BRONCHIECTASIAS (bronchial tube[s] + grech, ektasis extension; synonym bronchietasia) — the inborn or acquired pathological expansions of limited sites of bronchial tubes with structural change of their walls. The anatomic changes of a wall and a mucous membrane of a bronchial tube always taking place at B. distinguish them from the reversible (functional) bronchiectasias observed at bronchial obstruction and designated as a distenziya, or a relaxation, a bronchial tube.
For the first time B. was described in 1819 by Laennek who gave their anatomic characteristic and assumed a pathogenetic role of cough and an inflammation of bronchial tubes in development B. Throughout century of knowledge of B. hl were based. obr. on studying of section material and on the clinical analysis of cases of the bronchiectasias complicated by a purulent inflammation which on features of a current it is intravital were distinguished among other forms of pulmonary suppurations. In 20 century, especially after implementation in clinic of a bronchography, knowledge of B.'s role at bronchopulmonary diseases significantly extended due to intravital recognition segmented, not complicated by a purulent inflammation — the so-called dry B. which do not have clinical manifestations or shown single symptoms. Except B. which are formed at inflammatory bronchopulmonary processes began to allocate inborn B. which role in pathology to a crust, time is unequally regarded by different researchers.
According to pathoanatomical data, B.'s frequency is estimated by different researchers within 0,4 — 5%. Messages on B.'s prevalence at the population are not numerous. As approximate data Wynn-Williams (N. Wynn-Williams, 1953) about B.'s frequency at the population of Bedford (150 000 inhabitants) which made 1,3 for 1000 are provided.
Among all bronchopulmonary diseases B.'s frequency makes 10 — 30% (And. Yonkov, S. Todorov, 1966), and among the dead from hron, nonspecific pneumonia of B. were found in 71,7% of cases (A. Ya. Tsigelnik, 1968). B. occur at any age, a thicket at women.
The ratio of frequency of the inborn and acquired B. is least studied. V. I. Struchkov and D.F. Skripnichenko (1958) carry to inborn 40% of a bronchietasia of adults; according to A. Ya. Tsigelnik, inborn B.' frequency cannot exceed 6,1%. According to the data provided by F. Zauerbrukh (1920) it can reach 80%. Some researchers consider that not less than a half of all B. at adults and the majority them at children are inborn.
Unilateral make of all cases of B. apprx. 70%, bilateral — apprx. 30%. Most often bronchial tubes of segments of the lower shares of lungs, and at the left are surprised a little more often than on the right. At most of patients find B. of the lower share and lingular segments of an upper share of the left lung. The second place on frequency is taken by B. of the lower share of the right lung, the third — the lower and average share, the fourth — defeat only of an average share.
In an origin of the acquired B. an important role is played by acute virus and bacterial bronchopulmonary inflammations, and also hron, pneumonia, the Pneumoconiosis, tuberculosis. Some authors emphasized value of pleurisy. At B.'s development at children's age among etiological factors clumsy pneumonia, whooping cough, flu prevail.
Inborn B. can be considered as a malformation, a consequence of a dysplasia of a bronchial wall or intersticial stroma of a lung. In some cases B. are combined with situs viscerum inversus. At a so-called triad of Kartagener situs viscerum inversus, B. in the lower share of the left lung and paranasal sinusitis come to light. Besides, also other anomalies of development — the arrow-shaped sky, a labium leporium, anomalies of teeth meet. Reliable cases of family B., including and at twins are described, and also B.'s combinations to various malformations — status thymico-lymphaticus, multiple birthmarks, teleangiectasias, lack of edges, etc.
the Pathogeny of the acquired B. in different cases, apparently, is not identical. R. Laennek explained stretching of bronchial tubes at Qatar with existence in their gleam of a large number of a phlegm and high pressure of air on bronchial walls at cough. W. Stokes, D. Corrigan, K. Rokitansky, Zh. Kryuvelye, Yu. Kongeim, A. Marfan, etc. showed a pathogenetic role of such factors as pan-bronchitis with damage of a muscular coat of a bronchial tube, a focal pneumosclerosis, an atelectasis, bronchial obstruction that found confirmation and in
A. I. Abrikosov, I. V. Davydovsky, I. K. Yesipova, A. I subsequent researches. Strukova, etc. Generally, B.'s development is promoted by the factors increasing transmural pressure in bronchial tubes (bronchial obstruction, a valve bronchostenosis, cough, accumulation in bronchial tubes of a phlegm, peribronchial fall of pulmonary fabric, stretching of walls of a bronchial tube cirrhotic process, etc.), and the damages of a muscular and connective tissue framework of a bronchial wall reducing its resistance to the stretching influence of transmural pressure.
Depending on what of factors prevail in the mechanism of stretching of a bronchial wall allocate retentsionny, destructive and atelectatic B. Decrease in a tone of a bronchial tube at destruction of elastic and muscular tissue in its walls (and also owing to disturbance of a nervous and vascular trophicity) most often plays the defining role in B.'s development though in most cases stretching of a bronchial wall comes at the combined influence of several pathogenetic factors.
