "expert." The teacher offers a "doctor" technique on patients. "Expert" tribute to the
"doctor" in section 3: what is done correctly? that wrong? How should they do? The conclusion makes a teacher.
Discussion regarding AT ADMISSION PATIENTS:
1. Clinic and diagnosis of abscess lung
2. Clinic and diagnosis of complications of abscess of the lungs.
3. Differ. diagnosis of acute pulmonary abscess.
Analytical part:
Case studies on lung PATHOLOGY
1. In a patient 45 years after the lifting of the severity of the pain suddenly appeared on the right side of chest,
shortness of breath, because of what can not lie because of respiratory failure, and forced to sit or stand. On
examination the patient the right half of the chest behind the breath, revealed percussion box sound, breath right
auscultated only in the root zone, and other noise there.
I. Your diagnosis and a survey should be carried out to confirm the diagnosis:
II. What is the X-ray semiotics of spontaneous pneumothorax:
III. Where should treat a patient:
№
Answers
1
Bullous transformation of the right 30
lung is complicated by spontaneous
pneumothorax, chest x-ray review
Pneumothorax and collapsed lung, 30
pleural effusion in the sinuses,
mediastinal shift to the opposite side
In the thoracic compartment in the 40
thoracic surgical unit ward
2
3
Max
mark
Excellent
100-86
Good
85-71
Bad
70-55
Very
bad 55
30-25,8
25,7-21,3
21,2-16,5
0
30-25,8
25,7-21,3
21,2-16,5
0
40-34,4
34,3-28,4
28,3-22,0
0
2. The patient was 42 years old pneumonectomy was performed on multiple chronic abscesses of the right lung. The
operation was complicated by the development of pleural empyema. Treating a patient for 8 months of pleural
punctures, pleural cavity lavage and drainage of empyema has not eliminated it. The general condition is
satisfactory, the patient is exhausted. Signs of amyloidosis is not.
I. How to confirm the diagnosis, what is the clinic pleural empyema:
[43]
II. What is the preoperative patient:
III. As a further treat the patient:
№
1
2
3
Answers
Max
mark
clinical pain on the affected side, 30
aggravated by breathing, flattening
of the intercostal spaces, percussion
dullness over the pathology, the
absence of breath sounds, fever
necessary correction of homeostasis, 30
acid-base balance, antibiotic therapy,
transfusion of protein drugs, blood
transfusion, pleural lavage
pleuraeectomy, lung decortication 40
and thoracostomy, thoracoplasty by
Lindberg
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad
70-55
21,2-16,5
Very
bad 55
0
30-25,8
25,7-21,3
21,2-16,5
0
40-34,4
34,3-28,4
28,3-22,0
0
3. Patient 34 years old on the 2nd day after upper lobectomy performed for chronic abscess of the upper lobe of right
lung, the condition deteriorated. Increased chest pain, shortness of breath, and tachycardia. Low 370S. The right side
of the chest behind breathing, breath sounds are heard not. Shortening of the right percussion sound. Radiographic
marked darkening of the right half of the chest. Mediastinum toward the right.
I. What is the complication occurred in a patient:
II. The causes of this complication:
III. How to treat a patient:
№
Answers
1
2
atelectasis of the right lung
failure of preoperative rehabilitation
bronchi and preparation of the
patient, technical error handling in
the upper lobe bronchus stump
lobectomy
3
remedial therapeutic bronchoscopy, 40
antibiotic therapy, cardiac therapy,
respiratory analeptics
Max
mark
30
30
Excellent
100-86
30-25,8
30-25,8
Good
85-71
25,7-21,3
25,7-21,3
Bad
70-55
21,2-16,5
21,2-16,5
Very
bad 55
0
0
40-34,4
34,3-28,4
28,3-22,0
0
4. A patient 20 years notes within 2 weeks of cough with purulent expectoration of 200-300 mL per day, sweating,
weakness, raising body temperature to 37.8-390S. Ill since childhood. Clubbed fingers, nails - watch crystals.
Examined a month ago. In the X-ray examination bronhososudisty drawing strengthened, there is a cellular structure
of the lower divisions of light on the right.
I. What research is needed to confirm the diagnosis:
II. Where should treat a patient:
III. What is the medical tactics:
№
Answers
1
bronchoscopy (purulent
endobronhit), bronchography
(bronchiectasis, bronchial
convergence syndrome charred
wood), sputum
in thoracic surgery department
2
Max
mark
30
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad 70-55
21,2-16,5
Very
bad 55
0
30
30-25,8
25,7-21,3
21,2-16,5
0
[44]
3
complex
antibiotic
therapy, 40
restorative, symptomatic therapy,
rehabilitation bronchoscopic (1 per
week), with localized bronchiectasis
and absence of contraindications,
surgery
40-34,4
34,3-28,4
28,3-22,0
0
5. In a patient 50 years after suffering flu with fever up to 390S during the 3 weeks of holding low-grade fever.
There is a dry cough, weakness, fatigue, shortness of breath. In the upper part of the left lung breathing relaxed. ESR
45 mm / hour. In the history of scanty sputum - a lot of red blood cells. X-ray determined in the upper lobe, uneven
shading intensity without clear boundaries. The side shot atelectasis segment III. Broncho graphically revealed
significant narrowing of the upper lobe bronchus and eaten its contours, the absence of the anterior segment of the
bronchus.
I. Your diagnosis:
II. Differ. diagnosis
III. Your tactics:
№
1
2
3
Answers
Max
mark
central cancer of the upper lobe of 30
right lung
metagrippal pneumonia,
30
bronchiectasis with peaking, OBDL,
empyema
pulmonectomia after a
40
comprehensive preoperative
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad
70-55
21,2-16,5
Very
bad 55
0
30-25,8
25,7-21,3
21,2-16,5
0
40-34,4
34,3-28,4
28,3-22,0
0
6. The patient, after 40 years after pneumonia in remission suddenly rose sharply body temperature, chills, chest
pain and cough. On the 7th day from the beginning of the deterioration of the patient once the cough is accompanied
by purulent sputum mouth full. One day was allocated to 300.0 ml of purulent sputum, reduced toxicity and body
temperature. But on the third day another cough is accompanied by bright red frothy sputum.
I. Your diagnosis, what research is needed to confirm the diagnosis:
II. What is the complication occurred:
III. The first medical care:
№
Answers
1
lung abscess, II stage, complicated
by bleeding, chest radiography
lung abscess complicated by
bleeding
bronchoscopic sealing the bleeding
segment bronchus, haemostatics,
separate intubation bronchial
haemostatics, bronchial
arteriography with embolization of
bleeding vessels, haemostatics
2
3
Max
mark
30
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad
70-55
21,2-16,5
Very
bad 55
0
30
30-25,8
25,7-21,3
21,2-16,5
0
40
40-34,4
34,3-28,4
28,3-22,0
0
7. Patient 60 years old enrolled in a matter of urgency with the clinic bleeding: from the mouth which bleed crimson
color, frothy character. The patient's condition serious, pale skin, rapid weight loss.
