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This article is about the disease, also known as pleuritis. For the plant known as pleurisy root, see butterfly weed
Pleurisy
Classification and external resources
ICD-10 J90., R09.1
ICD-9 511
DiseasesDB 29361
MeSH D010998

Pleurisy, also known as pleuritis, is an inflammation of the pleura,[1] the lining of the pleural cavity surrounding the lungs. Among other things, infections are the most common cause of pleurisy.

The inflamed pleural layers rub against each other every time the lungs expand to breathe in air. This can cause sharp pain with breathing (also called pleuritic chest pain).

Contents

Symptoms

The main symptom of pleurisy is a sharp or stabbing pain in the chest that gets worse with deep breathing, coughing or sneezing. The pain may stay in one place, or it may spread to the shoulder or back. Sometimes it becomes a fairly constant dull ache.

Depending on what's causing the pleurisy, one may have other symptoms:

Causes

Viral infection is the most common cause of pleurisy. However, many different conditions can cause pleurisy:

Some cases of pleurisy are idiopathic, meaning the cause cannot be determined.

Diagnosis

A diagnosis of pleurisy or another pleural condition is based on medical histories, physical exams, and diagnostic tests. The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so the underlying disorder can be treated.

Physical exam

A doctor uses a stethoscope to listen to the breathing. This detects any unusual sounds in the lungs. A person with pleurisy will have inflamed layers of the pleura that make a rough, scratchy sound as they rub against each other during breathing. This is called pleural friction rub, and it is a likely sign of pleurisy.

Diagnostic tests

Depending on the results of the physical exam, diagnostic tests are sometimes performed.

Chest x-ray

A chest x-ray takes a picture of the heart and lungs. It may show air or fluid in the pleural space. It also may show what's causing the pleurisy –for example, pneumonia, a fractured rib, or a lung tumor.

Sometimes an x-ray is taken while lying on the painful side. This may show fluid that did not appear on the standard x-ray taken while standing.

Computed tomography (CT) scan

A CT scan provides a computer-generated picture of the lungs that can show pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor.

Ultrasound

Ultrasonography uses sound waves to create pictures of the lungs. It may show where fluid is located in the chest. It also can show some tumors.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI), also called nuclear magnetic resonance (NMR) scanning, uses powerful magnets and radio waves to show pleural effusions and tumors.

Blood tests

Blood tests can detect bacterial or viral infection, pneumonia, rheumatic fever, a pulmonary embolism, or lupus.

Arterial blood gas

In arterial blood gas sampling, a small amount of blood is taken from an artery, usually in the wrist. The blood is then checked for oxygen and carbon dioxide levels. This test shows how well the lungs are taking in oxygen.

Thoracentesis
The illustration shows a person having thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag.

Once the presence and location of fluid is confirmed, a sample of fluid can be removed for testing. The procedure to remove fluid in the chest is called thoracentesis. The doctor inserts a small needle or a thin, hollow, plastic tube through the ribs in the back of the chest into the chest wall and draws fluid out of the chest.

Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is used to guide the needle to the fluid that is trapped in small pockets around the lungs.

Thoracentesis usually does not cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following:

  • Pneumothorax, or buildup of air in the pleural space, with a collapsed or partially collapsed lung. Sometimes air comes in through the needle or the needle makes a hole in the lung. Usually, a hole will seal itself. But sometimes air can build up around the lung and make it collapse. A chest tube can remove the air and let the lung expand again.
  • Pain.
  • Bleeding and bruising where the needle went in. In rare cases, bleeding may occur in or around the lung. The doctor can use a chest tube to drain the blood. In some cases, surgery is needed.
  • Infection where the needle went in.
  • Rarely, liver or spleen injury.

The fluid removed by thoracentesis is examined under a microscope. It is evaluated for the presence of chemicals and for its color, and texture. The clearness of the fluid is an indicator of infection, cancer, or other conditions that may be causing the buildup of fluid or blood in the pleural space.

