Pleurisy – various inflammatory defeats of the serous cover in the etiologichesky relation surrounding lungs. Pleurisy is followed by thorax pains, short wind, cough, weakness, temperature increase, auskultativny phenomena (noise of friction of a pleura, weakening of breath). Diagnosis of pleurisy is performed by means of a X-ray analysis (-skopiya) a thorax, ultrasonography of a pleural cavity, a pleural puncture, a diagnostic torakoskopiya. Treatment can include conservative therapy (antibiotics, NPVS, LFK, physical therapy), carrying out a series of medical punctures or drainage of a pleural cavity, surgical tactics (, a plevrektomiya).
Pleurisy – an inflammation visceral (pulmonary) and parietal (pristenochny) pleura leaves. Pleurisy can be followed by accumulation of an exudate in a pleural cavity (ekssudativny pleurisy) or to proceed with education on a surface of the inflamed pleural leaves of fibrinozny imposings (fibrinozny or dry pleurisy). The diagnosis "pleurisy" is made to 5-10% of all patients who are on treatment in therapeutic hospitals. Pleurisy can burden the course of various diseases in pulmonology, phthisiology, cardiology, rheumatology, oncology. Statistically more often pleurisy is diagnosed for men of middle and advanced age.
Reasons and mechanism of development of pleurisy
Often pleurisy is not independent pathology, and accompanies a number of diseases of easy and other bodies. On the causes pleurisy is divided into infectious and noninfectious (aseptic).
Serve as the reasons of pleurisy of an infectious etiology:
- bacterial infections (staphylococcus, pneumococcus, gramotritsatelny flora, etc.);
- fungal infections (candidiasis, , );
- virus, parasitic (, echinococcosis), mikoplazmenny infections;
- tuberculosis infection (comes to light at 20% of patients with pleurisy);
- syphilis, sypny and belly typhus, brucellosis, tulyaremiya;
- surgical interventions and injuries of a thorax;
Pleurisy of a noninfectious etiology causes:
- malignant tumors of a pleura (pleura mesothelioma), metastasises in a pleura at lung cancer, a breast cancer, lymphoma, tumors of ovaries, etc. (at 25% of patients with pleurisy);
- diffusion defeats of connecting fabric (system red a wolf cub, rheumatoid arthritis, a sklerodermiya, rheumatism, system vaskulit, etc.);
- TELA, lung heart attack, myocardial infarction;
- other causes (hemorrhagic diathesis, leukoses, pancreatitis etc.).
The mechanism of development of pleurisy of various etiology has the specifics. Causative agents of infectious pleurisy directly influence a pleural cavity, getting into it in various ways. Contact, limfogenny or hematogenic ways of penetration are possible from subplevralno the located infection sources (at abscess, pneumonia, a bronkhoektatichesky disease, the suppurated cyst, tuberculosis). Direct hit of microorganisms in a pleural cavity happens at violation of integrity of a thorax (at wounds, injuries, surgeries).
Pleurisy can develop as a result of increase in permeability of lymphatic and blood vessels at system vaskulita, tumoral processes, sharp pancreatitis; violations of outflow of a lymph; decrease in the general and local reactivity of an organism.
The insignificant amount of exudate can back be soaked up by a pleura, leaving a fibrinous layer on its surface. So there is a formation of dry (fibrinozny) pleurisy. If education and accumulation of an exudate in a pleural cavity exceeds the speed and a possibility of its outflow, then ekssudativny pleurisy develops.
The sharp phase of pleurisy is characterized by inflammatory hypostasis and cellular infiltration of leaves of a pleura, an exudate congestion in a pleural cavity. At a rassasyvaniye of a liquid part of exudate on the surface of a pleura shvarta - the fibrinozny pleural imposings conducting to a partial or full plevroskleroz (an obliteration of a pleural cavity) can be formed.
Classification of pleurisy
Most often in clinical practice the classification of pleurisy offered in 1984 by professor SPBGM N. V. Putovym is used.
On an etiology:
- infectious (on the infectious activator – pnevmokokkovy, staphylococcal, tubercular, etc. pleurisy)
- noninfectious (with designation of the disease leading to development of pleurisy – lung cancer, rheumatism etc.)
- idiopathic (not clear etiology)
On existence and character of exudate:
- ekssudativny (pleurisy with serous, serous , the purulent, putrefactive, hemorrhagic, cholesteric, eozinofilny, hilezny, mixed exudate)
- fibrinozny (dry)
On a current of an inflammation:
On localization of an exudate:
- osumkovanny or limited (pristenochny, top, diafragmalny, kostodiafragmalny, intershare, paramediastinalny).
Symptoms of pleurisy
- Dry pleurisy
As a rule, being secondary process, a complication or a syndrome of other diseases, symptoms of pleurisy I can prevail, masking the main pathology. The clinic of dry pleurisy is characterized by the pricking thorax pains amplifying at cough, breath and the movement. The patient is forced to adopt the provision, lying on a sick side, for restriction of mobility of a thorax. Breath is superficial, sparing, the struck half of a thorax considerably lags behind at the respiratory movements. A characteristic symptom of dry pleurisy is the noise of friction of a pleura listened at an auskultation, the weakened breath in a zone of fibrinozny pleural imposings. Body temperature sometimes increases to subfebrilny values, the course of pleurisy can be followed by oznoba, night then, weakness.
Diafragmalny dry pleurisy has specific clinic: pains in a podreberye, a thorax and an abdominal cavity, a meteorizm, a hiccups, tension of muscles of an abdominal tension.