I. What do you suspect:
II. How accurately verify the diagnosis:
III. First aid in this situation, the emergency doctor:
№
Answers
Max
Excellent
[45]
Good
Bad
Very
1
2
3
mark
lung Cancer
30
bronchoscopy with biopsy
30
start hemostatic therapy and blood 40
transfusion urgently transported to a
specialized hospital
100-86
30-25,8
30-25,8
40-34,4
85-71
25,7-21,3
25,7-21,3
34,3-28,4
70-55
21,2-16,5
21,2-16,5
28,3-22,0
bad 55
0
0
0
8. Patient 60 years old enrolled in a matter of urgency with the clinic bleeding: from the mouth which bleed crimson
color, frothy character. The patient's condition serious, pale skin, rapid weight loss. Suspected lung cancer?
I. How to confirm the diagnosis:
II. What is the complication probably occurred:
III. Where to start therapy:
№
1
2
3
Answers
Max
mark
bronchoscopy, chest radiography, CT 30
disintegration of the tumor with a 30
breakthrough in the bronchus
the appointment of 1% vikasole, 40
aminocaproic acid, Dicynone
Excellent
100-86
30-25,8
30-25,8
Good
85-71
25,7-21,3
25,7-21,3
Bad
70-55
21,2-16,5
21,2-16,5
Very
bad 55
0
0
40-34,4
34,3-28,4
28,3-22,0
0
9. In the emergency department enrolled 30 patients with signs of severe intoxication, a dry tongue, belly soft
painless, heart rate 100 beats. in minutes. RR 20, the body temperature 39C. Of history: Two years ago, the patient
revealed hydatid cyst of the lung. In the analysis: leukocytosis, eosinophilia, increased erythrocyte sedimentation
rate.
I. Plan Survey:
II. Your diagnosis:
III. Tactics of treatment:
№
Answers
1
2
3
X-ray of the chest
Hydatid festering of cyst lung
operative therapy
Max
mark
30
30
40
Excellent
100-86
30-25,8
30-25,8
40-34,4
Good
85-71
25,7-21,3
25,7-21,3
34,3-28,4
Bad
70-55
21,2-16,5
21,2-16,5
28,3-22,0
Very
bad 55
0
0
0
10. In a patient 45 years after supercooling temperature rose to 390S, appeared in the left side of chest, worse when
breathing, coughing. Sputum is almost there. The temperature was 8 days, despite intensive anti-inflammatory
therapy. Under the right scapula dullness of percussion sound, easing breathing.
I. What disease in a patient:
II. What additional methods of investigation should be undertaken:
III. X-ray semiotics lung abscess to break into the bronchus:
№
1
2
3
Answers
Max
mark
acute abscess of the right lung
30
chest x-ray, X-ray of lungs, blood 30
tests and urine
circular shadow of light in the II and 40
VI
segments
with
perifocal
inflammatory infiltration
Excellent
100-86
30-25,8
30-25,8
Good
85-71
25,7-21,3
25,7-21,3
Bad
70-55
21,2-16,5
21,2-16,5
Very
bad 55
0
0
40-34,4
34,3-28,4
28,3-22,0
0
11. In a patient 45 years after supercooling temperature rose to 390S, there were pains in the right side of chest,
worse when breathing. Cough and phlegm almost was not. The temperature was 8 days, despite intensive antiinflammatory therapy. Then, the patient appeared cough with purulent sputum odor, mouth full, was separated and
[46]
200 ml of purulent sputum per day. Temperature returned to normal, the condition improved, it was satisfactory.
Under the right shoulder blade back is determined by the shortening of the percussion sound, impaired breathing,
and large bubbling rale amphoric breath.
I. What disease you suspect a patient:
II. What additional research is needed to clarify the diagnosis for:
III. What is your medical tactics:
№
1
2
3
Answers
Max
mark
acute abscess of the right lung, after 30
a breakthrough in the bronchus
X-ray light in two projections, the 30
overall
analysis
of
sputum,
bronchoscopy, blood tests and urine
the patient should be treated in the 40
department of thoracic
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad
70-55
21,2-16,5
Very
bad 55
0
30-25,8
25,7-21,3
21,2-16,5
0
40-34,4
34,3-28,4
28,3-22,0
0
12. Patient 50 years operated on for multiple chronic abscesses of the right lung. Right-sided pneumonectomy
performed. After waking the patient after 20 minutes the anesthesiologist noted tachycardia 140 beats per minute,
pulse small filling. The maximum blood pressure fell to 50 mmHg In the right half of the percussion of the chest
revealed dullness in the sloping ground on the right chest.
I. What kind of complications should be thinking:
II. How can we confirm the hypothesis emerged:
III. What steps should be taken:
№
1
2
3
Answers
Max
mark
slippage of ligatures to the 30
pulmonary vessels, complicated by
bleeding
chest X-ray
30
Emergency rethoracotomia,
40
acufilopressure, hemostatic therapy,
supplementation of the bcc
Excellent
100-86
30-25,8
Good
85-71
25,7-21,3
Bad
70-55
21,2-16,5
Very
bad 55
0
30-25,8
40-34,4
25,7-21,3
34,3-28,4
21,2-16,5
28,3-22,0
0
0
Tests
Tests with one correct answer
1. Specify the location favored by lung abscess:
* A. 2 and 6 segments of the lungs.
B.1 and 9-segments of the lungs.
C. All segments of the basement of the pyramid.
D. The average proportion of lung
E. Reed segment.
2. Describe the radiological signs of uncomplicated hydatid cyst lung:
* A. Rounded homogeneous darkening with distinct smooth boundary
B. Rounded shadow with a thin shaft of inflammatory
C. Rounded shading with horizontal fluid level
D. Rounded shadow without clear boundaries, and the path to the root of the lung
E. The presence of shade tops with lung calcium salt accumulation.
3. In the sample as determined by the nature Galkina fluid evacuated from the pleural cavity?
A. Folding of a punctured blood from the pleural cavity indicates continued bleeding.
[47]
B. Do not minimize the blood evacuated from the pleural cavity said to stop bleeding.
* C. Compare rates hemoglobin peripheral blood and blood from the pleural cavity.
D. When breeding of blood from the pleural cavity with distilled water it becomes cloudy, with flakes.
E. The blood from the pleural cavity when diluted with distilled water remains clear.
4. What is the result of tests Petrov speaks of festering coagulated hemothorax?
A. Folding of a punctured blood from the pleural cavity indicates continued bleeding
B. Do not minimize the blood evacuated from the pleural cavity said to stop bleeding.
C. Compare the performance of peripheral blood hemoglobin and blood from the pleural cavity.
* D. At a dilution of blood from the pleural cavity with distilled water it becomes cloudy, with flakes.
E. The blood from the pleural cavity when diluted with distilled water remains clear.
5.What result Petrova samples indicates the absence of suppuration coagulated hemothorax?
