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Acute purulent pleurisy is an acute purulent inflammation of the pleura. In the vast majority of cases, it is a secondary disease - a complication of purulent lesions of various organs.

Purulent pleurisy sometimes develops as a result of the spread of infection by the lymphogenous route during various purulent processes of the abdominal cavity, retroperitoneal space: purulent cholecystitis, appendicitis, pancreatitis, perforated gastric ulcer, subphrenic abscess, peritonitis, paranephritis, etc. The development of metastatic acute purulent pleurisy in sepsis is described, phlegmon, osteomyelitis and other purulent processes various localizations. There are reports of pleurisy caused by a specific or mixed infection with scarlet fever, measles, typhus, etc.

The causative agents of the disease are various pyogenic microorganisms. During bacteriological examination of pus from the pleura, streptococcus is most often found (up to 90%), less often staphylococcus and pneumococcus. In children, pneumococcus is the most common (up to 70%). Mixed flora is often observed.

The pleura reacts to infection differently, which depends on the virulence of the latter and the reactivity of the organism.

With a weakly virulent infection, a small fibrinous effusion is formed, gluing the visceral and parietal pleura, which contributes to the formation of adhesions and adhesions around the source of infection - this is dry pleurisy. More virulent microbes cause the formation of abundant exudate - exudative pleurisy, which, with high virulence of the microflora, becomes purulent in nature.

There are several classifications purulent pleurisy:

1) by pathogen - streptococcal, pneumococcal, staphylococcal, diplococcal, mixed, etc.;

2) according to the location of the pus: a) free - total, medium, small; b) encysted - multi-chamber and single-chamber (basal, parietal, paramediastinal, interlobar, apical);

3) according to pathological characteristics: a) acute purulent; b) putrefactive; c) purulent-putrefactive;

4) according to the severity of the clinical picture: a) septic; b) heavy; c) average; d) lungs.

Symptomatology and clinic. The clinical picture of acute purulent pleurisy is layered with the clinical manifestations of primary disease(pneumonia, lung abscess, etc.), of which it is a complication. The disease begins with severe stabbing pain in one side or another of the chest, sharply intensifying with breathing and coughing.

The temperature rises to 39-40°, the dry cough intensifies, the pulse becomes frequent and small. Increased stabbing pain when trying to deepen breathing leads to superficial, rapid breathing, which entails an increase in hypoxia. With an increase in the amount of exudate, the pleural layers move apart and the pain decreases somewhat, but compression of the lung by the exudate reduces the respiratory surface of the lungs, and shortness of breath appears.

When examining the patient, an increase in half of the chest on the side of the process, widening of the intercostal spaces, and a lag in breathing are noted. Voice tremors weakened on the affected side.

In the lower section pulmonary field- muffled percussion sound and weakened breathing, sometimes pleural friction noise, dry or moist rales are heard, lung excursions are limited.

With further progression of the disease, accumulation of pus in the pleura, the patient’s general condition worsens, the temperature remains at high levels, sometimes fluctuations between morning and evening temperatures reach 2-2.5 °, the pain becomes less severe, a feeling of fullness of the chest appears, and the general weakness, appetite disappears.

On percussion, dullness is noted, its border is higher at the back, lower at the front (Demoiseau line), above and medially the dullness is clear percussion sound in an area resembling a triangle in shape, which corresponds to the contour of the lung, pressed by the effusion to its gate.

The accumulation of pus leads to displacement of the mediastinum into healthy side, therefore, at the bottom of the spine on the healthy side there is a triangular dullness above the displaced mediastinal organs. Cardiac dullness is shifted by exudate to the healthy side. With left-sided pleurisy with a large amount of effusion, the diaphragm lowers, and therefore Traube’s space disappears.

On auscultation, in the area of dullness there are completely no respiratory sounds; above the dullness, weakened breathing and pleural friction noise are detected. Blood changes are characterized by a decrease in the percentage of hemoglobin, an increase in the number of leukocytes, neutrophilia with a shift to the left, and an acceleration of ROE.

Often acute purulent pleurisy develops from the very beginning of the disease as encysted, which is explained by the presence of pleural adhesions and adhesions due to earlier past diseases. Localization, combination of cavities and their sizes can be very diverse.

Schematically, pleurisy can be divided into basal, parietal, paramediastinal, apical, interlobar, single and multiple.

General clinical manifestations with encysted pleurisy are almost the same as with free ones, but somewhat less pronounced. Poor general condition, localized chest pain, cough, high temperature, leukocytosis with neutrophilia, etc. are noted. Percussion and auscultation data can be obtained only with apical and parietal localization of the process.

