Pleural effusion pathology is not caused by tuberculosis

2021-01-28 12:00 AM

In addition to pleural effusions that are caused outside the lungs - pleura, which are caused by infection, have an important role, the disease often occurs in people with bad atopic, chronic disease.

Pleural effusion diagnosisbook

Pleural effusion

Outline

Pleural effusion is a common disease in the diseases of respiratory system, the diagnosis of pleural effusion is often not difficult, but diagnosing the cause is important for deciding the direction of treatment.

Depending on the cause and progress of the disease, pleural fluid has many different colour properties (clear, lemon yellow, cloudy, pus, blood-red, white opaque ...) biochemical (fluid, exudate, blood ...), about cells (leukocytes, lymphocytes, red blood cells, endothelial cells), about bacteria and other properties.

Epidemiology

In addition to pleural effusions that are caused outside the lungs - pleura, which are caused by infection, have an important role, the disease often occurs in people with bad atopic, chronic disease. TDMP accounts for a relatively high rate compared to diseases of the lower respiratory tract, medical treatment is sometimes ineffective, leaving many complications and long-term residues affecting respiratory function. Today, thanks to a wide range of good and powerful antibiotics, mortality rates are somewhat limited and complications are reduced.

Causes

In the lungs - the pleura

Infection:

Usually secondary to lung damage (pneumonia, pleurisy, pleural rupture of the pleural sinus, lung cancer necrotic or superinfection ...) or from neighbouring organs (liver, pericardium, central the seventh).

Viral:

Primary or secondary:

Cancer:

Bronchi, lung, pleura, primary or metastatic, BBS (Besnier - Boeck - Schaumann)

Parasites:

Common due to amoeba (due to liver abscess, diaphragm abscess rupture into the pleural sinus), a fluke.

Chest tube injury:

Breaking into the pleura causes TDMP to nourish.

Allergy, severe stage Hodgkin, colloidosis.

Chest injury, chest surgery, pleural puncture complications ...

Undefined reason.

Extrinsic - pleural

Often it is fluid due to heart disease (heart failure), liver (cirrhosis), kidney (HCTH, kidney failure), malnutrition, or ovarian cyst (H / C Demons Meigs), an autoimmune disease.  colloid disease, acute pancreatitis.

Here, the only emphasis is given to the cause of purulent bacteria, commonly pneumococci, streptococci, staphylococcus aureus. E.Coli, Klebsiella pneumonia, Actinomyces, green pus bacillus, if there is a rotten smell caused or combined with anaerobic types.

Lesions can be primary in the pleura but are usually secondary to damage to the lungs, pericardium, or from other organs such as the liver, mediastinum, sub-diaphragmatic abscess ... or from the bloodstream (infection sepsis) or on a pre-existing lung lesion (tuberculosis, cancer ...) then superinfection or effusion after pneumothorax.

Mechanism of pathogenesis

Normally, between the two pleural leaves, there is a very thin layer of fluid that allows the two pleural leaves to slide over each other. Pleural effusion occurs when there is increased capillary permeability, decreased colloid pressure in the blood, changes in hydrostatic pressure, decreased lymphatic circulation, haemorrhage ... in which the role of inflammation is the most important, causing pleural thickening and pulmonary parenchymal compression, but this fluid can be seeped back into the intercellular, blood, after treatment to reduce inflammation.

People divide the fluid and exudate based on the number of proteins, enzymes, cells, white blood cells ... This division is valuable in diagnosing the cause and direction of treatment.

Symptoms

Freeform (whole-body)

Acute infection syndrome:

With fluctuating high fever, anorexia, anorexia, an emaciated face, a dirty tongue, low and dark urine, an increased number of leukocytes, an increase in neutrophils, an increase in VS.

Pleural effusion syndrome:

Function:

Severe chest pain that increases with coughing or deep breathing or a change in position. If the effusion is gradual, the pain is less.

Cough: Usually a dry cough, if there is lung damage, sometimes there is internal mucus or purulent sputum, cough when changing positions.

Difficulty breathing: Depending on the amount of fluid, the rate of effusion, rapid difficulty breathing, difficulty breathing partly due to high fever and pain.

Entity:

Seeing the lesion side ribs is high, the ribs are stretched, the skin of the lesion area has redness, swelling, and possibly collateral circulation. The palpation of the sound is reduced, the intercostal pressures are very painful, the knocking is cloudy, and the sound of the bronchial cells is reduced or lost.

If the effusion is too much, especially the left-sided effusion that pushes the heart to the right, it can cause acute respiratory failure (difficulty breathing, sweating, purple lips and limbs, tachycardia, decreased blood pressure).

Subclinical:

X-rays and ultrasound indicate effusion. X-ray often shows the Damoiseau curve, if air spill is included, the displacement level is horizontal, if the fluid is small, there is the only diaphragmatic angle.

Pleural puncture shows cloudy pus, much polymorphonuclear leukaemia, endothelial cells, high protein, Rivalta (+), fresh microscopy, culture and antibiotic to find pathogenic bacteria.

Note that when searching, you must ask for a thorough medical history, examine the whole body and nearby organs to find the focus of primary or secondary infection.

Localized

Pleural effusion is common in the adjacent area of ​​the damaged lung, patients have the acute septic syndrome, but effusion is difficult to determine clinically, but relies only on radiographs, ultrasound and puncture. It is divided into mediastinal effusion, diaphragm, armpit body, inter-lobe furrow, septum ...

