The prognosis for pleurisy depends on the cause of this ailment, as well as on the stage of the disease ( at the time of diagnosis and the beginning of therapeutic procedures). The presence of an inflammatory reaction in the pleural cavity, accompanying any pathological processes in the lungs, is an unfavorable sign and indicates the need for intensive treatment.
Since pleurisy is a disease that can be caused by a fairly large number of pathogenic factors, there is no one treatment regimen shown in all cases. In the overwhelming majority of cases, the goal of therapy is the initial ailment, after the cure of which, the inflammation of the pleura is eliminated. However, in order to stabilize the patient and improve his condition, they often resort to the use of anti-inflammatory drugs, as well as to surgical treatment ( puncture and extraction of excess fluid).
Interesting Facts
- pleurisy is one of the most common pathologies in therapy and occurs in almost every tenth patient;
- it is believed that pleurisy was the cause of death of the French queen Catherine de 'Medici, who lived in the 14th century;
- drummer of the Beatles ( The beatles) Ringo Starr suffered chronic pleurisy at the age of 13, which is why he missed two years of school and never finished school;
- the first description of pleural empyema ( accumulation of pus in the pleural cavity) was given by an ancient Egyptian physician and dates back to the third millennium BC.
Pleura and its defeat
The pleura is a serous membrane that covers the lungs and consists of two sheets - parietal or parietal, covering the inner surface of the chest cavity, and visceral, directly surrounding each lung. These sheets are continuous and pass one into the other at the level of the lung gate. The pleura consists of special mesothelial cells ( squamous epithelial cells), located on a fibroelastic frame, in which blood and lymphatic vessels and nerve endings pass. Between the pleural sheets, there is a narrow space filled with a small amount of fluid, which serves to facilitate the sliding of the pleural sheets during respiratory movements. This liquid results from seepage ( filtration) plasma through the capillaries in the apex of the lungs, followed by absorption by the blood and lymphatic vessels of the parietal pleura. In pathological conditions, excessive accumulation of pleural fluid may occur, which may be associated with its insufficient absorption or excessive production.The defeat of the pleura with the formation of an inflammatory process and the formation of an excess amount of pleural fluid can occur under the influence of infections ( directly affecting the pleura or covering closely spaced lung tissue), injuries, pathologies of the mediastinum ( a cavity located between the lungs and containing the heart and important vessels, the trachea and the main bronchi, the esophagus and some other anatomical structures), against the background of systemic diseases, as well as due to metabolic disorders of a number of substances. In the development of pleurisy and other lung diseases, the place of residence and occupation of a person is important, since these factors determine some aspects of the negative impact on the respiratory system of a number of toxic and harmful substances.
It should be noted that one of the main signs of pleurisy is pleural effusion - an excessive accumulation of fluid in the pleural cavity. This condition is optional for inflammation of the pleural sheets, but it occurs in most cases. In some situations, pleural effusion occurs without the presence of an inflammatory process in the pleural cavity. As a rule, such an ailment is considered precisely as a pleural effusion, but in some cases it can be classified as pleurisy.
Pleurisy reasons
Pleurisy is a disease that in the overwhelming majority of cases develops on the basis of any existing pathology. The most common cause of the development of an inflammatory reaction in the pleural cavity is various infections. Pleurisy often occurs against the background of systemic diseases, tumors, and injuries. Some authors refer to pleurisy and cases of pleural effusion without an obvious presence of an inflammatory response. This situation is not entirely correct, since pleurisy is an ailment that involves an obligatory inflammatory component.
The following causes of pleurisy are distinguished:
- an infectious lesion of the pleura;
- an allergic inflammatory reaction;
- autoimmune and systemic diseases;
- exposure to chemicals;
- chest trauma;
- exposure to ionizing radiation;
- the effect of pancreatic enzymes;
- primary and metastatic tumors of the pleura.
Pleural infection
Infectious lesion of the pleura is one of the most common causes of the formation of an inflammatory focus in the pleural cavity with the development of purulent or other pathological exudate ( excretions).A pleural infection is a serious medical condition that, in many cases, can be life-threatening. Adequate diagnosis and treatment of this condition requires the coordinated actions of pulmonologists, therapists, radiologists, microbiologists, and, often, thoracic surgeons. The therapeutic approach depends on the nature of the pathogen, its aggressiveness and sensitivity to antimicrobial drugs, as well as on the stage of the disease and the type of infectious and inflammatory focus.
Pleurisy of an infectious nature affects patients of all age categories, but they are most common among the elderly and children. Men get sick almost twice as often as women.
The following comorbidities are risk factors for the development of pleural infections:
- Diabetes. Diabetes mellitus develops as a result of disruption of the endocrine function of the pancreas, which produces insufficient amounts of insulin. Insulin is a hormone that is essential for the normal metabolism of glucose and other sugars. With diabetes mellitus, many internal organs are affected, and there is also a slight decrease in immunity. In addition, the excessive concentration of glucose in the blood creates favorable conditions for the development of many bacterial agents.
- Alcoholism . In chronic alcoholism, many internal organs suffer, including the liver, which is responsible for the production of protein components of antibodies, the lack of which leads to a decrease in the body's protective potential. Chronic alcohol abuse leads to impaired metabolism of a number of nutrients, as well as a decrease in the number and quality of immune cells. In addition, people with alcoholism are more prone to chest injuries as well as infections. respiratory tract... This happens due to hypothermia against a background of reduced sensitivity and behavioral disturbances, as well as due to suppression of protective reflexes, which increases the risk of inhalation of infected materials or one's own vomit.
- Rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease that can cause pleural damage on its own. However, this ailment is also a serious risk factor for the development of an infectious lesion of the pleura. This is due to the fact that drugs that reduce immunity are often used to treat this disease.
- Chronic illnesses lungs. Many chronic lung diseases such as chronic bronchitis, chronic obstructive pulmonary disease, emphysema, asthma and some other pathologies create prerequisites for pleural infections. This happens for two reasons. Firstly, many chronic lung diseases are characterized by sluggish infectious and inflammatory processes that can progress over time and cover new tissues and areas of the lungs. Secondly, with these pathologies, the normal operation of the respiratory apparatus is disrupted, which inevitably leads to a decrease in its protective potential.
- Pathology of the gastrointestinal tract. Diseases of the dental apparatus can cause the accumulation of infectious agents in the oral cavity, which, after a deep breath ( for example, while sleeping) can end up in the lungs and cause pneumonia with subsequent pleural damage. Gastroesophageal reflux ( reflux of food from the stomach into the esophagus) promotes respiratory tract infection by increasing the risk of inhalation of gastric contents, which may be infected, and which reduces local immunity ( due to the irritating effect of hydrochloric acid).
Infectious agents can enter the pleural cavity in the following ways:
- Contact with an infectious focus in the lungs. When an infectious-inflammatory focus is located in close proximity to the pleura, a direct transition of pathogens with the development of pleurisy is possible.
- With lymph flow. The penetration of microorganisms along with the lymph flow is due to the fact that the lymphatic vessels of the peripheral regions of the lungs are drained into the pleural cavity. This creates the prerequisites for the penetration of infectious agents from areas that do not come into direct contact with the serous membrane.
- With blood flow. Some bacteria and viruses are capable, at a certain stage of their development, to penetrate into the bloodstream, and with this into various organs and tissues.
- Direct contact with the external environment ( traumatism). Any penetrating trauma to the chest cavity is considered potentially infected and, accordingly, a possible source of infection of the pleura. Openings and incisions in the chest wall, made for therapeutic purposes, but in inappropriate conditions or in the absence of proper care, can also act as a source of pathogenic microorganisms.
Under the influence of these microorganisms, an inflammatory process develops, which is a special protective reaction aimed at eliminating infectious agents and limiting their spread. Inflammation is based on a complex chain of interactions between microorganisms, immune cells, biologically active substances, blood and lymphatic vessels and tissues of the pleura and lungs.
In the development of pleurisy, the following successive stages are distinguished:
- Exudation phase. Under the influence of biologically active substances, which are secreted by immune cells, activated as a result of contact with infectious agents, the blood vessels expand with an increase in their permeability. This leads to increased production of pleural fluid. At this stage, the lymphatic vessels cope with their function and adequately drain the pleural cavity - there is no excessive accumulation of fluid.
- The phase of formation of purulent exudate. As the inflammatory reaction progresses, deposits of fibrin, a "sticky" plasma protein, begin to form on the pleura. This happens under the influence of a number of biologically active substances that reduce the fibrinolytic activity of pleural cells ( their ability to break down fibrin strands). This leads to the fact that friction between the pleural sheets increases significantly, and in some cases adhesions occur ( areas of "gluing" of serous membranes). A similar course of the disease contributes to the formation of divided areas in the pleural cavity ( so called "pockets" or "bags"), which significantly complicates the outflow of pathological contents. After a while, pus begins to form in the pleural cavity - a mixture of dead bacteria that have absorbed their immune cells, plasma and a number of proteins. The accumulation of pus is promoted by progressive edema of mesothelial cells and tissues located near the inflammatory focus. This leads to the fact that the outflow through the lymphatic vessels decreases and an excess volume of pathological fluid begins to accumulate in the pleural cavity.
- Recovery stage. At the stage of recovery, either resorption occurs ( resorption) pathological foci, or, if it is impossible to independently eliminate the pathogenic agent, connective tissue ( fibrous) formations that limit the infectious and inflammatory process with a further transition of the disease to a chronic form. Foci of fibrosis adversely affect lung function, since they significantly reduce their mobility, and in addition, increase the thickness of the pleura and reduce its ability to reabsorb fluid. In some cases, either separate adhesions ( mooring lines), or complete overgrowth with fibrous fibers ( fibrothorax).
Tuberculosis
Despite the fact that tuberculosis is a bacterial infection, this pathology is often considered separately from other forms of microbial damage to the respiratory system. This is due, firstly, to the high infectivity and prevalence of this disease, and secondly, to the specificity of its development.Tuberculous pleurisy occurs as a result of the penetration into the pleural cavity of mycobacterium tuberculosis, also known as Koch's bacillus. This ailment is considered as the most common form of extrapulmonary infection that can occur when primary foci are located both in the lungs and in others. internal organs... It can develop against the background of primary tuberculosis, which occurs upon first contact with the pathogen ( typical for children and adolescents), or secondary, which develops as a result of repeated contact with a pathogenic agent.
The penetration of mycobacteria into the pleura is possible in three ways - lymphogenous and contact with the location of the primary focus in the lungs or spine ( rarely), and hematogenous, if the primary infectious focus is located in other organs ( gastrointestinal tract, lymph nodes, bones, genitals, etc.).
