LUNGS (pulmones) — the pair respiratory bodies located in pleural cavities and which are carrying out gas exchange between inhaled air and blood.
- 1 The COMPARATIVE ANATOMY
- 2 EMBRYOLOGY
- 3 ANATOMY
- 4 HISTOLOGY
- 5 PHYSIOLOGY
- 6 METHODS of the RESEARCH
- 7 PATHOLOGICAL ANATOMY
- 8 PATHOLOGY
- 8.1 Classification
- 8.2 Malformations
- 8.3 Bronchopulmonary manifestations of genetically caused general diseases
- 8.4 Damages
- 8.5 Diseases
- 8.5.1 Nonspecific diseases of the bacterial and virus nature
- 8.5.2 Specific diseases
- 8.5.3 Parasitic diseases
- 8.5.4 The diseases connected with inhalation of dust particles
- 8.5.5 The diseases pathogenetic connected with an allergy
- 8.5.6 Damages of lungs at collagenoses
- 8.6 Tumors
- 9 OPERATIONS
The COMPARATIVE ANATOMY
Emergence of lung respiration — one of the most important stages of evolution of animals. It is connected with their exit to the land. For the first time L. are found in amphibians though lung respiration at them in comparison with strongly developed skin insufficient. L. amphibians are primitive and represent two sacculate protrusions. Amphibians having a tail have an expressed trachea, at tailless a trachea very short and L. open almost directly in a throat. At reptiles respiratory bags are divided by partitions and have a spongy appearance; all air ways and the courses are covered by a ciliary epithelium. Bronchial tubes of birds of more difficult branching, L. are divided by furrows into 4 — 7 metamericly located segments. The primary and secondary bronchi outside L. form 5 pneumatic bags which are the reserve tanks of inhaled air providing pnevmatization at birds) bodies. At mammals evolution of L. it is generally expressed by further development of the respiratory tracts getting in L. a cartilaginous skeleton and smooth muscles, increase in contact area of pulmonary fabric with air that is provided with crushing of alveolar structures, division of L. on shares, the complication and an intensification of the act of breath connected with emergence at mammals of a diaphragm.
Development of L. the person begins on the 3rd week of an antenatal life. Their bookmark has an appearance of the unpaired sacculate protrusion of an endoderm of a ventral wall of a pharyngeal gut which is intensively growing caudally. On the 4th week of development (fig. 1) on the lower end of protrusion there are two thickenings: primary bronchopulmonary kidneys (gemmae bronchopulmonariae) — rudiments of bronchial tubes and lungs (fig. 1, and, b). From the 5th week to the 4th month of development the bronchial tree forms. Rudiments of bronchial tubes, actively proliferating and growing into the mesenchyma surrounding a front gut dichotomizing branch, forming on the ends spherical expansions from which there is a branching of bronchial tubes of the lesser caliber (fig. 1, in, d). By the beginning of the 6th week appear share and by the end of the 6th week — segmental bronchi (fig. 1, O). Mesenchyma (fig. 1, e), surrounding the growing bronchial tree, is differentiated in connecting tissue, smooth muscles and cartilages of bronchial tubes. In it vessels of pi sprout nerves. On 4 — respiratory bronchioles are stuffed up 5th month of pre-natal development and the first alveoluses appear. An acinus is found by Boyden (E. A. Boyden, 1974) on the 17th week of development. From 4th month cartilages and smooth muscle cells in bronchial tubes to 4 — the 5th orders are formed. The splanchnopleura and a somatopleure of a coelomic cavity, in to-ruyu vpyachivatsya the growing L., turn into a visceral and parietal pleura. By the time of the birth the quantity of shares, segments, segments generally corresponds to the number of these educations at the adult. From the beginning of breath of L. quickly finish, fill pleural cavities; fabric L. becomes air. After the birth development of L. proceeds.
L. in a form it is similar and a half a dissect cone. Actually it repeats a form of the pleural space limited to a parietal pleura (fig. 2). The right lung is shorter and wider left more it on volume. Form and sizes L. are individual. They change at the same person depending on a phase of breath. Form L. depends on a shape of a thorax. At a long and narrow thorax of L. extended and narrow, at wide — shorter and wide. According to the measurements made on corpses, the average height of the right L. Men have 27,1 cm and women have 21,6 cm; left L. Men have 29,8 cm and women have 23 cm. Men and 12,2 cm have average width of the basis of the right easy 13,5 cm at women; left L. — Men have 12,9 cm, women have 10,8 cm. The Perednezadny size of the basis is equal on average 16 cm. According to Simon and Gams (G. Simon, G. Gamsu, 1977), the average length of the right lung at living adults measured on roentgenograms makes 24,46 ± 2,39 cm. According to their data, the linear sizes of H.p. age change a little. So, at the same people at an interval between researches not less than 10 years length of the right lung increased on average by 0,2 cm, and width — by 0,47 cm. Sizes l. change at change of position of a body. According to Miller (W. Miller, 1943), at horizontal position of a body length of the right L. 17,5 cm, left — 20 cm, and at vertical position length of the right L. — 21 cm left — 23,5 cm Nivener and Kleynerman (D. E. Niewoehner, J. Kleinerman, 1974) determined average weight of one L. — 374 ± 14 g. The heaviest L. weighed 470 of Uimster and Mac-Farlen (VV. Whimster, A. J. MacFarlane, 1974) during the studying of 456 normal L. established that the average mass of the right L. men have 455 g, women have 401 g, left — 402 g are at men and women have 342 g. Coefficient of a ratio of mass of the left and right L. at men 0,9, at women 0,86, On Nivenera and Kleynermana, the average total capacity of lungs (with a pressure of air of 25 cm w.g.) reaches 2680 ± 120 ml with fluctuations of 1290 — 4080 ml. Average minimum lung volume 712 ± 90 ml with fluctuations of 250 — 1860 ml.
In each L. distinguish the rounded-off top (apex pulmonis), the basis (basis pulmonis), three surfaces — costal (facies costalis), medial (facies medialis), phrenic (facies diaphragmatica) and two edges — front (margo ant.) and lower (margo inf.). On a costal surface of a top of L. there is a furrow corresponding to a subclavial artery, and ahead from it — a furrow of a brachiocephalic vein. On a costal surface the non-constant print of the I edge in the form of a subapical furrow is defined. Costal and phrenic surfaces of L. are divided by the pointed bottom edge. At a breath and an exhalation bottom edge of L. moves in the vertical direction on average to 7 — 8 cm. Medial surface of L. (fig. 3) in front separates from a costal surface the pointed first line, and from below from a phrenic surface — bottom edge. On a first line of the left L. there is a cordial cutting (incisura cardiaca) passing from top to bottom into a uvula (lingula pulmonis sin.). Medial surface gate of L. and by a pulmonary sheaf it is divided into 2 parts — mediastinal (pars mediastinalis), turned to a front mediastinum, with cordial impression (impressio cardiaca), well noticeable on it, and vertebral (pars vertebralis), adjacent to a postmediastinum and chest department of a backbone, at the left L. along a vertebral part the furrow from a chest aorta (sulcus aorticus) vertically is located. On a medial surface of the right L., ahead from its gate, there is impression from a prileganiye of an upper vena cava, and behind gate — superficial furrows from a prileganiye of an unpaired vein and a gullet. Approximately in the center of a medial surface of both L. deepening — gate of L is located funneled. (hilus pulmonis). Skeletotopicheski of a collar of L. correspond to the V—VII level of chest vertebrae behind and the II—V edges in front. Perhaps the shift of gate is higher or lower than the specified level on one vertebra. Roots of the right and left L. are at one level more often, the root of the left L is more rare. it is projected below a root right. Height of gate of L. from 4,3 to 9 cm fluctuate. Diameter of gate in an upper part of 1,5 — 3,5 cm, in lower — 0,5 — 1,5 cm. Form of cross-section of gate of L. also various. At people of a brachymorphic constitution it often pear-shaped or in the form of an ellipse, at dolikhomorfny — narrower oval or in the form of the comma turned by camber of a kzada. Through gate of L. there passes the primary bronchus, a pulmonary artery and veins, bronchial arteries and veins, neuroplexes, limf, vessels (fig. 4), in gate and along primary bronchi are located limf. nodes. The listed anatomic educations in total make a root L. (radix pulmonis). Arrangement of elements of a root L. usually such is that an upper part of gate of L. the primary bronchus, a pulmonary artery and limf borrow, nodes, and adjoin a bronchial tube bronchial vessels and a considerable part of branches of pulmonary neuroplex (fig. 5). The bottom of gate is occupied by pulmonary veins. The primary bronchus is more kzada in comparison with pulmonary vessels in the front-back direction. Most often in a root of the left L. from above there is a pulmonary artery or its branches, below and behind — a primary bronchus, in the bottom of and ahead of a bronchial tube — pulmonary veins. In a root of the right L. the primary bronchus lies behind a pulmonary artery, pulmonary veins — in a bottom corner of gate of L. and partially cover branches of a pulmonary artery in front. Root L. it is covered with a pleura. Below a root L. a duplikatury pleura the pulmonary sheaf is formed triangular shape (lig. pulmonale) located in the frontal plane and dividing the bottom of an okolomediastinalny crack of a pleural cavity into front and back departments.
Top of L. at the adult corresponds to a dome of a pleura and acts through an upper aperture of a thorax to the area of a neck to the level of a top of an acantha of the VII cervical vertebra behind and 2 — 3 cm higher than a clavicle in front. Position of borders of L. and a parietal pleura it is very similar (fig. 6). First line of the right L. it is projected on a front chest wall on the line, to-ruyu carry out from a top of L. by the medial end of a clavicle, continuing to the middle of the handle of a breast and further down to the left of the sternal line to an attachment of the VI costal cartilage to a breast where the lower bound of L begins. First line of the left L. deviates from the level of connection IV of an edge with a breast dugoobrazno to the left and down to the place of crossing of the VI edge with the okologrudinny line. Lower bound of the right L. corresponds on the sternal line to a cartilage of the V edge, on the median and clavicular line — the VI edge, on the front axillary line — the VII edge, on the average axillary line — the VIII edge, on back axillary — to the IX edge, on the scapular line — the X edge, on the paravertebral line — an acantha of the XI chest vertebra. Lower bound of the left L. differs from the same border right in what begins on a cartilage of the VI edge on the okologrudinny line.
To a top of H.p. of the medial party the subclavial artery prilezhit. Costal surface of L. adjoins to a parietal pleura. At the same time behind to L. prilezhat the intercostal vessels and nerves separated from them by a pleura and an intrathoracic fascia. Basis of L. lies on the corresponding dome of a diaphragm. Right L. separates a diaphragm from a liver, left — from a spleen, a left kidney with an adrenal gland, a stomach, a cross colon and a liver. Medial surface of the right L. in front from gate prilezhit to the right auricle, and above — to the right brachiocephalic and upper vena cava, behind gate — to a gullet. Medial surface of the left L. adjoins in front from gate to a left ventricle of heart, and above — to an aortic arch and the left brachiocephalic vein, behind gate — to a chest aorta (fig. 7). Syntopy of roots L. it is various (fig. 8 and 9) on the right and at the left. In front from a root of the right L. the ascending aorta, an upper vena cava, a pericardium and partially right auricle are located; from above and behind — an unpaired vein. To a root of the left L. from above the aortic arch, behind — a gullet adjoins. Both roots in front cross phrenic, and behind — vagus nerves.
NOMENCLATURE OF BRONCHOPULMONARY SEGMENTS
L. are divided into shares by means of interlobar cracks (fig. 2) into which the visceral pleura gets, covering interlobar surfaces of L. V interlobar cracks the pleura on 1 — 2 cm does not reach a root L. Left L. it is divided on top and bottom shares (lobi sup. et inf.) by means of a slanting crack (fissura obliqua) passing on a surface of L. in the direction from above and behind down and forward. The projection of a slanting crack to a chest wall is defined from an acantha of the III chest vertebra behind to the conjunction of bone and cartilaginous part VI of the left edge (fig. 6,6). Right L. consists of three shares: upper, average and lower (lobi sup., med. et inf.). Upper and average shares separate from lower the slanting crack corresponding to the same crack of the left L. The average share from upper separates a horizontal crack (fissura horizontalis). The projection to a chest wall passes it from a point of intersection of a projection of a slanting crack with the average axillary line almost horizontally forward to the place of an attachment to a breast of a cartilage of the IV edge (fig. 6, c). Size, form and quantity of shares of L. vary. So, the average share usually borrows on a costal surface of the right L. 1/3 all areas, but can occupy also from 1/4 to 1/2 these surfaces. Extent of merge by a top and bottom share of each L. various as approximately in 20% of cases the incomplete interlobar slanting crack is found. An union between upper and average shares of the right L. it is observed in 10 — 20% of cases. Sometimes additional cracks which form the following more or less separate additional shares meet: 1) cordial share of the right L., corresponding to a medial basal segment; 2) back share (lobus post.), arising owing to eliminating of an apical segment of the lower share from group of basal segments; 3) division of an upper share of the left L. on top and bottom half; 4) additional share of the right L. (lobus azygos), separated from an upper share by a furrow on its medial surface from abnormally located unpaired vein; 5) division of an average share of the right L. an additional crack between medial and lateral segments.
The bronchopulmonary segment represents site L., more or less fully separated from the same neighboring sites by connective tissue layers, in limits to-rogo branch a segmental bronchus (see. Bronchial tubes ) and the branch of a pulmonary artery (fig. 10 and 11) corresponding to it. The veins which are taking away blood from segments pass in connective tissue partitions between the next segments. Segments L. have the form of pyramids or cones which top is directed to gate, and the basis — to a surface of L. According to the International nomenclature of pulmonary segments (London, 1949) fixed with little terminological changes in PNA, in each L. allocate 10 bronchopulmonary segments (color. fig. 1).
On PNA, in an upper share of the left L. the apical segment combines with back (segmentum apicoposterius S1-2). A medial basal segment in the left L. can be absent or be poorly expressed.
Majority of segments L., especially large, are divided into 2 — 3 subsegments ventilated by bronchial tubes of the 4th order. In clinic topography of segments L. has very essential value.
Right upper share. The apical segment has the cone-shaped form, is located in the verkhneperedny site of an upper share. On a costal and medial surface of L. borders on front and back segments. The top of a segment is directed down to an upper lobar bronchus. The segmental bronchus (B1) has the vertical direction and is divided into two subsegmental bronchi.
The back segment occupies a dorsal part of an upper share, adjoins to a posterolateral chest wall at the level of II — the IV edges. From above borders on an apical segment, in front — with front, from below a slanting crack separates from an apical segment of the lower share, from below and ahead borders on a lateral segment of an average share. The top of a segment is directed in front to a superlobar bronchial tube. B2 goes kzad, lateralno and several up.
The front segment borders from above with apical, behind — on a back segment of an upper share, from below — on lateral and medial segments of an average share. The top of a segment is turned back and is medially from a superlobar bronchial tube. The front segment adjoins to a front chest wall between cartilages of the I—IV edges, the medial surface of a segment is turned to the right auricle and an upper vena cava. B3 goes from top to bottom, kpered and lateralno.
Right average share. The lateral segment of a pyramidal form, is located with the basis on a costal surface of L., at the level of IV — the VI edges. The segment from above is separated by a horizontal crack from a front and back segment of an upper share, from below and behind — and medially borders by a slanting crack from a front basal segment of the lower share on a medial segment of an average share. The top of a segment is turned up, medially and back. B4 goes lateralno forward and from top to bottom.
The medial segment is defined preferential on medial and partially on costal and phrenic surfaces of an average share, is turned to a front chest wall, between cartilages of the IV—VI edges, medially adjoins to heart, from below — to a diaphragm. The segment from above is separated by a horizontal crack from a front segment of an upper share, lateralno the c in front borders on a lateral Segment of an average share. B5 goes forward and from top to bottom, parallel to a bronchial tube of a front segment of an upper share.
Right lower share. The apical (upper) segment occupies an upper part of the lower share and prilezhit to a back chest wall at the V—VII level of edges, to a backbone and a postmediastinum. From above by a slanting crack it is separated from a back segment of an upper share, from below borders with back basal and partially on a front basal segment of the lower share. B6 is the first back branch of the right lower lobar bronchus and passes to a segment slantwise.
The medial (cordial) basal segment the basis comes to medial and partially phrenic surfaces of the lower share, adjoining to the right auricle, the lower vena cava and a diaphragm. In front, lateralno and behind borders on other basal segments of the lower share. The top of a segment is turned to gate of L up. B7 is an upper branch of the general trunk of a bronchial tube of segments, there are kpered and down.
The front basal segment is turned by the basis on a phrenic surface of the lower share. The lateral surface of a segment prilezhit to a side chest wall between VI — VIII edges. The segment in front is separated by a slanting crack from a lateral segment of an average share, medially borders on a medial basal segment, behind — with apical lateral and back basal segments. B8 departs from the general bronchial tube of basal segments anterolateralno.
The lateral basal segment in the form of the small extended pyramid puts between other basal segments so that its basis is on a phrenic surface of the lower share, and the lateral surface is turned to a side chest wall between the VII—IX edges. Fish-traps sha a segment it is directed up and medially. B9 departs the general trunk with a back basal segment and follows in the posterolateral direction.
The back basal segment is behind other basal segments, below an apical segment of the lower share. Is defined on costal, medial and partially on phrenic surfaces of the lower share, adjoining to a back chest wall at the level of VIII — the X edges, to a backbone, to a postmediastinum. An upper part of a segment sometimes separates in the form of an independent subapical segment. B10 continues the direction of the lower lobar bronchus and extends kzad and down.
Left upper share. The apical segment in a form and situation corresponds to an apical segment of the right L. Behind the segment prilezhit to a back chest wall at the level of the first II—III edges, medially — to an aortic arch and the left subclavial artery. B1 often departs from the general bronchial tube with a back bronchial tube (an apical back bronchial tube).
The back segment by situation is also similar to a similar segment of the right lung. Prilezhit to a posterolateral chest wall at the level of III — the V edges. B2 branches off from an apical back bronchial tube.
The front segment is one of the largest segments of the left L. It adjoins to a lobby and a lateral chest wall at the I—IV level of edges. A medial surface it adjoins to a left ventricle of heart. B3 from an upper trunk of an upper lobar bronchus goes kpered, up and lateralno.
The upper lingular segment is located under front and back segments and prilezhit to a front chest wall at the level of III — the IV edges, and to a sidewall — at the level of IV — the VI edges. B4 departs from the lower (lingular) trunk of an upper lobar bronchus and goes up, kpered and lateralno.
The lower lingular segment is located under upper lingular. From below and behind the segment separates a slanting crack from front and medial basal segments of the lower share. B5 arises from a lingular bronchial tube and extends from top to bottom, kpered and lateralno.
Left lower share. The apical (upper) segment on borders and topography is similar to the same segment of the right lung. The B of Q departs from the lower lobar bronchus of an upper lobar bronchus 1 cm lower than the mouth and extends kzad.
Medial (cordial) basal segment non-constant. Is located on the medial surface of a lung of a kpereda from a pulmonary sheaf in the form of a narrow wedge. B7 departs from the general trunk together with a bronchial tube for a lateral basal segment and lies usually kpered from it.
Front, lateral and back basal segments by situation and borders are similar to basal segments of the right lung. Segmental bronchi of front and back basal segments — final divisions of the lower lobar bronchus.
Blood supply of L. it is carried out by pulmonary and bronchial vessels. Pulmonary vessels make a small circle of blood circulation and carry out hl. obr. function of gas exchange between blood and air. Bronchial vessels provide food of L. also belong to a big circle of blood circulation. Between these two systems there is rather expressed anastomosis. Bronchial branches branch only to respiratory bronchioles, and food of a wall of alveoluses occurs through a capillary network of pulmonary vessels. The right and left pulmonary arteries are branches pulmonary trunk (see). Pulmonary arteries in L. are divided into share, and then segmented branches (fig. 12). The front trunk departs from the right pulmonary artery up (truncus ant.), divided into apical and front segmented arteries (aa. segmentales apicalis et ant.). Back segmented artery (. segmentalis post.) independently distalny departs began a front trunk. The piece of a pulmonary artery after an otkhozhdeniye of a front trunk is called an interlobar trunk (truncus interlobaris). At the level of a midlobar bronchial tube the average share artery (a. lobaris media) which is divided into lateral and medial segmented arteries originates from an interlobar trunk (aa. segmentales lat. et med.). After an otkhozhdeniye of an average share artery the interlobar trunk proceeds in the form of the lower share artery down (a. lobaris inf.), edges gives an apical segmented artery (a. segmentalis apicalis) and proceeds as a basal part. 4 segmented arteries depart from it to basal segments of the lower share: medial, front, lateral and back basal (aa. segmentales basales med., ant., lat. et post.). The left pulmonary artery in gate of L. lies on an upper semi-circle of the left primary bronchus, bends around behind the left upper bronchial tube and goes down. Apical and back segmented arteries depart from the forefront of the left pulmonary artery (aa. segmentales apicalis et post.), from an interlobar part — a front segmented artery (a. segmentalis ant.) and the general lingular artery (a. lingularis communis), edges is divided on top and bottom lingular segmented arteries (aa. segmentales lingulares sup. et inf.). Interlobar part passes directly into the lower share artery (a. lobaris inf.), from a cut segmented arteries depart: apical (a. segmentalis apicalis) and 4 basal — medial, front, lateral and back (aa. segmentales basales med., ant., lat. et post.). Division of a pulmonary artery into segmented branches is individually changeable. The quantity of branches, their length, levels and corners of an otkhozhdeniye (fig. 13) can be various. Branching of segmented arteries happens preferential dichotomizing and corresponds to branching of a bronchial tree. Branches of a pulmonary artery of different orders up to intra lobular vessels are arteries of muscular and elastic type, the arteries accompanying terminal bronchioles - — arteries of muscular type. In arterioles and at the beginning of precapillaries in their wall the smooth muscle sphincters providing regulation of a blood-groove lie. In a wall of arterioles bezmyshechny sites alternate with muscular, and in precapillaries (to dia. 40 — 70 microns) muscle cells are absent. Precapillaries are located between the alveolar courses and give 12 — 20 capillaries to dia. 6 — 12 microns in Interalveolar partitions. Capillaries form 4 — 12 loops on a wall of alveoluses merge in post-capillaries. Network of capillaries in L. very dense. The total area of a capillary network is one L. makes 35 — 40 m 2 . Not all capillaries are open for a blood flow. At rest the most part of capillaries is fallen down, and blood flows in the short way from precapillaries to post-capillaries. Width of post-capillaries apprx. 50 microns, in their walls is not present smooth muscle cells. Post-capillaries proceed in the venules 50 — 80 microns wide containing separate muscle cells in a wall.
Intra lobular veins, leaving segments, fall into veins of interlobular partitions. Here veins of subpleural connecting fabric fall. From interlobular veins intersegmental veins, veins of segments and shares which in gate of L form. pulmonary veins merge in top and bottom. Formation of pulmonary veins differs in complexity and big variability (fig. 14). In the right L. the upper pulmonary vein forms from veins an upper and average share, lower — from veins of the lower share. In the left L. top and bottom pulmonary veins are formed by merge in pulmonary veins according to a top and bottom share. From 2 to 5 large inflows can take part in formation of a pulmonary vein. Top and bottom pulmonary veins of both L. fall into the left auricle. The left pulmonary veins before falling into an auricle often merge in the general trunk. The number of the right pulmonary veins falling into the left auricle can increase to six.
Bronchial branches depart from a back surface of an aorta, most often on border between its arch and the beginning of the descending aorta: (fig. 15). On the right bronchial arteries can depart from the first intercostal artery and an internal chest artery. Total quantity of bronchial arteries is most often equal 4 (on 2 for each lung), but from 2 to 6 can fluctuate. Except bronchial branches, esophageal and pericardiac arteries which branches get into L take part in blood supply of a lung. through a pulmonary sheaf. Bronchial branches in L. follow on the course of bronchial tubes. One bronchial tube is followed more often by 2 — 3 branches. On bronchial tubes form the peribronchial arterial network giving the arterioles and capillaries connecting to capillaries of pulmonary arteries. In pulmonary fabric bronchial branches anastomose with branches of a pulmonary artery; a numerous arteriovenous anastomosis — transition of the closing arteries to veins of bronchial tubes, subpleural veins, interlobular veins — inflows of pulmonary veins is found (color. fig. 4).
Bronchial veins of the right L. fall into unpaired, it is rare in an internal chest vein; left L. — in semi-unpaired or is more rare directly in the left brachiocephalic vein. Some small bronchial veins arising from a peribronchial veniplex of bronchial tubes, bifurcation of a trachea from limf, nodes, fall in gate of L. in pulmonary veins. In pulmonary sheaves and cellulose of a mediastinum bronchial veins anastomose with veins of a mediastinum.
Beginning limf, ways of L. superficial and deep networks limf, capillaries (fig. 16 and 17) are. The superficial network is located in a visceral pleura and consists of thin limf, capillaries to dia, in 9 — 25 microns from which the lymph passes into a texture limf, vessels of the 1, 2 and 3 orders. The deep capillary network is in connecting fabric in pulmonary segments, in interlobular partitions, in a submucosa of a wall of bronchial tubes, around vnutriletochny blood vessels and bronchial tubes. According to D. A. Zhdanov, in a pulmonary segment limf, capillaries are located in interalveolar partitions and proceed in the capillaries accompanying the alveolar courses and small blood vessels. Krokeatto (O. S. of Croxatto, 1972) claims that in distal parts of segments of L. about alveoluses limf, there are no capillaries, but Louerins (J. M of Lauweryns, 1974) described yukstaalveolyarny limf, capillaries as most distally located limf, formations of L. Perivascular and peribronchial limf, capillaries and vessels anastomose in segments and on the way to gate of L., where they, merging among themselves, form collector taking away limf, vessels L. Limf, the vessels located in a visceral pleura anastomose with interlobular and intra lobular limf, capillaries and vessels. Thanks to these bonds current of a lymph from a superficial limf, network L. can go to deep limf, networks and further to gate of L. Regional limf, nodes L. on PNA combine in the following groups: 1) pulmonary (nodi lymphatici pulmonales), located in a parenchyma of L., hl. obr. in places of division of bronchial tubes; 2) bronchopulmonary (nodi lymphatici bronchopulmonales), lying in gate and adjacent sites L.; 3) upper tracheobronchial (nodi lymphatici tracheobronchiales sup.), connected on an arrangement with a trachea and an upper part of primary bronchi; 4) the lower tracheobronchial — bifurcation (nodi lymphatici paratracheobronchiales inf.), the bifurcations of a trachea located on a lower surface and on primary bronchi; 5) peritracheal (nodi lymphatici tracheales), located along a trachea (fig. 18). On ways of a lymph drainage everyone L. it is divided into three areas: upper, average and lower which do not match shares. In the right L. the lymph from the upper area including an anteromedial part of an upper share flows in right peritracheal and upper tracheobronchial limf, nodes. From the average area occupying posterolateral departments of an upper share, an average share and an upper part of the lower share, the lymph goes partially in right upper, and mostly in lower tracheobronchial limf. nodes. From the lower area, i.e. from the remained departments of the lower share, the lymph flows in lower tracheobronchial limf, nodes; a part of a lymph goes from top to bottom to phrenic limf. nodes. In the left L. the lymph from upper area arrives in left tracheal and upper tracheobronchial limf. nodes, and also in front mediastinal nodes. From the average area including a uvula upper, a top and a middle part of the lower share, the lymph extends in two directions: to the left upper tracheobronchial, upper lobbies mediastinal and to lower tracheobronchial limf, to nodes. From the lower area the lymph flows in lower tracheobronchial limf. nodes. Besides, from the lower shares of both L. there are limf, vessels going down between leaves of a pulmonary sheaf to the back mediastinal nodes located behind a gullet at a diaphragm. Taking out limf, vessels of these nodes go to an abdominal cavity to celiac limf, nodes. Limf, nodes of the left and right L. widely anastomose among themselves, with front and back mediastinal limf, nodes. In lower tracheobronchial limf, nodes of an outflow tract of a lymph from lungs connect to vessels from heart and a gullet. The taking-out vessels left peritracheal and upper tracheobronchial limf, nodes go preferential to the right same nodes which are according to D. A. To Zhdanov, «the main station of a lymph of both lungs». From the right limf, nodes the right bronkhosredostenny trunk begins (truncus bronchomediastinalis dext.), falling into the corresponding jugular trunk (truncus jugularis) or into deep cervical nodes. Thus, the most part of a lymph from both L., flows in the right limf, a channel (ductus lymphaticus dext.). From upper parts of the left L. the lymph flows directly to the chest canal (ductus thoracicus) more often.
Nerves of L. separate from a vagus nerve, nodes of a sympathetic trunk, and also a phrenic nerve in the form of the bronchial and pulmonary branches forming in gate of L. the pulmonary plexus (plexus pulmonalis), a cut is divided on front and back (fig. 19). Their branches form in L. the peribronchial and perivazalny textures accompanying branchings of bronchial tubes and blood vessels. On the course of textures small accumulations of nervous cells of the parasympathetic nature meet. In bronchial tubes distinguish three neuroplexes: adventitious, muscular and subepithelial; the last on bronchioles extends up to alveoluses. Interoceptors are located in bronchial tubes, blood vessels, an alveolar parenchyma, a visceral pleura, connecting fabric L.
In an adventitia of vessels glomal cells meet. Sensitive innervation of L. it is carried out by dendrites of cells of the lower node of a vagus nerve and cells of the lower cervical and upper chest spinal nodes. V. F. Lashkov established a possibility of participation in an innervation of easy spinal nodes from C5 up to L2. Nervous impulses from bronchial tubes are carried out by hl. obr. but to afferent fibers of vagus nerves, and from a visceral pleura — on afferent spinal fibers. Sympathetic innervation of L. comes from cells of side horns of gray matter of Th2-5 segments of a spinal cord (fig. 20). The way of a parasympathetic innervation begins in a myelencephalon from cells of a back kernel of a vagus nerve. Axons of these cells pass in L. as a part of branches of a vagus nerve.
