1. Andriy Lepyavko, MD, PhD Department of Internal Medicine № 2
Pleurisy
Andriy Lepyavko, MD, PhD
Department of Internal Medicine № 2

2. Pleurisy is inflammation of the pleura.
Classification:
Dry pleurisy (pleuritis sicca)
Pleurisy with effusion (pleuritis exudativa)
The character of the inflammatory effusion may be different: serous, serofibrinous, purulent, and haemorrhagic.

6. Etiology and pathogenesis
Serous and serofibrinous pleurisy (tuberculosis in per cent of cases, pneumonia, certain infections, and also rheumatism in per cent of cases)
Purulent process (pneumococci, streptococci, staphylococci, and other microbes)
Haemorrhagic pleurisy (tuberculosis of the pleura, bronchogenic cancer of the lung with involvement of the pleura, and also in injuries to the chest)

9. DRY PLEURISY Clinical picture
pain in the chest (a characteristic symptom )which becomes stronger during breathing and coughing.
cough (is usually dry)
general indisposition;
subfebrile temperature
Respiration is superficial (deep breathing intensifies friction of the pleural membranes to cause pain). Lying on the affected side lessens the pain. Inspection of the patient can reveal unilateral thoracic lagging during respiration. Percussion fails to detect any changes except decreased mobility of the lung border on the affected side. Auscultation determines pleural friction sound over the inflamed site.

11. Transudative pleural effusion
Congestive heart failure (most common transudative effusion) Hepatic cirrhosis with and without ascites Nephrotic syndrome Peritoneal dialysis/continuous ambulatory peritoneal dialysis Hypoproteinemia (eg, severe starvation) Glomerulonephritis Superior vena cava obstruction Urinothorax

16. PLEURISY WITH EFFUSION
Clinical picture
Complains: fever, pain or the feeling of heaviness in the side, dyspnea (which develops due to respiratory insufficiency caused by com­pression of the lung). Cough is usually mild (or absent in some cases).
Objective examination: The patient's general condition is grave, especially in purulent pleurisy, which is attended by high temperature with pronounced circadian fluctuations, chills, and signs of general toxicosis. Inspection of the patient reveals asymmetry of the chest due to enlargement of the side where the effusion accumulated; the affected side of the chest usually lags behind respiratory movements. Vocal fremitus is not transmitted at the area fluid accumulation.

17. Cyanosis in pleurisy with effusion due to respiratory insufficiency is caused by lung collapse and limitation of its respiratory surface

21. Pleurisy with effusion: posterior view:
1—Damoiseau's curve; —Garland's triangle;
3—Rauchfuss-Grocco triangle.

27. Treatment
Antibiotics (eg, for parapneumonic effusions) and diuretics (eg, for effusions associated with CHF) are commonly used in the initial management of pleural effusions in the ED. The selection of drugs in each class depends on the cause of the effusion and its clinical presentation. Particular attention must be given to potential drug interactions, adverse effects, and preexisting conditions.

28. Pleural punction and drainage

30. Clinical Manifestations
Generalized symptoms of toxicity of TB: fever, sweats, fatigue, weight loss ss, etc.
Pleuritic pain, dyspnea, coughlea, etc.
Pleural fluid is exudative and usually
reveals lymphocytosis
Rarely pleural fluid is blood stained
Tubercular tests usually positive

31. Empyema Thick purulent fluid with more than 100,000
cells per cubic millimeter or fluid with PH
values less than or equal to should
be treated as a presumptive empyema
The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.

35. Treatment of acute and chronic empyema
1. Control of infection
systemic and local
2. Repeated thoracentesis or drainage of the empyema
3. Chronic empyema is primarily treated operatively
4. Operative therapy is also indicated in the empyema with associated bronchopleural fistula or with the ipsilateral ruined lung