Pleurisy - Causes, symptoms and treatment. MF.

Pleurisy is an inflammatory disease of the pleura that is characterized by the deposition of fibrin on their surface( fibrinous or dry pleurisy), or the accumulation of fluid in the pleural cavity( exudative pleurisy).

Normally a pleura is a thin transparent shell. The outer pleura leaf covers the inner surface of the thorax( parietal pleura), and the inner one - the lungs, the mediastinum organs and the diaphragm( visceral pleura).Between the pleura sheets under normal conditions, a small amount of liquid is contained.

Causes of pleurisy

Depending on the cause of the onset, all pleurisy divide into two groups: infectious and non-infectious. Infectious pleurisy are associated with the vital activity of pathogens. The causative agents of infectious pleurisy can become:

• bacteria( pneumococcus, streptococcus, staphylococcus, hemophilic rod and others).
• Mycobacterium tuberculosis.
• The simplest, for example, amoeba.
• fungi.
• parasites, for example, echinococcus.

As a rule, such pleurisy arise on the background of pneumonia, active pulmonary tuberculosis, less often with abscess of the lung or subdiaphragmatic space.

Non-infectious pleurisy occur in the following diseases:

• malignant tumors. It can be either a primary pleural tumor or a metastatic lesion in a tumor of another organ.
• systemic diseases such as systemic lupus erythematosus, rheumatoid arthritis and others, systemic vasculitis.
• chest trauma and surgery.
• pulmonary infarction after pulmonary embolism.
• myocardial infarction( post-wrinkle syndrome Dressler).
• Enzymatic pleurisy in acute pancreatitis, when pancreatic enzymes dissolve the pleura and turn out to be a pleural cavity.
• terminal stage of chronic renal failure( uremic pleurisy).

For the emergence of infectious pleurisy, the penetration of microorganisms into the pleural cavity is necessary. This can occur by contact from the foci of infection of the lung tissue, lymphogenous way with the current of the lymph, hematogenous - with the circulation of the pathogen in the blood. In the more rare cases, direct penetration of the pathogen from the environment is possible with injuries of the chest, and also during the operation. Penetrating microorganisms cause inflammation of the pleura with fluid swelling( exudate) into the pleural cavity. If the vessels of the pleura function normally, then this fluid is absorbed back. On the pleural sheets, fibrin settles( protein, in considerable amounts is contained in the sweat), dry pleurisy is formed. With a high intensity of the process, the vessels of the pleura can not cope with a large volume of exudate, it accumulates in a closed cavity. In this case, exudative pleurisy is diagnosed.

Schematic representation of right-sided exudative pleurisy.

In tumors, toxic products of the tumor damage the pleura, which leads to the formation of exudate and significantly hampers its reabsorption. In systemic diseases, as well as in vasculitis, pleurisy is caused by the defeat of small vessels of the pleura. Traumatic pleurisy occur as a pleural reaction to hemorrhage. Pleurisy in chronic renal failure is associated with the action of uremic toxins. Enzymatic pleurisy is associated with irritation of the pleura by enzymes from the damaged pancreas. When a lung infarct occurs, noninfectious inflammation by contact passes to the pleura. And with myocardial infarction, the leading role in the occurrence of pleurisy plays a violation of immunity.

Symptoms of pleurisy

In most cases, dry pleurisy develops acutely. Patients usually clearly indicate the time of onset of the disease. Characteristic complaints of pain in the chest, an increase in body temperature, a pronounced general weakness.

Pain in the chest is associated with irritation of the nerve endings of the pleura with fibrin. The pain is more often one-sided on the side of the lesion, quite intense, with a tendency to increase with deep inspiration, coughing, sneezing. Body temperature rises to 38 ° C, rarely higher. With the gradual onset of the disease at first, the body temperature can be normal. Also worried about general weakness, sweating, headache, unstable pain in the muscles and joints.

In exudative pleurisy, the symptoms are caused by the accumulation of fluid in the pleural cavity. Complaints vary depending on the variant of onset of the disease. If exudative pleurisy appeared after fibrinous, then it is possible to trace a clear chronology of events. At the beginning of the disease, the patient is disturbed by intense unilateral pain in the chest, which is intensified by deep inhalation. Then, when the exudate forms, the pain disappears, and in its place comes a feeling of heaviness, pressure in the chest, shortness of breath. There may also be dry cough, fever, general weakness. If exudative pleurisy occurs primarily, then in this case the pain syndrome is not characteristic. In this case, patients complain of general weakness, sweating, fever, headache. A few days later, shortness of breath, a feeling of heaviness in the chest with little physical exertion, and with a large amount of exudate - at rest. In this case, the nonspecific symptoms of intoxication are intensified.

If you have the above complaints, you urgently need to contact the therapist .With progressive deterioration of the condition( increase in body temperature, the appearance of difficulty breathing, increased dyspnea), hospitalization is shown in the hospital.

Diagnosis of pleurisy

An external examination performed by a doctor is very important for diagnosing pleurisy and determining its nature. When auscultation( listening to the lungs in different phases of breathing with a stethoscope), a noise of friction of the pleura can be detected, which is specific for fibrinous pleurisy, with exudative pleurisy during percussion( tapping a certain area to reveal characteristic sound phenomena), dullness of percussion sound above the effusion zone is noted. Thus, it is possible to determine the spread of exudate in the pleural cavity.

In general and biochemical blood tests, nonspecific inflammatory changes are noted: acceleration of ESR, increase in the number of leukocytes;appearance or increase in the concentration of inflammatory proteins-CRP, seromucoid and others.