A. Folding of a punctured blood from the pleural cavity indicates continued bleeding.
B. Do not minimize the blood evacuated from the pleural cavity said to stop bleeding.
C. Compare the performance of peripheral blood hemoglobin and blood from the pleural cavity.
D. When breeding of blood from the pleural cavity with distilled water it becomes cloudy, with flakes.
* E. The blood from the pleural cavity at a dilution of distilled water remains clear.
Multiple-choice tests
1. Specify the locations where the results of tests Ruvilua-Gregoire evaluated correctly:
* A. Folding of a punctured blood from the pleural cavity indicates continued bleeding.
* B. Do not minimize the blood evacuated from the pleural cavity said to stop bleeding.
C. Compare the performance of peripheral blood hemoglobin and blood from the pleural cavity.
D. When breeding of blood from the pleural cavity with distilled water it becomes cloudy, with flakes.
E. The blood from the pleural cavity when diluted with distilled water remains clear.
2. What are methods to stop pulmonary hemorrhage:
* A. Separate intubation bronchial haemostatics
* B. Bronchoscopic sealing the bleeding bronchus, haemostatics
* C. BUG with embolization of bronchial artery bleeding branch, haemostatics
D. angio pulmonography, haemostatics
E. Improved sanitation bronchoscopy, haemostatics.
3. Etiologic agent of acute pleural empyema may be:
A. acute lung abscess *
B. Chronic lung abscess *
C. festering lung echinococcus *
D. Exudative pleurisy clotted hemothorax or *
E. bronchiectasis
4.Press confirm the diagnosis of acute lung abscess than physical methods need the following list of studies:
A. X-ray *
B. angiography
C. Bronchoscopy *
D. EGDFS
E. RHPG
5. For the diagnosis of bronchiectasis than physical methods need the following list of studies:
A. angiography
B. X-ray *
C. Bronchoscopy *
D. EGDFS
E. bronchography*
[48]
6. To confirm the diagnosis of uncomplicated lung echinococcus than physical methods need the following list of
studies:
A common blood *
B. Latex agglutination test for *
C. X-ray *
D. bronchoscopy
E. radiography *
7. For the diagnosis of lung echinococcus fester than physical data requires the following list of research:
A. radiography *
B. bronchoscopy
C. EGDFS
D. bronchography
E. latex agglutination test for *
8. For the diagnosis of lung echinococcus break into the pleural cavity than physical need the following list of
studies:
A. radiography *
B. Latex agglutination test for
C. thoracoscopy *
D. bronchoscopy
E. EGDFS
9. Late diagnosis of lung cancer is caused by:
A. his appearance against the background of chronic diseases *
B. his appearance against the background of bronchitis of smokers *
C. absence of objective symptoms in the early stages of the disease *
D. bright signs in the early stages of the disease
E. long asymptomatic *
10. Peripheral lung cancer include tumor originating from the epithelium:
A sub segmental bronchus *
B. bronchi of the first order
C. bronchioles *
D. alveoli *
E. bronchi of the second order
11. To the central lung cancer do not carry a tumor originating from the epithelium:
A. sub segmental bronchus *
B. bronchioles *
C. main bronchus
D. equity bronchus
E. alveoli *
Tests with the clinical situation and several blocks of questions
1. In the emergency department enrolled 30 patients with signs of severe intoxication, a dry tongue, belly soft
painless, heart rate 100 beats. in minutes. CHDD20 body temperature 39C. Anamnesis: Two years ago, the patient
revealed hydatid cysts of the lung. In the analysis: leukocytosis, eosinophilia, increased erythrocyte sedimentation
rate.
I. Plan Survey:
A common blood and urine
B. Biochemical analysis of blood
* C. A chest X-ray
D. Laparoscopic study
[49]
II. Your diagnosis:
A perforation of the bowel with peritonitis
* B. festering cyst lung
C. acute gangrenous appendicitis
D. suppuration appendicular infiltrate
III. Tactics of treatment:
A conservative treatment
* B. surgery
C. observation of the dynamics of
D. antiparasitic treatment
E. Puncture therapy
2. In a patient 45 years after supercooling temperature rose to 39C, appeared in the left side of chest, worse when
breathing, coughing. Sputum is almost there. The temperature was 8 days, despite intensive anti-inflammatory
therapy. Under the right scapula dullness of percussion sound, easing breathing.
I. What disease in a patient:
* A. acute abscess of the right lung
B. acute respiratory viral infection
C. acute pleurisy
D. bronchopneumonia
E. typhoid
II. What additional methods of investigation should be undertaken:
A chest x-ray
* B. X-ray light
C. blood tests and urine
D. bacterial blood culture
E. scatology
III. X-ray semiotics lung abscess to break into the bronchus:
* A. round shadow in the lung ll or Vl with perifocal inflammatory infiltration
B. rounded with horizontal shading the water level
C. rounded shadow without clear boundaries with the path to the root of the lung, tracheobronchial lymph nodes
increase
D. rounded light without darkening perifocal inflammation
IV. Where the patient should be treated:
* A. in thoracic surgery ward offices
B. in the therapeutic department
C, Infectious Diseases Hospital
D. ambulatory
E. at home
* F. in specialized thoracic department
3. In a patient 45 years after supercooling temperature rose to 39C, there were pains in the right half of the chest,
aggravated by breathing. Cough and phlegm was not. The temperature was 8 days, despite intensive antiinflammatory therapy. Then, the patient appeared cough with purulent sputum with an unpleasant smell, a mouth
full, was separated and 200 ml of purulent sputum per day. Temperature returned to normal, the condition improved,
it was satisfactory. Under the right shoulder blade back is determined by the shortening of the percussion sound,
impaired breathing, and large bubbling rale amphoric breath.
I. What disease you suspect a patient:
* A. acute abscess of the right lung, after a breakthrough in the bronchus
[50]
B. Acute lung abscess with breakthrough into the pleural cavity
C. Acute lung gangrene
D. ARI
E. Tifo-paratyphoid infection
II. What additional research is needed to clarify the diagnosis for:
* A. X-ray light in the two projections
* B. general analysis of sputum
C. bronchoscopy
D. overall analysis of blood and urine
E. Vidal reaction
III. What is your medical tactics:
* A. the patient should be treated in the department of thoracic
B. the patient to be treated under the supervision of a dogma
C. patients treated in the therapeutic department
lV. Complex treatment includes:
A balanced diet and immunocorrection
B. therapeutic bronchoscopy
C. antibiotics broad spectrum of iv/im
* D. endotracheal pouring broad-spectrum antibiotics
E. Iv infusion of fat emulsions, blood, 33% alcohol, calcium chloride, etc.
4. Patient 50 years operated on for multiple chronic abscesses of the right lung. Right-sided pneumonectomy
performed. After waking the patient after 20 minutes the anesthesiologist noted tachycardia 140 beats per minute,
pulse small filling. The maximum blood pressure fell to 50 mm Hg Percussion of the right half of the chest revealed
dullness in the ground sloping to the right chest.