Establishment of breath and raspravleny L. leads to increase in its vertical size, smoothing of edges, fading in of impressions on a pulmonary surface from an aorta, the general sleepy and subclavial arteries, heart, domes of a diaphragm. Top of L. gradually rises over the level I of an edge and clavicle, front edges of L. approach a midline, fill costal and mediastinal sine, and their projection to a front chest wall is combined with a projection of front pleural borders. Lower bound of L. the breathing child falls by one edge in comparison with not breathing. Syntopy of L. the newborn differs in rather big area of a prileganiye to a thymus and heart. Newborns have lower shares of both L. much more upper. Approximately by 2 years of a ratio of the sizes of shares become same, as at adults. Specific weight (weight) of L. the breathing newborn — 0,49. Weight is both L. at the newborn with the established breath from 39 to 70 g, including right — from 21 to 37 g, left — from 18 to 33 g fluctuate. In the aerated L. the newborn the most part of alveoluses finishes, however there is a nek-swarm a quantity of the atelectatic alveoluses containing liquid. Elements of an acinus at the newborn are differentiated by incompleteness. Growth of L. the hl is caused. obr. increase in quantity and volume of alveoluses and consequently, and volume L. Objem L. by 8 years increases by 8 times, the child has 12 years — by 10 times, at the adult — by 20 times. Mass of L. after the birth grows very quickly, especially in the first 3 months of life. On average weight is both L. newborn 57 g, at children of 1 year have 225 g, 6 years — 350 — 400 g, by 15 years it reaches 600 — 900 g, and right L. at all age it is about 1,2 times heavier left. Pulmonary segments of the child and adult are externally similar, but in the first years of life they are delimited from each other by more plentiful layers of friable connecting fabric. To 8-year age in L. there are intensive processes of a differentiation of an epithelium, cartilages, elastic fibers and muscle bundles of bronchial tubes. From 12-year age of L. on external and to interior L are similar. adult.
Involution of lungs in the course of aging is most expressed after 70 years, but differently at people of the same age and even within the same L. It covers all structures. Epithelium of bronchial tubes becomes lower, in kernels are defined a polyploidy, the basal membrane is thickened, glands atrophy, the secret is condensed, the muscular layer atrophies, cartilages are exposed to a necrosis, calcification, ossification. All this breaks clarification of bronchial tubes and together with thinning of walls of alveoluses, change their elastics promotes development hron, bronchitis and L. Osobenno's emphysema atrophy and walls of respiratory bronchioles are sclerosed that also promotes emphysema. However emphysema develops not always, and only in cases of accession hron, bronchitis or disturbance of secretion of bronchial tubes at coronary heart disease»
On the roentgenogram of L. peripheral departments are engaged in a direct projection (fig. 21) with a shadow of soft tissues of a lower part of a neck, thorax and a shoulder girdle. At women on lower parts of pulmonary fields shadows of mammary glands are projected. Under an array of soft tissues the skeleton is located thorax (see). L. form in a picture so-called pulmonary fields — right and left. The right pulmonary field well and slightly more widely than left is normal. The sites of this field which are projected above a shadow of clavicles are called tops of L. Each pulmonary field is conditionally divided into three departments: upper, average and lower. The upper part is between the upper edge of the pulmonary field and the horizontal line drawn at the level of bottom edge of the front end of the II edge. The average department is located between this line and a line parallel to it drawn at the level of bottom edge of the front end of the IV edge. The lower part occupies the rest of the pulmonary field to a diaphragm. Besides, vertically directed parallel lines drawn according to border between thirds of a clavicle, the pulmonary field is divided into three zones: internal, or radical, average and outside.
L. the healthy person is filled with air and therefore on the roentgenogram are represented light. But pulmonary fields not of a besstrukturna. In their internal departments, between the front ends II and IV edges, the intensive shadow of roots L is visible. On the right it has the form of a half moon, is separated from a shadow of a mediastinum by a transparent strip of an intermediate and lower lobar bronchus. The shadow of the left root is located slightly above and partially hidden by a shadow of heart. The image normal poring differs in differentiation. In its upper part the shadow of a pulmonary artery decides on the vessel departing from it for an upper share. From this shadow the trunk of the lower share artery giving branches to other departments of L is projected from top to bottom. The lower bound of a root is the shadow of the large pulmonary veins going almost horizontally to the left auricle at the level of VIII — the IX chest vertebrae.
Against the background of pulmonary fields a peculiar pulmonary drawing appears. It is formed normal by shadows of arteries and veins; bronchial tubes, intersticial fabric and limf, system poorly participate in its formation. In radical area the largest vessels are located, and the drawing is expressed clearly here. To the periphery the caliber of vessels decreases, and only small vascular branches are outlined in an outside zone of the pulmonary field. Density of the drawing in different departments is not identical — wedge-shaped sites with abundance of vascular shadows and low-vascular zones naturally alternate. This results from the fact that share and segmented vessels proceed from a root in the form of several bunches dispersing at an angle. At the same time segmented arteries are projected in upper parts of pulmonary fields of a knutra from the veins of the same name, in average departments — over them and in lower — knaruzh from them. Correctness of branching, clearness of contours and reduction of caliber of vessels to the periphery is normal typical for the pulmonary drawing. Depending on an arrangement of vessels in relation to X-ray they give display in the form of strips, circles and ovals.
Each half of a diaphragm causes the arch going from a shadow of a mediastinum to side department of a thorax on the direct roentgenogram, with a contour a cut it makes the corner corresponding costal phrenically to a sine. The top of the right half of a diaphragm lies at the height of front end of VI edge, and left — is 1 — 2 cm lower. At individuals the diaphragm at a breath forms folds; in these cases the contour of a half of a diaphragm consists of 2 — 4 arches.
On the roentgenogram in a side projection both L. are projected at each other, making one pulmonary field (fig. 22). In it two big light sites are allocated: pozadigrudinny (retrosternal) space — between a breast and a shadow of an aorta and heart; pozadiserdechny (retrocardial) space — area between heart and a backbone. Between these sites there is a shadow of heart and large vessels. In an upper part of the pulmonary field, a kpereda from a shadow of a backbone, there is a light strip of a trachea width several more than 2 cm. Going from top to bottom, the trachea is narrowed at the level of the lower contour of an aortic arch and divided here into two primary bronchi. Right — as if continues a light strip of a trachea, and left — departs at an acute angle kzad. At the end of the image of the right primary bronchus the round enlightenment from the axial section of the right superlobar bronchial tube is usually visible.
Roots L. give a total shadow 2,5 — 3 cm wide on the side roentgenogram. Its upper part is formed by hl. obr. the left and right branches of a pulmonary artery, and the image of the left branch goes almost parallel to the lower contour of an aortic arch. The lower bound of a shadow of roots consider the image of the wide venous trunks seen against the background of retrocardial space at the level of VIII and IX chest vertebrae. These veins merge in the lower pulmonary vein. The pulmonary drawing on the side roentgenogram is also submitted generally by shadows of blood vessels; more clearly adjacent L. Luchshe's vessels are visible vascular bundles which go to front and back departments of L are defined., in particular arteries and veins of front segments, average share, uvula, upper segments. Arteries and veins of segments lower down with make a difficult bunch of vascular shadows against the background of retrocardial space, in Krom large vessels of the lower group of veins stand out most clearly.
Both half of a diaphragm cause the arches going one above another or crossed. The forefront of each arch forms the superficial corner corresponding to front department of a costal and phrenic sine with a contour of a front chest wall, and the tail makes the deep corner corresponding to back department of a sine with a contour of a chest wall.
For profound studying of a radioanatomy and X-ray physiology of L. apply special methods: tomography (see), bronchography (see), etc. On tomograms of roots L. bronchial tubes 1 — the 2nd order, the main branches of a pulmonary artery and large pulmonary veins are excreted. In pictures of various layers of L. it is possible to identify all share and segmented arteries and veins, and also the primary, lobar and segmental bronchi (bronchial tubes of the 3, 4, 5, 6 and 7 segments are visible to hl. obr. on side tomograms). On pictures through lattices applicators it is possible to estimate the mechanism of external respiration (by means of roentgenometry), and in the way densitometries (see) — ventilation of the lungs. Structure of a breath and exhalation, ventilation of different zones L. and rate of propagation of pulse wave in L. investigate by means of elektrokimografiya (see) and video densitometries (see). Studying of a series of bronkho-grams allows to make idea of morphology and function of a bronchial tree (see. Bronchography ), and series of angiograms of L. — about morphology and function of vessels of a small circle of blood circulation (see. Angiopulmonografiya ) and bronchial arteries.
Borders of shares and segments on roentgenograms of L. the healthy person are, as a rule, not visible since the interlobar pleura is thin and does not give the independent image. The location of shares and segments is defined approximately, being guided by data of topographical anatomy. In the figure 23 the projection of shares and segments to front and side roentgenograms is presented. It is visible that in a front picture the image of various shares substantially matches. Pulmonary fabric of an upper share is separately projected only in apical and side department of pulmonary zero, and the lower share — in a niya - not side. Therefore for topical diagnosis side roentgenograms have bigger value; on them shares of L. are projected generally separately. The projection of a slanting interlobar crack in a side picture goes from the highest point of a diaphragm, i.e. usually from the back end of front its third, up through the middle of a shadow of a root and further before crossing with a shadow of a backbone. The horizontal interlobar crack goes from the front end of the IV edge to the middle of a shadow of a root before crossing with a slanting crack.
At not breathing mortinatus child pulmonary fields on roentgenograms are not differentiated; only bones of a thorax are visible. At the newborn the light strip of a trachea and gleams of large bronchial tubes is defined. Pulmonary fields are rather small in connection with the big width of a median shadow and a high position of a diaphragm. Roots L. are presented by narrow strips and roundish shadows of branches of a pulmonary artery. Because of small caliber of vessels the pulmonary drawing is distinguishable poorly (fig. 24). At early children's age, in process of lowering of a diaphragm and reduction of a thymus, a shadow of roots L. become more and more visible, but are still located at one height (sometimes the left root is even lower than right). At shout, cough and tension of the child the shadow of roots becomes more widely and more intensively that can simulate existence patol, changes.
Children of the first years have lives anatomic feature of L. the deviation of a trachea to the right from the centerline of a body and a high position of its bifurcation is. By 10 — 12 years bifurcation falls from the level III of a chest vertebra, chest to level VI. At small children respiratory fluctuations of caliber of bronchial tubes are sharply expressed. At a strong exhalation the gleam even of rather large bronchial tubes can disappear. L. at children are more full-blooded, than at adults; veins are rather narrow; a blood flow in them more bystry. At children at the age of 7 years is also more senior the shadow of a normal pleura in the form of the arc-shaped strip over a top of L is quite often visible. and the narrow line in an outside zone of the pulmonary field in the area I and II of edges. The diaphragm is located highly, more flattened, than at adults, pleural sine less deep. For the first 12 years of life the diaphragm falls from level VIII to the XI chest vertebra and becomes more convex in this connection pleural sine go deep. At the big size of a thymus expansion of a shadow of an upper part of a mediastinum on the front roentgenogram and blackout of retrosternal space in a side picture is defined.
At people of advanced age (60 — 74 years) increase in intensity of a shadow of roots L is noted. and reduction of their differentiation. It is expressed even stronger at persons of senile age (75 — 89 years). Cross sectional dimensions of large bronchial tubes and veins during the aging do not change, arteries in roots L. extend, more at men. On tomograms in walls of a trachea and large bronchial tubes deposits of lime come to light. Transparency of pulmonary fields is increased, moderate diffusion strengthening of the pulmonary drawing without its deformation is defined. At senile age crimpiness of bronchial tubes accrues, their gleam becomes uneven, places chetkoobrazny.
L. consists of branchings of the bronchial tubes forming a bronchial tree (pneumatic ways of L.), and systems of alveoluses which together with respiratory bronchioles, the alveolar courses and alveolar sacks make an alveolar tree (a respiratory parenchyma of L.). As a result of 8 — 10 branchings of a primary bronchus small bronchial tubes to dia are formed. apprx. 1 mm which wall still contains cartilaginous plates. Branchings of each of them create secondary pulmonary segments (lobuli pulmonales secundarii; fig. 25). On Gayeka (H. Hayek, 1960), in both L. is apprx. 1000 lobular bronchial tubes. However, on sovr, to representations, lobular bronchial tubes and pulmonary segments in L. it is more — apprx. 800 in everyone. The next segments are separated one from another and from a visceral pleura by the interlobular partitions consisting of the friable fibrous connecting fabric connected by subpleural and peribronchial connecting fabric. In interlobular partitions there pass lobular veins and network limf, capillaries. Segments are located in two-three rows in a peripheral layer of a share of L. up to 4 cm thick, surrounding the central part of a share where in connecting fabric there pass branchings of a lobar bronchus, a branch of a pulmonary artery and a vein, limf, vessels and nerves (color. fig. 2). Superficial segments are similar to polygonal pyramids 21 — 27 mm high and 9 — 21 mm wide. Deep segments more small, have the irregular many-sided shape. The smallest segments 5 mm wide are in area of a top and bottom edge of L. In a segment there is a further branching of a lobular bronchial tube up to a trailer bronchiole (bronchiolus terminalis). Trailer bronchioles dichotomizing are divided into respiratory (respiratory) bronchioles (bronchioli respiratorii) 1 — the 4th orders. Respiratory bronchioles, in turn, are divided into the alveolar courses (ductuli alveolares) which are branching from one to four times and coming to an end with alveolar sacks (sacculi alveolares). On walls of the alveolar courses and alveolar sacks, and the Tat of respiratory bronchioles the alveoluses of L opening in their gleam are located. (alveoli pulmonis).
Morfofunktsionalny unit of respiratory department of L. the acinus is (acinus pulmonaris — color. fig. 3).
Given to morphology and physiology allow to consider that the acinus begins from a trailer bronchiole. The concept «acinus» joins all branchings of one trailer bronchiole — respiratory bronchioles of all orders, the alveolar courses and alveoluses. In one pulmonary segment there are 16 — 18 acinus. According to Hansen (J. E. Hansen) et al. (1975), an acinus contains one trailer bronchiole, 14 — 16 respiratory bronchioles, 1200 — 1500 alveolar courses, 2500 — 4500 alveolar sacks and 14 000 — 20 000 alveoluses. On average about 3,5 alveoluses with a maximum of 8 alveoluses are the share of one alveolar sack. The calculated volume of an acinus of 182,8 mm3. And. G. Eyngorn (1956), Rayen (S. Ryan, 1973), Raskin and Herman (S. P. Raskin, P. G. Herman, 1975) allocate in L. smaller structural parts — primary pulmonary segments (lobuli pulmonales primarii) which include one respiratory bronchiole and the related alveolar courses and alveoluses. One acinus contains about 16 such segments. In only one L. apprx. 15 000 acinus, 300 — 350 million alveoluses. General surface of all alveoluses of one L. it is very considerable. However data on this question are ambiguous. On Heysletona (P. S. Hasleton, 1972), the interior area of L., fixed during the inflating by vapors of formalin, 24 — 69 m 2 . Across Veybel (E. R. Weibel, 1963), it makes 95 m 2 , and on Hillsa (V. of A. Hills, 1973) — 146 m 2 .
Trailer bronchioles are covered by a single-layer secretory epithelium. In bronchioles there are two types of cells: ciliate and not ciliate. Thin own plate of a mucous membrane contains longitudinal elastic, collagenic, reticular fibers and spiral bunches of the smooth muscle cells forming in places a continuous layer. In a wall of trailer bronchioles there are no glands and cartilaginous plates. The connecting fabric surrounding bronchioles passes into a connective tissue basis of a respiratory parenchyma of L. V respiratory bronchioles cubic cells of an epithelium lose cilia; upon transition to the alveolar courses cubic epithelial cells are replaced with respiratory alveolotsita. The muscular plate in a respiratory bronchiole becomes thinner and breaks up to the directed smooth muscle cells separate spiralno. They are especially expressed in ring sites of respiratory bronchioles, free from alveoluses. Walls of the alveolar courses and alveolar sacks, shaped gemi-spheroid or the truncated cone, are entirely busy with alveoluses. In a form 6 types of alveoluses are allocated: spheroid about 3/4 spheres, spheroid about 1/4 spheres, the truncated cone, cylindroid with a hemispherical bottom, cylindroid with a flat bottom, the truncated long ellipsoid. In cross-section their form varies from a hexagon to an ellipse (fig. 26). According to Hansen, the size of the mouth of an alveolus of the adult makes 0,15 — 0,25 mm, and its depth — 0,06 — 0,3 mm. In old age diameter of the mouth of an alveolus increases. Alveoluses closely adjoin to each other therefore their walls adjoin and serve as interalveolar partitions. The edges of these partitions acting in a gleam of the alveolar course are a little thickened and form as if the rings surrounding entrances to alveoluses. In the alveolar courses in these rings there are bunches of smooth muscle cells forming muscles of a respiratory parenchyma of L. V alveolar sacks an entrance to alveoluses is surrounded only with rings of elastic reticular fibers. The next alveoluses are reported among themselves by an alveolar time (pori alveolares), openings to dia. apprx. 10 — 15 microns. The wall of an alveolus is covered by a single-layer flat respiratory alveolar epithelium and contains two types of cells: respiratory (scaly) and big (granular). It is established that cells of an alveolar vystilka from the air space are covered with a thin noncellular coat or a film. According to most of researchers, this layer partially or entirely consists of surfactant — the substance having well-marked surface-active properties. The third type of alveolar cells — alveolar phagocytes (macrophages) — is located in the air space of alveoluses, almost always in the neighbourhood with an alveolar wall. Cells of an alveolar epithelium form the continuous layer which is Becoming thinner to 0,2 microns, but not interrupted in places of a prileganiye to capillaries (fig. 27). The alveolar epithelium is located on a basal membrane 0,05 — 0,1 microns thick. Outside to a basal membrane prilezhat the circulatory capillaries passing on interalveolar partitions and also network of the elastic fibers braiding alveoluses (fig. 28). Besides, around alveoluses the supporting network of reticular and collagenic fibers is located. All fibers and circulatory capillaries are shipped in the main intercellular substance representing a difficult complex of proteins and mucopolysaccharides. In interalveolar partitions (septi interalveolares) several forms of cells meet. Among them there are sentalny cells which have phagocytal properties. They, getting into a gleam of alveoluses, become alveolar phagocytes. In interalveolar space also leukocytes meet. Since alveoluses closely prilezhat to each other, the capillaries braiding them border by one surface on one alveolus, and another — with next. It provides optimal ny conditions of gas exchange. The border between the blood proceeding on circulatory capillaries, and the air filling cavities of alveoluses is made by an endothelium of a capillary, its boundary membrane, a boundary membrane of an alveolus and an alveolar epithelium (fig. 29). Both boundary membranes can merge in one. In places of a prileganiye of capillaries the barrier between blood and air is thinned due to considerable reduction of a layer of cytoplasm of alveolar and endothelial cells. Thickness of a barrier, according to different authors, makes from 0,1 to 4 microns. Of a share of a thin part of a barrier blood — air is the share 60% of all area of alveoluses. This part of a barrier is the place of the most intensive gas exchange between blood and air.
Main function L. — respiratory. It consists in arterialization of blood in capillaries of a small circle of blood circulation. Three processes are necessary for its performance: ventilation of alveoluses air or gas mixture with rather high partial pressure of oxygen and low partial pressure of carbon dioxide; diffusion of oxygen and carbon dioxide through a pulmonary membrane; a blood stream through capillaries of a small circle of blood circulation. All three processes are closely connected among themselves. Ventilation of L. it is provided with periodic change of a breath and exhalation — external respiration. During a breath owing to increase in volume of a chest cavity pressure in a pleural cavity decreases. It leads to stretching of walls of the alveoluses having elastic properties and increase in volume of L. During an exhalation the elastic forces of lungs and walls of a chest cavity which are saved up during a breath provide reduction of lung volume. At the end of a quiet exhalation when practically all respiratory muscles are relaxed, an elastic energy of L. it is counterbalanced by tension of walls of a chest cavity. Amount of the gas which is at this time in L., is called functional residual capacity (see. Vital capacity of lungs ). If pressure around L. there is atmospheric (open pheumothorax, the isolated lungs), a L. almost are completely fallen down. In them there is only a so-called minimum air volume. In usual conditions, when L. are in the closed chest cavity, pleural pressure in highly located departments is most negative owing to increase in pressure in a pleural cavity in the direction from top to down. This pressure gradient (apprx. 0,23 cm w.g. on 1 cm) it is caused by weight of lungs and hydrostatic pressure of a column of pleural liquid. Big degree of static stretching of pulmonary fabric in upper zones L is a consequence., than in lower though ventilation is carried out more intensively in bottoms of L., than in upper.
Elastic properties L. approximately on 1/3 are caused by existence in walls of alveoluses of elastic fibers and on 2/3 surface intention on border of a concave surface of alveoluses with air. If alveoluses were moistened with a blood plasma from within, surface tension force would be big, about 0,4 — 0,5 mn/cm. Actually this force much less (0,05 — 0,1 mn/cm). Low surface intention is caused by the fact that the surface of alveoluses and a wall of bronchioles is covered with a vystilka from surfactant — surfactant (see). Thickness of a vystilka is 20 — 100 nanometers. It consists of lipids (generally from dipalmitoyllecithin) in a complex with proteins. Surfactant is formed in pnevmotsita of the II type. Increase in the sizes of alveoluses at a breath is followed by growth of surface intention.
Formation of surfactant is regulated by parasympathetic nerve fibrils. Surfactant is necessary for stabilization of a condition of alveoluses. At a lack of surfactant distensibility of L decreases., atelectases are formed, in alveoluses transudes liquid.
Air is carried out to alveoluses and from them on pneumatic ways. Gas exchange through walls of pneumatic ways of practical value has no, the volume of a cavity of pneumatic ways is called the anatomist about accurate dead space. The gleam of intra pulmonary bronchial tubes depends on an elastic energy of the parenchyma of lungs surrounding bronchial tubes and on a tone of smooth muscles of bronchial tubes. The elastic energy expands bronchial tubes, the tone of unstriated muscles narrows them. The gleam of bronchial tubes increases on a breath and decreases on an exhalation. Cholinergic (parasympathetic) fibers strengthen reduction of unstriated muscles of bronchial tubes, adrenergic (sympathetic) fibers weaken it (in bronchial muscles beta adrenoceptors prevail). Distinguish two ways of movement of molecules of gases («cross» and «longitudinal» diffusion). The first — convective — is caused by movement of mix of gases on a gradient of pressure, general for mix.
Besides, in pneumatic ways and alveoluses there is a diffusion of molecules of gases owing to a difference of partial pressure of gases. Existence of connections between the next zones of lungs is established. The air entered into a segmental bronchus iod by pressure of 4 — 8 cm w.g., gets into the next segments (the phenomenon of collateral ventilation). Connections are at the level of the alveolar courses and bronchioles.
Between alveolar air (see) and blood of capillaries of a small circle there is a pulmonary membrane consisting of a surface-active vystilka, a pulmonary epithelium, an endothelium of capillaries and two boundary (basal) membranes. Thickness of a pulmonary membrane is 0,4 — 1,5 microns. The area, through to-ruyu occurs gas exchange — about 90 m 2 . Transfer of gases through a pulmonary membrane is carried out by diffusion of molecules of gases thanks to a gradient of their partial pressure. Each capillary passes over 5 — 7 alveoluses. Time of passing of blood through capillaries 0,35 — 1,7 sec. (on average 0,8 sec.). The big surface of contact, small thickness of a pulmonary membrane, rather small speed of a blood flow on capillaries provide gas exchange (see) between an alveolar air and blood. Permeability of a pulmonary membrane for gas is expressed the size of diffusion capacity L. Uslovy of full gas exchange uniformity of ventilation of all alveoluses and a blood-groove on all capillaries of alveoluses, and also an identical ratio between alveolar ventilation and a blood-groove is. Actually this condition is met not completely. Irregularity of the relations between ventilation and a blood-groove is considered on model L. (fig. 30). It consists of anatomic dead space (volume of pneumatic ways in which there is no gas exchange), effective alveolar space (the ventilated and perfusing alveoluses) ventilated, but not the perfusing alveoluses (alveolar dead space) which are not ventilated, but perfusing alveoluses (the alveolar venoarterialny shunt). Alveoluses of alveolar dead space are ventilated, but gas exchange in them does not happen. In capillaries of the alveolar venoarterialny shunt blood is not arterialized. In actual practice there are gradations from alveoluses with the corresponding ventilation and perfusion to alveoluses without blood-groove and without ventilation. Irregularity of ventilation and a blood-groove is available normal. In the field of tops of an alveolus are ventilated less effectively, than at L. No's basis of distinction of a blood-groove between these areas are expressed even stronger. Therefore in the field of tops ventilation relatively prevails over a blood-groove, and in bottoms of L. the relation of ventilation to a blood-groove is less than unit. As a result tension of oxygen of the arterial blood flowing from area of tops, above, and from bottoms of L. — below an average. Irregularity of distribution of ventilation and blood-groove in separate parts L. — one of the main reasons for arterioalveolyarny voltage difference of oxygen and carbon dioxide. Irregularity increases at pulmonary pathology.
L. are supplied with a peculiar receptor device. V L. mammals there are three types of sensitive nerve terminations: stretch receptors, irritantny receptors, yukstakapillyarny receptors of alveoluses. Their afferent fibers are in vagus nerves. At overflow narrowing of arterioles of a small circle of blood circulation arises blood of the left auricle and pulmonary veins (see. Kitayeva reflex ).
Intensity of blood circulation in a small circle is influenced by the respiratory movements and structure of an alveolar air (see. Breath , Lung ventilation ). Influence of respiratory movements consists that at a breath when pressure in a chest cavity and venas cava decreases, increases inflow of blood to the right half of heart. As a result the consumption of blood a right ventricle, systolic pressure increases in a right ventricle and a pulmonary artery.
At the forced exhalation opposite shifts are observed and the size of a blood-groove decreases. Influence of structure of an alveolar air is defined by the fact that in normal conditions not all alveoluses of L are ventilated., and their considerable part makes a functional reserve of L. If at the same time blood proceeded evenly through capillaries of the air cells (both ventilated, and not ventilated), then a considerable part of blood would not be enriched in lungs with enough oxygen and inevitably there would be an arterial hypoxia. However it does not occur since the blood stream in lungs is not uniform and blood proceeds only through those sites of pulmonary fabric which alveoluses are well ventilated at present. Increase in a pulmonary blood-groove in intensively ventilated sites of pulmonary fabric and its termination in sites where ventilation is absent, does not depend on mechanical factors — inflating and fall of L. during a respiratory cycle. Even at intensive ventilation of one L. sharp reduction of a blood-groove through given L. Ustanovleno that the factor determining the size of a blood-groove through each site of pulmonary fabric with other things being equal is the composition of air in alveoluses of this site happens hydrogen, nitrogen and neon. With a high partial pressure of oxygen in an alveolar air of an arteriole of the respective site of pulmonary fabric extend, and the blood stream through pulmonary capillaries increases; with a low partial pressure of oxygen, on the contrary, there is a narrowing of arterioles and the blood stream decreases. The amount of blood which on average is contained in L., makes 8 — 10% of volume of all circulating blood. In about time physical. works, in the course of digestion, at blood loss and other cases a considerable part of blood leaves pulmonary vessels and is used in those fabrics which activity is most intensive. At return to a condition of rest or at increase in volume of the circulating blood its surplus accumulates in pulmonary vessels again. From all amount of blood of vessels of lungs no more than 60 l-l in one step participate in gas exchange with an alveolar air. It follows from this that the blood which is not participating in gas exchange represents the blood deposited, and L. perform function blood depot (see).
In pulmonary capillaries microorganisms and a cellular detritis are late. In the course of phylogenesis of L. gained ability to defense reaction on the foreign protein getting to them. A number of authors notes that at intravenous immunization by microbic bodies a significant amount antibodies (see) it is synthesized in L. Osobenno a large number of antibodies arises if immunization is carried out by the pneumococcus having the expressed tropism to fabric L. Through L. volatile substances are removed from blood (acetone, methyl mercaptan, ethanol, ether, nitrous oxide, etc.). V L. intensive power processes proceed. They consume apprx. 4% of the oxygen received by an organism, absorb from blood a lot of fat to - t. V L. processes of glycolysis prevail.
Mast cells of L. form heparin, a histamine, serotonin. The mucous membrane of bronchial tubes provides removal from L. dust particles, desquamated epithelium, leukocytes, etc. Mucous and scyphoid cells of a cover epithelium constantly form slime. Secretion of slime is strengthened by both parasympathetic, and sympathetic nerve fibrils. Respectively atropine and beta adrenolytic drugs weaken it. The ciliary epithelium mucous, covers of bronchial tubes moves slime towards large pneumatic ways with a speed of 7 — 19 mm/min. L. participate in process of a thermolysis, in them there is heat waste during the heating of air and evaporation of water (see. Thermal control ).
See also Breath .
METHODS of the RESEARCH
In number of methods of a research L. enter inquiry (see. Anamnesis ), physical methods, functional, tool and laboratory; a specific place is held by a X-ray and radio isotope inspection. In research problems of L. their assessment anatomo-fiziol, and funkts, states, patofiziol, disturbances, character patomorfol, process and an etiology of a disease enters.
Physical methods: survey, palpation (see), percussion (see), auscultation (see). These methods have independent diagnostic value, and also determine the volume of additional researches. Carrying out survey demands observance of certain conditions (the warm room, availability of survey from all directions, scattered daylight or white artificial). At the general survey pay attention to forced situation on a sick side (a lung fever, vypotny and dry pleurisy), sedentary — at the expressed asthma (pheumothorax, an attack of bronchial asthma, a stenosis of a throat, etc.); swelling of cervical veins and epigastric pulsation (decompensation of a pulmonary heart); changes of fingers in the form of drum sticks and nails in the form of clock glasses (chronic, especially purulent, processes in lungs); signs of a deep vein thrombosis of shins (possible source of a thromboembolism in system of a pulmonary artery); cyanosis (one of signs of respiratory insufficiency); a flush on cheeks (at in the fever TB patients and at pneumonia).