Development of fibrinozny pleurisy depends on the main disease. At a number of patients of display of dry pleurisy pass 2-3 weeks later, however, a recurrence is possible. At tuberculosis the course of pleurisy long, quite often followed by sweating of exudate in a pleural cavity.
- Ekssudativny pleurisy
The beginning of a pleural ekssudation dull ache in the struck side, the painful dry cough reflex arising, lag of the corresponding half of a thorax in breath accompanies, noise of friction of a pleura. In process of an exudate skaplivaniye pain is replaced by heavy feeling in a side, the accruing short wind, moderate cyanosis, smoothing of intercostal intervals. The general symptomatology is characteristic of ekssudativny pleurisy: weakness, febrilny body temperature (at a pleura empiyema – from oznoba), appetite loss, perspiration. At osumkovanny paramediastinalny pleurisy the dysphagy, a voice osiplost, face edemas and necks is observed. At the serous pleurisy caused by a bronkhogenny form of cancer the blood spitting quite often is observed. The pleurisy caused by a system red volchanka often is combined with perikardita, damages of kidneys and joints. Metastatic pleurisy is characterized by slow accumulation of exudate and proceeds malosimptomno.
A large amount of exudate conducts to sredosteniye shift to the opposite side, to violations from external breath and cardiovascular system (to considerable reduction of depth of breath, its increase, development of compensatory tachycardia, decrease HELL).
The pleurisy outcome in many respects depends on its etiology. In cases of a persistent course of pleurisy development of adhesive process in a pleura cavity, zarashcheny intershare cracks and pleural cavities, education massive , a thickening of pleural leaves, development of a plevroskleroz and respiratory insufficiency, restriction of mobility of a dome of a diaphragm is further not excluded.
Diagnosis of pleurisy
Along with clinical displays of ekssudativny pleurisy at survey of the patient asymmetry of a thorax, a vybukhaniye of intercostal intervals on the corresponding half of a thorax, lag of the struck party at breath comes to light. The Perkutorny sound over exudate is dulled, the bronkhofoniya and voice trembling are weakened, breath weak or is not listened. The upper bound of an exudate is defined perkutorno, at a X-ray analysis of lungs or by means of ultrasonography of a pleural cavity.
When carrying out a pleural puncture receive liquid which character and volume depends on the pleurisy reason. The cytologic and bacteriological research of pleural exudate allows to find out a pleurisy etiology. The pleural exudate is characterized with a relative density over 1018-1020, variety of cellular elements, positive reaction of Rivolt.
In blood increase in SOE, neytrofilny , increase in values of seromukoid, sialovy acids, fibrin are defined. For specification of the reason of pleurisy the torakoskopiya with a pleura biopsy is carried out.
Treatment of pleurisy
Medical actions at pleurisy are directed to elimination of an etiologichesky factor and simplification of symptomatology. At the pleurisy caused by pneumonia antibiotic treatment is appointed. Rheumatic pleurisy is treated by nonsteroid anti-inflammatory medicines, glucocorticosteroids. At tubercular pleurisy treatment is carried out by the phthisiatrician and consists in specific therapy by rifampicin, an isoniazid and streptomycin for several months.
With the symptomatic purpose purpose of analgetics, diuretic, cardiovascular means, after an exudate rassasyvaniye - physical therapy and physiotherapy exercises is shown.
At ekssudativny pleurisy with a large number of an exudate resort to its evacuation by carrying out a pleural puncture (torakotsentez) or drainage. It is in one stage recommended to evacuate no more than 1-1,5 l of exudate in order to avoid cardiovascular complications (owing to a sharp raspravleniye of easy and return shift of a sredosteniye). At purulent pleurisy washing of a pleural cavity is carried out by antiseptic solutions. According to indications antibiotics, enzymes, a hydrocortisone etc. are vnutriplevralno entered.
In treatment of dry pleurisy besides etiologichesky treatment rest is shown to patients. For simplification of a pain syndrome the mustard plasters, banks warming compresses and hard bandaging of a thorax are appointed. For the purpose of suppression of cough appoint reception of codeine, hydrochloride ethyl morphine. In treatment of dry pleurisy resolvents are effective: acetilsalicylic acid, ibuprofen, etc. After normalization of health and indicators of blood to the patient with dry pleurisy appoint respiratory gymnastics for prevention of unions in a pleura cavity.
For the purpose of treatment of recurrent ekssudativny pleurisy carry out (introduction to a pleural cavity of talc or himiopreparat for pasting of leaves of a pleura). For treatment of chronic purulent pleurisy resort to surgical intervention – a plevrektomiya with a lung dekortkation. At development of pleurisy as a result of inoperable damage of a pleura or a lung carry out by a malignant tumor according to indications a palliative plevrektomiya.
Forecast and prevention of pleurisy
The small amount of exudate can independently resolve. The termination of an ekssudation after elimination of the main disease happens within 2-4 weeks. After liquid evacuation (in case of infectious pleurisy, including a tubercular etiology) perhaps persistent current with a repeated congestion of an exudate in a pleura cavity. The pleurisy caused by the oncological reasons has the progressing current and a failure. Purulent pleurisy differs in an adverse current.
The patients who had pleurisy are on dispensary observation for 2-3 years. The exception of professional vrednost vitaminized and high-calorific food, an exception of a catarrhal factor and overcoolings is recommended.
In prevention of pleurisy the leading role belongs to the prevention and treatment of the main diseases leading to their development: an acute pneumonia, tuberculosis, rheumatism, and also to increase in resilience of an organism in relation to various infections.