Biopsy

If tuberculosis or cancer is suspected, a small piece of the pleura may be examined under a microscope to make a definitive diagnosis. This is called a biopsy.

Several approaches to taking tissue samples are available

  1. Insertion of a needle through the skin on the chest to remove a small sample of the outer layer of the pleura.
  2. Insertion of a small tube with a light on the end (endoscope) into tiny cuts in the chest wall in order to visualize the pleura. Small pieces of tissue can be biopsied though the endoscope.
  3. remove a sample of the pleura through a small cut in the chest wall. This is called an open pleural biopsy. It is usually done if the sample from the needle biopsy is too small for an accurate diagnosis.

Treatment

Treatment has several goals:

  • Remove the fluid, air, or blood from the pleural space
  • Relieve symptoms
  • Treat the underlying condition

Procedures

If large amounts of fluid, air, or blood are not removed from the pleural space, they may put pressure on the lung and cause it to collapse.

The surgical procedures used to drain fluid, air, or blood from the pleural space are as follows:

  • During thoracentesis, a needle or a thin, hollow, plastic tube is inserted through the ribs in the back of the chest into the chest wall. A syringe is attached to draw fluid out of the chest. This procedure can remove more than 6 cups (1.5 liters) of fluid at a time.
  • When larger amounts of fluid must be removed, a chest tube may be inserted through the chest wall. The doctor injects a local painkiller into the area of the chest wall outside where the fluid is. A plastic tube is then inserted into the chest between two ribs. The tube is connected to a box that suctions the fluid out. A chest x-ray is taken to check the tube's position.
  • A chest tube also is used to drain blood and air from the pleural space. This can take several days. The tube is left in place, and the patient usually stays in the hospital during this time.
  • Sometimes the fluid contains thick pus or blood clots, or it may have formed a hard skin or peel. This makes it harder to drain the fluid. To help break up the pus or blood clots, the doctor may use the chest tube to put certain medicines into the pleural space. These medicines are called fibrinolytics. If the pus or blood clots still do not drain out, surgery may be necessary.

Medications

A couple of medications are used to relieve pleurisy symptoms:

There may be a role for the use of corticosteroids (for tuberculous pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of pleurisy. Further studies are needed.

Lifestyle changes

The following may be helpful in the management of pleurisy:

  • Lying on the painful side may be more comfortable
  • Breathing deeply and coughing to clear mucus as the pain eases. Otherwise, pneumonia may develop.
  • Getting rest

Treating the cause

Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease.

  • If the pleural fluid is infected, treatment involves antibiotics and draining the fluid. If the infection is tuberculosis or from a fungus, treatment involves long-term use of antibiotics or antifungal medicines.
  • If the fluid is caused by tumors of the pleura, it may build up again quickly after it is drained. Sometimes antitumor medicines will prevent further fluid buildup. If they don't, the doctor may seal the pleural space. This is called pleurodesis. Pleurodesis involves the drainage of all the fluid out of the chest through a chest tube. A substance is inserted through the chest tube into the pleural space. This substance irritates the surface of the pleura. This causes the two layers of the pleura to squeeze shut so there is no room for more fluid to build up.
  • Chemotherapy or radiation treatment also may be used to reduce the size of the tumors.
  • If congestive heart failure is causing the fluid buildup, treatment usually includes diuretics and other medicines.

The most common and known treatment for pleurisy is generally to carry on as normal, ibuprofen is the only prescription given by doctors. Milder forms of Pleurisy can be noticed by less inflammatres of the arms and legs. If this is the case Pleurisy will clear of all symptoms within two weeks.

Alternative treatments

A number of alternative or complementary medicines are being investigated for their anti-inflammatory properties, and their use in pleurisy. At this time, clinical trials of these compounds have not been performed.

