List of Diseases
Pleurisy
- inflammation of the pleura with the formation of a fibrinous plaque on its surface or an effusion in its cavity. It is always secondary, it is a syndrome or complication of many diseases, but at a certain period it can come to the fore in the clinical picture, masking the main disease.
Etiology, pathogenesis . The appearance of pleurites of infectious nature is caused by the inactivity of pathogens specific (Mycobacterium tuberculosis, pale Treponema) and non-specific (pneumococci, staphylococci, Escherichia coli, viruses, fungi, etc.) infections; pathogens penetrate the pleura by contact, lymphogenously, hematogenously, in violation of the pleural cavity. A common cause of pleurisy is systemic connective tissue diseases (rheumatism, systemic lupus erythematosus, etc.); neoplasms; thromboembolism and pulmonary artery thrombosis.
The pathogenesis of most pleurisy is allergic. In development of a blastomatous pleuritis the great value has blocking by metastasises of a tumour of lymph nodes, lymphatic and venous vessels in the tumor invasion of adjacent organs — serous destruction of the skin.
Etiology, pathogenesis . The appearance of pleurites of infectious nature is caused by the inactivity of pathogens specific (Mycobacterium tuberculosis, pale Treponema) and non-specific (pneumococci, staphylococci, Escherichia coli, viruses, fungi, etc.) infections; pathogens penetrate the pleura by contact, lymphogenously, hematogenously, in violation of the pleural cavity. A common cause of pleurisy is systemic connective tissue diseases (rheumatism, systemic lupus erythematosus, etc.); neoplasms; thromboembolism and pulmonary artery thrombosis.
The pathogenesis of most pleurisy is allergic. In development of a blastomatous pleuritis the great value has blocking by metastasises of a tumour of lymph nodes, lymphatic and venous vessels in the tumor invasion of adjacent organs — serous destruction of the skin.
Symptoms, the course is determined by the localization, prevalence, nature of pleural inflammation, changes in the function of neighboring organs.
The main forms of pleurisy: dry, or fibrinous, and effusive, or exudative.
Exudative pleurisy, in turn, is divided by the nature of the effusion into serous, serous-fibrinous, purulent, hemorrhagic, chylous, mixed. Having determined the nature of the effusion, you can specify the cause of pleurisy and choose pathogenetic therapy. Thus, the cause of dry and serous, serous-fibrinous pleurisy is more often tuberculosis, pneumonia (parapneumonic, metapneumonic pleurisy), rheumatism and other systemic diseases of the connective tissue (rheumatic, lupus and other pleurisy). Hemorrhagic pleurisy most often develops with neoplasms, thromboembolism and thrombosis of the pulmonary vessels, hemorrhagic diathesis, influenza, less often with tuberculosis, rheumatism. According to the localization of the effusion, there are paracostal, diaphragmatic, paramediastinal, and interstitial pleurites.
Dry, or fibrinous, pleurisy. The main symptom is pain in the side, which increases when inhaling, coughing. Pain is reduced in the position on the affected side. There is a noticeable restriction of respiratory mobility of the corresponding half of the chest; with an unchanged percussion sound, weakened breathing may be heard due to the patient's sparing of the affected side, the noise of pleural friction. Body temperature is often subfebrile, there may be chills, night sweats, weakness.
Dry, or fibrinous, pleurisy. The main symptom is pain in the side, which increases when inhaling, coughing. Pain is reduced in the position on the affected side. There is a noticeable restriction of respiratory mobility of the corresponding half of the chest; with an unchanged percussion sound, weakened breathing may be heard due to the patient's sparing of the affected side, the noise of pleural friction. Body temperature is often subfebrile, there may be chills, night sweats, weakness.
It is difficult to diagnose diaphragmatic dry pleurisy . They are characterized by pain in the chest, hypochondrium, in the lower ribs, hiccups, abdominal pain, flatulence, abdominal muscle tension, pain when swallowing. The type of chest breathing involves only the upper part of the chest and increased pain in the lower part of the chest with a deep breath. Pain points are detected: between the legs of the sternocleidomastoid muscle, in the first intercostal spaces near the sternum, at the place of attachment of the diaphragm to the ribs, on the spinous processes of the first cervical vertebrae.
In the recognition of diaphragmatic pleurisy, x-ray examination helps, which reveals indirect symptoms of functional disorders of the diaphragm: its high standing, restriction of its mobility on the diseased side (Williams ' symptom).
The course is favorable, the duration of the disease is 10-14 days, but there may be recurrences of dry pleurisy for several weeks with subsequent recovery.