The development of tuberculous pleurisy is based on an inflammatory reaction supported by the interaction between immune cells ( neutrophils during the first few days and lymphocytes thereafter) and mycobacteria. In the course of this reaction, biologically active substances are released that affect the tissues of the lung and serous membranes, and which maintain the intensity of inflammation. Against the background of dilated blood vessels within the infectious focus and a reduced outflow of lymph from the pleural cavity, pleural effusion is formed, which, unlike infections of a different nature, is characterized by an increased content of lymphocytes ( more than 85%).
It should be noted that for the development of tuberculosis infection, a certain unfavorable combination of circumstances is necessary. Most people do not become infected by simple contact with Koch's bacillus. Moreover, it is believed that in many people, mycobacterium tuberculosis can inhabit the tissues of the lungs without causing disease or any symptoms.
The following factors contribute to the development of tuberculosis:
- High density of infectious agents. The likelihood of developing an infection increases with the number of inhaled bacilli. This means that the higher the concentration of mycobacteria in the environment, the higher the chances of infection. A similar development of events is facilitated by staying in the same room with tuberculosis patients ( at the stage of isolation of pathogenic agents), as well as the lack of adequate ventilation and the small volume of the room.
- Long contact time. Prolonged contact with infected people or prolonged stay in a room in which mycobacteria are in the air is one of the main factors contributing to the development of infection.
- Low immunity. Under normal conditions, with periodic vaccinations, the human immune system copes with the causative agents of tuberculosis and prevents the development of the disease. However, in the presence of any pathological condition in which there is a decrease in local or general immunity, the penetration of even a small infectious dose can cause infection.
- High aggressiveness of the infection. Some mycobacteria are more virulent, that is, an increased ability to infect humans. The penetration of such strains into the human body can cause infection even if a large number bacillus.
A decrease in immunity is a condition that can develop against the background of many pathological conditions, as well as with the use of certain medicinal substances.
The following factors contribute to a decrease in immunity:
- chronic diseases of the respiratory system ( infectious and non-infectious nature);
- diabetes;
- chronic alcoholism;
- treatment with drugs that suppress immunity ( glucocorticoids, cytostatics);
- HIV infection ( especially at the stage of AIDS).
Allergic inflammatory response
An allergic reaction is a pathological overreaction of the immune system that develops when it interacts with foreign particles. Since pleural tissues are rich in immune cells, blood and lymphatic vessels, and are also sensitive to the effects of biologically active substances released and maintain the inflammatory response in allergies, after contact with an allergen, the development of pleurisy and pleural effusion is often observed.Pleurisy can develop with the following types of allergic reactions:
- Exogenous allergic alveolitis. Exogenous allergic alveolitis is a pathological inflammatory reaction that develops under the influence of external foreign particles - allergens. In this case, damage to the lung tissue immediately adjacent to the pleura occurs. The most common allergens are fungal spores, plant pollen, house dust, and some medicinal substances.
- Drug allergy. Allergy to drugs is common in modern world... Have pretty a large number people are allergic to some antibiotics, local pain relievers and other pharmacological drugs. A pathological response develops within a few minutes or hours after drug administration ( depending on the type of allergic reaction).
- Other types of allergies . Some other types of allergies, which do not directly affect the lung tissue, can cause the activation of immune cells in the pleura with the release of biologically active substances and the development of edema and exudation. After eliminating the action of the allergen, the scale of inflammation decreases, and the reverse absorption of excess fluid from the pleural cavity begins.
It should be understood that the inflammatory response underlying allergy is not significantly different from the inflammatory response that occurs during an infectious process. Moreover, in most cases, microorganisms provoke an allergic reaction in the pleura, which contributes to the development of pleurisy and the formation of exudate.
Autoimmune and systemic diseases
Pleurisy is one of the most common forms of lung damage in autoimmune and systemic diseases. This pathology occurs in almost half of patients with rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis and other connective tissue diseases.Autoimmune diseases are pathologies in which the immune system begins to attack its own tissues ( usually connective tissue fibers). As a result, a chronic inflammatory reaction develops that affects many organs and tissues ( mainly - joints, skin, lungs).
Pleurisy can develop with the following systemic pathologies:
- rheumatoid arthritis;
- systemic lupus erythematosus;
- dermatomyositis;
- Wegener's granulomatosis;
- Churg-Strauss syndrome;
- sarcoidosis.
Exposure to chemicals
Direct exposure to certain chemicals on the pleural sheets can cause their inflammation and, accordingly, can cause the development of dry or effusion pleurisy. In addition, chemical damage to peripheral lung tissues also contributes to the formation of an inflammatory process, which can also cover the serous membrane.Chemicals can enter the pleural cavity in the following ways:
- With open injuries. With an open chest injury, various chemically active substances - acids, alkalis, etc., can enter the pleural cavity.
- With closed chest injuries. Closed injuries chest can cause a rupture of the esophagus, followed by ingestion of food or gastric contents into the mediastinum and the parietal layers of the pleura.
- Inhalation of chemicals. Inhalation of certain hazardous chemicals can cause burns to the upper and lower respiratory tract, as well as inflammation in the lung tissues.
- Chemical injection. When substances not intended for this use are injected intravenously, they can enter the tissues of the lungs and pleura and cause serious impairment of their function.
Chest trauma
Chest injury is a factor that, in some cases, is the cause of the development of an inflammatory reaction and the formation of pleural effusion. This may be due to damage to both the pleura itself and adjacent organs ( esophagus).In case of damage to the pleural sheets as a result of exposure to a mechanical factor ( with closed and open injuries), an inflammatory response occurs, which, as described above, leads to increased production of pleural fluid. In addition, traumatic exposure disrupts lymph circulation in the damaged area, which significantly reduces the outflow of pathological fluid and contributes to the development of pleural effusion. The penetration of pathogenic infectious agents is another additional factor, increasing the risk of developing post-traumatic pleurisy.
Damage to the esophagus, which can occur with a strong blow to the chest cavity, is accompanied by the release of food and gastric contents into the mediastinal cavity. Due to the frequent combination of a rupture of the esophagus with a violation of the integrity of the pleural sheets, these substances can enter the pleural cavity and cause an inflammatory reaction.
Exposure to ionizing radiation
Under the influence of ionizing radiation, the function of the pleural mesothelial cells is disrupted, a local inflammatory reaction develops, which, in combination, leads to the formation of a significant pleural effusion. The inflammatory process develops due to the fact that, under the influence of ionizing radiation, some molecules change their function and structure and provoke local tissue damage, which leads to the release of biological substances with pro-inflammatory activity.Exposure to pancreatic enzymes
Pleurisy and pleural effusion develops in about 10% of patients with acute pancreatitis ( inflammation of the pancreas) within 2 - 3 days after the onset of the disease. In most cases, a small amount of pathological fluid accumulates in the pleural cavity, which is independently absorbed after normalization of the pancreas function.Pleurisy develops due to the destructive effect on the serous membranes of pancreatic enzymes, which, during its inflammation, enter the bloodstream ( they are normally transported directly to duodenum ). These enzymes partially destroy the blood vessels, the connective tissue basis of the pleura, and activate immune cells. As a result, exudate accumulates in the pleural cavity, which consists of leukocytes, blood plasma and destroyed red blood cells. Amylase concentration ( pancreatic enzyme) in pleural effusion can be several times higher than the concentration in the blood.
Pleural effusion in pancreatitis is a sign of severe damage to the pancreas and, according to a number of studies, is more common in pancreatic necrosis ( death of a significant part of organ cells).
Primary and metastatic pleural tumors
Pleurisy, which has arisen against the background of malignant pleural tumors, is a fairly common pathology that doctors have to deal with.Pleurisy can develop with the following types of tumors:
- Primary pleural tumors . A primary tumor of the pleura is a neoplasm that has developed from cells and tissues that make up the normal structure of this organ. In most cases, these tumors are formed by mesothelial cells and are called mesotheliomas. They occur in only 5 - 10% of cases of pleural tumors.
- Metastatic foci in the pleura. Pleural metastases are fragments of a tumor that separated from the primary focus located in any organ, and which migrated to the pleura, where they continued their development. In most cases, the tumor process in the pleura is precisely metastatic in nature.
Pleural effusion, which is the most common manifestation of neoplastic pleurisy, develops as a result of the interaction of several pathological mechanisms in the pleura. First, a tumor focus, which occupies a certain volume in the pleural cavity, reduces the area of an efficiently functioning pleura and reduces its ability to reabsorb fluid. Secondly, under the action of products produced in tumor tissues, the concentration of proteins in the pleural cavity increases, which leads to an increase in oncotic pressure ( proteins are able to "attract" water - a phenomenon called oncotic pressure). And, thirdly, the inflammatory reaction, which develops against the background of primary or metastatic neoplasms, increases the secretion of pleural fluid.
Types of pleurisy
In clinical practice, it is customary to distinguish several types of pleurisy, which differ in the nature of the effusion formed in the pleural cavity, and, accordingly, in the main clinical manifestations. This division in most cases is rather arbitrary, since one type of pleurisy can often turn into another. Moreover, dry and exudative ( effusion) pleurisy is considered by most pulmonologists as different stages of one pathological process. It is believed that dry pleurisy is initially formed, and effusion develops only with further progression of the inflammatory reaction. In clinical practice, the following types of pleurisy are distinguished:
- dry ( fibrinous) pleurisy;
- exudative pleurisy;
- purulent pleurisy;
- tuberculous pleurisy.
Dry ( fibrinous) pleurisy
Dry pleurisy develops at the initial stage of inflammatory lesions of the pleura. Often, at this stage of the pathology, there are no infectious agents in the lung cavity, and the changes that arise are due to the reactive involvement of blood and lymphatic vessels, as well as an allergic component.With dry pleurisy, due to an increase in vascular permeability under the influence of pro-inflammatory substances, the liquid component of the plasma and a part of the proteins, among which fibrin is of the greatest importance, begins to seep into the pleural cavity. Under the influence of the environment in the inflammatory focus, fibrin molecules begin to combine and form strong and sticky threads, which are deposited on the surface of the serous membrane.
Since with dry pleurisy, the amount of effusion is minimal ( the outflow of fluid through the lymphatic vessels is slightly impaired), fibrin filaments significantly increase friction between the pleural layers. Since there are a large number of nerve endings in the pleura, increased friction causes a significant painful sensation.
The inflammatory process in fibrinous pleurisy affects not only the serous membrane itself, but also the cough nerve receptors located in its thickness. Due to this, the threshold of their sensitivity is reduced, and a cough reflex arises.
Exudative ( effusion) pleurisy
Exudative pleurisy is the next phase of the development of the disease after dry pleurisy. At this stage, the inflammatory reaction progresses, the area of the affected serous membrane increases. The activity of enzymes that break down fibrin filaments decreases, pleural pockets begin to form, in which pus can accumulate in the future. The outflow of lymph is impaired, which, against the background of increased fluid secretion ( filtration from dilated blood vessels at the site of inflammation) leads to an increase in the volume of intrapleural effusion. This effusion compresses the lower segments of the lung from the affected side, which leads to a decrease in its vital volume. As a result, with massive exudative pleurisy, respiratory failure may develop - a condition that poses an immediate threat to the patient's life.Since the fluid accumulated in the pleural cavity to some extent reduces the friction between the pleural layers, at this stage the irritation of the serous membranes and, accordingly, the intensity of the pain sensation decreases somewhat.
