Exudative pleurisy - Symptoms.

The clinical symptoms of exudative pleurisy are quite uniform for different types of effusion. The nature of the effusion is finally determined by pleural puncture.

Complaints of patients are quite typical and depend on the type of 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. At first, patients are bothered by acute, intense pain in the chest, which intensifies with breathing and coughing. With the appearance of effusion in the pleural cavity, the pain in the chest weakens or even disappears completely due to the fact that the pleural sheets are separated by the fluid appearing in the pleural cavity. At the same time, a feeling of heaviness in the chest, shortness of breath (with a significant amount of exudate) are characteristic, a dry cough may be noted (its reflex genesis is assumed), a significant increase in body temperature, sweating.

In some patients, exudative pleurisy develops without preceding fibrinous (dry) pleurisy, so there is no pain syndrome and quite quickly, after a few days (rarely after 2-3 weeks) after a period of slight weakness and an increase in body temperature, the above-mentioned characteristic complaints appear - shortness of breath and a feeling of "stuffiness" and heaviness in the chest.

Along with such variants of the onset of exudative pleurisy, an acute onset of the disease is also possible: body temperature quickly rises to 39-40°C (sometimes with chills), acute stabbing pain in the side appears (increasing with inhalation), shortness of breath (due to the rapid accumulation of exudate in the pleural cavity), pronounced 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 diseased side, which limits the displacement of the mediastinum to the healthy side and allows the healthy lung to participate more actively in breathing; with very large effusions, patients take a semi-sitting position;
• cyanosis and swelling of the jugular veins (a large amount of fluid in the pleural cavity makes it difficult for blood to flow out of the jugular veins);
• shortness of breath (rapid and shallow breathing);
• an increase in the volume of the chest on the affected side, smoothing or bulging of the intercostal spaces;
• limitation of respiratory excursions of the chest on the affected side;
• swelling and a thicker fold of skin in the lower chest on the affected side compared to the healthy side (Wintrich's symptom).

Percussion of the lungs reveals the following important symptoms of the presence of fluid in the pleural cavity:

• dull percussion sound over the effusion zone. It is believed that percussion can determine the presence of fluid in the pleural cavity if its amount is at least 300-400 ml, and an increase in the level of dullness by one rib corresponds to an increase in the amount of fluid by 500 ml. Extremely pronounced dullness of percussion sound ("dull femoral sound") is characteristic, increasing downwards. The upper border of dullness (Sokolov-Ellis-Damuaso line) runs from the spine upward outward to the scapular or posterior axillary line and then forward obliquely downwards. In exudative pleurisy, due to the stickiness of the exudate, both pleural sheets stick together at the upper border of the fluid, so the configuration of dullness and the direction of the Sokolov-Ellis-Damuaso line hardly change when the patient's position changes. If there is a trasudate in the pleural cavity, the direction of the line changes after 15-30 minutes. In front, along the midclavicular line, dullness is determined only when the amount of fluid in the pleural cavity is about 2-3 liters, while at the back, the upper border of dullness usually reaches the middle of the scapula;
• dullness of percussion sound on the healthy side in the form of a right-angled Raufus triangle. The hypotenuse of this triangle is the continuation of the Sokolov-Ellis-Damoiseau line on the healthy half of the chest, one leg is the spine, the other is the lower edge of the healthy lung. Dullness of percussion sound in the area of this triangle is caused by the displacement of the thoracic aorta to the healthy side, which produces a dull sound upon percussion;
• clear pulmonary sound in the area of the right triangle of Garland on the affected side. The hypotenuse of this triangle is the part of the Sokolov-Ellis-Damoiseau line starting from the spine, one leg is the spine, and the other is a straight line connecting the apex of the Sokolov-Ellis-Damoiseau line with the spine;
• tympanic sound zone (Skoda zone) - is located above the upper border of the exudate, has a height of 4-5 cm. In this zone, the lung is subject to some compression, the walls of the alveoli collapse and relax, their elasticity and ability to vibrate decreases, as a result of which, when percussing the lungs in this zone, the vibrations of the air in the alveoli begin to prevail over the vibrations of their walls and the percussion sound acquires a tympanic hue;
• with left-sided exudative pleurisy, Traube's space disappears (the zone of tympanitis in the lower parts of the left half of the chest, caused by the gas bubble of the stomach);
• the heart is displaced to the healthy side. With right-sided exudative pleurisy, the mediastinum is displaced to the left, the left border of relative cardiac dullness and apical impulse can be displaced to the axillary lines. With left-sided exudative pleurisy, the right border of relative dullness can be displaced beyond the midclavicular line. Displacement of the heart to the right is very dangerous due to possible kinking of the inferior vena cava and disruption of blood flow to the heart.

Auscultation of the lungs reveals the following data:

• with large volumes of effusion, vesicular breathing is not heard, since the lung is compressed by the fluid and its respiratory excursions are sharply weakened or even absent. With smaller amounts of fluid in the pleural cavity, sharply weakened vesicular breathing can be heard;
• with a large effusion, the lung is compressed so much 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 conducted from the larynx - the place of its origin). However, bronchial breathing is somewhat muffled, the degree of muffled is determined by the thickness of the fluid layer in the pleural cavity. Bronchial breathing can also be caused by the presence of an inflammatory process in the lung, in which case crepitation and moist rales can be heard. With a very large amount of fluid, bronchial breathing may not be heard;
• at the upper border of the exudate, pleural friction noise can be heard due to contact of the inflamed pleural layers over the exudate during breathing. It should also be taken into account that pleural friction noise in exudative pleurisy can also indicate the beginning of the resorption of the exudate. Pleural friction noise can be perceived by hand during palpation in the area of the upper border of the exudate;
• above the area of effusion, vocal fremitus is sharply weakened.

Thus, in case of exudative pleurisy there are quite characteristic percussion and auscultatory data. However, it should be taken into account that incorrect interpretation of these data is possible in some situations. Thus, dull percussion sound over the lungs and sharp weakening of vesicular breathing and vocal fremitus can be observed in case of very significant pleural fibrinous deposits, which can remain after previously suffered exudative pleurisy, less often - after fibrinous pleurisy. Pronounced dull sound almost throughout half of the chest and sharp weakening of vesicular breathing can also be caused by total pneumonia. Unlike exudative pleurisy, in case of total pneumonia the mediastinum does not shift to the healthy side, vocal fremitus is not weakened, but increased, bronchophony is clearly audible. In addition, the presence or absence of effusion in the pleural cavity can be easily proven by ultrasound examination.

During auscultation of the heart, attention is drawn to the muffled heart sounds (of course, this is much more pronounced in left-sided exudative pleurisy), various disturbances in heart rhythm are possible.

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

The course of exudative pleurisy

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

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

The resorption stage can last about 2-3 weeks, and even longer in weakened patients and those suffering from severe concomitant diseases. The duration of the resorption stage, in which the exudate is absorbed, is also affected by the clinical features of the underlying disease that caused the development of exudative pleurisy. The patient's age is also of great importance. In the elderly and weakened patients, the exudate can be absorbed within several months.

In most patients, after the exudate has been absorbed, especially if it was significant, adhesions (connections) remain. In some cases, adhesions are so numerous and massive that they cause pulmonary ventilation problems.

After suffering exudative pleurisy, patients may feel chest pain, which increases with changes in weather, changes in meteorological conditions. This is especially pronounced with the development of adhesions.

In some cases, adhesions can cause encapsulation of exudate (encapsulated pleurisy), which does not resolve for a long time and can become purulent. However, many patients experience a complete recovery.

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