Treatment (Pleurisy)

General management

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 ".)

Read More

Sampling the fluid (Pleurisy)

When fluid is present in amounts sufficient to give rise to physical signs, it is always wise to take a sample ; this is done to confirm the presence of fluid in a doubtful case and to proceed from the recognition of its presence to an attempt to discover why it is there. Sampling should always be carried out with full aseptic precautions. The best site for exploratory puncture (or thoracentesis) is decided after careful scrutiny of postero-anterior and lateral films, and the puncture is made with a needle mounted on a syringe after infiltration with a local anaesthetic right down to the pleura. In an average case the seventh or eighth interspace in the mid-axillary line is a suitable site. The patient may either be sitting up and leaning slightly forwards with the arms resting on a bed-table, or lying on his side with the site of the effusion uppermost.

Read More

Prognosis (Pleurisy)

Any individual with a hemithorax half filled, or more, with fluid is in danger on this account alone. It is true that the danger is not great but the potentialities constitute a definite threat to life. The more immediate prognosis in general terms has been well summarized (Wood, 1946) as depending not so much on the extent of the infection as on the unpredictable liability at any stage to acute miliary dissemination.

Read More

Complications (Pleurisy)

These can be considered in two groups : (1) those which are complications of an active tuberculous process and (2) those which are complications of the presence of fluid in the chest.

Complications of the tuberculous process

The complications of the tuberculous process are chronicity and dissemination. These are, of course, interconnected, and the chronicity of an effusion and the serial involvement of the opposite pleural space often go hand in hand. Dissemina­tion may be on a limited scale, or it may be widespread, resulting in miliary tuber­culosis, with the picture dominated by meningitis. Other sites to which dissemination commonly takes place are the pericardium, the peritoneum and the genito-urinary system. In the unstable and febrile phase of an effusion, dissemination and acute miliary spread are ever-present dangers.

Read More

Clinical course (Pleurisy)

Perhaps most typically the primary effusion proclaims its presence with malaise and discomfort in breathing.   The course of the illness is generally favourable.

The temperature subsides in the space of 2 weeks or so, the fluid is absorbed, function returns and the patient " recovers ". Death in the acute phase of the effusion is rare so that opportunities for post-mortem

Read More

Types of tuberculous pleurisy

There are two main varieties of tuberculous effusion :

(1)    occurring as a late primary manifestation ;

(2)          due to the presence sub-pleurally of post-primary foci.

Both groups sometimes continue to a tuberculous empyema. The second occurs perhaps, more usually in middle-aged or elderly subjects and is generally very chronic.

Read More

Pleurisy with effusion

Effusion may develop insidiously or it may follow or be accompanied by pleuritic pain. Fluid, in considerable quantities, can accumulate without symptoms if it collects slowly and the patient is thus given time to adjust to its presence gradually. On the other hand, it may sometimes accumulate with great rapidity, in which case distress and dyspnoea may become urgent.

Read More

Pleurisy without effusion

Dry pleurisy, whatever its cause, is a painful condition characterized by knife-like pain related to the respiratory excursion, which it tends to inhibit locally. The pain is not of critically sudden onset, and careful interrogation will generally distinguish it from intercostal neuralgia, fibrositis and pre-eruptive herpes. Friction is the cardinal sign and must always be sought. The friction has a rubbing, grating or scratching quality and, if coarse, can be palpated with the flat of the hand. Pressure with the hand will often cause the pain to disappear, and pressure with the chest-piece of the stethoscope may diminish, or even abolish, the friction sound while pressure is maintained. Friction in a peculiar way sou

Read More

PLEURISY

Pleurisy implies inflammation of the pleural surfaces, whether (1) fibrinous, (2) serous with effusion or (3) purulent. The most important single' cause of pleurisy, whether acute or chronic, dry or with effusion, is tuberculosis. Pneumonic consoli­dation—whatever the causative organism—single or multiple pulmonary abscess and primary or secondary neoplasia may also be accompanied by pleurisy, as may complicated bronchiectasis. Rarely, pleurisy complicates acute rheumatism. It may occur in nephritis, often terminally, or during the course of blood diseases such as leukaemia. Diaphragmatic pleurisy, with shoulder-tip pain, and medi­astinal pleurisy—both localizations with

Read More