- Clinic of fibrinous pleurisy. The patient complains of pain when breathing, coughing, when bending in the opposite direction. For a long time persistent low-grade fever, mainly in the evening, sweating. The objective data are as follows: shallow, rapid breathing, the position of the patient is forced (the patient lies on the patient side to reduce pain). During physical examination, along with the symptoms of the underlying disease, a localized or extensive pleural friction noise will be heard.
- In case of exudative pleurisy, pain may change its intensity, but the patient has a feeling of heaviness in one or the other half of the chest, shortness of breath, dry or with sparse sputum cough (reflex nature). The patient usually takes a forced position. At the general inspection revealed cyanosis, acrocyanosis, swollen veins of the neck. On examination of the chest: the swelling of the intercostal spaces, the affected half lags behind when breathing. Palpation reveals a limited chest excursion, voice trembling is not performed. When percussion is detected femoral dullness percussion sound. With ascultation, breathing is not performed (if the amount of fluid is small, then breathing may be performed, if there is pus, breathing may become hard or bronchial. In a horizontal position, there will be a weakening of vesicular breathing).
- The clinic of pleural empyema is characterized by a hectic fever, severe intoxication, and a change in the advisory data.
A reliable sign confirming the presence of pleurisy is radiography of the chest organs: the classic sign of effusion pleurisy is a homogeneous darkening of the lung tissue with an oblique upper level of fluid. This X-ray picture is observed in the case of diffuse pleurisy, if the amount of fluid exceeds 1 liter. If the fluid is less than a liter, the fluid accumulates in the sinuses, and there is a darkening of the lower side sinus. It is difficult to make a diagnosis if there is a total darkening of one or the other half of the chest (total acute pneumonia, lung atelectasis, a direct contraindication in thoracocentesis). If it is liquid, then there is a contralateral displacement of the mediastinum organs. When hydropneumothorax fluid level is horizontal. When interlobar pleurisy is usually, it is represented as a biconvex lens.
In the diagnosis of pleurisy, pleural puncture plays an important role. Thoracocentesis is carried out in 7-8 intercostal space along the posterior-axillary or scapular line. The resulting fluid inspect, determine its color, consistency. It is necessary to determine the transudate or exudate: it is necessary to determine the amount of protein, to make a Rivolt test, to examine LDH. Transudate: the amount of protein is less than 32 g / l, the LDH level is less than 1.3 mmol / l, the Rivolt sample is negative.
Exudate: protein greater than 36 g / l, LDH level 1.75 mmol / l, Rivolt's test is positive. For a clear determination of the transudate or exudate, it is necessary to determine the coefficients — the effusion protein level / serum protein level, the total LDH effusion level / serum LDH level. If these coefficients are respectively less than 0.5 and 0.6, then this is a transudate. Transudate mainly appears in three states: circulatory failure, liver cirrhosis, nephrotic syndrome. If the coefficients are greater than 0.5 and 0.6, then this is exudate, and further searches should be directed to finding the cause.
The normal composition of the pleural fluid.
- Specific gravity 1015
- Color - straw yellow
- Transparency - full
- Non viscous
- total number of red blood cells 2000-5000 in mm3
- total leukocyte count 800-900 mm3
- neutrophils up to 10%
- eosinophils up to 1%
- basophils up to 1%
- lymphocytes up to 23%
- endothelium up to 1%
- plasma cells up to 5%
- Protein 1.5 - 2 g per 100 ml (15-25 g / l).
- LDH 1.4 - 1.7 mmol / l
- glucose 20-40 mg per 100 ml (2.1 - 2.2 mmol / l)
- pH 7.2
In cases where the pleural fluid is clear, proceed to biochemical research (LDH, amylase, glucose). A decrease in the level of glucose is observed in tuberculous pleurisy, a sharp decrease in glucose in mesotheliomas. A slight decrease in glucose in acute pneumonia, especially with mycoplasma.
If the liquid is cloudy, you need to think about chylothorax or pseudochilothorax. Lipids are defined in the liquid - if cholesterol crystals fall out, then it is pseudochilothorax or cholesterol exudative pleurisy. If triglyceride crystals fall out, it is chylothorax (affection of the thoracic duct, most often in malignant tumors).
If the fluid is bloody, hematocrit needs to be determined. If more than 1% - you need to think about the tumor, trauma, and pulmonary embolism with the development of pulmonary infarction. If the hematocrit is more than 50%, this is a hemothorax that requires surgical intervention.
Then a cytological examination of the pleural fluid is performed. If malignant tumor cells are detected, the source of the tumor is determined. If leukocytes are prevailing - this is acute pleurisy, if pneumonic infiltrate, then most often it is parapneumonic pleurisy. If it is pneumonia, then you need to do a tomography, bronchoscopy, computed tomography. If mononuclear cells are predominant, this is chronic pleurisy, in which a double pleural biopsy is necessary, in which etiology can be established. If a double biopsy of the pleura is not diagnosed, then resort to scanning the lungs, angiography, computed tomography, ultrasound of the abdominal cavity.
Formulation of the diagnosis: the main disease is put in the first place, then the complications are dry pleurisy, diffuse or encapsulated (with indication of localization).
Pleurisy treatment Classification and causes of pleurisy
In clinical practice, the classification of pleurisy N.V. is most often used. Putov, proposed in 1984
According to it, the following types of pleurisy are distinguished:
- non-infectious (various non-infectious diseases - rheumatism, lung cancer and others) lead to their development,
- infectious (caused by various infections - tuberculous pleurisy, pneumococcal, staphylococcal),
- idiopathic (have unclear etiology).
according to the nature of the exudate:
- fibrinous or dry pleurisy (there is no exudate),
- exudative (pleurisy with purulent, serous, putrid, serous-fibrinous, chylous, cholesterol, hemorrhagic, eosinophilic, mixed effusion).
on localization of effusion:
- sacculated (apical, parietal, diaphragmatic, costodiaphragmatic, paramediastinal, interlobar),
by the nature of the inflammatory process:
Causes of infectious pleurisy are:
- parasitic, viral, mycoplasma infections,
- bacterial infections (pneumococcus, staphylococcus, gram-negative flora and others),
- tuberculosis infection (found in every fifth patient with pleurisy, in this case they talk about tuberculous pleurisy),
- tularemia, typhoid and typhus, syphilis, brucellosis,
- fungal infections (blastomycosis, candidiasis, coccidioidosis),
- chest injuries and surgical interventions.
