Exudative pleurisy treatment

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Exudative pleurisy

Exudative pleurisy is a disease of the respiratory system, which is characterized by damage to the pleura of an infectious, tumor or other nature. Most often, this disease acts as a secondary factor of any pathological changes.

Table of contents:

Pleurisy manifests itself as unilateral chest pain, which, as fluid accumulates, is replaced by a feeling of heaviness and pressure.

What is exudative pleurisy?

Exudative pleurisy is a pathology in which inflammation of the pleural layer of the lungs occurs with the accumulation of fluid in the costophrenic sinus. About 80% of cases of hydrothorax occur in patients with pulmonary tuberculosis. Every year, the pathology is diagnosed in 1 million people.

In its etiology, exudative pleurisy is similar to dry pleurisy, differs in that it often develops with pancreatitis, cirrhosis or liver tumor, subdiaphragmatic processes, and also accompanies some systemic diseases.

Exudate is a liquid released into the pleural cavity from the capillaries during inflammation.

Fluid in the pleural cavity can accumulate diffusely or limitedly. In the case of limited accumulation of effusion, encysted pleurisy (supradiaphragmatic, paracostal, paramediastinal) is formed, resulting from the adhesive process in the pleura.

Exudative pleurisy, according to its etiology, is divided into infectious and aseptic. Taking into account the nature of exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chylous (chylothorax), purulent (pleural empyema), putrefactive, mixed.

Taking into account the location, it may be:

Based on the degree of flow, there are:

In many cases, the disease is localized on the right, but more severe forms of the course are also possible - pleurisy of the left-sided and bilateral type.

Causes

The infectious form of exudative pleurisy appears against the background of the following processes in the lungs:

The cause of the disease in this case is the entry of infectious irritants from the listed diseases into the pleural cavity.

The aseptic type, as a rule, accompanies all kinds of pulmonary and extrapulmonary pathological processes, aggravating the development of diseases such as:

  • post-infarction autoallergic pericarditis;
  • Dressler's syndrome;
  • hypersensitivity interstitial pneumonitis;
  • various allergic reactions.

Moreover, approximately 75 percent of cases of effusion pleurisy are diagnosed in patients suffering from tuberculosis.

Symptoms

Signs and symptoms of exudative pleurisy depend on the volume, nature and intensity of fluid accumulation.

The main symptoms are:

  • patients complain of severe shortness of breath and discomfort in the chest area when breathing,
  • hacking cough with difficult to clear sputum,
  • general weakness,
  • loss of appetite,
  • short-term increase in body temperature to high numbers.

The severity of the manifestations of the disease depends on the rate of accumulation of effusion, volume, and severity of the underlying inflammation. With intense accumulation of fluid, pain occurs.

As exudate accumulates, the leaves become wetted, which reduces the severity of pain. When you try to press on the intercostal spaces above the location of the inflammatory focus, acute pain occurs due to irritation of the nerve receptors.

The general condition of the patient is serious, especially with the purulent form of exudative pleurisy, which is accompanied by:

There are three phases of the disease:

Left-sided exudative pleurisy leads to an acceleration of the heart rate, and arrhythmia may develop. Lack of air causes noticeable swelling of the veins in the neck area. At the same time, the pulse quickens and reaches one hundred and twenty beats per minute.

Most often, exudative pleurisy is unilateral, but in metastatic tumor processes, SLE, lymphoma, bilateral pleural effusion can be detected. The volume of fluid in the pleural cavity with exudative pleurisy can reach 2-4 or more liters.

In most patients, after resorption of the exudate, especially if it was significant, adhesions (moorings) remain. In some cases, the adhesions are so numerous and massive that they cause impaired ventilation.

After suffering exudative pleurisy, patients may feel pain in the chest, which intensifies with changing weather conditions. This is especially pronounced during the development of adhesions.

Diagnosis of the disease

Informative diagnostic methods:

  • physical. When performing it, doctors note a lag on the affected side of the chest during the act of breathing, its weakening, dullness of percussion sound during percussion, splashing noise during auscultation;
  • X-ray examination (method for diagnosing hydrothorax of any etiology, including tuberculosis). In the lower parts of the lungs there is significant darkening;
  • Ultrasound of the pleural cavity;
  • thoracentesis. All patients with suspected exudative pleurisy undergo this procedure. During its implementation, doctors receive some part of the effusion, which is then used for cytological, bacteriological and biochemical studies;
  • thoracoscopy;
  • computed tomography of the lungs;
  • blood chemistry.

Exudative pleurisy caused by nonspecific lung diseases, even with a prolonged course, usually has a favorable outcome.

Treatment of exudative pleurisy

The basic principles of treatment of exudative pleurisy are the evacuation of accumulated fluid from the pleural cavity and the impact on the main pathological process that caused the pleural reaction.

Taking into account the cause of pleurisy, drug treatment is prescribed:

  1. Tuberculostatic drugs (for the tuberculous form of exudative pleurisy);
  2. Antibacterial agents (for pneumatic pleurisy);
  3. Cytostatic agents (for tumors and metastases);
  4. Glucocorticoid drugs (for lupus erythematosus and rheumatoid arthritis)
  5. Diuretic treatment for pleurisy caused by cirrhosis of the liver (usually the lung located on the right is affected).

Regardless of the etiology of the disease, analgesics, anti-inflammatory, antitussive, and desensitizing agents are prescribed.

To increase the effectiveness of treatment after pleural puncture, physiotherapy is recommended:

  • Chest massage;
  • Vibration massage;
  • Paraffin therapy;
  • Electrophoresis;
  • Breathing exercises.

The chronic form of empyema is removed through surgery, performed during thoracostomy or lung decortication. One of the most important diagnostic and treatment measures is pleural puncture.