Purulent pleurisy
With purulent pleurisy ( empyema of the pleura) between the sheets of the serous membrane of the lung, purulent exudate accumulates. This pathology is extremely severe and is associated with intoxication of the body. Without proper treatment, it poses a threat to the patient's life.Purulent pleurisy can form both with direct damage to the pleura by infectious agents, and with the independent opening of an abscess ( or other accumulation of pus) of the lung into the pleural cavity.
Empyema usually develops in emaciated patients who have serious damage to other organs or systems, as well as in people with reduced immunity.
Tuberculous pleurisy
Often, tuberculous pleurisy is singled out in a separate category due to the fact that this ailment is quite common in medical practice. Tuberculous pleurisy is characterized by a slow, chronic course with the development of a syndrome of general intoxication and signs of lung damage ( in rare cases and other organs). The effusion with tuberculous pleurisy contains a large number of lymphocytes. In some cases, this ailment is accompanied by the formation of fibrinous pleurisy. When the bronchi are melted by an infectious focus in the lungs, specific curdled pus, characteristic of this pathology, can enter the pleural cavity.Pleurisy symptoms
The clinical picture of pleurisy depends on the following factors:
- the cause of pleurisy;
- the intensity of the inflammatory reaction in the pleural cavity;
- stage of the disease;
- type of pleurisy;
- the volume of exudate;
- the nature of the exudate.
Pleurisy is characterized by the following symptoms:
- increased body temperature;
- displacement of the trachea.
Dyspnea
Shortness of breath is the most common symptom associated with pleurisy and pleural effusion. Shortness of breath occurs as against the background of the initial lesion of the lung tissue ( the most common cause of pleurisy), and by reducing the functional volume of the lung ( or lungs with bilateral damage).Shortness of breath manifests itself as a feeling of lack of air. This symptom can occur with physical exertion of varying intensity, and in the case of severe course or massive pleural effusion - at rest. With pleurisy, shortness of breath may be accompanied by a subjective feeling of insufficient expansion or filling of the lungs.
Usually shortness of breath, caused by isolated lesions of the pleura, develops gradually. It is often preceded by other symptoms ( chest pain, cough).
Shortness of breath, persisting after treatment of pleurisy and drainage of pleural effusion, indicates a decrease in the elasticity of the lung tissue or that adhesions have formed between the pleural layers ( mooring lines), which significantly reduce mobility and, accordingly, the functional volume of the lungs.
It should be borne in mind that shortness of breath can develop with other pathologies of the respiratory system, not associated with pleurisy, as well as with impaired heart function.
Cough
Pleurisy cough is usually of moderate intensity, dry, unproductive. It is caused by irritation of the nerve endings located in the pleura. The cough is worse when the position of the body changes, as well as during inhalation. Chest pain during coughing may worsen.The appearance of sputum ( purulent or mucous) or bloody discharge during coughing indicates the presence of an infectious ( most often) lung damage.
Chest pain
Chest pain occurs due to irritation of the pain receptors of the pleura under the action of pro-inflammatory substances, as well as due to increased friction between the pleural layers with dry pleurisy. Pleurisy pain is acute, aggravated during inhalation or coughing, and decreases with holding the breath. The painful sensation covers the affected half of the chest ( or both with bilateral pleurisy) and extends to the shoulder and abdomen from the corresponding side. As the volume of pleural effusion increases, the intensity of pain decreases.Increased body temperature
An increase in body temperature is a non-specific reaction of the body to the penetration of infectious agents or some biological substances. Thus, an increased body temperature is characteristic of infectious pleurisy and reflects the severity of the inflammatory process and indicates the nature of the pathogen.With pleurisy, the following options for increased body temperature are possible:
- Temperature up to 38 degrees. Body temperature up to 38 degrees is typical for small infectious and inflammatory foci, as well as for some pathogenic agents with low virulence. Sometimes this temperature is observed at some stages of systemic diseases, tumor processes, as well as pathologies of other organs.
- The temperature is within 38 - 39 degrees. An increase in body temperature to 38 - 39 degrees is observed with pneumonia of a bacterial and viral nature, as well as with most infections that can affect the pleura.
- Temperatures above 39 degrees . A temperature above 39 degrees develops with a severe course of the disease, with the accumulation of pus in any cavity, as well as with the penetration of pathogens into the blood and with the development of a systemic inflammatory response.
In addition to the body temperature itself, the nature of its increase and decrease is important. In most cases, with an acute infectious process, the temperature rises rapidly during the first few hours from the onset of the disease, which is accompanied by a feeling of chills ( reflects the process of activation of mechanisms aimed at preserving heat). A drop in temperature is observed with a decrease in the scale of the inflammatory process, after the eradication of infectious agents, as well as with the elimination of the accumulation of pus.
Separately, mention should be made of fever in tuberculosis. This infection is characterized by subfebrile temperature values ( within 37 - 37.5), which are accompanied by a feeling of chills, night sweats, productive cough with phlegm, and weight loss.
Displacement of the trachea
Displacement of the trachea is one of the signs indicating excess pressure from one of the lungs. A similar condition occurs with massive pleural effusion, when a large volume of accumulated fluid presses on the mediastinal organs, causing them to shift to the healthy side.With pleurisy, some other symptoms may also be present, which depend on the pathology underlying the inflammation of the pleura. These manifestations are of great diagnostic value, since they allow you to establish the cause of the disease and begin adequate treatment.
Diagnostics of the pleurisy
Diagnosis of pleurisy as a clinical condition is usually not particularly difficult. The main diagnostic difficulty in this pathology is to determine the cause that caused the inflammation of the pleura and the formation of pleural effusion. The following examinations are used to diagnose pleurisy:
- examination and questioning of the patient;
- clinical examination of the patient;
- X-ray examination;
- blood test;
- analysis of pleural effusion;
- microbiological research.
Examination and questioning of the patient
During the questioning of the patient, the doctor identifies the main clinical symptoms, the time of their onset, and their characteristics. The factors that could provoke an ailment to one degree or another are determined, concomitant pathologies are clarified.During the examination, the doctor visually assesses the general condition of the patient, determines the existing deviations from the norm.
On examination, the following pathological signs can be detected:
- deviation of the trachea in a healthy direction;
- blue in the face skin (indicates severe respiratory distress);
- signs of a closed or open chest injury;
- swelling in the intercostal spaces on the affected side ( due to the large volume of accumulated liquid);
- tilt of the body to the affected side ( reduces the movement of the lung and, accordingly, irritation of the pleura during breathing);
- swelling of the veins of the neck ( due to increased intrathoracic pressure);
- lag of the affected half of the chest during breathing.
Clinical examination of the patient
During the clinical examination, the doctor performs the following manipulations:- Auscultation . Auscultation is a method of examination in which the doctor listens to the sounds that occur in the human body using a stethoscope ( before his invention - directly by the ear). Auscultation of patients with pleurisy may reveal a pleural friction noise, which occurs when the pleural sheets covered with fibrin threads are rubbed. This sound is heard during breathing movements, does not change after coughing, persists when imitating breathing ( performing several breathing movements with a closed nose and mouth). With effusion and purulent pleurisy in the area of fluid accumulation, a weakening of respiratory sounds is noted, which sometimes may not be heard at all.
- Percussion. Percussion is a method of clinical examination of patients in which the doctor uses his own hands or special devices ( a hammer and a small plate - a plessimeter) taps organs or formations of various densities in the patient's cavities. The method of percussion can determine the accumulation of fluid in one of the lungs, since when percussion above the fluid, a higher, dull sound is produced, which differs from the sound that occurs over healthy lung tissue. When tapping the boundaries of this percussion dullness, it is determined that the fluid in the pleural cavity forms not a horizontal, but a somewhat oblique level, which is explained by uneven compression and displacement of the lung tissue.
- Palpation. With the help of the method of palpation, that is, when "feeling" the patient, zones of spread of painful sensations can be identified, as well as some others Clinical signs... With dry pleurisy, there is pain when pressed between the legs of the sternocleidomastoid muscle, as well as in the cartilage of the tenth rib. When the palms are applied at the symmetrical points of the chest, there is some lag in the affected half in the act of breathing. In the presence of pleural effusion, a weakening of the vocal tremor is felt.
X-ray examination
X-ray examination is one of the most informative diagnostic methods for pleurisy, as it allows you to detect signs of pleural inflammation, as well as to determine the amount of fluid accumulated in the pleural cavity. In addition, with the help of an X-ray of the lungs, signs of some pathologies that could cause the development of pleurisy ( pneumonia, tuberculosis, tumors, etc.).With dry pleurisy, the following signs are determined on x-rays:
- on the affected side, the dome of the diaphragm is above normal;
- a decrease in the transparency of the lung tissue against the background of inflammation of the serous membrane.
- smoothing the f-angle ( due to the accumulation of fluid);
- uniform darkening of the lower region of the pulmonary field with an oblique border;
- displacement of the mediastinum towards the healthy lung.
Blood test
A general blood test reveals signs of an inflammatory reaction ( increased erythrocyte sedimentation rate (ESR)), as well as an increased content of leukocytes or lymphocytes ( with the infectious nature of pleural lesions).A biochemical blood test reveals a change in the ratio of proteins in blood plasma due to an increase in the content of alpha globulins and C-reactive protein.
Analysis of pleural effusion
Analysis of pleural effusion allows one to judge the initial cause of the pathology, which is extremely important for diagnosis and subsequent treatment.Laboratory analysis of pleural effusion allows you to determine the following indicators:
- the amount and type of proteins;
- glucose concentration;
- concentration of lactic acid;
- the number and type of cellular elements;
- the presence of bacteria.
Microbiological examination
Microbiological examination of sputum or pleural fluid allows you to identify infectious agents that could cause the development of an inflammatory reaction in the pleural cavity. In most cases, direct microscopy of smears made from these pathological materials is performed, but they can be cultured on favorable media for further identification.Pleurisy treatment
Treatment of pleurisy pursues two main goals - stabilization of the patient and the normalization of his respiratory function, as well as elimination of the cause that caused this ailment. For this purpose, various medications and medical procedures. Treatment of pleurisy with medicines
In the vast majority of cases, pleurisy is infectious in nature, so it is treated with antibacterial drugs. However, some others can be used to treat pleural inflammation. medicines (anti-inflammatory, desensitizing, etc.).It should be borne in mind that the choice of pharmacological drugs is based on previously obtained diagnostic data. Antibiotics are selected taking into account the sensitivity of pathogenic microorganisms ( determined by microbiological examination or identified by any other method). The dosage regimen of medicines is set individually, depending on the severity of the patient's condition.
