home Auditorium 7 Pleurisy. Causes, symptoms, signs, diagnosis and treatment of pathology. Infectious lesion of the pleura. Clinical picture, symptoms of exudative pleurisy

Pleurisy. Causes, symptoms, signs, diagnosis and treatment of pathology. Infectious lesion of the pleura. Clinical picture, symptoms of exudative pleurisy

Clinical symptoms exudative pleurisy is quite similar in various types effusion. The nature of the effusion is finally established using pleural puncture.

The complaints of patients are quite typical and depend on the type of onset of the disease. If the development of exudative pleurisy was preceded by acute fibrinous (dry) pleurisy, then it is possible to establish the following chronological sequence of subjective manifestations. At first, patients are concerned about acute intense pain in the chest, aggravated by breathing and coughing. With the appearance of effusion in pleural cavity pain in the chest weakens or even disappears completely due to the fact that the pleural layers are separated by the fluid appearing in the pleural cavity. At the same time, a feeling of heaviness in the chest, shortness of breath (with a significant amount of exudate), a dry cough may be noted (its reflex genesis is assumed), a significant increase in body temperature, and sweating.

In some patients, exudative pleurisy develops without previous fibrinous (dry) pleurisy, so there is no pain syndrome and quite quickly, a few days (rarely 2-3 weeks) after a period of slight weakness, increased body temperature, the above-mentioned characteristic complaints appear - shortness of breath and a feeling of " congestion”, heaviness in the chest.

Along with these options for the onset of exudative pleurisy, it is also possible acute onset diseases: body temperature quickly rises to 39-40°C (sometimes with chills), acute stabbing pain in the side (increased with inhalation), shortness of breath (due to the rapid accumulation of exudate in the pleural cavity), severe symptoms intoxication - headache, sweating, anorexia.

When examining patients with exudative pleurisy, extremely characteristic features diseases:

forced position - patients prefer to lie on the sore side, which limits the displacement of the mediastinum to the healthy side and allows the healthy lung to more actively participate in breathing; with very large effusions, patients occupy a semi-sitting position;
cyanosis and swelling of the jugular veins ( a large number of fluid in the pleural cavity impedes the outflow of blood from the neck veins);
shortness of breath (rapid and shallow breathing);
increase in volume chest on the affected side, smoothness or bulging of the intercostal spaces;
limitation of respiratory excursions of the chest on the affected side;
swelling and a thicker fold of skin in the lower parts of the chest on the affected side compared to the healthy side (Wintrich's sign).

Percussion of the lungs reveals the following most important symptoms of the presence of fluid in the pleural cavity:

Auscultation of the lungs is characterized by the following data:

with large volumes of effusion, vesicular breathing is not audible, since the lung is compressed with fluid and its breathing excursions sharply weakened or even absent. With smaller amounts of fluid in the pleural cavity, sharply weakened vesicular breathing may be heard;
with a large effusion, the lung is compressed so much that the lumen of the alveoli completely disappears, the pulmonary parenchyma becomes dense and, with preserved bronchial patency, begins to be auscultated bronchial breathing(it is carried out from the larynx - the place of its origin). However, bronchial breathing is somewhat muffled, the degree of muffling is determined by the thickness of the layer of fluid in the pleural cavity. Bronchial breathing can also be caused by the presence of an inflammatory process in the lung, and crepitus and moist rales can be heard. With a very large amount of fluid, bronchial breathing may not be heard;
At the upper border of the exudate, a pleural friction noise can be heard due to the contact of the inflamed pleura above the exudate during breathing. It should also be taken into account that the pleural friction noise during exudative pleurisy may also indicate the beginning of resorption of the exudate. The pleural friction noise can be perceived by the hand upon palpation in the area of the upper border of the exudate;
Over the area of effusion, the vocal tremor is sharply weakened.

Thus, with exudative pleurisy there are quite characteristic percussion and auscultation data. However, please note that this data may be misinterpreted in some situations. Thus, a dull percussion sound over the lungs and a sharp weakening of vesicular breathing and vocal tremor can be observed with very significant pleural fibrinous deposits, which can persist after previously suffered exudative pleurisy, less often - after fibrinous pleurisy. A pronounced dull sound throughout almost the entire half of the chest and a sharp weakening of vesicular breathing can also be caused by total pneumonia. In contrast to exudative pleurisy, with total pneumonia, the mediastinum does not shift to the healthy side, vocal tremors are not weakened, but intensified, and bronchophony is clearly audible. In addition, the presence or absence of effusion in the pleural cavity can be easily proven using ultrasound.

