hydrothorax - it is the excessive accumulation of transudate between the parietal and visceral pleura, is a complication of other diseases, and manifests itself in the form of breathing, and in more cardiovascular disorders.
Signs hydrothorax occur only in a situation where the normal relationship between disturbed colloid osmotic pressure of the blood plasma and capillary hydrostatic pressure towards the prevalence of the latter.Pathogenesis hydrothorax is that this state takes a long period of time, during which through the intact vascular wall of the capillary network propotevaet liquid containing a limited amount of protein (transudate).
hydrothorax characteristic feature is that this pathology is not an independent disease entities, and only occurs as a complication of other diseases.
etiopathogenetic most common cause of hydrothorax is chronic cardiovascular collapse with accompanying changes stagnant in all organs and systems.The major organic p
Bilateral hydrothorax often develops in severe forms of destruction pyelocaliceal apparatus kidneys, accompanied by renal insufficiency (amyloidosis, glomerulonephritis with nephrotic syndrome).The mechanism of propotevanie fluid in the pleural cavity in a given situation based on the expressed hyperproteinemia.
patients suffering from cirrhosis of the liver with concomitant ascites, in 10% of cases the right hydrothorax formed as a result of penetration of ascites from the abdominal cavity into the right pleural cavity through a small violation of the integrity of the dome of the diaphragm.The same pathogenetic mechanisms of hydrothorax observed during peritoneal dialysis.
Talking about the type of hepatic hydrothorax is possible only in the case of accumulation of exudate in one or both pleural cavities of more than 500 ml in the absence of changes in the activity of the heart and lung function.Favourite localization of hepatic hydrothorax genesis is the right pleural cavity that is at least 80% of the cases.
Despite the fact that the tumor growths of the mediastinum are rare disease, in most cases, the disease is accompanied by the development of signs hydrothorax with the accumulation of lymph in the pleural cavity.
only condition for the occurrence of an exception indication hydrothorax is a complete obliteration sheets visceral and parietal pleura.
Signs and symptoms of hydrothorax
Small hydrothorax (up to 150 mL volume of liquid), which was a complication of a particular organic disease had no effect on the severity of the underlying disease, whereas hydrothorax total may have independent clinical manifestations causedcompression of the mediastinum and the pulmonary parenchyma.
most common form of accumulation of transudate between the pleura is a double-sided and right-sided hydrothorax, while isolated hydrothorax on the left is very rare.In patients with severe cardiovascular disease is often observed associated accumulation of excess fluid in the pleural not only, but also the abdominal, the pericardial cavity, as well as subcutaneous fat.
Debut clinical manifestations usually has a gradual flow, and symptoms develop only in the accumulation of a large volume of liquid in one or both of the pleural cavity.The most common complaints that placing patients with hydrothorax, are gradually increasing shortness of breath, a feeling of heaviness in the lower chest cavity, a sense of shortness of breath.Unlike pneumothorax when existing fluid accumulation in the pleural cavity not observed pronounced pain and fever as a transudate offline inflammatory component.
by visual examination of the patient is determined by objective akrotsianoz skin and limit the affected part of the chest with unilateral localization process.In some cases, already at the first contact with the patient can be suspected the existence of a hydrothorax, because of shortness of breath to eliminate the patient is a typical situation for this disease, "half-sitting" or "lying on the affected side."
characteristic features of hydrothorax percussion lung is the presence of a blunt percussion sound with an upper limit of kosovoskhodyaschey locally over the place of the alleged accumulation of fluid, and auscultation symptoms is considered a complete absence of vesicular breath over the affected area.In marked pleural effusion, a shift percussion borders of relative dullness of heart, as a reduction of the compression effect of the fluid in the organs of the mediastinum.