  1. The patient sits on a chair with his back to the doctor, and the doctor, after preliminary anesthesia, makes a puncture with a special needle with a beveled cut in the sixth intercostal space along the scapular line.
  2. When a needle enters the pleural cavity, exudate begins to be released from it.
  3. The fluid is removed slowly and in small volumes to prevent a sudden shift of the mediastinum and the occurrence of acute heart failure.
  4. The pleural cavity is drained and washed with antiseptics, and it is also possible to administer antibiotics intrapleurally.

With the presented integrated approach to restoring the state of health in case of illness, it will be possible to eliminate the development of complications and negative consequences of the lungs. The medical history in this case will be the most positive.

A control radiograph is taken 4–6 months after the end of treatment for pleurisy. To avoid exudative pleurisy in the future, it is necessary to promptly treat all diseases of the respiratory system, avoid hypothermia and injuries, and strengthen the immune system.

The exudative form of pleurisy is a dangerous, but not critical disease, in order to recover from which the recovery process and prevention should be started in time. This will allow you to get out of the condition with minimal losses, even if a dry subtype of the disease has been identified.

In the future, it is recommended to avoid minimal provoking factors.

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Exudative pleurisy

Exudative pleurisy is a lesion of the pleura of an infectious, tumor or other nature, occurring with the phenomena of exudation - the formation and accumulation of effusion in the pleural cavity. Exudative pleurisy manifests itself as pain and a feeling of heaviness on the affected side, a reflex cough, increasing shortness of breath, and febrile body temperature. Crucial in the diagnosis of exudative pleurisy is chest x-ray, ultrasound of the pleural cavity, diagnostic puncture with cytological and bacteriological examination of exudate, and thoracoscopy. Treatment of exudative pleurisy consists of evacuation of accumulated fluid, pathogenetic and symptomatic treatment.

Exudative pleurisy

Exudative pleurisy (hydrothorax, effusion pleurisy) in clinical practice occurs as an independent disease (primary pleurisy), but more often it is a consequence of other pulmonary or extrapulmonary processes (secondary pleurisy). The true incidence of pleural effusions is difficult to judge; Presumably exudative pleurisy is diagnosed in at least 1 million people per year. Exudative pleurisy can be complicated by a significant number of pathological processes in pulmonology, phthisiology, oncology, cardiology, rheumatology, gastroenterology, and traumatology. The accumulation of exudate in the pleural cavity often aggravates the course of the underlying disease and therefore requires special diagnostic and therapeutic measures with the involvement of pulmonologists and thoracic surgeons.

The pleural cavity is a closed space formed by the outer (parietal) and inner (visceral) layers of the pleura, lining the inner wall of the chest and lungs. Normally, the pleural cavity contains a small amount (from 1-2 to 10 ml) of fluid, which ensures the sliding of the leaves during respiratory movements and ensures adhesion of the two surfaces. Per hour, the parietal pleura produces about 100 ml of fluid, which is completely absorbed by the capillaries and lymphatic vessels of the pleural layers, so there is practically no fluid in the pleural cavity. With exudative pleurisy, the amount of effusion formed exceeds the adsorption capabilities of the pleura, so a significant amount of exudate accumulates in the pleural cavity.

Classification of exudative pleurisy

Exudative pleurisy, according to its etiology, is divided into infectious and aseptic. Taking into account the nature of exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chylous (chylothorax), purulent (pleural empyema), putrefactive, mixed.

According to the course, acute, subacute and chronic exudative pleurisy are distinguished. Depending on the location of the exudate, pleurisy can be diffuse or encysted (demarcated). Enclosed exudative pleurisy, in turn, is divided into apical (apical), parietal (paracostal), bone-diaphragmatic, diaphragmatic (basal), interlobar (interlobar), paramediastinal.

Causes of exudative pleurisy

Most infectious exudative pleurisy is a complication of pathological pulmonary processes. Moreover, about 80% of cases of hydrothorax are detected in patients with pulmonary tuberculosis. Exudative pleurisy of a reactive nature can be observed with pneumonia, bronchiectasis, lung abscesses, and subphrenic abscess. In some cases, exudative pleurisy may be the next stage of dry pleurisy.

Thus, infectious exudative pleurisy can be caused by specific (mycobacterium tuberculosis) and nonspecific bacterial pathogens (pneumococcus, streptococcus, staphylococcus, Haemophilus influenzae, Klebsiella, Pseudomonas aeruginosa, typhoid bacilli, Brucella, etc.), rickettsia, viruses, fungi, parasites (echinococcus ), protozoa (amoebas), mycoplasma, etc.

Aseptic exudative pleurisy develops against the background of a variety of pulmonary and extrapulmonary pathological conditions. Allergic effusions can aggravate the course of drug allergies, exogenous allergic alveolitis, post-infarction autoallergic pericarditis or polyserositis (Dressler's syndrome), etc. Exudative pleurisy are frequent companions of diffuse connective tissue diseases - rheumatoid arthritis, rheumatism, scleroderma, systemic lupus erythematosus, etc.

Post-traumatic exudative pleurisy accompanies closed chest trauma, rib fractures, injury to the thoracic lymphatic duct, spontaneous pneumothorax, electrical burns, and radiation therapy. A significant group of exudative pleurisy consists of effusions of tumor etiology that develop with pleural cancer (mesothelioma), lung cancer, leukemia, metastatic tumors from distant organs (breast, ovaries, stomach, colon, pancreas).

Congestive exudative pleurisy is often etiologically associated with heart failure and pulmonary embolism. Dysproteinemic exudative pleurisy occurs in nephrotic syndrome (glomerulonephritis, renal amyloidosis, lipoid nephrosis), liver cirrhosis, myxedema, etc. Enzymatic exudative pleurisy can develop with pancreatitis. The causes of hemorrhagic pleurisy can be vitamin deficiencies, hemorrhagic diathesis, and blood diseases.