Complications of purulent pleurisy. In case of insufficient release pleural cavity from pus, the latter finds its way into the muscle beds and subcutaneous tissue of the chest wall, often along the mid-axillary line. With purulent inflammation of the visceral pleura, the process spreads along the lymphatic pathways, involving the cortical sections of the pulmonary parenchyma, and then the deeper sections of the lung with the lymph nodes of the root.

With long-term purulent pleurisy, the wall of the bronchus can melt with the formation of a bronchopleural fistula; when the lung collapses, irreversible sclerotic processes develop in it.

Diagnostics. Difficulties in diagnosing purulent pleurisy occur in cases where it develops against the background of unresolved pneumonia or a lung abscess. Great importance to clarify the diagnosis has X-ray examination, which makes it possible to establish the presence of homogeneous darkening of the pleural cavity, the level of fluid in the pleura, the state of compressed lung tissue, the degree of displacement of the heart and blood vessels, the boundaries of pus and the airy lung tissue above it. If there is an inflammatory process in the compressed lung, then focal shadows are visible against the background of the lung tissue. On the affected side, the diaphragm is motionless. With free empyema, the costophrenic sinus is not visible. If clearing is noted in its area, this allows us to suspect the presence of encysted pleurisy. Dynamic radiological observation is especially important.

To clarify the diagnosis, a test puncture of the pleural cavity is crucial, which makes it possible to determine the nature of the effusion and bacteriologically examine it.

Acute purulent pleurisy must be differentiated from a lung abscess, festering cyst, subphrenic abscess, festering echinococcus, lung cancer with perifocal inflammation and effusion, interstitial pneumonia of the lower lobe, etc.

It is especially difficult to distinguish an abscess from encysted pleurisy. An important differential sign is a cough with large amounts of foul-smelling sputum, which is characteristic of an abscess. Auscultation with an abscess shows a rather motley picture: sometimes bronchial, sometimes weakened breathing, dry and moist wheezing. With pleurisy, breathing sounds are weakened or absent. Radiologically, with an abscess, a rounded shadow with a distinct lower border is observed; with pleurisy, the lower limit is not determined. Pleurisy is characterized by displacement of the mediastinum, filling of the costophrenic sinus, and changes in the fluid level when changing position.

With festering cysts, in contrast to pleurisy, the general condition of patients suffers less; there is a cough with copious discharge sputum; on X-ray examination, the cyst is characterized by rounded contours of the shadow and clearing in the costophrenic sinus.

A distinctive feature of the clinical picture of a subdiaphragmatic abscess is the significant severity of pain and muscle tension in the right hypochondrium, often an enlarged liver, and the appearance of jaundice. The history includes indications of influenza, pneumonia or some purulent disease. An X-ray examination reveals clearing of the costophrenic sinus; a gas bubble is sometimes visible above the fluid level.

The development of sympathetic pleurisy with serous effusion significantly complicates differential diagnosis. In these cases, it is of great help diagnostic puncture. The detection of pus during puncture through the diaphragm and serous fluid with a higher puncture of the pleura confirms the presence of a subdiaphragmatic abscess. The deep location of the encysted abscess with interlobar empyema makes diagnosis extremely difficult. X-ray examination allows us to establish the presence of triangular or fusiform tissue located along the interlobar fissure. However, it should be borne in mind that such a shadow can be caused by a lesion of the middle lobe on the right or the lingular segment on the left.

Apical empyemas are difficult to distinguish from apical lung cancer. With a basal location of the abscess, it is difficult to determine the supra- or subphrenic accumulation of pus. X-ray examination and test puncture are of decisive importance.

Treatment. Since acute purulent pleurisy is most often a secondary disease, its treatment can only be successful with simultaneous treatment of the primary disease.

All methods of treating purulent pleurisy are essentially aimed at reducing intoxication, increasing the immunobiological forces of the body, eliminating hypoxemia and improving the functioning of vital organs.

A). Conservative treatment pleurisy: antibiotic therapy (parenterally and locally with repeated punctures). The punctures are repeated, the pus is removed and antibiotics are injected into the pleural cavity. wide range actions with preliminary determination of flora sensitivity. The puncture is performed in compliance with all rules of asepsis under local anesthesia. The point of greatest dullness is preliminarily determined. According to the instructions available in the literature and data from our clinic, purulent pleurisy is cured in 75% of patients by repeated punctures.

Much attention should be paid to detoxification and restorative therapy (blood transfusion, plasma, protein substitutes, glucose, administration of vitamins, high-calorie nutrition, etc.). Oxygen therapy, cardiac and sedatives are used according to indications.

b) Surgical treatment. Closed and open surgical methods are used. Both methods have the goal of creating unfavorable conditions for the development of infection by removing pus and creating favorable conditions for tissue regeneration.