Instrumental methods play a significant role in the diagnosis of pleurisy, as they allow you to see the area of ​​the lesion and determine the nature of the inflammatory process. When radiographing the lungs in the case of fibrinous pleurisy, it is possible to determine the high standing of the dome of the diaphragm on the affected side, limiting the mobility of the pulmonary margin during respiration, and also consolidating the pleura sheets.

Radiography of the lungs with fibrinous pleurisy. The arrow shows a thickened pleura.

In exudative pleurisy, a compressed, diminished lung in the side of the lesion is characteristic, below which a liquid layer is seen to be uniform or with inclusions.

Radiography of the lungs with exudative pleurisy. An arrow shows a layer of liquid.

Ultrasound of the pleural cavities with fibrinous pleurisy reveals the deposition of fibrin on the pleura sheets with their thickening, and with the escudative layer of the fluid below the lung. The nature of the effusion, and often the cause of pleurisy, is determined on the basis of the analysis of exudate obtained as a result of pleural puncture.

Treatment of pleurisy

Treatment of pleurisy should be complex, individual and directed at the main cause of the disease. With pleurisy caused by infections, shows the use of broad-spectrum antibacterial drugs for the first few days. Then, after determining the pathogen, specific therapy is recommended. Anti-inflammatory drugs( voltaren, indomethacin) and desensitizing therapy are also used.

Non-infectious pleurisy , as a rule, is a complication of another disease. Therefore, along with nonspecific treatment, a complex treatment of the underlying disease is necessary.

Surgical evacuation of exudate is performed in the following cases:

• large amount of exudate( usually reaching the II rib);
• when exudate by exudate surrounding organs;
• to prevent the development of empyema( the formation of pus in the pleural cavity) of the pleura.

Currently, a one-stage removal of not more than 1.5 liters of exudate is recommended. With the development of empyema after the evacuation of pus into the cavity of the pleura, a solution with an antibiotic is introduced.

Pleural puncture is performed, as a rule, under stationary conditions. This manipulation is carried out in the position of the patient sitting on a chair with the support on the hands. As a rule, puncture is carried out in the eighth intercostal space along the posterior surface of the thorax. Anesthesia is made for the site of the proposed puncture with novocaine solution. With a long thick needle, the surgeon punctures the tissue layer by layer and enters the pleural cavity. Exudate begins to flow down the needle. After removing the required amount of fluid, the surgeon removes the needle, a sterile dressing is applied to the puncture site. After the puncture, the patient is observed for several hours under the supervision of specialists because of the danger of a pressure drop or the development of complications associated with puncture technique( hemothorax, pneumothorax).The next day, a chest X-ray is recommended. After that, with good health, the patient can be sent home. Pleural puncture is not a complicated medical manipulation. Preoperative preparation, as well as subsequent rehabilitation, as a rule, is not required.

For fibrinous pleurisy is characterized by a favorable course. Usually, after 1-3 weeks of treatment, the illness ends with recovery. The exception is pleurisy with tuberculosis, which is characterized by a prolonged slow flow.

During exudative pleurisy of several stages are distinguished: in the first stage there is intensive formation of exudate and all the above-described clinical picture is revealed. This stage, depending on the cause of inflammation and the concomitant state of the patient, lasts 2-3 weeks. Then comes the stage of stabilization, when exudate is no longer formed, but also its reverse absorption is minimal. In the final of the disease, the excudation is removed from the pleural cavity by natural or artificial means. After the removal of exudate very often between the pleural sheets are formed connective tissue bands - adhesions. If the adhesion process is expressed, it can lead to impairment of lung mobility during breathing, development of stagnant phenomena, in which the risk of re-infection increases. In general, in most cases, in patients with exudative pleurisy after treatment a complete recovery occurs.

Complications of pleurisy

Complications of pleurisy include: the formation of adhesions of the pleural cavity, empyema of the pleura, a blood circulation disorder due to vasodilation with a large amount of exudate. Against the backdrop of inflammation, especially with prolonged recurrent or recurrent pleurisy, there is a thickening of the pleura sheets, fusing them together, as well as the formation of adhesions. These processes deform the pleural cavity, leading to a disruption of respiratory mobility of the lungs. In addition, due to the fusion of the pericardium with a pleural leaf, there may be a displacement of the heart. With a pronounced adhesive process, the risk of developing respiratory and heart failure is high. In this case, the surgical separation of pleural sheets is shown, the removal of adhesions. Empyema of the pleura occurs when suppuration exudate.

Empyema of the pleura

The prognosis for pleural empyema is always serious, in elderly and weakened patients the mortality rate is up to 50%.Suspicion of suppuration of exudate can be in the following cases:
• while maintaining a high body temperature or returning a fever against the background of antibiotic therapy.
• with the appearance or strengthening of pain in the chest, dyspnea.
• while maintaining a high level of white blood cells against the background of antibiotic therapy, and the addition of anemia.

Pleural puncture is necessary for the diagnosis of pleural empyema. If there is pus in the puncture, a large number of leukocytes and bacteria, the diagnosis of pleural empyema is beyond doubt. Surgical treatment consists in evacuating purulent contents, washing the pleural cavity with solutions of antiseptics, as well as massive antibiotic therapy.

Another dangerous complication of exudative pleurisy is the compression and mixing of blood vessels with the accumulation of a large volume of fluid. If the flow of blood to the heart is difficult, death occurs. To save the life of the patient in an emergency order, the removal of fluid from the pleural cavity is indicated.

Doctor therapist Sirotkina EV