pleurisy - this inflammatory changes in the pleural membranes, accompanied by accumulation of fluid in the pleural cavity.Pleurisy is a complication of various diseases and not a nosological unit.Depending on the origin of the main two groups of isolated pleurisy: infections (tuberculosis, staphylococcus, streptococcal) and aseptic (carcinomatous, rheumatic, cardiac).
If the fluid accumulates in the pleural cavity of a limited area, then set the conclusion of "encysted pleurisy", if the liquid contents freely spreads on the pleural cavity, it must be assumed "diffuse pulmonary effusion."
Depending on the composition of the contents of the pleural cavities are distinguished: fibrinous or dry pleurisy, serous, purulent and hemorrhagic types of pleural effusion.
cause infectious pleurisy can be various types of micro-organisms (viruses, anaerobes, fungi, Gram-negative and Gram-positive bacteria, Legionella, Mycobacterium tuberculosis, and others).
Infectious pleurisy are complications of lung diseases inflammatory nature, which include - pneumonia, lung abscess, pulmonary tuberculosis.
often pleurisy is the result of a fungal lung disease actinomycosis, blastomycosis, coccidioidomycosis.
pleurisy infectious and inflammatory nature most often occurs as a result of contact with pathogens from infected areas of the lung into the pleural cavity in the presence of foci of pneumonia or lung abscess.It is also possible hematogenous path of introduction of infection into the pleural cavity in septic lesions.During open abdominal surgical interventions, conditions are created for direct infection of the pleura microorganisms from the external environment.
Almost 100% of the infectious pleurisy arise in the case of existing infectious and allergic process, that is, during the initial contact with pathogenic bacteria in the pleural membrane starts primary sensitization mechanism which manifests itself a chain of chemical reactions with the formation of biologically active substances (serotonin, histamine).These bioactive substances induce an increase in vascular permeability at the microcirculatory level, whereby the engine runs exudate formation, which is the substrate of pleurisy.
main causes of aseptic pleurisy are:
- cancer of the chest cavity (central and peripheral lung cancer, pleural mesothelioma, lung metastases).Inflammation of the pleura is the result of direct destruction of lung tissue, and as a result of violations of lymph
- traumatic and surgical lung injury in which inflammation of the pleura caused by an accumulation of blood in the pleural cavity
- diffuse connective tissue diseases (systemic lupus erythematosus, scleroderma, dermatomyositis)accompanied by systemic lesion of the vascular bed at the microcirculatory level, followed by the formation of fluid in the pleural cavity
- pulmonary embolism always ends with the development of a heart attack, pneumonia due to massive perfusion disorders, which creates conditions for the formation of pleural effusion
- pancreatitis, in which pleurisy is caused by irritantpancreatic enzymes in the pleura
- rheumatic disease
- drug poisoning (overdose or long-term use of immunosuppressive agents, antibacterial agents)
- physical inactivity and poor nutrition
purulent pleurisy develops against the background of destructive lesions of the lung tissue, as well as public organ damagethoracic cavity.
The clinical picture of any pleurisy are three main symptom syndrome of dry, exudative and purulent pleurisy.
Dry pleurisy manifests itself in constant discomfort in the chest, pain in the respiratory movements of referred in the neck, upper extremities and the upper half of the abdomen.For relief of pain the patient takes a forced position "lying on its side."Breathing becomes shallow and rapid, and with one-sided pleurisy asymmetrical.Already at the initial examination of the patient experienced doctor may suggest a dry pleurisy due to the presence pathognomonic auscultatory phenomenon called "pleural rub."
exudative pleural effusion is characterized by a decrease in pain and come to the fore symptoms of respiratory failure - increasing shortness of breath, heart palpitations, acrocyanosis, throbbing veins of the neck, cough without sputum discharge.The affected side of the chest is not only involved in the act of breathing, but there is a slight protrusion of the intercostal spaces.
