Symptoms and treatment of purulent pleurisy. Purulent pleurisy of the lungs: treatment, symptoms, consequences

A lung abscess is a purulent-destructive cavity filled with pus, surrounded by an area of ​​inflammatory perifocal infiltration of the lung tissue.

Lung abscess is a polyetiological disease. Acute pulmonary pleural suppuration occurs as a result of polymicrobial infection by aerobic-anaerobic associations of microorganisms. Among them, pneumococcus, non-spore-forming anaerobic microorganisms (bacteroides, peptococcus, etc.), Staphylococcus aureus, and gram-negative aerobic rod microflora (Proteus, less often Escherichia coli, etc.) predominate.

Staphylococcus and pneumococcus are found in association with Klebsiella, Enterobacter, Serration, and Bacteroides. With lung abscesses, high bacterial contamination is noted (1.0 x 10 4 - 1.0 x 10 6 microbial bodies in 1 ml).

Diseases of the following groups lead to the development of acute abscesses or gangrene of the lung:
. lobar or viral pneumonia. This is the most common, if not the main, cause of lung abscesses;
. aspiration of foreign bodies, tumors or scars that narrow the bronchial lumen and thereby disrupt its drainage function with conditions for the development of microflora penetrating from the bronchi;
. septicopyemia, thrombophlebitis, other purulent diseases that can lead to damage to the lungs by hematogenous or lymphogenous route with the development of a pneumonic focus;
. traumatic injuries(open and closed) lung tissue with primary or secondary infection.

Embolic lung abscesses are often multiple and localized in the peripheral parts of both lungs. Aseptic pulmonary infarctions develop abscesses extremely rarely.

In acute purulent lesions of the lungs, infection most often occurs through the aerogenous route. This is a transbronchial entry of microorganisms with the development of pneumonia, when the infectious agent is mixed in the direction of the respiratory sections with the air flow. The aspiration route of infection is rare, and hematogenous-embolic infection is extremely rare.

The process of abscess formation in the lung can occur in different ways. I.S. Kolesnikov, M.I. Lytkin (1988) identifies three possible options (types) for the development of a destructive process in the lung.

Abscess formation of type 1 develops against the background of the usual favorable dynamics of the inflammatory process in the lung 1.5-3 weeks from the onset of pneumonia. After the patient’s condition improves, the body temperature rises again, chest pain increases, and the general condition worsens with manifestations of increasing intoxication. This all ends with the release of purulent sputum.

Abscess formation of type 2 usually occurs within 3-4 weeks from the onset of pneumonia and clinically manifests itself as prolonged pneumonia if treatment fails. A constantly high body temperature remains throughout the entire period of the disease, severe intoxication, then purulent sputum appears, the amount of which increases.

Abscess formation of these types leads to post-pneumonic abscesses.

Type 3 abscess formation leads to aspiration abscesses. In these cases, destruction in the lung begins in the first days, and an abscess forms 5-10 days after the onset of the disease.

Classification of lung abscesses

Clinical picture

The disease occurs predominantly in men (80-85%), most often at the age of 20-50 years (80-90%). The right lung is most often affected. An abscess can be localized in various parts of the lungs, but is most often found in the upper lobe of the right lung. Clinical manifestations of an abscess develop against the background of previous pathological process in the lung. Most often this is lobar, influenza pneumonia or atelectasis of pulmonary tissue. The semiotics of an acute abscess is determined by many factors, but primarily by the phase of development of the process, the general condition of the body, and the virulence of the flora.

The formation of an abscess is accompanied by purulent infiltration and melting of the lung tissue, when there is no communication between the abscess cavity and the bronchial lumen. In this phase, the clinical picture of a lung abscess is very similar to the clinical picture of severe pneumonia. Lung abscess is accompanied by general serious condition, pain when breathing on the affected side of the chest, high body temperature, cough, dullness of percussion sound and bronchial and sometimes weakened breathing over the abscess; leukocytosis increases to 16-30 x 109/l, a pronounced shift in the leukocyte formula to the left is noted.

X-ray examination shows a limited shadow varying intensity and magnitude.

The described phenomena increase over 4-10 days, then usually the abscess breaks into the bronchus and the second phase of acute abscess begins with coughing and the release of copious (up to 200-800 ml/day) fetid purulent sputum containing many leukocytes, red blood cells, bacteria and elastic fibers , as well as tissue detritus. When necrosis predominates in the abscess cavity, the sputum is especially foul-smelling, often mixed with blood. When settling, the sputum is divided into three layers: the lower layer of pus and disintegrated tissue, the middle layer of yellowish transparent liquid, and the upper layer of foamy liquid.

The amount of sputum discharge from a lung abscess does not correspond to the size of the abscess cavity. With small abscesses there may be a lot of sputum and, conversely, with large cavity abscess, the amount of sputum may be insignificant. The amount of sputum discharge depends on concomitant bronchitis, the prevalence of pneumonic changes, and the patency of the draining bronchi.

Diagnosis of a lung abscess is difficult in the early phase of development before it breaks through into the bronchus. Often an abscess is confused with focal pneumonia and other diseases. The most persistent symptoms: cough with sputum, chest pain, increasing as the pleura is involved in inflammatory process, high temperature, constant or with large fluctuations and heavy sweats. In the blood there is high leukocytosis with neutrophilia, increased ESR.

Data from percussion, auscultation and x-ray examination, although not pathognomonic for acute lung abscess, in some cases suggest a diagnosis before opening the abscess into the bronchus or pleural cavity. CG performed during this phase of abscess development often resolves diagnostic doubts, since the identified heterogeneous structure of the inflammatory infiltrate with areas of different density indicates the beginning of the process of destruction in the lung.

After opening an abscess in the bronchus, its diagnosis is greatly facilitated: the diagnosis is established on the basis of the discharge of copious sputum, which was preceded by a severe inflammatory process in the lung. Physical examination usually confirms the diagnosis of a lung abscess. A major role in clarifying the nature and localization of the process is played by X-ray examination, CT scans that allow you to accurately determine the cavity in the lung with gas and liquid.

The main method for diagnosing purulent lung diseases is x-ray; identifying the focus of destruction in the lung plays a major, but not exhaustive, role. Important have topical diagnostics - determination of the localization of the pathological process in the lung, the condition of the lung tissue.

X-ray changes in lung abscess vary. Most common option(up to 70% of observations) is a single cavity in the lung with fluid and inflammatory infiltration of the lung tissue around. The cavity is often round in shape with clear contours of the internal walls, but it is also possible irregular shape and uneven contours of the walls.

In 10-14% of cases of acute abscess, massive darkening of the lung tissue is determined, caused by the inflammatory process without signs of disintegration of the infiltrate. Changes also occur in prolonged pneumonia with severe purulent pneumonitis, damage to interstitial tissue and impaired drainage function of the bronchi, pronounced regional lymphadenitis in the root of the lung.

In such cases, CT makes it possible to identify cavities of destruction of lung tissue in the area of ​​inflammatory infiltration. Clinically, such changes correspond to a long-term, chronic inflammatory process in the lung. IN in doubtful cases CT increases the diagnostic capabilities of x-ray examination.

All these methods do not provide clear information about the state of the bronchial tree of the lung being studied. The absence of any changes in the pulmonary pattern during X-ray examination and CT is the basis for refusing bronchography. For “closed” (not communicating with the bronchus) abscesses, CT helps to resolve doubts regarding the presence of destruction of lung tissue in the area of ​​inflammatory infiltration.

Contrasting the bronchi (bronchography) allows you to determine the condition of the bronchi, but the method is ineffective for identifying abscesses in the lung, since the abscess cavities are not filled contrast agent due to swelling of the mucous membrane of the draining bronchi, as well as due to the filling of the abscess with pus and tissue detritus.

The transition from an acute lung abscess to a chronic one is characterized not only by a temporary factor, but also by certain morphological changes in the abscess itself, the surrounding lung tissue and adjacent bronchi and vessels.