At local survey pay attention to a form and symmetry of a thorax (see). The shape of a thorax can depend from patol, changes of lungs, a pleura or its bone skeleton. The combination of both factors is possible. Disturbances of symmetry of a thorax have great diagnostic value. The last is estimated and revealed as at static, and dynamic survey. At dynamic survey pay attention to extent of participation of each half of a thorax in the act of breath.
At diseases of a respiratory organs one half of a thorax or its part can be increased or reduced in comparison with another; also extent of participation of various parts of a thorax in the act of breath changes. Increase in the sizes of one half of a thorax is observed at exudative pleurisy, pheumothorax. At the same time expansion of intercostal spaces and their smoothing on the sick party, and also higher position of a shoulder and shovel is observed.
Reduction of the sizes of one half of a thorax is observed at extensive processes of wrinkling of pulmonary fabric, after a rassasyvaniye of extensive pleural exudates, at an atelectasis of L., after operations on L. A sick half of a thorax lags behind in the act of breath that is noted also at inflammatory infiltration enough big sites L., at new growths of L., at dry pleurisy, a fracture of edges, intercostal neuralgia and a miositis of intercostal muscles. The ratio of duration of a breath and an exhalation can be a diagnostic character (1: 2; 1: 3 — at obstructive processes), frequent shallow breathing with a short breath and an exhalation at restrictive diseases of L. At heavy dysfunctions of a respiratory center disturbances of a respiratory rhythm are observed (see).
The palpation of a thorax allows to specify its form, volume and symmetry of respiratory movements (for this purpose both hands are put palms on the explored sites of a thorax symmetrically from two opposite sides, as if covering it); to reveal and localize healthy places at miozita, intercostal neuralgia, fractures of edges, and also their consolidations and tuberosity; to establish resistance of a thorax and intercostal spaces; in certain cases to feel low dry rattles and a loud pleural rub, and also hypodermic emphysema; to define voice trembling (see) that has important diagnostic value.
Percussion of L. it is the most convenient to make in vertical (standing or sitting) position of the patient. In a standing position of a hand of the patient shall be lowered, in a sitting position — to lie on a lap.
At topographical percussion diagnostic value has delimitation of L. (the lower bound and its mobility at breath — for diagnosis of pleural unions); width and symmetry of fields Kreniga (see. fields Kreniga ). Their symmetric expansion is characteristic of emphysema of lungs; asymmetric narrowing — for wrinkling of pulmonary fabric that is observed at tuberculosis. At comparative percussion come to light: the centers of infiltration and consolidation on relative obtusion of percussion tone in unusual places; zones of hepatization at croupous and a heart attack pneumonia, availability of liquid in a pleural cavity — on a stupid percussion sound, pheumothorax — on a tympanic percussion sound; at emphysema of L. a classical percussion sign is the increased sonority passing into a bandbox shade. When emphysema is the syndrome accompanying a pneumosclerosis with repeated pneumonia in the past and development of rough focal changes irregularity of a shade of a percussion sound («mosaicity», according to B. E. Votchal) — the sites of a bandbox sound alternating with areas of dullness is observed.
Functional methods it is accepted to classify depending on what of the main functions of external respiration — ventilation, diffusion, a pulmonary blood stream — they study.
The condition of ventilation is estimated by means of the following methods.
1. The spirography (see) allows to determine the size of respiratory volume (see. Vital capacity of lungs ), the volume of the forced exhalation for 1 sec. — FZhEL1 (see. Votchala-Tiffno test ), maximal ventilation of lungs — MVL (see. Lung ventilation ), respiratory coefficient (see), etc. These indicators bear big information about anatomo-fiziol, properties of ventilation. At children of early age the method is applied to a research of ventilating function pneumography (see). 2. Methods of assessment of structure of the total capacity of lungs (TCL). At obstructive or (and) restrictive (restrictive) disturbances of external respiration structure of OEL it is often characteristic changes. Restrictive processes lead preferential to reduction of OEL and ZhEL, and the residual lung volume (RLV) and the funkts, residual capacity (F,RC) change a little, only relative increase in OOL in structure of OEL is observed. At obstructive disturbances OOL significantly increases. Increase in OOL on the absolute value and its share in OEL is characteristic of emphysema. At far come obstruction ZhEL decreases. From numerous methods of definition of OOL, FOE and OEL the method based on mixing of helium in the closed system by means of serially released POOL-1 installation (fig. 31) is most widespread and available. 3. Research of uniformity of ventilation. The method is based on definition of time of mixing or washing away of indicator gases from L. Naiboley the method of mixing of helium with use of the POOL-1 installation allowing to reveal the period of alignment of concentration of helium between the known volume of the spirocount and lungs of investigated is widespread. 4. Pneumotachometry — a method of measurement of the peak speeds of an air flow reached during the performance of the forced breath and an exhalation, by means of serially released pneumotachometers of PT-1 (fig. 32) and PT-2, giving an assessment to bronchial passability. Complexes of simple methods in performance — measurement of ZhEL by means of a lung-tester and pneumotachometry or definition of ZhEL and FZhEL1 at the spirography, are sufficient for the solution of a wide range of questions and, in particular, in a large number of cases allow to carry out differential diagnosis between obstructive and restrictive type of disturbance of ventilation. Use pharmakol. tests (measurement of the indicators called above with various mechanisms of action and in some cases — bronchoconstrictors) expands possibilities of the called methods in respect of studying of the nature of bronchial obstruction, selection of the most effective bronchodilator to use of bronchodilators even more. 5. Pnevmotakhografiya (see), impedance pneumography (see) and pletizmografiya (see). Pnevmotakhografiya allows to measure rate of volume flow of a breath and exhalation (quiet or forced), duration of various phases of a respiratory cycle, volume of a breath and exhalation, minute volume of breath, intra alveolar pressure, aerodynamic resistance of respiratory tracts, distensibility (pliability) of L. and thorax, work of breath. The method is based on use of inertialess optical and electric manometers. The whole-body plethysmography of a body is combined usually with a pnevmotakhografiya; measurements of mechanics of breath are carried out in a tight cabin — a plethysmograph of a body. Alveolar pressure, the total intrathoracic amount of gas, the functional residual capacity (FRC), bronchial resistance and other indicators are defined. 6. Methods of a research of regional ventilation of the lungs. Information obtained with their help allows to judge functioning of certain sites L., what opens perspective of identification of disturbances in an early stage when integral parameters of functioning of L. still are significantly not changed. The research of regional ventilation is conducted by means of x-ray methods: densitometries (see), rentgenokimografiya (see), pulmonografiya (see), and also radio pneumography (registration in the course of breath of the quantity of radioactive particles of 133 Xe added to respiratory mix over various departments of L.).
Existence and expressiveness of diffusion disturbances estimate by method of definition of diffusion capacity of easy (DL). Among various methods of determination of DL the method of a stable state using as indicator gas of carbon monoxide is most widely accepted.
The pulmonary blood stream is most precisely estimated at catheterizations of heart (see) and vessels of a small circle of blood circulation. The technique allows to determine pressure in cameras of the right heart and vessels of a small circle and is a basis of calculation of other hemodynamic indicators. The increasing value is gained by indirect methods of diagnosis of a pulmonary hemodynamics, such as reografiya (see), electrocardiography (see), electromyography (see), colorimetry (see), etc. The valuable information on a condition of pulmonary blood circulation is supplied rentgenol, and by tracer techniques of a research.
Extremely important and most early the vulnerable party of external respiration is compliance of ventilation and a blood-groove. Disturbance of this compliance — the most frequent reason respiratory insufficiency (see). About uniformity of a ventilating and perfused ratio in lungs judge by the size of functional dead space of easy (FMP), and also based on the ratio of FMP/DO (TO — respiratory volume) and EAV/fashion (EAV — effective alveolar ventilation, FASHION — the minute volume of breath). FMP define, applying indicator gases — carbon dioxide gas, oxygen, helium, argon, xenon, etc. Use techniques of a single respiratory cycle or rebreathing in a closed path; for the last technique it is convenient to use the POOL-1 installation. Assessment of ventilating and perfused disturbances can be received by means of a kapnografiya — continuous graphic registration of changes of concentration of CO2 in expired air with the inertialess analyzer — a kapnograf. The serially released kapnograf of GUM-2 is most eurysynusic.
At assessment of activity of all device of external respiration the research of gas structure of an arterial blood and acid-base equilibrium is important (see. Gas exchange ).
For identification of the remained reserve opportunities of an organism at patients and for studying of compensatory opportunities use test with physical. loading on the stationary bicycle. The dosed load of 50 — 60 — 80 W lasting 5 min. or loading of the increasing power are most widely accepted. External respiration in test with loading is investigated by means of the spirocount and other devices.
Tool methods. In addition to the tool methods used for funkts, researches of lungs apply to diagnosis of diseases of the device of external respiration some more high-informative tool techniques: the bronkhoskopiya (see), with the help a cut, in addition to survey of bronchial tubes, is carried out by a number of tool ways of a biopsy, mediastinoskopiya (see), torakoskopiya (see), etc.
Laboratory methods. 1. All-clinical lab. methods of a blood analysis (see), urine (see), phlegms (see), pleural exudate. Availability, reliability and informational content of these researches are very high, apply them at a research of all patients and use at diagnosis. 2. Tsitol, the research of a phlegm, the pleural exudate and material received at a biopsy is the most effective at recognition of tumors of L. and quite often allows to establish them gistol. a form that it is very important to lay down at the choice. tactics and definition of the forecast. 3. Bacterial., virusol, and serol, researches allow to establish an etiology patol, process that allows to carry out etiotropic treatment. Allocation and identification of the activator at pneumonia and other respiratory infections — very labor-intensive process, especially at viral and mycoplasmal diseases. Instead of with that it is often difficult to resolve an issue about etiol, roles of the allocated microorganism at this disease. In these cases it is necessary to conduct serodiagnostichesky researches. The same can be told about viral and mycoplasmal infections. 4. Immunol, researches in pulmonology are conducted for studying of immunity at diseases inf. character and an allergy at asthma. They allow to track also efficiency of the therapy which is especially desensibilizing, immunodepressive. 5. Biochemical, researches at diseases of lungs are conducted for definition of indicators of different types of a metabolism to reveal the nature of genesis of a disease (inflammatory, allergic etc.), for assessment of a condition of other bodies and systems, assessment of activity of inflammatory process. 6. Methods of definition of surfactant (see).
Radiological methods. In complex diagnosis of the majority of diseases of L. rentgenol, the method possesses the important place. For mass test inspections and identification it is hidden the proceeding diseases of L., including tuberculosis and cancer, apply fluorography (see). Flyuorogramma L. in direct and side projections make also all patient addressing to policlinic if they did not pass the next fluorographic inspection across the place of residence or works within calendar year. Persons at whom at fluorography are suspected patol changes, cause on special a wedge, and rentgenol, a research. The last begin with production of roentgenograms, electroroentgenograms or large picture frame flyuorogramm in direct and side projections. In case of need make roentgenoscopy and resort to special methods — tomographies, bronchographies, angiopulmonografiya, etc. Each roentgenogram is studied according to the plan. First of all define a projection of a research and correctness of installation of the patient. Then the general consideration of a form, size and a structure L. Daley follows make rentgenomorfol. and rentgenofunkts. analysis and synthesis. During them differentiate «norm» and «pathology», reveal and estimate rentgenol, symptoms of a disease. Results of the analysis compare with data of others a wedge, and tool researches, carrying out kliniko-rentgenol, the analysis and synthesis. Radiodiagnosis is based on identification rentgenol, symptoms of diseases of L. These symptoms are various. They reflect changes of size, a form and outlines of pulmonary fields, changes of the pulmonary drawing (its depletion, strengthening, deformation), various defeats of bronchial system and separate bronchial tubes, defeats limf, nodes (their hyperplasia, calcification), change of transparency of pulmonary fields. Those sites L., in which a lot of blood, exudate, connecting fabric, tumor cells etc. concentrates and, therefore, not enough air contains, on roentgenograms give shadows — blackouts. Those places in which there is a lot of air look as light sites — an enlightenment (fig. 33). If interstitial fabric, then transparency of L preferential is surprised. changes a little, and the pulmonary drawing amplifies.
The sizes and a form of blackouts and enlightenments depend on the volume of defeat: at defeat of an acinus the centers to dia appear. 0,1 — 0,2 cm; the changed segments give shadows up to 1,5 — 2 cm. Larger blackouts are found at defeat of a segment, share or all L. As for cavities in L., small call cavities to 1 cm in the diameter, average size — from 1 to 2 cm, large — St. 2 cm.
Changes of transparency of L. are often connected with disturbance of bronchial passability. The small resistant bronchostenosis leads to hypoventilation of the corresponding part L., edges on the roentgenogram looks slightly darkened, the drawing in it is strengthened owing to rapprochement of vessels and a plethora. At a valve stenosis of a bronchial tube obturatsionny emphysema develops: part L. increases, it seems on the roentgenogram is lighter, than the next departments. At full closing of a gleam of a bronchial tube there is an atelectasis. Airless department of L. decreases and gives an intensive shadow on roentgenograms. Atelectases of all shares and segments have a typical picture.
The radio isotope research of a respiratory organs in sovr, conditions is applied to studying of lung ventilation, blood supply and visualization of a pulmonary parenchyma.
Lung ventilation is investigated by means of inhalation administration of radioactive inert gases (usually 133 Xe). Radioactive gas at a breath fills all departments of L on bronchial tubes., what is registered the scintillation counters located over them. The procedure is carried out by the seven-channel Xenon radiometer with record of measurements of activity and obtaining characteristics of dynamics of removal of drug from each share of L.; by means of scanning or kompyyuterostsintigrafichesky system, use the cut allows to obtain quickly and most informatively data on distribution of radioactive drug on zones L. In both cases it is obviously possible during the determination of dynamics of removal of radioactive gas from L. to establish a percentage contribution of each zone to the total size of removal. The specified technique allows to give a quantitative assessment to ventilation of various departments of L. normal and at various patol, states (see. Lung ventilation, radio isotope research ).
The main tracer techniques of studying of pulmonary blood circulation are static radiometry of L. after intravenous administration of inert gases ( 133 Xe) and scanning of L. after perfusion of marked macrounits of albumine of blood serum of the person (see. Proteins, radioactive ). At intravenous administration solution 133 Xe gets to an arterial link of a small circle of blood circulation and quickly diffuses in a gleam of alveoluses in proportion to an arterial blood-groove in the field L. Issledovaniye conduct by means of the «Xenon» radiometer at establishment of sensors over a back surface of a thorax. At injuries of a breast and other medical emergencies of I. T. Korkulenko et al. (1978) the method of front spiroradiography is developed. The obtained data process by measurement of amplitude of the curves which are written down by sensors over all departments of L., with the subsequent definition of a percentage contribution of each zone to the total amount of a blood-groove. Disturbances of a pulmonary blood-groove and lung ventilation are sharply expressed at atelectases and malignant tumors of L.; at hron, inflammatory processes of disturbance of ventilation and perfusion are less expressed and are noted generally in a zone of defeat. A research using 133 Xe gives rather reliable information about a condition of pulmonary blood supply, but does not allow to receive a picture of vascular network L., what is possible at use of visualization of the functioning parenchyma of H.p. the help radio isotope scannings (see).
Visualization of the functioning parenchyma of L. it can be carried out at intravenous administration of macrounits of radioactive connections; after inhalation of radioactive aerosols which particles settle on a mucous membrane of bronchial tubes and alveoluses. The inhalation method of introduction of radioactive aerosols was not widely adopted in view of insufficient accuracy. Therefore apply the method of scanning after intravenous administration of marked connections allowing to reveal zones of the broken blood circulation more often. In certain cases, napr, at differential diagnosis of sites of loss at emphysema of L. or the embolism of branches of a pulmonary artery, needs consecutive scanning using inhalation and perfused ways of administration of radioactive drugs.
It is most perspective in the diagnostic relation to combine radio isotope funkts, methods of a research with scanning. Carrying out dynamic is optimum stsintigrafiya (see) with processing of the obtained data on the COMPUTER that allows to reveal and track precisely in dynamics of change of regional ventilation and a blood-groove in lungs. Information on a functional morfol obtained at the same time. gives to disturbances the chance to authentically estimate a current patol, process.
Dystrophy of lungs arises owing to action exogenous (dust, inf. activators, smoking, high temperature, gases, including the excess oxygen content, ozone, nitrous oxide, etc.) and endogenous (an anoxemia, release of biologically active amines at shock, others patol, states, influence of endotoxins, etc.) factors. The most universal answer of L. on damage gidropichesky dystrophy of respiratory alveolotsit, the endotheliocytes located on both sides of the merging basal membranes of alveoluses and capillaries is. In them the bigger quantity, in comparison with norm, pinotsitozny bubbles appears, they increase in sizes, merge among themselves, turning into microvesicles to dia. 0,06 — 0,09 microns and vacuoles which sizes are also estimated in micrometers. In formation of vesicles also fluid accumulation takes part in a cytoplasmic reticulum, swelled also swelling of mitochondrions from which cristas disappear. Development of so-called huge bubbles in an endothelium (to dia. 2 — 4 microns) can be followed by a rupture of cytoplasm and their penetration into a gleam of capillaries (fig. 34) where they come to light at electronic microscopic examination in the form of the bubbles which are accurately outlined by a glycocalyx containing fine-grained electronic and dense masses. If bubbles break through the back surface of endotheliocytes turned to a basal membrane, there is amotio of these cells from a membrane. Sometimes they remain the ends of the shoots attached to a membrane only, and between a body of a cell and a basal membrane thrombocytes get that gives an impetus to development of the prolonged thrombosis of vessels of L. Vacuolation in cells of an aerogemichesky barrier is followed by swelling of organellas, nek-ry compensatory changes in a type of increase in quantity of ribosomes, a rough cytoplasmic reticulum, mitochondrions that promotes recovery of cells. At dominance of alteration gidropichesky dystrophy can pass into diffusion intersticial and intra alveolar hypostasis of L. Cells of alveoluses become electron-optical light, contain amorphous osmiofilny flakes instead of organellas. If it is followed by death of a kernel, cells perish and are torn away in a gleam of alveoluses.
Granular dystrophy can accompany gidropichesky or (is more rare) independently arise (e.g., at influence 3 skatoles, allocated from tobacco smoke, at an anesthesia, denervations of L.). Process is characterized by increase in electron density of cytoplasm, increase and swelling of mitochondrions, expansion of a cytoplasmatic reticulum, and also emergence of separate miyelinopodobny figures of an abnormal structure in big alveolotsita. The combination of gidropichesky and granular dystrophy of respiratory alveolotsit passing into a necrosis of cells leads to their sharp swelling and increase in sizes therefore they become visible at light microscopy that, e.g., it is characteristic of a radiation pulmonitis (see the Pneumonitis). Dystrophy of respiratory alveolotsit, as a rule, leads to accumulation in a gleam of alveoluses of big alveolotsit, being predecessors of respiratory alveolotsit. At the same time in them the maintenance of the miyelinopodobny laminar structures going for creation of surfactant increases. Migrating in a gleam of alveoluses, big alveolotsita turn in alveolar macrophages and lie among the eosinophilic masses which is formed owing to allocation of laminar little bodies, their transformation into lattices (fig. 35) and disintegration of earlier torn away cells. At light microscopy such pictures incorrectly sometimes designate as display of desquamative pneumonia. Dystrophy of an aerogemichesky barrier is expressed not only by the above described changes of its cells, but also changes of basal membranes of alveoluses and capillaries which usually look as the uniform merged membrane. The last bulks up, its electron density changes. At sharply expressed changes there is a thickening of alveolar partitions that is followed by sharp increase in permeability of capillaries, hypostasis, hemorrhages.
Sharply expressed proteinaceous and fatty dystrophy of big alveolotsit with adjournment of a significant amount of laminar little bodies and drops of lipids in alveoluses and in their walls characterizes a so-called alveolar proteinosis.
Amyloidosis of L. it can clinically be shown in the form of several forms, but there is and subclinically a proceeding amyloidosis even more often revealed at biopsies of L. in the form of an accidental find. It accompanies primary amyloidosis, and also the amyloidosis connected with a multiple myeloma in 30% of cases. Amyloid in these cases comes to light at a submicroscopy in the form of a lattice on the course of capillaries of alveoluses. Free spaces of a lattice occupy the sufficient space of an inner surface of alveoluses in this connection disturbances of external gas exchange do not happen.
Amiloidopodobny little bodies have no relation to amyloid, their electronic and microscopic picture corresponds to a microlithiasis, but, according to Spencer (N. of Spencer, 1977), differs in lack of content of calcium.
In addition to gidropichesky, granular and amyloid dystrophy, the hyalinosis of the fibrous layers dividing anatomic units of L belongs to disturbance of protein metabolism. It arises at sharp disturbances of a lymphokinesis of L. is also the nonspecific reaction arising at disturbance of blood circulation or inflammatory processes of a long current.
Fatty dystrophy arises in certain sites L. and sometimes it is incorrectly designated as endogenous lipidic pneumonia. Meets usually at subacute and hron, diseases of L., followed by full and incomplete atelectases. In sites of disturbance of aeration (atelectases) process of synthesis and hydrolysis of lipids changes, the big alveolotsita rich with a lipase have the greatest relation to Krom. At diabetes and a hypoxia Macrophagic reaction amplifies, and lipophages together with the flocculent mass of freely lying lipids collect in a large number in zones of atelectases that can be followed by secondary inflammatory processes in the form of intersticial pneumonia or development of lipogranulomas.
Dystrophy of collagenic and elastic fibers of a respiratory parenchyma can be caused by elastase and other proteases of granulocytes and macrophages, in particular macrophages of smokers, and also in an experiment under the influence of papain and trypsin. As a result of influence of proteases elasticity of L decreases., develops emphysema of lungs (see). According to Uimster (W. Whimster), at biochemical, and gistokhy. studying of collagenic and elastic fibers disturbances of content of neutral and aromatic amino acids of protein of elastin and glikozaminoglikan of a cement substance are found. During the studying of ultrastructures of these fibers the disorientation and a spiralepodobny arrangement of collagenic fibrilla and disturbance of tinktorialny properties of elastic fibrilla is found.
Necrosis. In addition to a total necrosis of all components of pulmonary fabric, in the centers of gangrene and heart attack the limited necrosis of an alveolar vystilka and a mucous membrane of bronchioles is possible that it is followed by development of the hyaline membranes characteristic of acute respiratory insufficiency of newborns and adults. Hyaline membranes represent fabric a detritis, among to-rogo fragments of organellas of cells of an alveolar vystilka, including the osmiofilny laminar little bodies of big alveolotsit impregnated with blood proteins, in particular fibrinogen are distinguishable. The focal necrosis of a mucous membrane of bronchial tubes with the subsequent ulceration is characteristic for inf. bronchitis, and also can be result of a burn of bronchial tubes.
Circulatory disturbances of lungs happen not only result of disturbance of a hemodynamics of a small and big circle of blood circulation, but also a consequence of disturbance of aeration of L., as the gleam of capillaries and their orientation in walls of alveoluses depend on the intra alveolar tension of air. So, during the inflating of L. fabric it becomes ishemichny, light pink with accurately coming to light anthracosis on a pale background. In zones of an atelectasis at decrease in filling of pulmonary fabric air it is fallen down, becomes cyanotic, the plethora of capillaries, their protrusion develops in a gleam of alveoluses.
Ischemia of L., caused by a prelum or obturation of branches of a pulmonary artery, quickly is replaced by a plethora, hemorrhages owing to disclosure of an arterio-arterial and arteriovenous anastomosis, i.e. shunting that is followed by development of atelectases owing to disturbance of production of surfactant and aggravates a plethora. In fabric L. the dystrophic processes leading to hypostasis of L develop. According to G. D. Knyazeva, M. M. Morozov, at long moderate ischemia, napr, at Fallo's tetrad, there is a decrease in amount of phospholipids, but dystrophy does not develop owing to inflow of blood on bronchial system. The combined narrowing of branches of a pulmonary and bronchial artery and development of emphysema owing to long obstructive processes in L. lead to ischemia and so-called. the progressing pulmonary dystrophy (see), and in essence to an atrophy of a parenchyma of L., to thinning and disappearance of alveolar partitions.
Acute hyperemia of L. arises in the conditions of strangulyatsionny asphyxia, at injuries of L., a brain, at shock. The plethora has unevenly expressed character since is followed by spasms of arterioles, venules, a sladzh-syndrome (a syndrome of wet L.), hemorrhages in a parenchyma and under a pleura, sometimes with its amotio. Reflex kontraktilny atelectases aggravate irregularity of a krovenapolneniye that, e.g., is characteristic of «a shock lung».
Pulmonary hemorrhages and bleedings arise at injuries of t ruptures of vessels of a root L., explosions, any barotrauma breaking aeration and a krovenapolneniye of certain sites L. Massive hemorrhages in L. arise also at breaks of aneurisms of the descending department of a chest aorta, and also complicate a pulmonary embolism that is connected with strengthening of a blood-groove in ischemic L. Hemorrhage should be distinguished from aspiration of blood at gastric bleedings, tumors of bronchial tubes, mediastinums. At aspiration to blood slime and foreign debris is added. Hemorrhages in L. seldom carry lines of hematomas, hemorrhagic infiltration, petechias which resolve without formation of a hem by means of the macrophages turning into siderophages develop more often.
Disturbances of a lymphokinesis in L. in the form of a lymphostasis (see) arise: 1) in the mechanical way owing to build-up of pressure in pulmonary veins at a left ventricular failure or a prelum of pulmonary veins a tumor; 2) owing to dynamic insufficiency of a lymphokinesis at discrepancy between formation of an intercellular lymph and its assignment that is observed in zones of an atelectasis; 3) at rezorbtsionny insufficiency because of increase in permeability limf, capillaries and change of composition of fabric proteins, napr, at an inflammation. The first mechanism is followed more often by a diffusion lymphostasis while at the second and third it has usually focal character. Limf, vessels at the same time sharply extend, fibrous layers in their circle swell, are noted lymphangiectasias (see) or varicosity limf. vessels. As a result the lymphogenous sclerosis develops (see. Pneumosclerosis ) and increase in quantity limf, the follicles which are immunocompetent educations. At acute insufficiency of a lymphokinesis develops fluid lungs (see). In the beginning it is localized in an interstitium of alveolar partitions which is thickened; in cells of fabric L. there is gidropichesky dystrophy. At amotio, separation of respiratory alveolotsit intersticial hypostasis passes in intra alveolar since, judging by electronic microscopic examinations of Shneebergera-Kelly, Karnovsky (F. Schneeberger-Kelley, M. of Karnovsky), at damage of respiratory alveolotsit an exit of liquid in inside alveoluses develops. It is normal of connection between these cells stronger, than between endotheliocytes therefore, having left capillaries, liquid at first collects in walls of alveoluses, and then breaks inside. If hypostasis is followed by amotio, but not death of surfactant, in edematous liquid in alveoluses bubbles are accurately visible.
Compensatory and adaptive processes in L. are carried out by a compensatory and regeneration hypertrophy. According to L. K. Romanova, after a resection of part L. within a month dystrophic changes of an alveolar epithelium develop, synthesis nucleinic to - t goes down. In the subsequent the hypertrophy of the damaged and second L is noted., characterized by activation of synthesis nucleinic to - t cells of walls of alveoluses and strengthening of their mitotic activity. In cells there are compensatory and recovery processes: protrusions of a nuclear envelope, increase of number of pinotsitozny bubbles, hypertrophy of a lamellar complex and fibers of respiratory alveolotsit, increase in the sizes and number of osmiofilny little bodies of big alveolotsit. Also the quantity of alveolar macrophages and alveolotsit of the third type increases that is followed by the activation of synthesis of surfactant revealed as at the ultrastructural level, and the method of definition of superficial activity of washouts of L. Gipertrofiya L. characterizes by increase in volume of alveoluses and their depths, however, unlike emphysema, this process, according to H. X. Shamirzayeva, has reversible character. After a resection of L. comes or stabilization morfofunkts. recovery, or its decompensation in the form of development of emphysema of L., what is followed by flattening of alveoluses and a sclerosis of their walls. According to L. K. Romanova, during removal of 50% of mass of L. at mature animals and the person the decompensation does not develop within 4 — 15 years. At a resection of 60 — 65% of mass of L. the phenomena of a hypertrophy prevail over emphysema. At a resection of 70 — 85% emphysema, as a rule, develops.
Postmortem changes. So-called acid malacia of lungs — an autolysis owing to a pelting in L. gastric juice. These are sites L. brown-yellow color of a flabby consistence with badly defined kernels of cells. They should be differentiated with gangrene on lack of inflammatory reaction. Special researches of mass of L., their solid residue in an experiment, according to S. A. Zhanaydarov, revealed posthumous development of a plethora in 4 hours after death. It accrues to 12 hours and then stops; the plethora depends on movement of blood from veins of the head, a trunk and an abdominal cavity in connection with a cadaveric spasm of heart and increase in intra belly pressure because of gas generation in intestines. It is accompanied by increase in permeability of capillaries for liquid and proteins (it is revealed by means of posthumous penetration of blood proteins, marked before death, from capillaries in fabric). Intra alveolar hypostasis after death can decrease due to transition of nek-ry amount of liquid to pleural cavities.
Classification of diseases of L. presents great difficulties. They are caused by insufficient study of an etiology and pathogeny of a large number patol, the processes striking L., lack of the developed representations about nozol, independence of a considerable part of these processes and contradictory views of similarity and distinction of a set of the diseases, known from literature, patol, states and syndromes that complicates their association in these or those groups.