Drugs Used to Treat Pleurisy
| Group of drugs | Main representatives | Mechanism of action | Dosage and method of administration |
| Antibiotics | Ampicillin with sulbactam | Interacts with the cell wall of sensitive bacteria and blocks their reproduction. | It is used in the form of intravenous or intramuscular injections at a dose of 1.5 - 3 to 12 grams per day, depending on the severity of the disease. It is not used for nosocomial infections. |
| Imipenem in combination with Cilastatin | Suppresses the production of bacterial cell wall components, thereby causing their death. | It is prescribed intravenously or intramuscularly at a dose of 1 - 3 grams per day in 2 - 3 doses. | |
| Clindamycin | Suppresses bacterial growth by blocking protein synthesis. | It is used intravenously and intramuscularly at a dose of 300 to 2700 mg per day. Possible oral administration at a dose of 150 - 350 mg every 6 - 8 hours. | |
| Ceftriaxone | Violates the synthesis of components of the cell wall of sensitive bacteria. | The drug is administered intravenously or intramuscularly at a dose of 1 - 2 grams per day. | |
| Diuretic drugs | Furosemide | Increases the excretion of water from the body by acting on the kidney tubules. Reduces the reabsorption of sodium, potassium and chlorine. | It is prescribed orally at a dose of 20 - 40 mg. If necessary, it can be administered intravenously. |
| Regulators of water and electrolyte balance | Saline and glucose solution | Accelerates renal filtration by increasing the volume of circulating blood. Promotes the elimination of toxic decay products. | Introduced by slow intravenous infusion ( using drip infusion). The dosage is determined individually, depending on the severity of the condition. |
| Non-steroidal anti-inflammatory drugs | Diclofenac, ibuprofen, meloxicam | They block the enzyme cyclooxygenase, which is involved in the production of a number of pro-inflammatory substances. They have an analgesic effect. | The dosage depends on the drug chosen. They can be administered both intramuscularly and orally in the form of tablets. |
| Glucocorticosteroids | Prednisone | They block the breakdown of arachidonic acid, thereby preventing the synthesis of pro-inflammatory substances. They reduce immunity, therefore, they are prescribed only in conjunction with antibacterial drugs. | Inside or intramuscularly at a dose of 30-40 mg per day for a short period of time. |
When is a puncture necessary for pleurisy?
Pleural puncture ( thoracocentesis) is a procedure in which a certain amount of fluid accumulated there is removed from the pleural cavity. This manipulation is carried out both for therapeutic and diagnostic purposes, therefore it is prescribed in all cases of effusion pleurisy.The following conditions are relative contraindications to pleural puncture:
- pathology of the blood coagulation system;
- high pressure in the system pulmonary artery;
- chronic obstructive pulmonary disease in a severe stage;
- the presence of only one functional lung.
With a significant volume of pleural effusion, puncture allows to drain part of the pathological fluid, thereby reducing the degree of compression of the lung tissue and improving respiratory function. The therapeutic puncture is repeated as needed, that is, as the effusion accumulates.
Do I need hospitalization for pleurisy treatment?
In most cases, hospitalization of patients is necessary for the treatment of pleurisy. This is due, firstly, to the high degree of danger of this pathology, and secondly, to the possibility of constant monitoring of the patient's condition by highly qualified personnel. In addition, in a hospital setting, it is possible to prescribe more powerful and effective drugs, and there is also the possibility of carrying out the necessary surgical interventions.Can pleurisy be treated at home?
Treating pleurisy at home is possible, although not recommended in most cases. Treatment of pleurisy at home is possible if the patient has passed all the necessary studies, and the cause of this ailment has been reliably identified. A mild course of the disease, low activity of the inflammatory process, the absence of signs of disease progression, combined with a responsible attitude of the patient to taking prescribed medications, allow for treatment at home.Nutrition with pleurisy ( diet)
Diet for pleurisy is determined by the underlying pathology that caused the development of an inflammatory focus in the pleural cavity. In most cases, it is recommended to reduce the amount of incoming carbohydrates, since they contribute to the development of pathogenic microflora in the infectious focus, as well as fluid ( up to 500 - 700 ml per day), since its excess contributes to the more rapid formation of pleural effusion.Salty, smoked, savory and canned foods are contraindicated, as they provoke a feeling of thirst.
It is necessary to consume enough vitamins, as they are necessary for the normal functioning of the immune system. For this purpose, it is recommended to eat fresh vegetables and fruits.
The consequences of pleurisy
Pleurisy is a serious disease that significantly disrupts the function of the respiratory system. In most cases, this pathology indicates a complication of the course of the underlying ailment ( pneumonia, tuberculosis, tumor process, allergies). Correct and timely elimination of the cause of pleurisy allows you to completely restore lung function without any consequences.However, in many cases, pleurisy can cause partial or complete structural and functional rearrangement of pleural or lung tissue.
The consequences of pleurisy include:
- Adhesions between the layers of the pleura. Adhesions are connective tissue cords between the pleural layers. They are formed in the area of inflammatory foci that have undergone organization, that is, sclerosis. Adhesions, called moorings in the pleural cavity, significantly limit the mobility of the lungs and reduce the functional tidal volume.
- Overgrowth of the pleural cavity. In some cases, massive pleural empyema can cause complete overgrowth of the pleural cavity with connective tissue fibers. This almost completely immobilizes the lung and can cause severe respiratory failure.
Pleural diseases are common practice and can reflect a wide range of underlying pathological conditions involving the lungs, chest wall, and systemic diseases. The most common manifestation is the formation of pleural effusion, and the vast majority of these patients require X-ray confirmation and further examination. Recent advances in chest imaging, therapy and surgery have improved the diagnosis and treatment of patients with pleural pathology.
The pleura gives the chest the ability to shape and move the lungs with minimal energy. Why two pleural sheets (parietal and visceral) must slide over one another - this process is facilitated by a small amount (0.3 ml / kg) of fluid.
Pleural fluid is filtered from small vessels of the parietal pleura into the pleural cavity and is reabsorbed by the lymphatic vessels of the same leaf. Experimental data show that the volume and composition of pleural fluid is normally very stable, and effusion occurs only in cases where the filtration rate exceeds the maximum lymph outflow or re-absorption is impaired.
Pleural effusion
Pleural effusions are traditionally classified as transudates (total protein< 30 г/л) и экссудаты (общий белок >30 g / l). In intermediate cases (namely, when the protein content is 25-35 g / l), the determination of the content of lactate dehydrogenase (LDH) in the pleural fluid and the albumin gradient between serum and pleural fluid helps to distinguish between exudate and transudate.
The most common causes and characteristics of pleural effusions are given in and. Their differentiation is important because "low protein" effusions (transudates) do not require further diagnostic activities; only the treatment of the pathology that caused them is necessary, while when pleural exudate is detected, additional diagnostics are certainly needed.
Effusions can be unilateral or bilateral. The latter are often detected in heart failure, but can also occur in hypoproteinemic conditions and in collagenoses with vascular lesions. A thorough history, including occupation, international travel and risk factors for thromboembolism, and a careful physical examination are essential.
- The clinical picture. The most common symptom of pleural effusion is shortness of breath, the severity of which depends on the volume of the effusion, the rate at which fluid accumulates, and whether or not there is pre-existing lung disease. Pain caused by pleurisy can be an early sign and be caused by inflammation or infiltration of the parietal pleura.
Physical examination reveals a restriction of respiratory movements of the chest, "stone" dullness during percussion, dullness of breathing during auscultation, and often - a zone of bronchial breathing above the fluid level.
- Research methods. The diagnosis is confirmed by chest x-ray; but at least 300 ml of fluid must accumulate in the pleural cavity to be detectable on a conventional direct image. When the patient is supine, fluid moves along the pleural space, lowering the transparency of the pulmonary field on the affected side.
Small effusions should be differentiated from pleural thickening. This can be helped by taking an X-ray while lying down (with the fluid moving under the influence of gravity), as well as ultrasound (ultrasound) or X-ray computed tomography (CT).
Both ultrasound and CT are valuable techniques that are increasingly being used to differentiate between pleural fluid, an enveloped lung (pleural plaques commonly associated with asbestos exposure), and a tumor. These methods also allow you to find out if the pleural fluid is encapsulated, and to outline the optimal site for pleural puncture and biopsy.
Pleural puncture with aspiration and biopsy are indicated for all patients with effusion, while obtaining much more diagnostic information than with aspiration alone, and avoiding repeated invasive procedures (see Fig. 1).
Other tests to aid in the diagnosis include follow-up chest x-rays after aspiration to identify underlying pulmonary abnormalities, CT scans, isotopic lung scans (ventilation-to-perfusion ratios), intradermal tuberculin tests, rheumatoid and antinuclear serologic tests. factors.
If the above methods do not allow identifying the cause of pleural effusions, thoracoscopy is performed using video equipment. It allows not only to examine the pleura, but also to identify tumor nodes and carry out targeted biopsy. This procedure is most valuable for diagnosing mesothelioma. Be that as it may, in 20% of patients with exudative pleural effusions, conventional studies cannot diagnose the cause of the development of this condition.
- Treatment. Symptomatic relief of dyspnea is achieved with thoracocentesis and pleural drainage with effusion. Drainage of uninfected effusions is initially recommended to be limited to 1 L because of the risk of reactive edema of the expanding lung.
Treatment of a pathology that provokes the development of pleural effusion, such as heart failure or pulmonary embolism, often leads to its disappearance. Certain conditions, including empyema and malignant tumors, require special measures, which are discussed below.
Parapneumonic effusion and empyema
Approximately 40% of patients with bacterial pneumonia develop concomitant pleural effusion; in such cases, a pleural puncture should be performed to make sure that there is no empyema and to prevent or reduce the degree of subsequent pleural thickening.
However, in 15% of patients, parapneumonic effusions become infected a second time, empyema develops, that is, pus is formed in the pleural cavity (see Fig. 2).
Other causes of empyema include surgery (20%), trauma (5%), esophageal perforation (5%), and subphrenic infections (1%).
In empyema, most of the sown crops are represented by aerobic microorganisms. Anaerobic bacteria are sown in 15% of cases of empyema, usually a complication of aspiration pneumonia; the rest of the cases are due to a variety of other microorganisms (see table. 3). If antibiotics were given prior to the pleural puncture, the cultures often fail to grow.
- The clinical picture. In pneumonia, empyema should be thought of if the patient's condition, despite adequate antibiotic therapy, improves slowly, with persistent or recurrent fever, weight loss and malaise, or with persistent polymorphonuclear leukocytosis or elevated C-reactive protein.
The diagnosis is confirmed on the basis of X-ray signs of encapsulated pleurisy or in the case of detection of pus in the pleural punctate (see).
