Gidorothax is an excessive accumulation of transudate between the parietal and visceral pleural sheets, which is a complication of other diseases and manifests itself as respiratory, and more often cardiovascular disorders.
Signs of hydrothorax arise only in the situation when the normal relationship between colloid osmotic pressure of the plasma part of the blood and capillary hydrostatic pressure towards the prevalence of the latter. A feature of the pathogenesis of hydrothorax is that this state takes a long time, during which a liquid containing a limited amount of protein (transudate) swims through the intact vascular wall of the capillary network.
Causes of hydrothorax
A characteristic feature of hydrothorax is that this pathology does not represent an independent nosological unit and arises only as a complication of other diseases.
The most common etiopathogenetic cause of the development of hydrothorax is chronic cardiovascular failure with concomitant changes of stagnation in all organs and systems. The main organic pathologies accompanied by heart failure are heart defects in the stage of decompensation and pericarditis . These diseases are accompanied not only by an increase in hydrostatic pressure in the capillary vessel system, but also by a decrease in the colloid osmotic pressure of the plasma blood component.
Two-sided hydrothorax often develops in severe forms of affection of the renal calyxal apparatus, accompanied by renal insufficiency ( amyloidosis , glomerulonephritis with nephrotic syndrome). The mechanism of fluid penetration into the pleural cavity in this situation is based on pronounced hyperproteinemia.
In patients with cirrhosis of the liver with concomitant ascites, in 10% of cases, hydrothorax is formed on the right as a result of penetration of ascitic fluid from the abdominal cavity into the right pleural cavity through small disruption of the diaphragm dome integrity. The same pathogenetic mechanisms of development of hydrothorax are also observed during peritoneal dialysis.
Talking about the hepatic type of hydrothorax is possible only in the case of accumulation of effusion in one or both pleural cavities larger than 500 ml, provided there is no change in the activity of the heart and lung function. The preferred localization of the hydrothorax of hepatic genesis is the right pleural cavity, which is at least 80% of cases.
Despite the fact that tumor neoplasms of the mediastinal organs are a rare pathology, in most cases this disease is accompanied by the development of signs of hydrothorax with accumulation in the pleural cavities of lymph.
The only condition for excluding the appearance of signs of hydrothorax is complete obliteration of the leaves of the visceral and parietal pleura.
Signs and symptoms of hydrothorax
Small hydrothorax (up to 150 ml volume of fluid), which has become a complication of one or another organic pathology, never affects the severity of the underlying disease, while hydrothorax total can have independent clinical manifestations due to compression of the mediastinal and pulmonary parenchyma organs.
The most common form of accumulation of the transudate between the pleura is the bilateral and right-sided hydrothorax, while the isolated hydrothorax on the left is extremely rare. In patients with severe cardiovascular disease, an associated accumulation of excess fluid is often observed, not only in the pleural, but also the abdominal, pericardial cavities, as well as in the subcutaneous fat.
The debut of clinical manifestations, as a rule, has a gradual course, and the symptomatology develops only when a large volume of fluid accumulates in one or both of the pleural cavities. The most common complaints that patients with hydrothorax make are: gradually increasing dyspnea, a feeling of heaviness in the lower parts of the chest cavity, a feeling of shortness of breath. In contrast to pneumothorax, with the existing accumulation of fluid in the pleural cavities, there is no pronounced pain syndrome and fever, since there is no inflammatory component in the transudate.
When a visual objective examination of the patient is determined acrocyanosis of the skin and the restriction of the affected half of the chest with one-sided localization of the process. In some cases, even at the first contact with the patient, one can suspect that he has a hydrothorax, since for the elimination of dyspnoea, the patient occupies the typical "sour" position or "lying on the affected side" typical for this pathology.
Characteristic features of hydrothorax during percussion of lungs is the presence of blunt percussion sound with an oblique top border locally above the site of the supposed fluid accumulation, and auscultatory symptoms are the complete absence of vesicular breathing above the affected area. With pronounced pleural effusion, the percussion boundaries of relative cardiac dullness are shifted, as a reduction in the compression effect of fluid on the mediastinal organs.
In a situation where, in addition to fluid accumulation in the pleural cavity, signs of ascites and anasarca are observed, the patient has a visible abdominal enlargement with enlarged venous collaterals in the anterior abdominal wall, as well as a marked swelling of the soft tissues.
The features of the clinical picture is hydrothorax, which appears against the background of liver cirrhosis with signs of portal hypertension . In patients with cirrhotic changes in the liver, symptoms of respiratory failure occur even with a small amount of pleural effusion. Patients with hepatic hydrothorax are prone to complications in the form of spontaneous bacterial peritonitis and concomitant bacterial empyema of the pleura.
