Empiyema of a pleura () – the inflammation of pleural leaves which is followed by formation of purulent exudate in a pleural cavity. Empiyema of a pleura proceeds from oznoba, is resistant the high or gektichesky temperature, plentiful perspiration, tachycardia, short wind, weakness. Diagnostics of an empiyema of a pleura is carried out on the basis of radiological data, ultrasonography of a pleural cavity, results of a torakotsentez, a laboratory research of exudate, the analysis of peripheral blood. Treatment of a sharp empiyema of a pleura includes drainage and sanitation of a pleural cavity, massive antibiotic treatment, dezintoksikatsionny therapy; at a chronic empiyema the torakostomiya, a torakoplastika, a plevrektomiya with a lung decortication can be carried out.
Empiyema of a pleura
The term "empiyem" in medicine it is accepted to designate a pus congestion in natural anatomic cavities. So, gastroenterologists in practice should face with empiyemy a gall bladder (purulent cholecystitis), to rheumatologists – with empiyemy joints (purulent arthritis), to otolaryngologists – with empiyemy additional bosoms (purulent sinusitis), to neurologists – with subduralny and epiduralny empiyemy (a pus congestion under or over a firm brain cover). In pulmonology pleurae (piotoraksy, purulent pleurisy) understand a kind of the ekssudativny pleurisy proceeding with a congestion of a purulent exudate between visceral and parietal leaves of a pleura as empiyemy.
Classification of an empiyema of a pleura
Depending on etiopatogenetichesky mechanisms distinguish the metapneumonic and parapneumonic empiyema of a pleura (which developed in connection with pneumonia), postoperative and post-traumatic purulent pleurisy. On duration of a current of an empiyem of a pleura can be sharp (up to 1 month), subsharp (up to 3 months) and chronic (over 3 months).
Taking into account character of exudate allocate the purulent, putrefactive, specific, mixed empiy pleurae. As activators of various forms of an empiyema of a pleura nonspecific gnoyerodny microorganisms (streptococci, staphylococcus, pneumococci, anaerobe bacterias), specific flora (a tuberculosis mikobakteriya, fungi), the mixed infection act.
By criterion of localization and prevalence of an empiyema of a pleura happen unilateral and bilateral; subtotal, total, delimited: apikalny (top), parakostalny (pristenochny), basal (naddiafragmalny), intershare, paramediastinalny. In the presence of 200-500 ml of purulent exudate in pleural sine speak about a small empiyema of a pleura; at a congestion of 500-1000 ml of exudate which borders reach a shovel corner (the VII mezhreberye), – about an average empiyema; at quantity of an exudate more than 1 liter – about a big empiyema of a pleura.
can be closed (not reported with the environment) and opened (in the presence of fistulas – bronkhoplevralny, plevrokozhny, bronkhoplevralnokozhny, plevrolegochny, etc.). Open empiyema of a pleura are classified as .
Pleura empiyema reasons
Almost in 90% of cases of an empiyema of a pleura are secondary on the origin and develop upon direct transition of purulent process from a lung, a sredosteniye, a pericardium, a chest wall, poddiafragmalny space.
Most often the empiyema of a pleura arises at sharp or chronic infectious pulmonary processes: pneumonia, bronkhoektaza, lung abscess, lung gangrene, tuberculosis, the suppurated lung cyst, etc. In some cases an empiyemy pleura the course of spontaneous pheumothorax, ekssudativny pleurisy, a mediastinit, perikardit, osteomyelitis of edges and a backbone, poddiafragmalny abscess, abscess of a liver, sharp pancreatitis becomes complicated. Metastatic empiyema of a pleura are caused by spread of an infection in the hematogenic or limfogenny way from the remote purulent centers (for example, at an acute appendicitis, quinsy, sepsis, etc.).
Post-traumatic purulent pleurisy is, as a rule, connected with lung injuries, thorax wounds, a rupture of a gullet. The postoperative empiyema of a pleura can arise after a resection of lungs, a gullet, cardiac and other operations on bodies of a chest cavity.
Pathogenesis of an empiyema of a pleura
In development of an empiyema of a pleura allocate three stages: serous, fibrinozno-purulent and stage of the fibrous organization.
The first stage proceeds with education in a pleural cavity of a serous exudate. In due time begun antibacterial therapy allows to suppress ekssudativny processes and promotes a spontaneous resorption of liquid. In case of inadequately picked up antimicrobic therapy in pleural exudate growth and reproduction of gnoyerodny flora begins that leads to transition of pleurisy to the following stage - fibrinozno-purulent.
In this phase of an empiyema of a pleura owing to increase in quantity of bacteria, a detrit, polymorphic and nuclear leukocytes exudate becomes muddy, gaining purulent character. On the surface of a visceral and parietal pleura the fibrinozny raid is formed, there are friable, and then dense solderings between pleura leaves. Unions form the limited intra pleural osumkovaniye containing a congestion of dense pus.
In a stage of the fibrous organization there is an education dense pleural which, as an armor, hold down the drawn-in lung. Over time nonfunctioning pulmonary fabric is exposed to fibrous changes with development of plevrogenny cirrhosis of a lung.
