Pleurisy is inflammatory changes in the pleural membranes, accompanied by the accumulation of fluid in the pleural cavities. Pleurisy is a complication of various diseases and is not a nosological unit. Depending on the origin, the main two groups of pleurisies are distinguished: infectious (tubercular, staphylococcal, streptococcal) and aseptic (carcinomatous, rheumatic, cardiac).
If the fluid accumulates in a limited area of the pleural cavity, then the conclusion is "clotted pleurisy", but if the liquid content flows freely over the pleural cavities, then we must assume "diffuse pleurisy of the lungs".
Depending on the composition of the contents of pleural cavities distinguish: fibrinous, or dry pleurisy, serous, purulent and hemorrhagic types of pleural effusion.
Causes of pleurisy
The causative agents of infectious pleurisy can be various types of microorganisms (viruses, anaerobes, fungi, gram-negative and gram-positive bacteria, legionella, tuberculosis mycobacterium and others).
Infectious pleurisy are complications of lung inflammatory diseases, which include pneumonia, lung abscesses, and pulmonary tuberculosis .
Often pleurisy occurs as a result of a fungal lung injury with actinomycosis, blastomycosis, coccidioidosis.
Pleurisy of the infectious and inflammatory nature most often occurs as a result of the entry of pathogenic microorganisms from infected areas of the lung into the pleural cavity in the presence of foci of pneumonia or pulmonary abscess. It is also possible for the hematogenous pathway of infection to enter the pleural cavity in septic lesions. During open abdominal operations, conditions are created for direct infection of the pleura by microorganisms from the external environment.
Almost 100% of cases of infectious pleurisy occur in the case of an existing infectious allergic process, that is, when the pathogenic bacteria first enter the pleural shells, the primary sensitization mechanism is triggered, which is manifested by a chain of chemical reactions with the formation of biologically active substances (serotonin, histamine). These biologically active substances cause an increase in the permeability of the vascular wall at the microcirculatory level, as a result of which the mechanism of exudate formation, which is the main substrate of pleurisy, is triggered.
The main causes of aseptic pleurisy are:
- Oncological diseases of the thoracic cavity organs (central and peripheral lung cancer , pleural mesothelioma, metastatic lung injury). Inflammation of the pleura occurs as a result of direct destruction of the lung tissue, as well as due to impaired lymph flow
- traumatic and surgical damage to the lungs, in which inflammation of the pleura is due to the accumulation of blood in the pleural cavity
- diffuse connective tissue diseases (systemic lupus erythematosus , scleroderma , dermatomyositis ) are accompanied by a systemic lesion of the vascular bed at the microcirculatory level, followed by the formation of exudate in the pleural cavity
- thromboembolism of the pulmonary artery always ends with the development of infarct-pneumonia due to massive perfusion disorders, which creates conditions for the formation of pleural effusion
- pancreatitis , in which pleurisy is caused by the irritating action of pancreatic enzymes on the pleura
- rheumatic fever
- drug poisoning (overdose or long-term use of immunosuppressants, antibacterial agents)
- Inactivity and malnutrition
Purulent pleurisy develops against the background of destructive lesions of the lung tissue, as well as with open injuries of the thoracic cavity.
In the clinical picture of any pleurisy, three main symptoms are distinguished: a syndrome of dry, exudative and purulent pleurisy.
Dry pleurisy manifests itself in constant unpleasant sensations in the chest area, pain in respiratory movements, radiating to the neck, upper limbs and upper half of the abdominal cavity. To stop painful sensations the patient takes a forced position "lying on his side." Breathing becomes superficial and rapid, and with unilateral pleurisy asymmetric. Even at the initial examination of the patient, an experienced doctor can presume dry pleurisy due to the presence of pathognomonic auscultatory phenomenon called "pleural friction noise".
Excessive pleurisy is characterized by a reduction in the pain syndrome and the emergence of symptoms of respiratory failure, such as increasing dyspnea, palpitations, acrocyanosis, neck vein pulsation, and cough without sputum discharge. The affected side of the chest not only does not participate in the act of breathing, but there is also a certain protrusion of intercostal spaces.
If the volume of effusion is more than 300 ml, then it is possible to determine the sign of the presence of fluid in the pleural cavity in the form of a blunt percussion sound above the place of the supposed accumulation of exudate. Auscultatory signs of exudative pleurisy are: complete absence of vesicular breathing above the affected area of the lungs and crepitating wet wheezing above the liquid level.
Purulent pleurisy or pleural empyema is accompanied by a bright clinical picture, in which the signs of inflammatory changes in the body (sharp rise in body temperature to high figures, increased sweating and chills), as well as an increased intoxication syndrome (general weakness, lack of appetite, weight loss ). Pain syndrome and signs of respiratory failure progress with the accumulation of purulent contents in the pleural cavity.
If the course of pleurisy acquires a chronic character, the lungs form cicatricial changes in the form of pleural adhesions, which prevent the full spreading of the lung. Massive pneumofibrosis is accompanied by a decrease in the perfusion volume of lung tissue, thereby aggravating the symptoms of respiratory failure.
