Pleurisy – etiologically different inflammatory lesions of the serous membrane surrounding the lungs. Disease is accompanied by chest pains, shortness of breath, cough, weakness, fever, auscultative phenomena (pleural friction noise, weakening of breathing). Diagnosis is carried out using chest X-ray, ultrasound of the pleural cavity, pleural puncture, diagnostic thoracoscopy. Treatment may include conservative therapy (antibiotics, NSAIDs, exercise therapy, physiotherapy), a series of therapeutic punctures or drainage of the pleural cavity, surgical tactics (pleurodesis, pleurectomy)
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Pleurisy is an inflammation of the visceral (pulmonary) and parietal (parietal) pleural leaves. Pathology may be accompanied by an accumulation of effusion in the pleural cavity (exudative pleurisy) or proceed with the formation of fibrinous overlays on the surface of inflamed pleural leaves (fibrinous or dry pleurisy). The diagnosis of “pleurisy” is made by 5-10% of all patients being treated in therapeutic hospitals. Disease can aggravate the course of various diseases in pulmonology, phthisiology, cardiology, oncology. Statistically, disease is more often diagnosed in middle-aged and elderly men.
Causes of pleurisy
Often pleurisy is not an independent pathology, but accompanies a number of diseases of the lungs and other organs. For reasons of occurrence, disease is divided into infectious and non-infectious (aseptic).
The causes of pleurisy of infectious etiology are:
- bacterial infections (staphylococcus, pneumococcus, gram-negative flora, etc.);
- fungal infections (candidiasis, blastomycosis, coccidioidosis);
- viral, parasitic (amoebiasis, echinococcosis), mycoplasma infections;
- tuberculosis infection (detected in 20% of patients with pleurisy);
- syphilis, typhoid fever, brucellosis, tularemia;
- surgical interventions and chest injuries;
Pleurisy of non-infectious etiology causes:
- malignant tumors of the pleura (pleural mesothelioma), metastases to the pleura in lung cancer, breast cancer, lymphoma, ovarian tumors, etc. (in 25% of patients with pleurisy);
- diffuse connective tissue lesions (systemic lupus erythematosus, rheumatoid arthritis, scleroderma, rheumatism, systemic vasculitis, etc.);
- PE, lung infarction, myocardial infarction;
- other causes (hemorrhagic diathesis, leukemia, pancreatitis, etc.).
The mechanism of development of various etiologies has its own specifics. Pathogens of infectious form directly affect the pleural cavity, penetrating it in various ways. Contact, lymphogenic or hematogenic pathways of penetration are possible from subpleurally located sources of infection (with abscess, pneumonia, bronchiectatic disease, suppurated cyst, tuberculosis). Direct entry of microorganisms into the pleural cavity occurs when the integrity of the chest is violated (with wounds, injuries, surgical interventions).
Pleurisy can develop as a result of increased permeability of lymphatic and blood vessels in systemic vasculitis, tumor processes, acute pancreatitis; violations of lymph outflow; reduction of general and local reactivity of the body.
A small amount of exudate can be reabsorbed by the pleura, leaving a fibrin layer on its surface. This is how the formation of dry (fibrinous) pleurisy occurs. If the formation and accumulation of effusion in the pleural cavity exceeds the rate and possibility of its outflow, then exudative form develops.
The acute phase of pleurisy is characterized by inflammatory edema and cellular infiltration of pleural leaves, accumulation of exudate in the pleural cavity. When the liquid part of the exudate is absorbed, mooring – fibrinous pleural overlays leading to partial or complete pleurosclerosis (obliteration of the pleural cavity) can form on the surface of the pleura.
The classification of this disease, proposed in 1984 by Professor N.V. Putov of St. Petersburg State Medical University, is most often used in clinical practice.
- infectious (according to the infectious pathogen – pneumococcal, staphylococcal, tuberculosis, etc. pleurisy)
- non–infectious (with the designation of the disease leading to the development of pleurisy – lung cancer, rheumatism, etc.)
- idiopathic (unclear etiology)
By the presence and nature of the exudate:
- exudative (pleurisy with serous, serous-fibrinous, purulent, putrefactive, hemorrhagic, cholesterol, eosinophilic, chyletic, mixed effusion)
- fibrinous (dry)
Along the course of inflammation:
By localization of effusion:
- closed or limited (parietal, apical, diaphragmatic, costodiaphragmatic, interlobular, paramediastinal).
Symptoms of pleurisy
As a rule, being a secondary process, complication or syndrome of other diseases, the symptoms of pleurisy can prevail, masking the underlying pathology. The clinic of dry pleurisy is characterized by stabbing pains in the chest, which increase with coughing, breathing and movement. The patient is forced to take a position lying on the patient’s side to limit the mobility of the chest. Breathing is shallow, gentle, the affected half of the chest noticeably lags behind with respiratory movements. A characteristic symptom of dry form is the pleural friction noise heard during auscultation, weakened breathing in the area of fibrinous pleural overlays. Body temperature sometimes rises to subfebrile values, the course may be accompanied by chills, night sweats, weakness.
Diaphragmatic dry pleurisy has a specific clinic: pain in the hypochondrium, chest and abdominal cavity, flatulence, hiccups, abdominal muscle tension.