I. What kind of complications should be thinking:
A. atelectasis of lung
* B. slippage of ligatures to the pulmonary vessels, complicated by hemorrhage
C. pneumothorax
D. acute cardiovascular failure
E. acute respiratory failure
II. How can we confirm the hypothesis emerged:
* A. chest X-ray
B. Ultrasound chest on the amount of free fluid in the pleural cavity
* C. puncture of the pleural cavity in the presence of blood
D. a general analysis of blood
E. hematocrit
III. What steps should be taken:
* A. Emergency retoracothomy, acufilopressure
B. bronchoscopic sealing the main bronchus
C. Hemostatic therapy
D. sore bcc
E. bronchoscopic coagulation of vessels
5. Bolney 42 years of pneumonectomy was performed on multiple chronic lung abscess. The operation was
complicated by the development of pleural empyema. Treatment of the patient for 8 months pleural punctures,
pleural cavity lavage and drainage of empyema has not eliminated it. The general condition is satisfactory, the
patient is exhausted. Signs of amyloidosis is not.
I. How to confirm the diagnosis, what is the clinic pleural empyema:
[51]
* A. clinical pain on the affected side, aggravated by breathing, flattening of the intercostal spaces, percussion
dullness over the pathology, the absence of breath sounds, fever.
* B. on the radiograph with a horizontal homogeneous darkening level
C. determined the X-ray circular shadow with horizontal level
D. revealed free gas over the dome of the diaphragm, the disappearance of liver dullness
II. What is the preoperative preparation of the longitudinal:
* A. necessary correction of homeostasis, KHS
B. antibacterial therapy
* C. transfusion of protein drugs, blood transfusion
D. Pleural lavage.
E. gemodoliz
F. hemosorbtion
III. how to treat a patient on
* A. plevroektomiya, lung decortication drainage pleural cavity
B. thoracoplasty on Shede
C. thoracoplasty by Lindberg
D. lung transplant
6. At Bolney 34 years on the 2nd day after the upper lobectomy performed for chronic abscess of the upper lobe of
right lung, the state sharply become bad . Increased chest pain, shortness of breath, and tachycardia. The
temperature of 37C. right side of the chest behind breathing, breath sounds are heard not. Shortening of the right
percussion sound. Radiologically observed darkening of the right half of the chest. Mediastinum toward the right.
1. What is the complication occurred in a patient? and what to do?
* A. Atelectasis of the right lung.
B. The collapse of the lung,
C. Right-sided pneumonia.
D. empyema of the residual pleural cavity on the right.
E. Hypertension pulmonary circulation.
2. The causes of this complication?
* A. Lack of preoperative rehabilitation bronchi.
B. Technical factors treatment of bronchial stump in the upper lobectomy.
C. IVL
3. How to treat a patient?
* A. Remedial therapeutic bronchoscopy.
B. Antibiotics.
C. Cardiac therapy, respiratory analeptics.
D. Diuretics.
E. Stimulation of intestinal motility.
7. In the emergency department enrolled 30 patients with signs of severe intoxication, a dry tongue, belly soft,
painless .ChSS100 beats. min. RR 20, the body temperature 39C. History of 2 years ago the patient revealed hydatid
cysts of the lung. In the analysis leukocytosis, eosinophilia, increased erythrocyte sedimentation rate.
1. Study design:
A general analysis of blood and urine
B. Biochemical analysis of blood
C. X-ray examination of the chest.
D. Laparoscopy.
2. Your diagnosis?
A. Perforated ulcer with peritonitis.
[52]
* B. Festering cyst lung
C. Acute gangrenous appendicitis.
D. Suppuration appendicular infiltrate.
3. Tactics of treatment:
A. The conservative treatment.
* B. Surgical treatment.
C. Observation of the dynamics.
D. Anti-parasitic treatment.
E. Puncture therapy.
8. Patient 60 years old enrolled in a matter of urgency with the clinic bleeding: from the mouth which bleed crimson
foam character. The patient's condition serious, pale skin, rapid weight loss.
1. What do you suspect?
* A. Cancer of the lung.
B. Cancer of the stomach.
C. Cancer of the esophagus.
D. Cancer of the larynx
2. How can I verify the diagnosis?
* A. Bronchoscopy with biopsy.
B. EGDFS with biopsy.
C. X-ray contrast study.
D. CT scan
3. First aid emergency doctor in this situation:
A. Start hemostatic therapy.
B. Start transfusions.
C. was rushed to a specialized hospital.
* D. All of the above events run simultaneously.
9. Patient 50 years operated on for multiple chronic abscesses of the right lung. Right-sided pneumonectomy
performed. After waking the patient after 20 minutes the anesthesiologist noted tachycardia 140 beats per minute,
pulse small filling. The maximum blood pressure fell to 50 mmHg Percussion of the right half of the chest revealed
dullness in the ground sloping to the right chest.
1.What kind of complications should think about?
A. On the lung atelectasis
* B. On the sliding ligatures with pulmonary vessels, complicated by hemorrhage.
C. Pneumothorax
D. Acute cardiovascular failure
E. On the acute respiratory distress
2.How can we confirm the hypothesis has arisen?
* A.1. Chest X-ray
B. Ultrasound of the chest on the amount of free fluid in the pleural cavity
* C. Puncture of the pleural cavity in the presence of blood
D. overall analysis of blood
E. hematocrit
3.What steps should be taken?
* A.1. Emergency retoracothomy, acufilopressure
B. bronchoscopic sealing the main bronchus
C. Hemostatic Therapy
D. Completion of the bcc
[53]
E. bronchoscopic coagulation of vessels
10. The patient was 42 years old pneumonectomy was performed on multiple chronic abscesses of the right lung.
The operation was complicated by the development of pleural empyema. Treating a patient for 8 months of pleural
punctures, pleural cavity lavage and drainage of empyema has not eliminated it. The general condition is
satisfactory, the patient is exhausted. Signs of amyloidosis is not.
1.How to confirm the diagnosis? What is the clinic pleural empyema?
* A. Clinical pain on the affected side, aggravated by breathing, flattening of the intercostal spaces, percussion
dullness over the pathology, the absence of breath sounds, fever.
B. On the radiograph with a horizontal homogeneous darkening level
C. determined the X-ray circular shadow with horizontal level
D. revealed free gas over the dome of the diaphragm, the disappearance of liver dullness
2.What is the preoperative preparation of the patient?
* A. Necessary correction of homeostasis, acid-base balance
B. Antibiotics
* C. Transfusion of protein drugs, blood transfusion
D.Pleural lavage.
E. hemodialysis
F. hemosorbtion
3.As a further treat a patient?
* A. Pleuroecthomy, lung decortication and thoracostomy
B. thoracoplasty on Shede
C. Lindberg for thoracoplasty
D. lung transplant
11. Patient 34 years old on the 2nd day after upper lobectomy performed for chronic abscess of the upper lobe of
right lung, the condition deteriorated. Increased chest pain, shortness of breath, and tachycardia. The temperature
of 37C. The right side of the chest behind breathing, breath sounds are heard not. Shortening of the right percussion
sound. Radiographic marked darkening of the right half of the chest. Mediastinum toward the right.