In a situation where in addition to accumulation of fluid in the pleural cavity, there are signs of hydrops and ascites, the patient noted a visible increase in the abdomen with advanced venous collaterals on the anterior abdominal wall, as well as severe swelling of soft tissues.
clinical features has hydrothorax occurring against a background of cirrhosis with signs of portal hypertension.In patients with cirrhotic liver symptoms of respiratory failure occur even when a small amount of pleural effusion.Patients with hepatic hydrothorax likely to develop complications such as spontaneous bacterial peritonitis and concomitant bacterial pleural empyema.
Infection of the pleural cavity, containing effusion, accompanied by a significant deterioration of the patient: the emergence of stabbing chest pain, severe fever, increase of the phenomena encephalopathy.The most common causative agents of empyema in hepatic hydrothorax are Escherichia coli and Klebsiella.
Quality timely diagnosis of hydrothorax largely affects the healing process of the patient and the algorithm consists of the following laboratory and instrumental activities:
- initial examination of a patient with a thorough history of the disease and determine the complaints of the patient;
- an objective examination of the patient with palpation, auscultation of the heart and lungs, percussion borders of the heart and lung sounds;
- ray methods of diagnosis of the chest (X-ray, ultrasound, computed tomography);
- diagnostic pleural puncture followed by cytological, microbiological studies punctate.
most affordable and easy-to-use method of diagnosis of hydrothorax is an X-ray, which allows not only to reveal the existence of fluid in the pleural cavity, but also to establish the approximate amount of effusion, as well as to assess the state of the mediastinum.Characteristic signs skialogicheskimi hydrothorax is the presence of a homogeneous shade of various sizes with kosovoskhodyaschey a clear upper boundary, the lower loop adjacent to the dome of the diaphragm is displaced during respiratory movements.Pleural sinuses in such a situation it is not possible to visualize.If you have a limited small amount of effusion it is recommended to perform radiography in the "lying on the painful side."
In a situation where there is a large amount of fluid in the pleural cavity of one of the conditions are created for the compression of the mediastinum on chest radiograph that looks like a shift of the middle shade in a healthy way more in the lower divisions.
Ultrasound scan pleural cavities accurately estimate the amount of effusion, but with this method, it is impossible to assess the impact of research existing effusion on lung function.The ultrasonic method has been successfully applied in the performance of medical pleural puncture.
most informative method of diagnosis of hydrothorax is currently computed tomography, because in addition to establishing the existence of even a small amount of fluid in the pleural cavity, the imaging technique can reliably determine the pathology that is the root cause of occurrence of hydrothorax, which has a large role in determining treatment strategypatient.
diagnostic pleural puncture is performed after using established methods of radial diagnostics diagnosis "hydrothorax".Its purpose is to study of the pleural punctate for the presence of an inflammatory component, cytological examination, and in some cases perform bacterial seeding agents to determine the specific infectious diseases.
thoracentesis or pleural puncture is a minimally invasive surgical procedure, which can produce not only the surgeon but also a pulmonologist.It does not require medical intervention-specific training of the patient and is performed under local anesthesia.
To use a special needle thoracentesis "trocar" large diameter, has a connection with a rubber adapter, which is located at the end of a system for pumping the contents of the pleural cavity.The best position of the patient during pleural puncture is to "sitting with a slope of the upper part of the chest forward."As an anesthetic used Novocaine by which cut away the intended puncture site (seventh intercostal space on the anterior axillary line).After the manipulation necessarily imposed tight sterile dressing and the patient should stick to the day of bed rest.
Although pleural puncture that requires massive surgical intervention, in its implementation may be a manifestation of complications in the form of: violating the integrity of the lung, liver and diaphragm, followed by intrapleural bleeding, air embolism vessels supplying the brain.With a view to the diagnosis of complications pleurocentesis necessarily make test X-ray examination of the chest cavity.