The division of diseases of L is standard. on currents, acute and chronic according to preferential type, patol, process, but it is inapplicable to all nozol, to forms since some of them depending on influence etiol, a factor and features of reactivity of an organism of the patient can proceed differently (sharply, subacutely, chronically). In some cases the same disease, having begun sharply, it is inclined to pass in hron, a form.
It is possible to divide diseases and patol, conditions of L more accurately. on the following two essentially important signs. The first of them — preference of defeat at given patol, process of respiratory tracts or respiratory department (a so-called parenchyma) by L. Primer of diseases with preferential damage of airways bronchitis, a bronchoectatic disease, bronchial fistula, bronchogenic cancer etc. are. Examples of diseases with preferential defeat of respiratory department — pneumonia, emphysema of L., different types of the disseminated pneumoscleroses, granulomatoses etc.
The second important defining sign is diffusion or a lokalizovannost (regionarnost) of distribution patol, process on bronchopulmonary system. To group of diffusion processes bronchitis, a sarcoidosis of lungs, an alveolar microlithiasis, and concern to group of localized (regional) — pneumonia, tumors of L, e.g., foreign bodys of fabric L. or bronchial tubes etc.
The group of diseases of L is represented much more difficult. on etiol, to the principle. Such group, in to-ruyu practically all known diseases and patol, conditions of L are included., it is carried out in brought to the table developed in the All-Russian Research Institute of pulmonology of M3 of the USSR by N. V. Putov, G. B. Fedoseyev, H. N. Kanayev . In the analysis it should be considered that some of the main headings reflect an etiology of diseases only conditionally. So, anomalies of development of L are united in one group., which reasons are not studied, in another — tumors L. Hron, bronchitis and emphysema of L., in which etiology the general matter in many respects, but far not completely established factors, are also allocated in a uniform heading; at their isolation extremely great medico-social value of these nozol, forms, similarity Kliniko-fiziol, manifestations (obstruction) etc. was taken into account. Allergic diseases of L. are combined not so much by the general etiology, how many a similar pathogeny. The large number of preferential seldom found diseases of not quite clear etiology is united in one heading, in the majority of system character at which prevails or defeat of L is quite often observed. At patol, conditions of L., connected with disturbance of pulmonary blood circulation, it can be considered in quality etiol. a factor also conditionally also is, in effect, only the basic element of a pathogeny of the corresponding processes in
L. V a special heading allocated diseases and patol, the states proceeding with preferential damage of a pleura that in a certain measure breaks etiol, (pathogenetic) principle of classification.
For some important diseases in the practical relation basic elements of classification inside nozol, forms are given. In cases when such classification is difficult, but is officially accepted and approved in the USSR, the corresponding reference to this classification is given (e.g., for a pulmonary tuberculosis, bronchial asthma).
Disturbances of process of an embryogenesis of L. cause emergence of defects of their development. So, the termination of growth of bronchopulmonary kidneys at early stages (4 weeks) leads to an agenesia both or one L. The arrest of development of bronchopulmonary kidneys on the 5th week causes a hypoplasia both or one L., and on — 7th week — emergence of an agenesia or a hypoplasia of shares of L. Vozmozhno disturbance of formation of mesenchymal elements of the primary and lobar bronchi that is followed by a bronkhomegaliya and stenoses of bronchial tubes.
Ideas of various authors of the frequency of malformations of L. are contradictory. It makes from 2,5 according to A. I. Strukov and I. M. Kodolova (1970) to 20% according to G. L. Feofilov (1976) all nonspecific diseases of L.
The malformations connected with an underdevelopment of a lung, its anatomic, structural and fabric elements. It is necessary to carry an agenesia and an aplasia of L to the most frequent of them., hypoplasia of L. simple and cystous (polycystosis), inborn share emphysema, and also tracheobronchomegaly.
Understand lack of L as an agenesia. along with lack of a primary bronchus. An aplasia — lack of L. or its parts in the presence of the created or rudimentary primary bronchus. At a bilateral agenesia and an aplasia of L. children are impractical, at unilateral — they can normally develop. Overseeing by patients with an agenesia of L are described., who lived to a ripe old age. However at accession of the inflammatory phenomena in the only L. respiratory insufficiency develops quicker, and total drain pneumonia of the only L. can become the main reason for death.
Wedge, picture of an agenesia and aplasia of L. at newborns and children of advanced age has some differences. At an objective research at newborns and children of early chest age on the party of the absent L. at percussion shortening of a percussion sound is defined, and during the listening — total absence or considerable weakening of breath. Further there is a compensatory increase in the only L. Sredosteniye is considerably displaced. There is front mediastinal hernia with a prolapse of L. on the opposite side. At an objective research of the child at more advanced age on the party of the absent L. it is possible to listen in front normal vesicular, and behind — a little weakened breath. Borders of heart are considerably displaced in the sick party where cordial tones are better listened. Diagnosis of an agenesia and aplasia of L. (shares) are specified on the basis of a bronchoscopic and angiopulmonografichesky research, a cut it is more preferable than a bronchography. Children with an agenesia or an aplasia of L. (shares) in special treatment do not need, but shall be under observation of the doctor.
A hypoplasia — an underdevelopment of all elements L. (bronchial tubes, vessels, pulmonary parenchyma). Distinguish a simple hypoplasia and cystous (polycystosis). At the same time the underdevelopment of all L can take place., share or segment. The hypoplasia can be also unilateral and bilateral.
At early abortion there are sites reminding L. embryo: among wide layers of the remained parenchyma the tubes covered by a cylindrical epithelium (fig. 36) are visible. At late abortion fabric of a parenchyma reminds the centers of inborn atelectasis (see), the hypoplasia can be proved by a morphometric method. Distinguish primary hypoplasia which is quite often combined with a malformation of kidneys, and secondary, caused by phrenic hernias (is more often at the left) or hydroamnion (bilateral). Moderate degree of a hypoplasia can be a find during routine maintenance of the child. However is more often in underdeveloped L. the inflammation develops, a cut, as a rule, accepts hron, the current, is followed by symptoms of intoxication and respiratory insufficiency (see). At survey in cases of defeat of all L. note asymmetry of a thorax with flattening it on the sick party and narrowing of intercostal spaces. Percussion and auskultativny data depend on expressiveness of inflammatory changes in this L.
At rentgenol, a research blackout of the pulmonary field or the part it corresponding to the struck department is defined. The mediastinum is to a greater or lesser extent displaced towards defeat, the dome of a diaphragm is usually raised. At a polycystosis numerous thin-walled cavities with equal contours, usually free of liquids can come to light. At a bronkhoskopiya of pathology do not find or find signs hron, bronchitis. The bronkhografichesky picture is most demonstrative. At a simple hypoplasia the drawing of a bronchial tree is grown poor, diameter of bronchial tubes is sharply reduced, peripheral departments are not filled with a contrast agent or filled not completely. At a cystous hypoplasia, in addition to reduction of volume of L., multiple cystous cavities come to light, to-rymi segmental and subsegmental bronchi come to an end. Angiopulmonografiya shows that at a hypoplasia a blood stream in L. it is grown sharply poor or is absent.
The main method of treatment — operational (removal of the relevant departments of L.). At extensive bilateral defeats only conservative treatment consisting in the prevention and stopping of aggravations of suppurative process is possible.
Inborn share emphysema — a malformation of L., characterized by stretching of a parenchyma (usually shares of L.). For designation of a disease also terms are used: «the inborn localized emphysema», «lobar emphysema», «obstructive emphysema», «hypertrophic emphysema». Defect of development of cartilaginous elements of bronchial tubes, an aplasia of unstriated muscles of terminal and respiratory bronchioles is the cornerstone of a disease. Also the excess of a bronchial tube, a prelum its vessel, a hypertrophy of a mucous membrane are possible. The valve mechanism arising at the same time leads to sharp inflation of a parenchyma of L., a cut also defines kliniko-rentgenol, a picture of defect. Defeat should be differentiated with the secondary lobar emphysema of newborns caused by obstruction of a lobar bronchus a mucous stopper.
According to a wedge, a picture allocate the compensated, subcompensated and dekompensirovanny forms of inborn share emphysema. The last has the most expressed symptoms of respiratory and heart failure in connection with the acute inflation of the site of a pulmonary parenchyma leading to a collapse of adjacent departments of L. and to the shift of bodies of a mediastinum. At the same time short wind, the general cyanosis, dry cough, attacks of asphyxia during the feeding can be sharply expressed. It is necessary to differentiate this form of defect with a tension pneumothorax (see) and an intense solitary cyst of L. The diagnosis is specified by means of a X-ray analysis and an angiopulmonografiya (fig. 37). Bronkhologichesky methods of a research can give Nek-ry help in differential diagnosis. However in the presence of a syndrome of tension they are quite dangerous since they can aggravate respiratory insufficiency.
In most cases at inborn share emphysema operational treatment is shown. At a syndrome of tension it shall be carried out in the emergency order and consist at a distance the struck share.
At the subcompensated and compensated form perform planned operation.
Unilateral inborn emphysema (a «light» lung, a «supertransparent» lung, a hypoplasia of a lung with a preferential underdevelopment of a pulmonary artery, Mac-Lauda's syndrome) — group of diseases of L., having similar kliniko-rentgenol, the picture which is followed by increase in transparency of pulmonary fabric. Data on an etiology and a pathogeny of these diseases are contradictory. Wedge, manifestations depend on expressiveness of inflammatory changes in a tracheobronchial tree and a parenchyma, and also from degree of respiratory insufficiency which define to lay down. tactics (carry usually out symptomatic therapy).
The defects connected with existence of excess (additional) dizembriologichesky educations. It is accepted to carry to them additional L., sequestration of L., cysts of L., gamartoma and other inborn tumorous educations.
Additional lung (share of L.) — rare defect, at Krom along with normally developed by L., but separately from them there is a L., usually small sizes, the primary bronchus to-rogo departs from a trachea, and vessels have communication with a small circle of blood circulation. Depending on degree of a maturity of structural and fabric elements in additional L. it can participate in gas exchange. At absence in additional L. interlobar cracks and the message of its bronchial system with the primary or lobar bronchi of normal L. it is called an additional share of L. Existence of additional L. most often does not bring to funkts, and a wedge, to disturbances and in such cases it can be revealed accidentally on operation, at a bronchography or on autopsy. However additional L. can be gipoplazirovanny that promotes emergence in it inflammatory changes or funkts, disturbances. The bronchography and an angiopulmonografiya help to specify the diagnosis in such cases. Treatment consists additional L at a distance. (shares).
Pulmonary sequestration — existence of additional part L., reported or not reported with bronchial system L., but the located artery having independent blood circulation at the expense of anomaliyno departing directly from an aorta. Outflow of blood from the sequestered share, with rare exception, is carried out in pulmonary veins. Thus, pulmonary sequestration represents a cystous hypoplasia of additional L more often. (shares) with aortal blood supply. At an arrangement of the site with anomaliyny blood supply in normally developed L. speak about intra share or intralobarny sequestration L. Naiboley frequent localization of such defeat — the lower share of the right L. Raspolozheniye of additional L. (shares) with aortal blood supply out of normally developed L. (in a chest cavity, on a neck, in an abdominal cavity etc.) call extra share pulmonary sequestration (fig. 38). Pulmonary sequestration can not have a wedge, manifestation and to be accidentally found at life or on autopsy. However more often this defect is followed by clinic hron, inflammations in gipoplazirovanny L. On roentgenograms blackout of rounded or irregular shape is visible, is more often in lower internal department of the pulmonary field (fig. 39). With the help aortografiya (see) it is possible to find additional the vessel departing from an aorta and to verify the diagnosis (fig. 40). At establishment of the diagnosis operation is shown, edges consists the sequestered site L at a distance. An operative measure should be carried out to the period of remission. At operation for intra share pulmonary sequestration quite often there is a need together with sequestration and normally developed share of L at a distance. (see. Lobectomy ). At the same time it is necessary to remember existence of an abnormal vessel which usually passes in a pulmonary sheaf and demands separate bandaging and underrunning in order to avoid dangerous bleeding.
Inborn single cysts of a lung can be central and peripheral. The first are located in radical zones (fig. 41), arise at an arrest of development of large, is more often segmented, bronchial tubes and are sometimes reported with other departments of a bronchial tree. Contain slime in a gleam. Their walls are covered by a cylindrical epithelium, contain glands, cartilaginous plates, a little muscular and abundance of elastic fibers. Peripheral cysts arise at disturbance of branching of smaller bronchial tubes, often bronchioles. They are covered low by a cylindrical cubic epithelium of a pla, sometimes walls are presented by fabric of a parenchyma (fig. 42). Inborn cyst of L. can be type to a pnevmotsistotsela (during the filling air) and to the mukotsistotsela (at, filling by a mucous secret). Frequency of cysts of L. makes 2,9 — 5,3% of total number of patients with diseases of L. in surgical clinics. Wedge, a picture — an inborn cyst of L, small on volume. long time can prove nothing. However eventually most of them is complicated by tension or suppuration. It defines essentially active surgical tactics in relation to L. Pnevmotoraks's cyst as a complication of an inborn cyst of L. occurs at children seldom. For considerable on volume or the cysts complicated by tension existence of signs of respiratory insufficiency, a pulmonary sound with a bandbox shade, weakening of breath on the party of a cyst and the shift of a mediastinum to the opposite side is characteristic. The diagnosis is specified by means of a X-ray analysis (fig. 43), a tomography and an angiopulmonografiya. Angiopulmonografiya is more informative, than a bronchography. Besides, carrying out a bronchography at the expressed respiratory insufficiency is dangerous. At not clear anamnesis and indistinct rentgenol, the picture in case of lack of indications to an immediate surgery should watch the sick child in dynamics within 7 — 8 months. In the absence of dynamics the cyst is subject to removal. At children make lobectomies) together with the cyst which is in a share, more rare more often segmentectomy (see). At an empyema of cyst of L. operation is preceded by the careful conservative treatment including bronchoscopic sanitation, a puncture (at confidence available of commissural process in a pleural cavity) or drainage.
Unusual arrangement of anatomical structures of a lung is not followed, as a rule, by dysfunction and is an extreme form of variability or anomaly.
Anomalies of pulmonary furrows consist in increase or reduction of their number. Additional cracks are formed, as a rule, between segments. Quite often separated there are 6th, 7th and lingular segments, however it has no wedge, values. Lack of an interlobar furrow can be the cause of technical difficulties during an operative measure.
A «mirror» lung — the concept including anomaly of an otkhozhdeniye of bronchial tubes or quantity of pulmonary furrows when L. on one of the parties represents a mirror image of counterlateral L. Anomaliya meets seldom, is not followed funkts, disturbances also found accidentally at a bronchography, operation or on autopsy.
The return arrangement of lungs has a certain practical value since Kartagenera is a part of a so-called syndrome (or triads) (see Kartagener a triad).
Share of an unpaired vein (lobus v. azygos) most of authors belongs to the anomalies connected with existence of additional pulmonary furrows. Existence of an additional crack and eliminating of the site of an upper share of the right L is considered the reason of this anomaly. The additional crack represents a duplikatura of a parietal pleura, in a cut there passes unusually located unpaired vein. Similar anomaly meets, according to D. S. Lindenbraten and L. D. Lindenbraten (1957), in 0,5 — 1% of all rentgenol, researches L. Klien, this anomaly does not give manifestations and, as a rule, comes to light accidentally at rentgenol, a research. On the roentgenogram in a verkhnevnutrenny part of the right pulmonary field the arc-shaped line, convex knaruzh and falling to a root where it comes to an end with an oval shadow comes to light. The last represents the axial or semi-axial section of an unpaired vein. M. F. Lomov's researches and L. M. Nepomnyashchy (1971) were shown that the share of an unpaired vein in all cases has the bronchial tube which is reported with a trachea, a bronchial tube of an upper share or a bronchial tube of an apical segment of the right L. at the L which is normally created by the right.
At emergence hron, inflammatory process removal of this share is shown.
Anomalies of development of a bronchial tree are very various. The abnormal otkhozhdeniye of bronchial tubes (e.g., upper share tracheal — additional — a bronchial tube), accessory bronchial tubes, inborn stenoses of a trachea of bronchial tubes, tracheobronchial diverticulums meets (see. Bronchial tubes , Trachea ), trakheo-(bronkho-) esophageal fistulas (see. Gullet ).
Malformations of circulatory and absorbent vessels of a lung. Inborn arteriovenous aneurisms have the greatest practical value. The pathoanatomical picture of this disease is quite diverse, than and a variety of its names speaks (arteriovenous pulmonary fistulas, a pulmonary cavernous angioma, a varicosity of vessels of L.). Between branches of a pulmonary artery and veins there can be one or several patol. the anastomosis leading to dumping of blood from an artery in veins, passing a capillary network (shunting). Localization of aneurisms in L. it is various, more often they are located in the lower share of the right or left L. Odnako approximately multiple arteriovenous fistulas which are quite often combined with a malformation of vessels of other bodies, mucous membranes and skin (teleangiectasia) occur at 1/3 such patients. Such multiple malformations of vessels are described under the name of a disease of Osler — Randyu (see. Oslera-Randyu disease ).
A wedge, manifestations depend on the size, localization and the nature of arteriovenous aneurisms. At the size of the arteriovenous shunting exceeding 30% the expressed symptoms of air hunger develop (see. Hypoxia ). At the same time patients complain of weakness, bystry fatigue, the asthma amplifying at physical. tension; often there are headaches, dizziness, a sonitus, nausea and vomiting are more rare, diplopia (see), disturbance of the speech, paresis of separate groups of muscles, sudden kollaptoidny states, epileptiform attacks. Characteristic, though not constants, signs are polycythemia (see) and polyglobulia (see). At certain patients the quantity of erythrocytes reaches 10 — 12 million in 1 mkl blood, and a hemoglobin content — 155 g/l. Pathognomonic, though not at all patients, a symptom — vascular noncardiac the noise listened over those departments of L., where defeat is localized. A frequent symptom of arteriovenous pulmonary aneurism is pneumorrhagia (see). At the localized aneurism and small diameter of the shunt the wedge, symptoms can be absent, and patol, changes in L. happen an accidental find at rentgenol, a research. The roentgenoscopy and a X-ray analysis of a thorax reveal various form and the size a homogeneous shadow of aneurism in L. From it to a root L. there are shadows of expanded vessels which come to light on tomograms more clearly. Angiopulmonografiya allows to define not only localization, but also extent of shunting. Arteriovenous aneurisms of L. demand operational treatment, a cut consists in a resection of an affected area of a lung.
Anomalies of a venous bed. Most often the large vein bearing blood from the right L is defined. not in heart, and in the lower vena cava and causing emergence on tomograms of the shadow reminding a curved saber — a syndrome of a saber (scimitar syndrome — fig. 44). Otherwise the inborn varicosity looks. On roentgenograms the wide and unusually going vascular trunks are visible. Sometimes they unite in the ball giving a roundish shadow with scalloped outlines. Unlike arteriovenous aneurism, this education does not pulse. Besides, at arteriovenous aneurism caliber of the bringing artery it is much bigger, than the veins recovering from aneurism. In doubtful cases differentiation is carried out by means of an angiopulmonografiya.
Malformations of lymphatic system meet seldom and have no great practical value.
Bronchopulmonary manifestations of genetically caused general diseases
Treats number of genetically determined general diseases having pulmonary manifestations mucoviscidosis (see), insufficiency alpha 1 - antitrypsin (see. Emphysema of lungs ), primary immunodeficiency (see. Immunological insufficiency), Marfan's syndrome (see. Marfana syndrome ), Osler's disease — Randyu (see. Oslera-Randyu disease ), hyaline and membrane disease of newborns (see), a hereditary idiopathic pneumosclerosis (see the Pneumosclerosis). It is necessary to carry seldom found pulmonary alveolar microlithiasis which consists in adjournment in alveoluses of the inclusions containing glybk of lime to the same group. The reason of pathology is unknown. Sometimes the disease occurs at relatives that can indicate genetic predisposition. L. are pale, have big weight, stony density, especially in the lower shares where process is expressed most intensively. Morphologically defeat of L. it is characterized by existence in alveoluses of psammotozny little bodies of spherical shape (fig. 45). More young people from them have a concentric structure, contain calcium, phosphorus, iron, traces of magnesia, lipids, are intensively painted by hematoxylin, PAS-polozhitel-ny; walls of alveoluses of an infiltrirovana of a mononuklearama, sometimes contain colossal cells of foreign bodys. The disease leads to disturbance of microcirculation of L., to the kapillyarnoalveolyarny block. Meets at the age of 20 — 40 years. It can be combined with a stenosis of the left atrioventricular opening, a pneumosclerosis, hron, bronchitis. It should be differentiated with alveolar petrification of a lung, edges are reflected by metastatic calcification and is characterized by adjournment of plates of calcium under basal membranes of alveoluses and bronchioles.
Clinically the disease a long time flows asymptomatically. Then there is cough and the accruing short wind caused by obturation of alveoluses. Further there is cyanosis, a polycythemia, signs pulmonary heart (see). In a phlegm kaltsinata sometimes are found. Radiological being projected at each other, limy inclusions cause intensive blackout of pulmonary fields, especially in lower parts. Pictures at the increased tension allow to find microlites and to distinguish them from the branchy calcifications and okosteneniye observed at a branchy osteoplastic osteopathy of L. Zabolevaniye gradually progresses and comes to an end with death from a pulmonary heart. Effective treatment of methods does not exist.
the Isolated damages of L. hl meet seldom. obr. at the closed injuries of a breast; damages of L. are the main component of all damages breasts (see), they are followed such patofiziol, changes in an organism which are not inherent in an injury of other localizations (the head, a stomach, extremities).
As a result of the fire and closed injury of L. can arise pheumothorax (see), hemothorax (see), massive pulmonary bleeding (see), pneumorrhagia (see), syndrome of «a shock lung», syndrome of «a wet lung», hypodermic emphysema (see) and pneumomediastinum (see). These patol, a state are the cornerstone of the acute respiratory and cardiovascular insufficiency which is quite often accompanying an injury of a breast with damage L. Mekhanizm of its development extremely difficult, but in it four reasons have a principal value.
The first reason — reduction of volume of expansion of a thorax owing to disturbance of an integrity of edges, shovels, breasts, diaphragms. One of the heaviest injuries of bones of a thorax are double fractures of edges (so-called costal valves, folding changes) at which, especially if they multiple, develop a flotirovaniye of a thorax and paradoxical breath that leads to sharp reduction of volume of inhaled air (to 200 — 150 ml instead of 500 — 600 ml at a normal breath). At the combined damages of a bony frame of a breast and a diaphragm of restriction of mobility of a thorax are even more expressed. In these cases indicators of external respiration, including and ZhEL, sharply decrease. Decrease in mobility of a thorax and constant pain because of injury of a parietal pleura by fragments of edges aggravates.
The second reason is connected with a collapse of L. owing to positive pressure in a pleural cavity at pneumo - a hemothorax. Collapse of L. it is most considerable at valve (intense) pheumothorax. Combination of a collapse of L. and leads blood losses to reduction of a respiratory surface of L., to decrease in alveolar ventilation and transportation to fabrics of oxygen (because of deficit of volume of the circulating blood).
The third reason — disturbance of tracheobronchial passability. Obstruction of a gleam of a trachea and bronchial tubes krovyo (including and clots), secret, scraps of fabric L. complicates both breath, and evacuation of contents from pneumatic ways that can lead to atelectases (see), and sometimes and to acute hypostasis of a lung (see). Quite often in these cases the so-called vicious circle of Kurnan — ventilating disturbances and hypersecretion of bronchial glands develops (as response to tracheobronchial obstruction) cause a hypoxia, edges in turn supports hypertensia in a small circle of blood circulation and, on the contrary, hypertensia strengthens hypersecretion and consequently also ventilating disturbances. Extremely quickly disturbances of tracheobronchial passability arise at a combination of a mechanical injury of L. and a burn of respiratory tracts (e.g., at gunshot wounds of a breast and burns napalm).
The fourth reason — circulator disturbances. They can directly develop after injury of heart or large vessels with heavy blood loss (primary acute cardiovascular insufficiency) or as a result of the shift of a mediastinum at pneumo - a hemothorax and difficulties of blood circulation (secondary acute cardiovascular insufficiency).
Can be result of influence of this complex of the reasons creating acute respiratory and cardiovascular insufficiency hypoxia (see), hypercapnia (see), oppression respiratory center (see), asphyxia (see), shock (see).
According to the accepted classification of damage of L. in the absence of a wound of a chest wall call closed, and in the presence of a wound — open.
The closed damages there are owing to blow, concussions, prelums. They are subdivided into bruises, or contusions at which the integrity of a visceral pleura is kept, and gaps at which it is broken. Internal ruptures of fabric L. without injuries of a visceral pleura are observed seldom.
Bruises of L. depending on weight of an injury are followed by small subpleural hemorrhages, hemorrhages in alveoluses with hemorrhagic infiltration or crush of fabric L., with injury of bronchial tubes, large vessels and education to L. the cavities filled with air and blood.
Ruptures of fabric L. happen single and multiple, and in a form — linear, polygonal, scrappy. In cases of damage of L. the end of the broken rib gaps have an appearance of the gaping crack or a crater of irregular shape. In cases of especially rough injury crush of H.p. is observed by multiple ruptures of vessels and bronchial tubes.
At bruises of L. pheumothorax and a hemothorax usually does not happen, and the wedge, a picture generally is defined by the volume of intra pulmonary hemorrhage. In cases of extensive crushes of victims deliver with the picture of heavy shock expressed to respiratory insufficiency (see) and pneumorrhagia. The massive pneumorrhagia, pulmonary bleeding is sometimes observed. The physical research quite often possible to reveal shortening of a percussion sound, strengthening of voice trembling, easing or lack of respiratory noise. They disappear in 7 — 10 days.
At ruptures of L. air gets into a pleural cavity and blood streams. In cases of scrappy ruptures of L., deep wounds with injury of large bronchial tubes and a rupture of a mediastinal pleura the valve pheumothorax proceeding as internal often is complicated by emphysema of a mediastinum and hypodermic emphysema.
At ruptures of L. often there is traumatic shock. The pneumorrhagia or allocation of a foamy phlegm with impurity of scarlet blood, cyanosis, hypodermic emphysema are typical.
Sometimes at the severe closed injury of the breast which is followed by blood loss there is a syndrome of a shock lung. Clinically shock lung is shown by acute respiratory insufficiency at scanty auskultativny data: breath is vesicular, weakened or rigid, rattles are absent.
A heavy complication of the closed injury of L. also emergence of a syndrome of a wet lung is. This syndrome develops hl. obr. at disturbances of drainage function of bronchial tubes and simultaneous hypersecretion of intersticial liquid and a phlegm which fill a gleam of a bronchial tree. Klien, a picture at a syndrome of a wet lung is quite characteristic. Patients have sensation of fear, suffocation, are uneasy. Breath — to 40 — 50 in 1 min., superficial, discontinuous. At distance tracheal rattles are heard. Over L. the weakened vesicular breath with a set of mixed wet rattles is listened. Pulse can be intense, and the ABP raised in view of a hypercapnia. With the advent of a circulatory unefficiency pulse becomes frequent, the ABP decreases. Due to the disorder of gas exchange sometimes there comes the loss of consciousness and there is a suspicion on intracraneal hemorrhage. In 1 — 2 days the progressing respiratory insufficiency quite often leads to a lethal outcome.
A physical research at a rupture of L. often can be difficult or even impossible because of motive excitement of the patient, sharp morbidity of a chest wall and development of hypodermic emphysema. Therefore the most important diagnostic method of nature of damages is rentgenol. research.
At damages of L. the radiologist shall find out what of bodies is damaged what nature of damage what phenomena accompany it (a hemothorax, pheumothorax, a pneumomediastinum), whether is available disturbance of an integrity of bones of a thorax. At a heavy contusion of L. in the beginning intersticial hypostasis of L comes to light., and in 2 — 3 hours — alveolar hypostasis which sticks to from 1,5 to 10 — 12 days. Intra pulmonary hemorrhages cause the separate merging shadows differentiated by small light sites on roentgenograms. But there can be also a large hematoma, umbrageous to dia. 2 — 4 cm. At multiple ruptures of pulmonary capillaries (e.g., at contusions from a blast wave) the scattered small centers against the background of the strengthened drawing and bronchiolar emphysema are visible. The rupture of a small bronchial tube sometimes leads to a pnevmatotsela — in a picture the roundish thin-walled air bubble among the darkened part L. Rentgenol comes to light. manifestations of a shock lung — decrease in transparency of L., strengthening of the drawing at the expense of intersticial hypostasis, small indistinct focal shadows. Gradually the sizes and number of shadows increase. Pleurocentesis (see) allows to confirm or exclude availability of air and liquid blood in a pleural cavity.
Lech. actions at all closed damages of L. are carried out but to the same rules, as at other injuries of a breast (see). For removal of pains, especially in cases of a simultaneous fracture of edges, appoint analgesic drugs and do alcohol - novocainic blockade of the place of a fracture of edges, and also vagosympathetic blockade from the relevant party (see. Novocainic blockade ). At multiple fractures of edges and «an unstable thorax» fixing of the central fragment of a double fracture of edges, the prolonged peridural anesthesia is effective (see. Anesthesia local ). Disturbances of tracheobronchial passability because of bad expectoration demand transnasal catheterization, a microtracheostomy or a bronkhoskopiya with suction of a phlegm. At patients with a shock lung carry out anticoagulating therapy and at the expressed disorders of gas exchange — artificial ventilation of the lungs (see. Artificial respiration ).