X-ray semiotics of long-term both single and multiple abscesses includes shadows of uneven intensity and varying prevalence. The pulmonary tissue surrounding the abscess cavity has a medium compaction with a sharply deformed pulmonary pattern and connective tissue cords.

The condition of the lymph nodes in nonspecific lymphadenitis is revealed by X-ray examination. The expansion of the shadow of the lung root and the blurring of its structure are determined. Tomography and CT make it possible to differentiate such changes and determine the enlargement of bronchopulmonary lymph nodes. Such changes in regional lymph nodes are a constant sign of lung abscess.

This picture does not play a significant diagnostic role, but changes in the nodes during treatment are assessed as an indicator of the effectiveness of the therapy. Reducing the size and disappearance of nodes is a favorable prognostic criterion. Lymph nodes remain enlarged for another 1-2 months after scarring of the abscess.

Bronchoscopy allows you to assess the condition of the bronchi, determine the draining bronchus, take material for bacteriological examination, debride the abscess or catheterize the draining bronchus.

Modern research methods (CT, bronchoscopy) practically eliminate the need for a diagnostic puncture, since the risk of complications, in particular purulent pleurisy, significantly exceeds the diagnostic value of the method.

Lung abscess in 30% of cases is complicated by pleural empyema or pyopneumothorax. In these cases, thoracoscopy is performed, which often reveals bronchopleural fistulas and makes it possible to determine their location and size, and perform a biopsy of the pleura or lung to clarify the etiology of the disease. Pleuroabscessography reflects the state of the empyema cavity.

To verify the pathogen and establish a bacteriological diagnosis, cultures of bronchial swabs and punctate from the area are used. lung destruction. Among the isolated flora, pneumococcus, staphylococcus, and Proteus predominate (1 x 10 4 - 1 x 10 6 microbial bodies in 1 ml) in association with Klebsiella, Enterobacter, Serration, Bacteroides; in some cases, Escherichia coli is detected. To the results microbiological research expectorated sputum must be treated critically due to its mixing with the contents of the oral cavity.

Acute lung abscesses must be differentiated from cavernous tuberculosis, actinomycosis, echinococcosis, suppuration of a lung cyst, interlobar encysted pleurisy, focal pneumonia, as well as secondary abscesses in lung tumors. Cavernous tuberculosis is usually excluded by determining the history of the disease, the absence of mycobacterium tuberculosis, and characteristic X-ray and CT changes in the lungs outside the cavity containing the fluid.

In actinomycosis, the causative agent of drusen is found in the sputum. However, they are not easy to detect and therefore require repeated careful studies. With actinomycosis, neighboring organs and the wall of the difficult cell are involved in the process.

The differential diagnosis of an abscess is especially difficult with interlobar pleurisy that has opened into the bronchus, and with other encysted pleurisy. In such cases, CT is of great benefit, as it allows one to clarify the true nature of the disease.

It is necessary to differentiate a lung abscess from disintegrating peripheral lung cancer. It should be noted that it is not always possible to differentiate an abscess and lung cancer by the appearance of the decay cavity during X-ray examination. The wall of the cavity with cancer is thicker, there is no purulent sputum, but there is hemoptysis. In the differential diagnosis of disintegrating peripheral cancer and a lung abscess, what is more important is not the type of cavity and the condition of its internal walls, but the external outlines of the darkening in the lungs and the clinical manifestations of the disease.

The cavity during tumor disintegration, according to X-ray and CT scans, contains little fluid, but this is taken into account only if the tissue surrounding the cavity is tuberous and the wall of the disintegration cavity is thick. The leading “pathways” identified in cancer play a role, connecting the tumor with root of the lung, like cancerous implantation along the lymphatic drainage path.

In the differential diagnosis of lung abscess and tuberculosis with a cavity, microbiological testing plays a role.

Lung abscess must also be differentiated from aspergillosis. The disintegration of aspergiloma leads to the formation of a cavity. The mycelium of the fungus in sputum, washing water during bronchoscopy, and the contents of the decay cavity makes it possible to clarify the diagnosis of pulmonary aspergillosis.

In the differential diagnosis of a lung abscess, data from a comprehensive examination of patients are taken into account: anamnesis, clinical manifestations, course of the disease, instrumental and laboratory data. The results of bacteriological research play a certain role. Biopsy samples obtained during bronchoscopy, thoracoscopy, and transparietal puncture are also examined. Wash waters and impression smears obtained during bronchoscopy are subjected to cytological examination.

Treatment

Complex intensive therapy includes:
. optimal drainage and sanitation of the decay cavity in the lung;
. antibacterial therapy, selection of antibiotics taking into account the sensitivity of the isolated microflora to them;
. correction of volemic and electrolyte disturbances, elimination of hypo- and dysproteinemia;
. detoxification therapy: forced diuresis, plasmapheresis, indirect electrochemical;
. blood oxidation using sodium hypochlorite, ultraviolet irradiation of blood, hemofiltration;
. immunotherapy;
. high-calorie balanced nutrition, according to indications - parenteral nutrition and infusion of blood components;
. symptomatic treatment.

Rational antibiotic therapy along with active local treatment(bronchoscopic aspiration, sanitation, etc.) is the basis for effective conservative therapy and preoperative preparation of patients with purulent lung diseases. The use of proteolytic enzymes with necrolytic and anti-inflammatory properties has improved the results of conservative treatment and preoperative preparation of patients with purulent lung diseases. The dissolution of the thick contents of the bronchi and cavities and the anti-edematous effect of enzyme therapy help restore the drainage function of the bronchi, the disruption of which plays a leading role in the pathogenesis of pulmonary suppuration.

Thus, the combination of antibiotic and enzyme therapy is a successful combination of etiotropic and pathogenetic treatment.

To restore the patency of the bronchi draining the abscess, complex bronchological sanitation is carried out, the leading role in which is played by bronchoscopy. Taking into account the data of a preliminary X-ray examination, bronchoscopy allows you to catheterize the bronchus draining the purulent focus, wash it and administer antiseptics, proteolytic enzymes, and antibiotics.

If necessary, therapeutic bronchoscopy is repeated, which allows in most cases to achieve a positive effect. To improve sputum discharge, proteolytic enzymes, expectorants, and mucolytics are used. Proteinases have a proteolytic effect - they dilute sputum and lyse necrotic tissue. Proteinases have an anti-inflammatory effect and affect the drainage function of the bronchi.

In acute lung abscess, endobronchial use of enzymes and antiseptics (along with general antibiotic therapy) quickly eliminates purulent intoxication. A course of complex bronchological sanitation, as a rule, leads to complete clinical recovery with scarring of the abscess. Enzyme therapy gives pronounced effect and with giant abscesses of the lung, when there is little hope of cure without surgical intervention.

One of the components of complex bronchological sanitation is inhalation administration medications. Mucolytics, antiseptic drugs, proteolytic enzymes, etc. are administered in inhalations. Inhalation therapy has a number of valuable properties, but plays only an auxiliary role in the conservative treatment and preparation for surgery of patients with purulent lung diseases.

The main advantages of endotracheal drug infusions are simplicity and the absence of the need for x-ray monitoring. To administer the drug correctly, you need to know exactly the location of the purulent process and carefully observe the appropriate positions of the chest. With endotracheal administration of drugs, unfortunately, it is not possible to accurately deliver drugs to the draining bronchus, but the drugs are distributed throughout the entire bronchial mucosa, which is important for diffuse bronchitis.

Inhalations, endobronchial infusions of proteolytic enzymes, mucolytics, antiseptics - simple methods sanitation, but in terms of their effectiveness and speed of achieving results, they are inferior to therapeutic bronchoscopy. Bronchoscopy is the main method of bronchological sanitation.

Sanitation bronchoscopy is performed under local anesthesia. Therapeutic bronchoscopy with aspiration of the contents of the bronchial tree, its washing and administration of medicinal substances is widely used in the surgical clinic and is part of a comprehensive bronchological sanitation.

Modern bronchoscopy allows for transnasal insertion of a fiberscope and continuous lavage of the bronchi with instillation of the drug through one channel and aspiration through the other. Anesthesia is performed with an aerosol preparation of 10% lidocaine.

