4.2. Theoretical questions:

1. What is definition and causes of syndromes of lobar and focal consolidation of lung tissue?

2. What are symptoms and signs of the lobar and focal consolidation of the lung tissue?

3. How can consolidation of the lung tissue be confirmed by instrumental examination?

4. What is definition and causes of the pleural effusion?

5. What are symptoms and signs of the pleural effusion?

6. How pleural effusion can be confirmed by instrumental examination?

7. How pleural fluid should be investigated with laboratory methods

8. What is definition and causes of the pneumothorax?

9. What are symptoms and signs of the pneumothorax?

10. What is definition and causes of the atelectasis?

11. Which types of atelectasis do you know; their distinguishing symptoms and signs?

4.3. Practical task that should be performed during practical training

1. Revealing and assessment of symptoms and signs of focal and lobar consolidation of the lung tissue

2. Revealing and assessment of symptoms and signs of pleural effusion

3. Revealing and assessment of symptoms and signs of pneumothorax

4. Revealing and assessment of symptoms and signs of atelectasis

5. Assessment of the pleural fluid analysis

Topic content

Lobar and focal consolidation of lung tissue is the complex of symptoms that appears after effect on the lung different pathogenic mechanisms resulting to pulmonary infiltrate or proliferation. The lobar consolidation involves some segments or whole lobe of lung. The focal consolidation involves small site of lung tissue.

Causes of the lobar consolidation of lung tissue:

1. Community-acquired and nosocomial pneumonia – infiltration of lung by inflammatory cells due to non specific inflammation

2. Lobar tuberculosis - infiltration of lung by inflammatory cells due to specific inflammation

3. Lobar pneumofibrosis – proliferation at lung by connective tissue

4. Lung cancer and tumor - proliferation at lung by tumorous tissue

5. Infarction-pneumonia at patients with sub-massive pulmonary embolism - infiltration of lung by blood and inflammatory cells

Causes of the focal consolidation of lung tissue

1. Community-acquired, nosocomial, aspiration pneumonia

2. Focal tuberculosis

3. Focal pneumofibrosis

4. Lung tumor

Symptoms of the focal consolidation of lung tissue: Sometimes there is breathlessness because small part of lung is involved, lung function and gas exchange is not limited.

Cough can be dry or with purulent sputum. It is depended from stage of disease.

Signs of the focal consolidation of lung tissue:

Visual examination of the chest

Sometimes there is limitation of the chest moving at the affected side.

Palpation of the chest

May be, there is a tenderness of the pleural points, positive Potendzher symptom, amplifying of voice resonance if the site of consolidation is near surface of chest.

Percussion of the chest

Comparative percussion: If site of consolidation is near of the chest surface it can be dullness of percussion sound. Because account of solid components of lung tissue increase due to infiltration but air presents in alveoli which haven’t been involved to pathological process and they get to percussion sphere. If site of consolidation is deeply in lung percussion sound is clear without change.

Topographic percussion: Some change can be if site of consolidation is near of chest surface. There is dimension of lower lung border excursion.

Auscultation of the lung

There is diminished vesicular breathing because less alveoli involve to act of breathing. There are sonorous bubbling (moist) rales. They are formed in bronchus which around by consolidated lung tissue. Such tissue conduct sounds from bronchus better then healthy and we can hear them as sonorous. Sometimes if site of consolidation is near chest surface crepitations can be heard.

X-ray signs of the focal pulmonary consolidation: There is peribronchial and perivascular and/or focal infiltration of lung tissue.

Symptoms of the lobar consolidation of lung tissue:

• Breathlessness occurs due to large injury of lung that result to diminution of it function and changing of gas content of blood.

• Chest pain happens due to involving of pleura in inflammatory process.

• Cough can be dry or with purulent bloody sputum. It is depended from stage or form of disease.

Signs of the lobar consolidation of lung tissue

Visual examination: It is severe condition of the patient. He has redness in cheek at the affected side, herpes on his lips, sometimes prefers to lie on the affected side. There is tachypnea, cyanosis.

