Pleurisy

Pleurisy is an inflammation of the pleura. Pleurisy are a large group of different etiology and clinical features of the disease of the pleura. Pleurisy can occur when pneumonia, heart attacks, lung tumors and other diseases. This is secondary, or symptomatic, pleurisy. The most frequently encountered pleurisy tubercular etiology, considered as an independent disease.
Pleurisy is conventionally divided into dry and vpotnye (exudative). At a dry pleurisy pleura swells, thickens, becomes uneven. Exudative pleurisy noted the accumulation of inflammatory fluid - up to 2 liters or more. Symptoms and course of the disease depend on the form of pleurisy infection that caused the disease, General condition of the patient.
Dry pleurisy begins with chest pain (side) and cough. The pain increases when you inhale, you may receive General weakness, low grade, sometimes the feverish temperature. The pain is caused by friction inflamed rough pleura during breathing. Heard the noise pleural friction. Usually within a few days the disease ends recovery. Persistent dry pleurisy, particularly bilateral, always suspicious chronic pneumonia. These patients even with normal temperature subject to examination in the hospital.
For exudative pleurisy characterized by intense pain in the beginning of the disease, reduce pain at the height of the development process and the new growing pains in the recovery period. The reason is that at the beginning of the disease inflamed pleural sheets (parietal and visceral) remain in contact with each other and with the breath is irritation of sensitive endings intercostal nerves that Innervate the parietal pleura. Reducing pain in the midst of illness because accumulating exudate divides pleural sheets and thereby reduces irritation of sensitive endings intercostal nerves. Finally, the new rise of pain syndrome due to resorption of the exudate and emerging contact pleural leaves. It should be remembered that a new intensification of the pain may be associated with suppuration of the exudate (purulent pleurisy). In these cases, flank pain intensity exceeds the pain that took place in the beginning of the disease.


Fig. 1. Triangles Rauchfuss-Grocco (2) and garland (3); 1 - exudate.

When viewed from the position of the patient forced (on the sick side). At offset mediastinum in the opposite direction of the exudate may experience shortness of breath. When turning on the healthy side it is rising because the resulting restrictions respiratory excursions healthy lung aggravate existing respiratory insufficiency. The skin of the patient pale color bluish lips. Sometimes noticeable increase in the volume of the affected part of chest, restriction of movement during breathing, smoothness intercostal spaces. Notes tachycardia. Over the accumulation of fluid - dullness of percussion sound to dullness. Top blunting is located on the posterior axillary line and obliquely reduced to the mid-clavicle and blade lines (line Sokolov - Damaso). In some cases, the location of the upper boundary of stupidity is disturbed by osmawani of exudates or before pleural growths. Between the spine and Kosaya line Sokolov - Damaso formed space with pritulenko-tympanic sound (triangle of garland) over the site bogatogo light (see the lung Atelectasis). On the healthy side is determined dulling described by Rauchfuss - Grocco (Fig. 1). It is explained by the shift of the mediastinum in the healthy side. When left-exudative pleurisy disappears the Traub space (see).
Voice trembling and breathing noises sharply weakened over the area stupid percussion tone. Above stupidity heard bronchial shade of breath due to compression of the lung tissue - compression atelectasis (see lung Atelectasis). Fever persists for 5-10 days, with tuberculous pleurisy can persist for a long time.
Radiographically determined intensive homogeneous darkening of the lower section of the chest with a scythe top border, with mediastinal shift in the healthy side. The diagnosis is confirmed and specified by the study pleural exudate: when pleural puncture in the syringe is serous or sero-fibrinous, purulent or hemorrhagic (bleeding) exudate. Pleural puncture produced with strict observance of the rules of aseptics in the VIII-th intercostal space on the posterior axillary line at the top edges so as not to damage the blood vesselsgoing along the bottom edge of the rib. If the puncture is done by pumping the maximum possible amount of content pleural cavity. It determines the weight, the quantity of protein, cell composition of the sediment, do try Rivality. In the presence of serous exudate, it is important to differentiate it from transudate, i.e. swollen with fluid that has built up in the pleural cavity. The specific weight of the fluid above 1,015, the protein content of more than 3 g%, the reaction of Rivalty positive. Exudate contains special protein - serotonin. It find the reaction of Reality. In a solution of acetic acid (take 2 drops of acetic acid per 100 ml of water) added dropwise pleural fluid. If it completely dissolves in acetic acid is a transudate, if falling drops reserve the white trail - they contain serotonin, i.e. the fluid is an exudate.
Microscopic examination of the exudate to a certain extent helps to clarify the nature of pleurisy. In tuberculous pleurisy is dominated by lymphocytes, rheumatism - neutrophils; with cancer of the pleural fluid is sometimes possible to detect malignant tumors.
Serous exudative pleurisy usually end for 3-4 weeks, but sometimes stretch out for months. For purulent effusion depends on timeliness of its recognition and speed of surgical intervention. At the break of abscess or tuberculosis caverns in the pleural cavity is formed of pyopneumothorax (empyema) - accumulation of gas and purulent exudate in the pleural cavity. When pyopneumothorax shown destruction of pus through repeated punctures, and the introduction of antibiotics in the pleural cavity. In the absence of effective recourse to surgical treatment. After pleurisy often remain fusion between pleural sheets (adhesions).