In patients who produce purulent sputum, bronchial contents are aspirated during diagnostic endoscopy in order to provide conditions for examination. The next stage of sanitation is the removal of fibrinous deposits and purulent plugs from the bronchial orifices.

The next stage of bronchoscopic sanitation is washing the bronchi with a solution of enzymes. The table position is changed to the opposite to the drainage position. Into the bronchus, draining purulent cavities, insert a special tube and infuse 25-30 mg of chymopsin or trypsin, chymotrypsin, ribonuclease or 1 dose of terrilitin per 4-10 ml of sterile isotonic solution sodium chloride.

The number of washes depends on the extent of the purulent process and the general condition of the patient. Therapeutic bronchoscopy should be as effective as possible, and the risk associated with hypoxemia and hypercapnia during repeated endobronchial manipulations should be minimal. In seriously ill patients, therapeutic bronchoscopy should be carried out under the control of oxygemography or oxygemometry.

Sanitation bronchoscopy with catheterization of the abscess through segmental bronchus indicated when conventional bronchoscopy is ineffective. They are carried out under X-ray and computed tomography control.

Abscess drainage during bronchoscopy to a certain extent replaces conventional bronchoscopic sanitation.

In some cases, it is not possible to perform bronchoscopic sanitation (lack of a bronchoscope, technical difficulties, categorical refusal of the patient). This serves as an indication for sanitation of the bronchial tree through a microtracheostomy.

Special tactics are used in the most severely ill patients with decompensation of external respiration, severe pulmonary heart failure, when severe shortness of breath and hypoxemia at rest are an obstacle to endotracheal administration of drugs. Bronchoscopy is contraindicated for these patients; in some of them, inhalation of the aerosol alone causes increased shortness of breath and cyanosis.

In such a situation, along with parenteral administration of antibiotics, detoxification therapy, etc. local enzyme and antibacterial therapy is carried out by transparietal puncture of the abscess with aspiration of pus, washing the cavity with an antiseptic solution and subsequent administration of proteolytic enzymes. Thanks to this, purulent intoxication usually decreases, the general condition of the patient improves, external respiration and hemodynamic disturbances are partially compensated, which allows a gradual transition to comprehensive bronchological rehabilitation.

Puncture of acute abscesses is performed in case of complete obstruction of the draining bronchus (“blocked abscess”) or insufficient evacuation of pus through it in case of ineffective bronchoscopic sanitation. The point for puncture is marked under X-ray control or during ultrasound, which visualizes the position of the needle directly during puncture.

By transparietal puncture, it is possible to enter into the cavity of the abscess enzyme preparations: chymopsin, trypsin, chymotrypsin, ribonuclease, terrilitin. Solutions of sodium hypochlorite, dioxidine, potassium furagine, and chlorhexidine are used as antiseptics.

Transparietal punctures, aspiration of pus and administration of medications are repeated daily for 3-4 days. If the patient's condition improves, they move on to bronchological rehabilitation. The ineffectiveness of the puncture method in complex treatment is an indication for external drainage of the abscess. A contraindication to the administration of proteolytic enzymes by puncture method is excessive hemoptysis or pulmonary hemorrhage.

Transparietal drainage of an abscess or decay cavity in lung gangrene is carried out when bronchial drainage is insufficient or completely impaired, when bronchoscopic sanitation does not give the desired effect.

Drainage is performed under local infiltration anesthesia under multi-axial X-ray control. Due to its invasiveness, drainage is performed in the cath lab. It is possible that pus or blood (if a pulmonary vessel is damaged) enters the bronchial tree, so it is necessary to provide equipment for emergency bronchoscopy or tracheal intubation.

Microdrainage is used for lung abscesses with a diameter of up to 5-8 cm with insufficient or completely impaired bronchial drainage. The drainage is inserted along a line drawn through the lumen of the puncture needle and fixed with a suture to the skin. Drainage for lung abscesses with a diameter of more than 8 cm and lung gangrene with a decay cavity is carried out using a trocar or a special needle.

Drainage using a trocar is used for large superficial intrapulmonary purulent cavities. The drainage tube is passed through the trocar sleeve.

Drainage with a long puncture needle with a diameter of 2 mm, on which a drainage tube is attached, is used for deeply located intrapulmonary abscesses.

After draining the purulent cavity, its contents are completely evacuated. The cavity is washed with a solution of antiseptic and proteolytic enzymes. The free end of the drainage can be left open under a thick cotton-gauze bandage or connected to a tube inserted under a solution of aseptic liquid according to Bulau-Petrov. The use of continuous vacuum aspiration depends on the size of the purulent cavity. The vacuum during vacuum aspiration should not exceed 50 mm of water. Art., so as not to provoke arrosive bleeding.

The purulent cavity is washed through drainage 3-4 times a day. The amount of solution administered simultaneously through the drainage depends on the size of the cavity, but during the first rinses no more than 20-30 ml.

The drainage can be removed after the body temperature has normalized and the separation of purulent sputum and pus through the drainage has stopped. An X-ray examination should verify the disappearance of inflammatory infiltration around the cavity, a decrease in its size and the absence of a horizontal fluid level in the cavity.

Complications of puncture and drainage of lung abscesses include hemoptysis, pneumothorax and chest wall phlegmon, but these are rare.

The combination of therapeutic fibrobronchoscopy with punctures or drainage of a lung abscess creates optimal conditions for removing purulent contents and stopping inflammation, and as a result, for scarring of the abscess. Double option sanitation is effective for sequestration in the destruction cavity in the lung: sanitation is performed through drainage tube with transparietal drainage of the abscess cavity and through the draining bronchus.

For patients with acute destruction of the lungs admitted to the thoracic surgical department, it is difficult to select antibiotics, since most of them received massive antibacterial therapy in therapeutic departments or outpatient. Before isolating verification and the pathogen, an empirical antimicrobial therapy broad-spectrum drugs.

In the future, the selection of antibiotics depends on the sensitivity of the pathogens. In severe cases of the disease, intravenous administration of antibiotics is recommended, and to create the maximum concentration at the site of inflammation, catheterization of the bronchial arteries is possible, followed by regional antibiotic therapy.

An important place in complex treatment is occupied by detoxification therapy, which is carried out according to general rules for patients with severe purulent diseases. The effectiveness of therapy is significantly higher if a session of plasmapheresis, hemofiltration, and indirect electrochemical oxidation of blood is preceded by drainage of a purulent focus, removal of pus, and necrectomy. Plasmapheresis has clear advantages over other methods, but its use is not always possible for economic reasons.

Immunotherapy is carried out taking into account the immunocorrective effect of drugs - hyperimmune specific plasma, gamma globulins, pentaglobin, gabriglobin.

The option of complex conservative therapy, sanitation of acute lung abscess depends on the drainage function of the bronchi. It is possible to distinguish patients with good, insufficient bronchial drainage and with completely impaired bronchial drainage.

Indications for surgery include the ineffectiveness of conservative therapy and minimally invasive surgical procedures and the development of complications. Complex therapy before and after surgery allows us to perform both resection operations and the original version of thoracoabscessostomy developed in our clinic, followed by necrosequestrectomies and sanitation of the decay cavity using various methods chemical and physical necrectomy and the use of videoscopic technologies. Thoracoabscessostomy is the main operation for gangrenous abscesses.

With successful treatment of acute lung abscesses using complex therapy, the abscess is replaced by a scar and disappears completely clinical symptoms, and during X-ray examination, fibrous tissue is determined at the site of the abscess cavity. If it was possible to completely eliminate the clinical manifestations, but X-ray examination reveals small thin-walled cavities in the lung, the treatment result is considered satisfactory (clinical recovery).

These patients are discharged from the hospital for outpatient observation. The remaining cavities close on their own after 1-3 months. We observed good and satisfactory results in 86% of patients, the process became chronic in 7.8% of cases.

IN surgical treatment 13.3% of patients need it.

