Pleurisy

• Clinic of fibrinous pleurisy. The patient complains of pain during breathing, coughing, when bending to the opposite side. Subfebrile fever persists for a long time mainly in the evening; sweating. Objective data are as follows: superficial, rapid breathing, the patient’s position is forced (the patient lies on his sore side to reduce pain). During a physical examination, along with the symptoms of the underlying disease, a localized or extensive pleural friction noise will be heard.
• With exudative pleurisy, pain can change its intensity, but the patient has a feeling of heaviness in one or another half of the chest, shortness of breath, cough dry or with sputum, (reflex character). The patient usually takes a forced position. A general examination reveals cyanosis , acrocyanosis, swollen veins of the neck. When examining the chest: bulging intercostal space, the affected half lags behind when breathing. On palpation, a limitation of the excursion of the chest is detected, voice trembling is not carried out. With percussion, femoral dullness of percussion sound is detected. Ascultation, breathing is not performed (if the amount of fluid is small, then breathing can be carried out, in the presence of pus, breathing can become hard or bronchial. If the position is horizontal, weakening of vesicular breathing).
• The clinic of pleural empyema is characterized by hectic fever, severe intoxication, and a change in ascultative data.

A reliable sign confirming the presence of pleurisy is chest x-ray : a classic sign of effusion pleurisy is a homogeneous darkening of the lung tissue with an oblique upper level of fluid. This x-ray picture is observed in the case of diffuse pleurisy, if the amount of fluid exceeds 1 liter. If the fluid is less than a liter, then the fluid accumulates in the sinuses, and a darkening of the lower lateral sinus is observed. It is difficult to make a diagnosis if there is a total blackout of one or another half of the chest (total acute pneumonia , lung atelectasis , direct contraindication in thoracocentesis ). If it is a liquid, then contralateral displacement of the mediastinal organs is observed. With hydropneumothorax , the fluid level is horizontal. With interlobar pleurisy, it is usually, it appears in the form of a biconvex lens.

In the diagnosis of pleurisy, pleural puncture plays an important role. Thoracocentesis is performed in the 7-8 intercostal space along the posterior axillary or scapular line. The resulting liquid is inspected, its color, consistency is determined. It is necessary to determine transudate or exudate: it is necessary to determine the amount of protein, make a sample of Rivolt, examine LDH. Transudate: the amount of protein is less than 32 g / l, the LDH level is less than 1.3 mmol / l, the Rivolt test is negative.

Exudate: protein more than 36 g / l, LDH level 1.75 mmol / l, Rivolt test positive. For a clear definition of transudate or exudate, it is necessary to determine the coefficients — effusion protein level / serum protein level, total LDH effusion level / serum LDH level. If these coefficients are respectively less than 0.5 and 0.6 then this is a transudate. Transudate mainly occurs in three conditions: circulatory failure, liver cirrhosis, and nephrotic syndrome. If the coefficients are greater than 0.5 and 0.6 then this is an exudate, and further searches should be aimed at finding the cause.

The normal composition of pleural fluid.

• Specific Gravity 1015
• Color - Straw Yellow
• Transparency - Full
• Discreet
• Odorless

Cell composition:

• the total number of red blood cells is 2000-5000 in mm3
• total white blood cell count 800–900 mm3
• neutrophils up to 10%
• eosinophils up to 1%
• basophils up to 1%
• lymphocytes up to 23%
• endothelium up to 1%
• plasma cells up to 5%
• protein 1.5 - 2 g per 100 ml (15-25 g / l).
• LDH 1.4 - 1.7 mmol / L
• glucose 20-40 mg per 100 ml (2.1 - 2.2 mmol / l)
• pH 7.2

In those cases when the pleural fluid is transparent, they begin a biochemical study (LDH, amylase, glucose). A decrease in glucose levels is observed with tuberculous pleurisy, a sharp decrease in glucose with mesotheliomas . A slight decrease in glucose in acute pneumonia, especially in mycoplasma.

If the liquid is cloudy - you need to think about chylothorax or pseudochylothorax. Lipids are determined in a liquid - if crystals of cholesterol fall out, then it is pseudo-chylothorax or cholesterol exudative pleurisy. If triglyceride crystals precipitate, then it is chylothorax (damage to the thoracic duct, most often with malignant tumors).

If the liquid is bloody, you need to determine the hematocrit. If more than 1% - you need to think about a tumor, trauma, and pulmonary embolism with the development of pulmonary infarction. If the hematocrit is more than 50%, this is hemothorax, which requires surgical intervention.

Then a cytological examination of the pleural fluid is performed. If malignant tumor cells are detected, the source of the tumor is determined. If leukocytes predominate - it is acute pleurisy, if the infiltrate is pneumonic, then most often it is para-pneumonic pleurisy. If it is pneumonia, then it is necessary to do tomography, bronchoscopy, computed tomography. If mononuclear cells predominate, it is a chronic pleurisy, in which a double biopsy of the pleura is necessary, in which the etiology can be established. If a double biopsy of the pleura is not diagnosed, then they resort to lung scanning, angiography, computed tomography, ultrasound of the abdominal organs.

Diagnosis: the main disease is put in first place, then complications - dry pleurisy, diffuse or clotted (indicating localization).

Treatment of pleurisy should be comprehensive and aimed primarily at eliminating the main process that led to its development. Symptomatic treatment aims to anesthetize and accelerate the resorption of fibrin, to prevent the formation of extensive mooring and adhesions in the pleural cavity.

In the acute period of tuberculous pleurisy, treatment with anti-TB drugs is indicated: isoniazid — 10 mg / kg, streptomycin — 1 g, ethambutol — 25 mg / kg, rifampicin — 0.45-0.6 g / day. Etiotropic treatment of tuberculous pleurisy lasts 10-12 months.

The success of treatment of a patient with parapneumonic pleurisy depends on the early start and the correct selection of antibacterial agents, taking into account the type of microorganisms and their sensitivity. A positive effect is given by the appointment of immunostimulating therapy ( levamisole ).

With tumor pleurisy, targeted chemotherapy is required, with pleurisy of rheumatic etiology, glucocorticosteroid hormones ( prednisone in a daily dose of 15-20 mg) are needed.

Desensitizing and anti-inflammatory drugs ( calcium chloride , acetylsalicylic acid, butadion, analgin , indomethacin , etc.) give a good effect, which also usually significantly reduce pleural pain.

Pleurisy can be prevented, depending on its cause. For example, early treatment of pneumonia can prevent the accumulation of pleural fluid. In the case of heart, lung, or kidney disease, managing the underlying disease can help prevent fluid buildup. It is also necessary to conduct a medical examination in order to identify the disease in the early stages and urgently provide medical assistance to the patient.

• The great Russian ballerina of the XX century Anna Pavlova died of pleurisy at the age of 49 years.
• In the Tennessee Williams play, The Glass Menagerie , Laura Wingfield, who had childhood pleurisy, received the nickname “Blue Rose” as a result of the pun: pleurosis - blue roses .

Of the general phenomena, inhibition of animals is noted, a significant decrease in their appetite, and an increase in body temperature. Noteworthy is the breathing-frequent, superficial, abdominal type. With unilateral pleurisy, the symmetry of the excursions of the chest is broken. The cough at rest is weak and not frequent, the animal is trying to detain him. With percussion in the chest, the cough intensifies and becomes more frequent. Urination with exudative pleurisy is reduced, urine is highly concentrated and often contains protein. In the blood, neutrophilic leukocytosis with a shift of the nucleus to the left, degeneration of neutrophils and monocytes are detected. ^[four]

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