Pneumonia-like pleural effusion
Introduction
Introduction to pneumonia-like pleural effusion Although many powerful antibiotics are currently in clinical use, pneumonia is still one of the most common diseases. In the United States, pneumonia with pleural effusion is the second cause of pleural effusion, and the cause of exudative pleural effusion is the first. Bit. Most pneumococcal pleural effusions are treated with effective antibiotics and the fluid can be absorbed by themselves. However, approximately 10% of pleural effusions require surgical intervention. basic knowledge The proportion of the disease: the incidence rate is about 0.001% - 0.002% more common in patients with chronic pneumonia Susceptible people: no special people Mode of infection: non-infectious Complications: anemia
Cause
Causes of pneumonia-like pleural effusion
Exudative stage (30%):
This stage is characterized by the rapid exudation of aseptic pleural fluid into the pleural cavity. The source of pleural fluid is still unclear, possibly from the interstitium of the lung. The pleural fluid is characterized by low white blood cells, low lactate dehydrogenase, glucose levels and The pH is normal. If antibiotics are properly applied at this stage, the pleural effusion will not increase progressively, and no intrathoracic cannula drainage will be used.
Fibropurulent stage (20%):
If not treated properly, in some cases bacteria can invade from the adjacent pneumonia to the pleural fluid. This stage is characterized by a large amount of pleural fluid, many polymorphonuclear cells, bacteria and cell debris in the pleural fluid. Fibrin deposits in the affected visceral and parietal pleura. When this stage develops, the effusion tends to form a package and form a limiting membrane. The wrapping prevents the expansion of the empyema, but increases the difficulty of drainage of the pleural cavity. When this stage is reached, the pH and glucose levels of the pleural fluid are progressively decreased, and the LDH level is progressively increased.
Organization stage (10%):
Fibroblasts grow from the visceral and parietal pleural surface to the effusion, producing an inelastic membrane called pleural peel, which affects the expansion of the lungs. The pleural fluid is thick. If not treated, the pus can break through. The chest wall or lung forms a purulent sinus or bronchopleural fistula of the chest wall.
Prevention
Pneumonia-like pleural effusion prevention
1, the amount of chest fluid should not be too much and too fast to avoid accidents.
2, avoid the use of long-acting anesthetics, postoperative analgesics should also be used, because these drugs inhibit cough reflex. At the end of anesthesia, the lungs should be filled with a mixture of air and oxygen, as slow absorption of nitrogen improves the stability of the alveoli.
3, encourage cough and deep breathing, inhalation of aerosol bronchodilator, aerosolized inhalation of water or saline to liquefy the secretions and easy to exclude, if necessary, for bronchial suction.
Complication
Complications of pneumonia-like pleural effusion Complications anemia
Combined with anemia.
Symptom
Pneumonia-like pleural effusion symptoms common symptoms fever-conscious loss of abscess chest pain chills pleural effusion
The clinical manifestations of pneumococcal pleural effusion are mainly determined by the patient's aerobic or anaerobic infection.
The clinical manifestations of aerobic pneumonia with pleural effusion and pneumonia without pleural effusion are basically the same. Patients show acute onset, fever, chills, chest pain, cough, cough and white blood cells, lung inflammation and accumulation. The signs of fluid, the incidence of pleural inflammatory chest pain in patients with pulmonary infection without pleural effusion was 59%, 64% with pleural effusion, and the peripheral white blood cell count of patients without pleural effusion was 17.1×109/L. The liquid is 17.8×109/L. There is no significant difference between the two. If the patient is not treated in time for a longer period of time, the possibility of pleural effusion is greater. If antibiotic treatment is more than 48 hours, it is still fever, suggesting that it is complicated pneumonitis. Pleural effusion, patients with pleural effusion after pneumonia, diagnosis of pneumonia-like pleural effusion is easier, elderly frail and / or patients receiving glucocorticoids and immunosuppressive agents, without the above acute Symptoms and morbidity.
Examine
Examination of pneumonia-like pleural effusion
Early pleural effusion can be expressed as aseptic serous exudation, pH>7.30. The cell classification is mainly polymorphonuclear cells. With the further aggravation of the disease, it develops into a typical pneumonia-like pleural effusion, which is purulent. Exudation, pH <7.10, above, at this time, the pleural effusion smear Gram stain or bacterial culture can be positive.
Early pleural effusion can be expressed as aseptic serous exudation, glucose>3.3mmol/L, and the cell classification is mainly polymorphonuclear cells. With the further aggravation of the disease, it develops into a typical pneumonia-like pleural effusion. For purulent exudation, glucose <2.2mmol / L, at this time pleural effusion smear Gram stain or bacterial culture can be positive.
Early pleural effusion can be expressed as aseptic serous exudation, LDH<500U/L, and the cell classification is mainly polymorphonuclear cells. With the further aggravation of the disease, it develops into a typical pneumonia-like pleural effusion. Purulent exudation, LDH>1000U / L, at this time pleural effusion smear Gram stain or bacterial culture can be positive.
Early pleural effusion can be expressed as aseptic serous exudation. The cell classification is mainly polymorphonuclear cells. With the further aggravation of the disease, it develops into a typical pneumonia-like pleural effusion, which is characterized by purulent effusion. The total number of granulocytes is above 10×109/L.
Physical examination of the lungs combined with X-ray signs of the chest is easier to determine for fluids above the median volume, while a small amount of pleural effusion can be determined by careful examination. The anterior or lateral chest ribs are blurred or dull. Or the sacral muscles suggest that there is pleural effusion, can change the position of the fluoroscopy or lateral chest tube determination, when the liquid is scattered, the rib angle or the diaphragm becomes clear, CT is more efficient in the diagnosis of pleural effusion, can also identify the lung And pleural lesions, to understand the location and characteristics of lung parenchymal lesions, to help differential diagnosis and guidance treatment, in addition, ultrasound can also determine the presence or absence of pleural effusion and puncture positioning.
Diagnosis
Diagnosis and differentiation of pneumonia-like pleural effusion
Diagnostic criteria
Anaerobic infection of pneumonia with pleural effusion is mostly subacute onset, 70% of patients more than 1 week after treatment, the later the visit, the easier it is complicated with pleural effusion, many patients have poor oral hygiene, and have alcohol In the history of loss of consciousness or aspiration, most patients had a significant increase in white blood cells (median 23.5 × 109 / L) and mild anemia.
1. Determine lung inflammation
According to clinical symptoms, physical signs and chest X-ray examination is not difficult, pulmonary inflammation including bacterial pneumonia, lung abscess and bronchiectasis infection, should be as early as possible sputum culture and drug sensitivity, if necessary, fiberoptic bronchoscopy, ring nail puncture Or percutaneous extraction of secretion culture, as far as possible to identify pathogens to guide clinical treatment.
2. Determine the presence or absence of pleural effusion
The initial examination of every patient with pneumonia should pay attention to the presence of pneumonia-like pleural effusion; it is very important to determine whether there is complicated pneumonia-like pleural effusion, because the drainage of intrathoracic cannula is related to its mortality. .
3. Determine the nature of the effusion
Once diagnosed as pneumonia-like pleural effusion, chest puncture should be performed as soon as possible to check pleural fluid routine, biochemical (such as pH, protein, glucose, amylase and LDH), bacterial Gram staining and bacterial culture, and then according to pleural fluid examination In the case of a decision, whether or not a chest tube can be drained.
Differential diagnosis
Need to be differentiated from pleural disease, lung abscess, and lung cancer.