Indications for surgical treatment of acute lung abscesses: ineffectiveness of a complex of conservative and minimally invasive surgical treatment methods for 6-8 weeks, development of complications (pulmonary hemorrhage, recurrent hemoptysis, persistent bronchopleural fistulas), transition to a chronic abscess.

The prognosis for acute lung abscesses, if complex conservative treatment is started in a timely manner, is favorable for most patients (up to 90%). In other patients successful treatment possible using surgical methods.

Prevention of acute lung abscesses is closely related to the prevention of pneumonia (lobar, influenza), as well as timely and adequate treatment of pneumonia.

Reasons for development, pathogenesis. The main cause of the development of purulent pleurisy are pathogenic staphylococcus, pneumococcus, streptococcus, and less commonly - Pseudomonas aeruginosa, Proteus, Escherichia.

As a rule, purulent pleurisy is caused by a single pathogen, but it also happens that the disease is caused by several pathogens together. The occurrence of purulent pleurisy is based on a severe form of polysegmental or focal bronchopneumonia or staphylococcal destruction (destruction) of the lungs. Also, the development of purulent pleurisy is promoted by bronchiectasis and perforation (ruptures) of the esophagus (during bougienage (expansion). As a rule, the pathogen enters the pleural cavity by contact directly from pneumonic foci of inflammation, which are located subpleurally, or from small abscesses. Primary purulent pleurisy is rare , in its development, the hematogenous route of transmission of the pathogen from primary foci of inflammation plays a large role. This form of pleurisy is possible with osteomyelitis, otitis media, navel phlegmon, purulent appendicitis, pyelitis, peritonitis. Significant fibrinous accumulations on the pleura, covered with pus, are the main sign of purulent pleurisy. On the pleural layers, areas of hemorrhage, sharp redness (hyperemia), desquamation and destruction of the endothelium, abundant infiltration of poly- and mononuclear cells are revealed. Destruction of the endothelium and the formation of adhesions between the layers of the pleura lead to the limitation of pleural exudate. This process leads to the formation of encysted pleurisy. According to the nature of its occurrence, purulent pleurisy is divided into primary and secondary, according to its course - into acute and chronic pleurisy, according to the nature of the process - into total and limited, according to localization - into parietal (paracostal), apical, interlobar, mediastinal, basal (diaphragmatic) . Secondary pleurisy is divided into para- and metapneumonic.

Clinic, diagnostics

Clinical manifestations of purulent pleurisy depend on the age of the child. For example, in children in the first 3 months of life, purulent pleurisy develops slowly and has symptoms characteristic of umbilical sepsis, septicopyemia or staphylococcal pneumonia. The asymmetry of the chest is determined by eye, with its enlargement on the affected side. There is drooping of the shoulder, limited mobility of the arm, and the chest lags behind when breathing on the affected side. The intercostal spaces, the line of attachment of the diaphragm and the supraclavicular fossa completely lose mobility. Purulent effusion covers with a thin layer lung border and resembles a cloak (cloak-like pleurisy), as a result of which a shortening of the percussion sound is observed. The zone of greatest shortening of sound is located, as a rule, in lower section lung above the diaphragm area. The Ellis-Sokolov-Damoiseau line, the Grocco-Rauchfuss and Garland triangle and Traube space are insignificant in young children. Breathing, as a rule, can be heard throughout, but is slightly weakened and has a bronchial character. A large number of crepitating and fine bubbling rales are heard in the lungs. In some cases, a pleural friction rub may be heard. In older children, symptoms of total purulent pleurisy are most often observed. They have a painful dry cough with a small amount sputum, which is purulent in nature (if purulent contents enter the bronchial tree from the pleural cavity). The fever is hectic (wavy) or low-grade in nature. The thorax on the affected side takes on the shape of a barrel, its lag in respiratory movements is noticeable, the intercostal spaces widen and thicken skin fold. Dullness of percussion sound is most pronounced posteriorly and laterally in the axillary (axillary) region. The Ellis-Sokolov-Damoiso line, the Grocco-Rauchfuss and Garland triangle are clearly defined. While listening to the lungs above the zone where sound shortening is noted, bronchial breathing, sometimes a pleural friction noise can be heard, which disappears with the accumulation of fluid in the pleural cavity, and there is a complete absence of breathing sounds. With a sharp accumulation of effusion, wheezing. In the lateral and lower part of the dullness of purulent exudate, the mediastinal organs shift to the healthy side and a respiratory catastrophe develops: sharp pain behind the sternum, shortness of breath, the skin becomes bluish (cyanosis), anxiety, and the heartbeat increases.

Upon examination, a shift in the heart impulse to the healthy side is observed, which becomes more diffuse in nature. Vein enlargement and pulsation are clearly visible large vessels neck. Children who have suffered purulent pleurisy are inferior to their peers in development and are exhausted. Such children may develop chronic pulmonary empyema. IN general analysis blood, a huge number of leukocytes are detected (30-50 x 103 μl) with an increase in the number of neutrophils, a band shift of up to 15-20%, hypochromic anemia, an increase in ESR to 50-60 mm/h. To the earliest X-ray signs Acute purulent pleurisy includes the appearance of a shadow of mantle-shaped pleurisy and a uniform decrease in the transparency of the lung tissue. With pleural empyema, the images show a uniform darkening of the lung tissue with a clear boundary of the exudate and airy lung tissue above it, the dome of the diaphragm is not determined, the sinus is invisible. When exudate accumulates, a shift of the mediastinal organs to the healthy side is observed. As for other forms of purulent pleurisy, their radiological characteristics resemble serous pleurisy. Chronic pleural empyema on an x-ray is characterized by a collapsed lung, which is covered with a thick mooring, a dry pleural cavity or with exudate having a horizontal border. To confirm the diagnosis, a puncture of the pleural cavity is performed. As a rule, it contains pus. It is rare, but it happens that the punctate has a cloudy appearance. The resulting liquid is sent for testing to a bacteriological laboratory.

Despite the similarity of clinical and radiological parameters between purulent and serous pleurisy, they can still be distinguished. Purulent pleurisy usually occurs in children younger age and in most cases it is synpneumonic, which is not typical for serous pleurisy. They also reveal active purulent processes in the lungs (lung abscess, abscess pneumonia), severe toxicosis and a characteristic blood test picture (high leukocyte count with a shift in the leukocyte formula towards neutrophils, progressive anemia, increase in ESR). The final point in making a diagnosis is pleural puncture with its further laboratory research. Purulent inflammation of the pleura must be distinguished from confluent lobar pneumonia. The main distinguishing signs of purulent pleurisy are asymmetry and almost complete absence of chest movement during breathing, pasty soft tissues, and enlarged venous vessels of the skin on the affected side. During percussion, there is an increase in percussion dullness downwards. On auscultation, bronchophony is heard. Breath sounds in the lungs are sometimes heard, and in some cases completely absent. The boundaries of dullness in pneumonia are tapped only in the area of ​​the middle or lower lobe and do not extend beyond this area. During auscultation, strong bronchial breathing, bronchophony, and a large number of moist rales of various sizes are heard. On an x-ray, purulent pleurisy has a uniform thick shadow over the entire lung tissue and a shift of the mediastinum to the healthy side is observed, which is not observed with pneumonia. Pure purulent pleurisy must be distinguished from an abscess of the lower lobe of the lung. With a lung abscess, as a rule, there is moist cough with the discharge of large quantities of purulent, foul-smelling sputum. Radiologically, a lung abscess looks like a round or oval densely darkened shadow with clear lower boundaries and an air cavity above the horizontal level of fluid. Unlike pleurisy, the distinctive features of which are the filling of the costophrenic sinus and a change in the boundaries of the fluid when the body position changes, in a lung abscess there is a slight shift in the fluid level.

Treatment

In the treatment of purulent pleurisy, one of the key places is occupied by the treatment of the underlying disease - pneumonia. If we talk about treatment methods, they can be both surgical and conservative. The simultaneous administration method is often used antibacterial drugs through a vein or intramuscularly, through the trachea. Ultrasonic or simple aerosol inhalations are also indicated. As a rule, it is prescribed maximum doses antimicrobial drugs.