Extracts from the Brazilian folk remedy Wilbrandia ebracteata ("Taiuia") have been shown to reduce inflammation in the pleural cavity of mice.[3][4] The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs.[4] Similarly, an extract from the roots of the Brazilian Petiveria alliacea plant reduced inflammation in a rat model of pleurisy.[5] The extract also reduced pain sensations in the rats. An aqueous extract from Solidago chilensis has been shown to reduce inflammation in a mouse model of pleurisy.[6]

Pleurisy root

Pleurisy root, or butterfly weed, was so named because it was used by Native Americans to treat pleurisy. The root was said to encourage coughing by thinning the mucus in the lungs. Pleurisy root is not used much today because more effective medicines are available.

Related problems

Pleurisy is often associated with complications that affect the pleural space.

Pleural effusion

In some cases of pleurisy, excess fluid builds up in the pleural space. This is called a pleural effusion. The buildup of fluid usually forces the two layers of the pleura apart so they don't rub against each other when breathing. This can relieve the pain of pleurisy. A large amount of extra fluid can push the pleura against the lung until the lung, or a part of it, collapses. This can make it hard to breathe.

In some cases of pleural effusion, the extra fluid gets infected and turns into an abscess. This is called an empyema.

Pleural effusion involving fibrinous exudates in the fluid may be called fibrous pleurisy. It sometimes occurs as a later stage of pleurisy.

A person can develop a pleural effusion in the absence of pleurisy. For example, pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural effusion.

Pneumothorax

Air or gas also can build up in the pleural space. This is called a pneumothorax. It can result from acute lung injury or a lung disease like emphysema. Lung procedures, like surgery, drainage of fluid with a needle, examination of the lung from the inside with a light and a camera, or mechanical ventilation, also can cause a pneumothorax.

The most common symptom is sudden pain in one side of the lung and shortness of breath. A pneumothorax also can put pressure on the lung and cause it to collapse.

If the pneumothorax is small, it may go away on its own. If large, a chest tube is placed through the skin and chest wall into the pleural space to remove the air.

Hemothorax

Blood also can collect in the pleural space. This is called hemothorax. The most common cause is injury to the chest from blunt force or surgery on the heart or chest. Hemothorax also can occur in people with lung or pleural cancer.

Hemothorax can put pressure on the lung and force it to collapse. It also can cause shock, a state of hypoperfusion in which an insufficient amount of blood is able to reach the organs.

Prognosis

Pleurisy and other disorders of the pleura can be serious, depending on what caused the inflammation in the pleura.

If the condition that caused the pleurisy or other pleural disorders isn't too serious and is diagnosed and treated early, you usually can expect a full recovery.

Famous cases

References in literature

References

  1. ^ pleurisy at Dorland's Medical Dictionary
  2. ^ Klein RC (October 1984). "Effects of indomethacin on pleural pain". South. Med. J. 77 (10): 1253–4. PMID 6207594. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0038-4348&volume=77&issue=10&spage=1253. 
  3. ^ Peters RR, Saleh TF, Lora M, et al. (1999). "Anti-inflammatory effects of the products from Wilbrandia ebracteata on carrageenan-induced pleurisy in mice". Life Sci. 64 (26): 2429–37. PMID 10403502. http://linkinghub.elsevier.com/retrieve/pii/S0024320599002003. 
  4. ^ a b Siqueira JM, Peters RR, Gazola AC, et al. (March 2007). "Anti-inflammatory effects of a triterpenoid isolated from Wilbrandia ebracteata Cogn". Life Sci. 80 (15): 1382–7. doi:10.1016/j.lfs.2006.12.021. PMID 17286991. 
  5. ^ Lopes-Martins RA, Pegoraro DH, Woisky R, Penna SC, Sertié JA (April 2002). "The anti-inflammatory and analgesic effects of a crude extract of Petiveria alliacea L. (Phytolaccaceae)". Phytomedicine 9 (3): 245–8. PMID 12046866. 
  6. ^ Goulart S, Moritz MI, Lang KL, Liz R, Schenkel EP, Fröde TS (September 2007). "Anti-inflammatory evaluation of Solidago chilensis Meyen in a murine model of pleurisy". J Ethnopharmacol 113 (2): 346–53. doi:10.1016/j.jep.2007.07.003. PMID 17686594. 
  7. ^ Einhard, The Life Of Charlemagne (University of Michigan Press, 5th edition, 1964) at p. 59
  8. ^ The Autobiography of Benjamin Franklin
  9. ^ [1]
  10. ^ [2]
  11. ^ Timeline of Carson McCullers' Life
  12. ^ Templier, Pierre-Daniel, Erik Satie. Translated by Elena L. French and David S. French. Cambridge: MA Institute of Technology, 1969. 51-53.
  13. ^ Myers, F.W.H. (2006). Wordsworth. BiblioBazaar, LLC. pp. 177. ISBN 1426432267. http://books.google.com/books?id=Re-Kjc3RT5sC&pg=PA177&dq=wordsworth+Pleurisy&sig=LaKdRxXuaHhKhgOwno1v5Zr81so. 