In B.'s pathogeny disturbances of bronchial passability and hypoventilation of certain sites of a lung can play a significant role. In particular, explain with relative hypoventilation more frequent localization of B. in the lower shares, in the left lung, the respiratory movements to-rogo are limited to heart, adjacent to the lower share, and the bronchial tube to-rogo has fiziol. narrowing in the place of its decussation with the left branch of a pulmonary arterial trunk. Distinctions in ventilation of the left and right lung are confirmed with bronkhospirometrichesky researches.
In B.'s pathogeny development of the bronchial distenziya (relaxations) which are observed at acute bronchopulmonary inflammations and connected not with destruction, and with hypotonia of a muscular layer of a bronchial wall matters also. Apparently, such mechanism of development takes place at B. without inflammatory changes of walls of bronchial tubes that was observed at B. in the outcome of flu, whooping cough. At limited damage of a bronchial tube falling of a tone of its walls can be observed throughout the bronchial tube which is (especially vertically located) without its considerable inflammatory infiltration. Afterwards hypotonia of bronchial muscles can become irreversible in connection with development of dystrophy and infection of an affected area.
Macroscopically as a bronchiectasia allocate cylindrical, meshotchaty, spindle-shaped and chetkoobrazny B., and on thickness of walls of expanded sites — atrophic and hypertrophic. However the microscopic analysis shows that the hypertrophy of mucous or muscular covers is not always the cornerstone of a thickening of a wall of B., it can be caused by hypostasis, inflammatory infiltration, a sclerosis.
Retentsionny B. (tsvetn. fig. 1 and 5) more often happen a cylindrical or spindle-shaped form. Depending on pathogenetic option and a stage of development of B. prevail or signs of a condensation of a bronchial secret (e.g., at a mucoviscidosis), or (more often) loss of a tone of bronchial walls against the background of signs hron, pan-bronchitis. In the latter case the mucous membrane is thickened, sometimes with ulcer and polypostural changes, an epithelium with the phenomena of regeneration, sometimes metaplasias. Rodman's indexes (the relation of thickness of a mucous membrane to thickness of all wall of a bronchial tube) and Read change (the relation of thickness of a layer of glands to most thickly mucous membrane). Normal both indexes correspond to 1: 4. Gistokhim. CHIC reaction (reaction with shiff-iodine to - that) and reaction with toluidine blue is revealed by disturbance of secretion of glands and scyphoid cells. Instead of separate CHIC-positive granules in protoplasm of cells a lot of CHIC-positive substance, stretching all protoplasm of cells appears. Slime is heterogeneous on the maintenance of mukoproteid and the sulphated mucopolysaccharides. In late terms of gland atrophy, cystically stretch, their secret is condensed. The phase of hypersecretion is characterized by sharp expansion of mouths of glands, about the last the quantity limf, follicles increases. Lymphoid infiltration becomes more compact, than normal, covers all layers of walls of bronchial tubes; between lymphoid elements there are many plasmocytes and their pyroninophilia (see Plasmocytes) determined by Brashe's reaction accrues. Reaction with toluidine blue opens a large number of the mast cells which are located on the course of expanded bronchial veins and the increasing quantity of an arteriovenous anastomosis in B.'s walls. At B. in distal departments of bronchial tubes infiltrates usually spread to adjacent walls of alveoluses (perifocal pneumonia). Muscle fibers in B.'s walls are disconnected, atrofichna, the quantity of a glycogen in them is reduced, fatty dystrophy sometimes comes to light. In cartilaginous plates calcification and development of marrowy fabric is found. Defeat of the nervous device of bronchial tubes comes to light. In intramural and radical gangliya dystrophy of nervous cells, pycnosis of their kernels, vacuolation of protoplasm is defined. In nerve fibrils varicosity, the granular disintegration of axial cylinders which is especially intensively expressed in thick afferent and efferent conductors is noted. To a lesser extent fine pulpy and amyelenic fibers change. The accruing dystrophic and atrophic processes are replaced by a sclerosis and lead to deformation of a gleam of bronchial tubes.
Destructive B. (tsvetn. fig. 2 and 3) have mostly meshotchaty form. Are observed at suppuration of a bronchial tube and the fabrics surrounding it; for their designation quite often use the term «bronkhoektatichesky cavity». Purulent fusion of a wall is replaced by development of the granulyatsionny fabric replacing all components of a bronchial wall. Pneumonia and a sclerosis extend to a surrounding alveolar parenchyma to a large extent, than at retentsionny B. V such B.' walls the plentiful angiomatous structures which are a source of bleedings are noted.
Atelectatic B. (tsvetn. fig. 4 and 6) are caused by increase of a gradient between intrapleural and intra bronchial pressure at volume reduction of a part of a lung. They are characterized by hypodispersion of cystic bronchiectasias in a zone of an atelectasis. In walls of bronchial tubes structural components are usually well distinguishable, the inflammation is expressed unsharply, except for a bronchial tube, obturation to-rogo led to an atelectasis. In this bronchial tube destructive changes develop. In addition to foreign bodys of bronchial tubes, can lead radical inflammatory processes and a sclerosis to atelectatic B.