1. What is the complication occurred in a patient?
* A. Atelectasis of the right lung
B. collapsed lung
C. Right-sided pneumonia
D. empyema of the residual pleural cavity on the right
E. hypertension of pulmonary circulation
2. The causes of this complication?
A. Lack of preoperative decontamination of bronchi and preparation of the patient
B. Technical error processing bronchus stump in the upper lobectomy
C. IVL
3.How to treat a patient?
* A. Remedial therapeutic bronchoscopy
B. Antibiotics
C. Cardiac therapy, respiratory analeptics
D. diuretics
E. stimulation of intestinal peristalsis
12. In a patient 45 years after the lifting of the severity of the pain suddenly appeared on the right side of chest,
shortness of breath, which is why he even sat down. Since then can not lie because of respiratory failure and had to
sit or stand. On examination the patient the right half of the chest behind the breath, revealed percussion box sound,
breath right auscultated only in the root zone, and other noise there.
[54]
1.Your diagnosis and a survey should be carried out to confirm the diagnosis?
* A. Bullous transformation of the right lung, complicated spontaneous pneumothorax, chest x-ray review.
B. incarcerated diaphragmatic hernia, a contrast study of the gastrointestinal tract.
C. Abscess of lung with a breakthrough in the bronchus, lung X-rays.
D. bronchiectasis, bronchography.
E. empyema, lung X-rays.
2.What is the X-ray semiotics of spontaneous pneumothorax?
* A. Pneumothorax and collapsed lung, pleural effusion in the sinuses, mediastinal shift to the opposite side.
B. Homogeneous light with blackout pockets of enlightenment.
13. In a patient 45 years after supercooling temperature rose to 39 C, appeared in the left side of chest, worse when
breathing, coughing. Sputum is almost there. The temperature was 8 days, despite intensive anti-inflammatory
therapy. Under the right scapula dullness of percussion sound, easing breathing.
1.What disease in a patient?
* A. Acute abscess of the right lung
B. ARI
C. Acute pleurisy
D. Bronchopneumonia
E. Typhoid
2.What additional methods of investigation should be carried out?
* A. Chest x-ray
B. X-ray light
C. Total blood and urine
D. Bacterial blood cultures
E. Coprology
3. X-ray semiotics lung abscess to break into the bronchus
* A. circular shadow of light in the II and VI segments with perifocal inflammatory infiltration
B. rounded with horizontal shading the water level
C. rounded shadow without clear boundaries with the path to the root of the lung, increased tracheobronchial lymph
node.
4.Where the patient should be treated?
* A. in thoracic surgery ward offices
B. in the therapeutic department
C. Infectious Diseases Hospital in
D. outpatient
E. House
*F. in specialized thoracic department
14. In a patient 45 years after supercooling temperature rose to 39C, there were pains in the right side of chest,
worse when breathing. Cough and phlegm almost was not. The temperature was 8 days, despite intensive antiinflammatory therapy. Then, the patient appeared cough with purulent sputum with an unpleasant odor, mouth full,
was separated and 200 ml of purulent sputum per day. Temperature returned to normal, the condition improved, it
was satisfactory. Under the right shoulder blade back is determined by the shortening of the percussion sound,
impaired breathing, and large bubbling rale amforicheskoe breath.
1. What disease you suspect a patient?
* A. acute abscess of the right lung, after a breakthrough in the bronchus
B. Acute lung abscess with breakthrough into the pleural cavity
C. Acute lung gangrene
D. ARI
[55]
E. Tifo-paratyphoid infection
2.What additional research is needed to hold for the diagnosis?
* A. X-ray light in the two projections
* B. general analysis of sputum
C. bronchoscopy
D. overall analysis of blood and urine
E. Vidal reaction
3.What is your medical tactics?
* A. the patient should be treated in the department of thoracic
B. patient treated at home under the supervision of
C. patients treated in the therapeutic department
4.Complex treatment include?
A balanced diet and immunocorrection
B. therapeutic bronchoscopy
C. antibiotics broad-spectrum antibiotics in / or / m
*D. endotracheal pouring broad-spectrum antibiotics
E. Iv. infusion of fat emulsions, blood, 33% alcohol, calcium chloride, etc.
15. Patient 50 years old enrolled in the thoracic outlet in serious condition with complaints of pain in the right lung,
marked dyspnea, acrocyanosis, cough with fetid sputum color meat slops, expressed intoxication, fever, drop in
hemodynamic parameters and blood red.
On chest radiograph on the right notes with no clear boundaries intense darkening with many soft illumination and
fluid in the pleural cavity.
1.Your diagnosis?
• A. Gangrene of the right lung
B. abscessed pneumonia
C. The peripheral lung cancer with carcinogenic pneumonia
D. bronchiectasis, III stage
E. An abscess of the right lung, complicated pneumoempyema
2.Your medical tactics?
* A. Comprehensive pre-operative intensive care for 5-7 days (broad-spectrum antibiotics, blood transfusion,
hemosorbtion, heart, infusion-therapy disintoxication)
* B. pulmonectomy right
C. therapeutic bronchoscopy remedial
D. pleural puncture and pleural lavage
E. Immunotherapy
16. The patient, after 40 years after pneumonia in remission suddenly rose sharply body temperature, chills, chest
pain and cough. On the 7th day from the beginning of the deterioration of the patient once the cough is
accompanied by purulent sputum mouth full. One day was allocated to 300.0 ml of purulent sputum, reduced toxicity
and body temperature. But on the third day another cough is accompanied by bright red frothy sputum.
1.Your diagnosis? What research is needed to clarify the diagnosis?
• A lung abscess, II stage, complicated by bleeding, chest radiography.
B. OBDL or ulcerative gastric bleeding, EGDFS.
C. Gangrene of the lung, DIC, coagulogram.
D. bronchiectasis, bronchography.
2.What is the complication occurred?
* A. Lung abscess complicated by bleeding.
B. Erosive gastro complicated by bleeding.
[56]
C. Cirrhosis, complicated by bleeding from variceal.
D. aortic aneurysm rupture.
3.The first medical care:
• bronchoscopic sealing the bleeding segment bronchus, haemostatics.
• Separate intubation bronchial haemostatics.
Bronchial arteriography • embolization of a bleeding vessel, haemostatics.
4.Therapeutic tactics:
• A. After stopping pulmonary hemorrhage conducted a full examination and a comprehensive anti-bacterial,
haemostatic, symptomatic therapy, therapeutic bronchoscopy, during the transition to the chronic form - operation.
B. Emergency operation.
17. In a patient 45 years after supercooling temperature rose to 39 C, there were pains in the left side of chest,
worse when breathing, coughing. Sputum is almost there. The temperature was 8 days, despite intensive antiinflammatory therapy. Under the right scapula dullness of percussion sound, easing breathing.
1.What disease in a patient?
A. Acute abscess of the right lung *
B. ARI
C. Acute pleurisy
D. Bronchopneumonia
E. Typhoid
2.What additional methods of investigation should be carried out?
A chest x-ray
B. X-ray of light *
C. Total blood and urine *
E. Bacterial blood cultures
E. Coprology
3.X-ray semiotics lung abscess to break into the bronchus?