- Treatment. If pleural infection is established, treatment with large doses of antibiotics should be initiated. If culture results are not known, a combination of antibiotics that is potentially most effective should be used: penicillin or cephalosporin (second or third generation) in conjunction with metronidazole.
In addition, under ultrasound or CT guidance, drainage should be established from the lowest part of the empyema and connected to the underwater valve mechanism. In the past, it was recommended to use relatively large diameter drains, but today the use of narrower tubes is recognized as effective with less trauma to patients.
If adhesions are detected during ultrasound or CT, it is necessary to suction along the drain, which should be regularly rinsed with saline. In such cases, some experts advise daily intrapleural infusions of fibrinolytic drugs such as streptokinase or urokinase. The last of the named drugs is recommended in cases where for Last year the patient was injected with streptokinase or antibodies to streptokinase were found.
Recommendations regarding the advisability of using fibrinolytics are based on the results of small uncontrolled studies, according to which the rate of adhesion elimination was 60-95%, and the need for surgical interventions significantly decreased. The lack of controlled trials to date explains some of the uncertainty about when, for how long, and in what doses to use fibrinolytic drugs. Work is under way under the auspices of the Medical Research Council to answer these questions.
If, as a result of drainage from the intercostal access (with or without fibrinolytics), it is not possible to achieve adequate fluid drainage, if empyema persists, is organized and accompanied by thickening of the pleura and compression of the lung, then surgical intervention is indicated.
Thoracoscopy is usually successful in the early stages of the disease, but with extensive pleural adhesions it may fail. In these cases, thoracotomy and decortication are indicated. Although such surgery is highly effective in treating empyema (> 90%), there is significant operational risk associated with it, especially in debilitated patients.
Open drainage, which requires rib resection, is a rather unattractive procedure and is only performed when the patient cannot undergo a more invasive operation.
Without treatment, empyema can burst outward through the chest wall ("perforating" empyema) or into the bronchial tree to form a bronchopleural fistula, or cause extensive pleural fibrosis that restricts lung mobility. Rare complications include brain abscess and amyloidosis, and deformation of the phalanges of the "drumstick" type may also occur.
The defeat of the pleura in malignant neoplasms
Lung cancer is the most common cause of malignant pleural effusion, especially in smokers. Lymphoma can occur at any age and accounts for 10% of all malignant effusions. Pleural metastases are most common in breast (25%), ovarian (5%), or gastrointestinal (2%) cancers (see Fig. 3). In 7% of cases, the primary tumor remains unknown.
- Treatment. The defeat of the pleura by a malignant tumor is usually associated with an advanced disease, and, consequently, with a poor prognosis.
It is important to understand that in primary bronchogenic cancer, the presence of pleural effusion does not necessarily preclude operability. In 5% of these patients, effusion develops due to bronchial obstruction and distal infection, and the disease remains potentially curable.
Therefore, when the question arises about the possibility of an operation, it is extremely important to establish the cause of the pleural effusion.
Effusions due to malignant pleural infiltration usually re-accumulate rapidly. In order to avoid the need for repeated pleural punctures, the effusion must be completely ("dry") removed during primary drainage through the intercostal tube, and the pleural cavity must be obliterated by the administration of inflammation-inducing drugs, such as talc, tetracycline or bleomycin, and in the end pleurodesis develops. Currently the most effective remedy in this regard, talc is considered: when it is used, success is achieved in 90% of patients.
However, effective pleurodesis leads to significant pain in the postoperative period, which often requires the use of strong analgesics; it is recommended to avoid non-steroidal anti-inflammatory drugs, as they reduce the effectiveness of the operation.
Direct abrasion of the pleura during surgery, with or without pleurectomy, is used in young patients with a fairly long survival time who have failed chemical pleurodesis.
With extensive, painful pleural effusion for the patient and the ineffectiveness of chemical pleurodesis, an alternative method is the installation of a pleuroperitoneal shunt according to Denver. Surprisingly, during such an operation, there is no seeding of the tumor along the peritoneum, however, the development of infection and occlusion of the shunt can result in a real problem.
Pleural pathology associated with asbestos
- Benign pleural plaques. This pathology most often occurs in contact with asbestos, it manifests itself in the form of areas of thickening of the parietal and diaphragmatic pleura. The formation of benign pleural plaques caused by exposure to asbestos is asymptomatic, more often they are detected by accident, with a conventional chest x-ray. Often these plaques become calcified.
- Benign pleural effusion. It is a specific disease associated with asbestos exposure that can be accompanied by pleural pain, fever, and leukocytosis. The effusion is often bloody, making it difficult to differentiate with mesothelioma. The disease is self-limiting, but can cause pleural fibrosis.
- Diffuse pleural fibrosis. This is a serious illness that occurs when asbestos fibers are inhaled. In contrast to benign pleural plaques, it can restrict the movement of the chest during inhalation, which causes shortness of breath. The disease is progressive and can lead to severe disability. Table 4 provides details of when such patients are eligible for compensation.
- Mesothelioma. It is believed that the majority (> 70%) of this malignant pleural tumor is caused by inhalation of asbestos fibers, especially crocidolite, amosite and chrysolite. The long latency period in the development of mesothelioma (30-40 years) may explain the fact that the increase in the incidence of this pathology continues today, that is, many years after the introduction of strict laws on the use of asbestos.
In 2002, deaths from mesothelioma in the UK are projected to peak in 2020 at 3,000.
In most countries, men predominate among the sick, which confirms the leading role of the occupational factor in the development of this disease.
Age at the time of exposure to asbestos, as well as the duration and intensity of this exposure, are also important. Occupations that require direct contact with asbestos, especially construction workers, are at greatest risk, while the risk is much lower for people living in buildings containing asbestos.
The disease is manifested by chest pain and pleural effusion, which is bloody and causes shortness of breath. In the UK, patients with this disease are eligible for compensation, as for other diseases and injuries sustained at work (see).
In all cases, a histological examination is necessary, during which either material obtained by aspiration of pleural contents and biopsy under ultrasound control is used (which makes it possible to confirm the diagnosis in 39% of such patients), or tissue taken by thoracoscopy (the diagnosis is confirmed in 98% of patients) ... Thoracoscopy can also determine the extent of the tumor in the pleural cavity, since very limited disease can be cured at an early stage. surgically, while with damage to the visceral pleura, the prognosis is poor.
After such diagnostic interventions, seeding of the tumor along the pleura is often observed; prevention of this condition involves irradiation of the biopsy or drainage area.
Most patients come to the doctor for the first time with an inoperable tumor. In such a situation, none of the methods provides the possibility of curing the patient, however, today attempts are being made to use radical surgery, photodynamic therapy, intrapleural systemic chemotherapy and radiation therapy. And although gene therapy has not yet been successful, immunotherapy can be recognized as promising. Unfavorable diagnostic factors are: low functional reserves of the cardiovascular and respiratory systems, leukocytosis, degeneration into sarcoma (according to histological examination) and male sex. Within one year, from 12 to 40% of patients survive, depending on the listed prognostic factors.
Spontaneous pneumothorax
Spontaneous pneumothorax can be primary (without overt previous lung disease) or secondary (when there is evidence of pulmonary disease, such as pulmonary fibrosis). Uncommon causes of pneumothorax include pulmonary infarction, lung cancer, rheumatoid nodules, or a cavity-forming lung abscess. Subpleural emphysematous bullae, usually located at the apex of the lung, or pleural bullae are found in 48-79% of patients with ostensibly spontaneous primary pneumothorax.
Among smokers, the incidence of pneumothorax is much higher. The relative risk of developing pneumothorax is nine times higher in female smokers and 22 times higher in male smokers. Moreover, a dose-effect relationship was found between the number of cigarettes smoked per day and the frequency of pneumothorax.
- The clinical picture. If it is known from the history that the patient suddenly has shortness of breath with pain in the chest or supraclavicular region, then spontaneous pneumothorax is highly likely to be suspected. With a small volume of pneumothorax, physical examination may not detect any pathological signs, in which case the diagnosis is made on the basis of chest x-ray data (see Fig. 4).
In the diagnosis of small in volume, mainly apical, pneumothorax can be helped by images on the exhalation, which, however, are rarely used. A distinction should be made between large emphysematous bullae and pneumothorax.
- Treatment. Treatment of pneumothorax depends mainly on how much it affects the patient's condition, and not on its volume according to X-ray data.
The treatment algorithm is presented on. Percutaneous aspiration is a simple, well-tolerated, alternative to intercostal tube drainage and should be preferred in most cases. Aspiration allows satisfactory lung expansion in 70% of patients with normal pulmonary function and only in 35% of patients with chronic lung disease.
The average relapse rate after a single primary spontaneous pneumothorax, regardless of primary treatment, is 30%, most occurring in the first 6-24 months.
Patients should be warned of the possibility of recurrent pneumothorax: in particular, they are not advised to fly an airplane for six weeks after the pneumothorax has completely resolved. Surgery is usually required when persistent air accumulation is observed during the week.
Recurrent pneumothorax, especially if both lungs are affected, should be treated with either chemical pleurodesis or, more preferably, parietal pleurectomy or pleural abrasion.
The latter of these operations can be performed using video-guided thoracoscopy, which allows you to follow the progress of the procedure using a monitor, reduce hospital stay and speed up the patient's return to normal life. Surgery allows to reduce the recurrence rate to 4% compared to 8% after talc pleurodesis.
In this article, we talked about several aspects associated with pleural diseases, including the latest advances in this area. Pleural effusion is the most common manifestation of pleural pathology, requiring careful examination. If, after the usual research methods, the cause of the disease remains unclear, all necessary measures must be taken to exclude pulmonary thromboembolism, tuberculosis, drug reactions and subphrenic pathological processes.
Helen Parfrey, BSc in Medicine, BSc in Chemistry, Fellow of the Royal College of Physicians
West Suffolk Hospital
Edwin R. Chilvers BSc in Medicine natural sciences, Ph.D., professor
University of Cambridge, School of Clinical Medicine, Department of Internal Medicine, Addenbrook and Papworth Hospital
Note!
- Effusions can be unilateral or bilateral. The latter are often detected in heart failure, but can also occur in hypoproteinemic conditions and in vascular lesions caused by collagenoses. It is very important to take a thorough history with clarification of the profession, data on travel abroad and risk factors for thromboembolism, as well as a careful full physical examination.
- The most common symptom of pleural effusion is shortness of breath; pain from pleurisy can be an early sign of it, it is caused by inflammation or infiltration of the parietal pleura. Physical examination reveals a restriction of respiratory movements of the chest, percussion - "stone" dullness during percussion, muffling of breathing during auscultation and often the presence of a zone of bronchial breathing above the fluid level.
- Aspiration pleural puncture and biopsy are indicated for all patients with unilateral effusion. Be that as it may, in 20% of cases of exudative pleural effusions, conventional examinations fail to identify their cause.