A. I. Strukov and I. M. Kodolova allocate B. with emphysema, B. with an atelectasis and B. with atelectatic deformation of a lung. According to them, deformation of bronchial tubes is less expressed in segments of an upper share and the VI segment of the lower share. However abscessing with meshotchaty B.' development prevails in II and VI segments, i.e. in those bronchial tubes in which drainage is complicated owing to anatomic features. Change of an alveolar parenchyma in B.'s circle of all described types are various depending on character of an inflammation, type of disturbance of bronchial passability (dominance of an atelectasis or emphysema) and segmented features of a structure of bronchial tubes in which zone developed B.
Vozmozhna B. owing to a malformation of bronchial tubes (tsvetn. fig. 5) pre-and post-natal type. Only the first of them can be called inborn. Much more often expansion of a gleam of bronchial tubes is caused by accession of an infection to hypoplastic processes in a wall of a bronchial tube.
Inborn B. happen two types. The first of them is characterized by a reduction of branching of pnevmomer. Between cysts the connecting fabric deprived of alveoluses and elastic fibers is located. The second type is characterized by defect of branching of bronchial tubes — the admission of separate generation of a bronchial tree therefore segmental bronchi, e.g., open directly in a respiratory parenchyma. Between cysts in this case there is a layer of underdeveloped and atelektatichny alveolar fabric. Depending on the level of development of defect distinguish large and small cysts. On a structure of walls of B. without the nature of branching it is difficult to otdifferentsirovat inborn B. from the acquired B., their especially atelectatic form.
Clinical manifestations of bronchiectasias
not infected B., especially not numerous and the small sizes, can clinically not be shown a long time. At considerable on number and the sizes B. and, the main thing, in the presence a purulent inflammation develops a clinical picture with bigger or smaller expressiveness of the symptoms inherent in them B. On extent of inflammatory changes in bronchial tubes and lungs at B. and to clinical manifestations it is possible to allocate three stages of development of B. as peculiar pathological process. First (early) stage it is characterized by defeat of slime layer of bronchial tubes in the form of sclerous changes and a high-quality current. Bronchial tubes are deformed or slightly expanded in the form of cylindrical B. which in this stage are distinguished only accidentally at radiological inspection concerning a bronchopulmonary disease. Apparently, in this stage also the tranzitorny relaxation of bronchial tubes as in some cases involution of the specified changes under the influence of conservative treatment is noted meets.
At the second stage destructive process strikes already all thickness of a wall of bronchial tubes and peribronchial fabric. This stage is characterized by a clinical picture hron, pneumonia (see) with frequent aggravations. A large number of a mucopurulent phlegm separates, it is frequent «a full mouth» that is characteristic of its department from a cavity. Deformation of nail phalanxes of fingers in the form of drum sticks is defined (see. Drum fingers ); on bronkhogramma the expressed B. are found (more often in the lower share at the left).
Third stage it is characterized by deeper damage of bronchial tubes and pulmonary fabric and disease on type hron, pulmonary suppuration. At patients the purulent phlegm is constantly allocated (to 400 ml a day), it is frequent with a putrefactive smell, located in a vessel with three layers: lower (yellowish-green) — purulent, average — serous and upper (foamy) — mucopurulent. At a careful laboratory research in a phlegm elastic fibers can sometimes be found. In considerable percent of cases the pneumorrhagia is observed.
Percussion data are not characteristic. Auscultation: at it is central the located or, especially, «dry» B. changes can be absent, but at the meshotchaty B. filled with a phlegm quite often over them plentiful average and large-bubbling rattles, sometimes big sonority, «bitter», sometimes with a «metal» timbre are listened. The remote or oral sound which is explained with trembling of threads of a viscous phlegm in a wide bronchial tube, in the neighbourhood with a resonant cavity is considered a frequent auskultativny symptom. Important differentsialno - a diagnostic character of B. is diversity of auskultativny data over the same site of a thorax during the listening in various time, and also before expectoration. It is connected with changes of quantity and viscosity of the phlegm filling B.
Functions of external respiration at patients with single limited B. are not changed. At the multiple and large B. forming considerable cavities as cysts increase in functional dead space, increase in a minimal air and lengthening of time of mixing of gases (irregularity of ventilation) is observed. Irrespective of quantity and the sizes B., in any stage of their development can be revealed different extent of change of respiratory functions at the expense of the accompanying sclerosis of a pulmonary parenchyma (reduction of the total and vital capacity of lungs) or the accompanying obstructive bronchitis (decrease in indicators of pneumotachometry, the forced vital capacity of lungs, increase in a minimal air, significant increase in work of breath, etc.).
The course of inflammatory process at the infected B. various. Cases slow hron prevail, the current lasting for years, but sometimes within several months the clinical picture hron, pulmonary suppuration forms. B., not complicated by an inflammation, can latentno proceed a long time, without showing bent to progressing. Sometimes they are complicated by an unexpected pneumorrhagia or pulmonary bleeding, and then proceed asymptomatically for many years.
Recognition of bronchiectasias only on clinical symptoms (department of a phlegm «a full mouth», characteristic auskultativny signs, clinic of pulmonary suppuration, etc.) is not always possible. Reliable diagnosis is based hl. obr. on X-ray inspection, sometimes in combination with bronkhoskopiya (see).