External links


1911 encyclopedia

Up to date as of January 14, 2010

From LoveToKnow 1911

Medical warning!
This article is from the 1911 Encyclopaedia Britannica. Medical science has made many leaps forward since it has been written. This is not a site for medical advice, when you need information on a medical condition, consult a professional instead.

PLEURISY, or Pleuritis (Gr. it?eupa=ribs), inflammation of the pleura, caused by invasion by certain specific microorganisms. (See Respiratory System: Pathology.) Secondary pleurisies may occur from extension of inflammation from neighbouring organs.

The morbid changes which the pleura undergoes when inflamed consist of three chief conditions or stages of progress. (I) Inflammatory congestion and infiltration of the pleura, which may spread to the tissues of the lung on the one hand, and to those of the chest wall on the other. (2) Exudation of lymph on the pleural surfaces. This lymph is of variable consistence, sometimes composed of thin and easily separated pellicles, or of extensive thick masses or strata, or again showing itself in the form of a tough membrane. It is of greyish-yellow colour, and microscopically consists mainly of coagulated fibrin along with epithelial cells and red and white blood corpuscles. Its presence causes roughening of the two pleural surfaces, which, slightly separated in health, may now be brought into contact by bands of lymph extending between them. These bands may break up or may become organized by the development of new blood vessels, and adhering permanently may obliterate throughout a greater or less space the pleural sac, and interfere to some extent with the free play of the lungs. (3) Effusion of fluid into the pleural cavity. This fluid may vary in its characters.

The chief varieties of pleurisy are classified according to the variety of the effusion, should effusion take place. (I) Some pleurisies do not reach the stage of effusion, the inflammation terminating in the exudation of lymph. This is termed dry pleurisy. (2) Fibrinous or plastic pleurisy. In this variety the pleura is covered by a thick layer of granular, fibrinous material. Fibrinous pleurisy is usually secondary to acute diseases of the lung such as pneumonia, cancer, abscess or tuberculosis. (3) Sero-fibrinous pleurisy. This is the most common variety, and produces the condition commonly known as pleurisy with effusion. The amount may vary from an almost inappreciable quantity to a gallon or more. When large in quantity it may fill to distension the pleural sac, bulge out the thoracic wall externally, and compress the lung, which may in such cases have all its air displaced and be reduced to a mere fraction of its natural bulk. Other organs, such as the heart and liver, may in consequence of the presence of the fluid be shifted away from their normal position. In favourable cases the fluid is absorbed more or less completely and the pleural surfaces again may unite by adhesions; or, all traces of inflammatory products having disappeared, the pleura may be restored to its normal condition. When the fluid is not speedily absorbed it may remain long in the cavity and compress the lung to such a degree as to render it incapable of re-expansion as the effusion passes slowly away. The consequence is that the chest wall falls in, the ribs become approximated, the shoulder is lowered, the spine becomes curved and internal organs permanently displaced, while the affected side scarcely moves in respiration. Sometimes the unabsorbed fluid becomes purulent, and an empyema is the result.

