Pleural exudate

Description:

The concept of the pleural exudate (PE) means accumulation of liquid in a pleural cavity. The state, as a rule, has secondary character and can arise at a set of various pathological processes owing to close anatomo-physiological connection of a pleura with adjacent bodies of chest and belly cavities. Besides, PV can form at a number of system pathological processes. It is reported that
can lead more than 80 various diseases to emergence of PV. Therefore pertinently to consider PV as the clinical syndrome complicating development of a number of pathological processes. Emergence of PV always is a sign of an adverse current of a basic disease, and the symptomatology of a pleural exudate becomes the leader in a clinical picture of a disease. The reliable statistics about prevalence of PV in Ukraine is absent owing to their preferential secondary genesis. The latest data of researches among patients with ftizio-pulmonary pathology and existence of PV show that inflammatory processes are the most frequent reasons of their emergence, including infectious, among the last pneumonia prevails
and tuberculosis. Empyemas of a pleura of various nature and pleurisy of tumoral genesis have high specific weight, cardiogenic PV are slightly less widespread. It should be noted that the structure of PV depending on their etiology very much differs in the countries from various social and economic level of development and among the population of territories with various epidemiological characteristics.

Symptoms of the Pleural exudate:

Clinical manifestations of PV are defined by character of a basic disease and volume of an exudate. Inflammatory exudates (true pleurisy) form against the background of inflammatory process and begin with a characteristic syndrome of dry pleurisy (the acute pain in a side amplifying at deep breath, cough, sneezing; it is often felt directly in the field of damage of a kostalny pleura). The leading clinical complaints at patients – thorax pains, unproductive cough and an asthma of various degree of manifestation.
In case of development of PV and increase of its volume patients note heavy feeling in a side and an asthma at a significant amount of liquid. The massive PV reaching the volume of 5-6 l can cause the heavy disturbances of a hemodynamics demanding an urgent decompression of a lung. Hemodynamic disturbances at the same time are caused by vasoconstriction in the fallen-down lung as a result of hypoventilation, mediastinum shift towards a healthy lung with its compression, reduction of venous return to heart as a result of increase in intrapleural and intra mediastinal pressure and decrease in cordial emission. At patients considerable tachycardia and the progressing arterial hypotension with symptoms of a fabric hypoxia are registered.
At considerable exudates patients accept a forced sitting position or lie on a sick side, thus reducing pressure upon a mediastinum.
At survey some expansion and protrusion of intercostal spaces are noted. The increasing volume of liquid pushes aside a lung of a kpereda and up owing to what the liquid layer behind becomes thicker that at percussion outlines the upper edge of liquid in the form of the line of Damuazo which upper point is the share of the scapular line. Over an exudate the stupid percussion sound is defined. An important clinical symptom of availability of free liquid is the immovability of the bottom pulmonary edge. At considerable exudates of limit of relative cordial dullness are displaced in the healthy party. The limit of relative cordial dullness can be installed on the side of an exudate by means of a method of auskultativny percussion. At auscultation over an exudate easing or disappearance of respiratory noise, voice trembling and a bronchophony is defined, however at pleural unions in an exudate zone these symptoms can be absent. Directly over an exudate bronchial breath can be listened.
Important sign of PV is the shift of bodies of a mediastinum. At parapneumonic pleurisy the mediastinum is displaced in the healthy party. At an exudate which is combined with an atelectasis or with pneumocirrhosis, – towards defeat. Shift of bodies of a mediastinum towards defeat at secondary tumoral pleurisy at cancer of a lung is an adverse predictive sign.
The essential moment is the combination of symptoms of PV and symptoms of a basic disease.

Reasons of the Pleural exudate:

As it was already mentioned, the set of various pathological processes is the reason of PV. It is possible to allocate such main types: inflammatory the infectious nature and immunopathological genesis, exudates of a tumoral origin, traumatic, exudates of transsudativny character at cardiac pathology, disproteinemias and thromboembolisms. The sarcoidosis, a syndrome of yellow nails, an acute diffusion glomerulonephritis and some other states are the rare reasons of development of PV. Now representation of true pleurisy of the tubercular nature increases.

Treatment of the Pleural exudate:

Treatment of patients with PV includes the general conservative etiopatogenetichesky therapy and, if necessary, the topical treatment directed to evacuation of liquid from a pleural cavity.
However in all cases at the big exudates causing disturbances of a hemodynamics and breath the urgent decompression of a lung is required. Liquid is deleted before normalization of the ABP and reduction of tachycardia. Single-step removal of excessively large number of volume of pleural liquid (more than 3 l) can lead to development of unilateral hypostasis of quickly finished lung, with heavy disturbances of gas exchange. In these cases the oxygenotherapy is shown. As a measure of prevention of this complication serves creation of conditions for a gradual raspravleniye of a lung after a long collapse.
The repeated thoracocentesis with the maximum evacuation of liquid is widely used at PV of various etiology, especially infectious, for the purpose of prevention of pleural unions.
Regarding cases, at a small amount of an exudate without signs of disturbance of a hemodynamics and accurately established etiology of the disease which caused emergence of PV it is possible to use only conservative therapy with obligatory radiological control in 7-10 days. In the absence of positive dynamics carrying out a thoracocentesis is shown.
When finding patients in a therapeutic hospital we recommend repeated pleurocenteses with aspiration of contents of a cavity and input intraplevralno of the corresponding medicines against the background of the general conservative therapy. Especially it is important when the etiology of a disease is unknown, and the pleurocentesis has not only medical, but also diagnostic aspect. You should not try to obtain total removal of liquid as in a certain percent of cases there can be iatrogenic pheumothorax which will demand drainage of a pleural cavity.
If within 10-14 days the etiology of a disease remains unspecified and liquid continues to collect in a pleural cavity, then transfer of the patient in thoracic department for carrying out tool diagnostic methods and treatment is reasonable.
It is in the presence long the existing multipocket cavity we recommend carrying out a transdermal transthoracic biopsy of a parietal pleura with aspiration of exudate and carrying out (or without it at a small amount of PV) microdrainage or drainage of a pleural cavity. Installation of a drainage allows to evacuate as much as possible pleural liquid, it is safe to enter medicines intraplevralno, and also to carry out active aspiration of contents. The drainage is removed if within a day on it no more than 15-20 ml of contents of a pleural cavity are aspirated.
In the presence of considerable on PV volume carrying out a torakoskopiya or videotorakoskopiya which allow to specify the disease nature is reasonable, to destroy intrapleural unions, turning a multipocket cavity into a monocavity, and also to establish a drainage for administration of medicines and to carry out active aspiration.
At chronic PV when it is not possible to achieve the termination of exudation and there is a threat of development of pleurogenic cirrhosis of a lung, transition of process to a slow empyema of a pleura, operative measure performance – pleurectomies with a lung decortication is shown.
In the presence at the patient of PV of a tumoral origin, a gipoproteinemichesky exudate, an exudate at a syndrome of yellow nails, and also in certain cases at a circulatory unefficiency carrying out a chemical pleurodesis is shown. An indispensable condition of implementation of this procedure is the possibility of a full raspravleniye of the fallen-down lung. As sclerosing substances tetracycline, doxycycline, bleomycin, talc are used now.
In the presence at a sick chylous hydrothorax and inefficiency of drainage of a pleural cavity the thoracotomy with an alloying of a chest lymphatic channel is shown.