At the stopped bleeding in a pleural cavity and small pheumothorax pleurocenteses are shown. For a raspravleniye of L. at patients with valve pheumothorax or a recurrence of pheumothorax after 2 — 3 punctures make drainage of a pleural cavity with continuous aspiration (see. Aspiration drainage). If within 3 — 4 days through a drainage air continues to arrive and the lung does not finish, there are indications To thoracotomies (see) and to sewing up of a wound of a lung. The urgent thoracotomy is shown at the proceeding bleeding in a pleural cavity and lack of positive effect from drainage and aspiration in cases of valve pheumothorax. According to E. A. to Wagner (1969), at the closed damages of L. need of a thoracotomy arises only in 2 — 3% of cases. Constantly at treatment of the closed injuries of L. the physiotherapy exercises are shown, and at threat or emergence inf. complications — antibacterial therapy.
Open damages usually result chipped and cut and fire wound.
At chipped and cut wounds destruction and hemorrhagic treatment of fabric L. usually do not happen extensive and into the forefront the frustration connected with development pneumo - and a hemothorax act.
Gunshot wounds are heavier damages. The bullet wound has complex structure. Distinguish (fig. 46) the wound channel containing blood, scraps of fabrics and foreign bodys, a zone of primary traumatic necrosis, and to the periphery from it — a zone of molecular concussion. The last zone arises under the influence of force of side blow, a hurting fire shell (a bullet or a splinter). Richness of L. elastic fibers, laws of aerodynamics lead to depreciation of manpower of a shell in this connection the sizes of the wound channel as I. V. Davydovsky showed, do not exceed diameter of a bullet; he often is slit-like and begins to live a linear hem.
At small wounds of a chest wall signs of simultaneous damage of L. release of foamy blood from a wound, the pneumorrhagia, a hemothorax are. Quickly accruing hemothorax indicates wound of large vessels of L., mediastinum or chest wall.
At a X-ray analysis of a thorax fresh wounds of L. usually do not come to light. Only on tomograms or roentgenograms in later terms it is possible to see the course of the wound channel (fig. 48 and). Therefore the main objective rentgenol, researches consists in definition of existence of foreign bodys, in clarification of existence and amount of air and blood in a pleural cavity and assessment of degree of a raspravleniye of L. (fig. 47 and, 47, 48).
Treatment of wounds of L. it is carried out by the principles identical to all getting wounds of a breast. It is necessary to aim at the fastest full raspravleniye of L., to recovery of Hermeticism of a pleural cavity and release it from accumulation of blood. Identification of air and liquid serves as the indication to a pleurocentesis in a pleural cavity. At valve pheumothorax introduction of an intercostal drainage is shown. In cases of a large amount of air there can be indications to maintaining one more — two drainages. At intensive infiltration of air in the first 12 — 24 hours it is better to refrain from aspiration and to be limited to underwater drainage (see. Byulau drainage ). Then pass to continuous aspiration with depression 15 — 20 cm of a water column. Stronger depression is undesirable since it can interfere with closing of wounds of a lung with fibrin. Indications to a torapotomiya and sewing up of grazes at their open damages the following: lack of full effect of aspiration through drainages within 3 — 4 days; preservation of a tension pneumothorax and emphysema of a mediastinum at the functioning drainages (usually find big wounds of a lung or large bronchial tubes in these cases); the massive or proceeding intrapleural bleeding defined on the basis of general and clinical, rentgenol, data and at punctures of a pleural cavity; the curtailed hemothorax if conservative actions (a puncture of a pleura with irrigation, use of fibrinolitic means, etc.) were not effective: foreign bodys in a pleural cavity and in L., if they cause danger of emergence of complications (abscess, bleeding, etc.).
The technique of surgical treatment of a wound has some features. Small superficial wounds of L. take a clip, under the Crimea impose a usual ligature. Larger wounds take in thin noose or P-shaped sutures — synthetic threads on an atraumatic needle. Additional sealing of a suture line can be made tsianakrilatny glue. Deep wounds of L. take in with obligatory capture of their bottom in order to avoid formation of intra pulmonary air cysts and hematomas. Before sewing up of such wounds it is reasonable to tie up previously pl to sheathe the damaged vessels and bronchial tubes. In the presence of the fragmentary hurt or smashed wound of L. economically excise impractical fabrics or depending on extensiveness of damage make an atypical resection of L., lobectomy (see), a pneumonectomy (see. Pneumonectomy ).
Duration of treatment of patients with damages of L. is defined by weight of injuries and character of possible late complications. In uncomplicated cases duration of treatment varies from 2 to 3 weeks, working capacity is recovered in 2 — 3 months. A lethality in peace time at the closed and open damages of L. 2 — 4%.
Stage treatment in a field situation and conditions of GO at damages of L. is a component of a complex of actions of stage treatment of all wounds of a breast (see. Breast, stage treatment ).
Acquired diseases of L. are extremely diverse. The etiology of a considerable part of them is connected with biol, activators (bacteria, viruses, fungi, parasites). Etiology of another, not less numerous, groups of diseases of L. it cannot be reduced to this factor though biol, activators can play an essential role in a pathogeny and these sufferings and in development of complications.
In numerous group of diseases which etiology is not connected directly with inf. or others biol, activators, nonspecific diseases of L have the greatest value hron., to the Crimea carry hron, bronchitis (see), emphysema of lungs (see) and bronchial asthma (see). Role hron, nonspecific diseases of L. quickly increases in incidence, disability and mortality of the population of the majority of industrialized countries of the world; they occupy the third — the fourth place after cardiovascular diseases, malignant tumors and traumatism.
Nonspecific diseases of the bacterial and virus nature
From so-called nonspecific pathology of L. inf. the greatest value pneumonia (see), and also the pulmonary suppurations connected with destruction of pulmonary fabric has etiologies: abscess and gangrene of L.
Classification. S. I. Spasokukotsky (1935) considered abscess and gangrene of L. various stages of pulmonary suppuration. This point of view was eurysynusic many years and was based on data a wedge, and morphological researches about a possibility of transition of one form in another. However many clinical physicians (M. S. Grigoriev, V. I. Struchkov, I. S. Kolesnikov and B. S. Vikhriyev, etc.) and pathologists (A. M. Abrikosov, A. T. Hazanov and V. D. Tsinzerling, etc.) consider abscess and gangrene of L. independent diseases with peculiar a wedge, and morfol, signs. However they do not exclude situations at which limited purulent fusion of L. (abscess) gains the lines inherent its localized or even to widespread necrosis (gangrene).
Many classifications of abscesses and gangrene of L are offered., e.g. A. A. Opokin, S. I. Spasokukotsky, B. E. Linberg, H. M. Amosova, I. S. Kolesnikov and B. S. Vikhriyev, B. P. Fedorov and G. L. Vol-Epstein, F. G. Uglov and V. F. Egiazaryan. P. A. Kupriyanov and A. P. Kolesov's classification is most widespread (1955): acute purulent abscess (single, multiple); gangrenous abscess; widespread gangrene of L.; hron, abscess (single, multiple). Besides, specify localization of process on shares in classification, an etiology of abscess and gangrene of L. and their complications: a pyopneumothorax, developing of abscess in earlier not struck departments of L., bleeding, metastatic abscess of a brain, septicopyemia, amyloidosis, etc.
Fundamental difference of classification of P. A. Kupriyanov and A. P. Kolesov from other classifications consists in division of defeats of L., characterized by necrosis of fabric, on gangrenous abscess and gangrene of L. Such division is reasonable first of all the classical, described in old textbooks and the managements gangrene of L., permanently coming to an end with the death of the patient, meets now quite seldom.
Etiology. Specific causative agent of abscess and gangrene of L. no, and the bacterial flora at them needs to be characterized as microbic and virus. The microbic flora allocated at patients with abscess and gangrene of L., more often happens polymorphic. Associations of a streptococcus and staphylococcus which have high resistance to antibiotics have a principal value. Find the white and golden hemolitic staphylococcus which is green and a hemolitic streptococcus, fuzospirokhetny flora, colibacillus, Friedlander's bacillus in the center of defeat. Polymorphism of flora in a zone it is purulent - destructive process it can be connected with penetration of saprophytic microbic populations from an oral cavity and a nasopharynx. Being implemented into tissue of a lung, these saprophytic populations at once gain lines of pathogenic microorganisms. M. Ya. Elova, P.E. Lukomsky, T. V. Stepanova at acute abscesses of L. revealed rather small number of microbic populations, however in cases of transition of process to chronic the quantity of microbic forms considerably increased.
An essential role is played by the increasing frequency of antibiotic-resistant microbic forms and, first of all, strains of coccal group. At severe forms of pulmonary suppurations the microbic flora steady against the main antibiotics, according to L. M. Nedvedetskaya, comes to light in 60 — 70% of cases. On B. P. Fedorov and G. L. Vol-Epstein's materials, at patients with abscess and gangrene of L. microbic flora from the center of defeat was sensitive to the tested antibiotics only in 12 — 20%.
A number of authors emphasizes a role of mycoplasmas («agent Eaton») and viruses in development acute and hron, forms of pulmonary suppurations and indicates value of an influenzal virus in the course of abscessing.
Pathogeny. Abscesses and gangrene of lungs can have various pathogeny. They are metapneumonic, aspiration, hematogenous and embolic, traumatic, lymphogenous. Most often abscess and gangrene of L. are complications of acute pneumonias. The role of pneumonia at flu of which destructive changes in walls of bronchial tubes, deterioration in their drainage function, disturbance of microcirculation with thrombosis of small pulmonary vessels are characteristic that was shown by I. V. Davydovsky, L. S. Bekerman is very essential. By data I. S. Kolesnikova and B. S. Vikhriyev, at 63,9% of patients with abscess and gangrene of L. pneumonia, and at 14,1% — flu was the cause of their emergence. On B. P. Fedorov and G. L. Vol-Epstein's materials, in 76,1% of cases development of abscess and gangrene was directly connected with pneumonia. Broad use of antibiotics does not prevent regarding cases of abscessing at acute pneumonias, especially at the late beginning of antibacterial treatment. In process of increase of resistance of causative agents of pneumonia to antibiotics and change of reactivity of an organism frequency of development of abscesses and gangrene of L. began to increase a little. So, according to V. I. Struchkov, in 1952 — 1957 frequency it is purulent - destructive complications of acute pneumonias equaled 1,8%, and in 1960 — 1966 — 2,23%.
Aspiration way of development of abscess and gangrene of L. it is connected with infection of site L., ventilation to-rogo is broken as a result of obturation of the corresponding bronchial tube by a foreign body, emetic masses, blood, slime. Abscess and gangrene of L. aspiration genesis develop after a diabetic coma, an epileptic seizure, maxillofacial damages, heavy alcoholic intoxication, surgical interventions in a throat and a nasopharynx more often.
In more rare way of development of abscess and gangrene of L. is hematogenous and embolic. At the same time a septic embolus, having got with a blood flow to one of branches of a pulmonary artery, causes L. V heart attack to the infected zone heart attack (see) quickly enough there occurs purulent fusion and formation of abscess. Embolic abscesses of L. complicate the course of thrombophlebitis of deep veins of extremities and a basin, a septic endocarditis, osteomyelitis, postnatal sepsis. To a separation of blood clot and its drift in vessels of L. also operations on the infected fabrics can promote. Almost so often abscesses and gangrene of L. develop after an injury of a thorax with a fracture of edges and hemorrhages in pulmonary fabric. The lymphogenous way of a drift of an infection to lungs is casuistic. However anatomic bonds limf, systems L., pleurae and mediastinums do possible lymphogenous development of abscesses and gangrene of L. at purulent pleurisy or a mediastinitis.
To development of abscess and gangrene of L., in addition to the listed factors, diseases at which it is long promote the bronchial drainage and pulmonary blood circulation are broken — hron, bronchitis, bronchial asthma, emphysema.
A certain value in a pathogeny of abscesses and gangrenes of L. also disorders of nervous control and a lymphokinesis in
L. V development of a sphacelism play an essential role increase in coagulant potential of blood, observable, according to G. I. Lukomsky plays, at pulmonary suppurations. There is a condition of a pretromboz, a cut is aggravated with the progressing disproteinemia and a hypoalbuminemia.
Great value in a pathogeny of abscess and gangrene of L. belongs to the nature of change of reactivity of an organism. At preservation of protective forces of an organism elements of purulent fusion prevail and acute purulent abscess is formed; at decrease them necrotic changes prevail, there is gangrenous abscess or widespread gangrene of L.
Pathological anatomy. Abscess of L. — limited is purulent - necrotic defeat of pulmonary fabric with existence of one or several cavities which are gradually covered granulyatsionny fabric (color. tab., fig. 10). They seldom have correctly rounded shape (fig. 49) and promote development bronchiectasias (see) and pneumosclerosis (see).
Gangrene of L. — necrosis of pulmonary fabric with bent to the progressing distribution. Putridny, putrefactive gangrene of L. it is characterized by a diffuse necrosis with formation of unsharply outlined centers of brown-black color (color. the tab., fig. 11) which are exposed to disintegration with formation of cavities. In the central departments of a necrosis there is a lot of blood pigment, fabric detritis, crystals of a leucine, tyrosine, fat to - t. The bacterioscopy reveals various, preferential anaerobic, activators. Aputridny gangrene — a necrosis without ichorization, arises most often at patients with diabetes under the influence of fungi. It is necessary to distinguish a so-called acid pneumomalacia under the influence of agonal or cadaveric throwing of acid contents of a stomach in bronchial tubes from gangrene. These are the flabby centers of brown color in which the structure of L badly comes to light., however they are not followed by any reaction on the periphery.
Pathophysiological and biochemical shifts at abscess and gangrene of L. differ only with degree of manifestation. The hypoalbuminemia progresses, edges arises owing to loss of a significant amount of protein with pus and disturbances of belkovoobrazovatelny function of the liver caused by intoxication. At the same time there is an increase in globulinovy fractions — generally alfa1-, alfa2-and gamma-globulins. Therefore the general hypoproteinemia usually is not observed. Later, at development of a hypoproteinemia, the water connecting function of protein decreases and there are hypostases.
The accruing decrease in albumine promotes changes of water-salt and electrolytic balance which in turn change acid-base equilibrium (see). There is a tendency to increase in content of sodium in erythrocytes and to decrease it in a blood plasma. At the most severe forms of pulmonary suppurations metabolic develops acidosis (see). If abscess and gangrene arise against the background of emphysema, a pneumosclerosis, widespread bronchiectasias, bronchial asthma, the respiratory acidosis can be observed. According to G. I. Lukomsky, M. E. Alekseeva, the volume of the circulating blood and its components sharply changes. From indicators of coagulant and anticoagulative system of blood increase in maintenance of level of fibrinogen and increase in tolerance of plasma to heparin, i.e. dominance of activity of coagulant system over anticoagulative is noted.
In total patofiziol, and biochemical, changes are closely interconnected, depend on volume and the nature of defeat of L., from a phase of process, degree of intoxication, associated diseases. After natural or artificial evacuation of pus from an abscess cavity and reduction of intoxication these indicators are gradually normalized, objectively confirming efficiency of therapy.
Clinic and diagnosis. Abscessing at pneumonia happens usually by one of three options which described F. Zauerbrukh, O'Shonessi (O’Shaughnessy), and then L. S. Bekerman. First option: in 12 — 20 days from the beginning of pneumonia, after subsiding of the acute phenomena and the seeming recovery, there occurs considerable deterioration — temperature increases, stitches develop again, with cough the plentiful purulent phlegm begins to be allocated. Second option: pneumonia gains prolonged character and 20 — 30 days later from an onset of the illness against the background of rise in temperature the quantity of a purulent phlegm increases, and radiological in a zone of inflammatory focus the cavity comes to light. Third option: against the background of 1 — a 2 weeks indisposition, subfebrile temperature, stethalgias body temperature rises to high figures with the subsequent pouring sweats, and 2 — 3 days of the patient later suddenly begins to cough up a fetid phlegm «a full mouth» (a syndrome of break). At such disease P.E. Lukomsky, A. Ya. Gubergrits, Dekrua and Kuril (G. Decroix, R. Kourilsky, S. Kourilsky) wrote about «primary abscess of a lung».
Acute abscess of L. the hl is observed. obr. at men at the age of 30 — 50 years. In development of abscess it is accepted to allocate two phases. The first phase is characterized by an acute purulent inflammation and destruction of pulmonary fabric before break is purulent - necrotic masses in a gleam of a bronchial tree. The second phase begins after such break which usually comes on 2 — 3rd week from the beginning of a disease. Good emptying of a cavity is more often observed at abscesses of upper shares. In cases of intensive treatment the purulent cavity usually quickly decreases and ceases to be defined. Sometimes on site abscess (see) there is a thin-walled cavity without signs of an inflammation. At bad or insufficient emptying, a cut more often happens at localization of abscess in average and lower shares, it is purulent - the necrotic inflammation of a wall of a cavity and surrounding pulmonary fabric does not tend to a resistant zatikhaniye. There are repeating aggravations, in a wall of abscess there is a progressing development of connecting fabric, in surrounding fabric L. the pneumofibrosis develops. In 2 — 3 months from the beginning of a disease such abscess loses bent to healing and passes into chronic.
Gangrenous abscess of L. results from the begun gangrene, the edge does not extend to all L., and strikes only most or its smaller part. Such defeat, keeping symptoms of gangrene of L., at the same time has the lines characteristic of abscess. Allocation of gangrenous abscess as independent form of pulmonary suppuration is proved in view of peculiar a wedge, and rentgenol. pictures, disease severity and need of an emergency intensive care. Gangrenous abscess of L. it is more often observed at men at the age of 25 — 45 years. In the anamnesis most of them has instructions on hron, alcoholism, diabetes, hron, bronchitis, repeated pneumonia. Initial defeat is localized usually in an upper share of L., but process quickly extends, leaving intact most often only basal departments of the lower share.
The most characteristic symptoms of the beginning acute abscess of L. at any its etiology stethalgias, cough with a three-layered purulent phlegm, sometimes with a fetid smell, high intermittent fever with oznoba and sweats, frustration of a dream and appetite, a headache, short wind are. Percussion and auscultation reveal various changes in many respects depending on extent, localization, a stage patol, process, existence or lack of a pleural exudate. At large volume or at subpleural localization of defeat and existence of an exudate in a pleural cavity respiratory excursions of the corresponding half of a thorax are limited, the percussion sound is shortened, breath is weakened, and at a massive exudate is not listened at all; in other departments of L. the dry and wet mixed rattles caused by the accompanying bronchitis are often listened. ROE reaches high figures, indicators of hemoglobin in blood decrease, the leukocytosis with a deviation to the left before emergence of young forms of neutrophils and toxic granularity in them is typical. Symptoms of intoxication remain and even accrue until it is purulent - necrotic contents will not break in a bronchial tube and the patient will not begin to cough up it. The quantity of a phlegm sharply increases, temperature and other symptoms of intoxication gradually decrease, the leukocytosis decreases, ROE is slowed down. Auskultativno in a zone of destruction listens large-bubbling rattles, at big and huge cavities — on their background breath with an amphoric shade.
Wedge, current hron, abscess of L. usually has cyclic character and in many respects is defined by degree of passability of the draining bronchial tubes and an oporozhnyaemost of a purulent cavity. These factors are the most important in alternation of the periods of an aggravation and remission. At a good drainage of an aggravation happen seldom, intoxication is a little expressed. However cough usually remains, especially in the morning and at a postural change of a body. The phlegm (see) continues to remain purulent. Quite often there are streaks of blood in a phlegm or a blood spitting (see), a cut threatens with obstruction of the draining bronchial tubes clots. Sometimes arises pulmonary bleeding (see), easily leading to development of aspiration pneumonia. Disturbance of drainage function of bronchial tubes, as a rule, leads to an aggravation of process, increase of intoxication, secondary disorders of breath and blood circulation, increase in danger of development of an amyloidosis of internals.
Gangrenous abscess from the very beginning proceeds very hard, being followed by fever with a temperature up to 40 °, the hardest intoxication, disorders of breath and blood circulation. Patients complain of stethalgias and the painful cough which in the beginning is followed by allocation only relatively of a small amount purulent, the phlegm badly smelling. Integument dry, grayish color. Lips and nail phalanxes are cyanotic. Over a zone of defeat breath with an amphoric shade and a lot of wet rattles, over other departments of L is listened. — rigid breath with dry and single wet rattles. The liver is often increased and slightly painful. In analyses of urine emergence of protein is noted. In blood very high leukocytosis with shift of a formula is observed to the left, ROE reaches 60 — 70 mm an hour. Changes from a proteinogramma and volume of the circulating blood are considerably expressed. In 10 — 15 days fusion and sloughing begins. The quantity of a phlegm quickly increases and reaches 1 — 1,5 l a day. A consistence of a phlegm dense and even kashitseobrazny, color brown, began to smell putrefactive (gangrenous). At 1/4 patients the pneumorrhagia, pulmonary bleedings is observed. Despite usually good emptying of gangrenous abscesses which are, as a rule, drained by several bronchial tubes intoxication does not decrease, and in some cases even accrues due to the lack of a demarcation shaft, involvement in process of new sites L., existence in an abscess cavity of big necrotic sequesters of pulmonary fabric. At out of time begun intensive treatment or at its inefficiency patients die of the progressing intoxication or the joining complications — pulmonary bleeding, break of gangrenous abscess in a pleural cavity with rapid development pyopneumothorax (see). Under the influence of complex intensive treatment intoxication gradually decreases, breath, blood circulation, a metabolism are normalized. The phlegm becomes more liquid, homogeneous, purulent and loses a fetid smell. The pneumorrhagia arises less often and happens less plentiful, but danger of pulmonary bleedings remains. Further current most often favorable. However on site gangrenous abscess there is always a residual cavity which is well seen on roentgenograms, size the cut slowly decreases. Despite a wedge, wellbeing, normalization of a gemogramma, lack of a phlegm, wall of such residual cavity still a long time as the abstsessoskopiya shows, are covered with a necrotic plaque.
Gangrene of L. clinically proceeds most hard. Always there is sharply expressed intoxication, heavy disorders of breath, blood circulation and a metabolism are observed.
Complications. Possible complications during pulmonary suppuration are disturbances of drainage through a bronchial tube, break of pus in a pleural cavity, pulmonary bleedings. In such cases the condition of patients worsens again, stethalgias amplify, the quantity of a phlegm decreases, body temperature increases, the leukocytosis in blood accrues. Complications of gangrene of L. are similar to complications at abscess, but develop more often and proceed heavier.
Radiodiagnosis. At abscess of L. in the beginning the radiologist finds only a shadow of infiltrate, sometimes rounded shape, with indistinct contours. Preferential localization of abscess — the 1st, 2nd and 6th segments right L. Zatem, in process of emptying of an abscess through a bronchial tube, appear classical symptoms of abscess: in infiltrate the cavity containing gas and the liquid forming horizontal level is visible. At successful treatment the cavity decreases, liquid in it decreases. On site abscess there is a field of heterogeneous consolidation, sometimes with a residual cavity (fig. 50). At ichorization (gangrene) of pulmonary fabric in a zone of widespread infiltration appear irregular shape of a cavity with uneven outlines and shadows of necrotic sequesters (fig. 51). Root L. infiltrirovan.
Independently there are septic (metastatic) abscesses. Them rentgenol. the picture consists of interstitial pneumonia and sites of lobular or drain infiltration. In a lung one or several roundish thin-walled cavities of destruction to dia are formed. 0,5 — 1,5 cm containing gas and almost always free from liquid. There is no wall of these cavities equal, in surrounding fabric considerable infiltration, cavities can quickly change in sizes and, reaching a visceral pleura, to lead to developing of spontaneous pheumothorax and an empyema of a pleural cavity.
Treatment abscess of L. provides suppression of an infection, drainage of an abscess and increase in body resistance of the patient. Impact on an infection is carried out by use of antibiotics which shall be picked up taking into account character and sensitivity of the microbic flora allocated from a phlegm. It is reasonable to use at the same time two or even three drugs. Very difficult question is the choice of a method of introduction and doses of antibiotics, considering that abscesses of L. at many patients develop against the background of an inadequate antibioticotherapia. It is more preferable various special ways allowing to create higher concentration of antibiotics in the center of defeat. Drop intravenous injection of solutions of antibiotics and their introduction to an abscess cavity through a transnasal catheter, a microtracheostoma, the bronchoscope or a catheter established in an abscess cavity by a thoracocentesis in the conditions of an obliteration of a pleural cavity are most acceptable. All ways of introduction of antibiotics through catheters and the bronchoscope are combined with the actions improving drainage of a purulent cavity — suction, washing, administration of proteolytic enzymes.
Intravenously kapelno antibiotics enter in isotonic solution of sodium chloride or into 5% solution of glucose during 5 — 7 and more than a day. The daily dose of penicillin can reach 80 000 000 PIECES, Morphocyclinum — 1 000 000 PIECES, sodium salt of Methicillinum — 10 g.
Injection of solutions of antibiotics in an abscess cavity if it is well drained through a bronchial tube, is made every other day by transnasal catheterization after local anesthesia of a mucous membrane of a nose, a throat, a throat, a trachea and bronchial tubes. Use a rubber or plastic catheter which is entered under control of X-ray television. Technical implementation of catheterization is considerably facilitated by use of special catheters from the universal managing director of the handle. In cases of bad drainage of abscess conduct a course to lay down. bronkhoskopiya (see) during which carry out to lay down. catheterization of the draining bronchial tubes and, at an opportunity, an abscess cavity. At inefficiency or insufficient efficiency of these ways apply a puncture of abscess through a chest wall and drainage of abscess (see. Drainage ) by a thoracocentesis. Punctures carry out under local anesthesia and X-ray television control in a point of the chest wall located most close to abscess. During punctures suck away pus, wash out an abscess cavity solution of Furacilin 1: 5000 or 3% solution boric to - you and then enter solution of antibiotics. At punctures of abscesses of lungs there can be such complications as pheumothorax (see), a limited empyema of a pleura (see Pleurisy), phlegmon of a chest wall. Therefore sometimes hold events to cause commissural process in a pleura. Drainage of abscess of L. by a thoracocentesis in comparison with punctures more effectively. Therefore drainage is shown in the majority of hard cases when other therapy does not allow to liquidate purulent intoxication because of permanent disturbance of passability of the bronchial tubes draining an abscess cavity. The usual term of leaving of a drainage in an abscess cavity — 2 — 3 weeks.
High and resistant concentration of antibiotics in a zone of abscess of L. it is reached also them by fractional or long drop infusion in the corresponding branch of a pulmonary artery or, what is even more effective, in a bronchial artery. However these methods are connected with need of catheterization of a pulmonary artery through a subclavial vein, a vein of a shoulder or a hip and catheterization of an aorta through a femoral artery and therefore are applied seldom, generally in specialized departments.
The general actions promoting the best evacuation of contents of abscess of L. through bronchial tubes, the special respiratory gymnastics, a postural drainage, inhalations of alkaline aerosols, use of broncholitic drugs are.
Increase in resilience and improvement of the general condition of patients is reached by good nutrition with a large amount of proteins and vitamins, use of an autovaccine, infusions of plasma, proteinaceous solutions, 1% of solution of calcium chloride, and also administration of anabolic hormones and nonspecific stimulators of exchange, such as pentoxyl and methyluracil. Considerable strengthening of reactivity of an organism manages to be reached administration of staphylococcal anatoxin, gamma and polyglobulin, and also native anti-staphylococcal plasma.
Operative measures should be made approximately at 10% of all patients with hron, abscesses of L. At acute abscesses with necrotic sequesters rational operation remains pneumotomy (see). In all other cases this operation applied earlier very widely lost the value owing to insufficient efficiency and frequent need of the subsequent thoracoplasty and a myoplasty for closing of residual cavities and bronchial fistulas.
At patients with gangrene of L. conservative methods of treatment usually do not give success. Therefore if the diagnosis does not raise doubts, it is necessary to try to save the patient with perhaps early operation — as a rule, removal of all struck L., since it is not possible to stop the progressing necrosis of pulmonary fabric usually. The lethality at such operations and in modern conditions remains very high. The main operations at hron, abscesses of L. resections of the struck parts L are. — usually forehead silt and bilobectomy. In cases of involvement in process by a top and bottom share of L. or at multiple abscesses in different shares of L. it is shown pneumonectomy (see). Patients with heavy pulmonary bleedings have urgent indications to a resection of L.
The forecast of pulmonary suppuration in many respects is defined by its form and timely begun full therapy. At timely and correct use of the described conservative methods of treatment it is possible to achieve a wedge, recovery from 80% of patients with acute abscesses of L. An over-all mortality at conservative and operational treatment of abscesses of lungs — 5 — 7%.
In to prevention abscesses and gangrene of L. major importance have wide a gigabyte. the actions directed to prevention of diseases of bronchial tubes and L., timely begun full treatment of acute pneumonias, prevention of aspirations of foreign bodys in respiratory tracts.
Features of pulmonary suppurations at children
Suppurations of L. at children, as well as at adults, can be acute and chronic. Features of suppurations of L. at children's age are defined by many factors from which it is necessary to distinguish relative immaturity of the bronchopulmonary structures continuing the quantitative and high-quality development, and also various level of resilience of an infection in different age groups. Except the specified factors, on the frequency and weight of suppurations of L. at newborns and babies the complicated course of pregnancy and childbirth (a disease of mother, aspiration, a hypoxia in labor and so forth), prematurity, a hypotrophy, rickets influence directly or indirectly.
Among causative agents of suppurations there is a L. at children staphylococcus prevails. The majority of acute pulmonary suppurations arises owing to aero bronchogenic infection, however approximately in 20 — 30% of cases the hematogenous way in the presence of the previous extra pulmonary suppurative focuses takes place. In the period of a neonatality and early chest age hematogenous infection meets more often than at more senior children; the similar centers usually are the omphalitis, a pyoderma, abscess of soft tissues, otitis and so forth.
The special group is made by patients at whom inflammatory process develops against the background of inborn porsk of development of L. (single and multiple cysts, hypoplasia, sequestration and so forth). Considerably bigger specific weight, in comparison with adults, at children is made by pulmonary suppurations because of aspiration of foreign bodys.