1. With the closed surgical method, drainage is inserted into the pleura through the intercostal space, the outer end of the drainage is connected to a device for constant active aspiration of pus (water-jet pump, three-flask suction device, etc.).

Drainage can be inserted into the pleura and through the bed of the resected rib. Wherein soft fabrics it is sutured around the drainage, fixed to the skin, and the outer end is attached to a device for active aspiration.

If there is no apparatus for active aspiration, then a valve made from the finger of a rubber glove is placed on the end of the drainage and lowered into a bottle of antiseptic liquid suspended below the patient.

2. With the open surgical method, the pleura is widely opened through the bed of the resected rib. A wide drainage is inserted into the pleural cavity without connecting it to the suction apparatus. This method is now rarely used.

Closed treatment methods have the advantage that after removal of pus, negative pressure is formed in the pleural cavity. This promotes rapid expansion of the lung, fusion of the visceral and parietal pleura and elimination of purulent inflammation.

At open methods the air entering the pleura prevents the expansion of the lung, fixes the collapsed lung with scars, adhesions, and contributes to the development of pneumosclerosis, residual pleural cavity and chronic pleurisy. However, if there are large clots of fibrin, sequestration of lung tissue, etc. in the pleural cavity, open emptying of the cavity has advantages. After a wide thoracotomy, encysted pleurisy with multiple cavities are formed less often than with closed drainage.

The choice of method for evacuation of pus should be individual, taking into account the advantages and disadvantages of each of them.

c) Postoperative treatment. IN postoperative period a constant outflow of pus from the cavity is ensured, infection is fought, measures are taken to increase the body's resistance and to quickly expand the lung.

Ensuring good emptying of the pleural cavity from pus requires constant monitoring of the condition of the drainage and regular x-ray monitoring of the amount of fluid in the pleural cavity. It is necessary to strive for complete evacuation of pus whenever possible. The exudate should be sucked out slowly, since rapid emptying can lead not only to ex vasio hyperemia, but also to a sharp displacement of the mediastinum, which will cause severe violations cardiac and respiratory functions.

Antibiotic therapy is carried out taking into account the sensitivity of the microflora; on the first day after surgery, the doses of antibiotics should be large. They are administered both intramuscularly and locally using a puncture at the upper point of the purulent cavity.

To reduce intoxication and increase immunobiological strength, blood and plasma transfusions are performed, glucose and vitamins are administered, and high-calorie nutrition is provided. Therapeutic breathing exercises are of great importance for early expansion of the lung.

Guide to clinical surgery, 1967

Pleurisy is an inflammation of the pleura with the formation of fibrous plaque on its surface or effusion inside it. Appears as an accompanying pathology or as a consequence of various diseases.

Pleurisy can be an independent disease (primary pleurisy), but most often it is a consequence of acute and chronic inflammatory processes in the lungs (secondary pleurisy). They are divided into dry, otherwise called fibrinous, and effusion (serous, serous-fibrinous, purulent, hemorrhagic) pleurisy.

Pleurisy is often one of the symptoms systemic diseases(oncology, rheumatism, tuberculosis). However, the striking clinical manifestations of the disease often force doctors to put the manifestations of pleurisy in the foreground, and based on its presence, find out the true diagnosis. Pleurisy can occur at any age, many of them remain unrecognized.

Causes

Why does pulmonary pleurisy occur, what is it, and how to treat it? Pleurisy is a disease respiratory system, during its development, the visceral (pulmonary) and parietal (parietal) layers of the pleura become inflamed - the connective tissue membrane that covers the lungs and the inner surface of the chest.

Also, with pleurisy, fluids, such as blood, pus, serous or putrefactive exudate, can be deposited between the layers of the pleura (in the pleural cavity). The causes of pleurisy can be divided into infectious and aseptic or inflammatory (non-infectious).

Infectious causes Pulmonary pleurisy includes:

bacterial infections (pneumococcus, staphylococcus),
fungal infections (blastomycosis, candidiasis),
typhoid fever,
tularemia,
chest injuries,
surgical interventions.

Causes of non-infectious pleurisy of the lungs are as follows:

malignant tumors of the pleural layers,
metastasis to the pleura (in breast cancer, lung cancer, etc.),
connective tissue lesions of a diffuse nature (scleroderma,), pulmonary infarction,
TELA.

Factors that increase the risk of developing pleurisy:

stress and overwork;
hypothermia;
unbalanced, nutrient-poor diet;
hypokinesia;
drug allergies.