Noncommunicable pleurisy caused by:
- diffuse lesions of the connective tissue (for rheumatoid arthritis, systemic lupus erythematosus, rheumatism, scleroderma, systemic vasculitis),
- malignant tumors of the pleura, metastases in the pleura (detected in every fourth patient with pleurisy),
- pulmonary infarction, pulmonary embolism, myocardial infarction,
- other causes (leukemia, hemorrhagic diathesis, pancreatitis, and others).
Each type of pleurisy has its own specific development mechanism. Causative agents of pleurisy of an infectious nature directly affect the pleural cavity and penetrate there in a variety of ways.
Tuberculous pleurisy develops when the infection penetrates through the lymphogenous, contact, hematogenous route from subpleurally located foci of infection. The same happens in pneumonia, lung abscess, bronchiectasis.
In the case of breach of the integrity of the chest (for example, injuries, wounds, operations) microorganisms enter the pleural cavity directly.
Pleurisy can occur as a result of increased permeability of blood and lymphatic vessels in systemic vasculitis, tumor processes, acute pancreatitis, while reducing the body's reactivity, disorders in the process of lymph outflow.
A small amount of exudate can be sucked back into the pleura and leave a fibrin layer on its surface. Thus, dry pleurisy develops.
In that case, if the rate of accumulation of effusion in the pleura is higher than the rate of its outflow, then exudative pleurisy is formed.
Symptoms of pleurisy
Since pleurisy is a secondary process, which is a syndrome or a complication of other diseases, the symptoms of pleurisy can come to the fore and often mask the underlying disease.
Symptoms of dry pleurisy are reduced to stabbing pains in the chest, which become stronger with breathing, coughing, movements. The patient tends to lie on the patient's side in order to limit the mobility of the chest. He has gentle, shallow breathing, and the affected half of his chest lags far behind when making breathing movements. A distinctive feature of dry pleurisy is weakened breathing in the area of fibrinous overlays, listenable pleural friction noise. The patient's temperature can sometimes rise to subfebrile values, there can be chills, weakness, and increased sweating at night.
When diaphragmatic dry pleurisy observed pain in the chest, hypochondrium, abdominal cavity, hiccups, flatulence, tension of the abdominals.
The course of dry pleurisy is determined by the nature of the underlying disease. In some patients, the symptoms of pleurisy disappear in 2-3 weeks, but they may return again. Tuberculous pleurisy has a long course, which is often accompanied by exudate effusion into the pleura.
For exudative pleurisy, dull pain in the affected side, reflexively dry, excruciating cough, pleural rubbing sound, lagging in breathing of the affected half of the chest, are characteristic.
When the exudate accumulates, the pain turns into a feeling of heaviness in the side, shortness of breath increases, intercostal spaces are smoothed, moderate cyanosis is observed.
Common symptoms of exudative pleurisy are expressed in weakness, loss of appetite, febrile temperature, sweating. In case of paramediastinal pleated pleurisy, there are: hoarseness, dysphagia, swelling of the neck and face.
What is pleurisy
Lung pleurisy is an inflammatory process in the pleural membrane that leads to accumulation of fluid contents (exudate or fibrin) in the pleural cavity.
It occurs as a pathological condition, after various infectious diseases of the lungs or adjacent formations. Very rarely occurs as an independent disease.
The pleura is a membrane membrane that surrounds the surface of the lungs. It consists of a pair of petals that line the diaphragm, mediastinum and the inner surface of the chest cavity.
Healthy people in the pleural cavity contains a lubricant in the form of serous fluid, it contributes to the sliding of the lungs during breathing. Liquid residues are absorbed by lymphatic and blood vessels.
Pulmonary pleurisy on X-ray
With the beginning of the inflammatory or infectious process occurs edema, vasodilation, their permeability is disturbed.
Two days from the onset of inflammation occurs vascular thrombosis. The pleura swells, cell infiltration begins. Then exudate appears.
Depending on the type of inflammation, it can be purulent, serous, fibrinous, hemorrhagic. After treatment, the exudate can be absorbed, followed by the formation of adhesions. Purulent exudate does not resolve, it can only be removed surgically.
Lung pleurisy more often detected in elderly men aged 60-70 years.
Classification (types of disease)
All pleurisy by etiology are divided into:
- Infectious. The causative agent can be staphylococcus, streptococcus, mycoplasma, fungi, genus of opportunistic bacteria (Klebsiella), mycobacterium tuberculosis.
- Non-infectious (aseptic). Development contribute to cancer, autoimmune diseases (lupus erythematosus, Basedow's disease), diseases of the gastrointestinal tract, myocardial infarction, injury to the chest cavity.
According to the clinic of inflammation, pulmonary pleurisy is divided into:
- dry pleurisy (non-flush),
- exudative (effusion),
The composition of the content of pleural effusion is:
- Serous fibrinous - an inflammatory process characterized by the accumulation of serous contents. Fibrin is formed on the pleural surface.
- Hemorrhagic - inflammation of the pleura, manifested by the accumulation of blood exudate in its cavity.
- Purulent. Manifested by the formation of purulent contents in the pleural cavity. Can be summed or spilled. When sacculated form of pus is in a limited space. Filling purulent pleurisy begins after the pus has broken into the pleural cavity.
If pulmonary pleurisy begins during pneumonia, it is called parapneumonic; if after pneumonia, it is metapneumonic.
