Pleurisy

Pleurisy — excessive accumulation of fluid in the pleural cavity can occur in any disease, but more often accompanies long-term and decompensated chronic heart failure, severe inflammatory processes of the lung tissue and any malignant tumor.

Often, pleurisy becomes the main and most serious clinical problem of an oncologic patient, it also often passes unnoticed and is noted long after banal pneumonia.

Causes of Pleurisy

Normal human physiology involves the mandatory presence of several milliliters of serous exudate in both pleural cavities, facilitating friction of the pleural sheets when the volume of the lung changes during intake-exhalation. The pleural fluid is constantly «renewed» — it is produced every hour and also quickly absorbed through the lymphatic vessels, in the cavity there remains an optimal amount necessary for the movement of the lungs, which is not visible even on an X-ray.

In chronic diseases and malignant tumors with metastases in the pleura, the balance of exudate intake and removal is disturbed. In lung cancer and heart disease, fluid production increases due to inflammation or slower blood flow, and the absorption remains stable, and a constant excess is formed.

In malignant tumors, several mechanisms of excessive production of pleural exudate are activated:

  • Metastases on the pleural sheets squeeze small blood vessels, which increases the blood pressure in them and causes plasma to sweat through the wall;
  • Cancer cells clog the lymph gaps and block the lumen of the vessels, interfering with the absorption of fluid;
  • Cancer emboli thrombate small vessels, increasing intravascular pressure and causing stagnation;
  • An inflammatory shaft is formed around the tumor tissue, which additionally disrupts the blood flow in the block of blood and lymph movement through the vessels;
  • Mechanical obstruction to normal lung movements causes vascular congestion with edema of the lung tissue;
    In severe cancer ascites, a «reflex» effusion of small volume may occur, regressing after ascites.

Pleurisy can occur with any malignant tumor, but most often develops with pleural metastases of breast cancer and germinating pleura lung cancer, characteristic of pleural mesothelioma.

When cancer pleurisy appears, its cause is not as important as the choice of the optimal therapeutic strategy aimed at delaying or completely stopping the production of exudate.

Pleurisy Classification

  • For the reason that caused the formation of exudate, divided into inflammatory (infectious), aseptic, traumatic, malignant (tumor or metastatic).
  • By localization of effusion: encased (delimited) and diffuse.
  • By the nature of the fluid formed: serous, hemorrhagic, purulent, chyle, mixed.
  • By volume of fluid: basal (supraphrenic), subtotal, total.

Only the gradation is always the same due to the formation of effusion, all other characteristics may change: the basal effusion grows to a total and vice versa with effective treatment; serous over time becomes hemorrhagic; diffuse gradually absorbed and accumulated.

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Pleurisy Diagnostics

With sufficient accumulation of pleural fluid, an experienced oncologist will suspect the problem already when talking with the patient, having noticed cyanosis, the blue of the skin of the nasolabial triangle, against the background of the pallor of the face and the «breathlessness» of the patient’s speech. Listening with a stethoscope and tapping the chest wall will allow to determine the localization, including bilateral pleurisy and the approximate volume of fluid.
X-ray exudate is detected a little more than a glass, and CT or MRI can assess the condition of the pleural sheets and lung tissue, determine the size of metastases.

Treatment of the disease, especially with punctures, will require repeated and frequent monitoring of the condition of the pleural cavity radiographically or, which is harmless, ultrasonically (UST). With fluid getting encased, ultrasound of the chest cavity allows you to schedule a point for optimal puncture.

In case of primary effusion, when there is no clarity with the cause, the exudation obtained during puncture is necessarily subjected to microscopy for verification — confirming its malignant nature.

Pleurisy Symptoms

Most common, small pleurisy can go unnoticed, because the clinical manifestations are caused by changes in the volume of the pleural cavity and restriction of respiratory movements: the more fluid, the more pronounced signs of respiratory failure and symptoms of the disease.

Leading manifestations of the disease:

  • Dyspnea, which begins with a barely noticeable lack of breathing during physical exertion and comes to severely relaxed when the patient is forced to take a position that allows him to breathe at least superficially;
  • The heartbeat increases due to a change in the position of the heart, pushed aside by the fluid towards the healthy lung, interruptions are possible — extrasystoles and heart rhythm disturbances during movement;
  • Dry cough and seizures — reflex due to metastases irritation of the nerve endings on the pleura;
  • Feeling of heaviness in the chest and local pain during inhalation;
  • Weakness and swelling of the legs — a sign of the ineffectiveness of cardiopulmonary activity;
    ncrease in temperature to subfebrile as a result of stagnation of blood and activation of local microflora or absorption of degradation products of tumor tissue.

The combination of the symptoms can lead to a serious condition and immobility of the patient, when an urgent need to take resuscitation inherently measures — emergency evacuation of pleurisy.

Pleurisy Treatment

Treatment of a pathological effusion into the chest cavity consists in evacuating excess fluid during pleural punctures and a systemic effect on the cause of it — cancer or metastasis.

Puncture — pleurocentesis is performed only in the presence of pronounced symptoms of respiratory failure or for cytological examination of the fluid. The procedure is not complicated, but penetrating into the body is invasive and therefore involves possible but very infrequent complications:

  • damage to the lung by a needle with the development of pneumothorax, which aggravates the severity of the patient’s condition;
  • rupture of the pulmonary bulla — excessively swollen pulmonary segment, which is formed during adhesions between the pleural sheets;
  • injury of the neurovascular bundle in the intercostal space is painful, but passes without long-term consequences;
  • infection of the cavity;
  • the formation of adhesions, in a sense, this is useful, since the delimitation of the site is accompanied by a decrease in exudation.

Before the puncture, pleurocentesis and after it the control X-ray examination is obligatory in order to detect pneumothorax in time and conduct its emergency treatment.

The manipulation itself is carried out in a small operating room with sterility and under local anesthesia. First, the doctor in the intercostal space passes through the chest wall with a needle, through which a catheter is inserted inside, which is connected to the active aspiration system. After removal of the maximum possible amount of pleural effusion, a drug can be introduced into the cavity to reduce the rate of accumulation of exudation and sticking of pleural sheets — pleurodesis.

Chemotherapy, both intravenous and local, contributes to the elimination of pleurisy — cytostatics and other drugs are administered through the catheter into the chest cavity.

But antitumor treatment alone is not enough, because a patient with pleurisy suffers from concomitant pulmonary and heart failure, which significantly ruins his life, reduces his activity and appetite.

The treatment of such difficult patients is possible only by a team of specialists, together with oncologists, a thoracic surgeon and a cardiologist, a medical nutrition specialist and a rehabilitation specialist must work hand in hand. Such a team of professionals has already been established at the Medicine 24/7 clinic and our patients see the result of professional actions on themselves.