Course of pleurisy May be:

acute up to 2-4 weeks,
subacute from 4 weeks to 4-6 months,
chronic, more than 4-6 months.

Microorganisms enter the pleural cavity in different ways. Infectious agents can enter by contact, through blood or lymph. Their direct impact occurs during injuries and wounds, during operations.

Dry pleurisy

With dry pleurisy, there is no fluid in the pleura, fibrin appears on its surface. Basically, this form of pleurisy precedes the development of exudative pleurisy.

Dry pleurisy is often a secondary disease in many diseases of the lower respiratory tract and intrathoracic lymph nodes, malignant neoplasms, rheumatism, collagenosis and some viral infections.

Tuberculous pleurisy

IN Lately The incidence of tuberculous pleurisy has increased, which occurs in all forms: fibrous, exudative and purulent.

In almost half of the cases, the presence of dry pleurisy indicates that the tuberculosis process is occurring in a latent form in the body. Pleural tuberculosis itself is quite rare; for the most part, fibrous pleurisy is a response to tuberculosis of the lymph nodes or lungs.

Tuberculous pleurisy, depending on the course of the disease and its characteristics, is divided into three types: perifocal, allergic and pleural tuberculosis itself.

Purulent pleurisy

Purulent pleurisy is caused by microorganisms such as pathogenic staphylococci, pneumococci, streptococci. In rare cases, these are Proteaceae, Escherichia bacilli. As a rule, purulent pleurisy develops after exposure to one type of microorganism, but it happens that the disease is caused by a whole association of microbes.

Symptoms of purulent pleurisy. The course of the disease varies depending on age. In infants in the first three months of life, purulent pleurisy is very difficult to recognize, since it is disguised as general symptoms, characteristic of umbilical sepsis, pneumonia caused by staphylococci.

From the side of the disease, the chest becomes convex. Shoulder drooping and insufficient arm mobility also occur. In older children, standard symptoms of total pleurisy are observed. You can also note a dry cough with sputum, sometimes even with pus - when a pleural abscess breaks into the bronchi.

Encapsulated pleurisy

Encapsulated pleurisy is one of the most severe forms pleurisy, in which fusion of the pleural layers leads to the accumulation of pleural extrudate.

This form develops as a result of long-term inflammatory processes in the lungs and pleura, which lead to numerous adhesions and delimit the exudate from the pleural cavity. Thus, the effusion accumulates in one place.

Exudative pleurisy

Exudative pleurisy is distinguished by the presence of fluid in the pleural cavity. It can form as a result of a chest injury with bleeding or hemorrhage or lymph effusion.

According to the nature of this fluid, pleurisy is divided into serous-fibrinous, hemorrhagic, chylous and mixed. This fluid, often of unknown origin, is called effusion, which can also restrict the movement of the lungs and make breathing difficult.

Symptoms of pleurisy

In the event of pleurisy, symptoms may vary depending on how the pathological process proceeds - with or without exudate.

Dry pleurisy is characterized by the following symptoms:

stabbing pain in the chest, especially when coughing, deep breathing and sudden movements,
forced position on the sore side,
shallow and gentle breathing, while the affected side visually lags behind in breathing,
when listening - pleural friction noise, weakening of breathing in the area of fibrin deposits,
fever, chills and heavy sweating.

With exudative pleurisy, the clinical manifestations are somewhat different:

dull pain in the affected area,
severe lag in breathing of the affected area of the chest,
feeling of heaviness, shortness of breath, bulging of the spaces between the ribs,
weakness, fever, severe chills and profuse sweat.

Most severe course noted with purulent pleurisy:

high body temperature;
severe chest pain;
chills, aches throughout the body;
earthy skin tone;
weight loss.

If the course of pleurisy becomes chronic, then scar changes form in the lung in the form of pleural adhesions, which prevent complete expansion of the lung. Massive pulmonary fibrosis is accompanied by a decrease in the perfusion volume of lung tissue, thereby aggravating the symptoms of respiratory failure.

Complications

The outcome of pleurisy largely depends on its etiology. In cases of persistent pleurisy, the development of adhesive process in the pleural cavity, fusion of interlobar fissures and pleural cavities, formation of massive moorings, thickening of the pleural layers, development of pleurosclerosis and respiratory failure, limitation of the mobility of the dome of the diaphragm.

Diagnostics

Before determining how to treat pulmonary pleurisy, it is worth undergoing an examination and determining the causes of its occurrence. In a clinical setting, the following examinations are used to diagnose pleurisy:

examination and interview of the patient;
clinical examination of the patient;
X-ray examination;
blood analysis;
pleural effusion analysis;
microbiological research.