Parapneumonic pleurisy begins acutely in the presence of pneumonia. Worried cough, shortness of breath, pain in the chest when breathing. The amount of exudate is small.
Metapneumonic occurs more often in debilitated bedridden patients. It starts after pneumonia, is difficult to treat and in most cases is complicated by pleural empyema (pyothorax, purulent pleurisy).
Lower respiratory infections often contribute to the development of pulmonary pleurisy. From the primary focus in pulmonary tuberculosis, pneumonia, abscess, pathogens through the bloodstream or lymph enter the pleural cavity and cause inflammation.
Infection of the pleura can occur during intracavitary surgery or in the case of chest injury.
Concomitant diseases of non-infectious origin can also cause the development of pleurisy. In case of oncological diseases, metastases are secreted; when they enter the pleura, they contribute to the exudate. Myocardial infarction is often complicated by effusion pleurisy.
With severe immune system disorders (rheumatoid arthritis, hemorrhagic vasculitis, lupus erythematosus) develops pleural effusion. With such lesions is bilateral.
In older men, pleurisy may begin due to inflammation of the pancreas. In acute pancreatitis, the enzymes have a toxic effect on the pleural membrane, causing the formation of fibrin.
With timely identification of the cause of the disease and proper treatment, the disease ends with full recovery.
In some cases, such complications develop:
- Lung adhesions. It is a scar formation in the connective tissue of the pleura. More often formed after exudative pleurisy. With multiple spikes, the respiratory system of the lungs is disturbed.
- Formation of pleural mooring. Characterized by fibrinous layers on the surface of the pleura.Arise both after effusion pleurisy, and after dry. More often localized in the upper parts of the lungs. Patients with this complication are worried about shortness of breath, heaviness in the chest during physical exertion.
- Pneumosclerosis. The process by which lung tissue is replaced by coarse connective tissue. In areas of pulmonary fibrosis, lung tissue loses its elasticity and does not perform gas exchange function.
- Empyema pleura. A dangerous complication of pleurisy, leading to lung gangrene. It is characterized by high body temperature up to 40 C, unbearable chest pain. Cardiac and respiratory failure develops. What most often leads to death.
- Respiratory failure. Purulent inflammation or extensive inflammation of the pleura can cause respiratory failure.
Diagnostic measures include:
- examination and questioning of the patient,
- clinical examination
- X-ray and computed tomography,
- ultrasound procedure,
- general blood analysis,
- pleural puncture.
When examining a patient with pulmonary pleurisy, the asymmetry of the chest is visible, the patient part lags behind in the act of breathing. With a large accumulation of effusion may be observed cyanosis of the skin, since the blood supply in the cervical veins is disrupted due to compression. The sore side of the chest looks bigger.
During percussion, there is a weakening of percussion sound, and the upper boundary is an oblique line — Damoiseau, which is clearly visible on X-ray. When listening to the lungs with a phonendoscope, the pleural friction noise is clearly audible, it is similar to the creaking of snow. Breathing in areas of fluid accumulation dramatically weakened.
On radiography symptoms of pulmonary pleurisy are displayed as intense uniform darkening in the lower lobes of the organ. High standing of the diaphragm is observed with a small accumulation of fluid. The mediastinum is displaced to a healthy lung. When you take a picture in lateroposition (the patient lies on his side) there is a horizontal displacement of the exudate.
Non-effusion pleurisy of the lungs in the picture is manifested by intense shadows of heterogeneous structure, the sinuses are not detected. Pleural mobility is severely limited.
In general, the analysis of blood in pleurisy is a shift of the leukocyte formula to the left, an increase in the level of leukocytes, an increase in ESR. Eosinophilia and monocytosis are characteristic of tuberculous pleurisy.
Blood chemistry shows the presence of fibrinogen and high levels of sialic acids.
The main informative diagnostic method is thoracocentesis (pleural puncture). The patient is punctured the pleural cavity under local anesthesia for the purpose of fluid intake. Exudate research helps determine the shape of pleurisy and the infectious agent of the disease.
In tuberculous, traumatic pleurisy, erythrocytes are visible in the exudate. The color can vary from pink to deep red.
When the purulent process exudate dull gray or gray-green color, with the beginning of gangrene may have a fetid odor. If the exudate is transparent and odorless, serous pleurisy is diagnosed.
An ultrasound study shows increased echogenicity at the site of fluid accumulation, pleural thickening.
Effective in the treatment of pleurisy physiotherapy. With their help, the effusion is evacuated faster, and the adhesions dissolve.
From physiotherapeutic procedures apply:
- calcium chloride electrophoresis,
- warming up
- various compresses.
If pleurisy is caused by tumor metastasis, chemotherapy is performed.
Treatment of pleurisy should take place in a hospital under the supervision of specialists. Therapy is long from 2 to 4 weeks.
Treatment of pulmonary pulmonary folk remedies
The combination of traditional medicine and the treatment of pleurisy folk remedies will help more effectively and quickly cope with this disease.
Treatment of pleurisy folk remedies is to alleviate its symptoms.
Anise-based folk recipes help to eliminate cough, have a bronchodilator effect:
- 1 teaspoon anise fruit brew 1 cup boiling water. Leave to infuse for 20 minutes. Drink ¼ cup 4 times a day 30 minutes before meals.
Expectorant based on radish and honey:
- grate black radish of medium size, squeeze juice. A tablespoon of black radish juice mixed with 1 tablespoon of honey. Consume 2 tbsp. spoons 15-20 minutes before meals, 3-4 times a day.
Folk recipes with honey have anti-inflammatory and immunostimulating action.
Mucolytic agent for pleurisy:
- take 2 tbsp. spoons of butter, 2 boiled chicken yolks, 1 teaspoon flour, 2 teaspoons honey. Mix all the ingredients and take a teaspoon 5 times a day.
