pulmoПульмонологияPULMONOLOGIYA0869-01892541-9617Scientific and Practical Journal “PULMONOLOGIYA” LLC10.18093/0869-0189-2020-30-6-798-804pulmo-2215Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL STUDIESЛечебно-диагностическая тактика при плевральных выпотах различной этиологии в зависимости от коморбидного фонаThe impact of comorbidities on diagnosis and treatment of pleural effusions of various originshttps://orcid.org/0000-0001-8108-1655ПлаксинС. А.PlaksinS. A.

Плаксин Сергей Александрович - доктор медицинских наук, профессор кафедры хирургии с курсом сердечно-сосудистой хирургии и интервенционной кардиологии.

614000, Пермь, ул. Петропавловская, 26; тел.: (342) 276-10-98

Sergey A. Plaksin - Doctor of Medicine, Professor, Department of Surgery with a course of cardiovascular surgery and interventional cardiology.

Ul. Petropavlovskaya 26, Perm', 614990; tel.: (342) 276-10-98

splaksin@mail.ruhttps://orcid.org/0000-0002-4021-8595ФаршатоваЛ. И.FarshatovaL. I.

Фаршатова Лилия Ильдусовна - кандидат медицинских наук, ассистент кафедры хирургии с курсом сердечно-сосудистой хирургии и интервенционной кардиологии.

614000, Пермь, ул. Петропавловская, 26; тел.: (342) 276-10-98

Liliya I. Farshatova - Candidate of Medicine, Assistant, Department of Surgery with a course of cardiovascular surgery and interventional cardiology.

Ul. Petropavlovskaya 26, Perm', 614990; tel.: (342) 276-10-98

farshatovalilija@mail.ruФедеральное государственное бюджетное образовательное учреждение высшего образования Пермский государственный медицинский университет имени академика Е.А. Вагнера Министерства здравоохранения Российской ФедерацииРоссияАcademician E.A. Vagner Perm' State Medical University, Healthcare Ministry of RussiaRussian Federation202023122020306798804Copyright © Плаксин С.А., Фаршатова Л.И., 20202020Плаксин С.А., Фаршатова Л.И.Plaksin S.A., Farshatova L.I.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.pulmonology.ru/pulm/article/view/2215

Частота коморбидной патологии увеличивается, ее характер с возрастом меняется, а степень тяжести оценивается при помощи различных шкал.

Целью исследования явились особенности хирургической тактики при плевральных выпотах различной этиологии в зависимости от коморбидного фона.

Материалы и методы

Материалы и методы. Изучена коморбидная патология у пациентов (n = 425) с плевральным выпотом различной природы с оценкой по индексам Чарлсона, Карновского, Восточной совместной онкологической группы (Eastern Cooperative Oncology Group — ECOG). Для диагностики и лечения использовались плевральные пункции, дренирование плевральной полости и видеоторакоскопия (ВТС) с биопсией плевры.

Результаты

Результаты. В возрастной группе до 49 лет среди сопутствующей патологии преобладали вирус иммунодефицита человека, хронические гепатиты и заболевания желудочно-кишечного тракта, после 50 лет — патология сердечно-сосудистой системы и сахарный диабет. Индекс Чарлсона в группе больных в возрасте до 39 лет составил 2,6 ± 2,5; 60-69 лет - 7,9 ± 2,7; старше 70 лет — 9,5 ± 2,5. Плевральные пункции использовались у ослабленных больных с малыми и средними выпотами при индексе Карновского < 40 % и ECOG 3—4 балла (n = 34), дренирование плевральной полости — у тяжелых реанимационных больных с большими выпотами без фрагментации (n = 33). Выполнялась ВТС с биопсией плевры (n = 355) с интраоперационным плевродезом инсуффляцией порошка талька (n = 135) и марочным нанесением на плевру трихлоруксусной кислоты (n = 19). Умерли 17 (4 %) пациентов от прогрессирования и декомпенсации основного заболевания, один из них — от инфаркта миокарда. Индекс Чарлсона у пациентов с летальным исходом составил 9,4 ± 3,9, у выживших — 6,9 ± 3,1.

Заключение

Заключение. Декомпенсированная основная и коморбидная патология, возраст старше 60 лет, индекс коморбидности Чарлсона > 8 и неблагоприятный прогноз при плевральных выпотах различной этиологии служат показанием к проведению максимально консервативных лечебно-диагностических мероприятий.

Relevance

Relevance. The incidence comorbidities increases and and types of comorbidities change with the patient’s age. The severity can be assessed using multiple scales. The aim of this study was to identify the specifics of surgical intervention tactics to be used for treatment of pleural effusions of various etiologies, depending on comorbidities.

Methods

Methods. Comorbid pathology was assessed in 424 patients with pleural effusions of various origins using three indices developed by Charlson, Karnovsky, and the European Joint Oncological Group (ECOG). Thoracentesis, drainage of the pleural cavity, and videothoracoscopy with pleural biopsy were used for diagnosis and treatment.

Results

Results. HIV, chronic hepatitis, and diseases of the gastrointestinal tract represented the most common comorbid pathologies in patients below the age of 49; cardiovascular diseases and diabetes mellitus were the most common comorbidities in patients after the age of 50. The Charlson's index was 2.6 ± 2.5 for patients younger than 39, 7.9 ± 2.7 for patients in the age range between 60 and 69, and 9.5 ± 2.5 for patients who were older than 70. 34 patients underwent pleural punctures as treatment of small and medium effusions with the Karnowski index less than 40 % and ECOG of 3 — 4 points; 33 resuscitated patients with more severe pathology underwent pleural cavity drainage due to large effusions without fragmentation. 355 patients underwent video thoracoscopy with pleural biopsy; 135 patients received intraoperative pleurodesis by insufflation of talcum powder, and 19 patients had trichloroacetic acid applied to the pleura. 17 (4%) patients died from worsening of the underlying disease and decompensation, including one case of myocardial infarction. Patients with fatal outcome had the Charlson's index of 9.4 ± 3.9, and survivors — 6.9 ± 3.1.

Conclusion

Conclusion. Worsening of main pathology and comorbidities, age over 60, Charlson's comorbidity index higher than 8, and an unfavorable prognosis for pleural effusions of various origins serve as an indication for the most conservative diagnostic and treatment approach.

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The authors declare that there are no conflicts of interest present.