Diagnosis of pleurisy as a clinical condition usually does not present any particular difficulties. The main diagnostic difficulty in this pathology is to determine the cause that caused inflammation of the pleura and the formation of pleural effusion.

How to treat pleurisy?

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

Only patients with diagnosed dry (fibrinous) pleurisy can be treated at home; all other patients should be hospitalized for examination and selection of an individual treatment regimen for pulmonary pleurisy.

The specialized department for this category of patients is therapeutic department, and patients with purulent pleurisy and pleural empyema need specialized treatment in a surgical hospital setting. Each form of pleurisy has its own characteristics of therapy, but for any type of pleurisy, etiotropic and pathogenetic directions in treatment are indicated.

So, for dry pleurisy, the patient is prescribed:

To relieve pain, the following are prescribed: analgin, ketanov, tramadol, if these drugs are ineffective, in a hospital setting it is possible to administer narcotic painkillers.
Warming semi-alcohol or camphor compresses, mustard plasters, and iodide mesh are effective.
Cough suppressants are prescribed - Sinecode, Codelac, Libexin.
Since the root cause is most often tuberculosis, after confirming the diagnosis of tuberculous pleurisy, specific treatment is carried out at the anti-tuberculosis dispensary.

If the pleurisy is exudative with a large amount of effusion, a pleural puncture is performed to evacuate it or drain it. No more than 1.5 liters of exudate are pumped out at a time, so as not to provoke cardiac complications. For purulent pleurisy, the cavity is washed with antiseptics. If the process has become chronic, they resort to pleurectomy - surgical removal parts of the pleura to prevent relapses. After resorption of the exudate, patients are prescribed physiotherapy, physical therapy, and breathing exercises.

For acute tuberculous pleurisy, the complex may include drugs such as isoniazid, streptomycin, ethambutol or rifampicin. The course of tuberculosis treatment itself takes about a year. In case of parapneumonic pleurisy, the success of treatment depends on the selection of antibiotics based on the sensitivity of the pathological microflora to them. In parallel, immunostimulating therapy is prescribed.

Purulent pleurisy- this is a purulent inflammation of the pleura with the accumulation of purulent exudate in its cavity. Purulent pleurisy is a septic manifestation of a common severe infection.

There are: acute, diffuse purulent pleurisy (pleural empyema); encysted purulent pleurisy, the spread of which is limited by the presence of adhesions and adhesions in the pleura; mantle-shaped, interlobar and mediastinal pleurisy.

Acute purulent pleurisy begins high temperature intermittent nature, increasing shortness of breath. The temperature may be low, but the general condition of the patient is serious. The position in bed is forced (half sitting). On examination, there is a lag in the act of breathing on the affected side of the chest, and there is pronounced smoothness of the intercostal spaces. The heartbeat is shifted to the healthy side. Voice tremors are not detected.

On percussion - dullness spreading to the axillary region and to the anterior surface of the chest. The Sokolov-Damoiso line rarely retains its usual concavity. On the right, dullness merges with dullness of the liver. On the left there is no tympanitis in Traube space. Above dullness, a dull-tympanic percussion tone is determined, breathing with a bronchial hue is heard. General intoxication and respiratory failure.

With the accumulation of exudate, stagnation in the vena cava is observed. The pulse quickens, heart sounds become muffled. Breathing is shallow. When increasing oxygen starvation breathing becomes Kussmaul type. The liver enlarges due to toxic damage to the parenchyma; Renal function is impaired and albuminuria appears. In the future, dystrophy may develop with the manifestation of vitamin deficiency (dry and flaky skin, hemorrhages caused by capillary fragility). arise functional disorders from the liver, autonomic and endocrine systems.

With pleural empyema radiologically determined total darkening. To more accurately identify the localization of pleural changes, tomography is necessary.
In the blood leukocytosis with shift leukocyte formula to the left and increased ESR.

WITH diagnostic purpose A pleural puncture is performed, which usually results in purulent exudate. Microscopically found in liquid a large number of leukocytes.

In the early childhood Rapidly developing purulent pleurisy gives a picture of a very serious illness. Cyanosis of the skin quickly gives way to pallor and sallow (hypoxia), sometimes with a yellowish tint (hemolysis). The amount of hemoglobin decreases, the amount of direct and indirect bilirubin increases. Often join purulent complications from the ears, pericardium, kidneys.
In children with reduced resistance, the development of purulent pleurisy occurs slowly. Usually the disease is preceded by fibrinous or fibrinous-purulent pleurisy with subsequent accumulation of pus in the pleural cavity.