Infection of the pleural cavity containing effusions is accompanied by a significant deterioration in the patient's condition: the appearance of a stitching pain in the chest, a marked fever, an increase in the phenomena of encephalopathy. The most common pathogens empyema of the pleura in hepatic hydrothorax are Escherichia coli and Klebsiella.
Diagnosis of hydrothorax
The qualitative timely diagnosis of hydrothorax significantly influences the patient's recovery process and consists of the following algorithm of laboratory-instrumental measures:
- a primary examination of the patient with a careful collection of anamnesis of the disease and clarification of the patient's complaints;
- an objective examination of the patient using palpation, auscultation of the lungs and heart, percussion of the borders of the heart and pulmonary sound;
- Radiation methods of diagnosis of the chest cavity (X-ray, ultrasound, computed tomography);
- Diagnostic pleural puncture followed by a cytological, microbiological study of the punctate.
The most accessible and easy-to-use method for diagnosing hydrothorax is fluoroscopy, which allows not only to detect the presence of fluid in the pleural cavity, but also to establish the approximate volume of effusion, as well as assess the state of the mediastinal organs. The characteristic skiological signs of hydrothorax is the presence of a homogeneous darkening of different sizes with the oblique superior upper border, the lower contour of the diaphragm adjacent to the dome, displaced during respiratory movements. Pleural sinus in this situation is not possible to visualize. In the presence of a limited small amount of effusion, radiography is recommended in the "lying on the sore side" position.
In a situation where there is a large amount of fluid in one of the pleural cavities, conditions for compression of the mediastinal organs are created, which on the roentgenogram looks like the shift of the median shadow to the healthy side more in the lower parts.
Ultrasonic scanning of pleural cavities allows to estimate the amount of effusion accurately, however, in this method of investigation it is impossible to estimate the effect of the existing effusion on lung function. The ultrasonic method is successfully used in performing the pleural puncture.
The most informative method for diagnosing hydrothorax at the present time is computed tomography, since in addition to establishing the presence of even a small amount of fluid in the pleural cavity, this method of visualization makes it possible to reliably determine the pathology that is the root cause of hydrothorax, which has a big role in determining the tactics of treating the patient.
Diagnostic pleural puncture is performed after the diagnosis of the diagnosis "hydrothorax", established with the help of radiotherapy techniques. The purpose of its implementation is to examine the pleural punctate for the presence of an inflammatory component, a cytological study, and in some cases the performance of a bacterial inoculum in order to determine the causative agents of specific infectious diseases.
Pleural puncture or pleurocentesis is a minimally invasive surgical manipulation that can be performed not only by the surgeon but also by the pulmonologist. This medical manipulation does not require specific preparation of the patient and is performed under local anesthesia.
To implement the thoracentesis, a special "trocar" needle of wide diameter is used, having a connection with a rubber adapter, at the end of which there is a system for evacuating the contents of the pleural cavity. The best position of the patient when performing pleural puncture is the position "sitting with the inclination of the upper half of the thorax forward". As an anesthetic, Novocain is used, by which the prospective puncture site is cut (the seventh intercostal space in the anterior axillary line). After carrying out the manipulation, a tight sterile bandage must always be applied and the patient is advised to adhere to this day of bed rest.
Despite the fact that pleural puncture does not require massive surgical intervention, it can manifest complications in the form of: violation of the integrity of the lung, liver or diaphragm, followed by intrapleural bleeding, air embolism of blood vessels supplying the brain. In order to diagnose complications of pleural puncture, a control X-ray examination of the thoracic cavity organs must be carried out.
Laboratory methods of research are used to clarify the nature of the occurrence of hydrothorax. Among the diagnostic activities most often used:
- general urine analysis (as a rule, proteinuria of varying severity is detected, an increase in the relative density of urine, and an increase in the number of erythrocytes and leukocytes, indicative of the development of glomerulonephritis);
- changes in the biochemical blood test to a greater extent affect the quantitative protein content in the blood with the redistribution of protein fractions (lowering blood albumins);
- general analysis of pleural punctate (with hydrothorax effusion is a clear liquid of light yellow color with an increased protein content of more than 20 g / l and a relative density of less than 1.015);
- carrying out the Rivalta test (with hydrothorax it is negative);
- cytological analysis of punctate for the presence of atypical tumor cells;
- bacteriological analysis of pleural punctate for the presence of pathogens specific infectious diseases (mycobacterium tuberculosis).