A good effect is the treatment of folk remedies in the form of compresses and rubbing:
- rubbing with camphor. Camphor oil 50 ml mixed with 5 ml of eucalyptus oil. Rub the chest 2 times a day,
- compress warming with animal fat. 250 g of badger fat (can be replaced with pork) mixed with 4 leaves of aloe. Aloe should be crushed. Add to ingredients 4 tbsp. spoons of honey, mix everything. Sculpt the cake and wrap in gauze fabric. Apply to the chest 3 times a day.
At home, pleurisy can be cured with onion inhalations. This vegetable contains volatile, which help cleanse and strengthen the respiratory system.
- peel the onion, cut into small pieces. Put them on a gauze napkin, roll it up. Breathe over the onion sack 3-4 times a day.
Treatment of folk pleurisy can be started only after consulting a doctor. Folk recipes are an auxiliary therapy in the treatment of pleurisy, therefore should be used together with modern medicines. Treatment of pleurisy at home is possible only at the stage of recovery.
Preventive measures are based on the timely detection and treatment of diseases that cause inflammation.
To reduce the likelihood of illness, you must follow the rules:
- Strengthening immunity. In the season of rising incidence, take complex vitamins.
- Rejection of bad habits. Smoking harms the lungs and contributes to the development of pathological processes in them.
- Do not self-medicate. If you do not even have a strong cough, you should be examined by a doctor.
- Do sport. Physical activity increases the body's resistance.
- Time to cure viral diseases. Very often, later treatment of ARVI leads to the development of complications, including pleurisy.
- Undergo prophylactic examination. Once a year it is necessary to undergo fluorography. It will help to identify various pathologies in the early stages.
- Walks in the open air. Strengthen the respiratory system, contribute to its purification.
With adequate treatment, dry pleurisy has a favorable prognosis. But there may remain lifelong changes in the pleura - adhesions, pneumofibrosis, mooring lines.
An adverse prognosis has purulent pleurisy of the lungs. Difficult to treat. It is likely to break the purulent contents in the chest, which can lead to sepsis.
Tuberculous pleurisy has the ability to repeatedly repeat, so patients should be under close medical supervision for 2 months.
Pulmonary pleurisy in the presence of oncology also ends adversely. Metastases destroy the pleura, leading to severe intoxication and the development of respiratory failure.
Characteristics of the disease and types of pleurisy
Pleurisy is called inflammation of the pleura - the serous membrane that envelops the lungs. The pleura has the form of translucent connective tissue leaves. One of them is adjacent to the lungs, the other lining the chest cavity from the inside. A fluid is circulating in the space between them, which ensures that the two layers of the pleura slip during inhalation and exhalation. Its quantity does not normally exceed 10 ml. When pleural pulmonary fluid accumulates in excess. This phenomenon is called pleural effusion. This form of pleurisy is called effusion, or exudative. It is most common. Pleurisy can be dry - in this case, fibrin protein is deposited on the surface of the pleura, the membrane thickens. However, as a rule, dry (fibrinous) pleurisy is only the first stage of the disease, which precedes the further formation of exudate. In addition, when infection of the pleural cavity exudate may be purulent.
As already mentioned, medicine does not include pleurisy as an independent disease, calling it a complication of other pathological processes. Pleurisy may indicate lung disease or other diseases that do not cause lung tissue damage. By the nature of the development of this pathological condition and cytological analysis of pleural fluid, along with other studies, the doctor is able to determine the presence of the underlying disease and take adequate measures, but pleurisy itself requires treatment. Moreover, in the active phase, he is able to come to the fore in the clinical picture. That is why, in practice, pleurisy is often called a separate respiratory disease.
So, depending on the state of the pleural fluid, they release:
- purulent pleurisy,
- serous pleurisy,
- sero-purulent pleurisy.
The purulent form is the most dangerous, since it is accompanied by intoxication of the whole organism and, in the absence of proper treatment, threatens the patient’s life.
Pleurisy can also be:
- acute or chronic
- severe or moderate
- affect both parts of the chest or manifest on one side only
- development often provokes infection, in which case it is called infectious.
A broad list of non-infectious causes of pulmonary pleurisy:
- connective tissue diseases
- pulmonary embolism,
- chest injuries,
In the latter case, we can talk not only about lung cancer, but also about tumors of the stomach, breast, ovaries, pancreas, melanoma, etc. With the penetration of lymph nodes in the chest lymph nodes, the outflow of the lymph becomes slower, and the pleura leaves more permeable. Liquid seeps into the pleural cavity. It is possible to close the lumen of the large bronchus, which lowers the pressure in the pleural cavity, and therefore provokes the accumulation of exudate.
In non-small cell lung cancer (NSCLC), pleurisy is diagnosed in more than half of the cases. With adenocarcinoma, the frequency of metastatic pleurisy reaches 47%. With squamous cell lung cancer - 10%. Bronchiolar-alveolar cancer leads to a pleural effusion at an early stage, in which case pleurisy may be the only signal of the presence of a malignant tumor.
Depending on the form, the clinical manifestations of pleurisy vary. However, as a rule, to determine the pleurisy of the lungs is not difficult. It is much more difficult to find the true cause, which caused inflammation of the pleura and the appearance of pleural effusion.
Treatment of the condition
Treatment of pulmonary pleurisy should be comprehensive, aimed at eradicating the disease that caused it. Therapy of pleurisy itself, as a rule, is symptomatic, designed to speed up the absorption of fibrin, prevent the formation of adhesions in the pleural cavity and fluid "bags", and alleviate the patient's condition. The first step is to remove the pleural edema. At high temperatures, antipyretic drugs are prescribed for the patient, and for pain, analgesic NSAIDs are prescribed. All these actions allow to stabilize the patient’s condition, normalize the respiratory function and effectively treat the underlying disease.
Treatment of pleurisy in mild form is possible at home, in a complex - only in the hospital. It may include various methods and techniques.