Ensacculated purulent pleurisy occurs more often in the presence of previously formed adhesions after repeated pneumonia, less often, purulent exudate is located between the layers of the pleura and encystes there. With this form there are no symptoms characteristic of diffuse pleurisy (dullness, lack of breathing, heart displacement, etc.). It is difficult to establish the presence of encysted pleurisy by objective examination. The diagnosis is confirmed by x-ray.

Plaque pleurisy characterized by the location of purulent exudate in a thin layer throughout the visceral pleura. The patient is bothered by sharp pain when breathing, and the symptoms of a general septic condition are increasing. Dullness of percussion tone is detected
all over the chest on the affected side. Auscultation - weakened breathing. The diagnosis is confirmed by x-ray.

Interlobar purulent pleurisy characterized by a protracted course. In this case, pain in the intercostal spaces and increased temperature are noted. General state patients are not always severe. Percussion reveals dullness of sound from the corner of the scapula towards the anterior axillary line in the form of a narrow strip, breathing is weakened at the site of dullness. X-ray examination is decisive in clarifying the diagnosis (a typical wedge-shaped shadow with a base at the root of the lung).

Mediastinal purulent pleurisy starts sharply high fever, sharp pain in the chest, the appearance of a dull sound in the form of a strip located parallel to the sternum. There are symptoms of irritation and compression of the sympathetic nerve (constriction of the pupil and palpebral fissure). X-ray examination plays a decisive role in diagnosis (ribbon-shaped shadow, closely associated with the mediastinum).

TREATMENT

Applicable complex treatment , thanks to which in last years mortality decreased by 2.5 times.

Main therapeutic measure is evacuation of pus from the pleural cavity. Suction of purulent exudate in children early age It is best to use a 20-gram syringe; in older children, use the Poten apparatus. After removing the purulent effusion, one of the antibiotics (penicillin, streptomycin, monomycin) is injected into the pleural cavity.

IN further treatment empyema is carried out by repeated suction of pus and intrapleural administration of one of the antibiotics in the amount of 100-300 thousand units. However, when evacuating purulent exudate positive result is not always achieved. In such cases, surgery is recommended.

Rational is of great importance antibacterial therapy. It is necessary to first examine the purulent effusion of the pleural cavity for the sensitivity of the pathogen to antibiotics. In order to increase immunobiological reactivity, fractional transfusions of blood, plasma, concentrated albumin, etc. are used. Desensitizing agents include diphenhydramine, diprazine, and suprastin. In addition to this, it is necessary to organize balanced diet, careful care, widely carry out aerotherapy. During the recovery period, physiotherapeutic measures (UHF therapy, quartz) and therapeutic exercises are used.

Forecast both purulent and serous pleurisy depends on the effectiveness of therapy for the underlying disease, complicated by pleurisy, on age, the form of pleurisy, the state of reactivity of the body, on the pathogen and its resistance to antibiotics.

The outcome of purulent pleurisy depends on early diagnosis and timely comprehensive treatment.

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One of the insidious and dangerous diseases is purulent pleurisy, which is detected in people of any age, gender and race. Pyothorax (its second name) is a disease characterized by inflammation of the pleura with the formation of purulent masses in the pleural cavities. In case of absence in a timely manner medical intervention death may occur.

Causes

Pyothorax is an independent disease, rather complication, since it is the result of other pathologies already progressing in the body. The causes of purulent pleurisy may be infections or other options.

Pathologies such as alcoholism, chronic lung and intestinal disease, or diabetes mellitus can lead to pleural empyema.

Non-infectious causes:

Malignant tumors that affect outer surface lungs;
Destruction of connective tissue.

Can also cause suppuration of the pleura spicy pancreatitis, tumors and vasculitis (autoimmune inflammation of the vascular wall).

Symptoms

An increase in temperature to 38 degrees (with a slight inflammatory process) and up to 39-40 (with the spread of inflammation);
Persistent cough;
Feeling of heaviness, stuffiness, acute pain in the area of inflammation, which intensifies when coughing;
Weakness of the body;
The appearance of shortness of breath;
Impaired breathing, that is, the inability to breathe deeply.

Often the patient complains of pain, but with the formation of pus this symptom partially subsides. A cough with a lot of sputum often bothers you at night.

Difficulties in diagnostics purulent pleurisy occurs when it occurs with a lung abscess or pneumonia. In this case, it will be important to clarify the diagnosis using an x-ray examination, as well as taking a puncture from the pleural cavity.