Pathogenesis of exudative pleurisy

The initial mechanism of pathogenesis of exudative pleurisy is due to a change in the permeability of the vascular wall and an increase in intravascular pressure. As a result of disruption of the physiological relationships between the pleural layers, there is a decrease in the barrier function of the visceral pleura and the resorbing function of the parietal pleura, which is accompanied by an increased accumulation of exudate, which does not have time to be reabsorbed by capillaries and lymphatic vessels. Infection of pleural effusion can occur through direct (contact) transmission of infection from adjacent foci, lymphogenous or hematogenous, as a result of direct infection of the pleura when its integrity is violated.

The progressive accumulation of fluid between the pleural layers causes compression of the lung and a decrease in its airiness. When large volumes of fluid accumulate, the mediastinum shifts to the healthy side, which is accompanied by respiratory and hemodynamic disorders. Characteristic physicochemical signs of serous (serous-fibrinous) exudate are high specific gravity (>1.018), protein content >30 g/l, pH 1.0x109/l), increased LDH activity in pleural effusion, etc.

Most often, exudative pleurisy is unilateral, but in metastatic tumor processes, SLE, lymphoma, bilateral pleural effusion can be detected. The volume of fluid in the pleural cavity with exudative pleurisy can reach 2-4 or more liters.

Symptoms of exudative pleurisy

The severity of manifestations of exudative pleurisy depends on the volume and rate of accumulation of effusion and the severity of the underlying disease. During the period of exudate accumulation, intense pain in the chest occurs. As the effusion accumulates, the pleural layers become separated, which is accompanied by a decrease in irritation of the sensory endings of the intercostal nerves and subsidence of pain. The pain is replaced by heaviness in the corresponding half of the chest, a cough of reflex origin, shortness of breath, forcing the patient to take a forced position on the sore side.

Symptoms of exudative pleurisy intensify with deep breathing, coughing, and movements. Increasing respiratory failure is manifested by pallor of the skin, cyanosis of the mucous membranes, and acrocyanosis. Typically the development of compensatory tachycardia and a decrease in blood pressure.

Hydrothorax may be accompanied by febrile fever, sweating, and weakness. With exudative pleurisy of infectious etiology, remitting fever, chills, severe intoxication, headache, and lack of appetite are noted.

A small amount of serous exudate may undergo spontaneous resorption within 2-3 weeks or several months. Often, after spontaneous resolution of exudative pleurisy, massive pleural moorings (adhesions) remain, limiting the mobility of the pulmonary fields and leading to impaired ventilation of the lungs. Suppuration of the exudate is accompanied by the development of pleural empyema.

Diagnosis of exudative pleurisy

The algorithm for diagnosing exudative pleurisy includes a physical, x-ray examination, diagnostic pleural puncture with cytological and bacteriological examination of the effusion.

Physical findings in exudative pleurisy are characterized by a lag on the affected side of the chest during breathing, dullness of percussion sound, weakening of breathing in the projection of the accumulation of exudate, splashing noise when coughing, widening and bulging of the intercostal spaces, weakening or absence of vocal tremor over the area of ​​exudate.

A biochemical blood test reveals dysproteinemia, increased levels of sialic acids, haptoglobin, fibrin, seromucoid, and the appearance of CRP.

The diagnosis of exudative pleurisy is confirmed by radiography or fluoroscopy of the lungs, which reveals intense homogeneous darkening and a displacement of the heart to the healthy side. To preliminary determine the amount of effusion, it is advisable to perform an ultrasound of the pleural cavity.

A mandatory diagnostic procedure for exudative pleurisy is thoracentesis. The resulting pleural exudate is subjected to laboratory (cytological, biochemical, bacteriological) examination, which has important differential diagnostic significance. In some cases, to accurately diagnose the causes of exudative pleurisy, they resort to computed tomography of the lungs (MSCT, MRI) after evacuation of the fluid.

In case of persistent exudative pleurisy and massive accumulation of effusion, diagnostic thoracoscopy (pleuroscopy), pleural biopsy under visual control, followed by morphological examination of the biopsy specimen are indicated. Transthoracic puncture biopsy of the pleura has less diagnostic accuracy.

Treatment of exudative pleurisy

The basic principles of treatment of exudative pleurisy are the evacuation of accumulated fluid from the pleural cavity and the impact on the main pathological process that caused the pleural reaction. In the treatment of exudative pleurisy, pulmonologists, phthisiatricians, thoracic surgeons, traumatologists, rheumatologists, cardiologists, gastroenterologists, oncologists and other specialists can be involved.

If there is a clinically significant amount of exudate, a puncture or drainage of the pleural cavity is performed to remove fluid, straighten the compressed lung, reduce shortness of breath, lower body temperature, etc. Taking into account the main diagnosis, drug therapy is prescribed: tuberculostatic (for tuberculous pleurisy), antibacterial (for parapneumonic pleurisy), cytostatic (for tumor pleurisy), glucocorticoids (for lupus and rheumatic pleurisy), etc.

Regardless of the etiology of exudative pleurisy, it is advisable to prescribe analgesics, anti-inflammatory, antitussive, desensitizing, diuretics, oxygen therapy, and transfusion of plasma-substituting solutions. At the stage of exudate resorption, the treatment includes breathing exercises, chest massage, vibration massage, physiotherapeutic treatment (in the absence of contraindications) - electrophoresis, paraffin therapy.

For pleural empyema, sanitation of the pleural cavity with antiseptics and intrapleural administration of antibiotics are indicated. Chronic pleural empyema is treated surgically (thoracostomy, thoracoplasty, pleurectomy with lung decortication, etc.). For tumor pleurisy, chemotherapy, palliative pleurectomy, and obliteration of the pleural cavity (chemical pleurodesis) are performed.

