Internal illnesses. Pleurisy (lecture notes)

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Internal illnesses. Pleurisy (lecture notes)

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LECTURE No. 37. Pleurisy

Pleurisy is an inflammatory process in the pleura that develops a second time and is a reflection of an independent disease in the body (tumor, pneumonia, tuberculosis, pancreatitis, trauma, etc.).

Etiology. The etiological factors of the disease are the following: exacerbation of the tuberculosis process in the lungs or intrathoracic lymph nodes, non-specific inflammatory processes in the lungs, rheumatism, collagenoses, heart attacks, lung tumors, chest trauma, acute and chronic infectious diseases (dry pleurisy).

Pathogenesis. There is an excessive accumulation of pleural fluid. This is due to a violation of the ratio between the hydrostatic blood pressure in the capillaries of the pleura and the pleural fluid, an increase in the permeability of the pleura for protein, the ability of the parietal pleura to absorb it through the lymphatic ducts, and a change in the ratio between the oncotic pressure of the plasma and the pleural fluid (normally, the absorption capacity of the pleura is 3 times its secretory capacity).

There are transudates and exudates. The formation of transudate occurs in pathological conditions:

1) with left ventricular failure; with an increase in capillary hydrostatic pressure in the visceral pleura;

2) with right ventricular failure: with an increase in capillary hydrostatic pressure in the parietal pleura;

3) with nephrotoxic syndrome, liver cirrhosis, alimentary cachexia; with a significant decrease in the oncotic pressure of the blood plasma, which leads to a decrease in the absorption capacity of the pleura in relation to the liquid.

The formation of exudate is noted with the direct involvement of the pleura in the inflammatory process or when it is seeded with tumor cells.

Clinic. With dry pleurisy there is pain in the affected half of the chest, aggravated by breathing, coughing; with diaphragmatic pleurisy, pain radiates to the upper half of the abdomen or along the phrenic nerve (to the neck). The pain is most severe in the initial period. Body temperature is normal or subfebrile. The patient spares the affected side, lies on a healthy side. On palpation, soreness and rigidity of the trapezius and pectoralis major muscles are determined (Sternberg and Pottenger symptoms, pain in the hypochondrium), restriction of respiratory mobility of the lungs. Auscultation: breathing is weakened, a pleural friction rub is heard.

With exudative pleurisy there is a high body temperature, severe stabbing pains in the chest, aggravated by deep inspiration, excruciating dry cough, sweating, lack of appetite, shortness of breath, cyanosis, lag of the normal half of the chest during breathing, smoothness of the intercostal spaces. The patient takes a forced position, lies on his sore side. Palpation is determined by the weakening of voice trembling on the affected side. On percussion, dullness of the percussion sound is determined due to the accumulation of fluid with the formation of a characteristic arrangement of exudate in the form of a parabolic curve (Damuazo line). On the diseased side, there is the formation of Garland's triangle with tympanitis (between the spine and the ascending line of dullness), on the healthy side, the Rauchfus-Grokko triangle with dullness of percussion sound. There is a shift of the mediastinal organs to the healthy side due to the high standing of the fluid. On auscultation, a weakening of breathing is heard in the affected area, in the area of Garland's triangle - with a bronchial tinge, a pleural friction rub is heard at the onset of the disease and during resorption of the exudate.

Additional diagnostic study. A general blood test is performed (anemia, leukocytosis, an increase in ESR), a study of the pleural fluid (protein above 3%, relative density above 1,018, positive Rivalt test, many neutrophils in the sediment, straw-yellow color - with exudates, with empyema - pus), x-ray examination: intense darkening with an oblique upper border, shift of the mediastinum to the healthy side - with exudates, limited mobility of the dome of the diaphragm, lowering the transparency of the sinus on the corresponding side.

Complications. Complications of the disease are acute pulmonary heart failure, vascular insufficiency, limited encysted pleurisy, fistulas, adhesions.

Differential diagnostics. Should be carried out with pneumonia, spontaneous pneumothorax, lung cancer, diseases of the osteoarticular and muscular apparatus, tuberculosis.

Treatment. With dry pleurisy, the underlying disease is treated. Analgesics (up to narcotic), non-steroidal anti-inflammatory drugs are introduced.

For pleural effusions the underlying disease is treated, a diet rich in protein, vitamins, limited by salt, liquid is prescribed. Antibacterial drugs are introduced (taking into account the sensitivity of the flora), detoxification therapy (plasma-substituting solutions, vitamins of group B, C), pleural punctures are performed with the evacuation of the pleural fluid. Desensitizing therapy is prescribed.

With hydrothorax (with heart failure) diuretics, peripheral vasodilators, cardiac glycosides are introduced. The physical mode is limited.

For effusions associated with nephrotic syndrome and cirrhosis of the liver, replacement use of protein preparations, salt restriction is carried out.

With pleural empyema antibiotics, drainage of the pleural cavity, replenishment of protein losses are indicated.

For tumor-related effusions, careful intrapleural administration of cytostatics (thiotef, 5-fluorouracil) is carried out.

With recurrent pleural effusions (indomitable pleural effusions) sclerosing therapy is indicated (tetracycline is usually administered, since it causes aseptic inflammation of the pleural sheets, leads to obliteration of the pleural cavity).

With hemothorax consultation with a surgeon is necessary.

Flow. The course of the disease is long, acute, subacute, chronic.

Forecast. The prognosis depends on the underlying disease and the nature of the effusion, more often recovery.

Prevention. Prevention of the disease is aimed at preventing and timely treatment of diseases that can be complicated by inflammatory processes in the pleura, early recognition of the presence of pleural effusion, and its evacuation.

Author: Myshkina A.A.

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