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Behandlung des Pneumothorax

Treatment of pneumothorax

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Zusammenfassung

Ein Pneumothorax ist definiert als eine Luftansammlung im Pleuraspalt, d. h. zwischen der Lunge und der Brustwand. Entsprechend der Genese unterscheidet man zwischen primärem (idiopathischem) Spontanpneumothorax (PSP), sekundärem Spontanpneumothorax (SSP) sowie iatrogenem und traumatischem Pneumothorax. Der PSP tritt spontan ohne erkennbares Trauma und ohne zugrunde liegende Lungenerkrankung auf, der SSP entsteht aufgrund einer vorbestehenden Lungengerüsterkrankung. Die meisten Pneumothoraces erfordern eine therapeutische Intervention, die alleinige Beobachtung ist lediglich bei asymptomatischen Patienten mit einer kleinen partiellen Ablösung zu verantworten. Bei klinisch stabilen Patienten mit Erstereignis eines PSP ist die einfache Nadelaspiration eine mögliche Therapieoption, bei allen anderen Patienten mit symptomatischem Pneumothorax ist die sofortige Einlage einer Drainage in den Pleuraspalt der bewährte Therapiestandard. Die chirurgische Therapie des Pneumothorax verfolgt zwei Behandlungsziele: 1. die Sanierung des zugrunde liegenden Parenchymdefektes durch Resektion bullöser Veränderungen oder Naht vorhandener Parenchymfisteln, 2. die Rezidivprophylaxe durch Induktion einer Pleurodese. Dabei ist die Videothorakoskopie (VATS) das Verfahren der ersten Wahl bei Patienten mit PSP. Zur chirurgischen Versorgung eines SSP ist in der Regel die Thorakotomie erforderlich.

Abstract

Pneumothorax is defined as air in the pleural space, i.e. between the lung and the chest wall. Primary pneumothoraces (PSP) arise in otherwise healthy people without any lung disease. Secondary pneumothoraces (SSP) arise in subjects with underlying lung disease. Observation alone is recommended only in patients with small primary or secondary pneumothoraces of less than 1 cm depth or isolated apical pneumothoraces in asymptomatic patients. In symptomatic patients observation alone is inappropriate and active intervention is required. Although simple aspiration may be an option for first-line treatment in clinically stable patients with PSP, intercostal tube drainage is strongly recommended in all primary and secondary pneumothoraces requiring intervention. There are two objectives in the surgical management of pneumothorax. The first widely accepted objective is resection of blebs or the suture of apical perforations to treat the underlying defect. The second objective is to create a pleural symphysis to prevent recurrence. While video-assisted thoracic surgery may be the preferred surgical procedure for young, fit people with complicated or recurrent primary pneumothoraces, it is less reliable in cases of secondary pneumothorax. For the latter, open thoracotomy and repair is still the recommended approach.

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Klopp, M., Dienemann, H. & Hoffmann, H. Behandlung des Pneumothorax. Chirurg 78, 655–668 (2007). https://doi.org/10.1007/s00104-007-1358-9

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