- Approximately 40% of patients with bacterial pneumonia develop concomitant pleural effusion; in such cases, in order to exclude empyema, it is necessary to carry out a pleural puncture.
- Lung cancer is the most common cause of metastatic pleural effusion (36%), especially in smokers. The defeat of the pleura by a malignant tumor usually means an advanced disease, and, consequently, an unfavorable prognosis.
The lungs are the main organ of the human respiratory system. They have an anatomical structure that allows them to perform the function of providing oxygen assigned to them.
The serous membrane of the lungs is called the pleura, which can be visceral (pulmonary) or parietal (parietal):
- Visceral pleura - covers the lungs from all sides and is tightly connected to them. It enters the space between the pulmonary lobes, passing into the parietal at the surface of the lung root.
- Parietal pleura - lines the nearby walls of the thoracic region, shielding the lungs from the mediastinum. Spliced with the inner surface of the sternum. It forms a sac in each of the halves of the chest cavity, which contain the lungs covered with visceral pleura.
The lungs are a paired organ, dividing into the right lung and the left. Located in the chest cavity, they occupy up to 80% of its total volume. Lung tissue looks like a sponge with pink pores. Gradually, it darkens due to smoking, pathologies in the respiratory system, aging.
What is pulmonary pleurisy?
Pulmonary pleurisy is a complex inflammatory pathology, especially dangerous for children and the elderly. The disease begins as a result of inflammation (infectious or not) of the pleura. It is rarely independent, more often it is a consequence of painful processes in the lungs.
Inflammation of the pleural membranes of the lungs is accompanied by the release of exudate:
- With dry pleurisy, fibrin falls on the surface of the pleura.
- With exudative pleurisy, the secret accumulates in the pleural cavity.
Exudative pleurisy of the lungs is also called the processes accompanied by pathological effusion without inflammation - tumors, trauma, infection.
Species and general taxonomy
Depending on the reasons that gave rise to pulmonary pleurisy, its development and forms of manifestation, it happens:
- Purulent.
- It occurs due to the filling of the pleural cavity with purulent effusion. The pulmonary and parietal membranes become inflamed.
- Exudative.
- The pleura is affected by infections, tumors, injuries.
- Dry.
- Complications of diseases of the lungs and other organs located next to the pleural cavity. It can manifest itself as a symptom of systemic diseases.
- Tuberculous.
- Serous membranes, which create the pleural cavity and envelop the human lungs, are affected. The disease is diagnosed by the large volume of fluid released.
The symptomatology of each type is typical and depends on the nature of the course of the disease.
Stages of the disease
By the nature of the course, pleurisy of the lungs has three stages.
- The first stage is the exudation stage.
- There is an increased production of pleural fluid - a consequence of the expansion of blood vessels and an increase in their permeability. This happens when immune cells activate biological processes against the background of infection. Excess fluid has time to be excreted by the lymphatic system, since its volume in the pleura does not exceed normal.
- The second stage is the stage of formation of purulent exudate.
- A sticky, fibrin-rich exudate begins to be deposited on the pleural sheets. Friction between them increases, gradually the sheets are soldered (spliced). Formed "pockets", which significantly complicate the allocation of exudate from the pleural cavity. In places where the secretion accumulates, bacteria accumulate, which have died from contact with immune cells. Which, in combination with protein activity, leads to putrefaction and decomposition. Inflammatory processes begin to develop in the adjacent tissues, the outflow of fluids through the vessels is disrupted lymphatic system... In the pleural cavity, even more liquid purulent mass is collected.
- The third stage is the stage of chronicity or recovery.
- The stage of resorption of pathological formations or their transition to a chronic form. Chronization is manifested:
- a significant decrease in lung mobility;
- an increase in the thickness of the pleura;
- a decrease in the outflow of pleural fluid;
- the formation of pleural adhesions;
- sometimes, the pleura is completely overgrown with fibrous tissue.
- The stage of resorption of pathological formations or their transition to a chronic form. Chronization is manifested:
Causes
It is rarely possible to meet the disease in its pure form. You can get pleurisy with a chest injury or hypothermia, but more often this is a consequence of a complication of another disease. The nature of the symptoms depends on it.
Infectious pleurisy is the most common form. The general sensitivity of the patient is important for its development. The reactivity of the disease changes significantly when, due to microbes or toxins, allergization of the pleural cavity begins. The immune system directs the produced antibodies to the affected area, which, when combined with antigens, affect the production of histamines.
About three quarters of infectious problems are caused by exposure to bacterial agents:
- tubercle bacillus;
- fungal infection;
- streptococci;
- staphylococci;
- anaerobic bacteria;
- legionella.
A non-infectious form can occur for the following reasons:
- the formation of malignant tumors on the pleural sheets;
- spread of metastases in the pleural cavity;
- lung infarction;
- connective tissue injuries in the background:
- scleroderma;
- systemic vasculitis;
- lupus erythematosus.
The following diseases contribute to pleurisy of the lungs:
- angina;
Pulmonary pleurisy symptoms
The symptoms of pleurisy depend on the specific form of the disease and the nature of its course. Often, the onset of the development of the disease is missed by patients, since it is confused with the common cold. However, the main symptoms of the disease still differ from other respiratory pathologies.
Exudative, encapsulated pleurisy: symptoms
Substantial differences are possible clinical picture this form of the disease, depending on the place of localization and the age of the pathology. The nature of the discharge and its volume are also important.
Pleurisy of the indicated type includes:
- Inter-lobe:
- do not have pronounced symptoms.
- Encapsulated parietal:
- intensifying (with sneezing and coughing) chest pain;
- encapsulation of exudate in the sinus of the diaphragm leads to the spread of pain impulses to the upper abdomen, it becomes difficult to swallow;
- pain can spread to the area of the scapula, neck. By nature it resembles pain with Pancost's cancer or plexitis.
- Encapsulated purulent:
- gives a typical picture of pleural empyema:
- the temperature rises;
- the patient feels the strongest chills,
- there is an obvious intoxication.
- Of not pronounced symptoms:
- the patient feels general weakness;
- malaise;
- purulent encapsulated effusion can break through into the bronchi and tissues of the chest cavity, forming pleuro-cutaneous or pleural-bronchial fistulas.
- gives a typical picture of pleural empyema:
Signs of dry (fibrinous), adhesive pleurisy
Adhesive pleurisy - a form of fibrinous pleurisy - the most common chronic illness affecting the membrane of the lungs. From the fibrinous plaque on the pleura, adhesions are formed, which lead to tissue immobilization, reducing the volume of the lungs.
The disease corresponds to the symptoms characteristic of all types of dry pleurisy:
- a dry cough appears, manifested by attacks;
- body temperature rises, chills begin;
- rapid and labored breathing;
- pleura leaves when rubbing against each other cause wheezing;
- shortness of breath occurs;
- the patient feels a general malaise;
- in the evening the fever intensifies against the background of a sharp increase in sweating.
Against the background of these symptoms begin severe pain in the affected lung, aggravated by deep breaths or sharp bends / turns of the body. Sometimes pains appear in the region of the heart, in the upper abdomen and neck.
A characteristic feature is the suddenness of the manifestation of symptoms. The patient can accurately name the time of the onset of the development of pathology.
Manifestations of effusion (purulent, serous) pleurisy of the lungs
Purulent, effusive pleurisy of the lungs is the most severe form of pathology. It is diagnosed in all categories of citizens, regardless of gender and age. Causes damage to the membrane of the lung, the formation of arrays of liquid pus inside the organ.
The disease is characterized by the following symptoms:
- heaviness or pain in your chest;
- general weakness, loss of strength is felt;
- an annoying strong cough begins;
- shortness of breath appears;
- body temperature rises sharply;
- there is a constant feeling of fullness in the side
- breathing is disturbed, it becomes difficult for a person to inhale and exhale.
With purulent pleurisy, pain is the main symptom. Gradually, as pus accumulates in the pleural cavity, this symptom goes away. The cough is rarely accompanied by sputum discharge, manifesting itself mainly at night. If this is a complication after a previous infection, exudate may be released.
Differences between tuberculous, viral pleurisy
Tuberculous pleurisy is a pulmonary pathology with active release of exudate (into the pleural cavity and on the surface of the lung). The disease is typical for childhood, although it also occurs in adults. It can be either a separate form of tuberculosis or an independent disease.
- Allergic form.
- It occurs in tuberculosis patients, with sensitivity to tuberculin, prone to hyperergic reactions. Symptoms appear sharply: a rapid rise in temperature that lasts 10-14 days. Due to serous effusion, there are breathing problems, pain in the side, and increased heart rate.
- Perifocal form.
- It starts gradually. Symptoms are often associated with hypothermia or a viral infection. There is a dry cough, borderline temperature (37-38 0 C), tingling, burning in the chest. When pressing on the intercostal zones, painful sensations. Pain similar to myositis or intercostal neuralgia, with irradiation in abdominal cavity- for an attack of cholecystitis.
Pleurisy cough
With pleurisy, the pleural leaves become inflamed, it can be dry and exudative. When dry, a dry, often reflexive, cough appears. Patients try to restrain him, since the shuddering of the chest causes severe pain.
As fluid accumulates in the pleural plane, the intensity of the cough gradually decreases. Heaviness and shortness of breath appear in the side. Weak vesicular breathing may be pronounced, sometimes you can feel the noise from friction of the pleura.
Exudative pleurisy passes without obvious activation of the cough center. It is accompanied by a sharp weakening of breathing, the voice trembles and the percussion sound is shortened.
Possible complications
Pleurisy treatment must be carried out on time, this is the only way to avoid possible complications... And the disease has many of them:
- adhesions form in the pleural cavity;
- general respiratory failure of organs and systems;
- adhesive form of pleurisy;
- obliteration of interlobar fissures;
- the pleural cavity is healed;
- decreased mobility of the diaphragm;
- pleurosclerosis.
The appearance of complications depends on the causes of the pathology, the course of its development. To avoid complications, one should not hesitate to visit a doctor.
Diagnostics
It is easy to diagnose pleurisy itself; defining it as a clinical condition is not a problem. It is difficult to determine the causes of the painful condition. Diagnostics will require the following methods:
- inspection and questioning;
- examination of the patient in a clinical setting;
- blood test;
- collection and analysis of pleural effusion;
- microbiological examination.
Based on the results of the diagnostic examination, the necessary treatment is prescribed.
Treatment
In the treatment of pleurisy, two main tasks are pursued: to stabilize the patient's condition and to normalize his respiratory function. But first, it is required to eliminate the cause that caused the disease. For this, both methods of traditional and alternative medicine are suitable.
Traditional medicine
The basis of medical methods for treating pleurisy are antibacterial drugs, since the nature of the disease is infectious. The pleura itself is treated with desensitizing and anti-inflammatory drugs.
The selection of drugs depends on the data obtained after the diagnosis. The choice of antibiotics is based on the sensitivity of the pathogenic microflora, which is detected during laboratory examination. Dosage rates - according to the current state of the patient.