If the amount of effusion is more than 300 ml, it is possible to determine the sign of the presence of fluid in the pleural cavity in a dull percussion sound over the place of the alleged accumulation of fluid.Auscultation signs of effusion pleurisy are: the complete absence of vesicular breath over the affected areas of the lungs and krepitiruyuschie crackles above the liquid level.
purulent pleural effusion or empyema accompanied by a bright clinical picture, in which the fore signs of inflammatory changes in the body (a sharp increase in body temperature to high numbers, sweating and chills), and the growing intoxication syndrome (general weakness, loss of appetite,weight loss).Pain and signs of respiratory failure progresses the accumulation of pus in the pleural cavity.If
for pleurisy becomes chronic, the light generated in the form of scarring of the pleural adhesions that prevent the full unfolding of the lung.The massive fibrosis is accompanied by a decrease in the volume of lung tissue perfusion, thus aggravating the symptoms of respiratory failure.
exudative pleurisy principal difference is the presence of fibrinous pleural effusion.
flow exudative pleurisy, regardless of etiology, can be divided into three main periods: the phase of exudation, the stabilization period and the phase of resolution.
Clinical manifestations of exudative pleurisy presented symptoms of respiratory failure and simptomokopleksom inflammatory.Patients complain of dyspnea and discomfort in the chest when breathing, hacking cough with difficult expectoration, general weakness, loss of appetite, as well as a transient increase in body temperature to high numbers.
Already at the initial examination there are signs of the presence of fluid in the pleural cavity (dull percussion sound, the absence of vesicular breath), but to establish a definite diagnosis is necessary to conduct a number of additional studies, among which the most important are the ray diagnostic techniques.With the help of X-rays can be installed localization process and the presence of complications such as pleural moorings, adhesions and signs of displacement of the mediastinum.
for the diagnosis of small exudative pleurisy pleurisy or atypical localization is necessary to conduct an ultrasound examination of the pleural cavities, which allows to determine even 50 ml of liquid.
to determine the nature of exudate should perform diagnostic pleural puncture and analyze indicators of blood for the presence of inflammation or allergic reactions.
pleural fluid may accumulate diffuse or limited.In the case of a limited accumulation of exudate formed encysted pleurisy (epiphrenic, parakostalny, paramediastinalny) arising as a result of adhesions in the pleura.
Tuberculous pleurisy is a complication of various forms of pulmonary tuberculosis manifested acute, chronic or periodical course.It is often available in the patient diagnosis of tuberculosis process begins with pleurisy.
In the structure of morbidity leading position occupied by children and young persons, as pleurisy most often occurs on the background of the primary tuberculous complex bronhoadenita and disseminated forms of pulmonary tuberculosis.
The main forms of pleural tuberculosis include: allergic and perifocal pleurisy and pleural tuberculosis isolated.Allergic form of pleurisy develops during primary infection with tubercle bacilli and is accompanied by an active reaction exudative pleural membranes, so that the conditions for the formation of an abundant and serous exudate seroplastic and fibrin deposition layers on the surface of the pleura.Allergic pleurisy is not accompanied by specific pathologic changes in pleural tuberculosis.
In these forms of pulmonary tuberculosis, as the focal, infiltrative, cavernous and disseminated, there is a contact infection of the pleural membranes in contact with the infected areas of the pleura of the lung tissue.First, there are signs of the local fibrinous pleurisy, and then run the mechanism of formation of exudate.The involution of tuberculous pleurisy is resorption of effusion, pleural thickening membranes and total or partial obliteration of the pleural cavity.
In a situation where the patient is cavernous tuberculosis, there is the risk of complications in the form pneumoempyema and chronic tuberculous empyema, which is a massive inflammatory reaction manifested nonspecific nature.
often chronic tuberculous empyema combined with amyloidosis of internal organs.Complete cure of tuberculous empyema when virtually impossible to achieve, since in any case, a residual effects in the form of massive pleural moorings and obliteration of the pleural sinuses, which can only be eliminated by surgery.Patients with residual post-tuberculosis changes in the lungs often suffer encysted pleurisy.