Forecast and prevention of exudative pleurisy

Exudative pleurisy caused by nonspecific lung diseases, even with a prolonged course, usually has a favorable outcome. In some cases, a massive adhesive process in the pleural cavity can lead to respiratory failure. In case of exudative pleurisy of tuberculous etiology, patients are monitored by a phthisiatrician. An unfavorable prognosis for life is associated with the development of carcinomatous pleurisy.

Prevention of exudative pleurisy is facilitated by timely treatment of various underlying diseases, prevention of hypothermia, increasing the protective properties of the body, and preventing injuries. 4-6 months after resolution of exudative pleurisy, X-ray control is necessary.

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Pleurisy. Causes, symptoms, signs, diagnosis and treatment of pathology

The site provides reference information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious doctor.
  • pleurisy is one of the most common pathologies in therapy and occurs in almost every tenth patient;
  • it is believed that the cause of death of the French queen Catherine de Medici, who lived in the 14th century, was pleurisy;
  • Beatles drummer Ringo Starr suffered from chronic pleurisy at the age of 13, causing him to miss two years of school without graduating;
  • The first description of pleural empyema (an 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 damage

Causes of pleurisy

  • infectious lesion of the pleura;
  • tuberculosis;
  • allergic inflammatory reaction;
  • autoimmune and systemic diseases;
  • exposure to chemicals;
  • chest injury;
  • exposure to ionizing radiation;
  • exposure to pancreatic enzymes;
  • primary and metastatic pleural tumors.

Infectious lesion of the pleura

  • Diabetes mellitus. Diabetes mellitus develops as a result of a violation of the endocrine function of the pancreas, which produces insufficient amounts of insulin. Insulin is a hormone that is necessary for the normal metabolism of glucose and other sugars. In diabetes mellitus, many internal organs are affected, and a slight decrease in immunity occurs. In addition, excessive concentrations of glucose in the blood create favorable conditions for the development of many bacterial agents.
  • Alcoholism. With 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 disruption of the metabolism of a number of nutrients, as well as a decrease in the number and quality of immune cells. Additionally, people with alcoholism are more prone to chest injuries as well as respiratory tract infections. This occurs due to hypothermia combined with decreased sensitivity and behavioral disturbances, as well as suppression of protective reflexes, which increases the risk of inhaling infected materials or one’s own vomit.
  • Rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease that can independently cause damage to the pleura. However, this disease is also a serious risk factor for the development of infectious lesions of the pleura. This is due to the fact that drugs that reduce immunity are often used to treat this disease.
  • Chronic lung diseases. Many chronic lung diseases, such as chronic bronchitis, chronic obstructive pulmonary disease, emphysema, asthma and some other pathologies create the preconditions for infectious damage to the pleura. 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 functioning of the respiratory apparatus is disrupted, which inevitably leads to a decrease in its protective potential.
  • Pathologies 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, during sleep) can end up in the lungs and cause pneumonia with subsequent damage to the pleura. Gastroesophageal reflux (the backflow of food from the stomach into the esophagus) contributes to infection of the respiratory tract by increasing the risk of inhaling gastric contents, which may be infected, and which reduces local immunity (due to the irritating effect of hydrochloric acid).

Infectious lesions of the pleura occur as a result of the penetration of pathogenic agents into the pleural cavity with the development of a subsequent inflammatory response. In clinical practice, it is customary to distinguish 4 main methods of penetration of pathogens.

  • Contact with an infectious focus in the lungs. When the infectious-inflammatory focus is located in close proximity to the pleura, direct transfer 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 areas of the lungs drain into the pleural cavity. This creates the preconditions 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 of penetrating into the bloodstream at a certain stage of their development, and at the same time into various organs and tissues.
  • Direct contact with the external environment (injury). Any penetrating trauma to the chest cavity is considered potentially infected and, accordingly, as a possible source of pleural infection. Openings and incisions in the chest wall made for therapeutic purposes, but under inappropriate conditions or lack of proper care, can also act as a source of pathogenic microorganisms.

It should be noted that in many cases, pneumonia (pneumonia) is accompanied by the appearance of pleural effusion without direct infection of the pleura. This is due to the development of a reactive inflammatory process that irritates the pleura, as well as a slight increase in fluid pressure and the permeability of blood vessels in the area of ​​the infectious focus.

  • bacteria (streptococci, staphylococci, pneumococci, rickettsia, chlamydia, etc.)
  • viruses (influenza, parainfluenza, enteroviruses, etc.);
  • fungi (candidiasis, blastomycosis, coccidioidosis);
  • parasites (amoebiasis, echinococcosis).

It should be noted that in the vast majority of cases, pleurisy is caused by bacteria, most often streptococci and staphylococci.

  • Exudation phase. Under the influence of biologically active substances that are secreted by immune cells activated as a result of contact with infectious agents, blood vessels dilate and their permeability increases. 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 occurs under the influence of a number of biologically active substances that reduce the fibrinolytic activity of pleural cells (their ability to destroy fibrin threads). This leads to the fact that friction between the pleural layers increases significantly, and in some cases adhesions occur (areas of “gluing” of the serous membranes). This course of the disease contributes to the formation of separated areas in the pleural cavity (the so-called “pockets” or “bags”), which significantly complicates the outflow of pathological contents. After some time, pus begins to form in the pleural cavity - a mixture of dead bacteria, absorbed immune cells, plasma and a number of proteins. The accumulation of pus is facilitated by progressive swelling of mesothelial cells and tissues located close to 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 recovery stage, either resorption (resorption) of pathological foci occurs, or, if it is impossible to independently eliminate the pathogenic agent, connective tissue (fibrous) formations are formed that limit the infectious-inflammatory process with the further transition of the disease into a chronic form. Foci of fibrosis adversely affect lung function, as 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 (moorings) or complete overgrowth with fibrous fibers (fibrothorax) are formed between the parietal and visceral layers of the pleura.

