Exudative pleurisy: symptoms

The clinical symptoms of exudative pleurisy are quite similar for different types of effusion. Finally, the nature of the effusion is established with the help of a pleural puncture.

Complaints of patients are quite typical and depend on the variant of the onset of the disease. If the development of exudative pleurisy was preceded by acute fibrinous (dry) pleurisy, then it is possible to establish the following chronological sequence of subjective manifestations. Initially, patients are concerned about acute, intense pain in the chest, worse with breathing, coughing. With the appearance of an effusion in the pleural cavity, pain in the chest weakens or even disappears completely due to the fact that the pleural sheets are separated by a liquid appearing in the pleural cavity. At the same time, a feeling of heaviness in the chest, dyspnea (with a significant amount of exudate), dry cough (its reflex origin is assumed), a significant increase in body temperature, sweating.

In some patients exudative pleurisy develops without previous fibrinous (dry) pleurisy, so the pain syndrome is absent and quickly enough, after a few days (rarely 2-3 weeks) after a period of slight weakness, a rise in body temperature, the abovementioned characteristic complaints appear - shortness of breath and a feeling of " stasis, "heaviness in the chest.

Along with such variants of the beginning of exudative pleurisy, an acute onset of the disease is also possible: the body temperature rises rapidly to 39-40 ° C (sometimes with a chill), acute stitching in the side appears (intensifying with inspiration), dyspnea (due to rapid accumulation of exudate in pleural cavity), marked symptoms of intoxication - headache, sweating, anorexia.

When examining patients with exudative pleurisy, extremely characteristic signs of the disease are revealed:

• forced position - patients prefer to lie on the sore side, which limits the shift of the mediastinum to a healthy side, and allows the healthy lung to participate more actively in breathing, with very high effusions, the patients occupy a semi-sidereal position;
• cyanosis and swelling of the cervical veins (a large amount of fluid in the pleural cavity complicates the outflow of blood from the cervical veins);
• shortness of breath (rapid and rapid breathing);
• an increase in the volume of the chest on the side of the lesion, smoothness or bulging of the intercostal spaces;
• restriction of respiratory chest excursions on the side of the lesion;
• puffiness and a thicker fold of the skin in the lower parts of the chest on the side of the lesion compared with the healthy side (Wintrich's symptom).

With lung percussion, the following are the most important symptoms of the presence of fluid in the pleural cavity:

• blunt percussion sound over the zone of effusion. It is believed that with the help of percussion you can determine the presence of fluid in the pleural cavity, if its amount is not less than 300-400 ml, and an increase in the blunting level per one edge corresponds to an increase in the amount of liquid by 500 ml. Characterized by the extremely pronounced stupidity of the percussion sound ("blunt horn sound"), increasing downwards. The upper border of dullness (the Sokolov-Ellis-Damoiso line) runs from the spine to the top outside to the scapula or back axillary line and further anteriorly obliquely downward. In exudative pleurisy due to the stickiness of the exudate, both pleural sheets stick together at the upper boundary of the liquid, so the configuration of dullness and the direction of the Sokolov-Ellis-Damoiso line hardly changes when the patient changes position. If there is a tracudate in the pleural cavity, the direction of the line changes after 15-30 minutes. In the middle of the middle-clavicular line, stupidity is determined only when the amount of fluid in the pleural cavity is about 2-3 liters, while at the rear the upper border of dullness usually reaches the middle of the scapula;
• blunting percussion sound on the healthy side in the form of a rectangular triangle Raufus. The hypotenuse of this triangle is the continuation of the Sokolov-Ellis-Damoiso line on the healthy half of the thorax, one is the spine, the other is the lower edge of the healthy lung. Dullness of percussion sound in the area of this triangle is due to displacement in the healthy side of the thoracic aorta, which gives a blunt sound when percussion;
• clear pulmonary sound in the area of the rectangular triangle of Garland on the diseased side. The hypotenuse of this triangle is the part of the Sokolov-Ellis-Damuazo line starting from the spine, one spine is the vertebral column, and the other is the straight line connecting the top of the Sokolov-Ellis-Damuazo line with the spine;
• the zone of tympanic sound (Skoda zone) is located above the upper border of the exudate, it has a height of 4-5 cm. In this zone, the lung is subjected to some compression, the walls of the alveoli collapse and relax, their elasticity and the ability to oscillate diminish, as a result of percussion of the lungs in this the zone of air fluctuations in the alveoli begin to predominate over the vibrations of their walls and the percussion sound acquires a tympanic hue;
• with the left-sided exudative pleurisy, the Traube (traumas) zone disappears (the tympanite zone in the lower parts of the left half of the chest, caused by the gas bubble of the stomach);
• the displacement of the heart into a healthy side is determined. With right-sided exudative pleurisy, the mediastinum shifts to the left, the left border of relative dullness of the heart and apical impulse can be shifted to the axillary lines. With left-sided exudative pleurisy, the right border of relative dullness can shift for the mid-inclusive line. The displacement of the heart to the right is very dangerous due to the possible inflection of the inferior vena cava and the violation of the inflow of blood to the heart.