The symptoms of pleurisy vary; the onset is sometimes obscure but usually well marked. It may be ushered in by rigors, fever and a sharp pain in the side, especially on breathing. Pain is felt in the side or breast, of a severe cutting character, referred usually to the neighbourhood of the nipple, but it may be also at some distance from the affected part, such as through the middle of the body or in the abdominal or iliac regions. On auscultation the physician recognizes sooner or later "friction," a superficial rough rubbing sound, occurring only with the respiratory acts and ceasing when the breath is held. It is due to the coming together during respiration of the two pleural surfaces which are roughened by the exuded lymph. The pain is greatest at the outset, and tends to abate as the effusion takes place. A dry cough is almost always present, which is particularly distressing owing to the increased pain the effort excites. At the outset there may be dyspnoea, due to fever and pain; later it may result from compression of the lung.

On physical examination of the chest the following are among the chief points observed: (I) On inspection there is more or less bulging of the side affected, should effusion be present, obliteration of the intercostal spaces, and sometimes elevation of the shoulder. (2) On palpation with the hand applied to the side there is diminished expansion of one-half of the thorax, and the normal vocal fremitus is abolished. Should the effusion be on the right side and copious, the liver may be felt to have been pushed downwards, and the heart somewhat displaced to the left; while if the effusion be on the left side the heart is displaced to the right. (3) On percussion there is absolute dullness over the seat of the effusion. If the fluid does not fill the pleural sac the floating lung may yield a hyper-resonant note. (4) On auscultation the natural breath sound is inaudible over the effusion. Should the latter be only partial the breathing is clear and somewhat harsh, with or without friction, and the voice sound is aegophonic. Posteriorly there may be heard tubular breathing with aegophony. These various physical signs render it impossible to mistake the disease for other maladies the symptoms of which may bear a resemblance to it, such as pleurodynia.

The absorption or removal of the fluid is marked by the disappearance or diminution of the above-mentioned physical signs, except that of percussion dullness, which may last a long time, and is probably due in part to the thickened pleura. Friction may again be heard as the fluid passes away and the two pleural surfaces come together. The displaced organs are restored to their position, and the compressed lung re-expanded. Frequently this expansion is only partial.

In most instances the termination is favourable, the acute symptoms subsiding and the fluid (if not drawn off) becoming absorbed, sometimes after reaccumulation. On the other hand it may remain long without undergoing much change, and thus a condition of chronic pleurisy becomes established.

Pleurisy may' exist in a latent form, the patient going about for weeks with a large accumulation of fluid in his thorax, the ordinary acute symptoms never having been present in any marked degree. Cases of this sort are often protracted, and their results unsatisfactory as regards complete recovery.

In the treatment of early pleurisy, pain may be relieved by a hypodermic of morphia or the application of leeches. A purgative is essential. Fixation of the affected side of the thorax by strapping with adhesive plaster gives great relief. The icebag is useful in the early stages, as in pneumonia. The open-air treatment of cases is recommended, as the majority of the cases are of tuberculous origin. When effusion has taken place, counter irritation and the exhibition of iodide of potassium are useful. Dry diet and saline purgatives have been well spoken of. The most satisfactory method of treatment is early and if necessary repeated aspiration of the fluid. The operation (thoracentesis) was practised by ancient physicians, but was revived in modern times by Armand Trousseau (1801-1867) in France and Henry I. Bowditch (1808-1892) in America; by the latter an excellent instrument was devised for emptying the chest, which, however, has been displaced in practice by the still more convenient aspirator. The chest is punctured in the lateral or posterior regions, and in most cases the greater portion or all of the fluid may be safely drawn off. In many instances not only is the removal of distressing symptoms speedy and complete, but the lung is relieved from pressure in time to enable it to resume its normal function.

In cases of chronic pleurisy after the failure of repeated aspirations, Samuel West reports well of free incision and drainage. He has reported cases of recovery of effusion, fifteen or eighteen months standing. Sir James Barr has advocated the treatment of these cases by the withdrawal of the fluid and the substitution of sterilized air and solution of supra-renal extract; others have introduced physiological salt solution or formalin solution into the cavity, after the removal of the fluid. Vaquez injects nitrogen into the cavity and reports a number of cases in which it prevented recurrence.


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