When auscultating the heart, one notices the muffled heart sounds (of course, this is much more pronounced in left-sided exudative pleurisy); various heart rhythm disturbances are possible.

Blood pressure tends to decrease; with large effusions in the pleural cavity, significant arterial hypotension is possible.

Course of exudative pleurisy

During exudative pleurisy, 3 phases are distinguished: exudation, stabilization and resorption. The exudation phase lasts about 2-3 weeks. In this phase, the entire clinical picture of exudative pleurisy described above unfolds with a gradual progressive accumulation of fluid in the pleural cavity. The amount of exudate can reach 6-10 liters, especially in young people, who are characterized by greater mobility and pliability of the chest tissue.

In the stabilization phase, exudation into the pleural cavity progressively decreases, but at the same time, exudate resorption is practically blocked or becomes minimal. It is very difficult and almost impossible to accurately determine the beginning of this phase and its duration. One can only note the stabilization of the level of exudate (using ultrasound, x-ray) and a certain stabilization of the clinical picture of the disease.

The resorption stage can last about 2-3 weeks, and even longer in weakened patients and those suffering from severe concomitant diseases. The duration of the resorption stage, in which the exudate is reabsorbed, is also influenced by the clinical features of the underlying disease that caused the development of exudative pleurisy. Great importance also has the age of the patient. In the elderly and weakened patients, the exudate can resolve within several months.

In most patients, after resorption of the exudate, especially if it was significant, adhesions (moorings) remain. In some cases, the adhesions are so numerous and massive that they cause impaired ventilation.

After suffering exudative pleurisy, patients may feel pain in the chest, which intensifies with changing weather conditions. This is especially pronounced during the development of adhesions.

In some cases, adhesions can cause encysted exudate (encysted pleurisy), which does not resolve for a long time and can fester. However, many patients experience complete recovery.

Exudative pleurisy is a disease respiratory system, which is characterized by damage to the pleura of an infectious, tumor or other nature. Most often, this disease acts as a secondary factor of any pathological changes. It manifests itself as unilateral chest pain, which, as fluid accumulates, is replaced by a feeling of heaviness and pressure.

What is exudative pleurisy?

Exudative pleurisy is a pathology in which inflammation of the pleural layer of the lungs occurs with the accumulation of fluid in the costophrenic sinus. About 80% of cases of hydrothorax occur in patients with pulmonary tuberculosis. Every year, the pathology is diagnosed in 1 million people.

In its etiology, exudative pleurisy is similar to dry pleurisy, differs in that it often develops with pancreatitis, cirrhosis or liver tumor, subdiaphragmatic processes, and also accompanies some systemic diseases.

Exudate is a liquid released into the pleural cavity from the capillaries during inflammation.

Fluid in the pleural cavity can accumulate diffusely or limitedly. In the case of limited accumulation of effusion, encysted pleurisy is formed (supradiaphragmatic, paracostal, paramediastinal), resulting adhesive process in the pleura.

ICD-10 code: J.90.

Exudative pleurisy, according to its etiology, is divided into infectious and aseptic. Taking into account the nature of exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chylous (chylothorax), purulent (pleural empyema), putrefactive, mixed.

Taking into account the location, it may be:

diffuse;
left-handed;
encysted;
right-sided;
exudative pleurisy.

Based on the degree of flow, there are:

subacute;
acute;
chronic form.

In many cases, the disease is localized on the right, but more are likely severe forms flow - pleurisy of left-sided and bilateral type.

Causes

The infectious form of exudative pleurisy appears against the background following processes in the lungs:

lung abscess;
gangrene;
tuberculosis.

The cause of the disease in this case is the entry of infectious irritants from the listed diseases into the pleural cavity.

The aseptic type, as a rule, accompanies all kinds of pulmonary and extrapulmonary pathological processes, aggravating the development of diseases such as:

post-infarction autoallergic pericarditis;
Dressler's syndrome;
hypersensitivity interstitial pneumonitis;
various allergic reactions.

Moreover, approximately 75 percent of cases of effusion pleurisy are diagnosed in patients suffering from tuberculosis.

Symptoms

Signs and symptoms of exudative pleurisy depend on the volume, nature and intensity of fluid accumulation.