Diagnose

Implementing the quadrants

Diagnosis of pleural effusion is usually not difficult for the free body, based on clinical, radiograph and diagnostic decision is a fluid puncture, with localized X-ray, and ultrasound is important because clinical is difficult determined.

Diagnose the cause

Based on colour, biochemistry, cytology and odours of the pleural fluid and most importantly, the culture of pleural fluid and antibiotic mapping.

Differential diagnosis

Atypical pneumonia:

Clinically, X-ray and puncture are no fluid.

Pleural thickening:

Narrow rib space, X-ray with thick sticky mark.

Atelectasis:

The space of narrow ribs is triangular translucent, the base is turned outwards, the puncture is not fluid.

Abscess under the diaphragm:

Push the diaphragm up, have to rely on X-rays and ultrasound.

Symptoms

Broken lung, bronchi cause lung abscess - purulent concept.

Leaked out into the chest wall.

Secondary or coordinated gas spillage. Pericardial effusion. Sepsis.

If treated early, correctly, the disease will be cured but leaving pleural thickening, sometimes with pleural wall.

If the treatment is not correct or treated late, there will exist an exponential deposit in the pleura, causing prolonged infection, causing atelectasis, and respiratory failure.

Depending on the cause of the disease and response to treatment and treatment methods.

Treatment

The principle is early, strong, adequate therapy, coordinated, and monitored for treatment progress.

Internally medical treatment

Treatment of the cause:

It must be based on the standard of pleural fluid and antibiotic, if there is no antibiotic, it will be based on the clinical situation, the nature of the pleural fluid, the clinical experience of epidemiological factors and the course of the disease.

Mainly antibiotic by systemic and local route into the pleura.

Systemic antibiotics: At least 2 antibacterial antibiotics should be combined by intramuscular or intravenous injection in severe cases with a high risk of drug resistance.

Due to pneumococcus, streptococcus: Antibiotics still work well today are:

Penicillin G 1-3 million units / 6 hours intramuscularly, can be combined with

Gentamycin 3-4 mg/kg / 24 hours in 3 divided doses if reacting with Penicillin, use

Erythromycin 1500-2000 mg / day in 3 divided doses or Roxycillin 150 mgx 3v / day.

Staphylococcus aureus: Most staphylococci are resistant to Penicillin; should use

Cephalosporin II: (Ceclor, Keflor ...) dose 3-6 g / day in 3 divided doses or IV or

Cephalosporin III (Cefomic, cefobis, claforan, Rocéphin ...) as above dose, in combination with an amino side such as

Amiklin 1-2 g / day intramuscularly (TB) or Gentamycin. Or use

Vancomycin 30-60 mg / kg / day TB or IV combination of the above.

By Klebsiella pneu. (Friedlander). Use the aminoxide group like

Amiklin1 - 2 g / day intramuscularly or Gentamycin and/or even

Cephalosporin III dose 3-6 g / 24 hours in 3 divided doses or intravenous TB (IV).

Tobramycin 3-5 mg / kg / 24 hours TB or IV.

Due to anaerobic bacteria:

Penicillin G: a dose of 4- 12 million units/day TB, IV divided 4 times to coordinate with

Metronidazole 250 mg x 4-8 tablets/day and add Gentamycin if necessary, or

Clindamycin (Dalacin C) 300-450 mg 4 times / day or

Cephalosporin III dose as above.

Do Pseudomonas:

Cephalosporin III combined with Gentamycin or Kanamycin or used

Carbenicillin 70 mg / kg / 8 hours TB or IV aminoxide combination.

If no bacteria are found, then based on clinical circumstances, epidemiological factors, physician's experience ...

Antibiotics into the pleura:

Perform after pleural drainage, rinse the pleura with physiological saline solution, put antibiotics into the pleura, especially in the case of thick pleural antibiotic cannot be absorbed.

Antibiotics indicated in the pleura are usually group Lactamin, Gentamycin group ...

Symptomatic treatment

Analgesic and antipyretic: Paracetamol 500 mg x 3-4 times / day, or Acetaminophen, Diantalvic. If the pain is much, you can use Efferalgan - Codeine 2 - 3 tablets / day.

If breathing is difficult, remove the fluid, not more than 500 ml/time. Or breathe oxygen through the nose tube.

Anti-thickening film spectrum i:

Prednisone 5 mg x 6 -10 tablets/day in 2 divided doses or Hydrocortisone, Depersolone ... pumped into the pleura once every 1-2 days.

Supportive treatment

Bed rest during an advanced illness.

Snack, digestible, high protein, calorie and vitamins B and C groups.

Provide adequate rehydration and electrolytes, especially with high fever, take a lot of pleural fluid ...

Surgical treatment

Minimal pleural drainage, pleural rinsing and antibiotic introduction into the pleura, especially in case the caps are too thick.

Peel off the pleura when there is a thick stick, forming a wall, cocoon ...

The disease is considered to be cured when the whole condition is healthy, has a good appetite, has no fever, has no symptoms of the body, X-rays and punctures are not fluid, blood tests return to normal.

Prevention

Diagnosis of pleural effusion is usually not difficult, but finding the cause and course of treatment is complicated, with many complications and sequelae. The pathogens are usually from the respiratory tract, so it is necessary to detect and treat early infections in the upper respiratory tract, in the bronchopulmonary tract, especially patients with bad atopic sites, chronic diseases ...

Must be treated early, strongly, fully and closely monitor pleurisy patients to have a good solution, prevent complications.

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