A. Rounded dimming light in the 2 or 4 segments with perifocal inflammatory infiltration *
B. Rounded shading with horizontal fluid level
C. Rounded shadow without clear boundaries with the path to the root of the lung, tracheobronchial lymph nodes
increase.
4.Where the patient should be treated?
A. In the thoracic surgery department Chamber *
B. In the therapeutic department
C. In the infectious diseases hospital
D. Ambulatory
E. At home
F. In a specialized thoracic department .*
18. In a patient 45 years after supercooling temperature rose to 39 C, there were pains in the right side of chest,
worse when breathing. Cough and phlegm almost was not. The temperature was 8 days, despite intensive antiinflammatory therapy. Then the patient cough with purulent sputum release foul-smelling, mouth full, sputum was
separated by up to 200 ml per day of a purulent character. Temperature returned to normal, the condition improved,
it was satisfactory. Under the right shoulder blade back is determined by the shortening of the percussion sound,
impaired breathing, and large bubbling rale amphoratic breath.
1 What disease you suspect a patient?
A. Acute abscess of the right lung after a breakthrough in the bronchus *
B. Acute abscess of the right lung with a breakthrough in the pleural cavity
C. Acute gangrene of the lung
[57]
D. ARI
E. Tifo paratyphoid infection
2.What additional research should be carried out for the diagnosis?
A. X-ray of the lungs in two projections *
B. Overview of the sputum *
C. Bronchoscopy
D. Complete blood and urine
E. The reaction of Widal
3.What is your medical tactics?
A. The patient should be treated in the department of thoracic *
B. The patient treated at home under the supervision of
C. The patient treated in the therapeutic department
4.Complex treatment include?
A. Good nutrition and immunocorrection
B. Therapeutic Bronchoscopy *
C. Antibiotics broad-spectrum antibiotics in / or / m
D. Endotracheal pouring broad-spectrum antibiotics *
E. IV infusion of fat emulsions, blood, 33% ethyl alcohol, calcium chloride .*
19. Patient 50 years operated on for multiple chronic abscesses of the right lung. Produced right-sided
pulmonectomy. After waking the patient after 20 minutes the anesthesiologist noted tachycardia 140 beats per
minute, pulse small filling. The maximum blood pressure fell to 50 mmHg Percussion of the right half of the chest
revealed dullness in the ground sloping to the right chest.
1.What kind of complications should think about?
A. On the lung atelectasis
B. On the slippage of pulmonary vascular ligation complicated by hemorrhage *
C. Pneumothorax
D. Acute cardiovascular insufficiency
E. Acute respiratory failure
2.How can we confirm the hypothesis has arisen?
A chest radiograph
B. Ultrasound of the chest on the amount of free fluid in the pleural cavity
C. pleural puncture for blood *
D. A common blood test
E. The hematocrit
3.What steps should be taken?
A. Emergency rethoracothomy, acufilopressure *
B. bronchoscopic sealing the main bronchus
C. Hemostatic Therapy
D. Completion of the bcc
E. bronchoscopic coagulation of vessels
20. The patient was 42 years old was pulmonectomy on multiple chronic abscesses of the right lung. The operation
was complicated by the development of pleural empyema. Treating a patient for 8 months of pleural punctures,
pleural cavity lavage and drainage of empyema has not eliminated it. The general condition is satisfactory, the
patient is exhausted. Signs of amyloidosis is not.
1.How to confirm the diagnosis? What is the clinic pleural empyema?
A. Severe pain on the affected side, aggravated by breathing, flattening of the intercostal spaces, percussion dullness
over the pathology, the absence of breath sounds, fever .*
[58]
B. On the X-ray shadow with horizontal homogeneous fluid level
C. In the X-ray determined by circular shading with horizontal fluid level
D. is revealed free gas on the dome of the diaphragm, the disappearance of liver dullness
2.What is the preoperative preparation of the patient?
A necessary correction of homeostasis, acid-base balance *
B. Antibiotics
C. Transfusion of protein drugs, blood transfusion *
D.Pleural lavage.
E. Hemodialysis
F. hemosorbtion
3.As a further treat a patient?
A. Pleuroecthomy, lung decortication and thoracostomy *
B. thoracoplasty on Shede
C. Lindberg for thoracoplasty
D. Transplantation of the lung.
21. Patient 34 years old on the 2nd day after upper lobectomy performed for chronic abscess of the upper lobe of
right lung, the condition deteriorated. Increased chest pain, shortness of breath began to increase, and tachycardia.
Temperature 37 C. The right side of the chest behind breathing, breath sounds are heard not. Shortening of the right
percussion sound. Radiologically observed darkening of the right half of the chest. Mediastinum toward the right.
1.What is the complication occurred in a patient?
A. Atelectasis of the right lung *
B. The collapse of the lung
C. Right-sided pneumonia
D. empyema of the residual pleural cavity on the right
E. Hypertension pulmonary circulation
2.The causes of this complication?
A. Lack of preoperative decontamination of bronchi and preparation of the patient *
B. Technical error processing bronchus stump in the upper lobectomy
C. IVL
3.How to treat a patient?
A remedial medical Bronchoscopy *
B. Antibiotics
C. Cardiac therapy, respiratory analeptics
D. Diuretics
E. Stimulation of intestinal motility.
22. A patient 20 years notes within 2 weeks of cough with purulent expectoration of 200-300 mL per day, sweating,
weakness, rise in body temperature to 37.8-39 C. Bohlen since childhood. Clubbed fingers, the nails in the form of
watch crystals. Examined a month ago. In the X-ray examination bronhososudisty drawing strengthened, there is a
cellular structure of the lower divisions of light on the right.
1.What research is needed to clarify the diagnosis?
A remedial bronchoscopy (purulent endobronhit) *
B. bronchography (bronchiectasis, bronchial approximation, the charred tree syndrome) *
C. Tomography
D.The analysis of sputum
E. Biochemical and clinical blood and urine
2.Where should the patient be treated?
A. At home under the supervision of a physician
[59]
B. In the therapeutic department
C. In-hospital
D. In the thoracic surgery department *
3.What and how patient should be treated?
A comprehensive antibacterial therapy, restorative, symptomatic therapy
B. bronchoscopic reorganization (1 weekly)
C. When localized bronchiectasis and absence of contraindications - surgical treatment .*
23. In a patient 50 years after suffering flu with fever to 39 C for 3 weeks kept low-grade fever. There is a dry cough,
weakness, fatigue, shortness of breath. In the upper part of the left lung breathing relaxed. ESR 45 mm / hour. In the
analysis of sputum poor - lots of red blood cells. Radiographically determined in the upper lobe of non-uniform
intensity of shading without clear boundaries. On the side of the picture atelectasis 3 segments. Bronchographic
revealed significant narrowing of the upper lobe bronchus and eaten its contours, the absence of the anterior
segment bronchus.
1.Your diagnosis?