The main symptoms are:

patients complain of severe shortness of breath and discomfort in the chest area when breathing,
hacking cough with difficult to clear sputum,
general weakness,
loss of appetite,
short-term increase in body temperature to high numbers.

As exudate accumulates, the leaves become wetted, which reduces the severity pain syndrome. When you try to press on the intercostal spaces above the location of the inflammatory focus, sharp pain due to irritation of nerve receptors.

The patient's general condition is serious, especially when purulent form exudative pleurisy, which is accompanied by:

high temperature;
symptoms of intoxication;
chills.

There are three phases of the disease:

Left-sided exudative pleurisy leads to an acceleration of the heart rate, and arrhythmia may develop. Lack of air causes noticeable swelling of the veins in the neck area. At the same time, the pulse quickens and reaches one hundred and twenty beats per minute.

More often, exudative pleurisy is unilateral, but with metastatic tumor processes, SLE, lymphoma, bilateral pleural effusion can be detected. The volume of fluid in the pleural cavity with exudative pleurisy can reach 2-4 or more liters.

After suffering exudative pleurisy, patients may feel pain in the chest, which intensifies with changing weather conditions. This is especially pronounced during the development of adhesions.

Diagnosis of the disease

Informative diagnostic methods:

physical. When performing it, doctors note a lag on the affected side of the chest during the act of breathing, its weakening, dullness of percussion sound during percussion, splashing noise during auscultation;
X-ray examination (method for diagnosing hydrothorax of any etiology, including tuberculosis). In the lower parts of the lungs there is significant darkening;
Ultrasound of the pleural cavity;
thoracentesis. This procedure undergo all patients with suspected exudative pleurisy. During its implementation, doctors receive some part of the effusion, which is then used for cytological, bacteriological and biochemical studies;
thoracoscopy;
computed tomography of the lungs;
blood chemistry.

Exudative pleurisy caused by nonspecific diseases lung diseases, even with a prolonged course, usually have a favorable outcome.

Treatment of exudative pleurisy

The basic principles of treatment of exudative pleurisy are the evacuation of accumulated fluid from the pleural cavity and the impact on the underlying pathological process, causing a pleural reaction.

Taking into account the cause of pleurisy, drug treatment is prescribed:

Tuberculostatic drugs (for the tuberculous form of exudative pleurisy);
Antibacterial agents (for pneumatic pleurisy);
Cytostatic agents (for tumors and metastases);
Glucocorticoid drugs (for lupus erythematosus and)
Diuretic treatment for pleurisy caused by cirrhosis of the liver (usually the lung located on the right is affected).

Regardless of the etiology of the disease, analgesics, anti-inflammatory, antitussive, and desensitizing agents are prescribed.

To increase the effectiveness of treatment after pleural puncture, physiotherapy is recommended:

Chest massage;
Vibration massage;
Paraffin therapy;
Electrophoresis;
Breathing exercises.

The chronic form of empyema is removed by surgical intervention carried out during thoracostomy or lung decortication. One of the most important diagnostic and treatment measures is pleural puncture.

The patient sits on a chair with his back to the doctor, and the doctor, after preliminary anesthesia, makes a puncture with a special needle with a beveled cut in the sixth intercostal space along the scapular line.
When a needle enters the pleural cavity, exudate begins to be released from it.
The fluid is removed slowly and in small volumes to prevent a sudden shift of the mediastinum and the occurrence of acute heart failure.
The pleural cavity is drained and washed with antiseptics, and it is also possible to administer antibiotics intrapleurally.

When presented integrated approach to restore the state of health in case of illness, it will be possible to eliminate the development of complications and negative consequences lungs. The medical history in this case will be the most positive.

After 4–6 months After treatment for pleurisy is completed, a control radiograph is taken. To avoid exudative pleurisy in the future, it is necessary to promptly treat all diseases of the respiratory system, avoid hypothermia and injuries, and strengthen the immune system.

The exudative form of pleurisy is a dangerous, but not critical disease, in order to recover from which the recovery process and prevention should be started in time. This will allow you to get out of the condition with minimal losses, even if a dry subtype of the disease has been identified.

Exudative pleurisy is a pathology in which inflammation of the pleural layer of the lungs occurs with the accumulation of fluid in the costophrenic sinus. Nonspecific pathogens rarely provoke nosology, since the body has reliable local and general systems protection.

Exudation is detected by auscultation (when listening with a phonendoscope) and on a chest x-ray.

