Hydrothorax( chest water drop) - Causes, symptoms and treatment. MF.

Hydrotorax( thoracic edema) is a collection of fluid of non-inflammatory nature and origin( transudate) in the pleural cavities.

The causes of hydrothorax

Hydrotorax may occur when cardiac failure is decompensated with the development of stagnation in a large circulatory system;with kidney diseases accompanied by the development of nephrotic syndrome( glomerulonephritis, kidney amyloidosis and others);with cirrhosis of the liver, with myxedema( a disease caused by insufficient production of thyroid hormones);in the presence of large tumors in the mediastinum( anatomical space in the middle of the thoracic cavity, bounded in front of the sternum, and behind the spine), squeezing the upper vena cava and the shoulder-head veins. The accumulation of non-inflammatory fluid in the pleural cavities in some cases can be observed with alimentary dystrophy, caused by a pronounced lack of vitamins B and C, as well as in connection with a violation of lymph drainage.

Symptoms of hydrothorax

The main manifestations of hydrothorax are caused by the dynamic accumulation of fluid in the pleural cavities and compression of the lungs, as well as displacement of the mediastinal organs. The onset of the disease is usually gradual. With an increase in the amount of transudate in the pleural cavities, a feeling of heaviness in the chest appears, the intensity of the subjective sensation of lack of air increases, which is accompanied by an increase in the frequency and depth of the respiratory movements. Appears and intensifies cyanosis( bluish coloration of the skin, due to the accumulation of carbon dioxide in the blood).

Pain sensations in the chest are not typical. With a significant accumulation of fluid, protrusion and restriction of mobility of the corresponding half of the thorax is determined and its lagging behind in the act of breathing from the healthy one, as well as the smoothness of the intercostal spaces on the diseased side. In the lying position, it is easier for the patient to be on the sore side, since this does not lead to difficulty breathing. With very large volumes of fluid, the patient tries to adopt a semi-sitting position. Body temperature, as a rule, does not increase.

Examination of

A doctor examines the dullness of percussion sound( percussion - tapping on individual parts of the body followed by analysis of the sound phenomena that occur there) over the accumulated fluid, and with auscultation of the lungs( auscultation - listening to sounds generated by the functioning of organs)or weakening of breathing in this place.

More often hydrothorax is bilateral and is often accompanied by hydropericardium( accumulation of fluid in the pericardial bag) and ascites( accumulation of fluid in the abdominal cavity).
In the diagnosis of chest radiology, ultrasound( ultrasound) of the pleural cavities and computed tomography( CT) scan of the thoracic organs are of great importance. Radiologically, hydrothorax manifests itself as a uniform darkening occupying the most low-lying parts of the pleural cavity;this obscuration is easily displaced when the position of the body changes. When ultrasound is found free fluid in the pleural cavity, it is possible to more accurately estimate its volume. In CT, it is possible to detect, in addition to free fluid in the pleural cavity, some of the causes that triggered the development of hydrothorax( for example, tumors or enlarged mediastinal lymph nodes that squeeze the upper vena cava).

X-ray of a patient with a left-sided hydrothorax( uniform darkening in the lower parts of the left pulmonary field - surrounded by a black circle).

What tests will you have to take if you suspect a hydrothorax.

1. General blood test: usually does not have diagnostic significance with hydrothorax, as changes in it in chest water drop are usually not observed. In diseases of the kidneys that caused breast dropsy, anemia, an increase in ESR, is possible.

2. General analysis of urine: reflects characteristic changes in hydrothorax caused by renal disease due to impairment of their function: massive proteinuria( excretion of protein in the urine), presence of urine in cylinders, erythrocytes, leukocytes, increased relative density of urine.

3. Biochemical blood test: can reflect changes caused by impaired renal function( hypoproteinemia - decrease in plasma protein content, increase in nitrogenous slag content) or liver( increased direct and indirect bilirubin, hypoproteinemia, alanine aminotransferase, etc.).

4. The general analysis of obtained from pleural puncture fluid from the pleural cavity with hydrotorax corresponds to the transudate: the liquid is clear, light yellow or light green in color, in some cases it can contain bloody impurity, has an alkaline reaction, the protein content in it does not exceed2-3%( 20-30 g / l), the relative density is not more than 1.015.

5. Rivolta( Rivolta) assay is a qualitative reaction to a protein used to distinguish between a transudate and an exudate. In a solution of acetic acid, the laboratory assistant adds 1-2 drops of the test fluid from the pleural cavity. In an acid medium, the dissolved protein is denatured and precipitates. If the falling drop forms a cloudiness in the form of a white cloud falling to the bottom of the tube, the sample is positive, respectively, the test fluid is an exudate with a protein content of more than 3%.A drop of turbidity does not form turbidity.

