1. Leakage pleural effusion
Pleural effusion caused by congestive heart failure, constrictive pericarditis, liver cirrhosis, superior vena cava syndrome, nephrotic syndrome, glomerulonephritis, dialysis, mucinous edema, etc. It just leaks often.
2. Exudative pleural effusion
(1) Malignant pleural tumors include primary mesothelioma and metastatic pleural tumors.
(2) Chest and lung infections, such as tuberculosis and other bacterial, fungal, viral and parasitic infections.
(3) connective tissue diseases, such as systemic lupus erythematosus, polymyositis, scleroderma and Sjogren's syndrome.
(4) Lymphocyte abnormalities, such as multiple myeloma and lymphoma.
(5) Drug-induced pleural diseases such as minoxidil, bromocriptine, ergonovine, methotrexate, levodopa, etc.
(6) digestive system diseases, such as viral hepatitis, liver abscess, pancreatitis, esophageal rupture, diaphragmatic hernia, etc.
(7) Other hemothorax, chylothorax, uremia, endometriosis, radiation injury, post-myocardial infarction syndrome, etc.
clinical picture
1. Symptoms
(1) Chest tightness and dyspnea are not obvious when there is less effusion (less than 300ml), but obvious chest pain can appear when there is less effusion in the early stage of acute pleurisy, which is aggravated when inhaling. Patients prefer the affected side. When hydrops increases, the visceral layer and parietal layer of pleura are separated, and chest pain can be alleviated or disappeared. When there is a moderate or large amount of pleural effusion (more than 500ml), shortness of breath, chest tightness, palpitations, dyspnea, and even cyanosis when sitting.
(2) Patients with pleural effusion caused by tuberculosis may have symptoms of tuberculosis poisoning such as low fever, fatigue and consumption; Symptoms of cardiac insufficiency in patients with heart failure; Pneumonia-related pleural effusion and purulent blood often appear fever, cough and expectoration; Pain in liver area of patients with liver abscess.
2. Symbols
Patients with fibrous pleurisy can hear or touch pleural friction. When there is moderate or large amount of effusion, it can be seen that the breathing movement of the affected side is limited, the breathing is shallow and fast, the intercostal space is filled, the trachea is displaced to the healthy side, the voice tremor of the affected side is weakened or disappeared, the breathing sound above the effusion area is enhanced, and sometimes the bronchial breathing sound can be heard.
After the diagnosis is clear, treatment should be carried out according to different conditions. If you need to relieve symptoms, you should take a certain amount of pleural effusion to relieve the symptoms of dyspnea.
1. Tuberculous pleural effusion
Most patients received anti-tuberculosis drugs and the effect was satisfactory. A small amount of pleural effusion generally does not require aspiration or only diagnostic puncture. Thoracic puncture is not only helpful for diagnosis, but also can relieve the pressure on lung, heart and blood vessels, improve breathing, prevent fibrin deposition and pleural thickening, and prevent lung function from being damaged. After the liquid is pumped out, the symptoms of poisoning can be alleviated and the patient's body temperature can be lowered. A large number of pleural effusion can be pumped 2 ~ 3 times a week until the pleural effusion is completely absorbed. The amount of liquid to be pumped each time should not exceed 65,438+0,000 ml. Too fast and too much fluid withdrawal can lead to sudden drop of chest pressure, pulmonary edema or circulatory disorder, which is characterized by severe cough, shortness of breath, coughing up a lot of foam-like sputum, wet rales in both lungs, decrease of PaO2 _ 2, and pulmonary edema sign on X-ray chest film. At this time, oxygen should be inhaled immediately, glucocorticoids and diuretics should be used as appropriate, water intake should be controlled, and the condition and acid-base balance should be closely monitored. In case of "pleural reaction", manifested as dizziness, cold sweat, palpitation, pallor, rapid pulse and chills in limbs, the patient should immediately stop moving and lie on his back, and if necessary, inject 0.5 ml of 0. 1% adrenaline subcutaneously, closely observe the condition, pay attention to blood pressure and prevent shock. In general, there is no need to inject drugs into the chest cavity after pleural effusion is pumped out.