Purulent pleurisy of the lungs treatment

Since the disease is most often secondary, therapy can only bear fruit if the underlying cause is simultaneously treated. All methods of treating pyothorax are aimed at reducing intoxication, increasing the body's resistance, eliminating hypoxemia and improving the functioning of organs. The following methods are distinguished:

Conservative - Antibiotics are used parenterally and locally for repeated punctures. The pus is removed and the medicine is injected into the pleural cavity. All procedures are performed under local anesthesia. Also, to detoxify and strengthen the body, blood, plasma, glucose transfusions are performed, vitamins and a diet containing high-calorie foods are administered. According to statistics, using this method you can treat up to 75 percent of patients.
In critical situations treatment of purulent pleurisy carry out surgical intervention on lungs. Use open or closed varieties. Both techniques are aimed at hindering the development of infection by removing the purulent mass and creating an environment for tissue regeneration. With a closed intervention, the drainage hose is inserted into the pleura between the ribs and connected to the drainage apparatus. At open surgery the pleura is opened, a hose is inserted and not connected to the device.
Postoperative period. The main thing is to constantly ensure the outflow of pus, eliminate infectious processes, increase the body's resistance and eliminate intoxication.

Conclusion

Purulent pleurisy – serious illness, without which therapy it is possible Just die. In order not to lead to this disease, you must follow some simple rules: avoid complications with ARVI, if you suspect, undergo x-ray diagnostics, strengthen immune system, perform breathing exercises and quit smoking. This will significantly reduce the chance of adding to the list of patients with purulent pleurisy of the lungs.

Purulent pleurisy, which can also be called “pleural empyema” or “pyothorax,” is a variant of exudative pleurisy, the effusion in which is represented by purulent masses. Pus, in turn, is called effusion, which in large quantities contains fragments of dead white blood cells - leukocytes and pathogenic microorganisms. It has a thick consistency and white-yellow color.

The figure shows a diagram of the pleural cavity in normal conditions and with purulent pleurisy.

Acute purulent pleurisy is characterized by the rapid accumulation of pus in the pleural cavity, its effect on the body - intoxication, as well as the development of respiratory failure, which can also be combined with signs of heart failure.

Purulent pleurisy is usually identified as an independent disease, because the main symptoms that form clinical picture disease, and its possible consequences differ from those with other types of exudative pleurisy. At the same time, treatment of patients, as a rule, requires active efforts at the local level and must be accompanied by their stay in a surgical hospital.

By origin this type pleurisy may result from:

Complicated pneumonia
Purulent-destructive diseases of the lungs, the most common of which should be considered abscess and gangrene of the lung.
Injuries and surgical interventions on the lungs
Acute inflammatory processes in the abdominal cavity: for example, subphrenic abscess
Spread of infection through the bloodstream from a distant purulent focus: for example, in cases of osteomyelitis - damage to the vertebral bodies. In this case, a lung abscess forms again. The abscess, in turn, leads to pleural empyema.

The picture shows upper lobe left lung, in which an abscess has formed. In this case, the pathological process has already melted the lung tissue and is ready to move into the pleural cavity.

Nowadays, an abscess in the lungs gives an incidence of pleural empyema of about 10%, while pneumonia is 5%. But in patients with lung gangrene, this frequency is about 97%. This is due to the fact that gangrene is a very dangerous condition, which is characterized by the death of tissues in contact with external environment. It is caused by a special group of pathogenic microorganisms, usually characterized by particularly pronounced viability and pathogenic properties.

It is worth talking about abscesses in a little more detail. Most often, a lung abscess is a consequence of a general decrease in immunity, or exposure to Airways foreign body. Often, an abscess is formed as a result of aspiration, that is, inhalation, by the patient of vomit, food particles, or other foreign particles. Usually the abscess is surrounded by a dense capsule.

However, over time, pus can melt its wall: then the abscess breaks through, and nearby tissue melts. It is at the moment of breakthrough of the abscess and spread of inflammation throughout lung tissue pleural empyema can form towards the visceral pleural layer. Therefore, it is important to diagnose an abscess in a timely manner and prevent its complications.

It is important to remember that purulent inflammation in the lining of the lungs can be a consequence of puncture of the pleural cavity or subclavian vein, if these manipulations are performed roughly and illiterately, which results in injury to the pleural layers. However, nowadays such a complication occurs quite rarely.

Microorganisms that cause purulent inflammation of the lung lining are most often the following bacteria:

Quite often, the above microorganisms are found in association with anaerobes bacteroides, fusobacteria or prevotella. Anaerobes are microorganisms that do not require oxygen for adequate life. In patients who long time are located on artificial ventilation lungs, in general anaerobes can be the only causative agents of purulent pathological process in the cavity of the lung lining.