Intrapleural administration of antibiotics into currently is considered unfounded. As a rule, antimicrobial therapy is carried out simultaneously by several medicines, while taking into account their compatibility with each other and the drug sensitivity of the pathogen. It is recommended to carry out several consecutive courses of treatment (7-10 days). Full course Antibacterial therapy ranges from 1 to 1.5 months or more. Sulfonamides are used in combination with antibiotics long acting- sulfadimethoxine or sulfapyridazine, biseptol or nitrofurans. 0.25% has a strong antimicrobial effect alcohol solution chlorophyllipt. It is used intravenously at 0.5-2 ml twice a day. Good effect observed during transfusion of hyperimmune antistaphylococcal plasma, blood transfusion, plasma albumin, red blood cells, native staphylococcal toxoid. Blood transfusions are carried out at least 2 times a week at 5-10 mg/kg body weight. Antistaphylococcal plasma is administered daily at a dose of 5-10 ml/kg of body weight until positive results are obtained.

To replenish lost fluid and relieve symptoms of intoxication, intravenous drip administration of polyglucin, rheopolyglucin, neocompensan, Ringer's solution and a 5% solution of glucose, alvesin, aminon is used, which are prescribed at the rate of 10 ml/kg of weight and at a rate of 10-12 drops in 1 minute. The volume of infused liquid should not exceed 70% of daily requirement child in liquid, which averages 50-80 ml/kg body weight. In this case, it is necessary to strictly monitor the volume of urine excreted. Correction of the acid-base state is carried out by intravenous administration of a 4% sodium bicarbonate solution. The use of hormones (prednisolone, hydrocortisone) is advisable in the first 2 days in order to remove the patient from toxic shock. The anti-shock effect is caused by intravenous, intramuscular or subcutaneous use of a 0.25% solution of dro-peridol at a dose of 0.1-02 ml/kg or a 0.5% solution of haloperidol at a dose of 0.1-0.2 ml/kg. . Neuroplegic drugs are prescribed - seduxen, aminazine, luminal, sodium hydroxybutyrate (50-100 mg/kg body weight) intravenously, 1% solution of promedol per 1 year of a child’s life, 0.1 ml (single dose) intramuscularly. For intestinal weakness, an enema is prescribed hypertonic solution, proserin is administered intramuscularly, potassium chloride is administered intravenously.

For therapy, it is recommended to use semisynthetic penicillins, cephalosporins, aminoglycosides, antimicrobial drugs of different groups (lincomycin, rifampicin, ristomycin, vancomycin), semisynthetic tetracyclines (doxycycline, metacycline).

To treat purulent pleurisy, puncture of the pleural cavity is also used to pump out pus. This manipulation is carried out in children from 6 months to treat cape-like and limited pleurisy. With extensive purulent inflammation pleura, this method of treatment is usually used in children over 1 year old and only in cases where the effusion is not very thick and there is a tendency to reduce its volume after the first punctures. In the first 2 days of therapy, punctures are performed daily, then at intervals of 1-2 days, and when the child’s condition is stabilized - after 3-4 days under the supervision of radiological and clinical studies. In case of severe total pleural empyema in children older than six months, in the absence of effect from punctures and in the presence of viscous effusion, thoracoceggesis and drainage of the pleural cavity using passive drainage according to Bulau or through active aspiration of the contents are advisable. In case of severe purulent pleurisy in children under 2 years of age, immediate surgical treatment is recommended. Children with a history of a diagnosis of purulent pleurisy are subject to dispensary observation at the pediatrician. Such children are indicated for sanatorium-resort treatment. The outcome of the disease depends on the age of the child, how quickly and correctly the diagnosis was made, and on the correct treatment regimen. In children early age Possible death.

The most complex and dangerous pathology lung disease is pleurisy, and people of any gender are at risk. As this disease progresses, an inflammatory process develops on the outer surface of the lung tissue, and pus accumulates inside the organ.

Acute purulent pleurisy causes an increase in body temperature and constant shortness of breath, and the patient is in extremely serious condition.

The reasons for the development of such pathologies may be different, and in the absence effective therapy Possible death.

Causes of development and forms of the disease

Experts say that pleurisy is not independent disease. Mostly this disease develops as a result of progression various ailments in other organs.

All causes that provoke pulmonary pleurisy are conventionally divided into:

• infectious;
• non-infectious.

Medical practice shows that the following pathologies can cause infectious pleurisy:

• the appearance of problems with the functioning of the gastrointestinal tract;
• diabetes;
• chronic lung pathologies;
• alcoholism.

Causes non-infectious- these are different malignant tumors, and their place of localization becomes the outer surface of the lungs. In addition, pleurisy of lung tissue can cause various damages and connective tissue injuries.

Experts identify several forms of pulmonary pleurisy, taking into account the clinical picture. The dry form of the disease is considered the initial stage of the development of the disease. This form of pathology is characterized by damage to the circulatory system, and no infectious pathogens are detected in the pulmonary cavity.

The dry form of the disease is accompanied by an increase in vascular permeability under the influence of anti-inflammatory components. In addition, the patient has leakage of liquid plasma, and this results in the appearance of fibrous threads on the pulmonary surface. Such pleurisy is characterized by a violation of the outflow of fluid, which causes severe friction of the pleural layers. The consequence of this is the appearance of severe pain in the patient.

In the absence of timely effective therapy, the dry form of the disease transitions to next stage. There is an increase in the focus of inflammation and exudative disease develops.

At this stage of the development of the disease, the activity of enzymes decreases significantly and a kind of cavity appears, where pus subsequently accumulates. The exudative form of pleurisy is accompanied by a significant increase in pleural fluid, and under its influence the volume of the lung is significantly reduced.

In a situation where the disease progresses to advanced stage, then the patient begins to suffer from respiratory failure. There is a decrease in friction in the pleural layers due to increased fluid accumulation, which causes a decrease in pain.

The next stage in the development of the disease is purulent pleurisy or pleural empyema. This form of the disease is quite complex and poses a serious threat to the patient’s life. There is an accumulation of large amounts of pus in serosa, and the general intoxication of the patient’s body increases. Medical practice shows that empyema most often forms with the progression of complex pathologies of other organs or in patients with impaired functioning of the immune system.

With purulent pleurisy in acute form, a rise in body temperature and the appearance of shortness of breath are noted, and the general condition of the patient is diagnosed as extremely severe.

Symptoms of the disease

Purulent lung disease is characterized by the following symptoms:

With purulent pleurisy, the patient complains of the appearance of severe painful sensations, but with the accumulation of pus they begin to decrease. Purulent pleurisy is accompanied by the appearance of a dry cough, which especially bothers the patient at night. In a situation where pleurisy develops as a complication after inflammation or a lung abscess, sputum mixed with pus begins to appear.

A characteristic feature purulent lung disease is considered to be a rise in temperature to 39-40 degrees. Fever may persist all the time or appear periodically. The pulse reaches 120-130 beats per minute and the cause of this condition is purulent intoxication of the body, as well as a displacement of the heart to one side.

This patient's condition is considered serious and requires immediate medical attention. If effective therapy is not carried out, pus may leak into the pleural cavity. During the development of the inflammatory process, not only pus, but also air accumulates in the pleural cavity. This pathological condition is medical practice called “pyopneumothorax” and is accompanied by the appearance in the patient severe shortness of breath and pain.

If purulent pleurisy enters an advanced stage, the result is tissue scarring and the appearance of adhesions. In addition, bronchiectasis is diagnosed, and the inflammatory process becomes chronic with relapses.

Possible consequences and diagnosis

In the absence of effective therapy, the pathology can pose a serious threat to the patient's life. This is due to the fact that the progression of purulent pleurisy in the human body can result in the development of a lung abscess.

If a purulent pocket breaks through, the infection spreads into the pleural cavity. The consequences of this pathological condition become pneumonia, cystic formations and gangrene.