Tuberculosis

  • High density of infectious agents. The likelihood of developing an infection increases as the number of bacilli inhaled increases. This means that the higher the concentration of mycobacteria in the environment, the higher the chances of infection. This development of events is facilitated by staying in the same room with tuberculosis patients (at the stage of releasing 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 tuberculosis pathogens 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 infection. Some mycobacteria have greater virulence, that is, an increased ability to infect people. The penetration of such strains into the human body can cause infection even with a small number of bacilli.

Decreased immunity is a condition that can develop against the background of many pathological conditions, as well as with the use of certain medications.

  • chronic diseases of the respiratory system (infectious and non-infectious nature);
  • diabetes;
  • peptic ulcer of the stomach and duodenum;
  • chronic alcoholism;
  • treatment with drugs that suppress the immune system (glucocorticoids, cytostatics);
  • pregnancy;
  • HIV infection (especially at the AIDS stage).

Allergic inflammatory reaction

  • 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 directly adjacent to the pleura often occurs. The most common allergens are fungal spores, plant pollen, house dust, and some medications.
  • Drug allergy. Allergies to medications are common in the modern world. Quite a large number of people are allergic to certain antibiotics, local anesthetics and other pharmacological drugs. A pathological response develops within a few minutes or hours after administration of the drug (depending on the type of allergic reaction).
  • Other types of allergies. Some other types of allergies that do not directly affect lung tissue can cause activation of pleural immune cells with the release of biologically active substances and the development of edema and exudation. After eliminating the effect of the allergen, the scale of inflammation decreases, and reabsorption of excess fluid from the pleural cavity begins.

It should be noted that true allergic reactions do not develop upon first contact with a foreign substance, since the body’s immune cells are not “familiar” with it and cannot quickly respond to its arrival. During the first contact, the allergen is processed and presented to the immune system, which forms special mechanisms that allow rapid activation upon repeated contact. This process takes several days, after which contact with the allergen inevitably causes an allergic reaction.

Autoimmune and systemic diseases

  • rheumatoid arthritis;
  • systemic lupus erythematosus;
  • scleroderma;
  • dermatomyositis;
  • Wegener's granulomatosis;
  • Churg-Strauss syndrome;
  • sarcoidosis

It is necessary to understand that the basis of the autoimmune reaction is an inflammatory process that can either directly affect pleural tissue, which leads to the development of classic pleurisy, or indirectly when the function of other organs (heart, kidneys) is impaired, which leads to the formation of pleural effusion. It is important to note that clinically pronounced pleurisy is quite rare, however, a detailed examination of such patients suggests a fairly wide distribution of this phenomenon.

Exposure to chemicals

  • With open trauma. With an open chest injury, various chemically active substances - acids, alkalis, etc. - can enter the pleural cavity.
  • For closed chest injuries. Closed chest injuries can cause rupture of the esophagus with subsequent entry of food or gastric contents into the mediastinum and onto 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 an inflammatory process in the lung tissues.
  • Injections of chemicals. When substances not intended for such use are administered intravenously, they can enter the tissues of the lungs and pleura and cause serious impairment of their function.

Chemical substances provoke the development of the inflammatory process, disrupt the structural and functional integrity of tissues, and also significantly reduce local immunity, which contributes to the development of the infectious process.

Chest trauma

Exposure to ionizing radiation

Effects of pancreatic enzymes

Primary and metastatic pleural tumors

  • Primary pleural tumors. A primary pleural tumor is a neoplasm that has developed from cells and tissues that make up the normal structure of this organ. In most cases, such 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 tumor fragments that have separated from the primary focus located in any organ and which have migrated to the pleura, where they continued to develop. In most cases, the tumor process in the pleura is of a metastatic nature.

The inflammatory reaction during the tumor process develops under the influence of pathological metabolic products produced by tumor tissues (since the function of tumor tissue differs from the norm).

Types of pleurisy

In clinical practice, the following types of pleurisy are distinguished:

  • dry (fibrinous) pleurisy;
  • exudative pleurisy;
  • purulent pleurisy;
  • tuberculous pleurisy.

Dry (fibrinous) pleurisy

Exudative (effusion) pleurisy

Purulent pleurisy

Tuberculous pleurisy

Symptoms of pleurisy

  • cause of pleurisy;
  • intensity of the inflammatory reaction in the pleural cavity;
  • stage of the disease;
  • type of pleurisy;
  • volume of exudate;
  • nature of the exudate.

The following symptoms are characteristic of pleurisy:

Dyspnea

Cough

Chest pain

Increased body temperature

  • 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.
  • Temperature above 39 degrees. A temperature above 39 degrees develops with severe 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.

An increase in body temperature reflects the degree of intoxication of the body with waste products of microorganisms, and therefore is often accompanied by a number of other manifestations, such as headache, weakness, pain in the joints and muscles. During the entire period of fever, decreased performance is noted, some reflexes slow down, and the intensity of mental activity decreases.

Tracheal displacement

Diagnosis of pleurisy

  • examination and interview of the patient;
  • clinical examination of the patient;
  • X-ray examination;
  • blood analysis;
  • pleural effusion analysis;
  • microbiological research.

Examination and interview of the patient

  • deviation of the trachea to the healthy side;
  • blue discoloration of the skin (indicates serious respiratory failure);
  • signs of closed or open chest trauma;
  • bulging in the area of ​​the intercostal spaces on the affected side (due to the large volume of accumulated fluid);
  • tilting the body to the affected side (reduces lung movement and, accordingly, irritation of the pleura during breathing);
  • bulging neck veins (due to increased intrathoracic pressure);
  • lag of the affected half of the chest during breathing.