- Thoracentesis. This is a procedure in which accumulated fluid is removed from the pleural cavity. Assign in all cases of effusion pleurisy in the absence of contraindications. Thoracocentesis is carried out with caution in the presence of pathology of the blood coagulation system, increased pressure in the pulmonary artery, obstructive pulmonary disease in a severe stage or the presence of only one functional lung. For the procedure, apply local anesthesia. A needle is inserted into the pleural cavity on the side of the scapula under ultrasound control and the exudate is collected. The compression of the lung tissue decreases, it becomes easier for the patient to breathe.
- Often the procedure needs to be performed again, for this purpose, modern and completely safe have been developed. intrapleural port systems, providing continuous access to the pleural cavity for evacuation of exudate, and for the introduction of drugs, including through chemotherapy.
It is a system consisting of a catheter, which is injected into the pleural cavity, and a titanium chamber with a silicone membrane. Installation requires only two small cuts, which are later sewn up. The port is installed in the soft tissue of the chest wall, under the skin. In the future, it does not cause the patient any inconvenience. Manipulation takes less than an hour. The very next day after installing the port, the patient can go home. When it is necessary to evacuate the exudate again, it suffices to pierce the skin and the silicone membrane under it. It is fast, safe and painless. With the sudden need and lack of access to medical care, with a certain skill and knowledge of the rules of the procedure, even relatives are able to independently release the patient's pleural cavity from the fluid through the port.
- Another type of intervention is pleurodesis. This is an operation to artificially create adhesions between the leaves of the pleura and the destruction of the pleural cavity so that the fluid has nowhere to accumulate. The procedure is prescribed, as a rule, for oncological patients with the ineffectiveness of chemotherapy. The pleural cavity is filled with a special substance that prevents the development of exudate and has an antitumor effect - in the case of oncology. These can be immunomodulators (for example, interleukins), glucocorticosteroids, antimicrobial agents, radioisotopes and alkylating cytostatics (oxazaphosphorine derivatives and bis -? - chloroethylamine, nitrosoureas or ethylenediamine, platinum preparations, alkyl sulfonates, triazines or tetrazines, triazines or tetrazines, alkylsulfonates, triazines or tetrazines, ethylenediamine, platinum preparations, alkylsulfonates, triazines or tetrazines, triazines or tetrazine ureas .
- If the above methods failed, it is shown removal of the pleura and the installation of the shunt. After shunting, the fluid from the pleural cavity passes into the abdominal. However, these methods are classified as radical, capable of causing serious complications, and therefore resort to them last.
- Drug treatment. In the case when pleurisy has an infectious nature or is complicated by an infection, antibacterial drugs are used, the choice of which completely depends on the type of pathogen and its sensitivity to a specific antibiotic. Drugs, depending on the nature of the pathogenic flora, can be:
- natural, synthetic, semi-synthetic and combined penicillins (benzylpenicillin, phenoxymethylpenicillin, methicillin, oxacillin, nafcillin, ticarcillin, carbpenicillin, Sultasin, Oxamp, Amoxiclav, mezlocillin, azlocillin, methyl)
- cephalosporins ("Mefoxin", "Ceftriaxone", "Keiten", "Latamoktsef", "Zefpirim", "Cefepim", "Sefterra", "Ceftolosan"),
- fluoroquinolones ("Microflox", lomefloxacin, norfloxacin, levofloxacin, sparfloxacin, moxifloxacin, hemifloxacin, gatifloxacin, sitafloxacin, trovafloxacin),
- carbapenems ("Tien", doripenem, meropenem),
- glycopeptides (“Vancomycin”, “Vero-Bleomycin”, “Targocid”, “Vibativ”, ramoplanin, decaplanin),
- macrolides ("Sumamed", "Yutatsid", "Rovamitsin", "Rulid"),
- ansamycins ("Rifampicin"),
- aminoglycosides (amikacin, netilmicin, sizomitsin, izepamitsin), but they are incompatible with penicillins and cephalosporins with simultaneous therapy,
- linkosamides (lincomycin, clindamycin),
- tetracyclines (doxycycline, "Minoleksin"),
- amphenicol ("Levomitsetin"),
- other synthetic antibacterial agents (hydroxymethylquinoxalinedioxide, fosfomycin, dioxidine).
For the treatment of inflammation of the pleura, anti-inflammatory and desensitizing drugs are also prescribed (electrophoresis of a 5% solution of novocaine, analgin, diphenhydramine, 10% calcium chloride solution, 0.2% solution of platyfillin hydrotartrate, indomethacin, etc.), regulators of water-electrolyte balance ( saline and glucose solution), diuretics (“Furosemide”), lidase electrophoresis (64 U every 3 days, 10–15 procedures for a course of treatment). May appoint funds for the expansion of the bronchi and cardiac glycosides that enhance the contraction of the myocardium ("Eufillin", "Korglikon"). Pulmonary pleurisy in oncology responds well to chemotherapy — after it is given, the edema and symptoms usually go away. Drugs are administered systemically - by injection or intrapleurally through a port-system diaphragm valve.
According to statistics, chemotherapy courses in combination with other methods of treatment help to eliminate pleurisy in approximately 60% of patients who are sensitive to chemotherapy drugs.
During the course of treatment, the patient must always be under the supervision of a physician and receive maintenance therapy. After completing the course, it is necessary to conduct an examination, and after a few weeks to reappoint it.
Prognosis of the disease
Launched forms of pulmonary pleurisy can have serious complications: the occurrence of pleural adhesions, bronchopleural fistulas, impaired blood circulation due to compression of the vessels.
In the process of developing pleurisy under the pressure of fluid, the arteries, veins and even the heart are able to shift in the opposite direction, which leads to an increase in intrathoracic pressure and impaired blood flow to the heart. In this regard, the prevention of pulmonary heart disease is the central task of all therapeutic interventions for pleurisy. At detection of displacement the patient is shown emergency pleurocentesis.