Radiodiagnosis it is carried out by means of a complex of radiological techniques (see Angiopul the monograph, the Bronchography, the Tomography). Radiological data allow to define morphological changes in bronchial tubes and pulmonary fabric, to reveal and estimate disturbances of regional ventilation, to establish surgical indications.
The X-ray morphological analysis is important very in objective diagnosis of B., specification of their location, distribution, a form and size. At raying and according to usual roentgenograms of lungs it is possible to assume changes in bronchial tubes on considerable change of the pulmonary drawing. At a cylindrical bronchiectasia the polosovidny enlightenments and shadows located closely to each other and which are not decreasing in caliber to the periphery can be defined occasionally. Meshotchaty B. are sometimes visible as the multiple roundish enlightenments with dense walls giving to this site of the pulmonary field a peculiar «cellular» look. On tomograms all these changes come to light more clearly; it is possible to estimate thickness of bronchial walls and extent of infiltration of peribronchial fabric. Fullestly all changes of a bronchial tree are reflected in bronkhogramm (fig. 1). B. appear on them as resistant bronchiectasias at which diameter of the struck trunk is equal or exceeds the average diameter of a bronchial tube of the previous order. In a form distinguish cylindrical, spindle-shaped and meshotchaty B. (fig. 2). Cylindrical B.'s diameter is more than diameter of bronchial tube draining it no more than for 15%, spindle-shaped B.'s diameter — for 15 — 30%, meshotchaty B.'s diameter — more than for 30%. Almost at sick B.' half different forms of bronchiectasias are at the same time observed. At a complication of process by abscessing on bronkhogramma one or several bronkhoektatichesky cavities which are reported with the affected bronchial tubes are visible. The last as if fall into an abscess cavity.
Other changes in bronchial system depend on a form and an origin B. Uneven rapprochement of bronchial tubes in a zone of defeat, their considerable deformation, angular curvatures and excesses is characteristic of the acquired B.
Along with expanded bronchial tubes usually there are bronchial tubes with normal or even the narrowed gleam. Substantially such picture is inherent also to the so-called atelectatic B. arising because of the previous full atelectasis. Defeat in these cases has strictly expressed share or segmented character.
At dizontogenetichesky inborn B. bronchial tubes in the condensed share are pulled also together, but differ in uniformity of changes; all of them are evenly expanded and come to an end with club-shaped swellings further which a contrast agent does not get. Segmental bronchi can be underdeveloped, and then the lobar bronchus seems extended. At cystous B. the pulled together bronchial tubes come to an end with multiple thin-walled cavities. To the periphery from cysts a contrast agent does not arrive; there underdeveloped pulmonary fabric decides on the grown poor pulmonary drawing.
At the infected B. are noted, in addition to B., various inflammatory and sclerous defeats in lungs and the phenomena of disturbance of bronchial passability. They are expressed in strengthening and deformation of the pulmonary and root drawing, in sites of infiltration and a fibroatelektaz of various extent, in formation of «couplings» around the affected bronchial tubes, in development of bronchiolar emphysema, changes of a pleura. Point the following radiological symptoms to an aggravation of process: the accruing infiltration of a parenchyma and interstitial fabric, emergence of the centers of disintegration, emergence of liquid in B. and in a pleural cavity, increase in volume of pathological changes. At an angiopulmonografiya in a zone of defeat reduction of number of small vascular branchings is noted; segmented arteries are narrowed, deformed and displaced. On bronchial arteriogramma deformation of vessels in the presence of the functioning bronchial and pulmonary arterio-arterial and arteriovenous anastomosis is defined. The expanded branch of a bronchial artery can be a source of pulmonary bleeding. In these cases on an arteriogramma sometimes it is possible to register an ekstravazation of a contrast agent.
X-ray functional analysis. At roentgenoscopy on the party of defeat find restriction of respiratory mobility of edges and a diaphragm, and in pictures through lattices applicators — decrease in ventilation in a zone of defeat at its strengthening in the next departments of lungs.
At a bronchography and a bronkhokinematografiya establish disorder of functional activity of a bronchial tree — uneven (accelerated or slowed down) filling and emptying of bronchial tubes, a bronchospasm, a bronkhodilatation. In the area B. the caliber of bronchial tubes almost does not change at breath (fig. 3). Contrast agent is long is late in B., especially in meshotchaty, and does not come to smaller bronchial branchings.
Extent of disturbance of a blood-groove in zones of defeat can be objectively estimated on intensity and speed of emergence on angiopulmonokinematogramma of a capillary phase. At patients with sharp wrinkling of a lung or a share complete cessation of a blood-groove in a zone of defeat is noted.