Glucocorticoid can alleviate allergic and inflammatory reactions, improve toxic symptoms, accelerate the absorption of pleural effusion, and reduce sequelae such as pleural adhesion or pleural thickening. However, there are some adverse reactions or lead to the spread of tuberculosis, and the indications should be carefully grasped. Acute tuberculous exudative pleurisy has severe systemic toxic symptoms and more pleural effusion, which can be treated with glucocorticoid, usually prednisone or prednisolone. When the patient's body temperature is normal, the symptoms of systemic poisoning are alleviated or subsided, and the pleural effusion is obviously reduced, it should be gradually reduced or even stopped. The withdrawal speed should not be too fast, otherwise it is easy to rebound, and the general course of treatment is 4-6 weeks.
2. Pneumonia associated pleural effusion and empyema
The treatment principle is to control infection, drain pleural effusion, promote lung recruitment and restore lung function. In view of the pathogenic bacteria of empyema, effective antibacterial drugs should be applied as soon as possible and administered systemically and intrapleural. Drainage is the most basic treatment for empyema, which can be repeatedly aspirated or closed drainage. 2% sodium bicarbonate or normal saline can be used to wash the chest repeatedly, and then appropriate antibiotics and streptokinase can be injected to dilute the pus, which is beneficial to drainage. A few empyemas can be implanted with drainage tubes between ribs and connected with water-sealed bottles to lead to pleural effusion. For patients with bronchopleural fistula, it is not advisable to flush the chest to avoid spreading bacteria.
When patients with chronic empyema have symptoms such as pleural thickening, thoracic collapse, chronic failure, clubbed fingers (toes), surgical pleural stripping should be considered. In addition, general supportive treatment is also very important, and foods with high energy, high protein and vitamins should be given. Correct water-electrolyte disorder and maintain acid-base balance, and transfuse a small amount of blood many times when necessary.
3. Malignant pleural effusion
Therapeutic thoracocentesis and pleurodesis are common methods to treat malignant pleural effusion. Due to the rapid growth and persistent existence of pleural effusion, patients often have serious breathing difficulties and even death due to the compression of a large number of pleural effusion. Therefore, for such patients, it is necessary to repeatedly puncture the chest to extract fluid. However, repeated aspiration will cause excessive protein loss (1 liter of pleural effusion containing 40 grams of protein), which is very difficult to treat and the effect is not ideal. Therefore, it is of great significance to correctly diagnose malignant tumors and tissue types and carry out reasonable and effective treatment in time to relieve symptoms, relieve pain, improve quality of life and prolong life. Systemic chemotherapy has a certain effect on pleural effusion caused by some small cell lung cancer. Local radiotherapy is feasible for patients with mediastinal lymph node metastasis. After aspiration of pleural effusion, intrathoracic injection of antineoplastic drugs including adriamycin, cisplatin, fluorouracil, mitomycin, Nicaraguan mustard and bleomycin is a common treatment method. This helps to kill tumor cells, slow down the production of pleural effusion, and can cause pleural adhesion. Intrapleural injection of biological immunomodulators, such as Corynebacterium parvum vaccine (CP), IL-2, interferon β, interferon γ, lymphokine activated killer cells (LAK cells) and tumor infiltrating lymphocytes (TIL), is a successful method to treat malignant pleural effusion in recent years, which can inhibit malignant tumor cells, enhance local infiltration and activity of lymphocytes, and make pleura adhere. In order to block the pleural cavity, pleural adhesion agents, such as tetracycline, erythromycin and talcum powder, can be injected after pleural intubation to drain the pleural effusion, so as to make the two layers of pleura adhere to prevent the pleural effusion from forming again. If a small amount of lidocaine and dexamethasone are injected at the same time, the adverse reactions such as pain and fever can be alleviated.
4. Seepage pleural effusion
For leaking pleural effusion, the primary disease is mainly treated. After the primary disease is controlled, the effusion will generally disappear on its own. When a large amount of effusion causes obvious clinical symptoms or the treatment effect of the primary disease is not good, closed thoracic drainage and other methods can be used to relieve the symptoms.
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