Clinical examination of the patient

  • Auscultation. Auscultation is an examination method in which the doctor listens to sounds arising in the human body using a stethoscope (before its invention, directly with the ear). When auscultating patients with pleurisy, a pleural friction noise can be detected, which occurs when the pleural sheets covered with fibrin threads rub against each other. This sound is heard during breathing movements, does not change after coughing, and persists when breathing is imitated (several breathing movements with the nose and mouth closed). With effusion and purulent pleurisy in the area of ​​fluid accumulation, there is a weakening of respiratory sounds, which sometimes may not be heard at all.
  • Percussion. Percussion is a method of clinical examination of patients, in which the doctor, using his own hands or special devices (a hammer and a small plate - a plessimeter), taps organs or formations of varying densities in the patient’s cavities. The percussion method can be used to determine the accumulation of fluid in one of the lungs, since percussion above the fluid produces a higher-pitched, dull sound, different from the sound that occurs above 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. Using the palpation method, that is, by “feeling” the patient, areas of distribution of painful sensations, as well as some other clinical signs, can be identified. With dry pleurisy, pain is observed when pressing between the legs of the sternocleidomastoid muscle, as well as in the area of ​​​​the cartilage of the tenth rib. When applying the palms to symmetrical points of the chest, a slight lag of the affected half in the act of breathing is noted. In the presence of pleural effusion, a weakening of vocal tremors is felt.

In most cases, the data obtained as a result of clinical examination and interview are sufficient to diagnose pleurisy. However, the information obtained does not allow us to reliably determine the cause of the disease, and in addition, it is not sufficient to differentiate this condition from a number of other diseases in which fluid also accumulates in the pleural cavity.

X-ray examination

  • on the affected side, the dome of the diaphragm is higher than normal;
  • decreased transparency of the lung tissue against the background of inflammation of the serous membrane.

With effusion pleurisy, the following radiological signs are revealed:

  • smoothing of the diaphragmatic angle (due to fluid accumulation);
  • uniform darkening of the lower region of the pulmonary field with an oblique border;
  • shift of the mediastinum towards the healthy lung.

Blood analysis

Pleural effusion analysis

  • quantity and type of proteins;
  • glucose concentration;
  • lactic acid concentration;
  • number and type of cellular elements;
  • presence of bacteria.

Microbiological examination

Treatment of pleurisy

Treatment of pleurisy with medications

When is puncture necessary for pleurisy?

  • pathologies of the blood coagulation system;
  • increased pressure in the pulmonary artery system;
  • chronic obstructive pulmonary disease in a severe stage;
  • having only one functional lung.

Thoracentesis is performed under local anesthesia by inserting a thick needle into the pleural cavity at the level of the eighth intercostal space on the side of the scapula. This procedure is carried out under ultrasound control (with a small volume of accumulated fluid), or after a preliminary x-ray examination. During the procedure, the patient sits (as this allows you to maintain the highest level of fluid).

Is hospitalization necessary to treat pleurisy?

Is it possible to treat pleurisy at home?

Nutrition for pleurisy (diet)

Consequences of pleurisy

  • Adhesions between the layers of the pleura. Adhesions are connective tissue strands between the layers of the pleura. 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 serious respiratory failure.

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Source: http://www.polismed.com/articles-plevrit-prichiny-simptomy-diagnostika-lechenie.html

Pleurisy: causes, signs, forms, diagnosis, how to treat

Pleurisy is a disease of the respiratory system characterized by inflammation of the pleura - a thin, transparent, two-layer membrane consisting of connective tissue fibers and designed to restrict the movement of the lungs. In healthy people, there is a lubricant in the pleural cavity that allows the pleural layers to slide during breathing. As the disease develops, the fluid becomes inflammatory in nature, contains pus or blood, the leaves rub against each other, which is manifested by chest pain, which is called pleural.

Typically, pleurisy is a secondary disease that develops against the background of respiratory or cardiovascular pathology. In children, pleurisy accompanies pneumonia.

There are several classifications of this disease:

  • By origin, pleurisy can be infectious and aseptic,
  • According to the location of the source of inflammation - right-sided, left-sided, diffuse, bilateral, encysted,
  • According to the course - acute, subacute, chronic,
  • According to the nature of the pathology - dry or fibrinous and exudative or effusion.

Etiology

Pleurisy is a polyetiological disease, the causes of which are: specific and nonspecific infection, allergies, systemic diseases, radiation, neoplasms, traumatic injury.

Infection

Microbes penetrate into the pleural cavity in any way: hematogenous and lymphogenous in infectious diseases of the lungs, as well as directly in case of injuries, operations on the organs of the chest cavity.

  • Bacteria - Staphylococcus aureus, hemolytic streptococcus, pneumococcus, gram-negative bacilli;
  • Spirochete pallidum, Brucella, typhoid bacillus are representatives of a specific infection;
  • Legionella;
  • Viruses - influenza and parainfluenza, coronoviruses, rhinoviruses, enteroviruses, adenoviruses;
  • Fungi of the genus Candida, actinomycetes;
  • Intracellular microbes - chlamydia, mycoplasma;
  • Protozoa - amoebas;
  • Rickettsia;
  • Parasites - echinococci.

Tuberculous pleurisy is classified as a separate group, since it is highly contagious and rapidly spreading. The pathology complicates the course of primary or secondary tuberculosis of the lungs or other organs. Mycobacteria penetrate the pleura with the flow of lymph or blood from the affected lungs, organs of the digestive system, lymph nodes, and bones. In children, tuberculous pleurisy is much less common than in adults.

In rare cases, pleurisy is a contagious disease: viruses and bacteria that cause the pathology spread from sick people to healthy people who were in close contact.

