胸腔外科学重点培训.ppt

胸管引流的適應症 氣胸(pneumothorax) 血胸(hemothorax) 膿胸(empyema) 肋膜積水(hydrothorax) 乳糜胸(chylothorax) 理想胸管插入位置 在緊急狀況下,任何可以引流肋膜腔的位置都是可被接受的 理想位置為第五、六肋間的腋中線 解剖構造簡單,軟組織較薄 肋間空間較寬 胸管較不易插入肺葉間空間 美觀上的考量 胸管引流只要能達到 肋膜內無沾黏或隔腔胸水 使得壁層與臟層肋膜閉合 毛細現象產生自然可得到良好的引流效果 胸管引流裝置 水下密封引流裝置(underwater seal) 單向活塞水柱,防止空氣逸入 平衡大氣壓與肋膜腔之負壓環境 病人端之外科接管 若液面隨呼吸起伏,表示胸管功能良好 若起伏消失可能為管路阻塞 若起伏消失且液面升高,表示肺葉漲滿、肋膜腔關閉且負壓穩定 呼吸時持續漏氣 管路銜接不良、瓶身裂隙 破裂之氣泡持續漏氣 支氣管廔管 於插管前、插管後、拔管前、拔管後常需CXR評估 氣胸(Pneumothorax) 分類 Spontaneous pneumothorax Primary Secondary Chronic obstructive pulmonary disease, COPD Bullous disease Cystic fibrosis Idiopathic pulmonary fibrosis Pulmonary embolism Catamenial pneumothorax Pneumothorax in AIDS Traumatic pneumothorax Iatrogenic pneumothorax Etc. Boerhaave complex syndrome Spontaneous penumothorax Risk factor: 高瘦年輕男性 heavy smoker 矽肺症 肺氣腫 肺癌 Marfan syndrome Early complication Prolonged air leakage Non re-expansion of the lung Bilaterality Hemothorax Tension Complete pneumothorax Potential hazard Occupational hazard Absence of medical facilities in isolated areas Associated single bulla Psychological Second Episode Ipsilateral recurrence Contralateral recurrence after a first pneumothorax Surgical indication for primary spontaneous pneumothorax Recurrence of Primary Spontaneous Pneumothorax Therapy Recurrence (%) Expectant 30 Aspiration 20-50 Chest tube drainage 20-30 Pleurodesis (tetracycline) 25 Pleurodesis (talc) 7 Surgery 2 Removal of Chest Tube Indications No fluctuation in the fluid column of the tube (complete lung reexpansion or tube occlusion) Daily fluid drainage 100ml in 24 hours Air leakage has stopped Proper timing (controversy) Spontaneous pneumothorax after tube thoracostomy removal tube within 6 hours of reexpansion--25% collapse Parathymic syndrome 40% with par