most severe form of tuberculous pleurisy considered tuberculous empyema, as it occurs with the emergence of violent symptoms and is often accompanied by complications.The most threatening and life-threatening complication of the patient is draining pus in the bronchus, which is accompanied by a painful cough with purulent fetid copious sputum and fistula formation plevrobronhialnogo.An objective examination of the patient the benefit of a fistula formed amforicheskogo evidenced by the appearance of breathing during auscultation.Additional methods of diagnosis in this situation include: bronchoscopy, X-rays and tests with methylene blue.
rare, but serious complication of the tuberculosis patient empyema is the formation of a fistula plevrotorakalnogo when pus pleural cavity bursts into the subcutaneous tissue over the front of the chest wall intercostal spaces.
specific methods of verification of the diagnosis in tuberculous pleurisy is sowing the contents of the pleural cavity in the Mycobacterium tuberculosis and determination of sensitivity to tuberculin.To assign a specific anti-tuberculosis therapy should have laboratory confirmation of the causative agent of pleurisy.
outpatient treatment only applies to patients diagnosed with dry (fibrinous) pleurisy, all other patients should be hospitalized for examination and selection of an individual regimen.Specialized department for this category of patients is a therapeutic department, and patients with purulent pleurisy and pleural empyema in need of specialized treatment in a surgical hospital.
Only patients with significant pleural effusion is shown to bed, in the other cases, patients are at polupostelnom mode, during which permitted limited physical activity, improves the drainage function of bronchi.
Each form has its own characteristics of pleurisy treatment, but any type of pleurisy shown etiotropic direction and pathogenetic treatment.Thus, when dry pleurisy patients received pain therapy, anti-inflammatory agents in combination with desensitization, and a wide range of preventive treatments (applying hot compress on the chest, tight chest compression with elastic bandages or medical corset, use warming anti-inflammatory ointment on the basis ofNSAIDs).Antibiotic therapy is advisable only when indicated (inflammatory changes in blood, fever more than 48 hours).
Pi availability pleural effusion of any nature to the patient should follow the diet with limited carbohydrate content of foods and liquids origin.
After pleural puncture is necessary to carry out the sowing punctate with determination the flora and the sensitivity of microorganisms to antibiotics specific group.The presence of purulent pleural effusion, even nature is an indication for the appointment of antibacterial agents.
To increase the effectiveness of antibiotic therapy is recommended to the parenteral route of administration.In the absence of the results of seeding punctate should prefer broad-spectrum antibiotics - Amoxiclav 625 mg 2 times a day, ceftriaxone 1 g, 2 times a day intramuscularly, Gentamicin 120 mg 1 time per day intramuscularly.The course of antibiotic treatment by an average of 10 - 14 days.
obligatory point in the treatment of pleurisy effusion is hyposensitization therapy, and in the absence of pleural empyema expedient appointment of glucocorticoid hormones.When purulent pleurisy develop powerful inflammatory changes in the body, resulting in the suffering of the immune system, and therefore, recommended the use of drugs obschestimuliruyuschih (immunoglobulin, adjuvants).
In severe purulent pleurisy creates conditions for violations of protein metabolism and lack of vitamins in the body.In this situation it recommended vitamin complexes parenteral administration, a solution of glucose and protein drugs.
pleurocentesis used not only for diagnostic purposes, but also as a therapeutic manipulations with massive pleural effusion.Such as the purulent pleurisy, post-traumatic and hemorrhagic an indication for the complete evacuation of pleural effusion.In order to prevent further accumulation of fluid or pus drainage and establish patient monitor not only the quantity, but also the nature of the discharge.When set carcinomatous pleurisy pleural puncture is recommended to combine with the introduction of cytotoxic drugs into the pleural cavity.
If confirmed by instrumental and laboratory diagnosis methods of investigation "empyema" patient is recommended to sanitize the pleural cavity to completely remove pathogens.For this purpose the daily aspiration of pus, combined with antiseptic solution furatsilina empyema cavity, followed by intrapleural administration of solutions of antibacterial drugs.
effective method of treatment of purulent pleurisy, the patient spends less time in the hospital, a sonication thoracoscopic pleural cavity through the access.Treatment in combination with antibiotic therapy is 5-6 manipulation.
The effectiveness of conservative treatment should be assessed under the constant supervision of laboratory and instrumental performance.