Breakouts of a pocket of pus in a patient are accompanied by a rise in temperature, as well as increased coughing and increased heart rate. In addition, breathing becomes more frequent and when the abscess breaks through, hypoxia begins to develop.

If pleurisy reaches an advanced stage, this causes a significant increase in the affected area of ​​the chest. The progression of pleurisy in the human body causes general intoxication, and the content of a large amount of pus provokes expansion of the intercostal space and respiratory arrest.

In the absence of effective therapy, the consequences of such a disease can develop in the form of adhesions and pleural calcification. In addition, restriction of lung mobility and the development of acute heart failure may occur.

The main and only method for detecting purulent pleurisy is an X-ray examination of the chest. The images obtained during the procedure show darkening of the lung tissue and oblique top level liquids. The location of the fluid accumulation is determined by its quantitative volume.

Another effective method for diagnosing purulent pleurisy is pulmonary puncture. Fluid is taken from the patient's lungs, which is subsequently carefully studied. Thanks to this procedure, it is possible to diagnose the type of pathology and select an effective course of treatment.

Features of treatment of the disease

If purulent pleurisy is suspected, the patient is subject to mandatory hospitalization.

Treatment of this pathology involves solving the following problems:

• stabilization of the patient's condition;
• restoration of normal breathing;
• eliminating the cause that provoked pleurisy.

In most cases, this pathology is of infectious origin, so drug therapy is carried out using antibiotics and anti-inflammatory drugs.

When fighting purulent pleurisy, the following antibacterial drugs are prescribed:

1. Ceftriaxone.
2. Ampicillin.
3. Clindamycin.

Taking antibiotics to treat pleurisy helps prevent further dissemination bacteria and cause their death.

Restore water-electrolyte balance This can be done with saline or glucose. This drug treatment helps speed up renal filtration and quickly get rid of waste products.

Therapy for purulent pleurisy can be carried out using the following medications:

If dry pleurisy is detected, treatment involves bed rest. In addition, medications that have an antimicrobial, analgesic and anti-inflammatory effect on the body are prescribed. Cupping and warm compresses help speed up the healing process.

When diagnosing a form of the disease such as purulent exudative pleurisy, the patient is placed in an inpatient medical facility. Conservative therapy involves taking drugs with antitumor and anti-infective effects on the body.

An important role in this form of the disease is following a special diet with a sufficient content of vitamins and proteins. Special food involves the complete exclusion of salt from the diet and the consumption of a limited amount of liquid.

If an increased amount of fluid appears in the pleural cavity, then specialists decide to perform a puncture. To perform this procedure, a special needle is inserted into the pleural area on the side of the scapula. Thanks to the puncture, it is possible to remove it from the body. excess liquid, will significantly reduce the pressure in the pulmonary cavity and restore breathing. After the puncture, the patient is prescribed therapeutic exercises and physiotherapy.

Treatment of purulent pleurisy is carried out only in inpatient conditions. Self-treatment of the disease at home can pose a threat to the patient’s life and cause the development of severe consequences.

The main task in the treatment of such pathology is to prevent the process of tissue destruction. Daily puncture is performed, the cavity is washed with antiseptic agents, and drainage is applied.

With purulent pleurisy, drug treatment may not bring the desired result, so they resort to surgical intervention. During the operation, specialists remove dense scars of the pleura or its parietal sheets, and this is determined by the degree of damage to the lung.

Acute purulent pleurisy is an acute purulent inflammation of the pleura. In the vast majority of cases it is a secondary disease - a complication purulent lesions various organs.

Purulent pleurisy sometimes develops as a result of the spread of infection by the lymphogenous route during various purulent processes of the abdominal cavity, retroperitoneal space: purulent cholecystitis, appendicitis, pancreatitis, perforated gastric ulcer, subphrenic abscess, peritonitis, paranephritis, etc. The development of metastatic acute purulent pleurisy in sepsis is described, phlegmon, osteomyelitis and other purulent processes of various localizations. There are reports of pleurisy caused by a specific or mixed infection with scarlet fever, measles, typhus, etc.

The causative agents of the disease are various pyogenic microorganisms. At bacteriological research pus from the pleura is most often found to be streptococcus (up to 90%), less commonly staphylococcus and pneumococcus. In children, pneumococcus is the most common (up to 70%). Mixed flora is often observed.

The pleura reacts to infection differently, which depends on the virulence of the latter and the reactivity of the organism.

With a weakly virulent infection, a small fibrinous effusion is formed, gluing the visceral and parietal pleura, which contributes to the formation of adhesions and adhesions around the source of infection - this is dry pleurisy. More virulent microbes cause the formation of abundant exudate - exudative pleurisy, which, with high virulence of the microflora, becomes purulent in nature.

There are several classifications of purulent pleurisy:

1) by pathogen - streptococcal, pneumococcal, staphylococcal, diplococcal, mixed, etc.;

2) according to the location of the pus: a) free - total, medium, small; b) encysted - multi-chamber and single-chamber (basal, parietal, paramediastinal, interlobar, apical);

3) according to pathological characteristics: a) acute purulent; b) putrefactive; c) purulent-putrefactive;

4) according to the severity of the clinical picture: a) septic; b) heavy; c) average; d) lungs.

Symptomatology and clinic. The clinical picture of acute purulent pleurisy is layered with the clinical manifestations of primary disease(pneumonia, lung abscess, etc.), of which it is a complication. The disease begins with severe stabbing pain in one side or another of the chest, sharply intensifying with breathing and coughing.

The temperature rises to 39-40°, the dry cough intensifies, the pulse becomes frequent and small. Increased stabbing pain when trying to deepen breathing leads to superficial, rapid breathing, which entails an increase in hypoxia. With an increase in the amount of exudate, the pleural layers move apart and the pain decreases somewhat, but compression of the lung by the exudate reduces the respiratory surface of the lungs, and shortness of breath appears.

When examining the patient, an increase in half of the chest on the side of the process, widening of the intercostal spaces, and a lag in breathing are noted. Vocal tremor on the affected side is weakened.

In the lower part of the pulmonary field - muffled percussion sound and weakened breathing, sometimes pleural friction noise, dry or moist rales are detected, lung excursions are limited.

With further progression of the disease, accumulation of pus in the pleura, the patient’s general condition worsens, the temperature remains high, sometimes fluctuations between morning and evening temperatures reach 2-2.5°, pain becomes less severe, a feeling of chest fullness appears, general weakness increases, appetite disappears.

On percussion, dullness is noted, its border is higher at the back, lower at the front (Demoiseau line), above and medially the dullness is a clear percussion sound in an area resembling a triangle in shape, which corresponds to the contour of the lung, pressed by the effusion to its gate.

The accumulation of pus leads to a displacement of the mediastinum to the healthy side, so at the bottom of the spine on the healthy side there is a triangular dullness above the displaced mediastinal organs. Cardiac dullness is shifted by exudate to the healthy side. With left-sided pleurisy with a large amount of effusion, the diaphragm lowers, and therefore Traube’s space disappears.

On auscultation, in the area of ​​dullness there are completely no respiratory sounds; above the dullness, weakened breathing and pleural friction noise are detected. Blood changes are characterized by a decrease in the percentage of hemoglobin, an increase in the number of leukocytes, neutrophilia with a shift to the left, and an acceleration of ROE.

Often acute purulent pleurisy develops from the very beginning of the disease as encysted, which is explained by the presence of pleural adhesions and adhesions due to previous diseases. Localization, combination of cavities and their sizes can be very diverse.

Schematically, pleurisy can be divided into basal, parietal, paramediastinal, apical, interlobar, single and multiple.

General clinical manifestations with encysted pleurisy are almost the same as with free ones, but somewhat less pronounced. There is a poor general condition, localized pain in chest, cough, high temperature, leukocytosis with neutrophilia, etc. Percussion and auscultation data can be obtained only with apical and parietal localization of the process.