A dangerous complication is empyema - the formation of a “pocket” with pus, which ultimately can lead to scarring of the cavity and the final blocking of the lung. A breakthrough of purulent exudate in the lung tissue is fatal. Finally, pleurisy can cause amyloidosis of parenchymal organs or kidney damage.
Special attention is paid to pleurisy when diagnosing it in cancer patients. Effusion in the pleural cavity aggravates the course of lung cancer, increases weakness, gives additional shortness of breath, provokes pain. When squeezing the vessels violated tissue ventilation. Given immune disorders, this creates a favorable environment for the spread of bacteria and viruses.
The consequences of the disease and the chances of recovery depend on the main diagnosis. In cancer patients, fluid in the pleural cavity usually accumulates in the late stages of cancer. This makes treatment difficult, and the prognosis is often poor. In other cases, if the fluid from the pleural cavity was removed in time and prescribed adequate treatment, there is no threat to the life of the patient. However, patients need regular monitoring in order to diagnose relapse in time when it appears.
Before considering the mechanism of development of the disease, let's slightly delve into the human anatomy.
The pleura, as we have already mentioned several lines above, is a serous membrane consisting of mesothelial cells that cover the fibroelastic framework. In the frame are nerve endings, blood and lymphatic vessels.
The pleura includes 2 leaves (layers) - parietal and visceral.
Parietal (parietal) sheet is the surface membrane of the inner surface of the chest cavity, which promotes the free sliding of the lungs relative to the chest.
Visceral sheet is the surface enveloping shell of each lung, which ensures the free sliding of the lungs relative to each other.
Both parts of the pleura are interconnected at the level of the gates of the lung.
There is also a narrow space between the layers of the pleura, which is filled with a small amount of fluid, providing improved lung glide during breathing. The pleural fluid is formed after plasma leakage through the capillaries, in the upper part of the lungs, at the same time the blood and lymphatic vessels of the parietal leaf suck up the excess of this fluid. Thus, pleural fluid circulates.
Pleurisy is a pathological process in which an excess amount of pleural fluid (pleural effusion) is present in the pleural region. This disorder usually develops under 2 main circumstances - excessive production of liquid or its insufficient absorption.
There are cases when pleurisy is characterized only by the inflammatory process in the pleura, without an excess amount of pleural fluid, however, nevertheless, pleural effusion is the main symptom of pleurisy.
The most common cause of such a failure is infection, injuries of the chest organs, metabolic disturbances, tumors, and systemic diseases.
As for pleurisy, which develops on the background of infection, then it should be noted that its formation requires a combination of 3 conditions:
1. Getting into the area of lung infection, as well as the level of its pathogenicity,
2. The state of the immune system, which serves to protect the body against infection,
3. Local conditions in the pleural cavity - air, blood and the amount of fluid inside the pleural cavity.
A few words about fibrinous and exudative pleurisy.
When the formation of pleural fluid on the surface of the lungs occurs in a moderate or limited amount, but its outflow is not disturbed, there is a possibility of resorbing it, which leads to the release of fibrin from the exudate on the surface of the pleura. In this case, the pathological process is called fibrinous (dry) pleurisy.
In another case, when the rate of formation of exudate exceeds the rate of its outflow, an increased amount of pleural fluid in the lungs begins to squeeze them. Such a process is called exudative pleurisy.
Some experts identify several stages of development of pleurisy.
Stages of development of pleurisy
Pleurisy stage 1 (exudation phase) - characterized by enhanced production of pleural fluid. This process begins due to the expansion and increased permeability of blood vessels, which occurs due to activation of various biological substances by immune cells in response to infection in the body. The lymphatic system manages to remove excess fluid, so its amount in the pleura is still normal.
Pleurisy stage 2 (phase of the formation of purulent exudate) - characterized by the beginning of the deposition on the leaves of the pleura fibrin (plasma protein), which has a sticky property. This leads to friction of the pleura leaves among themselves, which is why the process of their soldering (splicing) is formed. Such an action leads to the appearance of so-called. "Bags" (pockets), because of which the outflow of fluid from the pleural cavity is difficult. Further, due to the constant accumulation in the pockets of pathological exudate, they accumulate particles of dead bacteria killed by immune cells, which, in combination with a number of proteins and plasma, leads to processes of festering. Pus in turn contributes to the development of inflammation of the adjacent tissues, and the outflow of fluid through the lymphatic vessels is disturbed. In the pleural cavity begins to accumulate in an excessive amount of pathological exudate.
Pleurisy stage 3 (recovery or chronic) - characterized by unauthorized resorption of pathological foci, or the transition of the disease into a chronic form.
Chronic pleurisy is characterized by a significant decrease in the mobility of the lungs, an increased thickness of the pleura itself, and deterioration of the outflow of pleural fluid. Sometimes this stage is accompanied by the formation of adhesions of the pleura (mooring) in some places, or the complete overgrowth of the pleura with fibrous fibers (fibrotorax).
The disease pleurisy is one of the most common pathological processes developing in the lungs, which occurs in 5-15% of all patients referring to the therapist.
There are no differences on the basis of gender - the disease is equally diagnosed in both men and women. The only thing noted is that 2/3 of pleurisy occurs in women with malignant tumors in the genitals, breasts, and systemic lupus erythematosus, while in men this pathology is most often found in alcoholism, rheumatoid arthritis and pancreatitis.
Often, pleurisy cannot be detected; therefore, there are no exact statistics of this disease, as well as no deaths. This is due to the fact that pleurisy is in most cases a complication of various diseases, which are already counted. Therefore, when opening people after an accident, the examination shows a high percentage of pleural fusion (about 48%), which indicates that the pleurisy had been transferred by a person before.