Non-communicable diseases

  1. Autoimmune diseases, which are based on the body’s ability to produce antibodies to its own cells and tissues, resulting in the development of chronic inflammation, affecting almost all internal organs. Pleurisy complicates the course of a number of systemic diseases - dermatomyositis, sarcoidosis, diffuse fasciitis, relapsing polychondritis, vasculitis, periarteritis nodosa.
  2. Malignant neoplasms and metastases into the pleura cause inflammation, which increases the production of exudate. Acute leukemia, lymphoma, lung and breast cancer in women are often complicated by the development of pleurisy.
  3. Fractured ribs, pleural injury, hemorrhage into the pleural cavity, pneumothorax.
  4. Allergic pleurisy complicates the course of exogenous allergic alveolitis, drug or food allergies, and hay fever.
  5. Acute pancreatitis, perforation of the esophagus.
  6. Uremia.
  7. Pulmonary pathology - pulmonary infarction.
  8. Blunt cardiac injury, pericarditis.
  9. Spontaneous hemothorax or pneumothorax.

Impact of environmental factors

  • Chemicals have an aggressive effect on the serous membrane, which leads to the development of reactive inflammation.
  • Radiation causes dysfunction of pleural cells, the development of local inflammation, and accumulation of exudate.
  • In case of chest injuries, infection of the affected tissues occurs, the process of absorption of pathological fluid is disrupted, which leads to the development of exudative pleurisy.

Despite the fact that pulmonary pleurisy occurs with the same frequency among both men and women, the causes of the pathology are fundamentally different. In women, the causes of pleurisy are usually breast or ovarian cancer, collagenosis, and in men - chronic pancreatitis or rheumatoid arthritis.

Factors contributing to the development of pathology:

  1. Endocrine pathology - diabetes mellitus.
  2. Alcoholism.
  3. Chronic diseases of the bronchi and lungs.
  4. Reflux esophagitis.
  5. Immunodeficiency states.
  6. Hypothermia.
  7. Stress.
  8. Overwork.
  9. Poor nutrition.
  10. Allergy.

Pathogenesis

Inflammation of the pleura develops in response to the introduction of pathogenic microbes and consists of 3 stages: exudation, formation of purulent discharge and recovery.

  • Exudate is a liquid released into the pleural cavity from capillaries during inflammation. During exudation, blood vessels dilate, their permeability and blood pressure in the affected area increase. These processes are regulated by inflammatory mediators - serotonin, histamine. At this stage, exudate does not accumulate in large quantities, since the absorption capacity of the lymphatic vessels exceeds the secreting capacity of the pleura.
  • The exudation stage gradually turns into the stage of formation of purulent discharge. This occurs during the further development of the pathology. Fibrin deposits appear on the pleural layers, which create friction between them during breathing. This leads to the formation of adhesions and pockets in the pleural cavity, complicating the normal outflow of exudate, which becomes purulent in nature. Purulent discharge consists of bacteria and their waste products. Due to impaired outflow, an excess amount of pathological fluid accumulates in the pleural cavity, and purulent pleurisy develops.
  • During the treatment process, pathological lesions completely resolve or turn into limited connective tissue formations that prevent further spread of infection, but impair lung function. The outcome of the disease is often an adhesive process between the pleural layers or their complete overgrowth with fibrous tissue - fibrothorax.

Symptoms

Fibrinous pleurisy begins acutely. Patients complain of burning pain in the chest, the intensity of which increases with deep inspiration, coughing, sneezing and weakens or completely disappears when standing still. Pleural pain lasts from several hours to several days. To relieve it, you should breathe slowly and shallowly.

Inflammation of the pleura is usually accompanied by a state of hypoxia and is manifested by corresponding symptoms: chronic fatigue, depression, insomnia, chest and head pain, tachypnea, tachycardia, shortness of breath, nausea and vomiting, deterioration of hearing and vision.

Patients show signs of intoxication: low-grade fever, malaise. Breathing becomes more frequent, and on the affected side the excursion of the lungs is limited. Pain in the abdomen or side, hiccups and sore throat may occur.

Exudative pleurisy is manifested by unilateral chest pain, which, as fluid accumulates, is replaced by a feeling of heaviness and pressure.

Other symptoms of pleurisy include:

  1. Pain in the shoulder girdle;
  2. Nonproductive cough;
  3. Signs of general intoxication;
  4. Acrocyanosis, swelling of neck veins, protrusion of intercostal spaces;
  5. Shortness of breath is a subjective sensation manifested by tightness in the chest, changes in the frequency and depth of breathing.

The patient takes a forced position - lies on the sore side. This position reduces friction of the pleura and the intensity of pain.

During the examination of the patient, the doctor pays attention to the asymmetry of the chest. Palpation reveals a weakening of vocal tremors and crepitus. On percussion, a dull sound appears above the exudate; on auscultation, weakened breathing with a bronchial hue, fine rales, and pleural friction noise are heard at a distance.

Diagnostics

Diagnosis of pleurisy requires a subjective and objective examination of the patient. A subjective examination includes questioning the patient, collecting an anamnesis of life and illness, clarifying allergological status, bad habits and occupational factors. Objective examination - examination, palpation, percussion, auscultation, clinical examination of other organs. Additional methods include: laboratory diagnostics, instrumental examination, pleural puncture.