Exudative pleurisy: causes

The most common reason exudative pleurisy – tuberculosis infection. When the pleural layers are damaged, the mycobacterium forms inflammatory changes gradually. Only with a strong decrease in immunity does the microorganism gain the opportunity for active reproduction.

Exudation may be a consequence of fibrinous changes, when a chronic infection “dorms” in fibrin threads.

To detect exudative fluid on an x-ray, its amount must exceed 200 ml. With a large amount of exudate in the pleural cavity, breathing difficulties are created, as the liquid compresses the lungs.

In practice, the tumor nature of pleurisy is sometimes encountered. The accumulation of exudate makes it difficult to visualize the tumor. Only pleural puncture allows you to open the visible part lung tissue where the neoplasm is localized.

Symptoms of exudative pleurisy

The main symptom of exudative pleurisy is pain in the lungs and hypochondrium. With fibrinous inflammation of the lungs, the pain syndrome is not expressed. Exudate does not accumulate in the pleural cavity. The only symptom of the disease is shortness of breath. Violation respiratory function causes hypoventilation of the pulmonary field.

With exudative pleurisy, auscultatory symptoms are observed:

Dullness of pulmonary sound in the projection of the location of the fluid;
Breathing is weakened in the lower part of the lungs;
Above the location of the exudate, bronchial breathing is heard.

The severity of the manifestations of the disease depends on the rate of accumulation of effusion, volume, and severity of the underlying inflammation. With intense accumulation of fluid, pain occurs. As exudate accumulates, the leaves become wetted, which reduces the severity of pain. When you try to press on the intercostal spaces above the location of the inflammatory focus, acute pain occurs due to irritation of the nerve receptors.

Increasing respiratory failure leads to shortness of breath and reflex cough.

Upon external examination of the patient, the forced position on the sore side is striking. Pallor of the skin, cyanosis of the face, decreased blood pressure, tachycardia.

Lecture No. 10.

Topic: Pleurisy.

Pleurisy- an inflammatory process in the layers of the pleura, accompanied by the formation of fibrous deposits on their surface and (or) accumulation of liquid exudate in the pleural cavity.

The pleura covers the lung parenchyma, mediastinum, diaphragm and lines inner surface chest. Normally, the parietal and visceral layers of the pleura are separated by a very thin layer of fluid.

Classification.

1. Pleurisy can be primary and secondary. Most pleurisy is secondary process and occurs as a complication of purulent-inflammatory processes in adjacent or distant organs and tissues (pulmonary tuberculosis, pneumonia, liver abscess, mediastinitis, pancreatitis, osteomyelitis, otitis media, sinusitis, etc.).

2. Clinically, pleurisy is divided into dry (fibrinous) And exudative (effusive).

By the nature of the effusion exudative pleurisy are divided into:

Serous, - serous-fibrinous, - purulent, - putrid, hemorrhagic, - chylous.

3. Variants of the course of the disease (acute, subacute, chronic).

4. According to the localization of effusion, pleurisy is: encysted, diffuse; apical, parietal.

Etiology.

Depending on the etiology, all pleurisy can be divided into two large groups: infectious and non-infectious(aseptic). In infectious pleurisy, the inflammatory process in the pleura is caused by the influence of infectious agents; in non-infectious pleurisy, inflammation of the pleura occurs without the participation of pathogenic microorganisms.

Infectious pleurisy are caused by the following pathogens:

Bacteria (pneumococcus, streptococcus, staphylococcus, Haemophilus influenzae, Klebsiella, Pseudomonas aeruginosa)

Mycobacterium tuberculosis;

Rickettsia; protozoa (amoebas);

Fungi;

Viruses.

Non-infectious (aseptic) pleurisy observed in the following diseases:

Malignant tumors (pleural carcinomatosis is the cause of pleurisy in 40% of cases). These may be a primary pleural tumor (mesothelioma); metastases malignant tumor in the pleura, in particular with ovarian cancer; lymphogranulomatosis, lymphosarcoma, hemoblastosis and other malignant tumors;

Systemic connective tissue diseases (systemic lupus erythematosus, dermatomyositis, scleroderma, rheumatoid arthritis);

Systemic vasculitis;

Chest injuries, rib fractures and surgical interventions (traumatic pleurisy);

Pulmonary infarction due to thromboembolism pulmonary artery;

Acute pancreatitis (pancreatic enzymes penetrate the pleural cavity and “enzymatic” pleurisy develops);

Myocardial infarction (post-infarction Dressler syndrome);

Chronic renal failure(“uremic pleurisy”).