A. The central cancer of the upper lobe of right lung *
B. metagrippal pneumonia
C. bronchiectasis with aggravation
D. OBDL
E. empyema
2. Your tactics?
A. Pulmonoecthomy after a comprehensive preoperative preparation *
B. Endotracheal pouring broad-spectrum antibiotics
C. Application of anti flu drugs
D. Therapeutic bronchoscopy remedial
E. Radiation and chemotherapy.
24. Patient 50 years old enrolled in the thoracic outlet in serious condition with complaints of pain in the right lung,
marked dyspnea, acrocyanosis, cough with phlegm-colored fetid meat slops, expressed intoxication, fever, drop in
hemodynamic parameters and blood red.
On chest radiograph on the right notes with no clear boundaries intense darkening with many soft illumination and
fluid in the pleural cavity.
1.Your diagnosis?
A. Gangrene of the right lung *
B. abscessed pneumonia
C. The peripheral lung cancer with carcinogenic pneumonia
D. bronchiectasis, Stage 3
E. An abscess of the right lung, complicated pneumoempyema
2.Your medical tactics?
A comprehensive pre-operative intensive care for 5-7 days (broad-spectrum antibiotics, blood transfusion,
hemosorbtion, heart medications, infusion therapy, disintoxication) *
B. pulmonectomy right *
C. Therapeutic bronchoscopy remedial
D. Pleural puncture and pleural lavage
E. Immunotherapy
25. In a patient 40 years after pneumonia in remission suddenly rose sharply body temperature, chills, chest pain
and cough. On the 7th day from the beginning of deterioration of the patient's regular cough is accompanied by
purulent sputum mouth full.
One day was allocated to 300 ml of purulent sputum, reduced toxicity and body temperature. But on the third day
another cough is accompanied by bright red frothy sputum.
[60]
1.Your diagnosis? What research is needed to clarify the diagnosis?
A lung abscess, 2 stage, complicated by bleeding, chest radiography .*
B. OBDL or ulcerative gastric bleeding, EGDFS.
C. Gangrene of the lung, DIC, coagulogram.
D. bronchiectasis, bronchography
2.What is the complication occurred?
A lung abscess complicated with hemorrhage *
B. Erosive gastro, complicated by hemorrhage
C. Cirrhosis, complicated by variceal bleeding
D. aortic aneurysm rupture
3.The first medical aid
A bronchoscopic sealing the bleeding segment bronchus, haemostatics *
B. Separate intubation bronchial haemostatics
C.Bronchial arteriography with B. embolization of bleeding vessels, haemostatics
D. Blood transfusion, haemostatics
4.Therapeutic tactics
A. After stopping pulmonary hemorrhage conducted a full examination and a comprehensive anti-bacterial,
haemostatic, symptomatic therapy, surgery.
B. Emergency operation
26. In a patient 45 years after the lifting suddenly there were pains in the right side of chest, shortness of breath.
Since then can not lie because of respiratory failure, and forced to sit or stand. On examination the patient the right
half of the chest behind the breath, revealed percussion box sound, breath right auscultated only in the root zone,
and other noise there.
1.Your diagnosis and a survey should be carried out to confirm the diagnosis?
A. Bullous transformation of the right lung, complicated spontaneous pneumothorax, chest x-ray Review *.
B. incarcerated diaphragmatic hernia, a contrast study of the gastrointestinal tract.
C. Abscess of lung with a breakthrough in the bronchus, lung X-rays.
D. bronchiectasis, bronchography.
E. empyema, lung X-rays.
2.What is X rays semiotics spontaneous pneumothorax?
A. Pneumothorax and collapsed lung, pleural effusion in the sinuses, mediastinal shift to the opposite side .*
B. Homogenous darkening light with a center of enlightenment.
C. Rounded blackout in the 2nd segment of the lung with perifocal infiltration.
D. Strengthening bronchial vascular pattern of lung, the cellular structure of the lower lungs.
E. Contrast the stomach into the thoracic cavity.
3.Where should the patient be treated?
A. Outpatient
B. In the therapeutic department
C. In the thoracic compartment *
D. In the House of Thoracic surgery department .*
4.Clinical management of
A. Pleural puncture
B. thoracostomy on Byulau, X-ray control, and failure within 3 days of surgery.
C. Antibiotic therapy, exercise therapy.
Practical part:
Standards for the acquisition of practical skills
[61]
Pleural puncture
1. Indications: pleural puncture performed for diagnostic and therapeutic purposes in exudative pleurisy,
hemothorax, pyothorax, pleural empyema, spontaneous pneumothorax and stress
2. The necessary tools - 0.5% solution of novocaine, syringes, needle-type Dufour.
3. Student assignment - Identify the indications and technique of pleural puncture.
4. Information for the Examiner: Identify knowledge and skills of the student and evaluated separately for
each of the below listed items
№
Мх
Мин
Нет
балл
балл
ответа
1
Pleural puncture is performed in the second intercostal space on
10
5
0
mid clavicular line (pneumothorax) or in the eighth intercostal
space on the middle axillary line (in the presence of fluid in the
pleural cavity)
2
Position the patient sitting
10
5
0
3
Treatment of surgeon and the surgical field
10
5
0
4
Conduct local infiltration anesthesia of 0.5% solution of
10
5
0
novocaine
5
Puncture of the pleural cavity with a thick needle type Dufour
10
5
0
6
Suction of air or fluid from the pleural cavity through a syringe
10
5
0
7
To prevent sucking air from the atmosphere through the needle
10
5
0
into the pleural cavity using insertion of rubber tubing between
the needle and syringe
8
Detach the syringe from the tube filled with the necessary after
10
5
0
overlaying the clamp on the rubber tube.
9
The introduction of antibiotics into the pleural cavity, if necessary
10
5
0
10
Removal of needles and aseptic dressings superimposition
10
5
0
The maximum score for the station
100
50
0
[62]
Pleural puncture
Trauma to the chest. Pneumothorax. hemopleura
The task for the student: Identify a particular patient signs of pneumothorax, both describe aloud the
examiner that you found during the inspection.
Information for the Examiner: Evaluate student separately for each of the below listed items.
Max
Min
No answer
mark
mark
1. A student comes to the patient on the right side (with one
10
5,6
0
hundred hand-injury)
2.When examination: the patient's position forced (damage the
10
5,6
0
assertion of chest spares the patient, especially during inspiration)
3. For percussion: Mark box sound in pneumothorax and
10
5,6
0
hemothorax in stupidity.
4. Auscultation of the sharp weakening of the respiratory noise
10
5,6
0
(from injury)
5. In the chest X-ray revealed displacement of the mediastinum in a
10
5,6
0
healthy direction for pneumothorax with collapsed lung. In the Xray examination revealed haemothorax fluid accumulation in the
lower regions of the pleural cavity, the upper limit of the liquid
forms a clear horizontal level
6. Puncture of pleural cavity with pneumothorax (in the second
15
8,25
0
intercostal space at the middle clavicular line)
7. Puncture of pleural cavity with hemothorax is on the back of the
15
8,25
0
[63]
axillary line in the seventh intercostal space
8. Thoracostomy (with a large hemothorax in the seventh intercostal
space on the posterior axillary line)
9. Thoracostomy (with pneumothorax in the second intercostal
space at the middle clavicular line).