Effusive, or exudative, pleurisy. At the beginning of pleural exudation, there is pain in the side, restriction of respiratory mobility of the affected side of the chest, and noise of pleural friction. Often there is a dry painful cough of a reflex nature. As the effusion accumulates, the pain in the side disappears, there are feelings of heaviness, increasing shortness of breath, moderate cyanosis, some swelling of the affected side, smoothing of the intercostal spaces. Percussion over the exudate revealed a dull sound; voice trembling and bronhofoniya weakened, the respiration is not carried out or significantly weakened; the above stupidity — timpieces shade of percussion sound, bronchial breathing, tone and finely wheezing.
Effusive, or exudative, pleurisy. At the beginning of pleural exudation, there is pain in the side, restriction of respiratory mobility of the affected side of the chest, and noise of pleural friction. Often there is a dry painful cough of a reflex nature. As the effusion accumulates, the pain in the side disappears, there are feelings of heaviness, increasing shortness of breath, moderate cyanosis, some swelling of the affected side, smoothing of the intercostal spaces. Percussion over the exudate revealed a dull sound; voice trembling and bronhofoniya weakened, the respiration is not carried out or significantly weakened; the above stupidity — timpieces shade of percussion sound, bronchial breathing, tone and finely wheezing.
During percussion and x-ray examination, the characteristic arched contour of the upper border of the effusion (the Sokolov-Ellis-Damoiseau line) can be determined.
A large effusion causes displacement of the mediastinum to the healthy side and significant impairment of respiratory function due to an impairment of the mechanics of breathing: reduced depth of breathing, it quickens; methods of functional diagnostics revealed a decrease in external respiration (lung vital capacity, reserves of ventilation, etc.). Disturbances of cardiovascular system: a decrease in the shock and minute volume of the heart due to a decrease in blood suction to the Central veins due to ventilation disorders, displacement of the heart and large vessels with large pleural effusions; compensatory tachycardia develops, blood PRESSURE tends to decrease.
For exudative pleurites, especially of an infectious nature, febrile body temperature is characteristic from the very beginning of pleural exudation, pronounced symptoms of intoxication, neutrophilic leukocytosis, increased ESR. Pleural exudate has a relative density higher than 1.016-1.018, is rich in cellular elements, gives a positive reaction of Rivalt.
The tumor etiology of pleurisy is excluded by cytological examination of exudate.
The course depends on the etiology of pleurisy. In infectious and allergic pleurisy, including tuberculosis, exudate can resolve within 24 weeks. Possible outcome with the development in the pleural cavity of the adhesive process, the growth of pleural cavities and interstitial slits, the formation of massive overlays, mooring, thickening of the pleura, the formation of pleuropneumocyrrosis and respiratory failure.
For purulent pleurisy, see "Empyema of the pleura".
Treatment is complex, includes active influence on the underlying disease and early energetic treatment of pleurisy, with effusive pleurisy is carried out in a hospital.
Treatment consists of the following components.
1. Antibacterial therapy for infectious and allergic pleurisy and targeted chemotherapy for pleurisy of other etiology (for example, tumor); antibiotics and chemotherapy drugs are administered parenterally, if indicated — intrapleural.
2. Sanitation of the pleural cavity by evacuation of exudate, and if necessary — washing with antiseptic solutions.
Indications for urgent evacuation: displacement of the heart and large vessels to the healthy side with a pronounced violation of heart function, collapse of the lung (severe shortness of breath, cyanosis, frequent small pulse, arterial hypotension).
Non-urgent indications: sluggish, prolonged course of pleurisy, no tendency to resorption of exudate.
3. Appointment of anti-inflammatory drugs (acetylsalicylic acid 1 g 3-4 times a day, voltaren or indamethacin 0.025 g 3-4 times a day, etc.).
In pleurisy of tuberculosis and rheumatic etiology, the use of prednisone in a daily dose of 15-20 mg is effective.
4. Inclusion of means aimed at mobilizing protective and immunobiological reactions of the body: individual regimen (in the acute period bed), a rational fortified diet with sufficient protein (1.5-2 g / kg), restriction of water and table salt, intravenous drip administration of plasma — substituting solutions for intoxication, individually dosed physical therapy, oxygen therapy, during the subsiding of pleurisy-physical methods of treatment.
5. Symptomatic therapy — immobilization of the sick half of the chest with tight bandaging (for pain), codeine for coughing; cardiotonic agents for circulatory insufficiency.
In the future, patients are subject to medical supervision for 2-3 years. Occupational hazards are excluded, and high-calorie nutrition rich in vitamins is recommended.