A pleural puncture resulting from a puncture of the pleural cavity of a patient with hepatic hydrothorax is also a transudate, but it has some peculiarities: the protein content is less than 25 g / l, the ratio between pleural and whey protein is less than 0.5, acidity greater than 7.4
To diagnose the hepatic type of hydrothorax, which is observed with severe degree of cirrhosis, surgical methods are used to visualize the defects of the diaphragm and determine their types (blisters, cracks) for the subsequent determination of the volume of surgical treatment.
The detection of atypical cells in the pleural punctate indicates a process of malignancy. A patient with such changes needs a follow-up with thoracoscopy with a pleural biopsy.
Treatment of hydrothorax
Due to the fact that hydrothorax is not an independent disease, but a complication of other pathologies, in determining the tactics of patient management and its treatment, it is necessary to rely on the identification of the underlying pathology, which became the primary cause of fluid accumulation in the pleural cavities and the conduct of etiopathogenetic therapy. In the absence of adequate therapy of the underlying disease, further progression of the hydrothorax and the occurrence of severe respiratory and cardiovascular disorders are observed.
In a situation where hydrothorax is a complication of chronic pathology of the cardiovascular system, accompanied by stagnant changes in the lungs, treatment should begin with a correction of the patient's behavior and the appointment of a rational diet. So, the patient should adhere to the correct optimal mode of work with the normalization of night sleep, as well as the exclusion of stressful effects, accompanied by psycho-emotional overstrain. Correction of eating behavior involves the use of a fractional diet with a restriction of edible salt and daily intake of liquid.
Conservative treatment of this group of patients is to increase the contractility of the heart muscle, and for this purpose, preparations of the group of cardiac glycosides (Digoxin 0.25 mg 4 r / day orally), phosphodiesterase inhibitors (Theophylline at a daily dose of 400 mg orally) are used. With the aim of removing excess fluid from the body and preventing its accumulation in the pleural cavities, it is recommended to systematically prescribe diuretic drugs: inhibitors of carbonic anhydrase (Diacarb in a daily dose of 250 mg in the morning), thiazide diuretics (Indapamide 0.25 mg in the morning), potassium-sparing diuretics (Veroshpiron in daily dose of 200 mg). To reduce preload on the left heart, in this case, the use of ACE inhibitors (Captopril at 6.25 mg 2 p / day orally), peripheral vasodilators (nitroglycerin 5 mg sublingually 2 p / day) is appropriate.
If the development of hydrothorax is due to severe renal pathology accompanied by edematous nephrotic syndrome, the treatment of the patient should begin with ensuring strict bed rest and the appointment of a special diet with the complete exception of table salt and diuresis control (the volume of excreted urine should in no case be less than the amount drunk per day of fluid).
For the purpose of correcting the protein composition of blood, a replacement transfusion of 20% of albumin is recommended, with a course of at least five infusions and a single volume of 150 ml, as well as the simultaneous administration of drugs that prevent excessive release of protein in the urine (ramipril at a daily dose of 2.5 mg orally) . A positive effect on the control of excessive fluid accumulation is diuretic drugs used by long-term courses.
In hepatic hydrothorax, the main method of treatment is liver transplantation, as well as palliative methods of therapy (use of an adequate diuretic therapy regimen, therapeutic thoracocentesis, and if necessary massive antibacterial therapy using cephalosporins of the third generation in combination with fluoroquinolones).
In the absence of a marked clinical improvement in the patient's condition, despite the ongoing conservative treatment measures, the use of operative methods of treatment (closure of diaphragmatic defects, the imposition of a shunt) is recommended.
In a situation where there is total hydrothorax or if conservative methods of treatment are ineffective, it is necessary to perform therapeutic puncture of the pleural cavity in order to reduce the risk of acute respiratory and cardiovascular disorders.
Obligatory conditions for the puncture is the slow gradual evacuation of the fluid in small volumes, since the evacuation of a large number of pleural effusions will inevitably lead to acute disorders of central hemodynamics.
Given the timely diagnosis of hydrothorax and an adequate volume of therapeutic measures, the prognosis for recovery is relatively favorable. When administering a patient with hydrothorax, it is always necessary to remember the risk of infection of the pleural cavities and the transformation of the transudate into exudate with the further development of symptoms of pleural empyema, which is difficult to treat.
As a preventive measure to prevent the development of recurrence of hydrothorax, a good effect of long-term use of traditional medicine, having a diuretic effect. To these tools are various tinctures based on parsley: a teaspoon of chopped parsley should be steamed in two cups of boiling water for 12 hours, then strain through a sieve and take 1 tbsp. before each meal.