The main symptoms of pleurisy
- Cough - dry, unproductive, or with sputum of purulent character (usually with an infectious lesion), usually average in intensity,
- Shortness of breath, especially during exercise,
- The pain in the chest, which is caused by friction between the pleural sheets,
- Increased and high body temperature (up to 39 ° C and above, in diseases such as pneumonia) is characteristic mainly in the infectious form of the disease,
- Tracheal displacement - caused by excessive pressure of a large amount of exudate on the organs of the mediastinum, while the trachea is shifted to a healthy side.
Causes of pleurisy
The main causes of pleurisy:
- Chest injuries,
- Systemic diseases - rheumatoid arthritis, rheumatism, systemic lupus erythematosus, dermatomyositis, scleroderma, vasculitis (Churg-Strauss syndrome, Wegener's granulomatosis), sarcoidosis,
- Allergic reaction in response to allergens, pathological factors, infectious agents (exogenous allergic alveolitis, allergy to drugs and food),
- Effects on the body of toxic substances, including poisoning by ammonia, mercury and other substances,
- Irradiation of the body with ionizing radiation
- The impact on the lungs and pleura of pancreatic enzymes, which, when this organ becomes inflamed, enters the blood and affects the pleura in a destructive way, since these parts of the body are relatively close to each other,
The following factors may contribute to the development of pleurisy:
- The presence of respiratory diseases - sore throat, pharyngitis, laryngitis, tracheitis, bronchitis, pneumonia, emphysema, bronchial asthma, obstructive pulmonary disease and others,
- The presence of other diseases - diabetes, hypothyroidism,
- Alcoholism, smoking,
- Reduced reactivity of immunity than usually contribute to - hypothermia, hypovitaminosis, stress, abuse of drugs (especially glucocorticoids, cytostatics), the presence of infectious diseases (ARVI, ARD, influenza, HIV infection and others), gastric and 12 duodenal ulcers, pregnancy,
- Gastroesophageal reflux (re-throwing food from the stomach into the esophagus).
How does pleural infection occur?
- Airborne path - when you inhale polluted air, which often happens when you are near a sick person who is coughing and sneezing at this time,
- Hematogenous way (through blood) - pathogens in the presence of an infectious disease in any part of the body can get into the blood and with the blood flow into the pleura,
- Lymphogenous path (through the lymphatic system) - similarly, as through blood, an infection from any part of the body with a current of lymph can get into the pleura,
- Penetrating chest injury can lead to infection inside the body.
By the nature of inflammation:
Dry (fibrinous) pleurisy - it is characterized by sedimentation on the pleura of a high-molecular protein of blood plasma - fibrin, while the exudate remains in a minimum amount. Fibrin is a sticky filament, the presence of which with minimal fluid increases the friction of the pleura and, therefore, the lungs against each other. This leads to pain. Many experts distinguish dry pleurisy as the first stage of development of this pathology, after which exudative pleurisy develops.
Exudative (effusion) pleurisy - characterized by a significant amount of exudate in the pleural cavity, which leads to excessive pressure on nearby tissues and organs. Exudative pleurisy is accompanied by an increase in the area affected by the inflammatory process, a decrease in the activity of enzymes involved in the splitting of fibrin filaments, the formation of pleural pockets, in which pus can accumulate over time. In addition, lymph outflow is disturbed, and copious amounts of effusion helps to reduce the vital volume of the lung, which can cause respiratory failure.
According to etiology:
1. Infectious diseases that may be:
- Bacterial (staphylococcal, pneumococcal, streptococcal and others),
- Fungal (candidal, actinomycous and others),
- Parasitic (with amebiasis, paragoniasis, echinococcosis, and others),
- Tuberculosis - is characterized by a slow course with symptoms of general intoxication of the body, cough, effusion with a large number of lymphocytes, and sometimes characteristic cheesy pus.
2. Non-infectious (aseptic):
- Traumatic - caused by significant hemorrhage with injury to the chest, which leads to accumulation of blood in the pleural cavity (hemothorax). Further, coagulated blood, in the absence of suppuration, in combination with connective tissue begins to form thick moorings that limit the functioning of the lung. It is worth noting that with a small hemothorax, the blood is usually absorbed in the pleural fluid and does not have enough time to cause harm. With large hemothorax and severe trauma to the chest wall and lung, blood in the pleural cavity is clotted (coagulated hemothorax). Subsequently, if the nasal cord does not occur, a massive clot is subjected to organization by the connective tissue, as a result of which thick mooring lines are formed, limiting the function of the lung.
- Due to systemic diseases,
- Caused by other diseases - uremia, pulmonary infarction, asbestosis and others.
4. Idiopathic (the cause of the pathology is not identified).
By the nature of the effusion:
- fibrinous - characterized by a minimum amount of exudate with fibrin settling on the pleura,
- serous - characterized by a minimum amount of exudate without fibrin settling on the pleura,
- serous purulent - characterized by serous purulent effusion,
- purulent (pleural empyema) - characterized by accumulation of purulent exudate between the pleural sheets, which is accompanied by symptoms of intoxication and the presence of a threat to human life. The development usually occurs against the background of the defeat of the organism by the infection against the background of a decrease in the reactivity of the immune system, or by spontaneous opening of an abscess from the lung to the pleura.
- hemorrhagic - characterized by exudate with an admixture of blood, which usually develops with tuberculosis, pulmonary infarction, pancreatitis, pleural carcinomatosis,
- chillosis (chilothorax) - characterized by an abundant amount of exudate, in appearance resembling milk, which is associated with an admixture in the exudate of the lymph (hilyus),
- cholesterol - characterized by the presence in the effusion of cholesterol crystals,
- eosinophilic - eosinophils predominate in the effusion.
- Primary - the development of the disease occurs independently, without other pathologies,
- Secondary - the development of the disease occurs after other diseases (pneumonia, bronchitis, tracheitis, malignant neoplasms), various pathologies, inflammatory processes in the tissues adjacent to the pleura, etc.
1.1. Anti-infective therapy
As we have repeatedly mentioned, in many cases the cause of pleurisy is an infection - viruses, bacteria, fungi. Depending on this, they prescribe this or that group of drugs - antiviral, antibacterial, antifungal, etc.