Pleurisy (pleuritis) - an inflammation of the pleura. There are two main forms of P.: dry, or fibrinous (pleuritis sicca, fibrinosa), and vpotnye, or exudative (pleuritis exsudativa).
The nature of exudative pleural effusion P. divided into serous, sero-fibrinous, purulent, putrid, hemorrhagic, Jelesnia, pseudofilename and mixed. This division P. conditionally. In different stages of the disease character of the inflammatory reaction of the pleura may change: fibrinous effusion goes sometimes in serous, and serous in purulent or putrid. P. complicating penetrating wounds of the chest, often just takes purulent. Localization of the inflammatory process allocate P. costal part of the pleura, diaphragm, parameterstyle and Magdalene.
Pleurisy is a secondary condition in which the primary disease process is localized in the lymph nodes, lung parenchyma or the mediastinum, abdominal cavity.
Actually the primary disease of the pleura are rare and occur in soil damage or malignant tumors of the pleura type of mesothelioma. Recently, there is a decrease in the incidence of P. Mortality and void due to a primary disease.

Etiology
The most frequent cause of pleurisy is TB infection. Some authors admit the possibility of pleurisy and rheumatic etiology.
The cause of pleurisy can be also coccal flora (pneumococci, diplococci, staphylococci, streptococci). Sometimes the disease develops due to hematogenous penetration into the pleural cavity infection with influenza, tonsillitis, fever, scarlet fever, tularemia, septicaemia (especially postpartum), and other
Pleurisy of infectious origin are developing for thromboembolic heart attacks and Echinococcus easy. Serosanguineous and purulent P. often observed in bronchogenic cancer, Hodgkin disease, lymphosarcomatous, disintegrating cancer of the esophagus, breast cancer, stomach, liver, the small pelvis, hypernephroma. Tumors are sometimes a source of damage to the thoracic lymphatic duct. In such cases, the pleural space is filled by the lymph, rich in fat, and exudate acquires molokopodobnye view - jeleznyi P. He may develop with other traumatic injuries of the thoracic duct.
Among non-communicable form pleurisy encountered in the collagenoses (disseminated lupus erythematosus, polyarteritis nodosa, systemic vasculitis) and pneumoconiosis. These P. not have clinical significance, invariably end with formation of adhesions.
Pleural exudate sometimes develop chronic circulatory failure. Appearing in such cases, unilateral effusion is different from hydrothorax (see) a high content of protein and a high content of cellular elements in the sediments, which was the basis for the allocation of unique clinical syndrome of heart pleurisy (I. E. Liechtenstein, 1960).
Inflammatory reaction of the pleura is developing in artificial pneumothorax (pneumophilia). Meet P. traumatic origin. P. may occur when izotermicheskoi uremia on the ground of autointoxication products of nitrogen metabolism. P. for scurvy and disease Verligofa due to increased permeability of blood and lymphatic vessels of the pleura. However, when noncommunicable P. accession of secondary infection has an impact on the clinical and pathological manifestations of the disease.