With tuberculous
pleurisy this is a long-term matter. In the absence of any reliable specific
remedy, the indications are to support the patient by every means at
our disposal while his own recuperative powers and specific resistance develop.
Rest is the " sheet anchor "—general bodily rest during the febrile phase and stilling of the lung
and pleural movement until absorption has taken place. Strict rest can be a
most valuable measure if the temperature is obstinate in settling, and it is
essential in total effusion. Patients with large effusions are best nursed
propped up and must be very well supported with pillows. Just as too rapid decompression
of the thorax in these cases can lead to fatal consequences, so can sudden redistribution
within the thorax of a large effusion. Fidgeting and restlessness can initiate
such a redistribution. This state of affairs sometimes arises very critically,
the aspect of the patient changing in a moment from one of relative comfort and
calm to one of alarm, apprehension and respiratory embarrassment. He becomes
collapsed, cold and clammy, with a rapid pulse and shallow respiration, and it
is very difficult to rescue him. Oxygen and restoratives should be used at once
and aspiration should be carried out. (See also under "
Complications " and " Management of the fluid ".)
The temperature takes a variable time to subside,
sometimes up to 6 weeks. From 10 to 14 days after it has become normal,
provided that absorption is proceeding satisfactorily and there are no
complications, a patient may start getting up. By the end of a further 6 weeks—that is approximately 3 months from
the beginning of the illness-—he will have arrived at the stage of being up for
4 hours a day and doing incidental walking of, perhaps, half a mile a day.
Graduated walking exercise is now instituted with increased time up, and by the
end of a further 3 months he will be up all day and walking 5 miles per day. In
most cases it will be permissible at this stage to let him resume work, but
supervision and serial x-ray observation must continue for 5 years.
A good working rule is to examine clinically and
radiographically patients who have had an effusion at the following intervals :
every 3 months for a year ; every 4 months for the second year ; every 6 months
up to the end of 5 years. In the clinical examination, special importance
attaches to the weight, and to the possibility that metastatic tuberculous
deposits have made their appearance in the interim.
Attempts should not be made during convalescence to
promote absorption of the fluid or adhesions by expansion breathing exercises,
or to " unfreeze " a lung (unless after some months of constitutional
stability). The aim is a compromise—to obtain settlement of an inflammatory process, which carries with it
always the hazard of dissemination. Within limits, the anatomical result per
se is unimportant, and the existence of a poorly expanding hemithorax with
movements reduced to a minimum may have to be accepted, at least for a time.
What should be emphasized is the functional result, as seen by a patient's
ability to get about and earn his own living or continue his training. Any
decision about instituting active rehabilitation or the use of surgical
measures as decortication must take account of the fact that it is the early
months which follow an effusion that offer the maximal incidence of breakdown.
Management
of the fluid
A sample
should always be taken, but it is less easy to lay down rules about removal of fluid therapeutically.
The general principle is that, so far as possible, the fluid shall be allowed
to become absorbed of its own accord. Over-enthusiasm in aspiration is more
likely to do harm than would conservatism, even allowing for those patients
whose breathing becomes urgently and critically embarrassed. There are three
indications to interfere :
(a)
in fever lasting a disproportionately long time ;
(b)
in fluid persisting a disproportionately long time ;
(c)
to
relieve respiratory distress.
It
will often be found that removal of up to 1 pint of fluid will suffice to tip
the scale towards stabilization or absorption in the case of (a) or (b).
The method of removal is immaterial, provided that the process is slow, is
conducted under sterile precautions, and does not involve the introduction of
air into the free pleural space. This point of view is maintained, although the
policy of complete evacuation of the fluid in successive stages and
pneumothorax induction is not without its supporters (Feldman and Lewis, 1946).
For the aspiration a large-capacity syringe, fitted with a two-way tap, is
convenient. Local anaesthesia must be used down to the pleura, and a stout
needle, preferably incorporating some means of clearing with a stilette, is the
most serviceable. Tubing, other than stout-walled pressure tubing, often
collapses under suction and aspiration becomes impossible. Alternatively, Potain's aspirator can be
used.
When
aspiration is undertaken to relieve dyspnoea it is generally because fluid has
accumulated rapidly and the circumstances which have initiated the rapid
accumulation will in all probability operate again. It is unlikely that the
removal of a pint or two from a space containing 10 or 12 pints " total
effusion", will contribute much to the comfort of the patient and
theoretically the removal of a large amount will be necessary. To remove
amounts in excess of 3 pints presents technical difficulties.
Rapid
removal is dangerous, involving, as it does, the risk of disturbing the
pulmonary circulation and producing oedema of the lung with albuminous
expectoration and death. Warning of this development is given by the patients
experiencing discomfort and oppression in the chest, and by the appearance of a
spasmodic dry cough. Aspiration must be stopped at once and restoratives used.
It would be possible to remove a large quantity, taking up to 2 hours in the
process; but the patient is apt to tire, and the needle not infrequently
becomes dislodged, or at least sufficiently altered in position for the flow to
cease. To leave a needle in position connected to an underwater drain, or
simply to a bottle on the floor by the bedside, is very apt to be followed by
sepsis, and this is a very serious complication indeed. Some authors advocate a
really big-volume aspiration with air replacement, compensating for the removal
of the fluid by the introduction of air. Theoretically this is a sound method,
but practically it cannot always be carried out and it should certainly not be
attempted by the inexperienced. Another plan (perhaps the method of choice) is
to remove 20-30 ounces daily for 4-6 days, although with this method one is
very apt to encounter a " dry tap " at the third or fourth attempt
and to fail of one's purpose.
Among
prophylactic measures are limitation of fluid intake (allowing 30-50 fluid
ounces in 24 hours in all), and the administration of diuretics by the mouth (Diuretin, 10 grains thrice daily) or of one of the
mercurial preparations by intramuscular injection. There are instances in which
these measures appear to have been of use.
Other
methods of treatment
The institution of artificial pneumothorax by air
replacement of the fluid is mentioned above. The field of application of this
technique is, however, probably very limited. Pneumoperitoneum with phrenic
interruption has its advocates, but insufficient time has as yet elapsed for
assessment of its worth as compared with the ordinary conservative regimen.
Although there is at present insufficient experience
on which to base a final judgment—and here again insufficient time has as yet elapsed for an assessment
to be made—there is good reason to think that streptomycin has a definite place
in the management of large effusions or those associated with prolonged fever.
Certainly the immediate benefit is striking. The dose for an adult is 1 gramme
daily intramuscularly in a single dose. The antibiotic is given alone for 7-10
days. As soon as the general condition of the patient permits, para-aminosalicyclic
acid (15 grammes per diem in divided doses) is added. After a loading
dose of 30 grammes of streptomycin in daily injections, the frequency of the
injections can be reduced to 3 times a week, perhaps some 45 grammes of
streptomycin in all being used.