Dry pleurisy clinic.

Chest pain - the most characteristic symptom of acute dry pleurisy (the patient’s priority problem). They are caused by irritation of sensitive nerve endings pleura and are localized in the corresponding half of the chest (on the affected side). Pain usually appears with a deep breath, sharply intensifies when coughing (the patient reflexively puts his hand on the sore spot and, as it were, tries to reduce the movement of the chest while inhaling, thereby reducing the pain). It is also common to experience increased pain when the body is tilted to the healthy side.

There are also complaints about general weakness, increased body temperature (usually up to 38°C, sometimes higher). With non-spread dry pleurisy, body temperature may be normal. Many patients are bothered by pain in muscles, joints, and headaches. The course and outcome of dry pleurisy is determined by the nature of the underlying disease. With a favorable outcome, after 10-14 days it undergoes reverse development with the formation of pleural adhesions without clinical manifestations. With a protracted and recurrent course of dry pleurisy (usually tuberculous etiology), moorings form on the leaves of the pleura with the deposition of calcium salts in them. In some patients, dry pleurisy turns into exudative.

Objective research . Patients find significant relief (reduction of pain) in the position on the sore side, since in this case the chest is immobilized and irritation of the parietal pleura is reduced. There is rapid shallow breathing (with such breathing the pain is less pronounced), and there is a noticeable lag in the affected half of the chest due to pain.

With percussion lung sound remains clear pulmonary if pleurisy is not caused inflammatory process in the lung parenchyma.

On auscultation lungs in the projection of the localization of inflammation of the pleura is determined most important symptom dry pleurisy - pleural friction noise. It occurs due to friction against each other during breathing of the parietal and visceral layers of the pleura, on which there are fibrin deposits, and the surface of which becomes rough. Normally, the surface of the pleural layers is smooth and the sliding of the visceral pleura over the parietal pleura during breathing occurs silently. The pleural friction noise is heard during inhalation and exhalation and resembles the crunch of snow underfoot or the rustling of paper.

Complications: acute or chronic (with recurrent course) respiratory failure; transition to exudative pleurisy.

Clinic of exudative pleurisy.

Since exudative pleurisy is characterized by the accumulation of effusion in the pleural cavity, the following complaints are most typical: feeling of heaviness in the chest on the affected side, shortness of breath (with a significant amount of exudate - a priority problem), may be noted dry cough , significant increase in body temperature, sweating .

At inspection In patients with exudative pleurisy, characteristic signs of the disease are revealed:

Forced position - patients prefer to lie on the sore side, which limits the displacement of the mediastinum to the healthy side and allows the healthy lung to more actively participate in breathing; with very large effusions, patients occupy a semi-sitting position;

Cyanosis and swelling of the neck veins (a large amount of fluid in the pleural cavity impedes the outflow of blood from the neck veins);

Shortness of breath (rapid and shallow breathing);

Increased volume of the chest on the affected side, smoothness or bulging of the intercostal spaces;

Lagging half of the chest on the affected side in the act of breathing;

At percussion lungs, symptoms of the presence of fluid in the pleural cavity are revealed:

Dull percussion sound over the effusion area.

Nursing diagnosis: chest pain; chills; cough; weakness; dyspnea; fever; headache; increased sweating; poor sleep and appetite.

Diagnosis of pleurisy.

Laboratory data.

1. CBC - an increase in ESR, leukocytosis and a shift in the leukocyte formula to the left - the severity of changes in the blood depends on the underlying disease that caused pleurisy.

2. OAM - usually without pathological changes, but with exudative pleurisy at the height of the disease there may be slight proteinuria, single red blood cells.

3. BAC - “biochemical inflammation syndrome” (dysproteinemia (decreased albumin levels and increased globulins) and increased sialic acids, increased thymol test, fibrin, the appearance of C-reactive protein).

4. In case of exudative pleurisy, a pleural puncture is performed with examination of the pleural fluid - the nature of the effusion is established.

Instrumental studies

X-ray examination of the lungs It is the most accessible method, which makes it possible to reliably diagnose the presence of effusion in the pleural cavity - an intense homogeneous darkening with an oblique upper border going downward and inward is detected, the mediastinum shifts to the healthy side. However, it should be taken into account that using the x-ray method, the amount of liquid is detected at least 300-400 ml. With dry pleurisy, only with significant fibrin deposits is it sometimes possible to identify a vague, indistinct shadow along the outer edge of the lung (a rare sign).

