Old Wang, 51 years old, suddenly felt chest pain on his right side one day and did not dare to breathe deeply. 2 days later the pain got better and only vaguely still had some painful sensations. Old Wang thought it was fine at first, but he gradually felt chest tightness, breath-holding and difficulty in moving. So, Old Wang went to the hospital, took an X-ray, and the doctor said it was a right pleural effusion.
Old Wang was thinking, “What do you mean by pleural effusion? Why would he have pleural effusion? What should I do? How to treat it?
I. What is pleural effusion?
Any cause of excessive fluid in the pleural cavity is called pleural effusion, commonly known as pleural fluid. The following are common in clinical practice.
1.Classification according to the characteristics of pleural effusion
Pleural effusion can be classified as leakage, exudate (plasma or blood), pus, hemothorax, and celiac disease.
2.Classification according to etiology
(1) Infectious diseases: pleurisy (tuberculosis, various types of infections), subdiaphragmatic inflammatory tuberculosis, various types of lung infections, pulmonary tuberculosis.
(2) Circulatory system disorders: superior vena cava obstruction, congestive heart failure, constrictive pericarditis.
(3) Tumors: malignant tumors, pleural mesothelioma.
(4) Pulmonary infarction.
(5) Ruptured hemangioma, pulmonary infarction, thoracic duct obstruction.
(6) Hypoproteinemia, nephrotic syndrome, liver cirrhosis.
(7) Other disorders: peritoneal dialysis, mucinous edema, drug allergy, radiation reaction, rheumatic fever, systemic lupus erythematosus, post-thoracic surgery, pneumothorax trauma, esophageal fistula, pneumothorax, septic infection trauma secondary to thoracentesis, pneumothorax (with pleural adhesion band tear), rupture of thoracic duct due to trauma, filariasis.
Second, what are the symptoms of pleural effusion
Tuberculous pleurisy is mostly seen in young people, often with fever. The presence of pleural effusion in middle-aged and elderly people should be alerted to the possibility of malignant lesions.
Inflammatory effusions are mostly exudative and are often associated with chest pain and fever. Pleural effusion due to heart failure is leaky. Right-sided pleural effusion associated with liver abscess can be reactive pleurisy or abscess chest.
If the amount of fluid is less than 0.3 liter, the symptoms are not obvious; if it exceeds 0.5 liter, the patient may feel chest tightness. When the doctor conducts physical examination of the patient, he/she will find that the local percussion is turbid and the sound of breathing is reduced. When the amount of fluid accumulation is large, the two layers of pleura are separated and no longer rub together with breathing, and chest pain is gradually relieved, but dyspnea will gradually increase. If the effusion further increases, the mediastinal organs will be compressed, and the patient will have obvious palpitations and dyspnea.
How to treat pleural effusion
After the diagnosis of pleural effusion is clear, treatment should be carried out for different conditions.
1.Tuberculous pleurisy
Most patients are treated satisfactorily with anti-tuberculosis drugs. A small amount of pleural fluid usually does not need to be extracted or only diagnostic puncture is done. Thoracentesis not only helps to diagnose, but also relieves the lungs and heart and blood vessels from pressure, improves breathing, prevents fibrin deposition and pleural thickening, and protects lung function from damage. After aspiration, it can reduce the symptoms of toxicity and make the patient’s body temperature drop. A large amount of pleural fluid can be pumped 2 to 3 times a week until the pleural fluid is completely absorbed. The amount of fluid should not exceed 1000 ml each time. Too fast or too much fluid can cause a sudden drop in chest pressure, resulting in pulmonary edema or circulatory disorders, manifested as severe cough, shortness of breath, coughing up large amounts of foamy sputum, both lungs covered with cloudy wet rales, PaO2 dropping, and X-ray chest film showing pulmonary edema signs. At this time, oxygen should be administered immediately, glucocorticoids and diuretics should be applied as appropriate, water intake should be controlled, and the condition and acid-base balance should be monitored closely. If “pleural reaction” occurs during fluid extraction, which is characterized by dizziness, cold sweat, palpitation, pallor, thin pulse and cold extremities, fluid extraction should be stopped immediately, the patient should be made to lie down, and if necessary, 0.1% epinephrine 0.5ml should be injected subcutaneously, and the condition should be closely observed to pay attention to blood pressure and prevent shock. In general, after pumping chest fluid, there is no need to inject drugs into the chest cavity.