shall be based on the basis of comprehensive examination of the patient, in Krom the radiological method possesses very important role. The combination of data of the anamnesis, a clinical picture, bronchoscopic, radiological, laboratory and radio isotope researches gives the chance to distinguish B. which resulted hron, pneumonia or because of anomaly of development of a lung from hron, fibrous and cavernous tuberculosis, a sarcoidosis, a cystous lung and a pneumoconiosis. Special difficulties sometimes meet in differential diagnosis of B. and cancer of the lung complicated by an atelectasis, retrostenotic abscesses or parakankrozny pneumonia. Tells preservation of passability of the main bronchial tube of a share (segment) or its break about B. from the mouth, an uneven bronchiectasia in a zone of defeat, identification of the bronchial tubes and cavities filled with air in rubtsovo the changed and infiltrirovanny tissue of a lung, signs of inflammatory damage of bronchial tubes in the next departments of lungs at a great distance. In particularly complex cases the selection bronchography made at serial filling with a contrast agent of bronchial tubes of separate segments with suction from them a contrast agent before filling of each subsequent segment can be applied. This technique demands existence of the special equipment.
the Forecast at B. depends on their size, prevalence of N of character of complications. At the multiple B. complicated hron, suppuration it is adverse. At B.'s suppuration in separate segments and at their unilateral localization the forecast is less adverse in connection with a possibility of surgical treatment, a cut in some cases can lead to practical recovery.
Treatment of patients with B. — complex, directed to fight against already available infection, on its prevention, and also on maintenance of a bronchial drainage and recovery of protective forces of an organism; if necessary and opportunities surgical treatment is applied. Antibacterial agents are selected individually by results of crops of flora from a phlegm, and a way of their introduction (intravenously, in inhalations, instillations etc.) it is chosen depending on localization and character of an inflammation. At a pyogenic infection bronchoscopic sanitation (under anesthetic) with aspiration of purulent contents and careful washing of a bronchial tree Ringer's solution with addition of antibiotics, sodium bicarbonate, proteolytic enzymes, and at a putrefactive phlegm — solution of Furacilin 1 becomes method of the choice: 5000 (see. Bronkhoskopiya ).
Among conservative methods of treatment the position (postural) drainage, especially in the presence of a purulent phlegm is of great importance. This method can be effective only at its correct carrying out. Localization of process in the lower zones demands obligatory position of the patient in a bed with the raised foot end, at the same time the patient shall be in the special provisions (depending on localization of process) promoting full evacuation of a phlegm from B. Pomogayut an otkhozhdeniya of a phlegm to lay down. physical culture and massage of a thorax. At a viscous phlegm expectorants, inhalations of proteolytic enzymes, caustic solutions are applied. Drainage is more effective at simultaneous use of the means improving bronchial passability.
Indications to surgical treatment depend on B.'s prevalence and the nature of clinical treatment.
Surgical treatment is carried out by the patient with B. in the second and third stage after preliminary estimate of indications of a research of function of blood circulation, breath, etc. also carrying out the necessary preoperative preparation including conservative treatment.
Contraindications to surgical treatment are: 1) bilateral defeats of thirteen and more segments; 2) heart failure with a decompensation of blood circulation; 2) the expressed amyloidosis of parenchymatous bodies with signs of their functional insufficiency.
The vast majority of operations at B. is made in a planned order. Only at the repeating massive blood spitting or profuse pulmonary bleeding there can be a question of indications to an immediate surgery.
Rational preoperative preparation, a main objective a cut — creation of the conditions ensuring the greatest safety of carrying out the most economical and at the same time radical operation is of great importance. The main attention at the same time should be paid to sanitation of a bronchial tree. The last can be carried out: 1) inhalations using alkali, proteolytic enzymes, phytoncides (an extract from garlic, onions); 2) purpose of expectorant drugs; 3) use of a position (postural) drainage; 4) carrying out course of sanatsionny bronkhoskopiya. In addition, it is necessary to carry out the fortifying treatment including the good nutrition rich with calories and vitamins, the drug treatment directed to desintoxication and normalization of the vital functions of an organism. In preoperative preparation great attention is given to lay down. to physical culture and especially respiratory gymnastics that well influences development of compensatory processes. Also psychological training of such patients — an explanation to them the main objectives of operation, possible complications in the postoperative period, need of expectoration, etc. has obvious value. The better preoperative preparation is carried out, the it is better results of operational treatment of B., and successful sanitation of bronchial tubes, according to V. I. Struchkova (1967), V. R. Yermolaeva (1969), etc., is reliable prevention of postoperative complications.
The choice of anesthesia at surgical treatment of B. plays an important role in providing a favorable result of operation. Features and difficulties of anesthesia at surgical treatment of B. are connected with the fact that already before operation patients have more or less expressed disturbances of gas exchange, a hemodynamics and function of internals. During anesthesia ensuring appropriate level of gas exchange and a hemodynamics, and also preservation of passability of respiratory tracts and prevention of throwing of bronchial contents from a sore lung in healthy is necessary. Fully the intubation anesthesia meets these requirements (see. Inhalation anesthesia ) using muscular relaxants and use of artificial ventilation of the lungs (see. Artificial respiration ). Maintaining such anesthesia is facilitated by use of tubes for a separate intubation of bronchial tubes that allows to carry out constantly ventilation of one or both lungs, to change its mode irrespective of stages of operation, to constantly aspirate contents of a bronchial tree.
Distinguish radical and palliative operations at B., and also one - and bilateral. The last depending on terms of performance subdivide on single-step and two-stage, or consecutive. Removal of the struck part or all lung belongs to radical operations (see. Lobectomy , Pneumonectomy , Segmentectomy ), to palliative — pneumotomy (see), bandaging of a pulmonary artery, pneumolysia (see).