  • A general blood test shows neutrophilic leukocytosis or lymphocytosis.
  • X-ray and ultrasound examinations make it possible to determine the deposition of fibrin on the layers of the pleura, its thickening, and in case of exudative pleurisy - a layer of fluid below the lung, wedge-shaped echo-negative areas, spread apart pleural layers, and lung tissue displaced towards the root.
  • Computed tomography allows you to determine the condition of the pleural cavity, lungs and mediastinal organs, and detect pleural effusion and plaques in the early stages of pathology.
  • Pleural puncture is a therapeutic and diagnostic procedure widely used in pulmonology and thoracic surgery. During puncture, medications are injected directly into the pleural cavity, affecting the lesion, and accumulated fluid and excess air are evacuated. Before starting the procedure, you should calm the patient and adjust him psychologically. Then the anesthesiologist performs premedication - administers tranquilizers, sedatives and antihistamines to the patient to relieve tension and prevent allergies, and measures pulse and blood pressure. During the procedure, the patient sits with his back to the doctor, raising his arm to expand the intercostal space. The skin is disinfected with iodine, the puncture site is anesthetized with novocaine, the pleura is pierced in the 6-7 intercostal space in the midline and the contents are evacuated. In one procedure, no more than 1.5 liters of exudate can be pumped out to avoid displacement of the mediastinal organs. The puncture site is treated with an antiseptic, a sterile bandage is applied and the chest is tightly bandaged. The material is delivered to the laboratory for testing within an hour. Contraindications to the procedure are: blood clotting disorders, obstructive syndrome, pulmonary hypertension, respiratory failure in the stage of decompensation. Complications of pleural puncture: tachycardia, bleeding, convulsions, collapse. A pleural puncture should be performed by an experienced doctor who is fluent in this technique.
  • Using a pleural puncture, fluid is obtained, examined visually, and then sent to the laboratory for further examination. In a clinical laboratory, the punctate is examined to determine the root cause of the disease.
  • Bacteriological examination and direct microscopy of sputum and pleural fluid make it possible to identify the causative agent of the pathology, fully identify and determine its sensitivity to antibiotics.

Treatment

Treatment of pleurisy is carried out in a hospital under medical supervision. Patients are prescribed powerful and effective medications, and, if necessary, surgical intervention is performed.

At home, it is permissible to treat only those patients who approach this issue responsibly, take care of their health and strictly follow the instructions of doctors. If the disease is mild, does not progress, there are no complications, and the patient feels satisfactory, treatment at home is allowed.

Diet therapy is indicated for patients with pleurisy. Products containing large amounts of carbohydrates, which contribute to the development of pathogenic bacteria, are prohibited. You should not drink a lot of fluids or eat foods that make you thirsty. To stimulate the immune system, it is necessary to enrich the diet with fresh vegetables and fruits, as well as juices from them.

Drug treatment

Complex treatment of pleurisy consists of etiotropic, pathogenetic, symptomatic and restorative therapy.

  1. Etiotropic treatment is the use of antibacterial, antiviral and antituberculosis drugs. For infectious pleurisy, Ampicillin-sulbactam, Imipenem, Clindamycin, and Ceftriaxone are used. These drugs from different pharmaceutical groups have a bactericidal and bacteriostatic effect against most gram-positive and gram-negative bacteria. Depending on the severity of the disease, antibiotics are prescribed as intramuscular or intravenous injections. Anti-tuberculosis treatment - "Ethambutol", "Isoniazid", "Rifampicin", "Streptomycin". These drugs should be taken for a long time - about a year under strict medical supervision.
  2. Pathogenetic and symptomatic treatment consists of prescribing painkillers, antipyretics, antihistamines - Ibuprofen, Indomethacin, Meloxicam, Analgin. Patients are prescribed diuretics - Furosemide, Diacarb, Mannitol. To restore water and electrolyte balance, saline solution with glucose is administered intravenously. It accelerates filtration in the kidneys, increases the volume of circulating blood and helps remove toxins from the body. In severe cases, patients are prescribed intramuscular injections of glucocorticosteroids - Prednisolone, Dexamethasone. To suppress the cough reflex, codeine-containing drugs are used - Codelac, Terpinkod.
  3. General strengthening therapy - immunostimulating drugs: Levamisole, Imunorix, Ismigen, vitamin and mineral complexes.

Physiotherapy

In cases of exacerbation of dry pleurisy, patients are prescribed warming of the chest with infrared rays, ultraviolet irradiation of the chest, and daily paraffin applications. After acute inflammation subsides, calcium and iodine electrophoresis is performed. A month after recovery, water procedures, exercise therapy, manual and vibration massage are indicated.

For exudative pleurisy, mud or paraffin applications, UHF, diathermy, inductothermy, ultraviolet irradiation, sun-air baths, and climatotherapy are performed.

ethnoscience

Traditional medicine helps speed up recovery (but does not replace treatment!), alleviate the patient’s condition, and improve respiratory function. All procedures must be carried out with the permission of the attending physician.

  • Traditional treatment for pleurisy consists of using decoctions and infusions of medicinal herbs - sage, licorice, marshmallow, anise.
  • It is useful to rub essential oils into the skin of the chest - camphor, lavender, eucalyptus, fir. Then you should bandage your chest tightly and warm up.
  • Linden honey mixed with aloe juice, sunflower oil and linden decoction is taken three times a day before meals.
  • Warming semi-alcohol or camphor compresses, mustard plasters, and iodide mesh are effective.
  • A folk pain reliever for pleurisy is a bandage with mustard, which is applied to the sore spot.
  • Onion or black radish juice mixed with honey in equal proportions is taken three times a day after meals.
  • Inhalation over fresh, chopped onions or hot water with essential oils improves respiratory function and reduces pain.
  • Bay leaves are mixed with butter and rubbed on the chest.

Pleurisy can be treated with traditional medicine only in combination with traditional medications, since the disease progresses rapidly and can lead to dysfunction of the respiratory system. Traditional medicine may not be able to cope with such a serious illness on its own.

Complications

Pleurisy itself is a consequence of a number of serious pathologies - pneumonia, tuberculosis, cancer, vascular disorders.

The severe consequences of pleural inflammation include:

Prevention

Persons who have had pleurisy in any form are followed up by a pulmonologist for 2-3 years. It is recommended to exclude occupational hazards, hypothermia and drafts.

Preventive measures for pleurisy:

  • Early detection and adequate treatment of acute respiratory viral infections, pneumonia and other diseases of the respiratory system, the course of which is complicated by pleurisy,
  • Regular breathing exercises
  • Strengthening the immune system - hardening, prolonged exposure to fresh air, regular exercise,
  • Vitaminized and balanced nutrition,
  • Fight against smoking
  • Climate change with frequent respiratory diseases.

Source: http://uhonos.ru/dyxanie/plevrit/