The main difference between exudative pleurisy and fibrinous is the presence of effusion in the pleural cavity.
The course of exudative pleurisy, regardless of etiology, can be divided into three main periods: the phase of exudation, the period of stabilization and the phase of resolution.
Clinical manifestations of exudative pleurisy are represented by symptoms of respiratory insufficiency and symptomocomplex of inflammatory nature. Patients complain of pronounced dyspnea and discomfort in the chest with breathing, a cough with hard-to-resolve sputum, general weakness, loss of appetite, and a brief rise in body temperature to high digits.
Already during the initial examination, there are signs of the presence of fluid in the pleural cavity (blunt percussion sound, lack of vesicular breathing), however, in order to establish a reliable diagnosis, it is necessary to conduct a number of additional studies, among which the most important are the radiation methods of diagnosis. With the help of X-ray, it is possible to establish the localization of the process and the presence of complications in the form of pleural cleavage, adhesions and signs of displacement of the mediastinal organs.
For the diagnosis of small exudative pleurisy or pleurisy of atypical localization, an ultrasound examination of the pleural cavities is necessary, which allows to determine even 50 ml of liquid.
To determine the nature of exudate should be performed diagnostic pleural puncture, as well as analyze blood indicators for the presence of an inflammatory or allergic reaction of the body.
The fluid in the pleural cavity may accumulate diffusely or limitedly. In the case of limited accumulation of effusion formed pleural pleurisy (supra-diaphragmatic, paracostal, paramedistinal), resulting from the adhesive process in the pleura.
Tuberculous pleurisy is a complication of various forms of pulmonary tuberculosis, manifested by acute, chronic or intermittent course. Very often, the diagnosis of the patient's TB process begins with pleurisy.
In the structure of morbidity, the leading positions are occupied by children and young people, as pleurisy often occurs against the background of the tuberculosis primary complex, bronchoadenitis and disseminated forms of pulmonary tuberculosis.
The main forms of lesions of the pleura in tuberculosis are: allergic and perifocal pleurisy, as well as isolated tuberculosis of the pleura. The allergic form of pleurisy develops during primary infection with a tubercle bacillus and is accompanied by an active exudative reaction of the pleural membranes, as a result of which conditions are created for the abundant serous and serous-fibrinous exudate and the deposition of fibrinous layers on the surface of the pleura. Allergic pleurisy is not accompanied by specific pathomorphological tuberculous changes in the pleura.
With such forms of pulmonary tuberculosis as focal, infiltrative, cavernous and disseminated, contact pleurisation of the pleural membranes occurs when the pleura contacts the infected areas of the lung tissue. First, there are signs of local fibrinous pleurisy, and then the mechanism of exudate formation is triggered. Involution of tuberculous pleurisy consists in resorption of effusion, thickening of pleural membranes and complete or partial obliteration of pleural cavities.
In a situation where the patient has a cavernous form of tuberculosis, there is a risk of a complication in the form of pyopneumothorax and chronic tuberculosis empyema, which manifests itself as a massive inflammatory reaction of a non-specific nature.
Often chronic tuberculosis empyema is combined with amyloidosis of internal organs. Complete recovery for tuberculous empyema is almost impossible to achieve, because in any case, residual events are formed in the form of massive pleural clefts and obliteration of pleural sinuses, which can only be removed surgically. Patients with residual post-tuberculosis changes in the lung often suffer from drained pleurisy.
The most severe form of tuberculous pleurisy is tuberculous empyema, as it occurs with the emergence of violent clinical symptoms and is often accompanied by complications. The most formidable and life-threatening complication of the patient is the drainage of purulent contents in the bronchus, which is accompanied by a painful cough with a profuse withdrawal of purulent fetid sputum and the formation of the pleurobronchial fistula. With an objective examination of the patient in favor of the fistula formed, the appearance of amphoric breathing during auscultation is indicated. Additional diagnostic methods in this situation are: bronchoscopy, radiography and samples with methylene blue.
Rare, however, difficult for the patient complication of tuberculosis empyema is the formation of the pleurotora fistula, when the purulent contents of the pleural cavity breaks into the subcutaneous tissue of the anterior thoracic wall through the intercostal spaces.
Specific methods for verifying a diagnosis for tuberculous pleurisy are sowing the contents of the pleural cavity with mycobacterium tuberculosis and determining susceptibility to tuberculin. For the appointment of specific anti-tuberculosis therapy, it is necessary to have laboratory confirmation of the causative agent of pleurisy.
Only patients with diagnosed dry (fibrinous) pleurisy are eligible for outpatient treatment, all other patients should be hospitalized for examination and selection of an individual treatment regimen. The specialized department for this category of patients is the therapeutic department, and patients with purulent pleurisy and empyema of the pleura need specialized treatment in a surgical hospital.
Only patients with a significant amount of effusion in the pleural cavity are shown bed rest, in other cases, patients are in a semi-fast mode, during which limited motor activity is allowed, improving the drainage function of the bronchi.