Clinical picture of pleural empyema

In the first few tens of hours from the onset of the disease, signs of purulent pleurisy are usually masked. The patient mainly complains of symptoms characteristic of most pathological processes in the lungs: chest pain, weakness, lethargy, slight shortness of breath, fever.

By the third day of illness, the patient's condition usually deteriorates quickly and significantly. Severe pain appears in the chest, which intensifies or occurs when breathing and coughing: the so-called “pleural pain”. Body temperature rises to 39-40 degrees. In this case, fluctuations in body temperature per day can reach 2 degrees. The patient experiences shaking chills, increasing shortness of breath, becomes lethargic and gradually loses interest in reality, his face may be haggard, his eyes sunken, his features sharpened: all these are signs of intoxication syndrome, that is, the harmful effect of accumulated pus on the patient’s body. Upon examination, the doctor’s attention is immediately drawn to such symptoms as increased breathing, sweating, difficulty breathing and diffuse cyanosis, that is, the bluish color of the patient’s skin.

As pus accumulates, it tends to spread: it simply melts nearby structures and spreads to the soft tissue of the chest wall. This may lead to the formation of a fistula, that is, an anastomosis between the pleural cavity and the external environment.

If a fistula forms between the cavity of the lung membrane and the bronchus, then spontaneous removal of purulent exudate from the pleural cavity occurs. In this case, the patient develops or significantly intensifies a cough, and a large amount of purulent sputum is released, often containing an admixture of blood. Moreover, the cough with the separation of purulent masses becomes stronger when the patient is positioned on the healthy side: the so-called “drainage position.”

A blood test reveals an increase in white blood cells - leukocytes: up to 15-20 thousand per 1 microliter, with a norm of up to nine thousand. The erythrocyte sedimentation rate increases to 50-60 mm/h, which is 4 times higher than normal. Leukemoid reactions are possible. This means that the number of young and juvenile forms of leukocytes in the blood formula increases significantly.

Confirmation of the diagnosis of purulent pleurisy usually occurs during the examination of the actual contents of the cavity of the lung membrane, which is obtained through puncture. Purulent exudate is usually cloudy and viscous. It can have different colors. This depends mainly on the causative agent of the pathological process and its properties. If the causative agent is pneumococcus or staphylococcus, then the pus will have yellow tint, if streptococcus is grayish. If the pathogens are mainly anaerobic, then the pus will be dirty gray in color and have a sharp, very unpleasant odor.

Later, a bacteriological examination of the purulent effusion is carried out. It allows you to accurately determine the causative agents of the process and their individual sensitivity to antibacterial drugs. This makes it possible to assign adequate treatment.

Warning

If the prevalence of the purulent process in the lungs is quite high, and treatment is insufficient and untimely, then an acute inflammatory process in the pleura can develop into chronic pleural empyema. In this case, the pus in the pleural cavity over time becomes surrounded by a kind of “bag”, the walls of which consist of dense and rough connective tissue, poor in blood vessels. The reason for the transition of an acute inflammatory process in the lining of the lungs to a chronic one, as a rule, is late detection and incomplete, “poor” drainage of pleural empyema. This outcome is also an obstacle to the complete expansion of lung tissue, previously compressed by purulent exudate.

Often, after delimitation of what has passed into chronic form process, the inflammatory focus is completely replaced by connective tissue. This condition is called fibrothorax.

Bright external sign fibrothorax is a visible decrease in the affected half of the chest and its lag in movement during breathing.

Necessary treatment measures

If the diagnosis of purulent pleurisy is confirmed in a patient, it is necessary to urgently prescribe adequate treatment. This will avoid the transition of acute purulent inflammation into a chronic form and other complications, such as increasing respiratory failure, for example.

The patient must be prescribed antibacterial therapy. The choice of a specific drug should be dictated by the results of bacteriological examination of the pleural effusion obtained during puncture.

In addition, detoxification therapy should be carried out aimed at reducing harmful effects the causative microorganism and the exudate itself on the patient’s body. It consists of intravenously introducing solutions into the patient’s body that improve the properties of the blood and promote the accelerated functioning of the kidneys as a filter, that is, the accelerated removal of harmful waste products of the causative bacteria from the patient’s body.

In addition to treatment aimed at the patient’s body as a whole, it is important to carry out active and regular local therapy. The latter consists of providing regular pleural punctures, which will allow the evacuation of exudate from the pleural cavity. The pleural cavity is washed antiseptic solutions, a drainage tube is inserted into it, through which the newly formed exudate drains, and drugs that accelerate tissue healing and solutions for washing the pleural cavity are also introduced.

Sometimes the drainage tube is connected to a special pump, which makes the work of medical personnel easier.