Pleurisy - Information Overview

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

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

Pleural syndrome can be assessed as a manifestation of some pathological process or a complication of some disease. For example, in hemopneumothorax - as a manifestation of lung damage and as a complication of chest trauma; in pneumothorax - as a manifestation of a violation of lung hermeticity and as a complication of bullous lung disease.

The pleura, being connected with the pulmonary circulation and the lymphatic system, has a great functional significance in regulating blood flow in the pulmonary circulation. It is richly innervated, therefore it produces a pain syndrome with a projection onto the chest wall (the lung itself, even with severe inflammation, does not form a pain reaction). The visceral leaflet covering the lung and the parietal leaflet covering the chest wall form the pleural cavity. The functional significance of the leaflets is different: the visceral leaflet exudes pleural fluid, which acts as washing water and lubricant for the lung, and the parietal leaflet resorbs it. Normally, a balance is maintained between exudation and resorption; dysfunction of one of the leaflets leads to an imbalance, which leads to fluid accumulation.

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

Pleural syndrome and pleurisy

Pleurisy - inflammation of the pleural cavity - is not an independent disease, but complicates the course of other pathologies: lungs, heart, mediastinum; less often - the chest wall and subdiaphragmatic space, and even less often it forms with pleural mesoepithelioma.

How does pleurisy manifest itself?

The clinical picture consists of: aggravation of the underlying disease and development of lung compression syndrome, with suppuration, intoxication syndrome is additionally formed. With accumulation of serous or hemorrhagic exudate up to 200 ml, there are almost no clinical manifestations. With conventional chest radiography standing, such effusion is not detected, but when using the Leuck phenomenon (during an X-ray examination of the patient on a trochoscope, they are transferred from a standing to a lying position: a uniform decrease in the transparency of the lung field is noted). With accumulation; exudate up to 500 ml, local changes are poorly expressed: a feeling of heaviness, moderate pain with deep breathing and coughing; percussion - dullness of sound; auscultation - weakening of breathing. On radiographs, homogeneous, intense darkening is detected according to the accumulation of fluid (during fluoroscopy, the radiologist can outline the optimal point for puncture).

Only accumulation of large volumes of exudate leads to development of the lung compression syndrome: dyspnea, cyanosis of the face and upper half of the body, acrocyanosis, tachycardia and other obvious symptoms of exudate accumulation. X-rays reveal homogeneous intense darkening, if the compression is intense (air or exudate), a shift of the mediastinum to the side opposite to the darkening is revealed. Cardiac and respiratory failure develops.

According to the clinical picture, there are 3 leading pleurisy syndromes:

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

The patient complains of acute pain in the chest, most often in the basal sections, increasing with coughing and deep breathing. On examination, the position is forced, on the sore side, the chest is spared during movements, while standing, tilted towards the pleurisy (Schepelman's symptom). Breathing is shallow, rapid up to 24 per minute, without dyspnea. Temperature is subfebrile. Palpation of the chest is painful, crepitus is noted.

Palpation reveals pain in the trapezius muscles (Sternberg's symptom) and intercostal muscles (Pottenger's symptom). With apical location, the Bernard-Horner symptom may develop (enophthalmos, pseudoptosis, miosis). Percussion sound changes are not noted. Auscultation reveals pleural friction noise, which can be heard at a distance (Shchukarev's symptom). The process lasts 2-3 weeks; earlier pain relief indicates fluid accumulation.

• Exudative (reactive) pleurisy is formed mainly in pulmonary hypertension, which can be caused by heart failure (cardiogenic effusion), pathology in the lung or pleura (pulmonary contusion, mesoepithelioma, inflammatory process in the lung) - pneumonic effusion, pathological process in the chest wall, subdiaphragmatic space, mediastinum. Such pleurisy develops quickly and is acute.

The clinical picture is typical. Chest pain is minor, there is a feeling of heaviness that increases with coughing and deep breathing. Respiratory rate is 24-28 per minute with dyspnea and varicose veins in the neck. The position is forced, on the affected side, to reduce pressure on the mediastinum. The complexion is purple, cyanosis of the lips and tongue, acrocyanosis - increases during coughing. The affected half of the chest lags in the act of breathing, is increased in volume, sometimes there is a displacement of the xiphoid process to the side opposite to the effusion (Pitres' symptom). 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 several deep breaths, twitching of the upper part of the rectus abdominis muscle appears (Schmidt's symptom).

During coughing, the intercostal spaces bulge over the effusion and a splashing sound is heard (Hippocratic symptom).

When pressing on these places on the intercostal spaces, a sensation of fluid movement and pain appear (Kulekampf's symptom). Percussion reveals a dull sound over the fluid, but overly obvious tympanitis is revealed over the percussion dullness zone (Skoda's symptom); when changing the position, the tonality of the dull sound changes (Birmer's symptom). Vocal tremor and bronchophony are increased (Bachelli's symptom). Auscultation reveals weakening of breathing, a splashing noise can be heard, especially when coughing. With large accumulations of exudate, tracheal breathing can be performed. Wheezing is heard only in case of lung pathology.

The presence of effusion is confirmed by radiography or fluoroscopy - a homogeneous, intense darkening is revealed. With free effusion, it has a horizontal border (with hydrothorax and serous exudate, it can also be along the Demoiseau line) with localization in the sinuses, most often the costophrenic. With limited effusion, the position and shape of the darkening are different. In doubtful cases, an ultrasound examination can be performed to confirm the presence of free fluid. To determine the nature of the effusion and conduct a cytological study, a puncture of the pleural cavity is performed (remember that encapsulated exudates can only be punctured by a thoracic surgeon and then under X-ray control).

• Purulent pleurisy with effusion. There are many reasons for its formation, most often it is a consequence of a breakthrough of pus from the lung, subdiaphragmatic and mediastinal spaces, abscesses of the ore wall, failure of the bronchial stump after lung operations, etc. This pleurisy has the same local manifestations as reactive pleurisy, but is accompanied by the development of intoxication syndrome with a rapid and severe course. When puncturing the pleural cavity, obvious pus or turbid exudate with high neutrophilia, protein content and specific gravity (transudate) is obtained.

What types of pleurisy are there?

• By etiology, 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, tumors of the pleura and lungs, subdiaphragmatic abscesses, etc. Infection may also join in.
• Depending on the nature of tissue changes, a distinction is made between dry (fibrinous) and exudative pleurisy.
• According to the clinical course, pleurisy can be acute, subacute and chronic.
• Exudative pleurisy, according to the nature of the effusion, is divided into: serous, serous-fibrinous, serous-hemorrhagic (hemopleurisy), hemorrhagic, purulent, putrefactive pleurisy.
• According to prevalence, exudative pleurisy can be limited (encapsulated), diffuse and diffuse.
• According to localization, encapsulated pleurisy is divided into apical, parietal, interlobar, costodiaphragmatic, and mediastinal.
• Purulent pleurisy is defined by the duration of its course: the first 3 weeks - as acute purulent pleurisy; from 3 weeks to 3 months - as acute pleural empyema; more than three months - as chronic pleural empyema.