The correct scoping of a resection of lungs has paramount value for results of surgical treatment both concerning respiratory functions, and for the prevention of palindromias.
Modern development of pulmonary surgery does not allow scoping of a resection only on the basis of a bronchography; it is necessary to apply special methods of a research: angiopulmonografiya (see), a bronkhospirometriya (see. Spirography )., radio isotope scanning of lungs (see. Lungs ).
Segmented resections at B. — quite rare operation, its opportunities, especially at adult patients, are very limited. In the leading clinics such operation is carried out only in 2 — 5% of all operations for B. (V. I. Struchkov, Η. M. Amosov, etc.). The resection of segments of a basal pyramid with leaving of the VI segment is most often made. Preservation of the VI segment is shown only when defeat is absent not only in it, but also in adjacent subsegmental bronchi and vessels of the X segment. Distribution of cicatricial and inflammatory process on an intersegmental partition serves as a contraindication for preservation of the VI segment since its wound surface after such resection becomes insolvent, and sewing up leads it to deformation of a segment, interferes with its raspravleniye and often leads to formation of a resistant atelectasis.
At B. of basal segments one of segments of an average share or a uvula quite often is surprised. Considering anatomic features of an average share (and a uvula), the isolated removal IV or V segments is not made; more reasonable in such cases to remove both segments.
Most often B. are localized in the lower share and the IV—V segments at the left therefore to the most widespread, so-called standard, operation is the combined resection of t — removal of the lower share and a uvula. Such operation makes about 40 — 45% of number of all interventions at this pathology. The second place on frequency is taken a forehead - and bilobectomies. And the lower bilobectomy is carried out considerably more often than upper. Bilobectomies make approximately the same percent among all operations, as well as the isolated lobectomies (20 — 25%).
The pneumonectomy is made for B.'s treatment seldom (apprx. 4% of all interventions), it is shown only to patients with total defeat of all segments of one lung at healthy the second. Besides, when on the party of defeat comes to light not changed one any segment, it is more reasonable to remove all lung since preservation of one — two segments often conducts to serious complications of the postoperative period.
B. A. Korolev (1963), V. I. Kukosh (1965), S. A. Gadzhiyev (1972), etc. specified that bilateral defeats which make 15 — 30% of number of all B most hard proceed. Indications to surgical treatment of bilateral B. the same that at hemilesion. During operation it is necessary to aim at the minimum traumatization of fabrics (separate processing of elements of a root of a lung, use of staplers, removal giperplazirovanny limf, nodes which leaving can be the cause of complications in the postoperative period). Experience of both single-step, and consecutive interventions is accumulated at bilateral B. Bolshinstvo of surgeons prefers step-by-step operating — at first on the one hand, and through a nek-swarm time — with another. A consensus about time of carrying out the second stage of operation it is not developed. The term of repeated operation shall be defined strictly individually at each patient depending on his state, existence of complications in the postoperative period, associated diseases, etc.; usually the interval between the first and second operation makes 4 — 6 — 12 months. At the first stage make operation on the party of the greatest defeat. It is connected with the fact that removal of the main center can lead to involution of process in an opposite lung; besides, the unextracted suppurative focus is potentially dangerous to development of complications in the postoperative period.
Palliative operations at B. are applied extremely seldom. They had a certain value only during an initial stage of formation and development of pulmonary surgery. From the middle of the 60th years such operation as bandaging of a pulmonary artery, at B. is not applied at all. At large B.' suppuration at the patients who are in a serious condition with the expressed decompensation of the vital functions in extremely exceptional cases the pneumotomy can be made. It is shown at formation of the single or multiple cavities filled with pus and which are not emptied through bronchial tubes, supporting the general intoxication when it is impossible to make any other effective treatment (a puncture of a lung, catheterization of a bronchial tube, radical lung operation).
Postoperative treatment patients with B. it is directed to prevention of complications and recovery of the broken functions of an organism. The oxygenotherapy is applied to reduction of the anoxemia which is available for all patients after lung operations; in the presence of indications respiratory analeptics of heart and vascular drugs, hemotransfusion, etc. are appointed. Removal of pain after operation is reached by use of various analgetics; it is possible to use also to lay down. anesthesia or peridural anesthesia. From the first hours after operation it is necessary to begin occupations to lay down. physical culture, edges exerts beneficial effect on a state and health of patients.
The paramount importance has the correct drainage of a pleural cavity. It is necessary to aim at the most bystry and full raspravleniye of the remained segments of a lung after its partial resections. After a pneumonectomy it is necessary to watch amount of exudate in a pleural cavity, the shift of a mediastinum, tightness of a stump of a bronchial tube. The mode of drainage along with rational use of antibacterial drugs plays a part and in fight against an infection. Sanitation of a bronchial tree in the postoperative period is carried out by inhalation of proteolytic enzymes, phytoncides or antibiotics, and at obturation of a gleam of bronchial tubes their catheterization or a sanatsionny bronkhoskopiya is shown. The rational diet to lay down. the physical culture, a symptomatic treatment proceed at all stage of the postoperative period — before recovery of working capacity.