Most often, it is bacteria that cause the pathology, so antibiotic therapy (antibiotic treatment) is the most common. Moreover, in the beginning it is usually prescribed broad-spectrum antibiotics, and after receiving the results of laboratory research to determine the infection and its sensitivity to a particular substance that is part of the drug, a specific drug is prescribed. The dosage and regimen of the drug depends on the diagnosis and the severity of the pathological process.
The most popular antibiotics for pleurisy:
- "Ampicillin" + "Sulbactam" - refers to penicillins, - acting on the wall of bacteria, blocks their reproduction. It is administered intravenously or intramuscularly. The daily dosage is 1.5 (mild), 3 (moderate), 12 (severe degree of the disease), but no more.
- Imipenem + Cilastatin, a broad-spectrum beta-lactam antibacterial drug, destroys the bacterial wall causing their death. The daily dosage is 1 - 3 g, for 2-3 doses.
- "Clindamycin" - blocks the synthesis of protein bacteria, due to which it stops its growth and reproduction. The dosage intravenously and intramuscularly is 300-2700 mg per day, orally - 150-350 mg.
- “Ceftriaxone” - destroys the wall of bacteria causing their death. The daily dosage is 1-2 g per day, intravenously or intramuscularly.
1.2. Anti-inflammatory therapy
The course of pleurisy during friction processes of the pleural sheets between them is accompanied by pain. For pain relief, nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids (hormones) are used.
Among the drugs NSAIDs can be distinguished - "Diclofenac", "Ibuprofen", "Nimesil", "Meloxicam".
Among the glucorticoids can be distinguished - "Prednisolone."
1.3. Detoxification therapy
Bacteria during their stay in the body poison it with products of their vital activity, which are toxins (poison) for humans. At the same time, the dead pathogens contribute to the formation inside the human foci of rotting. These two factors lead to symptoms of body toxicity, causing loss of appetite, nausea, general malaise and soreness.
Detoxification therapy is used to remove dead bacteria and toxins from living representatives of the infection, which includes:
- Intravenous infusion of solutions of glucose, polysaccharides ("dextran") and water-salt solutions,
- The use of diuretic drugs (diuretics) - "Furosemide",
- The use of detoxification drugs - "Atoxil", "Albumin".
Plentiful drink at pleurisy is not appointed as the excess liquid will increase an amount of an exudate in a pleural cavity.
1.4. Strengthening the immune system
The development of infectious diseases and pathologies is usually associated with a weakened immune system, since it is the immune system that is responsible for the body's resistance to the pathogenic microflora. In addition, the poisoning of the body with an infection further weakens the immune system.
To strengthen the immune system, immunomodulators are prescribed - "Imudon", "IRS-19", "Timogen".
Vitamin C (ascorbic acid) is a natural stimulant of immunity, a large amount of which can be found in dogrose, cranberries, lemon, dogwood, mountain ash, currants, and Kalina.
1.5. Normalization of beneficial intestinal microflora
In normal health, the human intestine contains beneficial microflora - bacteria that are involved in the digestion and assimilation of food, as well as the transformation of some of the beneficial substances of their food and their further absorption by the body.
The use of antibiotic therapy has a negative effect on this beneficial microflora, partially destroying it, therefore, the use of antibiotics is often accompanied by various side effects.
To restore the intestinal microflora, the use of probiotics is prescribed - Linex, Bifiform, Atsipol.
2. Surgical treatment of pleurisy
In many cases, with pleurisy, a pleural puncture is performed, which is also called thoracocentesis.
The essence of thoracocentesis is the introduction of a thick needle into the pleural cavity under local anesthesia, through which a certain amount of fluid is excreted from the body.
This manipulation is carried out for two purposes - taking pleural fluid (exudate) for diagnosis, as well as to remove excess exudate, if the main therapy did not lead to the desired results, or in combination, to more quickly release the pleural cavity from it.
The result of this manipulation for therapeutic purposes is the removal of pressure from the lung, which improves their respiratory mobility, and therefore the patient's well-being.
3. Diet for pleurisy
There are no specific nutritional guidelines for pleurisy. The diet is prescribed depending on a particular disease, due to which pathology has developed in the pleura.
But if to summarize the situation, then all the same it can be said that food for various, especially infectious, diseases should consist of products enriched with vitamins and microelements. This will lead to the strengthening of not only the immune system, but also the whole organism.
Treatment of pleurisy folk remedies
Important! Before using folk remedies for the treatment of pleurisy, consult with your doctor!
Horseradish. Mix 150 g of dry chopped horseradish root with juice of 3 lemons. It is necessary to accept means for half a teaspoon 2 times a day, in the morning on an empty stomach and in the evening before bedtime.
Badger fat. Make a mixture of 250 g of badger fat, 300 g of peeled and crushed aloe leaves and a glass of honey. Put the mixture for 15 minutes in the oven, for heating, after that the product must be drained and the remaining raw material discarded. Take this folk remedy for pleurisy need 1 tbsp. spoon 3 times a day, 30 minutes before meals.
Bow. Make a mush from a bulb of medium size, put it in a container. Then, closing his eyes, tilt his head to the mush and inhale with the mouth of her pair. This tool perfectly helps in the fight against various diseases of the respiratory system.
Onions and wine. Crush 300 g of onion and add 500 ml of dry white wine and 100 g of light honey. Put the mixture in a dark place to insist, shaking it daily. After that, strain the product and take 1 tbsp. spoon 4 times a day, 30 minutes before meals.
Ginseng. Grind the Caucasian ginseng root, which is not less than 3 years old, and put it in compression paper with small holes, after wrapping it with gauze, apply the product to the stomach area as a compress. Apply cotton on top of the compress and wrap the whole thing with a warm cloth. This procedure should be carried out after exudate is excreted from the body.