Treatment.

Regime and diet are prescribed according to the underlying disease.

Drug treatment pleurisy should be comprehensive and aimed primarily at eliminating the main process that led to its development. Antibacterial therapy; immunostimulating drugs (thymalin, thymogen), desensitizing drugs, non-steroidal anti-inflammatory drugs; in case of tuberculosis etiology - anti-tuberculosis drugs, in the presence of a malignant tumor - radiation therapy, chemotherapy.

Symptomatic treatment aims to relieve pain, accelerate the resorption of fibrin, and prevent the formation of adhesions and adhesions in the pleural cavity. The danger of transformation serous exudate in purulent conditions necessitates regular pleural punctures(in 1-2 days) with its maximum evacuation. This tactic gives the best results, since the lung is completely expanded. At purulent pleurisy exudate is evacuated, the cavity is drained and washed antiseptic solutions, antibiotics are administered intrapleurally. In case of intoxication, severe shortness of breath, cardiac dysfunction, they are used intravenously. plasma replacement solutions, oxygen inhalation. To prevent the formation of moorings, they are prescribed lidase injections.

To reduce pain(especially in patients with dry pleurisy) you can use jars, mustard plasters, dry heat, warming compresses with tight bandaging lower sections chest, lubricating the affected side with iodine tincture in the form of a grid.

As the exudate resolves, after the pain disappears and body temperature normalizes, patients are recommended to engage in exercise therapy with the inclusion of breathing exercises to prevent pleural adhesions. In the absence of contraindications, physiotherapeutic treatment is carried out (sollux, inductothermy, electrophoresis with absorbable agents).

Nursing interventions. The nurse ensures: timely and accurate implementation of doctor’s orders; tolerance control medicines; control of blood pressure, respiratory rate, pulse, body weight and diuresis; sanitary and anti-epidemic regime (wet cleaning, quartz treatment, ventilation of wards, provision of an individual spittoon, its disinfection); skin and mucous membrane care, timely change of underwear and bed linen; carrying out oxygen therapy, exercise therapy; preparing the patient for pleural puncture and everything necessary for its implementation, as well as preparing for other laboratory and instrumental studies. Assist the doctor during pleural puncture. She also conducts: conversations about the rules of maintaining a hygienic regime, about carrying out exercise therapy with pleurisy; provides training to patients in exercise therapy techniques (dynamic breathing exercises with an emphasis on exhalation, increased excursion of the sore side, increased mobility of the diaphragm). The nurse puts cups, mustard plasters, applies dry heat to the chest, warm compresses with tight wrapping; The skin of the chest is lubricated in the form of a mesh with tincture of iodine. During the period of improvement of the patient’s general condition, she conducts exercise therapy and chest massage. If you have a dry cough, you should provide warm alkaline drink, ventilation of the room 3 - 4 times a day, ensure the implementation of simple physiotherapeutic procedures as prescribed by the doctor, ensure steam inhalations(as prescribed by a doctor). If there is shortness of breath, calm the patient down, help keep him occupied. comfortable position, loosen tight clothing, increase access fresh air, ensure monitoring of the patient’s condition (breathing, pulse, blood pressure, skin color).

Prevention. Prevention of pleurisy consists of preventing those diseases that are complicated by pleurisy.

Primary: increasing the body's defenses (hardening, physical training, sanitizing foci of chronic infection), eliminating bad habits, balanced diet, motor activity. Secondary: dispensary registration and observation according to the profile of the underlying disease (pulmonary tuberculosis, lung cancer, systemic disease connective tissue). Dispensary observation after suffering pleurisy for a year (general clinical analysis of blood and urine, X-ray examination).

Pleural puncture.

Pleural puncture is of great importance, as it allows not only to confirm the presence of effusion, but also to carry out differential diagnosis. Taking this into account, pleural puncture should be considered a mandatory procedure in patients with exudative pleurisy. Assess the physical and chemical properties of the resulting liquid, perform its cytological, biochemical, bacteriological examination and carry out differential diagnostics

As directed by the physician, the nurse will prepare the patient and equipment necessary for pleural puncture;

Before the manipulation, the nurse will conduct a psychotherapeutic conversation with the patient, explain the goals, sequence of actions, and clarify the availability of informed consent for the puncture. It is necessary to seat the patient facing the back of a chair with an arched back, tilted to the healthy side for better separation of the intercostal spaces.

