Pleurisy: an overview of information

Pleurisy is an inflammation of the pleural leaves with the formation of fibrin on their surface ( dry, fibrinous pleurisy ) or accumulation in the pleural cavity of various exudates ( exudative pleurisy ).

Pleural syndrome is a symptom complex that develops when the pleura irritates with various pathological processes. The main focus can be in the lung with the transition to the pleura, in the pleural cavity, in the chest wall with the transition to the pleura. They can proceed without compression of the lung or with the development of the syndrome of lung compression. With compression of the lung, hypoxic and respiratory failure syndromes are additionally formed.

Pleural syndrome can be regarded as a manifestation of some pathological process or complication of some disease. For example, with hemopneumothorax - as a manifestation of lung damage and as a complication of a chest injury; with pneumothorax - as a manifestation of a violation of lung hermetism and as a complication of bullous lung disease.

Pleura, being associated with a small circle of circulation and lymphatic system, has great functional significance in regulating blood flow in a small circle. It is richly innervated, so it gives a pain syndrome with a projection to the chest wall (the lung itself, even with severe inflammation, does not form a pain reaction). The visceral leaf covering the lung, and parietal fox-4: the current covering the chest wall, form a pleural cavity. Functional value of the leaflets is different: the visceral leaf exudes the pleural fluid, which plays the role of washing water and lubricant for the lung, and the parietal leaf resorbs it. Between exudation and resorption is normally maintained a balance, with the dysfunction of one of the sheets an imbalance develops, which leads to the accumulation of fluid.

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Pleural syndrome and pleurisy

Pleurisy - an inflammation of the pleural cavity - is not an independent disease, but complicates the course of another pathology: lungs, heart, mediastinum; less often - the chest wall and subdiaphragmatic space, is even less likely to form with mesoepithelioma of the pleura.

How does pleurisy appear?

The clinical picture consists of: weighting the course of the underlying disease and developing the syndrome of lung compression, with suppuration additionally formed intoxication syndrome. With the accumulation of serous or hemorrhagic exudate up to 200 ml of clinical manifestations is almost none. With normal chest radiography, standing such an effusion is not detected, but when using the phenomenon of Lake (when X-ray examination of a patient on a trochoscope is transferred from standing to lying: there is a uniform decrease in the transparency of the pulmonary field). With the accumulation; exudate up to 500 ml local changes are expressed little: a feeling of heaviness, moderate pain with deep breathing and coughing; percussion - dullness of sound; auscultatory - weakening of breathing. X-rays reveal a homogeneous, intense darkening, respectively, the accumulation of fluid (with X-rays, an x-ray can identify the optimal point for puncture).

Only the accumulation of large amounts of exudate gives development, the syndrome of compression of the lung: dyspnea, cyanosis of the face and upper body, acrocyanosis, tachycardia and other obvious symptoms of exudate accumulation. X-rays reveal a homogeneous intense darkening, if the compression is intense (air or exudate), the mediastinum shift is seen in the direction opposite to the blackout. Heart and respiratory failure is formed.

According to the clinic, there are 3 leading pleurisy syndromes:

• Dry pleurisy, which is morphologically characterized by the thickening of the pleura sheets and the deposition on the walls of fibrin (then the connective tissue strands, films, tubercles or pleural sheets are welded together at this site - pleurodesis).

The patient complains of acute pain in the chest, more often in the basal areas, worse with coughing and deep breathing. Upon examination, the position forced, on the diseased side, sparing the thorax during movements, standing inclined towards the pleurisy (Shepel'man's symptom). Breathing is superficial, tended to 24 per minute, without shortness of breath. The temperature is subfebrile. Palpation of the chest is painful, crepitation is noted.

Palpation is noted soreness of the trapezius muscles (a symptom of Sternberg), intercostal muscles (a symptom of Pottenger). At an apical location, the development of the Bernard-Horner symptom (enophthalmus, pseudoptosis, miosis) is possible. Changes in percussion sound are not noted. Auscultatory evidence of pleural friction noise, which can be heard at a distance (Shchukarev's symptom). The duration of the process is 2-3 weeks, the earlier stagnation of pain indicates accumulation of fluid.