Glucocorticoids can reduce the metabolic and inflammatory reactions of the body, improve the toxic symptoms, accelerate the absorption of pleural fluid, and reduce the sequelae such as pleural adhesions or pleural thickening. However, there are certain adverse effects or lead to the spread of tuberculosis, so the indications should be carefully controlled. Acute tuberculous exudative pleurisy has serious systemic toxicity symptoms. For patients with more pleural fluid, glucocorticoids, usually prednisone or prednisolone, can be added to the anti-tuberculosis drug therapy. When the patient’s body temperature is normal, the symptoms of systemic toxicity are reduced or subside, and the pleural fluid is obviously reduced, the dosage should be gradually reduced or even discontinued. The speed of discontinuation should not be too fast, otherwise it is easy to rebound phenomenon, and the general course of treatment is about 4-6 weeks.
2.Pustothorax
Pustothorax is an infection of the pleural cavity caused by various pathogenic microorganisms, accompanied by a cloudy appearance and pus-like characteristics of the pleural exudate. Bacteria are the most common pathogens of pustulothorax. Most bacterial abscess thorax is associated with failure to effectively control bacterial pleurisy. A small number of pustular pleural effusions can be caused by tuberculosis or fungi, actinomycetes, and nocardia. By far the most common pathogens in infected pleural effusions are gram-negative bacilli, followed by Staphylococcus aureus and pneumococcus. Pneumonia complicated by pneumothorax is often a monobacterial infection. In case of lung abscess or bronchiectasis complicated by pneumothorax, it is more often a mixed bacterial infection. Fungal and gram-negative bacillary infections are common in patients on immunosuppressive drugs.
Acute abscess chest often presents with high fever, wasting state, chest distension and pain. The principles of treatment are to control the infection, drain the pleural effusion, as well as to promote lung reopening and restore lung function. For the pathogenic bacteria of abscess chest, effective antibacterial drugs should be applied as early as possible, and systemic and intrathoracic drugs should be administered. Drainage is the most basic treatment for abscess chest, which can be repeatedly pumped or closed drainage. The thoracic cavity can be repeatedly flushed with 2% sodium bicarbonate or saline, and then appropriate amount of antibiotics and streptokinase can be injected to make the pus dilute and facilitate drainage. In a few cases, drainage tubes can be implanted between the ribs and connected to a water seal bottle to export the pleural effusion. For those with bronchopleural fistula, it is not advisable to flush the chest cavity to avoid bacterial dissemination.
Patients with chronic abscess chest with symptoms such as pleural thickening, thoracic collapse, chronic wasting and pestle finger (toe) should be considered for treatment such as surgical pleurodesis. In addition, general supportive treatment is also quite important, and high energy, high protein and vitamin-containing food should be given. Correct water-electrolyte disorders and maintain acid-base balance, and if necessary, give a small amount of multiple blood transfusions.
3.Malignant pleural effusion
Malignant pleural effusion is mostly caused by the progression of malignant tumor and is a common complication of advanced malignant tumor, such as lung cancer with pleural effusion is already in advanced stage. Imaging examination can help to understand the extent of lesions in the lungs and mediastinal lymph nodes. Due to the rapid growth and persistence of pleural fluid, patients often suffer from severe respiratory distress and even death due to the compression of large amount of fluid. Therefore, repeated thoracentesis aspirations are required for such patients. However, repeated aspiration can cause too much protein loss (1 liter of pleural fluid contains 40 grams of protein), so the treatment is very difficult and the effect is not satisfactory.
For this reason, correct diagnosis of malignant tumor and tissue type and timely reasonable and effective treatment are important to relieve symptoms, reduce pain, improve survival quality and prolong life. Systemic chemotherapy has certain efficacy for pleural effusion caused by some small cell lung cancers. Local radiation therapy is feasible for those with metastasis in mediastinal lymph nodes. Intrathoracic injection of antitumor drugs including adriamycin, cisplatin, fluorouracil, mitomycin, nitrocarbamazine, bleomycin, etc., after aspiration of pleural fluid is a common treatment method. This helps to kill tumor cells, slow down the production of pleural fluid, and can cause pleural adhesions. Intrathoracic injection of biological immunomodulators is a more successful method to explore the treatment of malignant pleural effusion in recent years, such as Corynebacterium shortum vaccine (CP), IL-2, interferon beta, interferon gamma, lymphokine-activated killer cells (LAK cells), and tumor-infiltrating lymphocytes (TIL), which can inhibit malignant tumor cells, enhance local infiltration and activity of lymphocytes, and cause pleural adhesions. In order to occlude the pleural cavity, pleural adhesives such as tetracycline, erythromycin, talc can be injected after the drainage of pleural fluid by thoracic cannula to make the two layers of pleura adhere to avoid the re-formation of pleural fluid. If a small amount of lidocaine and dexamethasone is injected at the same time, it can reduce pain and fever and other adverse reactions.