It is possible to distinguish two main forms from acute pulmonary suppurations: melkoochagovy and macrofocal abscessing. The first of these forms is very typical for the staphylococcal abscessing pneumonia — so-called staphylococcal destructions of L., the acute pulmonary suppurations winning first place in structure at children's age. At melkoochagovy abscessing abscesses have the small sizes, they most often multiple also are located preferential in peripheral departments of a lung. In this regard in inflammatory process the pleural cavity is quickly involved (owing to strengthening of exudation in a pleura or by break of abscesses). As a result legochnoplevralny suppuration develops, a cut can consist in various forms of a pyothorax (plashchevidny, delimited, total) or a pyopneumothorax (intense, without tension, delimited). It is important to emphasize that bystry accession of pleural complications masks rentgenol, signs of abscessing, and into the forefront act signs of inflammatory process in a pleura. The following pattern is characteristic — the child is younger, the tendency to generalization of inflammatory process in a pleura consisting in dominance of severe forms of a total pyothorax (see Pleurisy), intense and not intense is more often pyopneumothorax (see). It is especially noticeable at children of the period of a neonatality and chest age.
At children is aged more senior than one year more expressed there is a tendency to an otgranicheniye of inflammatory process in a pleura, at them such rather favorable forms as the plashchevidny and delimited pyothorax, the delimited pyopneumothorax meet along with heavy more often. According to the specified tendency, at newborns and babies it is incomparable more often than at more seniors, purulent process is followed by development of symptoms of sepsis.
Macrofocal abscessing is observed at children by 4 — 5 times less than melkoochagovy, and can have three main rentgenomorfol. forms: abscess with a fluid level, the filled abscess and abscessing as a lobit. In these cases the pleural cavity is usually not involved in inflammatory process, or the last has reactive character and is more expressed in the field of an arrangement of abscess. Macrofocal abscessing at children most often is one of forms of staphylococcal destruction of L. Odnako it can arise at aspiration of foreign bodys and as a result of «innidiation» from extra pulmonary suppurative focuses (osteomyelitis, peritonitis and so forth).
One of the most frequent forms hron, inflammatory process in L. is bronchoectatic disease (see). At this disease suppuration on type hron, abscessings in a parenchyma of L is very seldom noted. Most often more or less expressed hron, purulent bronchitis with deformation of bronchial tubes as cylindrical or saccular bronchiectasias takes place. However at bronchiectasias because of a malformation (a so-called polycystic lung) a wedge, and rentgenol, the picture is very close to hron, to pulmonary suppuration. Hron, abscesses of L. at children's age meet considerably less than at adults. Their formation is, as a rule, connected with insufficiently effective treatment in the acute period when full and early emptying of a cavity and its fall is not provided. In some cases formation hron, abscess is connected with a vykhozhdeniye of foreign bodys from a gleam of a bronchial tube in a parenchyma of L. At pulmonary and pleural forms of acute purulent process the outcome in hron is possible, suppuration, a cut takes the form hron, empyemas of a pleura. The last can be followed also by irreversible changes in L. (bronchiectasias, the created bronchopleural fistulas). The outcome of acute pulmonary and pleural suppurations in hron, an empyema occurs at children incomparably less than at adults, and fluctuates within 0,5 — 3% of cases. The rare reasons hron, empyemas are fistulas of a stump of a bronchial tube after a resection of L. and foreign bodys of L. and pleurae.
All forms of acute pulmonary suppuration are followed by symptoms of quickly developing purulent intoxication (high fever, loss of appetite, frustration of a hemodynamics and microcirculation, metabolic disturbances and so forth). Usually they are accompanied also by respiratory frustration which expressiveness depends on the volume of the pulmonary parenchyma involved in inflammatory process and existence of the factors which are mechanically complicating breath (the intrapleural or intra pulmonary tension, obstruction of respiratory tracts a phlegm, restriction of respiratory excursions of a diaphragm owing to paresis of intestines). They come down to an asthma, disturbance of depth and a respiratory rhythm, up to attacks of asphyxia (see). The prevalence of displays of toxicosis or respiratory frustration depends on a form of suppurative process. Disturbances of breath usually act into the forefront at the pulmonary suppuration which is followed by intrapleural or intra pulmonary tension. With other things being equal both symptoms of toxicosis, and disturbance of breath are more expressed and quicker progress at patients of the period of a neonatality and early chest age. At acute pulmonary suppurations at first the general symptoms of intoxication at children prevail over clinically revealed signs of local pulmonary process. At a part of patients the masking syndromes are observed (pseudoabdominal, neurotoxic).
Pulmonary process it is quite often long it is regarded as usual pneumonia, especially if in diagnosis are limited to physical methods of a research. An important condition of recognition of various forms of acute pulmonary suppuration is perhaps earlier use rentgenol, researches. On the basis of survey roentgenograms (in vertical position of the patient) it is possible to suspect of two projections with a high probability macrofocal abscessing. More difficultly melkoochagovy abscessing comes to light, a cut quite often masks perifocal infiltration. In these cases the tomography is reasonable (see), edges can reveal cavities in L. small sizes. This research less informatively in the presence of pleural complications.
At pulmonary and pleural forms of suppuration a necessary additional method of a research is the puncture of a pleural cavity (see. Pleurocentesis ). At pulmonary forms of suppuration the diagnostic bronkhoskopiya is reasonable (see). In diagnosis hron, forms of pulmonary suppurations tool methods are widely used — bronkhoskopiya (see), torakoskopiya (see) and rentgenol, methods — a bronchography (see), plevrografiya (see), angiopulmonografiya (see). They allow to confirm the irreversible nature of change in L. and a pleura and to specify localization and volume of defeat.
At acute pulmonary suppurations the philosophy of treatment is the combination of intensive conservative care to tool and surgical methods. The choice of the last is defined by a form of suppurative processes and age features of their current. For treatment of acute abscesses of JT. at children various methods are offered. Eurysynusic in 50 — the 60th puncture treatment and drainage of an abscess cavity, and also operational methods in modern conditions are applied seldom. Bronchoscopic drainage gains ground (see Bronkhoskopiya), the most effective sanitation is provided at the same time by chrezbronkhialny catheterization of abscess. Operational treatment is shown only in cases of inefficiency of bronchoscopic drainage that more often happens in the period of a neonatality and early chest age. In treatment of acute pulmonary and pleural suppurations the puncture method is reasonable in the presence of rather favorable pleural complications (a plashchevidny pyothorax, «the delimited forms of a pyothorax and a pyopneumothorax). At severe forms of a total pyothorax, an intense and not intense pyopneumothorax (pheumothorax) drainage of a pleural cavity with active aspiration is most often applied. For the purpose of acceleration of a raspravleniye of a lung sometimes apply the forced its inflating under anesthetic. By more perspective method of a raspravleniye of L. at a pyopneumothorax artificial sealing of bronchial system by temporary occlusion of the bronchial tube bearing peripheral fistulas is. In a number of specialized institutions apply expanded operations on L. and a pleura (so-called radical operations) at severe forms of acute pulmonary and pleural suppuration. They consist in single-step sanitation of the pleural cavity which is combined with removal of a suppurative focus in L. Naiboley such operations at children of the period of a neonatality and early chest age at which tendency to progressing of purulent process is expressed are proved, and efficiency of drainage of a pleural cavity is insufficient. The best results, according to Yu. F. Isakov et al. (1978), at this age give early operative measures. At pulmonary and pleural suppurations at children a number of surgeons applies operational treatment in later terms, at stabilization or improvement of the general state at patients at whom remains to not straightened L. Treatment of all forms hron, pulmonary suppuration at children (a bronchietasia, hron, abscess, the suppurated cysts, hron, an empyema), as a rule, operational. The philosophy is the combination of radicalism and economy of the operative measure providing the greatest possible preservation of healthy sites L.
The forecast at acute pulmonary suppurations depends on many factors: age of patients, one - or the bilateral nature of process, adequacy of the carried-out treatment. The greatest threat is posed by development of sepsis that is more often observed at children of the period of a neonatality and early chest age at severe forms of pulmonary and pleural suppuration. The long-term results at the children who had acute pulmonary suppuration in general are favorable. The forecast at hron, suppurations of L. at children depends on radicalism of operational treatment.
To specific, preferential chronically current inf. to processes in L. tuberculosis belongs, first of all, (see. Tuberculosis of a respiratory organs ). Syphilis meets extremely seldom. Inborn syphilis of L. it is observed at premature, mortinatus fruits or at the newborns perishing in the first days after the birth. L. at the same time are diffuzno condensed. Microscopically the expressed fibrosis of intersticial fabric, abnormal development of the alveoluses covered by a cubical epithelium and a large number of pale treponemas is found (see. White pneumonia ). The acquired syphilis of L. it is characterized by development of large or small gummas which, being exposed to a necrosis and scarring, disfigure L. as pulmo lobatus, especially if gummas develop in walls of bronchial tubes and lead to an ulceration of the last with accession of a nonspecific sclerosis. Syphilis of branches of a pulmonary artery is shown in a look endo-or a mesovasculitis and in the conditions of pulmonary hypertensia can, according to Spencer (N. of Spencer), to cause development of aneurism of its branches. Treponemas come to light badly and more often in the form of atipichesky forms contrary to inborn syphilis.
Syphilis of L. radiological it is expressed by a combination of interstitial pneumonia and the centers or infiltrates (gummas) in a parenchyma of L. The diagnosis is made on the basis of detection of suspicious shadows at a X-ray analysis and positive serol, reactions on syphilis (see). In not clear cases the biopsy of L is reasonable. confirming the specific nature of defeat. Treatment is same, as at other forms of tertiary syphilis.
Fungus diseases. Fungal flora can be the cause of a number of preferential chronically current diseases of L., combined in group pneumomycoses (see).
Reason of parasitic diseases of L. there are both elementary unicells, and various helminths.
To protozoan infections of L. the pneumocystic pneumonia caused by Pneumocystis carinii belongs (see the Pneumocystosis), for a cut foamy contents of alveoluses (fig. 52) with existence of cysts of 2 in size — 5 microns which are well revealed by PAS reaction are characteristic.
Pulmonary defeats at the toxoplasmosis caused by the elementary Toxoplasma gondii consist in formation in pulmonary fabric of granulomas in which the center of a necrosis is surrounded with lymphocytes and plasmocytes. Further calcification can be observed. A toxoplasmosis at adults proceeds as acute intersticial pneumonia; the parasite is found in macrophages (fig. 53). The general manifestations are clinically noted toxoplasmosis (see). Quite often there is cough, wet rattles at auscultation. Radiological multiple focal shadows are visible, further the centers are exposed to calcification. Usually the same centers come to light on roentgenograms of a skull in a brain. Lab. diagnosis and treatment, as well as at other forms of a toxoplasmosis.
Amebiasis of L. is caused by Entamoeba histolytica which is initially affecting a large intestine. From the last parasites gematogenno get into a liver where the abscess for the second time extending to a diaphragm and the lower share of the right L. Isklyuchitelno seldom hematogenous amoebic abscess of L forms. forms without damage of a liver. The amebiasis is characterized by the centers of a necrosis of chocolate color because of adjournment of a blood pigment. At secondary infection of the field of a necrosis are exposed to purulent fusion with formation of the true abscesses surrounded with a zone of nonspecific pneumosclerosis (see).
Clinically the patient has pains in the right half of a thorax, high fever about oznobam, cough with release of plentiful grayish-brown liquid pus, in Krom amoebas can be found. Radiological high standing of the right half of a diaphragm, blackout in lower parts of H.p. by the subsequent formation of a cavity with horizontal level, sometimes a pleural exudate is observed. Treatment is carried out, as well as at other forms amebiasis (see). Sometimes drainage of an empyema or abscess cavity is necessary. Upon transition in hron, a form — a resection of L.
From parasitic diseases of L., caused by helminths, the greatest value has Echinococcosis (see).
Much more rare in L. meets alveococcosis (see), at Krom pulmonary fabric, as a rule, is surprised for the second time in the hematogenous way or owing to germination of alveokokkozny nodes from a liver through a diaphragm.
Paragonimiasis of L. (a local pneumorrhagia) is caused by a pulmonary fluke (Paragonimus westermani). The parasite getting into intestines of the patient through a wall of a gut, a peritoneum and a diaphragm gets into pulmonary fabric (fig. 54 and 55) where there is its maturing. There is bronchitis, a circulatory disturbance, in certain sites L. like heart attacks with the subsequent disintegration and formation of cavities (cysts) with brown contents. Cysts can be emptied in a bronchial tree and be filled with air and obyzvestvlyatsya. Clinically the disease is shown by stethalgias, cough with a plentiful phlegm of rusty color or impurity of fresh blood. Radiological at paragonimiasis (see) in L. the sites of infiltration which do not have any peculiar features and reminding focal pneumonia can be found. In the subsequent in them there are small cavities combining in the cyst surrounded with a perifocal inflammation. Cysts exist many months, are gradually replaced with granulyatsionny fabric and cicatrize. The diagnosis is specified by detection of eggs of a parasite in a phlegm. Treatment is carried out by emetine, Resochinum, potassium iodide.
Defeat of L. at schistosomatosis (see) it is connected with a hematogenous drift of eggs of the parasites nesting hl. obr. in distal departments of a large intestine and in an urinogenital path, in pulmonary arterioles where they cause inflammatory reaction, destruction of walls of vessels, fibrinferments, sometimes formation of pseudoaneurysms. A schistosomatosis in L. gives four types of defeats: a) embolism parasites (fig. 56); b) embolism eggs of parasites; both forms in case of death of parasites cause development of the granulomas similar to tubercular (fig. 57); c) allergic arteritis (see) with fibrinoid necroses and productive reaction of an internal cover up to an obliteration of a gleam; d) the changes characteristic of high hypertensia with development of a glomal anastomosis. Disturbance of passability of a considerable part of arterioles is resulted by pulmonary hypertensia and the pulmonary heart forms (see). Clinically the disease is shown by small cough, the accruing asthma, signs of stagnation in a big circle of blood circulation. Radiological multiple melkoochagovy shadows, expansion of a pulmonary artery, increase in the right departments of heart are found. Besides, at a schistosomatosis as the allergic phenomenon can appear limited hypostasis of pulmonary fabric (flying eosinophilic infiltrate). The exact diagnosis is established on finding of eggs of parasites in urine, excrements, is more rare in a phlegm. Treatment — by the general principles of treatment of a schistosomatosis.
Defeat of L. at ascaridosis (see) meets seldom and preferential at children's age. At hematogenous hit of larvae of ascarids in L. there is an obstruction of arterioles which is followed by developing of microheart attacks. Clinically the disease is shown by fever, cough, short wind, emergence in blood of an eosinophilia. Radiological fast-passing melkoochagovy shadows come to light. Treatment of an ascaridosis is carried out by the general principles. The allergens emitted by the ascarids parasitizing in intestines matter in a pathogeny of pulmonary eosinophilias, in particular Leffler's syndrome (see. Lefflera syndrome ).
The diseases connected with inhalation of dust particles
Professional factors and first of all dust content of air in a zone of jobs are the reason of numerous group of occupational diseases of L. The most part of these diseases is connected with hit in L. together with inhaled air of the most fine particles of the inorganic matters making more or less specific harmful effects on pulmonary fabric. These diseases combine the term the Pneumoconiosis (see). Carry to the same group of diseases and byssinosis (see) — a disease of L., connected with inhalation of dust of cotton, flax or hemp.
The diseases pathogenetic connected with an allergy
the Most frequent disease to-rogo are the cornerstone of a pathogeny allergic mechanisms, is bronchial asthma (see). To more rare similar pathology of L. the group of diseases not always a clear etiology combined by existence of the expressed eosinophilia of peripheral blood belongs.
Eosinophilic infiltrate. Acute eosinophilic infiltrate L. — see Leffler a syndrome. Hron, eosinophilic infiltrate (a synonym eosinophilic infiltrate of Kartagener) meets seldom and differs from acute in longer current (from one to several months). Allergic reaction of pulmonary fabric is the cornerstone of a disease, apparently. At morfol, a research find the center of well delimited intersticial pneumonia: walls of alveoluses of an infiltrirovana the histiocytes, lymphocytes, plasmocytes and eosinophils which however are strongly varying by quantity in different sites of infiltrate. The outcome in focal fibrosis and small cysts with accumulation here of siderophages is usually observed. Quite high fever at a satisfactory general condition of the patient is clinically observed long, sometimes, cough with the scanty phlegm containing eosinophils. At physics flax a research quite often listens wet rattles in a zone of defeat. Radiological more or less homogeneous blackout, usually decides on indistinct contours, sometimes bilateral. Throughout a disease infiltrates can resolve and be replaced with others, sometimes in opposite L. Kolichestvo of eosinophils of blood usually exceeds 10%. At treatment the desensibilizing therapy is applied, at expressed a wedge, a picture — glucocorticoids for 4 — 6 weeks. The forecast — favorable.
An asthmatic pulmonary eosinophilia — a combination hron, eosinophilic infiltrate of H.p. a wedge, displays of bronchial asthma.
Exogenous allergic alveolites. Some occupational diseases of L. are connected with inhalation of organic production dust. The majority of diseases of this group is caused by allergic reactions of pulmonary fabric to the antigens which are contained in dust and carries the name of exogenous allergic alveolites. Many forms of allergic alveolites are described. The so-called lungs of the farmer caused by an allergy to the thermophilic actinomycetes which are contained in rotten hay are most known among them; the bagassosis connected with processing of a mouldy sugarcane; «the lung of tanners», at Krom an allergy develops to a fungus, vegetans on the maple bark used at a tanning of skin; the «lung of poultry breeders» which is result of inhalation of allergens of a bird's dung; «a lung of the workers processing mushrooms», apparently, connected with an allergy to thermophilic actinomycetes, etc. Unlike bronchial asthma, edge can also arise owing to an allergy to the production factors mentioned above, at allergic alveolites not attacks of a bronchospasm, and the reaction of the slowed-down type which is expressed hypostasis and infiltration of walls of alveoluses lymphocytes, plasmocytes and neutrophils, development of bilateral intersticial pneumonia with preferential localization of a productive inflammation in walls of bronchioles, their obliteration which is observed according to H. Pepys in 25% of cases are observed. The gleam of the affected bronchioles can be corked with inflammatory exudate. At the long course of a disease small knots from the epithelial cells surrounded lymphoid, plasmatic, and sometimes with colossal cells form (see Pneumonia, an allergic alveolitis). Clinically the disease can proceed sharply, subacutely, more rare — chronically. At a typical acute current in several hours of contact with allergen (e.g., rotten hay) there is an indisposition, fever, cough with the scanty phlegm sometimes painted by blood. In lungs crepitant rattles can be listened. Symptoms disappear during 2 — 3 weeks, but at repeated contacts are shown less sharply and proceed longer time. The disease can pass in hron, a form with the progressing respiratory insufficiency (see). Radiological changes are absent or consist in emergence of the melkoochagovy shadows which were more expressed in lower parts of L. The diagnosis is made on a combination of the listed signs, identification of possible contact with allergenic production factors, the reaction to contact with allergen delayed at several o'clock. Sometimes pretsipitinovy tests with the corresponding allergens help. Prevention consists in prevention of work with rotten and superheated organic matters and materials, respect for the correct technology of preparation of hay, a sugarcane, mushrooms etc., ensuring perfect ventilation of workrooms. At emergence of an allergy the prevention of further contact with allergen and professional reorientation is necessary. Treatment by glucocorticoids in acute and subacute cases renders the expressed effect. Hron, forms will badly respond to treatment.
Diffusion pneumoscleroses, granulomatoses and damages of lungs at general diseases. Sarcoidosis (see) — a general disease with preferential localization patol, changes in L. and limf, nodes of a mediastinum; in sovr, conditions meets even more often.
A diffusion fibroziruyushchy alveolitis, or Hammen's syndrome — Rich (see. Hammena-Rich syndrome ) — very heavy, though infrequently found disease.
An alveolar proteinosis — the rare disease described in 1958 by S. H. Bosen et al. Its essence consists in accumulation in alveoluses of rather dense belkovopodobny substance. The etiology of a disease is not clear.
The alveolar proteinosis is characterized by dystrophy and a necrobiosis of big alveolotsit, accumulation in their protoplasm, and also in gleams of the alveoluses and bronchioles P AS positive granules merging in dense proteinaceous masses in the form of dense eosinophilic liquid (fig. 58). The last gives reaction of a metachromasia with toluidine blue, is not painted by alcian blue, contains lipids. Walls of alveoluses rykhlo infiltrirovana lymphocytes. L. are increased, the centers like gray hepatization alternate with fields of atelectases. Process meets by 3 times more often at men, sometimes initially, but is more often described at leukoses, lymphoma, a pneumoconiosis. Experimentally Yu. P. Likhachev (1975) with sotr. the model of an alveolar proteinosis under the influence of quartz dust is received and at aerosol inhalation, containing copper. The phlegm is sterile, contains lamellar bodies — desquamated big alveolotsita that confirms communication of process with death of a vystilka of alveoluses under the influence of zapyleniye.
Clinically the disease can sharply begin, high rise in temperature, stethalgias, dry or with a phlegm cough, sometimes a pneumorrhagia. In other cases — the beginning imperceptible, with fading in of weakness, an indisposition, lose of weight etc. Further cough, dry or with a scanty phlegm joins. In both cases the disease flows wavy, with periodic aggravations and incremental respiratory insufficiency. Physical symptoms from L. are poor (the weakened or rigid breath, sometimes crepitation). Radiological the plumose, indistinctly knotty shadows reminding a picture of hypostasis of L. V to a phlegm are found and rinsing waters of bronchial tubes substance with positive CHIC reaction sometimes comes to light. Specifies the diagnosis a biopsy of lungs. Treatment consists in inhalation of the means liquefying patol, contents of alveoluses (Acetylcysteinum, Bisolvon). The most effectively serial washing of each of L. isotonic solution of Acetylcysteinum in the conditions of an anesthesia and artificial ventilation, giving a long-term effect.
Damages of lungs at collagenoses
Patol. changes in L., sometimes speakers into the forefront in a wedge, a picture, are characteristic of the majority of general diseases of connecting fabric — so-called kollagenoz (see. Collagenic diseases ). Distinguish primary defeats of L. at collagenoses, caused by the changes typical for a basic disease, and secondary, being result of stagnation and consecutive infection, characteristic of a terminal phase of a disease. Allocate two types of primary defeats of L. at collagenoses: so-called pulmonary vasculitis (see), at Krom preferential vascular system, and intersticial is surprised pneumonitis (see) when first of all connecting fabric of interalveolar and interlobular partitions is surprised. Both of these processes, as a rule, develop at the same time though one of them can prevail that finds expression in a wedge, and rentgenol, a picture.
Pulmonary manifestations at rheumatism, a pseudorheumatism, a system lupus erythematosus, a system scleroderma, a nodular periarteritis and a dermatomyositis differ in a certain originality and at the same time have a number of common features. In L, characteristic of defeat. at collagenoses consider a rarity of development of emphysema and a pulmonary heart. Closely to defeat of L. at a nodular periarteritis there is Wegener's granulomatosis which does not have typical rentgenol, semiotics; at it also infiltrates in pulmonary fields, both retikulonodulyarny reorganization of the drawing, and consolidation of the whole segments and shares are observed (see. Wegener granulomatosis ).
The picture at a scleroderma is most typical rentgenol. In lower parts of L. a peculiar close-meshed drawing and small thin-walled cavities is defined. Also small centers, discal atelectases are noted. It is more difficult to suspect other collagenoses radiological; here the accounting of clinical laboratory data is especially important. At a system lupus erythematosus the high position of a diaphragm, a small exudate in a pericardium and a pleura, increase in heart, diffusion strengthening of the pulmonary drawing with the advent of indistinctly delimited sites of infiltration attracts attention. Similar strengthening of the drawing is observed at a nodular periarteritis; but on this background there are nodular educations, sometimes to 2 — 3 cm in the diameter. There can be a disintegration of intra pulmonary nodes and a hyperplasia limf, nodes in roots. Great value for check rentgenol, the diagnosis collagenose has overseeing of L. at treatment of an immunosuppressant-mi and glucocorticoids.
Shegren's syndrome is, apparently, option of a current of a pseudorheumatism with pulmonary manifestations. For a syndrome it is considered characteristic: 1) a pseudorheumatism (see); 2) a dry keratoconjunctivitis (see. Keratitis ); 3) xerostomia (see). The last two components of a syndrome are caused by rhematoid defeat and dysfunction of the lacrimal and sialadens. Pulmonary manifestations are similar to those which are observed at a pseudorheumatism. Patients often complain of the dry cough caused by reduction of secretion and dryness of a mucous membrane in a throat and a trachea. Disturbance of mukotsiliarny function leads to development of consecutive infection in bronchial tubes and lungs. Quite often patients perish from pneumonia. Radiological in L. the changes characteristic of kollagenoz come to light. Sometimes the pleural exudate is found. The diagnosis is made on the basis of a combination of manifestation of a pseudorheumatism, a keratoconjunctivitis and a xerostomia. Treatment, as at a pseudorheumatism.
The idiopathic hemosiderosis of lungs is a peculiar diffusion defeat of L. the obscure etiology it is also characterized by repeated hemorrhages in fabric L., a pneumorrhagia and a secondary iron deficiency anemia (see. Idiopathic hemosiderosis of lungs ).
Gudpascher's syndrome has a certain looking alike an idiopathic hemosiderosis. The etiology is unknown. The disease meets more often at adults. Changes at Gudpascher's syndrome are usually represented by massive intra pulmonary diapedetic bleedings with accumulation in alveoluses, regional limf, nodes of hemosiderin and at the same time arising glomerulonephritis (see). Unlike an idiopathic hemosiderosis in alveoluses deposits of fibrin are more often observed. A wedge, manifestations consist in the repeating blood spitting, a picture of the glomerulonephritis proceeding usually without the expressed arterial hypertension and the leader to progressing renal failure (see), from a cut most of patients perishes. Radiological Gudpascher's syndrome causes during remission only strengthening of the pulmonary drawing. But during the periods of a blood spitting in radical departments of L. there are numerous focal shadows reminding sites of hypostasis.
The diagnosis is made on the basis of the combined defeat of L. and kidneys. A certain value has detection of siderophages in a phlegm, sometimes a renal biopsy. Treatment is developed insufficiently and comes down generally to use of corticosteroid drugs.
The amyloidosis usually arises as a complication hron, infectious diseases. Much less often primary amyloidosis of L meets., observable, according to Spencer, in the form of four morfol, forms: a) the localized tumorous; b) melkouzelkovy damage of bronchial tubes; c) nodular; d) diffusion defeat of respiratory department (fig. 59). In bronchial tubes amyloid is located under a mucous membrane that conducts to an atrophy of glands and cartilages; is exposed to a rassasyvaniye colossal cells. Large nodes in respiratory department often mistakenly macroscopically take for metastasises of a tumor. Diffusion defeat of respiratory department can meet also at secondary amyloidosis (see), begins under an endothelium of capillaries. Amyloid in L. often treats paraamyloid and can not give typical reactions with Congo and other dyes. More often men are ill 50 — 60 years are aged more senior. Clinically and radiological the disease is shown by symptoms of bronchial obstruction that quite often leads to the wrong diagnosis of adenoma of a bronchial tube or bronchogenic cancer. The diagnosis is established on the basis of results of the biopsy executed via the bronchoscope. At diffusion defeats of a parenchyma of L. the progressing asthma can be observed. The disease quite often comes to light accidentally at rentgenol, inspection and in the presence of the centers is quite often regarded as metastasises of cancer. For establishment of true nature patol, process the biopsy is necessary. Treatment at the localized damage of large bronchial tubes consists the centers of an amyloidosis in the operational or endoscopic way at a distance. At diffusion defeat a symptomatic treatment.
Ossification of lungs is shown in two forms. 1. The osteoplastic bronchopathy (see Trakheobronkhopatiya hondroosteoplastichesky) which is characterized by development of rings and plates of a bone tissue in the course of a metaplasia of fibrous and cartilaginous tissue of bronchial tubes (fig. 60). Glands of bronchial tubes atrophy, a mucous membrane, remaining intact, rises over the bone plates getting into a muscular layer. Meets more often at men after 50 years; with an inflammation or changes of content of calcium of blood it is not connected. 2. Diffusion parenchymatous ossification of L. arises at mitral heart disease, in walls of cavities, seldom in intact L. Islands of a bone tissue (fig. 61) at first are localized in peribronchial or perivascular fabric, and then can take entirely a share. In plates marrow is visible.
At diseases of accumulation damages of lungs can be also observed. At Nimann's disease — Peak sphingomyelin is laid in macrophages, is preferential in alveolar that gives L. rubber consistence. The disease to Awnless wheat is characterized by the fact that the glycogen is postponed not only in macrophages, but also cartilages, glands, a cover epithelium of bronchial tubes. At Fankoni's disease crystals of cystine find in walls of alveoluses, in peribronchial and perivascular fabric.
The morbid conditions connected with disturbance of pulmonary blood circulation, can be acute and chronic. Acute circulatory disturbances are connected with obstruction of a pulmonary artery or its branches emboluses which sources can be pathology of veins of a big circle of blood circulation — thrombophlebitis (see), phlebothrombosis (see) or cavities of the right heart — endocarditis (see). Obturation an embolus of a trunk of a pulmonary artery or its large branches can immediately end with death or cause a complex of heavy disorders of the vital functions (see. Embolism of a pulmonary artery ). At a thromboembolism of a large artery its shadow on roentgenograms and tomograms breaks, and part L fed by it. becomes more transparent.
Heart attack of lungs. The thromboembolism of branches of a pulmonary artery of average caliber (e.g., 1 — the 4th order) under certain conditions can cause L. Prichina's heart attack of a heart attack, apparently, there can be also thrombosis of a branch of a pulmonary artery owing to vasculitis (see), more often observed at rheumatism. The thrombogenesis is promoted by cardiogenic stagnation in a small circle of blood circulation, characteristic of heart failure (see), decrease in rheological properties of blood, hypercoagulation and some other factors.