Pleura empiyema symptoms
The sharp empiyema of a pleura demonstrates from development of the simptomokompleks including oznoba, with firmness high (up to 39 °C and above) or the gekticheky temperature, plentiful sweating, the accruing short wind, tachycardia, cyanosis of lips, . Endogenous intoxication is sharply expressed: headaches, the progressing weakness, lack of appetite, slackness, apathy.
The intensive pain syndrome on the party of defeat is noted; the pricking breast pains amplify at breath, the movements and cough. Pains can irradiate in a shovel, the top half of a stomach. At the closed pleura empiyema cough dry, in the presence of the bronkhoplevralny message – with office of a large number of a fetid purulent phlegm. The compelled situation is characteristic of patients from an empiyemy pleura - semi-sitting with the emphasis on the hands located behind a trunk.
Owing to loss of proteins and electrolytes the volemichesky and water and electrolytic frustration which are followed by reduction of muscle bulk and weight loss develop. The person and the struck half of a thorax gain pastosity, there are peripheral hypostases. Against the background of hypo - and disproteinemiya develop dystrophic changes of a liver, myocardium, kidneys and functional polyorgan insufficiency. At a pleura empiyema the risk of the thromboses and TELA leading to death of patients sharply increases. In 15% of cases the sharp empiyema of a pleura passes into a chronic form.
Diagnostics of an empiyema of a pleura
Recognition of a piotoraks demands carrying out comprehensive fizikalny, laboratory and tool examination. At survey of the patient from an empiyemy pleura lag of the struck side of a thorax at breath, asymmetric increase in a thorax, expansion, smoothing or a vybukhaniye of mezhreberiya comes to light. Are typical external signs of the patient from a chronic empiyemy pleura scoliosis with a backbone bend in the healthy party, the lowered shoulder and the being shovel on the side of defeat.
The Perkutorny sound on the party of purulent pleurisy is dulled; in case of a total empiyema of a pleura absolute perkutorny dullness is defined. At an auskultation breath on the party of a piotoraks is sharply weakened or is absent. The polyposition X-ray analysis and roentgenoscopy of lungs at an empiyema of a pleura find intensive shading. For specification of the sizes, forms of an osumkovanny empiyema of a pleura, existence of fistulas carry out a plevrografiya with introduction of water-soluble contrast to a pleural cavity. For an exception of destructive processes in lungs carrying out KT, MPT of lungs is shown.
In diagnostics limited empiy pleurae informational content of ultrasonography of a pleural cavity which allows to find even a small amount of exudate is big, to define the place of performance of a pleural puncture. Crucial diagnostic importance at an empiyema of a pleura is allocated for a puncture of a pleural cavity by means of which purulent character of exudate is confirmed. The bacteriological and microscopic analysis of a pleural exudate allows to specify a pleura empiyema etiology.
Treatment of an empiyema of a pleura
At an empiyema of a pleura of any etiology adhere to the general principles of treatment. The great value is attached to early and effective depletion of a pleural cavity from purulent contents. It is reached by means of drainage of a pleural cavity, vacuum aspiration of pus, a pleural unleavened wheat cake, introduction of antibiotics and proteolytic enzymes, medical bronkhoskopiya. Evacuation of purulent exudate promotes reduction of intoxication, a lung raspravleniye, accustoming to drinking of leaves of a pleura and elimination of a cavity of an empiyema of a pleura.
Along with local introduction of antimicrobic means massive system antibiotic treatment (tsefalosporina, aminoglycosides, karbapenema, ftorkhinolona) is appointed. Dezintoksikatsionny, immunocorrective therapy, vitamin therapy, transfusion of proteinaceous medicines (plasma of blood, albumine, hydrolyzates), solutions of glucose, electrolytes is carried out. For the purpose of normalization of a homeostasis, decrease in intoxication and increase in immunoresistant opportunities of an organism Ural federal district blood, a plasma exchange, , haemo sorption is carried out.
In the period of a rassasyvaniye of exudate the procedures preventing an obyorazovaniye of pleural unions - respiratory gymnastics, LFK, ultrasound, classical, perkutorny and vibration massage of a thorax are appointed.
When forming a chronic empiyema of a pleura surgical treatment is shown. At the same time the torakostomiya (open drainage), a plevrektomiya with a lung decortication, an intraplevralny torakoplastika, closing of bronkhoplevralny fistula, various options of a resection of a lung can be carried out.
Forecast and prevention of an empiyema of a pleura
Bronkhoplevralny fistulas, septikopiyemiya, secondary bronkhoektaza, , polyorgan insufficiency can be complications of an empiyema of a pleura. The forecast at a pleura empiyema always serious, a lethality makes 5-22%.
Prevention of an empiyema of a pleura consists in timely antibiotic treatment of pulmonary and extra pulmonary infectious processes, observance of a tshchayotelny asepsis at surgical interventions on a chest cavity, achievement of a bystry raspravleniye of a lung in the posleoperatsiyoonny period, increase in the general resistance of an organism.