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Dry (fibrinous) pleurisy: a review of information
Last reviewed: 29.11.2021
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In the majority of patients dry (fibrinous) pleurisy begins acutely, less often - gradually. Extremely characteristic complaints of patients: pain in the chest, increased body temperature, general weakness.
Pain in the chest is a characteristic symptom of acute dry pleurisy. It is caused by the irritation of the sensitive nerve endings of the parietal pleura and is localized in the corresponding half of the thorax (on the affected side), most often in the anterior and lateral sections. Pain appears with a deep breath, while at the height of inspiration, the appearance of a dry cough, sharply increases with a cough (the patient reflexively puts his hand to the sore spot and, as it were, tries to reduce the movement of the chest on inhalation, thereby reducing pain). Characteristic is also increased pain when the body tilts to a healthy side (Shepelman-Degio symptom), as well as with laughter and sneezing.
The most typical acute pain in the chest, but quite often the chest pain is insignificant (with the gradual development of the disease). Depending on the different location of the inflammatory process, pain can be localized not only in typical anterior and lower thoracic parts of the chest, but also in other areas.
Characteristic are also complaints of general weakness, an increase in body temperature (usually up to 38 ° C, sometimes higher). With poorly expressed unspoken dry pleurisy, body temperature can be normal, especially in the first days of the disease. Many patients are concerned about transient, non-intensive pain in the muscles, joints, headache.
An objective study of patients reveals a number of characteristic features of dry pleurisy. The patient spares the affected side and therefore prefers to lie on a healthy side. However, some patients find considerable relief (reduction of pain) in the position on the diseased side, since in this case the chest is immobilized, the irritation of the parietal pleura decreases.
There is also a marked rapid breathing (with this breath pain is less expressed), and the lag of the affected half of the thorax is noticeably lagging due to painful sensations.
With palpation of the chest, in a number of cases it is possible to palpate the pleural friction noise at the site of the inflammatory process (there is a crunch of snow near the breathing).
With percussion of the lungs, the sound remains clear if the pleurisy is not caused by the inflammatory process in the lung parenchyma.
With auscultation of the lungs in the projection of inflammation of the pleura, the most important symptom of dry pleurisy is the pleural friction noise. It occurs due to friction against each other during the breathing of the parietal and visceral pleura sheets, on which there are deposits of fibrin and the surface of which becomes rough. Normally, the surface of the pleural sheets is smooth and the visceral pleura slides through the parietal pleura during breathlessness.
The noise of friction of the pleura is heard at the inhalation and exhalation and resembles the crunch of snow underfoot, the creak of new skin or the rustle of paper, silk. Most often, the pleural friction noise is loud enough, but in some cases it can be subtle, and for its detection a very careful auscultation in silence is needed.
Due to the variety of timbre of noise, the friction of the pleura can be confused with crepitus or wheezing. The noise of friction of the pleura differs from them in the following signs:
- the noise of friction of the pleura is heard both during inspiration and exhalation, crepitation is audible only on inhalation;
- the noise of friction of the pleura is perceived as intermittent, consecutive sounds of a varied character, and dry rales are heard as a continuous, continuous sound;
- the noise of friction of the pleura does not change when coughing, wheezing after a cough may disappear, or intensify or reappear;
- The noise of friction of the pleura can be heard at a distance;
- when pressing with a stethoscope or a finger on the intercostal space near the stethoscope, the pleural friction noise intensifies due to closer contact of the pleural sheets; At the same time, this reception has no effect on the volume of wheezing;
- the noise of friction of the pleura during auscultation seems to arise near the ear, while rales and crepitation are perceived more distantly;
- The noise of friction of the pleura can be felt by the patient himself.
In some cases, it is very difficult to distinguish the pleural friction noise from other additional respiratory noises. In this situation, one can use the Egorov-Bilenkin-Muller method in the modification of SR Tatevosov. The patient is offered to lie on a healthy side with the legs brought to the stomach, bent at the knee and hip joints. Corresponding to the sick side, the hand is placed behind the head. The patient makes respiratory movements, closing the nose and mouth, and then for comparison, opening them. In both cases, the site of the chest is heard in the place where the respiratory noise is determined, which requires differential diagnosis. In respiratory movements with a closed nose and mouth, only the noise of friction of the pleura continues to be heard, other respiratory noises (wheezing, crepitation) disappear. In breathing movements with an open mouth and nose, both pleural friction noise and other respiratory noises are heard.
Dry pleurisy can be localized near the heart, in this case, the adhesion process between the pleura and the pericardium can develop, and therefore the friction of both pleural sheets occurs not only with breathing, but with every contraction of the heart - there is a pleuropericardial friction noise. A characteristic feature of this noise is that it continues to be heard and when breathing is delayed.
It should be noted that in the region of the apex of the lungs, the friction of the pleura is rarely heard, which is explained by the poor respiratory mobility of the apexes.
The noise of friction of the pleura in some patients can continue to be heard for many years after the pleurisy, which is caused by an uneven thickening of the pleural sheets.
Pleurisy - Causes and pathogenesis
[Symptoms of dry (fibrinous) pleurisy
Pristenochny (costal) pleurisy is the most common form of fibrinous pleurisy, the symptomatology of it is described above. The main signs of this variant of dry pleurisy are pains in the chest (in the projection of fibrinous overlays), intensifying with breathing and coughing, and a typical pleural friction noise.
The course of dry pleurisy, as a rule, is favorable. The disease lasts about 1-3 weeks and usually ends with recovery. A prolonged recurrent course is characteristic of the tuberculous etiology of the disease.
Where does it hurt?
Diagnosis of dry (fibrinous) pleurisy
With fibrinous pleurisy, the high standing of the dome of the diaphragm from the corresponding side can be determined, its lagging behind deep breathing, limitation of the mobility of the lower pulmonary margin and slight turbidity of the part of the pulmonary field. With significant deposits of fibrin, it is sometimes possible to determine an unclear, indistinct shadow along the outer edge of the lung (a rare sign).
Using ultrasound, intensive fibrin overlays can be detected on the parietal or visceral pleura. They look like a thickening of the pleura with an uneven, wavy contour, increased echogenicity, a homogeneous structure.