• Excessive (exudative, reactive) pleurisy is formed mainly with pulmonary, hypertension, which can be caused by cardiac failure (cardiogenic effusion), pathology in the lung or pleura (lung contusion, mesoepithelioma, inflammatory process in the lung) - pneumonic effusion, pathological process in the chest wall , subdiaphragmatic space, mediastinum. This pleurisy is developing rapidly and is flowing sharply.

The clinic is typical. Pain in the chest is minor, worried about a feeling of heaviness, aggravated by coughing, deep breathing. The frequency of breathing is 24-28, per minute with shortness of breath swelling of the veins of the neck. The position is forced, on the sore side, to reduce pressure on the mediastinum. The complexion is purple, cyanosis of the lips, tongue, acrocyanosis - intensified during coughing. The affected half of the chest lags behind in the act of breathing, is increased in volume, sometimes there is a displacement of the xiphoid process in the direction opposite to the effusion (the symptom of Pitres). The skin in the lower half of the chest, in comparison with the opposite side, is edematous, the skin fold is thicker (Wintrich's symptom). After a few deep breaths, the upper part of the rectus muscle appears to be twitching (Schmidt's symptom).

During coughing, the intercostal spaces swell over the effusion and a splash noise is heard (a symptom of Hippocrates).

When pressing in these places on the intercostal spaces there is a feeling of fluid movement and pain (a symptom of Kulekampf). Percussion over the fluid is a dull sound, but overly pronounced tympanitis (the Skoda symptom) is revealed above the percussion dull area; when the position changes, the key of the blunt sound changes (Birmer's symptom). Voice tremor and bronchophonia are strengthened (a symptom of Bachelli). Auscultatory marked weakening of breathing, you can hear the sound of splashing, especially when you cough. With large clusters of exudate, tracheal breathing can be performed. Chryps are audible only with pathology of the lungs.

Confirm the presence of effusion X-rays or fluoroscopy - reveals a homogeneous, intense darkening. With free exudation, it has a horizontal boundary (with hydrothorax and serous exudate can also be along the line of Demoiso) with localization in sinuses more often bone-diaphragmatic. With a delimited sweat, the position and shape of the shading are different. In doubtful cases, an ultrasound can be performed to confirm the presence of a free liquid. To determine the nature of the effusion and conduct cytological examination, a puncture of the pleural cavity is performed (remember that the drained exudates can be punctured only by the thoracic surgeon and then under x-ray control).

• Excessive purulent pleurisy. The reasons for its formation are many, more often a consequence of the breakthrough of pus from the lung, subdiaphragmatic and mediastinal spaces, ulcers of the ore wall, the incompetence of the stump of the bronchus after operations on the lung, etc. This pleurisy has the same local manifestations as reactive pleurisy, but is accompanied by the development of intoxication syndrome with a fast and heavy current. When puncturing the pleural cavity, clear pus or turbid exudate with high neutrophilia, protein content and specific gravity (transudate) is obtained.

What kinds of pleurisy does it have?

• The etiology of pleurisy is divided into infectious and reactive. Infectious pleurisy, depending on the microflora, is divided into nonspecific pleurisy caused by pyogenic and putrefactive microflora; and specific pleurisy caused by tuberculosis, parasitic, fungal microflora.
• Reactive pleurisy often develops with pulmonary hypertension, pleural and pulmonary tumors, sub-diaphragmatic abscesses, etc. Infection can also join them.
• By the nature of tissue changes distinguish between dry (fibrinous) and exudative (exudative) pleurisy.
• According to the clinical course pleurisy can be acute, subacute and chronic.
• Excess pleurisy, according to the nature of the effusion, is divided into: serous, serous-fibrinous, serous-hemorrhagic (hemoplethritis), hemorrhagic, purulent, putrefactive pleurisy.
• The prevalence of exudate pleurisy is delimited (drained), diffuse and diffuse.
• By localization, the titrated pleurisy is divided into apical, parietal, interstitial, bodily diaphragmatic, mediastinal.
• Purulent pleurisy by duration of a current define: the first 3 weeks - as an acute purulent pleurisy; from 3 weeks to 3 months - as acute empyema of the pleura; more than three months - as a chronic empyema of the pleura.