The nurse will prepare the necessary instruments and sterile equipment for the manipulation. dressing;

The nurse will administer premedication 20-30 minutes before the procedure as prescribed by the doctor;

The nurse will prepare laboratory glassware and directions to the laboratory; For diagnostic purposes, 20-50 ml of pleural fluid is taken. Part of her nurse sends to the laboratory for physico-chemical and cytological examination, the other part is placed in a sterile tube and delivered to a microbiological laboratory for bacteriological examination (to determine microflora and sensitivity to antibiotics).

During the manipulation, the nurse will assist the doctor and monitor the patient’s condition;

During a pleural puncture, the nurse sequentially gives the doctor:

Antiseptic for surgical treatment doctor's hands;

Tampons for treating the puncture field, moistened with an antiseptic;

Syringe with novocaine for local anesthesia;

A syringe with a puncture needle, then a rubber adapter with a clamp, laboratory glassware, after taking the material, an electric suction is connected.

After the manipulation, the nurse will monitor the patient. It is necessary to tightly bandage the chest with sheets, take the patient to the ward on a gurney, provide bed rest throughout the day, monitor general condition, bandage.

Complications: 1) collapse, fainting, tachycardia due to rapid displacement of mediastinal organs after removal of a large amount of fluid from the pleural cavity; 2) damage to the intercostal neurovascular bundle; 3) bradycardia due to irritation of the pleura); 4) pneumothorax (pain in the puncture area, cough); 6) infection of the pleural cavity due to violation of the rules of asepsis and antisepsis; 7) injury to the lung parenchyma; 8) injury to the abdominal organs.

pleurisy exudative physical education therapeutic

Pleurisy is an inflammation of the layers of pleura covering the lungs, inner part the chest, diaphragm and mediastinal organs are most often secondary disease associated with the tuberculous process in the peribronchial and mediastinal glands or with rheumatism, pneumonia, scurvy, cancer.

Clinical picture. In some patients, the disease develops gradually, and low-grade fever, chest pain, cough, general weakness, sweating, decreased appetite, disturbed sleep. Only after 3-4 weeks the patients’ condition more or less sharply deteriorates: the temperature reaches high levels, chest pain and cough intensify, and signs of pleural effusion are detected. Often, exudative pleurisy begins acutely: the temperature rises (often with tremendous chills) to 39-40°C, stabbing pain in the side occurs, intensifying with inhalation, shortness of breath quickly increases, headaches, sweating, and sometimes nausea and vomiting occur. It is also possible (relatively rare) asymptomatic accumulation of effusion in the pleural cavity, which is sometimes detected completely by accident.

When examining a patient at the height of the disease, a lag of the affected side of the chest during breathing, its bulging and smoothness of the intercostal spaces are noted. Vocal tremor over the effusion weakens or disappears, and dullness is determined by percussion. Breathing over exudate is sharply weakened or becomes bronchial. In peripheral blood there is increase in ESR and moderate neutrophilic leukocytosis with a shift to the left.

During the course of the disease, three phases are distinguished: exudation, stabilization and resorption. The duration and severity of pleurisy are determined by the nature of the leading pathogenetic factor and the state of the macroorganism. With tuberculous-allergic exudative pleurisy, the disease often lasts 1-2 weeks, while in the elderly and weakened patients the exudate can resolve within several months, and the disease proceeds with a blurred clinical picture (low-grade fever or even normal temperature, leukopenia instead of leukocytosis, etc.). The exudate can resolve completely without leaving any changes behind. However, in most patients, after resorption of the exudate, adhesions remain. If the effusion is poorly absorbed, large fibrinous deposits lead to the formation of massive cords, which seriously complicate ventilation of the lungs. The development of adhesions can lead to encystation of exudate, which under these conditions is poorly absorbed and often suppurates. There are encysted costal, supraphrenic, mediastinal, interlobar and apical pleurisy. (Leporsky A.A., 1955)

Most often, the accumulation of exudate in serous-fibrinous pleurisy occurs in the inferolateral areas of the chest, but exudate can also be located in the interlobar fissure (interlobar pleurisy) or be fixed by adhesions (encysted pleurisy). Depending on the localization of the process, there are prefixed, interlobar, mediastinal and diaphragmatic encysted pleurisy.