Complications after radical operations for B. meet in 20 — 25% of cases (this figure remains rather stable though the lethality considerably decreased). The most frequent complications are the atelectasis, pneumonia, bronchial fistula, an empyema of a pleura, bleeding. Prevention of complications consists in the correct preoperative preparation, the sparing technology of operation and rational maintaining the postoperative period. Timely recognition of the arisen complications and vigorous fight against them in most cases allow to prevent failures of operational treatment.
Results of surgical treatment of B. in general are more favorable, than during the performing only conservative therapy.
Recovery of working ability of the patients operated concerning B. is a complex and urgent challenge. Lack of respiratory insufficiency at patients whose profession has no harmful factors (the increased dust content, hot workshops, chemical harm, etc.) allows to consider them quite able-bodied. More than at a half of patients working capacity is completely recovered within the first year after operation.
Prevention of the acquired B. matches prevention of the bronchopulmonary defeats promoting B.'s education and their timely effective treatment (see. Atelectasis , Bronchitis , Bronchostenosis , Pneumonia ).
Prevention of inflammatory process at B. consists in elimination of the inflammatory extra pulmonary centers, such as sinusitis, polyposes of a nose, caries of teeth and other centers of an oral infection. The sinusitis which is often accompanying B., high sensitivity of patients to cooling justify the direction of patients (out of a phase of an aggravation) on a dignity. - hens. treatment in the conditions of arid, warm climate (The southern coast of the Crimea, Central Asia). In treatment and especially in prevention of complications of B. the huge role is played by the fortifying mode, a hardening of an organism, respiratory gymnastics, the correct employment of patients.
Purposeful preventive also to lay down. actions are extremely important in the postoperative period since at the arising complications conditions for B.'s recurrence in the operated lung are created.
Bronchiectasias at children
began to be studied by B. at children intensively during development of thoracic surgery and anesthesiology when operations on bodies of a chest cavity at children became possible.
It is difficult to establish the true frequency of B. at children, in particular because criteria of establishment of the diagnosis are various. Most of authors considers B. pathology of children's and young age (A. P. Kolesov, 1955; A. Ya. Tsigelnik, 1968). According to Yu. F. Dombrovskaya (1957), M. S. Maslov (1959), B.'s frequency at children fluctuates from 0,76% to 1,7%. Among hron, diseases of lungs the so-called bronchoectatic disease occurs at children in 20% (A. G. Pugachev et al., 1970), especially often aged up to 10 years (72%).
According to E. V. Ryzhkov, at children dizontogenetichesky B. which emergence is connected with inflammatory process owing to what development of a lung in the first years of life of the child when yet his formation did not end is broken are preferential noted. Other authors (S. M. Gavalov, 1968; A. Ya. Tsigelnik, 1968, etc.) B.'s development is connected generally with recurrent nonspecific inflammatory diseases of lungs (bronchitis, pneumonia) and nasopharynxes (sinusitis). The significant part in B.'s formation is assigned to children's infections (measles, whooping cough) and viral pneumonia. Sometimes tuberculosis is B.'s reason. In B.'s emergence also foreign bodys of bronchial tubes, especially organic origin have undoubted value.
In a pathogeny of the acquired B. at children the leading role is assigned to disturbance of bronchial passability at various levels. The narrowness of bronchial tubes, plentiful secretion promote easy emergence of obturation of the lower respiratory tracts and development of the infected atelectasis. In a zone of an atelectasis bronchial tubes develop incorrectly, their growth is broken, they are deformed and extend. In a parenchyma of a lung the phenomena of a pneumosclerosis gradually develop.
Most often at children the lower shares of lungs, then average shares and lingular segments are surprised. Bilateral process is observed more than in 30% of cases.
Usually in the anamnesis at patients with B. frequent long pneumonia, bronchitis, katara of upper respiratory tracts are noted.
Quite often similar displays of a disease are defined in the first months and years of life of the child. Rises in temperature are periodically noted. At limited processes overall health suffers a little. At extensive defeats weakness, bystry fatigue can take place, lag in the weight and physical development is possible. Expressiveness of symptoms depends on prevalence of process. The main symptom allowing to assume B. — wet cough. Unlike adults, children of preschool age swallow a phlegm. At extensive bilateral defeats an asthma at rest, cyanosis, deformation of fingers in the form of drum sticks, nails in the form of clock glasses can be observed.
Survey roentgenograms of a thorax in most cases give the chance only to suspect a disease on the basis of such radiological symptoms as a pneumosclerosis, an atelectasis of separate zones of a lung, small cellular enlightenments. Gives the greatest information on location and B.'s distribution bronchography (see), carried out at children, as a rule, under anesthetic with separate filling of bronchial tubes with a contrast agent on the right and at the left serially. Indications to angiopulmonografichesky researches at children arise generally at extensive bilateral processes for definition of an opportunity and volume of surgical intervention.
