pleurisy

Classification according to ICD-10
R09.1	pleurisy
ICD-10 online (WHO version 2019)

A pleurisy ( pleurisy or pleurisy , plurality pleurisy ) is an inflammation of the pleural (rib or pleura). The pleura covers the lungs and lines the inside of the chest cavity. Inflammation of the pleura typically manifests itself as breath-dependent pain, usually on one side of the chest. Pleuritides can be a sign of underlying diseases and have a significant impact on general well-being because of their painfulness. The earlier common tuberculous pleurisy has become very rare in Western Europe. The cause of infectious pleurisy usually remains unexplained, as invasive diagnostics are not indicated if the course is benign. Infants in their first year of life and people after the age of 65 are particularly affected.

Classification

The pleurisy is divided into different forms (mild to severe) based on the degree of severity or into an acute (sudden) or chronic (longer-lasting) form based on the course over time. On the basis of the possible causes, one can try to distinguish between an infectious and a non-infectious form:

Infectious forms are bacterial , viral or mycotic (caused by fungi). For example, in the case of pneumonia , pleural empyema or tuberculosis
Non-infectious forms occur in the context of pancreatitis , pulmonary embolism , pneumonia or pleural carcinosis (tumor infestation of the pleura) as well as in rheumatic diseases , postoperatively or traumatically, and after the instillation of pleural-irritating drugs.

The accompanying pleural effusion can be used to distinguish between dry pleurisy ( pleuritis sicca ) and wet pleurisy ( exudative pleurisy ). With most dry pleuritides, a minimal effusion can still be seen on ultrasound, so that such a classification cannot be made strictly.

Symptoms

The decisive symptom of the pleurisy described in antiquity (previously also called side disease ) is the breath-dependent pain in the chest (which is clearly different from stenocardial , intercostal neuralgic and muscular rheumatic pain), especially in pleurisy sicca (dry pleurisy, the inflammation of the pleura without exudation) Exudates). Another symptom of this stage and pathognomonic signs of dry pleurisy is the means auscultation vocal Pleural (also called "leather creak" and "snowball-crunching") of the two rubbing together Pleurateile. The pain can appear on the right, left, bilateral, front or back of the chest. However, pleurisy can also be associated without pain, especially if the mucous membranes are not rubbing due to an already advanced accompanying pleural effusion ( exudative pleurisy ). Other unspecific symptoms of pleurisy can include fever , shortness of breath , throat irritation and intercostal neuralgia .

Diagnosis

The aetiological (causal) clarification of the pleurisy can cause considerable difficulties, as a large number of infectious or non-infectious diseases can be the cause. In addition, numerous reasons for thoracic pain must be considered in the differential diagnosis.

Basic diagnostics

characteristic complaints with painful inhalation and exhalation
Pleural rubbing when listening ("leather creak")
Often small pleural effusion and irregular lung contour on ultrasound
Fever measurement , laboratory CRP values , blood count to determine the degree of inflammation

Further clarification of the cause

Leg vein ultrasound for possible detection of a thrombosis
Chest X-ray to rule out pneumonia
occasionally cytology and bacteriology from the pleural puncture
Determination of the pH value of the pleural fluid ( acidosis in complicated pleural infections)
Blood culture in the event of a high fever
possibly tuberculosis diagnosis
Rheumatism diagnostics

therapy

Treatment for simple uncomplicated pleurisy is aimed at reducing or eliminating the pain.

If a cause can be identified, treatment of the underlying disease makes sense.

Treat symptomatic pain with analgesics

Cough suppressant measures with an antitussive (not useful for sputum)

Causal Therapy:

Antibiotics for bacterial pleuropneumonia or for purulent pleurisy
Cortisone in rheumatic pleurisy
Instillation of a cytostatic agent in pleural cancer

Sometimes a larger pleural effusion that has arisen as part of the inflammation needs to be punctured. In the case of purulent pleurisy, irrigation and drainage of the pleural space together with systemic antibiosis are useful. Oxygen can be given to people who are very short of breath.

The patient should receive targeted breathing exercises . As long as the symptoms persist, the body should be spared as much as possible and strenuous activities and sport should be avoided.

The patient can choose to position himself when sleeping. In the case of severe unilateral pain, the patient will usually lie on the affected side, as this allows the healthy lungs to move and ventilate more freely. On the other hand, storage on the healthy side is recommended to allow better ventilation on the (more) diseased side.

course

The majority of pleuritides heal without consequences. Some pleuritides lead to pitted adhesions. However, if left untreated, purulent or tubercular pleurisy can also lead to death.

literature

Pleurisy . In: Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 100.
Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid 1986, ISBN 3-13-352410-0 , p. 84 f. and 91-94.

Individual evidence

↑ Arnoldo Baffoni: Storia della pleuriti since Ipocrate a Laennec. Rome 1947.
^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 91 f.
^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid 1986, ISBN 3-13-352410-0 , p. 84 f. and 92.
↑ Berthold Jany, Tobias Welte: Pleural effusion in adults - causes, diagnosis and therapy. In: Deutsches Ärzteblatt , Volume 116, No. 21, 2019, pp. 377–385, here: pp. 382 f.

[1] Arnoldo Baffoni: Storia della pleuriti since Ipocrate a Laennec. Rome 1947.

[2] Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 91 f.

[3] Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid 1986, ISBN 3-13-352410-0 , p. 84 f. and 92.

[4] Berthold Jany, Tobias Welte: Pleural effusion in adults - causes, diagnosis and therapy. In: Deutsches Ärzteblatt , Volume 116, No. 21, 2019, pp. 377–385, here: pp. 382 f.