Additional methods of examination

Clinical blood analysis: leukocytosis, neutrophilia, shift of leukocyte formula to the left, accelerated ESR.

X-ray examination: - the signs of pleura affection, significant darkness with slanting upper border of the fluid and dislocation of mediastenum to the healthy side.

Pleural fluid analysis includes: assessment of macroscopic characteristics (character, transparency, color, consistency, odor, relative density); chemical study (protein, Rivalts's reaction); microscopic study (cellular composition); bacterioscopic study.

Syndrome of fluide accumulation in the pleural cavity

Hydrothorax - the grouping of the symptoms that develop due to the pleura affection or general electrolyte dysbalance in the organism.

Etiology

The main causes of pleural fluid accumulation

Charactpr of pleural fluid	Main causes	Less frequent causes
Transudates	Heart failure	Nephritic syndrome Cirrhosis Myxidema Peritoneal dialysis
Inflammatory exudates (infectious)	Parapneumonic Tuberculosis	Subdiaphragmatic abscess Viral infectious Fungus infectious
Inflammatory exudates (noninfectious)	Pulmonary artery thromboembolia	Collagenosis Pancreatitis Reaction on drugs Dresler syndrome
Tumor induced exudates	Metastasis Lymphoma	Mesothelioma Meigsa syndrome
Hemothorax	Trauma	Spontaneous (impaired hemostasis)
Chylothorax	Lymphoma Carcinoma Trauma	Lymphogranulomatosis

Pathogenesis: in hydrothorax developing the primary affection belongs to inflammatory or reactive process in pleura that accompanied by fluid accumulation in the pleural cavity from several milliliters to 1 liter or more.

Classification

Depending on the etiology, character of excudates, duration and clinic-anatomic form there are the next forms of excudative pleurisy:

/. According to the etiology:

- infection;

- non-infection.

//. According to the character of exudates:

- serous;

- seropurulent;

- purulent;

- hemorrhagic;

- cholesterol;

- putrefactive.

ІІI. According to the duration:

- acute;

- subacute;

- chronic.

IV. According to the clinic-anatomic form:

- diffuse;

- local.

Besides exudates in pleural cavity may accumulate uninflammatory fluid (transudate) due to the impaired electrolyte exchange (increased hydrostatic pressure in the capillaries and decreased colloid and osmotic pressure in plasma).

As result pure of proteins plasma transits through unchanged capillary's wall and accumulates in the pleural cavity (heart failure, nephritic syndrome, liver cirrhosis, alimentary dystrophia, severe anemia, mediastenum tumor, myxedema, compression of vena cava superior).

Clinical features

Patients suffering from pleurisy with effusion usually complain of fever, pain or the feeling of heaviness in the side, and dyspnea (which develops due to respiratory insufficiency caused by compression of the lung) through is usually mild (or absent in some cases).

Objective examination. General patient's condition is from middle grave to extremely grave. Due to hypoxia, the inflammatory process and general intoxication may be observed the deranged consciousness.

The posture of the patients is frequently forced (lying on the affected side) in order to relieve the pain via limitation of the pleural layers movement and relieve dyspnea via decrease pressure of the fluid on mediastenum and therefore its displacement.

The color of the skin and visible mucous is characterized by diffuse cyanosis. In presence of effusion in mediastenum may be observed edematous face, swollen and pulsation of jugular veins, voice change and dysphagia.

Depending on the stage of pleural syndrome development there are the next particularities of objective examination:

/. In the initial stage of the hydrothorax there are more frequently observed the signs of dry pleurisy:

- poor movement of the affected side in respiration during dynamic inspection of the chest;

- in topographic percussion decreased of the lower lung's border respiratory mobility on the affected side;

- in auscultation of the lungs on the affected side over the region with pathologically decreased vesicular breathing is revealed pleural friction sound.

II. In stage of the fluid accumulation in pleural cavity there are observed the signs of effusive pleurisy:

- the chest is asymmetrical;

- affected half of the chest lags in the breathing act;

- vocal fremitus is badly transmitted or generally absent on the affected side (depending on pleural fluid volume);

- in comparative percussion of the lungs is determined the dull sound over the fluid. The minimum amount of the fluid that can be detected by percussion of the lungs is not less then 500 ml; determination of the dull sound from the IV rib is commensurable with 1.5L of fluid; from III rib – 2L; from II rib - more then 3L.

In presence of exudates. The upper border looks approximating a curve with apices along posterior subribs line (the line of Damuaso-Sokolsky) that characterized by unevenness of fluid accumulation due to the different lung tissue compliant. In body position change the border of the dullness isn't change via visceral and parietal pleura adhesion across the exudates upper border.

In occurrence of significant exudates amount in pleural cavity there are distinguish the next clinically and diagnostically zones:

- the zone of absolute dullness that accordant to exudates gathering and limited by Damuaso-Sokolsky line;

- the zone of dull sound that accordant to partial compressive atelectasis on the affected side (Garland triangle) and limit by spinal column, ascendant part of Damuaso-Sokolsky line and line drawing from top of Damuaso-Sokolsky line to spinal column;

- the zone of intermediate percussion sound on the health side accordantly to displaced mediastenum and joining of dull sound from exudates radiated on spinal-column (Rauxfux-Grokkus triangle);

- the zone of clear pulmonary sound that accordant to the lung free of fluid and placed over Garland triangle and Damuaso-Sokolsky line;

- the zone of bandbox percussion sound over the hyper inflated lung of emphysema on the health side.

Accordantly to distinguish zones the next auscultative records are observed:

- above the zone of absolute dullness - the breathing isn't detects or occurs pathologically decreased vesicular breathing;

- above the zone of dull sound (Garland triangle) - occurs pathologically bronchial breathing;

- above the zone of intermediate percussion sound (Rauxfux-Grokkus triangle) - vesicular breathing is absent via impaired sound transmition;

- over the zone of clear pulmonary sound and the zone of bandbox percussion sound (where the lungs are free of fluid) - occurs pathologically increased vesicular breathing.

In presence of transudates. The fluid's level is horizontal, more frequently bilateral and displaced throughout body's position change. The zone of dull sound (Garland triangle,) is absent.

Moreover, in patients observed the signs of main disease that leads to hydrothorax - heart failure, renal diseases, tumor of mediastenum.