Surgical treatment of B. is shown at the localized forms, total damage of one lung, and also at bilateral processes if there is a possibility of leaving more than 5 — 6 segments on both sides. Operation is not shown at a diffusion tracheobronchitis with absent-minded B.' presence or the deforming bronchitis. In these cases the conservative treatment directed to periodic sanitation of a tracheobronchial tree (a postural drainage, a bronkhoskopiya, inhalation), reduction of intoxication, suppression of virulent microflora (antibacterial therapy) is necessary. Technically performance of operation is possible at children of any age. Most often children operate at the age of 5 — 7 years. Processing of elements of a root of a remote part of a lung is made separately (or manually, or using staplers). At bilateral defeats operation is carried out step by step with intervals in 6 — 8 months. The volume of a resection depends on the volume of damage of a lung. Operation shall be most sparing and radical. At children performance and segmented resections is possible.
Results in many respects are defined by prevalence of defeat and an origin B. At the acquired limited B. within one — two shares operation in most cases leads to considerable improvement of a condition of patients.
The lethality fluctuates from 1 to 3%.
In the remote terms good and satisfactory results are noted in 80,9% (L. M. Roshal, 1970) — 93,8% (I. G. Klimkovich, 1965) cases. After operation children are subject to long dispensary observation; at bilateral process, and also hron, bronchitis — to treatment in a hospital, sanatoria.
Bibliography: Gavalov S. M. Chronic nonspecific pneumonia at children, M., 1968, bibliogr.; And d and e in S. A. Questions of a pathogeny, diagnosis and treatment of a bronchietasia, Klin, medical, t. 48, No. I, page 9, 1970; Gilman A. G. Atelectases and their value in pathologies of lungs, Kazansk. medical zhurn., No. 10, page 1205, 1935; Glantsberg N. A. A bronchoectatic disease at teenagers, JI., 1970; About N of c about in I. A. Bronchoectatic disease, Chisinau, 1966; D and-vydovsky I. V. A chronic nonspecific pulmonary tuberculosis, in book: Probl, teort. and prakt. medical, under the editorship of B. S. Holzman, t. 9, page 83, M., 1939; Yesipova I. K. Questions of pathology of chronic nonspecific pneumonias, M., 1956, bibliogr.; Yesipova I. K. and Klimkovich I. G. Pathological anatomy of a bronchietasia at children according to the resected lungs, Arkh. patol., t. 29, No. 1, page 15, 1967; Kodolova I. M. O classifications of chronic nonspecific diseases of lungs, in the same place, t. 25, No. 10, page 3, 1963, bibliogr.; Kolesnikov I. S. and Yermolaev V. R. A bronchietasia, the Management on legochn. hir., under the editorship of I. S. Kolesnikov, page 236, JI., 1969; Kolesov A. P. An atelectatic bronchietasia, in book: Purulent having got sick, a pleura and lungs, under the editorship of P. A. Kupriyanov, page 261, L., 1955; V. I Boxes. Radiodiagnosis of chronic nonspecific pneumonia, Vestn, rentgenol, and radio-gramophones., J4s 1, page 43, 1972, bibliogr.; To r about f t about N of J. and Douglas A. Diseases of a respiratory organs, the lane with English, page 378, M., 1974, bibliogr.; Linberg B. E. A role of a neurogenic factor in a pathogeny and clinic of a bronchoectatic disease, Owls. medical, No. 2, page 1, 1951; To Linda nbraten D. S. and Lindenbraten L. D. Radiodiagnosis of a disease of a respiratory organs at children, L., 1957; Lukomsky G. I., etc. Bronchology, M., 1973, bibliogr.; Pugachev A. G., Gaydashev E. A. and Krasov-with to and y Yu. S. Surgical treatment of a bronchietasia at children, M., 1970, bibliogr.; Ryzhkov of E. V. Dizontogeneticheskiye and the acquired chronic nonspecific diseases of lungs, M., 1968, bibliogr.; Smirnova A. A. About inborn bronchiectasias, Pediatrics, No. 3, page 17, 1969, bibliogr.; Sokolov Yu. N. and Rozenshtraukh L. S. Bronchography, M., 1958; With t r at to about in A. I. and Kodolov I. M. Chronic nonspecific diseases of lungs, page 175, M., 1970; V. I Pods. Purulent diseases of lungs and pleura, L., 1967; V. I. Pods, etc. Antibiotics in surgery, M., 1973, bibliogr.; F. G. Rezektion's corners of lungs, L., 1954; C and of e of l N and to A. Ya. Bronchoectatic disease, L., 1968, bibliogr.; Fraser R. G., M expert of k 1 em P. T. a. Brown W. G. Airway dynamics in bronchiectasis, Amer. J. Roentgenol., v. 93, p. 821, 1965; Laennec R. Th. De l’auscultation m6diate, ou trait6 du diagnostic des maladies des poumons et du coeur, t. 1—2, P., 1819; Spencer H. Pathology of the lung, p. 136, Oxford, 1968; W at η n-W i 1 1 i a m s N. Bronchiectasis, Brit. med. J., v. 1, p. 1194, 1953.
M. L. Shulutko, I. V. Vigdorchik, I. V. Martynov, A.S. Mochulsky; I. K. Yesipova (stalemate. An.); G. B. Katkovsky, V. M. Sergeyev (Torahs. hir.); L. D. Lindenbraten, A. I. Shekhter (rents.); E. A. Stepanov (it is put. hir.).