As a result of the accumulation of exudate in the pleural cavity and a change in the ratio of elastic forces inside the chest, the latter assumes an inspiratory position with bulging chest wall on the sore side. The inspiratory position of the chest, the limitation of its excursion, the pushing of the diaphragm downward by exudate, the presence of pain during breathing and compression of the lung by exudate - all this leads in a patient with exudative pleurisy to difficulty breathing, to shallow breathing, a decrease in the vital capacity of the lungs and the suction force of the chest cavity. This leads to shortness of breath in the patient, especially when moving.

As the inflammatory phenomena in the lesion subside, the zone of perifocal inflammation in the pleura is gradually eliminated. The increase in exudate stops (phase II of the disease). By this time, the patient is significantly weaker, becomes lethargic, apathetic, has difficulty moving and is afraid of movements due to the pain that occurs with them. Vigorous movements are accompanied by shortness of breath and palpitations; anemia increases, ROE is increased.

During the recovery period, the patient experiences a reverse development of exudate (III period of the disease). This process is accompanied by resorption of exudate and the formation of pleural adhesions in the patient. The adhesions can take the form of either wide overlays (moorings) or the form of strands (adhesions). Ribbon-shaped adhesions occur most often in the inferolateral parts of the chest. Typically, adhesions fix the visceral, parietal and diaphragmatic pleura in various combinations. The process of organizing exudate in some cases can even result in complete obliteration of the pleural cavity. (Alexandrov A.N., 2000)

Small pleural adhesions left after the disease do not cause significant respiratory distress in patients. Common pleural adhesions can cause dysfunction in them breathing apparatus and blood circulation, which affects functional state of the whole organism and is accompanied by a decrease in the ability to work of patients. With a common adhesive process, patient complaints vary. In some cases, shortness of breath and chest pain in patients occur only with very intense or prolonged physical exertion, in others, pain and shortness of breath appear even with moderate physical activity. Adhesions under conditions of forced breathing (during physical work) can cause pleural tearing and spontaneous pneumothorax. The consequence of a widespread adhesive process in some cases may be the development of scoliosis in patients, pulling of the mediastinum to the painful side, retraction of the corresponding half of the chest and narrowing of the intercostal spaces.

All of the above pathological changes require timely intervention by a doctor, appropriate treatment and force us to persistently strive for the possible complete cure of the patient with exudative pleurisy and restoration of his full functions of the respiratory apparatus in order to preserve his ability to work. Therapeutic physical culture is one of the mandatory components complex treatment a patient suffering from exudative pleurisy (except for diseases of carcinomatous etiology).

The diagnosis is made on the basis of complaints, clinical picture and physical examination of the patient. X-ray examination is of great importance, especially when encysted pleurisy. Often decisive method pleural puncture becomes diagnostic. In cases of encysted pleurisy, the puncture site is best determined under the control of an X-ray screen. The protein content in pleural fluid usually exceeds 3%, the relative density is more than 1015. When microscopic examination effusion is detected by leukocytes, lymphocytes, and erythrocytes. The appearance of altered leukocytes indicates the transition of serous-fibrinous pleurisy to purulent. For lung cancer, infarction pneumonia, chest injuries, hemorrhagic diathesis a large number of red blood cells are found in the exudate. In case of pleurisy of tuberculous etiology, tuberculous mycobacteria are not always found in the exudate, but when cultured on special media they can be detected in 80-90% of cases. (Alexandrov A.N., 2000)

Exudative pleurisy often has to be differentiated from lobar and confluent focal pneumonia. The clinical picture, x-ray examination, and pleural puncture make it possible to recognize the nature of the disease. When making a differential diagnosis, one must also keep in mind lung cancer, echinococcosis, and abscess, which have a number of symptoms similar to pleurisy (dullness, decreased breathing, etc.). The prognosis for most patients is good. Only with the formation of massive moorings can respiratory failure occur. Neurogenic mechanisms in pleurisy have not yet been sufficiently studied, but they undoubtedly play a primary role in the occurrence of this disease. In the occurrence of pleurisy, disruption of the trophic innervation of the lungs is of great importance. Heaviness common manifestations The disease depends not so much on the size and properties of the effusion, but on the degree of inflammatory irritation and neuroreflex reactions, which affect the condition of the patient’s entire body as a whole.