With auscultation of the lungs the following data are characteristic:

• with large volumes of effusion, vesicular breathing is not audible, since the lung is pinched by fluid and its breathing excursions are sharply weakened or even absent. With smaller amounts of fluid in the pleural cavity, abruptly weakened vesicular breathing can be heard;
• with a large discharge, the lung is squeezed so that the lumen of the alveoli completely disappears, the pulmonary parenchyma becomes dense and, with preserved bronchial patency, bronchial breathing begins to be heard (it is carried from the larynx - the place of its origin). However, bronchial breathing is somewhat muffled, the degree of muffling is determined by the thickness of the liquid layer in the pleural cavity. Bronchial breathing can also be caused by the presence of an inflammatory process in the lung, and crepitation and wet rales can be heard. With a very large amount of fluid, bronchial breathing may not be heard;
• at the upper boundary of the exudate, the noise of friction of the pleura may be heard due to contact with the inflamed pleura sheets over the exudate when breathing. It should also be noted that the pleural friction noise in exudative pleurisy can also indicate the onset of resorption of the exudate. The noise of friction of the pleura can be perceived by hand at palpation in the region of the upper border of the exudate;
• Vocal tremor is sharply weakened over the area of effusion.

Thus, with exudative pleurisy there are enough characteristic percussion and auscultatory data. However, it should be taken into account that it is possible to misinterpret this data in some situations. Thus, blunt percussion sound over the lungs and a sharp decrease in vesicular breathing and vocal jitter can be observed with very significant pleural fibrinous overlays that can persist after previous exudative pleurisy, less often after fibrinous pleurisy. A pronounced blunt sound almost throughout the entire half of the thorax and a sharp weakening of vesicular breathing can also be caused by total pneumonia. Unlike exudative pleurisy with total pneumonia, the mediastinum is not shifted to a healthy side, voice tremor is not weakened, but is strengthened, bronchophonia is well audible. In addition, the presence or absence of effusion in the pleural cavity is easy to prove using ultrasound.

When auscultation of the heart draws attention to the muffled heart tones (of course, this is much more pronounced with left-sided exudative pleurisy), various heart rhythm disturbances are possible.

Arterial pressure tends to decrease, with large effusions in the pleural cavity possible significant arterial hypotension.

The course of exudative pleurisy

During the exudative pleurisy, 3 phases are distinguished: exudation, stabilization and resorption. The phase of exudation lasts about 2-3 weeks. In this phase, the entire clinical picture of exudative pleurisy with a progressive progressive accumulation of fluid in the pleural cavity unfolds. The amount of exudate can reach 6-10 liters, especially in young people, who are characterized by great mobility, compliance of the tissues of the chest.

In the stabilization phase, exudation into the pleural cavity progressively decreases, but at the same time the resorption of exudate is practically blocked or becomes minimal. It is very difficult and almost impossible to accurately determine the beginning of this phase and its duration. We can only note the stabilization of the level of exudate (using ultrasound, X-ray study) and a certain stabilization of the clinical picture of the disease.

The stage of resorption can last about 2-3 weeks, and in weakened patients and suffering from severe concomitant diseases even longer. The duration of the resorption stage, in which the exudate dissolves, also affects the clinical features of the underlying disease that caused the development of exudative pleurisy. Of great importance is the age of the patient. In old people and weakened patients, the exudate can resolve itself within a few months.

In most patients after dissolving the exudate, especially if it was significant, spikes remain (moorings). In some cases, spikes are so numerous and massive that they cause a violation of the ventilation of the lungs.

After suffering exudative pleurisy, patients can feel pain in the chest, intensifying with changing weather, changing weather conditions. This is especially pronounced in the development of adhesions.

In some cases, spikes can cause exudation (exsanguinated pleurisy), which is not absorbed for a long time and can be inflated. However, many patients recover completely.

[1], [2], [3], [4], [5], [6], [7], [8]