Each of the forms of pleurisy has its own peculiarities of therapy, but in any type of pleurisy, etiotropic and pathogenetic direction in treatment is shown. Thus, with dry pleurisy, the patient is prescribed analgesic therapy, anti-inflammatory drugs in combination with hyposensitization, as well as a wide range of preventive therapies (application of a warming compress to the chest, tight compression of the chest with elastic bandage or medical corset, the use of warming anti-inflammatory ointments based on non-steroidal anti-inflammatory drugs). Antibiotic therapy is suitable only in the presence of indications (inflammatory changes in blood tests, fever more than 48 hours).
In the presence of effusion in the pleural cavity of any character, the patient should adhere to dietary nutrition with a limited content of products of carbohydrate origin and liquid.
After the pleural puncture, it is necessary to sow the point with the definition of the flora and sensitivity of microorganisms to antibacterial drugs of a particular group. The presence of pleural effusion even of non-purulent character is an indication for the appointment of antibacterial agents.
To increase the effectiveness of antibacterial therapy, a parenteral route of administration is recommended. In the absence of the results of sowing punctate, a broad spectrum of antibiotics should be preferred - Amoxiclav 625 mg twice a day, Ceftriaxone 1 g 2 times a day intramuscularly, Gentamicin 120 mg once a day intramuscularly. The course of antibiotic therapy on average is 10 to 14 days.
A mandatory item in the treatment of exudative pleurisy is hyposensitizing therapy, and in the absence of signs of pleural empyema, it is advisable to administer glucocorticosteroid hormones. With purulent pleurisy, powerful inflammatory changes develop in the body, as a result of which the function of the immune system suffers, and therefore, the use of general stimulating drugs (immunoglobulin, immunostimulants) is recommended.
With a severe course of purulent pleurisy, conditions are created for the breakdown of protein metabolism and the lack of vitamins in the body. In this situation, parenteral administration of vitamin complexes, glucose solution and protein preparations is recommended.
Pleural punctures are used not only for diagnostic purposes, but also as a therapeutic manipulation for massive exudative pleurisy. Such pleurisy as purulent, posttraumatic and hemorrhagic are indications for the complete evacuation of pleural effusion. To prevent further accumulation of fluid or pus, the patient is placed in drainage and controls not only the quantity but also the nature of the discharge. With established carcinomatous pleurisy, it is recommended to combine pleural puncture with the introduction of cytostatic drugs into the pleural cavity.
When confirmed by instrumental and laboratory methods of studying the diagnosis of pleural empyema, the patient is recommended to sanitate the pleural cavities until the pathogens are completely removed. To this end, daily aspiration of pus is used in combination with antiseptic treatment of the empyema cavity with Furacilin solution followed by intrapleural administration of solutions of antibacterial drugs.
An effective method of treatment of purulent pleurisy, which reduces the duration of the patient's stay in the hospital, is ultrasonic treatment of pleural cavities through thoracoscopic access. The course of treatment in combination with antibiotic therapy is 5-6 manipulations.
The effectiveness of conservative treatment should be assessed under the constant monitoring of laboratory and instrumental indicators. Indication for surgical intervention is the absence of X-ray dynamics and signs of complete lung dilatation within 3 weeks. Surgical treatment means thoracotomy followed by decortication of the affected lung. If there is a chronic pleurisy with massive pleural adhesions, then one should resort to the complete removal of the irreversibly altered lobe of the lung along with the schwartz.
The obligatory complex of therapeutic measures includes physiotherapeutic methods of treatment, however, only in the absence of signs of acute inflammatory changes. Among the physiotherapy procedures, the most effective and appropriate in this situation are: irradiation of the affected half of the chest with the use of the Minin's Solux lamp, ultraviolet irradiation in weakly eritem doses, paraffinotherapy, electrophoresis, ozokeritotherapy and UHF therapy.
Of great importance in the treatment of pleurisy is a complex of rehabilitation measures, which is aimed at adapting the patient to the conditions of usual physical activity and to preventing possible complications. To this end, the patient is taught special breathing exercises and recommends walking and swimming, which contribute to the development of the respiratory apparatus.
Isolated pleurisy is quite easy to treat and with timely diagnosis is cured without any complications. In a situation where there is a purulent lingering pleurisy of the lungs, a carcinomatous form of pleurisy, and also with improper treatment tactics, complications may develop - the adhesion process in the pleural cavities, cardiovascular insufficiency , empyema of the pleura and pyopneumotorax.
Adhesive process in the pleural cavities has a strong effect on the progression of chronic respiratory failure due to the limitation of lung mobility. The only effective method of eliminating this complication is the surgical dissection of adhesions.
Empyema of the pleura takes a leading position in the structure of the causes of mortality of patients with pleurisy. As a preventive measure for the prevention of empyema, massive antibiotic therapy and antiseptic washing of the pleural cavities should be noted.
In the conditions of a large amount of fluid in the pleural cavity, the mediastinal organs contract, to which the heart and large blood vessels belong, in connection with which, cardiovascular insufficiency develops, which can cause the death of the patient. Thus, with a large amount of effusion in an emergency, it is necessary to perform a therapeutic pleural puncture with the establishment of drainage.