Laboratory Methods used in order to clarify the nature of occurrence of hydrothorax.Among the diagnostic procedures used most often:
- urinalysis (usually found varying degrees of severity of proteinuria, increased relative density of urine, as well as increasing the number of red blood cells and white blood cells, testifying in favor of the development of glomerulonephritis);
- changes in the biochemical analysis of the blood to a greater extent affect the quantitative content of protein in the blood with the redistribution of protein fractions (albumin decrease in the blood);
- general analysis pleural punctate (at hydrothorax effusion has the form of a transparent liquid of light yellow color with a high protein content of greater than 20 g / l and a specific gravity of less than 1.015);
- conduct tests Rivalta (hydrothorax when it is negative);
- cytological analysis of punctate for the presence of atypical tumor cells;
- bacteriological analysis of pleural punctate for the presence of specific pathogens of infectious disease (Mycobacterium tuberculosis).
pleural punctate obtained by puncture of the pleural cavity of the patient with hepatic hydrothorax, also represents a transudate, but has some features: protein content of less than 25 g / l, the ratio between the pleural and whey protein is less than 0.5, acidity over 7.4
Cthe purpose of diagnosing the type of hepatic hydrothorax, which occurs when severe cirrhosis apply surgical aperture imaging defects and for determining their type (blisters, slit) for subsequent determination of surgical treatment.
Identification in the pleural punctate atypical cells demonstrates the process of malignancy.Patients with such changes need doobsledovanii using thoracoscopy with biopsy of the pleura.
Due to the fact that the hydrothorax is not an independent disease, but a complication of other pathologies, in determining the tactics of the patient and the treatment must be based on the identification of the underlying pathology, which was the root cause of accumulation of fluid in the pleural cavity and carryingetiopathogenetic therapy.In the absence of adequate treatment of the underlying disease is observed hydrothorax and further progression of severe respiratory and cardiovascular disorders.
In a situation where hydrothorax is a complication of chronic diseases of the cardiovascular system, accompanied by stagnant changes in the lungs, treatment should begin with the correction of the patient's behavior and the purpose of a balanced diet.Thus, the patient should adhere to the correct optimum mode of work with normalization of sleep a night, and the exclusion of the effects of stress, accompanied by psycho-emotional strain.Correction of eating behavior involves the use of a fractional restricted diet Eat salt and fluid intake daily norm.
Conservative treatment of these patients lies in enhancing cardiac contractility and for this purpose the preparations of cardiac glycosides (digoxin 0.25 mg 4 / day orally), phosphodiesterase inhibitors (Theophylline in a daily dose of 400 mg orally).For the purpose of removing excess fluid from the body and prevent its accumulation in the pleural cavity is recommended systematic appointment of diuretic drugs: carbonic anhydrase inhibitors (Diakarb a daily dose of 250 mg in the morning), thiazide diuretics (indapamide 0.25 mg in the morning), potassium-sparing diuretics (a daily Veroshpiron200 mg).To decrease the preload on the left side of the heart in this case it is advisable use of ACE inhibitors (captopril 6.25 mg for 2 p / day orally), peripheral vasodilators (nitroglycerin 5 mg sublingual 2 p / d).
If the development of hydrothorax due to severe renal impairment accompanied by edema, nephrotic syndrome, the treatment the patient should begin with providing him strict bed rest and the appointment of a special diet with a full exception of salt and control diuresis (urine output in any case shall not be less thanvolume drunk per day of liquid).
To correct the protein composition of blood transfusions is recommended to replace 20% solution of albumin rate of not less than five and one-time infusion of 150 mL, and the co-administration of drugs that prevent excess urinary protein excretion (Ramipril at a daily dose of 2.5 mgp.o.).A positive effect in relation to the fight against excessive accumulation of fluid diuretics have used long courses.
in hepatic hydrothorax main treatment is a liver transplant and palliative therapies (use of adequate scheme diuretic therapy, therapeutic thoracentesis, and if necessary a massive antibiotic therapy with third generation cephalosporins in combination with fluoroquinolones).
In the absence of marked clinical improvement of the patient's condition, despite the ongoing conservative therapeutic measures, we recommend the use of operational methods of treatment (closure of diaphragmatic defects, overlay shunt).