Visual examination of the chest: There is limitation of the chest moving at the affected side. Auxiliary muscles take part in breathing.

Palpation of the chest

There is a tenderness of the pleural points, positive Potendzher symptom, because large part of lung with pleura is involved to inflammatory process and surrounded tissues react to this. It is obtained amplifying of voice resonance according to the affected lobe or segments, because consolidated lung tissue conducts acoustic waves better than normal one.

Percussion of the chest

Comparative percussion: Over the consolidated lobe the percussion sound is dull because only solid components of infiltrated lung tissue get to percussion sphere.

Topographic percussion: The lower border of the affected lung lifts up if pathological process localizes in lower lobe. The height of lung apex pulls down. But size of the lung doesn’t change. It is obtaining due to increasing of solidity of lung tissue. There is dimension of lower lung border excursion.

Auscultation of the lung

There is pathological bronchial breathing because all alveoli are filled up with inflammatory exudates, whispering pectoriloquy. There is pleural rub due to inflamed pleura rubbing against each other. You can hear depressed vesicular or bronchial breathing and crepitations in the beginning or end of pathological process.

X-ray signs of lobar pulmonary consolidation: There is intensive and homogeneous infiltration of lobe or segments.

A pleural effusion results from the accumulation of abnormal volumes (>10-20 ml) of fluid in the pleural space. According to causes of pleural effusion and content of pleural fluid there are two types – exudates and transudates.

Causes of the pleural effusion:

1. Cardiac failure

2. Pneumonia

3. Tuberculosis

4. Malignancy

5. Pulmonary embolism

6. Chest injury

7. Liver cirrhosis, pancreatitis and other

Symptoms of the pleural effusion:

It may be asymptomatic if little quantity of fluid accumulates in pleural space.

It is associated with breathlessness, dry cough, chest pain (suggesting pleural inflammation), chest “heaviness”, palpitation, if quantity of fluid is large (more than 400-500 ml).

Signs of the pleural effusion:

Visual examination

It is a severe condition of the patient. There is tachypnea, cyanosis and limitation of the chest moving at the affected side. Patient prefers to lie on the affected side because it facilitates his breathing.

Palpation of the chest

It is obtained reduced or absent tactile vocal fremitus, because fluid damps acoustic waves, and increased chest resistance. Sometimes, may be positive Potendzher symptom.

Percussion of the chest

Comparative percussion: It is dullness over fluid.

Topographic percussion: Lower lung border has shape named Ellis-Damuazo line which begins near column and rises to scapular then descends to axillary region and continues horizontally. This shape of line makes conditional upon different property of lung tissue to be squeezed.

Auscultation of the lung

There are no any sounds over the fluid. But sometimes may be diminished vesicular breathing if it is little quantity of fluid. You can hear diminished bronchial breathing if quantity of fluid much and squeezed lung has similar density as fluid. Above the fluid it is diminished vesicular breathing and, sometimes, pleural rub.

X-ray signs of the pleural effusion: It is usually detected effusion volumes of 200 ml or more by posterior-anterior position. Lateral chest X-ray is more sensitive and may detect as little as 50 ml pleural fluid. Classical chest X-ray appearance is of basal opacity obscuring hemidiaphragm, with concave upper border. Massive effusion may result in a ‘white-out’ of the hemithorax, with mediastinal displacement away from the effusion. Lack of the mediastinal shift in such cases raises the possibility of associated volume loss due to bronchial obstruction from a primary lung cancer.

Ultrasound is extremely sensitive at detecting fluid volumes of 100 ml or more, and is useful for distinguishing pleural fluid from pleural masses or thickening, and for demonstrating loculation.

Laboratory assessment of pleural fluid:

1. Common – visual assessment, comparative density, Rivalt test

2. Biochemistry for measurement of protein, LDH, glucose, cholesterol, triglycerides, amylase, depending on the clinical circumstances.

3. Cytology for examination for malignant cells and differential cell count

4. Microbiology for Gram stain and microscopy, culture, MBT examination