- Antibiotics:
- Clindamycin;
- Ceftriaxone;
- Ampicillin.
- Non-steroidal anti-inflammatory drugs:
- Meloxicam;
- Ibuprofen;
- Diclofenac.
- Glucocorticosteroid:
- Prednisone.
Folk remedies
You can treat pleurisy based on recipes traditional medicine... The most common home remedies include:
.Prevention of pleurisy, coupled with measures to strengthen the immune system, reduces the risk inflammatory diseases lungs.
Pleurisy is an inflammation of the serous membranes that cover the outside of the lungs. This disease is very common. This is the most commonly diagnosed lung pathology. In the general structure of the incidence of the population, pleurisy accounts for 5-15%. The incidence rate varies from 300 to 320 cases per 100 thousand people. Men and women suffer from this ailment equally often. Pleurisy is diagnosed less often in children than in adults.An interesting fact is that women are most often diagnosed with the so-called neoplastic pleurisy. It develops against the background of various neoplasms of the genitals and breasts. As for men, effusion pleurisy often occurs in the pathology of the pancreas and rheumatoid arthritis. In most cases, bilateral or unilateral pleurisy is secondary.
What it is?
Pleurisy - inflammation of the pleural sheets, with the prolapse of fibrin on their surface (dry pleurisy) or accumulation of exudate in the pleural cavity of different nature(exudative pleurisy).
The same term denotes processes in the pleural cavity, accompanied by the accumulation of pathological effusion, when the inflammatory nature of pleural changes does not seem indisputable. Among its causes are infections, chest injuries, tumors.
Causes
The causes of pleurisy can be conditionally divided into infectious and aseptic or inflammatory (non-infectious).
Non-infectious pleurisy usually occurs
- at ,
- with (vascular damage),
- with rheumatism,
- at ,
- at ,
- as a result of pulmonary embolism and pulmonary edema,
- with a lung infarction,
- at matastasis lung cancer into the pleural cavity,
- with a primary malignant tumor of the pleura - mesothelioma,
- lymphoma,
- during hemorrhagic diathesis (clotting disorders),
- during leukemia,
- in the tumor process of the ovaries, breast cancer as a result of cancerous cachexia (terminal stage of cancer),
- with myocardial infarction due to stagnation in the pulmonary circulation.
- with acute.
Infectious include:
In clinical practice, it is customary to distinguish several types of pleurisy, which differ in the nature of the effusion formed in the pleural cavity, and, accordingly, in the main clinical manifestations.
- Dry (fibrinous) pleurisy... It develops at the initial stage of inflammatory lesions of the pleura. Often, at this stage of the pathology, there are no infectious agents in the lung cavity, and the changes that arise are due to the reactive involvement of blood and lymphatic vessels, as well as an allergic component. Due to the increase in vascular permeability under the action of pro-inflammatory substances, the liquid component of the plasma and a part of the proteins, among which fibrin is of the greatest importance, begins to seep into the pleural cavity. Under the influence of the environment in the inflammatory focus, fibrin molecules begin to combine and form strong and sticky threads, which are deposited on the surface of the serous membrane.
- Purulent pleurisy... Purulent exudate accumulates between the leaves of the serous membrane of the lung. This pathology is extremely severe and is associated with intoxication of the body. Without proper treatment, it poses a threat to the patient's life. Purulent pleurisy can form both with direct damage to the pleura by infectious agents, and with the independent opening of an abscess (or other accumulation of pus) of the lung into the pleural cavity. Empyema usually develops in emaciated patients who have serious damage to other organs or systems, as well as in people with reduced immunity.
- Exudative (exudative) pleurisy... It is the next phase of the development of the disease after dry pleurisy. At this stage, the inflammatory reaction progresses, the area of the affected serous membrane increases. The activity of enzymes that break down fibrin filaments decreases, pleural pockets begin to form, in which pus can accumulate in the future. The outflow of lymph is impaired, which, against the background of increased fluid secretion (filtration from dilated blood vessels in the focus of inflammation), leads to an increase in the volume of intrapleural effusion. This effusion compresses the lower segments of the lung from the affected side, which leads to a decrease in its vital volume. As a result, with massive exudative pleurisy, respiratory failure may develop - a condition that poses an immediate threat to the patient's life. Since the fluid accumulated in the pleural cavity to some extent reduces the friction between the pleural layers, at this stage the irritation of the serous membranes and, accordingly, the intensity of the pain sensation decreases somewhat.
- Tuberculous pleurisy... Often it is singled out in a separate category due to the fact that this ailment is quite common in medical practice. Tuberculous pleurisy is characterized by a slow, chronic course with the development of a syndrome of general intoxication and signs of lung damage (in rare cases, and other organs). The effusion with tuberculous pleurisy contains a large number of lymphocytes. In some cases, this ailment is accompanied by the formation of fibrinous pleurisy. When the bronchi are melted by an infectious focus in the lungs, specific curdled pus, characteristic of this pathology, can enter the pleural cavity.
This division in most cases is rather arbitrary, since one type of pleurisy can often turn into another. Moreover, dry and exudative (effusion) pleurisy are considered by most pulmonologists as different stages of one pathological process. It is believed that dry pleurisy is initially formed, and effusion develops only with further progression of the inflammatory reaction.
Symptoms
The clinical picture of pleurisy is divided into dry and exudative.
Symptoms of exudative pleurisy:
- general malaise, lethargy, low-grade fever;
- chest pain, shortness of breath intensify, a gradual increase in fever - this is due to the collapse of the lung, the mediastinal organs are compressed.
Acute serous pleurisy usually has tuberculous origin, characterized by three stages:
- In the initial period (exudative), smoothing or even bulging of the intercostal space is noted. The mediastinal organs are displaced to the healthy side under the influence of a large amount of fluid in the pleural fissure.
- The stabilization period is characterized by a decrease in acute symptoms: the temperature drops, chest pains and shortness of breath disappear. Pleural friction may occur at this stage. In the acute phase, a blood test shows a large accumulation of leukocytes, which gradually returns to normal.
- It often happens that liquid accumulates above the diaphragm, so it is not visible with vertical X-rays. In this case, it is necessary to conduct research in the lateral position. Free fluid easily moves in accordance with the position of the patient's torso. Often, its accumulations are concentrated in the cracks between the lobes, as well as in the area of the dome of the diaphragm.
Dry pleurisy symptoms:
- chest pain;
- general unhealthy condition;
- subfebrile body temperature;
- local pain (depending on the site of the lesion);
- on palpation of the ribs, deep breathing, coughing, pain intensifies.
In the acute course of the disease, the doctor diagnoses a pleural murmur by auscultation, which does not stop after pressing with a stethoscope or coughing. Dry pleurisy usually goes away without any negative consequences- of course, with an adequate treatment algorithm.
Acute symptoms, in addition to the described serous pleurisy, include purulent forms - pneumothorax and pleural empyema. They can be caused by tuberculosis and other infections.
Purulent pleurisy is caused by the ingress of pus into the pleural cavity, where it tends to accumulate. It should be noted that non-tuberculous empyema responds relatively well to treatment, however, with an inadequate algorithm of actions, it can turn into a more complex form. Tuberculous empyema is difficult and can be chronic. The patient significantly loses weight, suffocates, experiences constant chills, suffers from bouts of coughing. In addition, the chronic form of this type of pleurisy causes amyloidosis of internal organs.
If optimal care is not provided, complications arise:
- cessation of breathing;
- spreading the infection throughout the body with the blood stream;
- development of purulent mediastinitis.
Diagnostics
The primary task in diagnosing pleurisy is finding out the location and cause of the inflammation or tumor. To make a diagnosis, the doctor examines the medical history in detail and conducts an initial examination of the patient.
The main methods for diagnosing pulmonary pleurisy:
- Blood tests can help determine if you have an infection, which may be causing your pleurisy. In addition, blood tests will show the state of the immune system.
- A chest x-ray will help determine if there is any pneumonia. A supine chest X-ray may also be taken to allow the free fluid in the lungs to form a layer. A supine chest X-ray should confirm if there is any fluid buildup.
- Computed tomography is performed even if any abnormalities are found on the chest x-ray. This analysis presents a series of detailed, cross-sectional views of the chest. Computed tomography images create a detailed picture of the inside of the breast, allowing the treating physician to obtain a more detailed analysis of the irritated tissue.
- During a thoracentesis, the doctor will insert a needle into the chest area to perform fluid detection tests. The fluid is then removed and analyzed for infections. Due to its aggressive nature and associated risks, this test is rarely done for the typical case of pleurisy.
- During a thoracoscopy, a small incision is made in the chest wall and then a tiny camera is inserted into the chest cavity and attached to the tube. The camera locates the irritated area so that a tissue sample can be taken for analysis.
- Biopsy is useful in the development of pleurisy in cancer. In this case, sterile procedures are used and small incisions are made in the skin of the chest wall. X-rays or computed tomography can confirm the exact location of the biopsy. A doctor can use these procedures to insert a lung biopsy needle between the ribs into the lung. Then a small sample of lung tissue is taken, the needle is removed. The tissue is sent to a laboratory where it will be analyzed for infections and abnormal cancer-compatible cells.
- Using ultrasound, high-frequency sound waves create an image of the inside of the chest cavity, allowing you to see if there is any inflammation or fluid build-up.
As soon as the symptoms of pleurisy are identified, treatment is prescribed immediately. Antibiotics against infection are in the first place in treatment. In addition to this, anti-inflammatory drugs or other pain relievers are prescribed. Sometimes a cough syrup is prescribed.
Pleurisy treatment
Effective treatment of pleurisy depends entirely on the cause of its occurrence and consists mainly in eliminating unpleasant symptoms of the disease and improving the patient's well-being. In the case of a combination of pneumonia and pleurisy, antibiotic treatment is indicated. Pleurisy accompanying systemic vasculitis, rheumatism, scleroderma is treated with glucocorticoid drugs.
Pleurisy, which has arisen against the background of the disease, is treated with isoniazid, rifampicin, streptomycin. Typically, this treatment lasts for several months. In all cases of the disease, diuretics, pain relievers and cardiovascular drugs are prescribed. Patients who do not have special contraindications are shown physiotherapy exercises and physiotherapy. Often, in the treatment of pleurisy in order to prevent recurrence of the disease, obliteration of the pleural cavity or pleurodesis is performed - the introduction of special preparations "sticking" it together into the pleural cavity.
The patient is prescribed analgesics, anti-inflammatory drugs, antibiotics, drugs to combat coughs and allergic manifestations. With tuberculous pleurisy, specific therapy with anti-tuberculosis drugs is carried out. For pleurisy resulting from a tumor of the lung or intrathoracic lymph nodes, chemotherapy is prescribed. Glucocorticosteroids are used for collagen disorders. With a large amount of fluid in the pleural cavity, puncture is indicated in order to suck out the contents and introduce drugs directly into the cavity.
