新英格兰：肺萎陷
一位终末期肝病的46岁女性因复发性肝性胸水需多次胸腔穿刺，现出现呼吸困难而就诊。胸部检查右肺未及呼吸音，X线检查示右肺液气胸(图A中箭头所示气胸，星号示胸水)。猪尾导管排尽积水后仍持续性气胸(图B箭头所示)。胸部CT检查示肺萎陷(阻塞性肺不张后气胸)，胸膜增厚，未见支气管阻塞(图C)。肺萎陷因慢性炎症引起的胸膜增厚阻止了肺复张引起。胸膜壁层不分离，其间充盈液体，从而引起液气胸。排净胸水后引起阻塞性肺不张后气胸的原因是肺不能再扩张到充满胸腔。阻塞性肺不张后气胸的其它原因排除了支气管阻塞。肺萎陷的治疗为手术治疗，切除纤维化的胸膜脏层以利于肺部扩张。该患者行胸腔镜手术切除了胸膜和胸膜固定术后右肺完全复张。
A 46-year-old woman with end-stage liver disease that was complicated by recurrent hepatic hydrothorax requiring multiple thoracenteses presented with breathlessness. Chest examination found no breath sounds on the right side. Radiography of the chest revealed a hydropneumothorax (Panel A; the arrows indicate pneumothorax, and the asterisk hydrothorax). The hydrothorax was drained with the use of a pigtail catheter, with persistent pneumothorax (Panel B, arrows). A computed tomographic scan of the chest showed trapped lung (pneumothorax ex vacuo) with thickened visceral pleura and no evidence of endobronchial obstruction (Panel C). Trapped lung is due to fibrous visceral pleural thickening from a chronic inflammatory process that prevents lung reexpansion. The noncompliant lung separates from the parietal pleura, and this space fills with fluid, with resultant hydropneumothorax. Drainage of the pleural fluid leads to pneumothorax ex vacuo because the lung cannot reexpand to fill the chest cavity. Once other causes of pneumothorax ex vacuo, such as endobronchial obstruction, are excluded, the management of trapped lung is surgical, with removal of the fibrosed visceral pleura to allow for the expansion of the underlying lung. In this patient, video-assisted thoracoscopic surgery with decortication and pleurodesis was performed, with complete reexpansion of the right lung.
Trapped Lung
A 46-year-old woman with end-stage liver disease that was complicated by recurrent hepatic hydrothorax requiring multiple thoracenteses presented with breathlessness. Chest examination found no breath sounds on the right side. Radiography of the chest revealed a hydropneumothorax (Panel A; the arrows indicate pneumothorax, and the asterisk hydrothorax). The hydrothorax was drained with the use of a pigtail catheter, with persistent pneumothorax (Panel B, arrows). A computed tomographic scan of the chest showed trapped lung (pneumothorax ex vacuo) with thickened visceral pleura and no evidence of endobronchial obstruction (Panel C). Trapped lung is due to fibrous visceral pleural thickening from a chronic inflammatory process that prevents lung reexpansion. The noncompliant lung separates from the parietal pleura, and this space fills with fluid, with resultant hydropneumothorax. Drainage of the pleural fluid leads to pneumothorax ex vacuo because the lung cannot reexpand to fill the chest cavity. Once other causes of pneumothorax ex vacuo, such as endobronchial obstruction, are excluded, the management of trapped lung is surgical, with removal of the fibrosed visceral pleura to allow for the expansion of the underlying lung. In this patient, video-assisted thoracoscopic surgery with decortication and pleurodesis was performed, with complete reexpansion of the right lung.
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