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sábado, 28 de janeiro de 2012

TÓRAX DE BÚFALO (BUFFALO CHEST) - UMA DESVANTAGEM ANATÔMICA

        

       A único contato entre as pleuras de cada lado do tórax acontece no ligamento pulmonar, abaixo do hilo pulmonar e atrás do coração, já que é uma membrana única. Porém, os espaços pleurais - entre as pleuras parietal e visceral - são isolados um do outro em cada lado.



        A situação em que há comunicação entre ambos espaços pleurais é dita "tórax de búfalo" (buffalo chest). Isso porque os búfalos americanos, ou bisões, têm uma única cavidade pleural envolvendo ambos os pulmões. Essa particularidade anatômica facilitava os índios americanos de abatê-los, já que apesar de grandes e robustos, uma simples flechada em um lado do tórax provocaria um pneumotórax bilateral, colabando ambos os pulmões e matando o animal.

        Em humanos pode ocorrer o mesmo! Congênito, traumático ou iatrogênico, este último mais comum, ocorre geralmente após cirurgias com esternotomia mediana, videotoracoscopia, transplantes cardíaco e de pulmão, pela ruptura dos recessos pleurais anteriores, gerando um canal pleuro-pleural.

        A literatura sobre a entidade clínica é baseada em relatos de casos. Para ilustrar, seguem 2 relatos:

- paciente de 18 anos, feminina, com história prévia de pneumotórax à direita e presença de bolha subpleural também à direita, dá entrada no pronto-atendimento com quadro de pneumotórax hipertensivo à direita. Após toracostomia e alívio da pressão intra-torácica, paciente apresenta pneumotórax à esquerda. O quadro foi resolvido com drenagem torácica fechada somente à direita.

A. Pneumotórax hipertensivo à direita com balanço de mediastino para esquerda, sem evidência de pneumotórax deste lado. B. Após punção torácica, resolvida a hipertensão, porém agora com evidência de pneumotórax bilateral. C. Drenagem torácica fechada com resolução do pneumotórax bilateral.

- paciente de 68 anos, masculino, que após revascularização cirúrgica do miocárdio via esternotomia evoluiu com pnemotórax após passagem de um catéter venoso central em subclávia direita. O raio-x de tórax mostrou pneumotórax bilateral e após a drenagem torácica fechada à direita, o dreno passou pelo mediastino anterior e seguiu para o tórax esquerdo. Reposicionado à direita, o dreno resolveu o pneumotórax bilateral.



  Após punção de subclávia à direita (note catéter), presença
  de pneumotórax bilateral. Não houve nenhuma tentativa de
  punção à esquerda.

Após passagem do dreno de tórax, este se posicionou
no tórax esquerdo, transmediastino anterior.

Mesma situação ao lado, visão pelo perfil esquerdo.

          Pneumotórax bilateral é um evento raro quando sem comunicação entre as pleuras (exceto em punções torácicas bilaterais), que ocorre mais em pacientes DPOC, longilíneos ou com pneumocistose pulmonar. Portanto, quando se deparar com um caso assim, pensar na possibilidade de ser, na verdade, somente um pneumotórax acomentendo ambos hemitórax. Apesar da gravidade do quadro, drenagem de tórax unilateral geralmente resolve o caso.

European Journal of Cardio-Thoracic Surgery 0 (2012) 1
Ann. Surg. March 1984 Vol. 199 No. 3
Emerg Med J 2006;23:483-486

N Engl J Med 349;19 November 6, 2003
Revista Portuguesa de Pneumologia, Vol XIII N.º 4 Julho/Agosto 2007

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