The maximum score for the station
10
5,6
0
10
5,6
0
100
56
0
Diagnostic and treatment of the syndrome "Hemoptysis".
Hemoptysis - a selection from the respiratory tract as an admixture of blood in the sputum
of the individual or spit, bubble.
Common causes:
ARI, acute bronchitis - 24%.
Chronic bronchitis - 17%.
Bronchiectasis - 13%.
Pulmonary tuberculosis - 10%.
lung cancer, metastasis - 4%.
pulmonary embolism, foreign body.
Left ventricular failure, mitral stenosis.
Rare causes:
Idiopathic pulmonary hemosiderosis.
Goodpasture's syndrome.
Violation of hemostasis.
Injury to the chest.
mucosal injury in the trachea during intubation.
Symptoms:
Blood red pinkish color with bubbles of air, not rolled,
the pH is alkaline.
Pale.
variegated wheezing.
Shortness of breath.
Reduction in blood pressure.
Frequent pulse.
The reason - a pulmonary pathology:
No pulmonary pathology:
Inspection.
A history.
KLA, OAM.
Coagulogramma .
X-ray, CT scan of the lungs.
Inspection.
A history.
KLA, OAM.
Coagulogramma.
ECG.
endoscopy.
bronchography.
Esophagitis gastro fiberscopes.
pulmonography.
[64]
Specials:
Separate intubation bronchi.
bronchoscopic sealing the bronchus, where it comes from the blood.
Bronchial arteriography followed by embolization of bleeding
Haemostatics, etiopathogenetic
Surgical treatment is indicated.
Diagnostic SYNDROME "COUGH"

Cough - jerky, forced expiration with simultaneous voltage of the locomotor
apparatus of light




Clarify the nature
особенности
 Additionalкашля
symptoms:




The reason is not clear
chest X-ray
The reason is clear



The most common
cause of cough:
SARS.
Rhinitis.
Acute bronchitis.
Chronic bronchitis.
The most dangerous diseases,
accompanied by cough:
Left ventricular failure.
Lung Cancer.
infections - tuberculosis, pneumonia,
influenza, lung abscess, HIV infection.
Asthma.
Cystic Fibrosis.
foreign body.
treatment
Лечение
Limited blackout of
pulmonary fields:
Sputum:
 Microscopy.
 Planting.
 cytology.
Flexible bronchoscopy.
Test Questions:
 CT of the chest.
Extensive or total blackout
pulmonary fields:
Exclusion of pulmonary edema.
Study of respiratory function:
 Total lung capacity.

Diffusion lung capacity
for CO 2.
 Flexible bronchoscopy.
NORM
Норма




X-ray in-datochnyh
sinuses.
The study of respiratory
function.
radiopaque IRS e-gullet.
Determination of pH in the
esophagus.
[65]

Pneumonia.

Left ventricular failure.

Bronchial asthma.
Diagnostic SYNDROME "sputum"
spitting
ВыделениЕ мокроты
Viral infection,
tuberculosis
Purulent
(yellowish-green
contains many
white blood cells)
Bak. respiratory
tract infections
Radiography of the
lungs, the KLA,
sputum analysis,
analysis on the BC,
TB tests
Radiography of the
paranasal sinuses, sputum
ti
m
e
In mornings
Slimy, whitish,
transparent
Sinuses
lobar pneumonia
Viscous, glassy
bronchial asthma
Ы
О
О
М
Я
И
Н
Е
Л
Е
car
e
В
Radiography of the
lungs, CT scans, the
study of external
respiration, KLA,
sputum
int
ens
ive
Я
In the form of casts
of the bronchi
Bronchial asthma, lung
cancer, aspergillosis
Р
К
At night
lung abscess
Д
bronchiectasis
Ы
Late-stage lung cancer
Radiography of the
lungs, computerized
tomography,
sputum cytology
and, bronchoscopy,
bronchography
[66]
М
Copious, offensive
Bronchioles,
alveolar-cell lung
cancer
Е
In the form of
jellies currant
Allergological skin
tests histamine
Р
Copious, watery
Т
Streaked with
blood
ECG,
echocardiography,
chest x-ray, sputum
analysis, KLA
After coughing
character of sputum
rusty
Left ventricular
shortage
sp
ut
u
m
Test Questions:
1. The concepts of injuries of the chest.
2. Classification of injuries of the chest.
3. Methods of diagnosis of abscess of the lungs and chest injuries.
7. Determination of pneumothorax
8. Types of pneumothorax
9. First aid in various forms of pneumothorax.
10. Hemothorax, definition, classification
11. Samples Ruvilua - Gregoire, Petrova and coll.
12. Spontaneous pneumothorax, the concept of etiology.
13. Pneumoempyema the concept.
REFERENCES P
-main
1. SH.I. Karimov "Surgical Diseases" T.1994
2. M.I Kuzin, "Surgical Diseases" M.1987
3. Clinical Surgery, edited by J.M Pantsyreva M.1998
4. V.I Pods "Purulent diseases of the lung and pleura" L.1967
5. ECVs suppurative disease of the lungs and pleura. T.1997
6. Standard protocols on the subject. T.1997
7. John Murtha, "Handbook of general practitioner," translated from English. M.1998
8. Surgery. Manual for physicians and students. Edited by V.S Saveliev M.1998
-additional
9. Algorithms for diagnosis and treatment of major syndromes for training GPs. T.2003
10. Algorithms for diagnosis and treatment of surgical. T.2003,
11. Algorithms for diagnosis and treatment of major surgical syndromes. The authors of Athalia A.E, Yunusov I.I,
Madaminov R.M, Arifzhanova Z.Sh. T.2006g.
12. Uniform practical skills in surgery, Educational handbook for students 7 year med. institutions. The authors of
Athalia A.E, V.H Shatemirov, Yunusov I.I, Narchaev Zh.A.T.2008g.
13. Wagner E.A, Bruns V.A phrenic and other injuries. Perm, 1992.
14. Guidelines for lung surgery. Under red.prof.I.S.Kolesnikova. Leningrad, 1969.
15. Handbook of medical-labor ekspertize.M.1972g
16. Resection of the lung. The authors are A. Bejan, E.Gr.Zitti. Translated from rumynskogo.M.1981g.
16. Stoyan Popkirov. Purulent - septic hirurgiya.Sofiya.1974g.
17. Struchkov V.I, Nedvedskaya L.M and other COPD complicated with bleeding .M.1985g.
18. Fedorov B.P, Wol-Epstein G.L. Lung abscesses. M.1976g.
19. Suppurative disease of the pleura and lung. Under red.akad. P.A Kupriyanov 1955.
20. Guidelines for lung surgery. Red.prof..Kolesnikova Under I.S.L.1969g.
21. Clinical guidelines and formulary. Chief editors of RAMS academician Igor Denisov and Y. Shevchenko, M.D
Professor F.G Nazyrov. Moscow, Acad. group "GEOTAR Media" 2005.
[67]