Complications of purulent pleurisy. If the pleural cavity is not sufficiently cleared of pus, the latter finds its way into the muscle beds and subcutaneous tissue of the chest wall, most often along the mid-axillary line. With purulent inflammation of the visceral pleura, the process spreads along the lymphatic pathways, involving the cortical sections of the pulmonary parenchyma, and then the deeper sections of the lung with the lymph nodes of the root.

With long-term purulent pleurisy, the wall of the bronchus can melt with the formation of a bronchopleural fistula; when the lung collapses, irreversible sclerotic processes develop in it.

Diagnostics. Difficulties in diagnosing purulent pleurisy occur in cases where it develops against the background of unresolved pneumonia or a lung abscess. Great importance To clarify the diagnosis, an X-ray examination is necessary to establish the presence of homogeneous darkening of the pleural cavity, the level of fluid in the pleura, the state of compressed lung tissue, the degree of displacement of the heart and blood vessels, the boundaries of pus and the airy lung tissue above it. If there is an inflammatory process in the compressed lung, then focal shadows are visible against the background of the lung tissue. On the affected side, the diaphragm is motionless. With free empyema, the costophrenic sinus is not visible. If clearing is noted in its area, this allows us to suspect the presence of encysted pleurisy. Dynamic radiological observation is especially important.

To clarify the diagnosis, a test puncture of the pleural cavity is crucial, which makes it possible to determine the nature of the effusion and bacteriologically examine it.

Acute purulent pleurisy must be differentiated from a lung abscess, suppurating cyst, subphrenic abscess, suppurating echinococcus, lung cancer with perifocal inflammation and effusion, interstitial pneumonia of the lower lobe, etc.

It is especially difficult to distinguish an abscess from encysted pleurisy. An important differential sign is a cough with large amounts of foul-smelling sputum, which is characteristic of an abscess. Auscultation with an abscess shows a rather motley picture: sometimes bronchial, sometimes weakened breathing, dry and moist wheezing. With pleurisy, breathing sounds are weakened or absent. Radiologically, with an abscess, a rounded shadow with a distinct lower border is observed; with pleurisy bottom line not determined. Pleurisy is characterized by displacement of the mediastinum, filling of the costophrenic sinus, and changes in the fluid level when changing position.

With festering cysts, in contrast to pleurisy, the general condition of patients suffers less; there is a cough with copious discharge sputum; on X-ray examination, the cyst is characterized by rounded contours of the shadow and clearing in the costophrenic sinus.

A distinctive feature of the clinical picture of a subdiaphragmatic abscess is the significant severity of pain and muscle tension in the right hypochondrium, often an enlarged liver, and the appearance of jaundice. The history includes indications of influenza, pneumonia or some purulent disease. An X-ray examination reveals clearing of the costophrenic sinus; a gas bubble is sometimes visible above the fluid level.

The development of sympathetic pleurisy with serous effusion significantly complicates differential diagnosis. In these cases, a diagnostic puncture is of great help. Detection of pus during puncture through the diaphragm and serous fluid with a higher puncture of the pleura, it convinces of the presence of a subdiaphragmatic abscess. The deep location of the encysted abscess with interlobar empyema makes diagnosis extremely difficult. X-ray examination allows us to establish the presence of triangular or fusiform tissue located along the interlobar fissure. However, it should be borne in mind that such a shadow can be caused by a lesion of the middle lobe on the right or the lingular segment on the left.

Apical empyemas are difficult to distinguish from apical lung cancer. With a basal location of the abscess, it is difficult to determine the supra- or subphrenic accumulation of pus. X-ray examination and test puncture are of decisive importance.

Treatment. Since acute purulent pleurisy is most often a secondary disease, its treatment can only be successful with simultaneous treatment primary disease.

All methods of treating purulent pleurisy are essentially aimed at reducing intoxication, increasing the immunobiological forces of the body, eliminating hypoxemia and improving the functioning of vital organs.

A). Conservative treatment of pleurisy: antibiotic therapy (parenterally and locally with repeated punctures). The punctures are repeated, the pus is removed and broad-spectrum antibiotics are introduced into the pleural cavity with a preliminary determination of the sensitivity of the flora. The puncture is performed in compliance with all rules of asepsis under local anesthesia. The point of greatest dullness is preliminarily determined. According to the instructions available in the literature and data from our clinic, purulent pleurisy is cured in 75% of patients by repeated punctures.

Much attention should be paid to detoxification and restorative therapy (blood transfusion, plasma, protein substitutes, glucose, administration of vitamins, high-calorie nutrition, etc.). Oxygen therapy, cardiac and sedatives are used according to indications.

b) Surgical treatment. Closed and open surgical methods are used. Both methods have the goal of creating unfavorable conditions for the development of infection by removing pus and creating favorable conditions for tissue regeneration.

1. When closed operative method drainage is inserted into the pleura through the intercostal space, the outer end of the drainage is connected to a device for constant active aspiration of pus (water-jet pump, three-flask suction device, etc.).

Drainage can be inserted into the pleura and through the bed of the resected rib. In this case, the soft tissues around the drainage are sutured, fixed to the skin, and the outer end is attached to a device for active aspiration.

If there is no apparatus for active aspiration, then a valve made from the finger of a rubber glove is placed on the end of the drainage and lowered into a bottle of antiseptic liquid suspended below the patient.

2. With the open surgical method, the pleura is widely opened through the bed of the resected rib. A wide drainage is inserted into the pleural cavity without connecting it to the suction apparatus. This method is now rarely used.

Closed treatment methods have the advantage that after removal of pus, negative pressure is formed in the pleural cavity. This promotes rapid expansion of the lung, fusion of the visceral and parietal pleura and elimination of purulent inflammation.

With open methods, the air entering the pleura prevents the expansion of the lung, fixes the collapsed lung with scars, adhesions, and contributes to the development of pneumosclerosis, residual pleural cavity and chronic pleurisy. However, if there are large clots of fibrin, sequestration of lung tissue, etc. in the pleural cavity, open emptying of the cavity has advantages. After a wide thoracotomy, encysted pleurisy with multiple cavities are formed less often than with closed drainage.

The choice of method for evacuation of pus should be individual, taking into account the advantages and disadvantages of each of them.

c) Postoperative treatment. In the postoperative period, a constant outflow of pus from the cavity is ensured, infection is fought, measures are taken to increase the body's resistance and to quickly expand the lung.

Ensuring good emptying of the pleural cavity from pus requires constant monitoring of the condition of the drainage and regular x-ray monitoring of the amount of fluid in the pleural cavity. It is necessary to strive for complete evacuation of pus whenever possible. The exudate should be sucked out slowly, since rapid emptying can lead not only to hyperemia ex vasio, but also to a sharp displacement of the mediastinum, which will cause severe disturbances of cardiac and respiratory functions.

Antibiotic therapy is carried out taking into account the sensitivity of the microflora; on the first day after surgery, the doses of antibiotics should be large. They are administered both intramuscularly and locally using a puncture at the upper point of the purulent cavity.

To reduce intoxication and increase immunobiological strength, blood and plasma transfusions are performed, glucose and vitamins are administered, and high-calorie nutrition is provided. Great value for early lung expansion has therapeutic breathing exercises.

Handbook of Clinical Surgery, 1967.

In the structure of infectious-inflammatory pathology of the respiratory tract in separate group includes diseases that are accompanied by the release of pus from the lungs. They are quite serious and require increased attention. Why such a situation may arise in a child, how it manifests itself and what is required to eliminate the purulent focus are the main issues that require consideration.

Purulent diseases are spoken of in the context of bacterial damage to the lower respiratory tract - the lungs and bronchial tree. Normally, these sections are sterile, that is, they do not contain microbes (even saprophytic ones). But in some cases, the protective mechanisms of the respiratory tract weaken, and bacteria appear on its surface. This is facilitated by:

• Viral infections (influenza, respiratory syncytial).
• Foreign bodies in the bronchi.
• Structural anomalies (dysplasia, ectasia).
• Defects in mucociliary clearance.
• Penetrating chest wounds.