6. Cytological examination of evacuated for pleural puncture fluid allows excluding exsudative pleurisy of tumor origin. For this, the fluid obtained by puncture is centrifuged and cytological preparations( smears) are prepared from the sediment, which are then stained using the Romanovsky-Giemsa method. Finished drugs, the cytologist examines under a microscope. With hydrotorax, there are no tumor cells in the smear, but mesothelium cells lining the inside of the pleural cavity can be detected.

7. Bacteriological study of fluid is performed to exclude tuberculous pleurisy. Sowing of the fluid obtained from the pleural cavity is performed on artificial nutrient media with subsequent evaluation of the results.

Treatment of hydrothorax

Treatment with hydrothorax is reduced to therapeutic measures and pleural puncture.
Therapeutic measures are aimed at treating the underlying disease that caused the development of hydrothorax.

Thus, in case of hydrothorax caused by the presence of heart failure in the patient, the patient is recommended to optimize the work and rest regime, exclude psychoemotional stress conditions, normalize sleep. Assign a diet number 10 or 10a with restriction of intake of water and table salt, and the food itself should be fractional( up to 5-6 times a day with a single meal intake of a small amount of food).Drug treatment may be aimed at increasing the reduced contractility of the myocardium( appoint cardiac glycosides, β-adrenoreceptor stimulants, phosphodiesterase inhibitors), removing excess fluid from the body by prescribing diuretics( carbonic anhydrase inhibitors, looped, thiazide and thiazide-like, potassium-sparing diuretics),reduction of the load on the left ventricle of the heart( peripheral venous, arterial and mixed vasodilators, ACE inhibitors).

With the development of hydrothorax, which is caused by kidney disease, accompanied by the development of nephrotic syndrome( glomerulonephritis, amyloidosis of the kidneys), it is recommended to rest bed, the observance of which contributes to the increase in urine production, prescribe diet number 7 with strict restriction of salt intake( until complete exclusion with a pronounced edematoussyndrome) and control of the volume of the drunk fluid, which should not exceed more than 200-300 ml of the volume of urine released per day. Correction of protein metabolism disorders is carried out, for which the optimal protein content in food is provided, drugs that help to reduce protein loss in the urine( ACE inhibitors) are prescribed, if necessary, 20% albumin solution is poured( 100-150 ml once every 2-3 days by the courseup to 5-6 infusions);appoint diuretics( thiazide, "loop", potassium-sparing diuretics).

In case of development of hydrothorax in cirrhosis, the amount of liquid to be drunk is reduced to 1.5 liters per day and table salt( diet No. 7), the amount of protein in the daily diet should be at least 70-80 g. If necessary, diuretics are prescribed.

With a significant accumulation of fluid in the pleural cavity leading to compression of the lungs and the development of respiratory failure, is used for pleural puncture with a slow removal of the transudate from the pleural cavity. This therapeutic manipulation is simultaneously diagnostic, as the nature of the obtained fluid and the results of its laboratory study make it possible to distinguish hydrothorax from exudative pleurisy, hemothorax, pleural empyema.

Pleural puncture is performed in the patient's position while sitting with the hands in front of him under local anesthesia, usually at the lowest point of the pleural cavity. A special long and thick puncture needle is used. A typical place for puncture is the eighth intercostal space on the posterior surface of the thorax. In the area of ​​the puncture, a thin needle is injected layer by layer into the soft tissues with 0.5 solution of novocaine in a volume of 10-15 ml, after which the doctor enters the puncture needle into the pleural cavity, through which the liquid slowly drains. It is recommended to remove at the same time not more than 1.5 liters of liquid, as evacuating more can cause a rapid displacement of the mediastinal organs and a drop in blood pressure. After removing the needle, the puncture site is sealed with a sterile bandage.

The liberation of the pleural cavity from the transudate leads to the relief of breathing and helps to normalize the circulation. Pleural puncture is considered relatively simple manipulation, which does not require any preliminary preparation from the patient and does not impose any significant restrictions on him after it has been performed. The next day after puncture, it is mandatory to perform a control radiograph of the lungs to exclude possible complications of pleural puncture( pneumothorax due to a lung puncture).With the recurrent nature of the hydrothorax, repeated pleural cavity punctures are resorted to, sometimes repeated.

Schematic representation of pleural puncture: 1 - left lung, pre-compressed by fluid in the pleural cavity;2 - free fluid in the left pleural cavity;3 - a reservoir for collecting the fluid sucked from the pleural cavity.

Complications of hydrothorax

The main complication of hydrothorax is the development of acute respiratory failure due to compression of the pulmonary tissue with liquid, which greatly aggravates the course of the underlying disease. In case of infection, it is possible to develop pleural empyema( accumulation of pus in the pleural cavity), which is a very serious disease.

Prevention of hydrothorax

Prevention of hydrothorax is reduced to the timely treatment of diseases, which in case of decompensation can lead to its development.

Prognosis

The prognostic value of thoracic dropsy is that its increase aggravates the severity of the underlying disease, especially decompensated heart failure.

Doctor surgeon Kletkin ME