The development of fibrinous form depends on the underlying disease. In a number of patients, manifestations of dry pleurisy pass after 2-3 weeks, however, relapses are possible. In tuberculosis, the course of pleurisy is prolonged, often accompanied by exudate exudation into the pleural cavity.
The onset of pleural exudation is accompanied by dull pain in the affected side, reflexively painful dry cough, lagging of the corresponding half of the chest in breathing, pleural friction noise. As the exudate accumulates, the pain is replaced by a feeling of heaviness in the side, increasing shortness of breath, moderate cyanosis, smoothing of intercostal spaces. Exudative form is characterized by general symptoms: weakness, febrile body temperature (with pleural empyema – with chills), loss of appetite, sweating. Dysphagia, hoarseness of the voice, swelling of the face and neck are observed in case of obstructed paramediastinal pleurisy. With serous pleurisy caused by bronchogenic cancer, hemoptysis is often observed. Disease caused by systemic lupus erythematosus is often combined with pericarditis, kidney and joint lesions. Metastatic pleurisy is characterized by a slow accumulation of exudate and is asymptomatic.
A large amount of exudate leads to a displacement of the mediastinum in the opposite direction, disturbances from the external respiration and the cardiovascular system (a significant decrease in the depth of breathing, its frequency, the development of compensatory tachycardia, a decrease in blood pressure).
The outcome of pleurisy largely depends on its etiology. In cases of persistent pleurisy in the future, the development of adhesions in the pleural cavity, the overgrowth of interstitial slits and pleural cavities, the formation of massive moorings, thickening of pleural leaves, the development of pleurosclerosis and respiratory failure, restriction of the mobility of the diaphragm dome is not excluded.
Diagnostics of pleurisy
Along with the clinical manifestations of exudative pleurisy, the examination of the patient reveals the asymmetry of the chest, the bulging of the intercostal spaces on the corresponding half of the chest, the lag of the affected side during breathing. Percussion sound over the exudate is blunted, bronchophony and vocal tremor are weakened, breathing is weak or not listened to. The upper border of the effusion is determined percutorially, by lung x-ray or by ultrasound of the pleural cavity.
During a pleural puncture, a fluid is obtained, the nature and volume of which depends on the cause of disease. Cytological and bacteriological examination of pleural exudate allows to find out the etiology of pleurisy. Pleural effusion is characterized by a relative density above 1018-1020, a variety of cellular elements, and a positive Rivolt reaction.
In the blood, an increase in ESR, neutrophilic leukocytosis, an increase in the values of seromucoids, sialic acids, and fibrin are determined. To clarify the cause of pleurisy, a thoracoscopy with a pleural biopsy is performed.
Treatment for pleurisy
Therapeutic measures for pleurisy are aimed at eliminating the etiological factor and relieving symptoms. With disease caused by pneumonia, antibiotic therapy is prescribed. Rheumatic pleurisy is treated with nonsteroidal anti-inflammatory drugs, glucocorticosteroids. With tuberculous form, treatment is carried out by a phthisiologist and consists in specific therapy with rifampicin, isoniazid and streptomycin for several months.
For symptomatic purposes, the appointment of analgesics, diuretics, cardiovascular agents is indicated, after resorption of effusion – physiotherapy and physical therapy.
With exudative pleurisy with a large amount of effusion, it is resorted to evacuation by pleural puncture (thoracocentesis) or drainage. At the same time, it is recommended to evacuate no more than 1-1.5 liters of exudate in order to avoid cardiovascular complications (due to a sharp expansion of the lung and reverse displacement of the mediastinum). With purulent pleurisy, the pleural cavity is washed with antiseptic solutions. According to indications, antibiotics, enzymes, hydrocortisone, etc. are administered intrapleurally.
In the treatment of dry pleurisy, in addition to etiological treatment, patients are shown rest. To relieve pain, mustard plasters, jars, warming compresses and tight bandaging of the chest are prescribed. In order to suppress cough, codeine and ethylmorphine hydrochloride are prescribed. Anti-inflammatory drugs are effective in the treatment of dry pleurisy: acetylsalicylic acid, ibuprofen, etc. After normalization of well-being and blood parameters, a patient with dry pleurisy is prescribed respiratory gymnastics to prevent fusion in the pleural cavity.
In order to treat recurrent exudative form, pleurodesis is performed (introduction of talc or chemotherapy drugs into the pleural cavity for gluing pleural leaves). For the treatment of chronic purulent pleurisy, surgical intervention is resorted to – pleurectomy with lung decortcation. With the development of pleurisy as a result of inoperable damage to the pleura or lung by a malignant tumor, palliative pleurectomy is performed according to indications.
Prognosis and prevention
A small amount of exudate can dissolve on its own. The cessation of exudation after the elimination of the underlying disease occurs within 2-4 weeks. After evacuation of the fluid (in the case of infectious pleurisy, including tuberculosis etiology), a persistent course with repeated accumulation of effusion in the pleural cavity is possible. Pleurisy caused by oncological causes has a progressive course and an unfavorable outcome. Purulent pleurisy is characterized by an unfavorable course.
Patients who have suffered pleurisy have been under dispensary supervision for 2-3 years. It is recommended to exclude occupational hazards, fortified and high-calorie nutrition, exclusion of the cold factor and hypothermia.
In the prevention, the leading role belongs to the prevention and treatment of the main diseases that lead to their development: acute pneumonia, tuberculosis, rheumatism, as well as increasing the body’s resistance to various infections.