At the heart of a heart attack of L. necrosis of the site of pulmonary fabric owing to the termination of a blood-groove on a pulmonary artery lies. The devitalized site imbibirutsya by the blood getting into it from system of bronchial vessels owing to what the heart attack gains character hemorrhagic (see. Heart attack ). Bronchial tubes in a zone of a heart attack usually keep viability since have autonomous arterial blood supply. Most often the heart attack develops in a peripheral layer of the lower and average parts of L. and quite often is followed by a fibrinous or serous and hemorrhagic exudate. Macroscopically the cone-shaped centers of red color which are eminating over a cut surface, leaving under the inflamed pleura come to light (see color. fig. of fig. 2). In the first days in a zone of a heart attack hemorrhage and hypostasis are defined, then there are signs of a necrosis of walls of alveoluses, siderophages collect. Fibrous layers of L. and walls of large vessels can be a source of the subsequent organization of heart attacks which occasionally heal the hem having a cellular appearance. The ischemic heart attacks which are found at collagenoses L., are caused by closing of a gleam of bronchial arteries and in view of complexity of very tectonics of the last have no wedge-shaped form. At infection and suppuration of the site of a necrosis L. Klinicheski's abscess a heart attack of L can be created. it is shown by stethalgias at breath and a pneumorrhagia at patients with thrombosis of peripheral veins or with a heart disease. Temperature is more often subfebrile. Tachycardia is noted. Physical symptoms are poor. Radiological heart attack of L. gives the limited homogeneous blackout matching by situation, a form and size with a segment or its part. Cardiogenic heart attacks always arise against the background of the general plethora in L., flebogenny heart attacks — without stagnation. The heart attack can be complicated by development of pneumonia (see) and pleurisy (see). At a thromboembolism of small vessels there are multiple small focal shadows. At a favorable current in 1 — 2 week of a stethalgia and a blood spitting stop, and radiological homogeneous blackout is gradually replaced with the center of fibrosis. In cases of suppuration of a heart attack there is plentiful purulent or is purulent - a bloody phlegm, temperature considerably increases, the leukocytosis accrues. Radiological in a zone of blackout the cavity with horizontal level comes to light. At establishment of the diagnosis of a heart attack of L. anticoagulating therapy is shown to the patient: heparin during 2 days with the subsequent transition to drugs of indirect action. Apply antibiotics to prevention of suppuration. At considerable pleural pains analgetics can be required. Prevention of a heart attack of L. comes down first of all to the prevention and treatment of the states which are a source of thromboembolisms and thromboses of a pulmonary artery (thrombophlebitises, phlebothromboses, an endocarditis, heart failure).
«Shock» lung. Multiple hemorrhages accompany a sladzh-syndrome and disseminated intravascular thrombosis at shocks of various origin which are characterized by the multiple hemorrhagic atelectases accepting resistant character owing to secondary destruction of surfactant (see) in the conditions of the broken blood circulation. This so-called shock lung, or the syndrome of acute respiratory insufficiency of adults reminding sometimes a hyaline and membrane disease of newborns (see). The acute disorders of pulmonary blood circulation connected with disturbance of outflow on pulmonary veins (e.g., at acute weakness of a left ventricle of heart or a mitral stenosis), can lead to edematization of lungs (see), at the same time on the roentgenogram intensive blackout of pulmonary fields (fig. 62) is visible.
Other disturbances of pulmonary blood circulation. Hron, the disorders of pulmonary blood circulation connected with disturbance of passability of small branches of a pulmonary artery are observed at pulmonary arterial hypertension as primary (see. Hypertensia of a small circle of blood circulation ), and secondary (see. Ayersa syndrome ).
At hron, the disorders of pulmonary blood circulation connected with difficulty of outflow, napr at left ventricular type of heart failure (see), the so-called congestive lung which in effect is not representing independent nozol, forms forms. Its typical manifestations is an asthma at physical. to loading or at rest, sometimes cyanosis, cough with a «rusty» phlegm, in a cut microscopically come to light erythrocytes and siderophages. Tendency to repeated pneumonia is noted. Auskultativno listens crepitant rattles, preferential in zadnenizhny departments of L. Rentgenologicheski strengthening venous, and in many cases and the arterial vascular figure L of components is noted. Treatment is carried out by the general principles of treatment of heart failure.
Tumours of L. represent group of high-quality and malignant new growths of various histogenesis of primary and secondary character.
On a wedge, to a current majority of primary tumors of L. it is possible to divide on high-quality and malignant.
Benign tumor of L. for the first time A. Muller in 1882 described. In Oncological scientific center of the USSR Academy of Medical Sciences patients with benign tumors of L. in relation to all L operated concerning tumors. made 10,8%.
Pathological anatomy. Among benign tumors there is a L. distinguish epithelial tumors (adenomas), tumors of a mesenchymal origin (a myxoma, a lipoma, a plasmacytoma, fibroma, etc.), gamartoma (teratoma). By data A. I. Rozhdestvenskoy (1964), among benign tumors of adenoma have the biggest specific weight (30 — 40%), gamartoma meet slightly less often and 20 — 30% are the share of others, the found tumors are more rare.
Adenomas of bronchial tubes (see Bronchial tubes) — group of tumors, the most various on a histogenesis and clinical manifestations. Apprx. 80% of adenomas make carcinoid tumors (see. Carcinoid ). They have the characteristic histologic structure different from structure of a bronchial wall. They proceed from neurosecretory cells of area of channels of bronchial mucous glands and may contain endocrine and exocrine secretory elements. In 2 — 7% of observations fabric of a tumor can cosecrete serotonin (see) and some vasoactive polypeptides, are more rare than AKTG.
Carcinoids of bronchial tubes at any age, but a thicket in 40 — 45 years meet, is slightly more rare at men. In 70% of observations bronchial tubes of large caliber are surprised. If the sizes of a tumor exceed 3 cm, innidiation on limf, to ways sometimes meets.
Patogistologicheski carcinoids of bronchial tubes are characterized by alveolar, tubular or acinar structures. At a submicroscopy of a cell of a tumor have the polygonal form and a significant amount of pseudopodiums, in cytoplasm accurately outlined secretory granules are defined.
Treats adenomas of bronchial tubes also tsilindroma (see), coming from bronchial glands. It meets only in large bronchial tubes, is located in deep layers of a mucous membrane, has slow infiltriruyushchy growth along nerves, quite often metastasizes.
Very rare form of adenoma of a bronchial tube are high-quality mucoepidermoid tumors (see).
On sovr, to views, the tsilindroma is a special form of slowly growing cancer (adenoidokistozny cancer). Carcinoid tumors are intermediate between high-quality and malignant new growths. Carcinoids and tsilindroma have potential ability to infiltriruyushchy growth, recuring (especially a tsilindroma) and to innidiation. It is not possible to predict degree of their aggression on the basis of microscopic data. Mucoepidermoid tumors do not malignizirutsya.
Adenomas develop generally in large bronchial tubes and grow endobronkhialno, gradually closing a gleam of a bronchial tube. In some cases adenomas grow towards a pulmonary parenchyma ekstrabronkhialno. It more often happens at the adenomas developing from walls of a small bronchial tube.
Occur among benign tumors of a mezenkhimny origin chondroma (see), osteoma (see), hemangioma (see), myoma (see), fibromas (see. Fibroma, fibromatosis ), neurinoma (see) and so forth. All these tumors are quite rare. In some cases mistakenly take a hyperplasia of a cartilage of a bronchial tube for a chondroma. A chondroma are connected with a wall of a bronchial tube and grow from cartilaginous elements of a bronchial tube. Plasmacytomas can be in the form of separate accurate educations in lungs or in the form of the infiltrates spreading on a wall of a bronchial tube without clear boundary. The tumoral nature of vascular tumors — hemangiomas is recognized not by all, including them malformations of vessels of a lung. Tumors from muscular tissue in L. meet seldom and can have a structure of a cross-striped and unstriated muscle. They have communication with bronchial tubes more often.
Gamartoma (see) represents anomaly of development; in L. hondrogamartoma which on frequency take the second place after adenomas are most often observed. Hondrogamartoma are not true tumors, but in some cases get invasive growth and can ozlokachestvlyatsya. Much more rare in L. it is possible to meet vascular, fatty gamartoma, etc. of Hondrogamartoma are located more often under a pleura and in the lower shares of L. Their sizes are various, but is more often small, to several centimeters in the diameter. They consist as if of the pressed segments of a cartilage, are dense, is frequent with melkopolitsiklichesky accurate contours and calcifications.
Clinical picture very scanty. The tumor, coming from walls of a large bronchial tube, can cause symptoms of disturbance of bronchial passability: cough with a purulent phlegm, recurrent pneumonia, astmoidny short wind; the pneumorrhagia is occasionally noted. At the carcinoid tumors cosecreting serotonin and corticosteroids the carcinoid syndrome can be observed, Cushing's syndrome is more rare (see. Cushing syndrome ). Along with it benign tumors of large bronchial tubes can not disturb patients and come to light only at a bronchoscopic research as accidental finds. The benign tumors developing in a parenchyma of L. far from large bronchial tubes, as a rule, proceed asymptomatically and are found at preventive rentgenol. inspections (fig. 63).
Diagnosis. At rentgenol, a research the most various benign tumors (adenoma, a hemangioma, a neurinoma, fibroma and so forth) give similar symptoms: single round intensive homogeneous blackout decides on sharp contours, especially on tomograms (fig. 63, 3). The tumor moves apart vessels and bronchial tubes and does not cause increase intrathoracic limf, nodes. The majority gamarty differs from this picture since contains chaotically scattered inclusions of lime or ossification. The teratoma causes intensive blackout with uneven contours. On its background deposits of lime, elements of a bone tissue and even a shadow of teeth (fig. 64) can be allocated. At intrabronkhialny development of a benign tumor that is especially peculiar to adenoma, is found hypoventilation, swelling or an atelectasis of part L ventilated by this bronchial tube. On tomograms (see the Tomography) or at a bronchography (see) find spherical education with a convex contour in the proximal direction in a gleam of a bronchial tube.
In diagnosis of the benign tumors which are localized in a gleam of a large bronchial tube, bronchoscopic inspection and a biopsy are of great importance (see Bronkhoskopiya). The benign tumors developing in small bronchial tubes and in a parenchyma of L., cannot be in most cases morphologically verified. Therefore at doubt in high quality of a tumor and lack of contraindications to thoracotomies (see) the patient it is necessary to operate also on the operating table after specification of the diagnosis (a biopsy, a puncture with tsitol, a research) to determine the necessary volume of a resection of L. Long overseeing by the patient with spherical formation of L. dangerously: it is necessary to remember that peripheral cancer of L. there can be many months and even years without seen rentgenol, loudspeakers.
Treatment. Extra bronchial tumors delete by usual enucleation with sewing up of a bed. If the tumor causes disturbance of passability of a bronchial tube and irreversible changes in a pulmonary parenchyma develop, the resection of the corresponding segments, shares, and sometimes and all L is necessary. At benign tumors of large bronchial tubes without signs of an atelectasis more conservative surgeries consisting in a circular resection of a bronchial tube and imposing of an interbronchial anastomosis gained distribution (see. Bronchial tubes, operations ).
The long-term results of operational treatment of patients with benign tumors of L. good.
Malignant tumors of lungs
Cancer of a lung.
The cover epithelium of a mucous membrane of bronchial tubes and an epithelium of bronchial mucous glands can be initial elements of growth of a tumor. Development of cancer from an epithelium of air cells is not proved.
Cancer of L. among other malignant tumors of internals holds a specific place. These features decide, on the one hand, by rapid growth of incidence, a tendency to a bigger acceleration of growth rates of incidence, on the other hand — features of development and the course of a tumor in body on the rich blood supply early giving lymphogenous and hematogenous metastasises.
On cancer of L. it is necessary to look as at a collective concept. There is several wedge, forms of a disease, depending not only from the location of a tumor in a lung, but also from it gistol, structures.
Statistics and epidemiology. Cancer of L. one of the most urgent problems wedge, oncology. Since the beginning of 20 century incidence of the population of cancer of L. grew in several tens of times. In many industrially developed countries (England, Belgium, Holland, Japan, Germany, the USA etc.) this disease in structure onkol, diseases wins first place among a male part of the population. Men have cancer L. considerably more often than women (in the ratio 4:1).
Etiology. Rapid growth of cancer cases of L. explain with the fact that most of the modern people living in big cities leads a slow-moving life and constantly inhales various harmful ingredients which are available in an ambient air. Mechanization, transport and features dignity. conditions of the large cities, undoubtedly, exert impact on concentration and composition of the inhaled carcinogens. They are present at dust of the tarred roads and exhaust gases of internal combustion engines, especially diesel (see. Oncogenous substances ). Strengthening of carcinogenic substances in the atmosphere of the cities is proved in L. M. Shabad's works. Life of the city is closely connected with the industrial enterprises releasing into the atmosphere a large amount of metal dust, the compounds of nickel, arsenic, asbestos, chrome and so forth having cancerogenic effect on pulmonary fabric. Models of cancer of L. in an experiment it was succeeded to cause by long inhalation by animals of the air saturated with dust with the chemical carcinogens and radioactive materials adsorbed on it.
It is fixed that risk of a disease of cancer of L. it is high at those who professionally contact to radioactive materials. So, cancer of L. is occupational disease at miners of uranium mines. The analysis of cancer cases of L is carried out. at Japanese after explosion of an atomic bomb. At the persons who received a total dose more than 90 I am glad, mortality from this disease significantly exceeded the average level. With improvement tekhnol, processes decrease in influence of the prof. of factors on cancer cases L.
Chastot of cancer of L is noted. is in direct dependence on duration and intensity of consumption of tobacco. On big material it is established that risk to develop cancer of L. smokers have more than two packs of cigarettes in day 20 times higher, than at non-smoking. Numerous researches, in particular L. M. Shabada, showed that the inhaled tobacco smoke contains carcinogenic substances by means of which it is possible to cause a malignant tumor in animals.
Many researchers point to growth of incidence among women. Though generally it contacts distribution of a habit of young women to smoke, it is impossible to exclude influences of the endocrine shifts connected with the increased consumption of hormonal drugs.
In literature it was repeatedly indicated communication of tubercular defeat of pulmonary fabric and cancer of L. The tumor quite often develops in the field of posttubercular hems in a pulmonary parenchyma or in the centers of specific fibrosis. But approximately with an identical frequency cancer develops also in opposite healthy L.
Pathogeny. The mechanism of influence of cancerogenic factors of surrounding and internal environment remains not up to the end found out. In the course of aging of an organism there is a progressing sklerozirovaniye of walls of bronchial tubes, disturbance of relationship in system an epithelium — connecting fabric, disturbance of the normal course of regeneration of a bronchial epithelium. The same changes are registered at hron, inflammations of any nature. The cylindrical epithelium of bronchial tubes under the influence of external irritants is exposed to desquamation, often turns in basal, extremely polymorphic. Considerable accumulation in cells of an epithelium of DNA testifies to its high potentiality to growth. At long contact of a mucous membrane with carcinogenic substances which get into a gleam of a bronchial tree with dust the functions of self-cleaning of a mucous membrane connected with the peristaltic movements of bronchial tubes, activity of ciliary movements of cilia of a respiratory epithelium and work of mucous glands are broken. It promotes a long delay of dust with the carcinogens adsorbed on motes, radioactive materials and their penetration into a pulmonary parenchyma.
In lobar and segmental bronchi there are sites of a deskvamirovanny epithelium where granulyatsionny fabric sometimes with polypostural outgrowths in a gleam expands. Mucous glands kistozno extend, cells change them a form, there is their atypia and proliferation. These processes are always followed by changes of a basal membrane and subjects of fabrics. Regeneration is followed by a metaplasia of a cylindrical epithelium in flat that breaks function of self-cleaning of bronchial tubes even more and supports a chronic inflammation.
Gradually among sites of proliferation and an epidermoid metaplasia there are cells with the changed polarity, the wrong mitoses. They are located within a mucous membrane or get out of its limits, being located in the form of tyazhy or chains. So the infiltriruyushchy growth of cancer begins. Under an epithelium there are lymphoid infiltrates with impurity of plasmocytes that is regarded as manifestation of an immune response on antigenic changes of fabric proteins in the course of carcinogenesis.
The hyperplasia and a metaplasia against the background of the centers of pneumonia and pulmonary fibrosis can arise also in the flattened cells of an epithelium of alveoluses and final bronchioles. Morphologists allocate three types of proliferation of an epithelium of bronchioles: acinar, planocellular and carcinoid; these changes are always combined with focal or diffusion fibrosis. Carcinoid proliferation of neurosecretory cells is followed by formation of tumorlets. From them in the subsequent undifferentiated cancer can develop.
Thus, to cancer of L. changes of inflammatory character or cicatricial process precede: tuberculosis, fibrosis, pneumonia, bronchiectasias, hron, abscesses, the healed heart attacks of L. These changes also should be considered optional precancerous states if they are followed by a metaplasia of an epithelium with the advent of an atipizm. In certain conditions they are available to diagnosis by means of modern endoscopic and tsitol, methods.
Pathological anatomy. According to Oncological scientific center of the USSR Academy of Medical Sciences, in the right L. cancer arises in 56% of cases, in left — in 44%. Preferential upper shares are surprised. Kliniko-anatomicheski cancer of L. divide into two groups: the central cancer affecting the primary, lobar and segmental bronchi (color. rice. A.1), and the peripheral cancer growing from an epithelium of small bronchial tubes on the periphery to L. Chastot of damage of bronchial tubes, different in caliber, is difficult to define. These data depend on on what material they are received. During the opening when prevalence of tumoral process is usually big, it is difficult to find out where there was primary center of cancer. I. L. Tager (1951) considers that cancer in small bronchial tubes arises more often, but with a growth the tumor can gain lines of the central cancer.
In the direction of growth allocate exophytic (endobronchial) cancer when the tumor grows in a gleam of a bronchial tube, and endophytic cancer when the tumor grows in the basic towards a pulmonary parenchyma. The wedge, picture of a disease also depends on a distributional pattern of a tumor.
Cancer of L. often proceeds with the secondary inflammatory changes caused in most cases by a prelum or obturation of a bronchial tube with disturbance of ventilation of a segment, share, and sometimes and L. Zasta of contents of bronchial tubes leads all to development of an infection in a zone of an atelectasis. Insufficient blood supply of the growing tumor creates conditions for disintegration of its fabric with destruction of a wall of vessels, sometimes large. The peripheral cancer proceeding with disintegration can remind L. Soputstvuyushchiye's abscess to cancer secondary inflammatory changes in L. lead to a hyperplasia and increase in the sizes limf, nodes of a root L. and mediastinums.
Gistol, a structure of a tumor differs in a big variety. N. A. Krayevsky (1976) developed gistol, classification of cancer of L., the simplest and convenient for use in clinic (it is not opposed to the WHO classification).
I. Planocellular cancer (color. fig. A.2): 1) with keratinization (high-differentiated); 2) without keratinization (moderately differentiated); 3) low-differentiated.
II. Adenocarcinoma: 1) acinous and papillary (high-differentiated); 2) ferruterous and solid (moderately differentiated).
III. The low-differentiated cancer:
1) small-celled-ovsyanokletochny; 2) small-celled-limfotsitopodobny; 3) macrocellular (see Cancer).
Most often meet highly - and moderately differentiated forms of cancer of L. Undifferentiated cancer comes to light more often at persons more young than 40 years, proceeds more zlokachestvenno with the bad forecast. In Oncological scientific center of the USSR Academy of Medical Sciences among the operated patients planocellular cancer is noted in 60,6% of observations, undifferentiated cancer — in 31,6%, an adenocarcinoma — in 7,8%.
Bronkhioloalveolyarny cancer in the past had many synonyms: adenomatosis of L., alveolar and cellular cancer, bronchiolar cancer and so forth. The term «bronkhioloalveolyarny cancer» reflects uncertainty in the relation of cells from which there is a tumor.
The Multitsentrichny form of bronkhioloalveolyarny cancer was for the first time described by L. Ch. Malassez in 1876. On sovr, to representations, this tumor is considered the high-differentiated adenocarcinoma. Primary centers of growth arise most likely in bronchioles with the subsequent distribution on alveoluses. Bronkhioloalveolyarny cancer makes a nodal, multitsentrichny and diffusion (pnevmoniyepodobny) growth form of this tumor apprx. 2,5% of all observations of cancer of L. Razlichayut. Growth in the form of solitary peripheral nodes meets more often. The submicroscopy can give essential help in recognition of bronkhioloalveolyarny cancer. For this purpose gistol. type lamellar inclusions in cytoplasm are characteristic.
Cancer of L. metastasizes on limf, to ways and gematogenno (see. Innidiation ). According to V. I. Lya-shchenko (1977), at planocellular cancer metastasises in the remote bodies on opening were found in 13,3% of observations, in limf, nodes of a mediastinum — in 17,7%. At ferruterous cancer metastasises in the remote bodies met in 34,5% of observations, in limf. nodes — in 25,3%. At undifferentiated cancer these figures made respectively 30,9 and 25,4%. Lymphogenous innidiation goes preferential on ways of a lymph drainage. Hematogenous metastasises are found most often in a liver, a brain and bones.
Classification. Domestic classification of lung cancer by stages is developed in MNIOI of P. A. Herzen and the I stage — a small limited tumor of a large bronchial tube with endo-and a peribronchial growth form, and also a small tumor of small and smallest bronchial tubes without germination of a pleura and signs of innidiation is approved in 1956. The II stage — the same tumor, as well as in the I stage, or the big sizes, but also without germination of pleural leaves, with existence of single metastasises in the next regional limf, nodes. The III stage — the tumor which exceeded the limit of L., growing into one of the next bodies (a pericardium, a chest wall, a diaphragm), with existence of multiple metastasises in regional limf, nodes. The IV stage — a tumor with extensive distribution on a chest wall, a mediastinum, a diaphragm, with dissimination on a pleura and the extensive regional or remote metastasises.
The international classification by the TNM system is offered in 1978 and approved by the International anticarcinogenic union.
Primary tumor — T: T0 — primary tumor is not defined; TX — existence of a tumor is proved by presence of cancer cells at a phlegm, at radiological and endoscopic inspection the tumor is not defined; TIS — preinvazivny cancer (cancer in situ); T1 — the tumor up to 3 cm in size on the largest diameter which is not sprouting a lobar bronchus (at a bronkhoskopiya); T2 — a tumor more than 3 cm on the largest diameter or a tumor of any size with the atelectasis or an obstructive pneumonitis extending to a root zone L., at a bronkhoskopiya proximal spread of a visible tumor shall be not less than on 2 cm distalny Kiel tracheas; TZ — the tumor of any size extending to the next structures (a mediastinum, a thorax, a diaphragm), the tumor extending at a bronkhoskopiya is closer than on 2 cm to Kiel than a trachea, the tumor is combined with an atelectasis, or an obstructive pneumonitis of all L., or pleural exudate.
Regional lymph nodes — N: There is no N0 — in regional limf, nodes metastasises; N1 — metastasises in limf, nodes of a root L. on the party of defeat, including direct spread of primary tumor; N2 — metastasises in limf, nodes of a mediastinum.
The remote metastasises — M: There is no MO — the remote metastasises; Ml — the remote metastasises, including limf, nodes preladder, cervical, supraclavicular, a root of opposite L. and metastasises in other bodies; M1a — a pleural exudate with existence in it of cancer cells; M1b — metastasises in cervical, preladder and supraclavicular limf, nodes; M1s — other remote metastasises; MX — the minimum complex of methods of inspection for identification of the remote metastasises cannot be carried out.
Proceeding from classification of TNM clinically allocate three stages of cancer of L. K of the first stage TISN0M0 (cancer in situ), a tumor of T1 without signs of innidiation (T1N0M0), with metastasises only in limf, nodes of a peribronchial and (or) ipsalateralny root zone (T1N1M0), and also a tumor of T2 without signs of innidiation (T2N0M0) belong. The diagnosis of TxN1M0 and T0N1M0 is theoretically possible, but to put it extremely difficult. If such diagnosis after all is established, then the tumor shall be carried to the first stage.
The second stage — a tumor of T2 with metastasises only in limf, nodes of a peribronchial or ipsalateralny zone (T2N1M0).
Treat the third stage: all tumors of the big sizes, than T2 (T3 with any combination of N or M), tumors with metastasises in limf, nodes of a mediastinum (N2 with any combination of T or M), tumors with the remote metastasises (M1 with any combination of T or N).
Such division into stages is important for all morfol, types of cancer of L., except an undifferentiated small-celled (ovsyanokletochny) carcinoma, at a cut there are no essential distinctions between stages on the main indicator — survival.
Clinical picture depends on type of growth of cancer of L., its kliniko-anatomic and gistol, forms, rates of innidiation, the accompanying (secondary) inflammatory changes. Distinguish the local symptoms caused by changes in bronchial tubes and pulmonary fabric and the general symptoms caused by influences of a tumor on an organism or intoxication in connection with a secondary inflammation.
Fabric of a tumor at cancer of L. can cosecrete a wide range of biologically active substances, on action of a pas an organism of the normal hormones reminding action, fabric antigens or toxins. Clinically it is shown by Cushing's syndrome, a hyponatremia, a hypercalcemia, a gynecomastia, a polycythemia, a hypoglycemia, a myasthenia, an osteoarthropathy, neuritis, a dermatomyositis, vascular fibrinferments, fever and exhaustion. Similar manifestations are quite often noted at tumors, small by the sizes, and disappear after treatment of the patient.
The local symptomatology depends on localization and a growth form of a tumor.
Frequent symptom of the central cancer of L. cough, sometimes a constant tussiculation in connection with the irritation caused by the tumor growing in a wall of a bronchial tube and accumulation in its gleam of slime is.
With an infiltriruyushchy growth of a tumor when the gleam of a bronchial tube remains free in connection with its distribution on a wall of a bronchial tube, cough can develop late or at all be absent (at some peripheral located tumors).
Various impurity have great diagnostic value in to a phlegm (see). For cancer of L. a small amount of a phlegm is more characteristic. The further the tumor extends, the more impurity appear in a phlegm. At first the mucopurulent phlegm by the form differs from a usual phlegm of the elderly and smoking person a little, but eventually at disintegration of an endobronchial tumor the pneumorrhagia can appear (see). On A. I. Savitsky's (1967) observations, 67,1% of patients have thorax pain, is more often on the party of defeat, is more rare on the opposite side and diffuse is even more rare. Patients cannot sometimes characterize the feelings as pain and speak about unpleasant feeling of weight, a pricking and so forth. This symptom, as a rule, happens at the considerable size of a tumor.
Fervescence can be the first symptom of cancer of L. This symptom is noted in 50 — 60% of cases and depends on the secondary inflammatory processes accompanying cancer of L. The cancer pneumonitis can develop around the tumoral center or is more often in a zone of an atelectasis. The repeating pneumonia at the elderly person should be regarded as possible display of cancer of L.
Objective inspection of the patient can reveal a number of additional symptoms though at early stages of a disease of objective symptoms of a disease does not happen. In late stages on the party of an atelectasis retraction of a chest wall, its lag at breath, a vtyanutost of intercostal spaces and rapprochement of edges is noted. Auscultation finds signs of defeat of a pulmonary parenchyma and bronchial tubes — pneumonia, pleurisy, bronchitis, etc. In a zone of an atelectasis breath is not listened. At obstructive emphysema when at a breath air enters through the narrowed bronchial tube, and at an exhalation hardly leaves, the rough whistling rattles are listened. Perkutorno over a zone of swelling is defined a bandbox sound, and over sites of an atelectasis — dullness. At an atelectasis high standing of a diaphragm and restriction of its respiratory excursion is noted. At the peripheral tumors adjacent to a parietal pleura, it is also possible to define borders of obtusion of a pulmonary sound.
Wedge, a current and terms of emergence of these or those symptoms depend on localization and the nature of growth of a tumor. Exophytic (endobronchial growth early leads to obstruction of a bronchial tube, development of an atelectasis and a pneumonitis and a wedge, to displays of a disease. The tumors creeping on a wall of a bronchial tube with endofitnoperibronkhialny growth long do not break its passability, and symptoms of a disease arise only at far come process.
Wedge, symptomatology of peripheral cancer of L. appears at germination by a tumor of the next anatomic educations, obstruction of bronchial tubes and disintegration of a tumor. At early stages peripheral cancer quite often proceeds absolutely asymptomatically.
Cancer of a top of L. (synonym: Pankost's tumor) represents a special kind of peripheral cancer of L., which already at early stages infiltrirut the anatomical structures of a chest wall located in the field of an upper chest aperture. This kliniko-anatomic form is shown by the syndrome described by Pankost (N. K. Pancoast) in 1932: the irradiating pains in an upper shoulder girdle, Bernard's syndrome — Horner (see Bernard-Horner a syndrome) and rentgenol, symptoms of a tumor of a top of L. Neredko is observed destruction of upper edges and vertebrae.
In late stages of cancer of L. complaints of the patient are numerous and various. Damage of a pleura is followed by symptomatology of exudative pleurisy, and punctate often has a characteristic hemorrhagic appearance. At extensive metastasises in a mediastinum symptoms of a prelum of large vessels, tracheas, bronchial tubes and a gullet develop: syndrome of a prelum of an upper vena cava, asthma, dysphagy. Defeat of a recurrent nerve results in hoarseness, germination of the sympathetic trunk wandering and phrenic nerves — to corresponding nevrol, symptomatology.
Atipichesky kliniko-anatomic forms of cancer of L. meet rather seldom. They are characterized by the small sizes and features of localization of primary center of a tumor which sometimes cannot be revealed not only clinically, but also on opening. Into the forefront the symptoms caused by metastasises act.
Mediastinal form of cancer of L. it is shown by multiple metastasises in limf, nodes of a mediastinum, at the same time primary tumor in L. all available a wedge, methods it is not possible to reveal.