During the rehabilitation period, breathing exercises, physiotherapy treatment, and general strengthening therapy are prescribed.
Prophylaxis
Of course, one cannot predict how the body will react to the action of one factor or another. However, anyone can follow simple guidelines for the prevention of pleurisy:
- First of all, complications should not be allowed in the development of acute respiratory infections. So that the pathogenic microflora does not penetrate the mucous membrane of the respiratory tract, and then into the pleural cavity, colds should not be allowed to take their course!
- With frequent infections of the respiratory tract, it is good to change the climate for a while. The sea air is an excellent means of preventing respiratory tract infections, including pleurisy.
- If pneumonia is suspected, it is better to take a timely chest X-ray and start adequate therapy. Improper treatment of the disease increases the risk of complications in the form of pleural inflammation.
- Try to strengthen your immune system. In the warm season, do hardening, be more in the fresh air.
- Stop smoking. Nicotine becomes the first cause of pulmonary tuberculosis, which in turn can provoke inflammation of the pleura.
- Practice breathing exercises. A couple of deep breaths after waking up will serve as an excellent prevention of the development of inflammatory diseases of the respiratory system.
Forecast
The prognosis of pleurisy is favorable, although it directly depends on the leading disease. Inflammatory, infectious, post-traumatic pleurisy is successfully cured and does not affect the quality of later life. Unless, during later life, pleural adhesions will be noted on radiographs.
An exception is dry tuberculous pleurisy, as a result of which fibrous deposits can calcify over time, the so-called armored pleurisy is formed. The lung is enclosed in a "stone shell", which interferes with its full functioning and leads to chronic respiratory failure.
To prevent the formation of adhesions that form after the removal of fluid from the pleural cavity, after treatment, when the acute period subsides, the patient should undergo rehabilitation procedures - this is physiotherapy, manual and vibration massage, it is imperative to carry out a daily breathing exercises(according to Strelnikova, with the help of Frolov's breathing trainer).
Pleurisy - inflammation of the pleura with the formation of fibrous plaque on its surface or effusion inside it. It appears as an accompanying pathology or as a consequence of various diseases.
Pleurisy is an independent disease (primary pleurisy), but most often it is the consequences of acute and chronic inflammatory processes in the lungs (secondary pleurisy). Divided into dry, otherwise called fibrinous, and effusion (serous, serous-fibrinous, purulent, hemorrhagic) pleurisy.
Pleurisy is often one of the symptoms of systemic diseases (oncology, rheumatism, tuberculosis). However, the vivid clinical manifestations of the disease often force doctors to highlight the manifestations of pleurisy, and, by its presence, find out the true diagnosis. Pleurisy can occur at any age, many of them remain unrecognized.
Causes
Why does pleurisy of the lungs occur, what is it, and how to treat it? Pleurisy is a disease of the respiratory system, with its development, the visceral (pulmonary) and parietal (parietal) layers of the pleura, the connective tissue membrane that covers the lungs and the inner surface of the chest, become inflamed.
Also, with pleurisy, fluids, such as blood, pus, serous or putrefactive exudate, can be deposited between the pleural layers (in the pleural cavity). The causes of pleurisy can be conditionally divided into infectious and aseptic or inflammatory (non-infectious).
Infectious causes pleurisy of the lungs include:
- bacterial infections (pneumococcus, staphylococcus),
- fungal infections (blastomycosis, candidiasis),
- typhoid fever,
- tularemia
- chest injury
- surgical interventions.
Causes of non-infectious pleurisy of the lungs are as follows:
- malignant tumors of the pleural sheets,
- metastasis in the pleura (for breast cancer, lung cancer, etc.),
- connective tissue lesions of a diffuse nature (, scleroderma,), pulmonary infarction,
- TELA.
Factors that increase the risk of development pleurisy:
- stress and overwork;
- hypothermia;
- unbalanced nutrition, poor in nutrients;
- hypokinesia;
- drug allergies.
Pleurisy may be:
- acute up to 2-4 weeks,
- subacute from 4 weeks to 4-6 months,
- chronic, more than 4-6 months.
Microorganisms get into the pleural cavity in different ways. Infectious agents can enter by contact, through the blood or lymph. Their direct hit occurs during injuries and wounds, during operations.
Dry pleurisy
With dry pleurisy, there is no fluid in the pleura; fibrin appears on its surface. Basically, this form of pleurisy precedes the development of exudative.
Dry pleurisy is often a secondary disease in many diseases of the lower respiratory tract and intrathoracic lymph nodes, malignant neoplasms, rheumatism, collagenosis and some viral infections.
Tuberculous pleurisy
Recently, the incidence of tuberculous pleurisy has increased, which occurs in all forms: fibrous, exudative and purulent.
In almost half of the cases, the presence of dry pleurisy indicates that a tuberculous process is taking place in the body in a latent form. By itself, pleural tuberculosis is quite rare, for the most part fibrous pleurisy is a response to tuberculosis of the lymph nodes or lungs.
Tuberculous pleurisy, depending on the course of the disease and its characteristics, is divided into three types: perifocal, allergic and actually pleural tuberculosis.
Purulent pleurisy
Purulent pleurisy is caused by such microorganisms as pathogenic staphylococci, pneumococci, streptococci. In rare cases, these are Proteus, Escherichia bacilli. As a rule, purulent pleurisy develops after exposure to one type of microorganism, but it happens that the disease is caused by a whole association of microbes.
Symptoms of purulent pleurisy. The course of the disease varies with age. In infants of the first three months of life, purulent pleurisy is very difficult to recognize, since it is masked under the general symptoms characteristic of umbilical sepsis, pneumonia caused by staphylococci.
From the side of the disease, the chest becomes convex. There is also a drooping of the shoulder, insufficient mobility of the hand. In older children, the standard symptoms of total pleurisy are observed. You can also note a dry cough with phlegm, sometimes even with pus - when a pleural abscess breaks out into the bronchi.
Encapsulated pleurisy
Encapsulated pleurisy is one of the most severe forms of pleurisy, in which the adhesion of the pleural sheets leads to the accumulation of pleural extrudate.
This form develops as a result of prolonged inflammatory processes in the lungs and pleura, which lead to numerous adhesions and delimit the exudate from the pleural cavity. Thus, the effusion accumulates in one place.
Exudative pleurisy
Exudative pleurisy is distinguished by the presence of fluid in the pleural cavity. It can form as a result of trauma to the chest with bleeding or hemorrhage, outpouring of lymph.
By the nature of this fluid, pleurisy is divided into serous-fibrinous, hemorrhagic, chyle and mixed. This fluid, often of unknown origin, is called effusion, which can also inhibit lung movement and make breathing difficult.
Pleurisy symptoms
In the case of pleurisy, the symptoms may differ depending on how the pathological process proceeds - with or without exudate.
Dry pleurisy is characterized by the following symptoms:
- stabbing pain in the chest, especially when coughing, deep breathing and sudden movements,
- forced position on the sore side,
- shallow and gentle breathing, while the affected side visually lags behind in breathing,
- when listening - pleural friction noise, weakening of breathing in the area of fibrin deposits,
- fever, chills, and heavy sweating.
With exudative pleurisy, the clinical manifestations are somewhat different:
- dull pain in the affected area,
- a strong lag of the affected area of the chest in breathing,
- a feeling of heaviness, shortness of breath, swelling of the spaces between the ribs,
- weakness, fever, severe chills and profuse sweat.
The most severe course is noted with purulent pleurisy:
- high body temperature;
- severe chest pain;
- chills, aches throughout the body;
- earthy skin tone;
- weight loss.
If the course of pleurisy becomes chronic, then in the lung, cicatricial changes are formed in the form of pleural adhesions, which prevent the complete expansion of the lung. Massive pulmonary fibrosis is accompanied by a decrease in the perfusion volume of the lung tissue, thereby aggravating the symptoms of respiratory failure.
Complications
The outcome of pleurisy largely depends on its etiology. In cases of persistent pleurisy, further development of the adhesions in the pleural cavity, overgrowth of interlobar fissures and pleural cavities, the formation of massive moorings, thickening of the pleural sheets, the development of pleurosclerosis and respiratory failure, limitation of the mobility of the dome of the diaphragm are possible.
Diagnostics
Before determining how to treat pulmonary pleurisy, it is worth undergoing an examination and determining the causes of its occurrence. In a clinic, the following examinations are used to diagnose pleurisy:
- examination and questioning of the patient;
- clinical examination of the patient;
- X-ray examination;
- blood test;
- analysis of pleural effusion;
- microbiological research.
Diagnosis of pleurisy as a clinical condition is usually not particularly difficult. The main diagnostic difficulty in this pathology is to determine the cause that caused the inflammation of the pleura and the formation of pleural effusion.
How is pleurisy treated?
When symptoms of pleurisy appear, treatment should be comprehensive and aimed primarily at eliminating the main process that led to its development. Symptomatic treatment aims to anesthetize and accelerate the resorption of fibrin, to prevent the formation of extensive joints and adhesions in the pleural cavity.
At home, only patients with diagnosed dry (fibrinous) pleurisy are subject to treatment, all other patients should be hospitalized for examination and selection of an individual treatment regimen for pulmonary pleurisy.
The specialized department for this category of patients is the therapeutic department, and patients with purulent pleurisy and pleural empyema require specialized treatment in a surgical hospital. Each of the forms of pleurisy has its own characteristics of therapy, but for any type of pleurisy, an etiotropic and pathogenetic direction in treatment is shown.
So, with dry pleurisy, the patient is assigned:
- To relieve the pain syndrome, they are prescribed: analgin, ketans, tramadol with the ineffectiveness of these funds, in a hospital setting, the introduction of narcotic anesthetic drugs is possible.
- Warming semi-alcoholic or camphor compresses, mustard plasters, iodine net are effective.
- Prescribe drugs that suppress cough - sinekod, codelac, libexin.
- Since the root cause is most often tuberculosis, after confirming the diagnosis of tuberculous pleurisy, a specific treatment is carried out in the anti-tuberculosis dispensary.
If pleurisy is exudative with a large amount of effusion, pleural puncture is done to evacuate it or drain. At a time, pump out no more than 1.5 liters of exudate, so as not to provoke heart complications. With purulent pleurisy, the cavity is washed with antiseptics. If the process has become chronic, they resort to pleurectomy - the surgical removal of part of the pleura in order to prevent relapse. After resorption of the exudate, patients are prescribed physiotherapy, physiotherapy exercises, and breathing exercises.
In acute tuberculous pleurisy, drugs such as isoniazid, streptomycin, ethambutol or rifampicin may be included in the complex. The course of tuberculosis treatment itself takes about a year. With parapneumonic pleurisy, the success of treatment depends on the selection of antibiotics based on the sensitivity of the pathological microflora to them. In parallel, immunostimulating therapy is prescribed.