The leading role in the development of purulent lung disease belongs to Staphylococcus aureus, pneumococcus, anaerobes (Klebsiella, Bacteroides, Fusobacterium, Peptostreptococcus), and Pseudomonas aeruginosa. Most often they enter by airborne droplets, but can come through the bloodstream (hematogenously), through aspiration of gastric contents or open damage to the lung tissue.

Diseases in which pus is likely to be discharged with sputum are quite diverse. They include the following infectious processes:

• Exacerbation of chronic obstructive pulmonary disease (COPD).
• Bronchiectasis.
• Lung abscess.
• Gangrene.

This group also includes festering cysts. And if we also consider specific infections, then purulent melting of lung tissue is often found in tuberculosis (fibrous-cavernous and caseous pneumonia).

Of no small importance in the development of bacterial infection in adults and children is the reduction of not only local, but also general reactivity of the body. Therefore, the risk group includes patients who often suffer from respiratory diseases, immunodeficiencies, blood diseases, smokers and alcohol abusers. Chronic processes in the ENT organs (tonsillitis, sinusitis) In addition, pay attention to material and living conditions and the nature of nutrition.

Against the background of a decrease in local and general resistance and taking into account other factors listed above, bacteria begin to multiply on the mucous membrane of the respiratory tract and in the alveoli. For anaerobic destruction, the determining factor is disturbances in the ventilation and drainage function of the bronchial tree. Purulent melting of the lung tissue is always preceded by a period of inflammatory infiltration, and against the background of pneumonia, decay cavities are already formed.

There are many reasons why pus accumulates in the lungs. And all conditions accompanied by a similar sign require differential diagnosis.

Symptoms

Every disease has its own manifestations. It is the clinical picture that becomes the basis for a preliminary diagnosis. The doctor interviews the patient about complaints and features of the pathology, and then conducts a physical examination. Inspection, palpation (feeling), auscultation (listening) and percussion (tapping) are methods that allow you to obtain objective information about what is happening.

Exacerbation of obstructive bronchitis

Obstructive disease is an infectious and inflammatory process that affects the bronchi and lungs, which is characterized by progressive ventilation problems. It develops gradually in patients over 40 years of age who smoke for a long time. Clear signs of bronchial obstruction include:

• Constant unproductive cough throughout the day.
• Steadily increasing shortness of breath.
• Barrel-shaped chest.

In patients, exhalation is prolonged; auscultation reveals harsh breathing with scattered dry rales. If the chronic inflammatory process worsens, the temperature rises, the amount of sputum increases, it becomes purulent, and shortness of breath increases. The long course of the disease is accompanied by respiratory failure (pallor, acrocyanosis) and the formation of a “pulmonary heart.”

Bronchiectasis

Local enlargements of the bronchial wall (bronchiectasis) mainly occur in children or young adults. The disease is accompanied by a chronic cough with the release of large amounts of purulent sputum, especially in the morning. In addition, the clinical picture will include:

• Hemoptysis.
• Dyspnea.
• Chest pain.
• Fever.

There is an unpleasant odor (purulent or foul) coming from the mouth. The development of bacterial flora is accompanied by an intoxication syndrome - patients are worried about weakness and fatigue, irritability, and headaches. Children with bronchiectasis often lag behind their peers in physical development and perform worse at school.

Due to secondary obstructive changes and a decrease in the volume of lung tissue (atelectasis, fibrosis), respiratory failure develops. Skin and mucous membranes turn pale (anemia), stress tolerance decreases, fingers become deformed (the terminal phalanges become like drumsticks, and the nails resemble watch glasses). A physical examination reveals harsh breathing and wheezing, which disappears after clearing the throat.

Pus released when coughing can accumulate in dilated areas of the bronchial tree - ectasia.

Lung abscess

An abscess is another purulent lung disease. This is a cavity surrounded by a capsule of granulations, fibrin and connective tissue. And inside there is exudate and melted tissue in the form of pus. There is reactive infiltration around the lesion or due to previous pneumonia.

Lung abscess begins acutely. The formation of an abscess is accompanied by severe fever (hectic) with heavy sweats and intoxication. Patients complain of chest pain, shortness of breath, and an annoying dry cough. After the abscess breaks through into the bronchus, the general condition improves: the temperature drops and pain decreases. A characteristic sign will be coughing up a large volume of purulent sputum (mouth full).

If the abscess is poorly drained, then intoxication continues to increase, shortness of breath increases, and the patient becomes exhausted. The skin becomes pale with a grayish tint, the fingers gradually take on the shape of " drumsticks" In such cases, complications may develop in the form of hemoptysis or pneumothorax. And after the acute phenomena have stopped, there is Great chance abscess chronicity.

Gangrene

Gangrene differs from an abscess in a more widespread process (necrosis) and a severe course. Sometimes the symptoms of the disease, on the contrary, do not correspond to changes in the lung tissue, becoming erased and unexpressed. However, in most cases, from the very first day, patients experience hectic fever and rapidly increasing intoxication.

Chest pain, shortness of breath, and cough appear. The breakthrough of caseous masses into the bronchus is accompanied by the release of copious gray foul-smelling sputum. Percussion reveals a wide zone of dullness with areas of higher sound (disintegration zones). The auscultatory picture is characterized by weakening of breathing, it acquires a bronchial hue. Gangrene is often complicated by pleural empyema or pyopneumothorax. There is a possibility of pathogens spreading into the blood with the development of sepsis.

Additional diagnostics

A purulent process in the lung can be assumed based on clinical data, but additional methods can confirm it. Laboratory and instrumental procedures help to clarify the pathogen and find out the nature of the disease:

• General blood test (leukocytosis, shift of the formula to the left, toxic granularity of neutrophils, acceleration of ESR).
• Blood biochemistry (indicators of the acute phase of inflammation, liver tests, protein, coagulation and immunogram).
• Sputum analysis (cytology, culture, antibiotic sensitivity).
• Chest X-ray.
• Bronchography and bronchoscopy.
• CT scan.
• Spirometry.

Electrocardiography and cardiac ultrasound are also becoming necessary diagnostic elements. And having established the reason why pus accumulates in the lungs, you can begin to treat the pathology.

During additional diagnostics, the causative agent of the infection, the nature of the disease and accompanying changes are determined.

Treatment

It is necessary to eliminate a purulent focus in the bronchial tree or lung tissue as early as possible, before dangerous complications develop. The impact should be comprehensive, using conservative and operational measures.

Conservative

First of all, you need to try to strengthen the body’s protective properties and improve your general condition. The patient is prescribed a nutritious diet containing increased amounts of protein and vitamins. At acute processes bed rest is indicated, and severe patients require care. Respiratory failure is treated by inhaling humidified oxygen.

But medications play a key role in conservative treatment. The importance of antibacterial therapy to combat infectious agents cannot be overestimated. To effectively treat purulent processes, use various groups antimicrobial agents:

• Penicillins.
• Cephalosporins.
• Fluoroquinolones.
• Macrolides.

Infusion support is required to perform the functions of detoxification, rehydration, correction of water-electrolyte and acid-base balance, and replenishment of protein deficiency. Complex therapy also includes expectorants, bronchodilators, immunomodulators, and vitamins.

To improve the drainage of pus from the lungs, breathing exercises are indicated, and patients are taught postural drainage. But in more severe cases, it is necessary to perform therapeutic bronchoscopy aimed at aspiration of exudate, washing the cavities with antibiotics, antiseptics and fibrinolytics.

Operational

If conservative measures are ineffective, medicinal substances into the lungs and drain purulent cavities using minimally invasive operations. They include microthoracentesis and microtracheostomy, when a thin catheter is inserted into the pathological lesion through an opening in the chest wall or trachea, respectively. If this does not help, then they move on to videothoracoscopy or dissection of the abscess with open drainage. And extensive decay cavities require radical interventions (resection of a segment, lobe, removal of the entire lung).

Purulent lung diseases are serious conditions, which sometimes hide a real danger for children and adults. Noticing alarming symptoms, you must contact us immediately medical care. After the diagnosis, the doctor will prescribe adequate treatment infectious process.