The miliary carcinomatosis is characterized by multiple focal metastasises in L., when primary node of cancer is not known. At a brain form of cancer of L. on the first place symptoms of defeat of c move forward. N of page: headaches, disturbances of mentality etc., at a bone form — signs of metastatic damage of bones of a skeleton, at cardiovascular — disturbances of a cordial rhythm, the exudate in a pericardium, a circulatory unefficiency, at went. - kish. to a form — disorders of function of a digestive tract, at a hepatic form — signs of tumoral damage of a liver.
Diagnosis. The main problem in diagnosis of cancer of L. — searches of opportunities of detection of a disease in doklin. stages. The methods suitable for mass use among almost healthy population, is fluorography (see), preventive rentgenol, inspection and tsitol, research of a phlegm. For implementation doklin. diagnoses of cancer of L. it is necessary to reveal «group of the increased risk» among the population, edges includes persons 50 years are more senior, especially there are a lot of smokers, with the burdened heredity, upper respiratory tracts, inclined to diseases, or suffering hron, pneumonia and so forth. Usually this group is revealed in the biographical way and dispanserizut. Routine maintenances are performed annually. Fluorographic inspection of «group of the increased risk» is obligatory. The best results are yielded by a combination rentgenol, and tsitol, methods of a research. Comparative analysis of two groups of the patients revealed by method preventive rentgenol, inspections (the first group) and addressed in to lay down. establishment independently (the second group), executed in Oncological scientific center of the USSR Academy of Medical Sciences, showed that a rezektabelnost of cancer of L. in the first group was much higher (90,7%), than in the second (78,6%).
Great value in timely diagnosis of cancer of L. also the correct assessment has a wedge, symptoms. Are always suspicious on cancer of L. the repeating short-term rises in temperature, cough, a stethalgia and a pneumorrhagia. Difficulties in recognition can meet even in late stages of a disease when complications (pneumonia, pleurisy, abscess, metastasises in the remote bodies and so forth) mask its true nature.
Diagnosis of cancer of L. it is specified on the basis of comprehensive examination: clinical, radiological, bronkhologichesky, radiological, morphological and surgical.
Klien, symptomatology, the anamnesis and data of survey allow to suspect cancer of L only. Auxiliary value have a lab. methods of inspection. In view of the fact that cancer of L. often proceeds with the expressed inflammatory phenomena in L., from blood the deviation to the left, a leukocytosis, acceleration of ROE, etc. can be observed. In clarification of prevalence of tumoral process blood tests have a certain value biochemical. determination of level of hormones can indicate hormonal activity of a tumor. However these shifts always need to be estimated in a complex with other methods of a research.
For specification of the diagnosis of a tumor of L. apply obligatory auxiliary methods.
Rentgenol, a method treats obligatory methods of inspection. It allows to define prevalence of a tumor in L. and beyond its limits to find out localization of metastasises etc. It includes roentgenoscopy of lungs, a X-ray analysis (at least — in a direct and side projection) and a tomography. In each case carry out an individual complex of additional methods rentgenol, inspections.
Rentgenol, picture of the central cancer of L. it is diverse. The cancer tumor developing in one of large bronchial tubes (the central cancer of L.), causes disturbance of its passability. As a rule, cancer endobronkhialno growing radiological comes to light in that phase when it causes hypoventilation, obturatsionny emphysema or an atelectasis of a segment, share or all L. (fig. 65 and 66).
If the tumor not completely closes a gleam of a bronchial tube, then on tomograms and bronkhogramma defect of filling with uneven contours is visible. At initial changes (i.e. infiltration of a wall of a bronchial tube still flat) defect of filling happens small from hardly noticeable uzuratsiy wall. At occlusive cancer the picture of a stump or amputation of a bronchial tube comes to light.
If cancer grows at hl. obr. peribronkhialno, on roentgenograms and tomograms radical infiltration is defined, in a cut the narrowed and uneven gleams of bronchial tubes appear. Both at endobronchial, and at peribronchial tumors metastasises in intrathoracic limf, nodes are early noted.
Difficulties in the diagnosis in many respects depend on secondary inflammatory changes in a zone of an atelectasis and pleural exudate. Pleurisy can be connected with planting or germination of a tumor in a pleura, transition to a pleura of the accompanying inflammatory process or a prelum of ways of a lymph drainage. Diagnostic mistakes at localization of cancer in the lower shares when their reduction and the accompanying exudate connect entirely with pleurisy are especially frequent.
Cancer developing in a share (peripheral cancer) originally has an appearance of a local condensation of the drawing, the small center or a small cavity with uneven walls (fig. 67 and 68). The center manages to be allocated accurately on tomograms. The volume of the center doubles approximately for half a year. Its shadow becomes more intensive, homogeneous, contours accurate, but hilly. In case of disintegration in a node the cavity with uneven outlines is found. At least in one place its wall is thickened, and fabric of a tumor presses in a gleam of a cavity.
Apical cancer (Pankost's tumor) radiological is shown by blackout of a top of D., a cut quite often reminds periapical pleurisy. The greatest difficulties at differential diagnosis arise with tuberculosis. Apical cancer, sprouting edges, causes destruction of preferential back departments, areas of a neck and a head of edges, and sometimes and cross shoots of upper chest vertebrae.
The specifying data are entered by a tomography. In hard cases of diagnosis when it is impossible to solve whether the tumoral node in L is located. or out of it, it is necessary to apply diagnostic pheumothorax (see. Pheumothorax artificial ).
Mediastinal cancer (fig. 69) at rentgenol, a research is shown by expansion of a shadow of a mediastinum, preferential vascular bundle, at the expense of increased limf, the nodes acting to the right and left pulmonary field. Increase in nodes can be asymmetrical, and sometimes unilateral. Contours of a mediastinum, as a rule, politsiklichna. However in some cases limf, nodes, increasing, remove a mediastinal pleura and give a picture of the expanded, straightened mediastinum which lost the normal outlines. At the same time in L. can not come to light any changes, and quite often even on section it is not possible to find primary tumoral node.
The miliary carcinomatosis in essence is manifestation of hematogenous innidiation of a cancer tumor. Considering that seldom or never the similar picture can be observed at primary cancer of L., this form is considered among other at bronchogenic cancer. In such cases additional methods of a research (a tomography and a bronchography) do not give any characteristic information. For final judgment of primacy of pulmonary process it is necessary to investigate other bodies, and only negative data will allow to claim that it is about primary cancer of H.p. extensive innidiation.
Morfol. methods of a research in confirmation of the diagnosis at cancer of L. have crucial importance. Treat them gistol, a research of biopsy material and tsitol, a research of a phlegm, washouts from a bronchial tree, scrapings and punctates.
Tsitol, a research of a phlegm allows to receive confirmation of the diagnosis the easiest way. In some cases it gives the chance to make the diagnosis of cancer of L. at absence a wedge, manifestations and unconvincing rentgenol, signs. However tsitol, a research at cancer of L. cannot replace full gistol, researches at all. The right choice of a method of treatment requires not only confirmation of the diagnosis, but also quite often full morfol, the characteristic of a tumor that can not always be established precisely cytologic.
Bronkhoskopiya (see) at cancer of L. — obligatory diagnostic method. She allows not only to examine a tumor, to define borders of its distribution, to diagnose the accompanying endobronchitis, but also to make a biopsy of a tumor for gistol, and tsitol, researches. If there are only indirect bronchoscopic symptoms of a tumor, material for a research can be received by means of scraping or washout from a bronchial tree or a transbronchial puncture patol, the center. The transbronchial puncture is applied to confirmation of metastatic defeat increased limf, nodes of a root L. and mediastinums. At peripheral cancer during the bronkhologichesky research under rentgenol, control carry out the special brush or a catheter allowing to receive material for tsitol, researches to the corresponding bronchial tube.
At the peripheral cancer located near a chest wall the transthoracic diagnostic puncture of a tumor with tsitol, a research of punctate widely is applied. This method can give such complications as pheumothorax, bleeding and so forth. Pheumothorax meets that more often than more deeply in a pulmonary parenchyma the tumor is located.
Surgical diagnostic methods are used as the final stage of inspection of the patient when other ways to finally confirm the diagnosis or to define prevalence of tumoral process do not work well. Here different types belong biopsies (see), including a preskalenny biopsy, and also a mediastinoskopiya (see), the Mediastinotomy (see) and a diagnostic thoracotomy (see).
Mediastinoskopiya is shown at suspicion on metastatic defeat limf, nodes of a mediastinum, its use in the preoperative period allows to lower number of trial thoracotomies. Sometimes this research is made at peripheral cancer with metastasises in limf, nodes of a mediastinum for morfol. confirmations of the diagnosis and choice of a method of treatment.
The front diagnostic mediastinotomy is applied according to the same indications, as a mediastinoskopiya. This surgical intervention is made under anesthetic. The small section of skin of a front chest wall is carried out over a cartilage of the II edge from outside where pathology in a mediastinum is more expressed. After a resection of a cartilage of the II edge and bandaging of an internal chest artery and a vein visually and palpatorno inspect structures of a mediastinum, carry out a biopsy or tsitol, a puncture increased limf, nodes or primary tumor. If necessary it is possible to open a mediastinal pleura and to take material for morfol, researches directly from pulmonary fabric. At an arrangement increased limf, nodes in the field of an aortal window at the left the Mediastinotomy can give more information, than a mediastinoskopiya.
A thoracotomy it is necessary to resort to diagnostic when suspicion of cancer of L. it is clinically proved, but there are no straight lines morfol, proofs of the diagnosis. It especially often meets at the small asymptomatic spherical centers in L. Tak the focal pneumosclerosis, benign tumors, a tuberculoma and peripheral cancer are shown. Long dynamic observation in doubtful cases is inexpedient. The diagnostic thoracotomy is less dangerous, than the threat to pass cancer L. Morfol, confirmation of the diagnosis receive usually at a total biopsy patol, the center (a plane or wedge-shaped resection of L.), if diagnostic tsitol, the puncture during operation does not yield positive takes. After morfol, confirmations of the diagnosis of cancer of L. carry out a radical resection of L. in necessary volume, or intervention comes to an end with a trial thoracotomy.
Differential diagnosis of cancer of L. it is quite often difficult because this disease often develops against the background of previous patol, processes: pneumonia, tuberculosis, the benign tumor having similar a wedge, and rentgenol, symptomatology.
At differential diagnosis first of all it is necessary to define, there is patol, an education in L. or a mediastinum whether has relation to a chest wall or to a diaphragm. Further it is necessary to find out whether the disease of tumoral process is or not. If there is an impression about a tumoral disease, it is necessary to decide what character it has — high-quality or malignant, and if a tumor malignant, then primary it or metastatic. In definition of pulmonary or extra pulmonary localization of the found changes crucial importance has rentgenol, a research in the conditions of artificial pheumothorax. For the answer to other questions it is strictly individualized apply methods of additional inspection.
Cancer of L. most often it is necessary to differentiate with hron, nonspecific pneumonia (see), hron, suppurative processes, tuberculosis (see Tuberculosis of a respiratory organs), benign tumors and parasitic cysts of L. Difficulties of differential diagnosis of the central and peripheral cancer allow to recommend more widely morfol, and surgical methods of a research, up to a diagnostic torapotomiya. The sequence of use of diagnostic methods of inspection shall be planned from the simplest to more difficult. Correctly made individual plan of inspection can save the patient from excessive burdensome and dangerous procedures.
Treatment. Definition of degree of prevalence of tumoral process is of great importance for a right choice of a method of treatment and the forecast. Real perspectives of full treatment from cancer of L. has only a surgical method. Radiation therapy does not give hope for full treatment, however allows to apply treatment to more wide range of patients and sometimes can prolong life considerably. Certain success was achieved by chemotherapy of cancer of L.
The first successful radical pneumonectomy concerning cancer of L. E. Graham in 1933 executed. In 23 years of the patient was in good shape. Since then surgery of cancer of L. it is continuously improved.
Surgical method of cancer therapy of L. is method of the choice, however it is necessary to define contraindications to operation which, unfortunately, there is a lot of.
Contraindications onkol, about concern to the first group. Operation is senseless at the remote metastasises in various bodies, opposite to L. or planting of a pleura, at histologically the confirmed metastasises in limf, nodes of a mediastinum, a syndrome of a prelum of bodies of a mediastinum (a syndrome of an upper vena cava, paresis of a recurrent nerve), at extensive germination of a tumor in the next bodies (heart, the main vessels, a trachea, a chest wall).
The second group of contraindications is connected with assessment of an individual risk degree of operation. Operations on L. are interfaced with raised funkts, load of an organism and first of all on cardiopulmonary system. Therefore at the solution of a question of operation it is necessary to estimate strictly the general condition of the patient, it funkts, and compensatory opportunities, a condition of healthy L., cardiovascular system, existence of associated diseases, age of the patient and volume of the planned operation. The wrong assessment of compensatory opportunities of an organism of the patient can be the cause of heavy complications in the postoperative period and, on the contrary, the unreasonable failure from operation can deprive of the patient of perspectives of recovery.
A state of disrepair of the patient not always is a contraindication for operation. E.g., the accompanying inflammatory changes in L., extensive atelectases can cause serious condition of the patient, accompanying the small resectable tumor which corked a large bronchial tube. Such patients can be considerably operated with the good remote result.
By sufficient training of the patient and a right choice of the volume of an operation it is undergone by patients with emphysema of L., coronary insufficiency and even a myocardial infarction in the anamnesis.
Pneumonectomy (see) — the operation demanding great adaptive opportunities from an organism of the patient than lobectomy (see). Patients are more senior than 60 years difficult transfer removal of L. and it is much better — removal of one — two of its shares.
The most frequent postoperative complication in connection with the wrong assessment funkts, conditions of cardiopulmonary system before operation is respiratory insufficiency (see).
In the solution of a question of indications to operation and its volume the separate bronkho-spirometry is of great importance. Trial switching off of sick L. allows to study funkts, a condition of the remaining L. This method among others gives the chance to establish indications to a pneumonectomy and to estimate a risk degree of operation. The researches conducted by Yu. Ya. Agapov (1970) revealed 5 options funkts, conditions of respiratory system at cancer of L. It is convenient to use this scheme at the solution of a question of indications to operation. The first option — struck with L. it is switched almost off from breath; the pneumonectomy does not threaten such patients with respiratory insufficiency. It is optimum option for the postoperative period. Such state most often happens at the central cancer of L., when extensive atelectases develop, are squeezed or the main vessels burgeon a tumor, are surprised limf, ways and the lymphostasis develops. The second option — equivalent funkts, a condition of both L. Serial switching off of sick and healthy L. keeps breath on datum level. It testifies to a high funkts, ability of the remaining L. also meets more often at young patients with small peripheral tumors. The pneumonectomy in such cases does not represent risk. The third option meets quite often. Both L. take active part in ventilation and gas exchange, however switching off from. breath of sick L. leads to nek-rum to falling of respiratory function, but in a few minutes ventilation of a healthy lung increases, an asthma does not arise. Removal of L. at such patients in most cases also does not represent risk, but demands a nek-swarm of preoperative preparation (respiratory gymnastics, an oxygenotherapy, etc.), and in the postoperative period — strict holding actions for prevention of respiratory insufficiency (to lay down. anesthesia, Tracheostomy, sometimes assisted breast). Such patients transfer a lobectomy well. The fourth option — struck with L. participates in breath more actively, than healthy. Therefore at switching off of sick L. there occurs considerable decrease in level of oxygenation of an arterial blood. Such nature of breath usually meets at a peripheral tumor of L. also depends from funkts, features of L. and cardiovascular system. The solution of a question of indications to a pneumonectomy is extremely difficult. Operation is accompanied by big risk since remaining L. functionally defectively. The lobectomy is accompanied by smaller risk. In certain cases it is possible to achieve increase in function of the remaining defective L. by the corresponding preoperative preparation then it is reasonable to repeat a separate bronkhospirometriya. As preoperative preparation imposing of pheumothorax is admissible. If a collapse of the struck L. the patient transfers well, it is possible to raise a question of its removal more reasonably. The fifth option — extremely low funkts, indicators of the remaining healthy L. Patients practically do not transfer switching off of the struck L. and operation is contraindicated.
It is necessary to estimate data of a separate bronkhospirometriya in a complex about a wedge, and rentgenol, indicators.
Early dissimination and weight of operation at cancer of L. result in low operability. The percent of operability and a rezektabelnost given by different authors is very various — from 60 to 30%. True opportunities to apply surgical treatment gives definition to operability in group of initially registered patients. So, according to Oncological scientific center of the USSR Academy of Medical Sciences, lobectomies and pneumonectomies are carried out in 10 — 12% of cases among for the first time the revealed suffering from cancer L. Other patients are by the time of diagnosis inoperable on onkol, and funkts, to indicators. A part of patients refuses operation. Generally patients with small asymptomatic cancer of L refuse surgical treatment.
The choice of operation — a pneumonectomy or a lobectomy — depends on character patol, process and localization of a tumor. The central cancer of H.p. metastasises in bronkhopulmonalny limf, nodes causes the necessity of a pneumonectomy. A pneumonectomy — the main operation at cancer of L., at a cut delete the struck body together with regional limf, nodes, including bifurcation nodes — important limf, the collector collecting a lymph from both L. and often struck by metastasises.
The lobectomy is shown at peripheral cancer of L., is more rare at cancer of the mouth of a segmental bronchus when there are no metastasises in bronkhopulmonalny (and the more so bifurcation) limf, nodes. Also the palliative lobectomy at an opportunity to remove metastatic limf, nodes at patients with low funkts, indicators is admissible. The lobectomies executed according to strict indications yield not the worst long-term results, than a pneumonectomy.
Planning operations, it is necessary to consider features of a lymph drainage. The upper lobectomy at cancer shall be followed by obligatory removal tracheobronchial limf, nodes since. A lymph drainage from an upper share of L. it is carried out generally in paratracheal limf, nodes, passing a root L. At the lower lobectomy removal bifurcation limf, nodes since outflow of a lymph from the lower share of the left L is obligatory., from lower and an average share of the right L., as D. A. Zhdanov (1952), M. A. Gladkova (1966) showed, occurs through tracheobronchial limf, nodes on the right, including a bifurcation node on group of the right paratracheal nodes. Radicalism of the planned lobectomy shall be checked urgent gistol, a research bronkhopulmonalny and tracheobronchial limf, nodes. If in them metastasises are found, it is necessary to estimate a possibility of a pneumonectomy.
Segmented resections (see. Segmentectomy ) at cancer of L. are not proved with onkol, the position demanding removal regional limf, nodes. They can be executed in exceptional cases. At uncertainty in the diagnosis of cancer at first delete a segment with a tumor for an urgent gistol, a research and if necessary pass to a forehead - or pneumonectomies. In the course of operation it is necessary to make urgent gistol, a research limf, nodes, suspicious on metastasises. The negative answer does not prove lack of metastasises in other limf, nodes of a mediastinum, but affirmative answer can change the plan of operation.
Use of radiation therapy at malignant tumors of L. it is based on the destroying or damaging action of radiation on tumor cells and fabrics. Principles of radiation therapy of tumors
of L. timeliness of use and the choice of the most rational technique providing radiation of a tumor and ways of regional innidiation in the dose causing final fracture of malignant cells at the minimum damage of healthy fabrics are. Beam treatment shall be combined with therapy by a kislorodnovitaminny complex and symptomatic means. Radiation therapy can be more effective when in early stages the tumor of the small sizes is irradiated in a dose by not less than 6000 is glad. Palliative radiation therapy in a total dose to 4000 I am glad apply at widespread processes at patients with a satisfactory general condition.
Radiation therapy is shown at resectable forms of the central and peripheral cancer at patients with funkts, contraindications to surgical treatment or refused operation; at nonresectable tumors, but rather satisfactory the general state; at the tumors of high degree of a zlokachestvennost inclined to bystry innidiation, at resectable patients in combination with chemotherapy before operation. Radiation therapy is contraindicated at disintegration of a tumor, metastatic exudative pleurisy, a specific limfangiit, the remote metastasises, active forms of tuberculosis, in the first year after a myocardial infarction, and also at the general serious condition of the patient (a cachexia, oppression of a hemopoiesis, the expressed cardiopulmonary insufficiency).
Radiation therapy is carried out static and mobile by ways on remote gamma-ray irradiation plants of AGAT-S, AGAT-R, LUCH, ROKUS. Big perspectives have sources of high energy — the betatrons and linear accelerators generating the brake and electronic radiation of energy from 4 to 35 MEV. The most important condition of radiation therapy is determination of optimum volume of the irradiated fabrics and the choice of the technique providing leading to a tumor of a necessary dose. All methods of definition of topography of a tumor, orientation of fields of radiation and centration are connected with rentgenol, a research. At radiation is central the located and peripheral tumors carry out from three fields: two passers — juxtaspinal and parasternal, and also supraclavicular or side depending on localization of a tumor with the direction of a bunch of radiation through the center of a tumor on a mediastinum. The total dose is led up to 6000 I am glad on a tumor and 3500 — 4500 I am glad on area of a mediastinum. In sovr, conditions there are several methodical options of radiation therapy of a tumor L. Naiboley widespread are melkofraktsionny when the tumor is irradiated daily in a dose 200 — 250 are glad together with ways of regional innidiation. The technique of large fractionation is that a single dose 400 — 450 I am glad bring to a tumor two-three times a week. Intensively concentrated option of radiation consists in leading of a total dose of 2000 is glad for 5 daily fractions that, according to nomograms biol, isoeffects, is equivalent to a dose 3400 is glad, given for 3,5 weeks in the conditions of small fractionation. Radiation therapy can be applied in two stages: on the first give a half of the planned dose; on the second, after 2 — a 3 weeks break — other. At any localization of a tumor of L. use radiation through a lead lattice. The smaller volumes of healthy fabrics getting to the radiation zone expand possibilities of this method.
The combined method which combines operation and radiation is studied. Preirradiation of a tumor and zones of regional innidiation reduces mitotic activity of malignant cells, conducts to their necrobiosis, and also reduces inflammatory infiltration around a tumor. Elimination of an inflammation and reduction of the sizes of a tumor create favorable conditions for operation, and in certain cases nerezektabelny tumors become rezektabelny. At the combined method of treatment intensively concentrated option is represented to the most rational, at Krom the interval between the end of radiation and operation shall not exceed 5 days.
Postoperative radiation is shown when find viable tumor cells after not considerably remote tumor or a trial torapotomiya in remote regional nodes. Will see him usually in the mode of small fractionation to a total dose 4000-5000 I am glad.
Indications to medicinal treatment are put when there are contraindications to surgical and beam methods. It is carried out at patients with the remote metastasises of cancer of L. and at its small-celled form. Contraindications: sharply weakened general condition of the patient, a cachexia, a leukopenia, thrombocytopenia, disturbance of functions of a liver and kidneys, the expressed pneumorrhagia in connection with disintegration of a tumor.
According to Oncological scientific center of the USSR Academy of Medical Sciences, from all himiopreparat developed by the end of the 70th in the most active L at cancer. Cyclophosphanum and a nitrozometilmochevin (NMM), the methotrexate, CCNU and adriamycin are.
Objective improvement — reduction of the sizes of a tumor of L. or metastasises — it is possible to receive at innidiation of cancer in limf, nodes of a root, a mediastinum, peripheral limf, nodes, another L., at hypodermic dissimination. Usually the chemotherapy is not effective at metastasises in bones, a liver, a brain. Efficiency of chemotherapy of cancer of L. depends generally from gistol, structures of primary tumor. Small-celled cancer of L is most sensitive to chemotherapy., least — an adenocarcinoma. At planocellular cancer the efficiency of chemotherapy which is expressed in direct reduction of a tumor is low and fluctuates depending on the used drugs from 6 to 26%, at small-celled cancer — from 17 to 48%, at an adenocarcinoma and macrocellular cancer — from 10 to 20%.
At undifferentiated small-celled tumors of L. it is reasonable to apply complex treatment, i.e. to combine radiation therapy with administration of chemotherapeutic drugs.
Combination of a remote gamma therapy in a dose 5000 I am glad also to chemotherapy Cyclophosphanum, a methotrexate and NMM (or CCNU) according to the special program allowed to gain good direct effect at 90% of patients with small-celled cancer of L. III \The IV stages, and longevity of patients increased by 2 — 3 times in comparison with those patients at whom one was carried out beam or chemotherapy, and reached on average 30 months.
The combined chemotherapy (polychemotherapy) of cancer L. Tak is widely used, at a combination of Cyclophosphanum and NMM the effect can be gained at 27% of patients with planocellular cancer of L. and at 70% of patients — small-celled cancer. The effect can be gained also at a combination of other himiopreparat, however in all cases of remission are usually short-term and do not exceed 2 months.
At an exudate in a pleural cavity intrapleural introduction of Thiophosphamidum in a dose of 30 — 40 mg on introduction or delagil (Chingaminum) on 250 mg (4 — 5 introductions) daily or every other day can be used. Repeated courses of treatment can be carried out in process of accumulation of exudate.
Practical application of a combination of different methods of treatment can be recommended at small-celled cancer (radiation and medicinal therapy) and after operation with doubtful radicalism. In this case after operation for planocellular cancer radiation of a mediastinum is sometimes reasonable.
At a recurrence of cancer of L. indications to radiation are defined by the general condition of the patient, time of emergence of a recurrent tumor and its histologic structure. Most often it is necessary to be limited to a smaller total focal dose.
To patients at whom the recurrent tumor appeared 1 — 1,5 years later and more, in some cases it is possible to carry out reirradiation in a total focal dose 6000 I am glad. The technique of radiation is chosen taking into account the accompanying postbeam pneumosclerosis. The combination of radiation therapy and chemotherapy is reasonable.
Considerable number of suffering from cancer L. needs symptomatic therapy. Antibiotics reduce the frequency of development and weight of a current inf. complications. The cough which is often proceeding with pain should be suppressed purpose of dionine, codeine and morphine. At tendency to a pneumorrhagia styptic means and hemotransfusion are shown. The tumors burgeoning in a chest wall cause severe pains at which help alcohol - novocainic blockade and drugs.
The forecast at cancer of L. it is always serious. According to L. E. Denisova (1975), patients from the moment of emergence of the first symptoms of a disease live without treatment on average of 12,8 months, and from the moment of establishment of the diagnosis of cancer of L. — 8,7 months. Patients with planocellular cancer of L. lived on average 15,1 months from the moment of emergence of the first symptoms of a disease and 8,2 months — from the moment of establishment of the diagnosis. For patients with an adenocarcinoma these terms respectively 11,6 and 5 months, with undifferentiated cancer — 7,6 and 3,8 months.
Use of surgical .metod of treatment gives the chance to completely cure the patient or to prolong it life. Among considerably operated patients there are 5 years and more live apprx. 30 — 35%, however the high postoperative lethality significantly worsens results of operational treatment. The lethality after pneumonectomies, a component, according to Oncological scientific center of the USSR Academy of Medical Sciences, 12 — 15% is especially high. The main reasons for deaths — cordial, pulmonary and septic complications.
Long-term results of surgical cancer therapy of L. structures of a tumor depend first of all on a stage of a disease and gistol. The low-differentiated cancer yields the bad long-term results. Especially bad results are noted at small-celled cancer.
According to aggregated data of seventeen foreign and domestic surgeons who are most actively engaged in surgical cancer therapy of L., five-year favorable outcomes after pneumonectomies in 1960 — 1975 made 24,1%, and after 2486 lobectomies — 31,5%.
Beam and chemotherapeutic methods of treatment can on a nek-swarm time detain progressing of process.
Prevention. Main reasons for cancer of L. are not opened yet. But the saved-up facts allow to carry out measures of prevention of malignant tumors of bronchial tubes. Main ways: 1) technical — the organization of production and construction taking into account elimination of contact of the person with carcinogens; 2) sanitary and hygienic — pollution control of air and smoking; 3) medical — treatment and the accounting of patients with precancerous diseases of L.
Allocation of precancerous diseases in separate group is very important in the practical relation since promotes onkol, vigilances of doctors of the general to lay down. networks in relation to a wide range neonkol. diseases of L. This installation allows to conduct systematically mass preventive examinations of the population and it is the most rational to allocate «groups of the increased risk». Success of prevention of cancer of L. in many respects depends on efficiency of fight against smoking, with inf. and viral diseases of respiratory tracts, with hron, nonspecific pneumonia and bronchitis.
Sarcoma of a lung
Primary sarcoma of L. — extremely rare disease. The tumor develops from interstitial fabric L. In some exceptional cases separate forms of cancer of L. can be differentiated in a carcinosarcoma, and then in various sites of a tumor the structure is found sarcomas (see) and cancer (see). More often in L. the solitary metastasises of sarcoma keeping a structure of primary tumor meet. Primary sarcomas can have a structure veretenoobraznokletochny, polymorphocellular less often fibrosarcomas (see). Meet also angiosarcoma (see) and reticulosarcoma (see).
Sarcomas are localized on the periphery of L., is more often in upper shares, quickly grow, have the rounded and polycyclic shape, sometimes with affiliated (metastatic) nodes in L. Men and women are ill equally often.
Wedge, and rentgenol, picture of primary sarcoma of L. almost does not differ from a picture of peripheral cancer. It is possible to suspect sarcoma on the basis of quickly developing a wedge, pictures of a tumor of L. or at gistol, a research limf, the nodes of a mediastinum taken at a mediastinoskopiya. Usually sarcoma of L. is an unexpected find at gistol, studying of a tumor.
The only method of treatment of sarcoma is operation, however radical operation is seldom feasible in connection with early innidiation in the remote bodies.
Forecast bad. The long-term results of treatment are unsatisfactory though in separate exceptional cases the good long-term results after operation were observed.
All operations on L. treat big surgical interventions and often demand carrying out thorough preoperative training.
Preoperative preparation is necessary approximately at a half of patients with PURULENT diseases of L. (at an aggravation of inflammatory process and the related purulent intoxication). The risk of operation and postoperative complications is much less if operation on L. make in a phase of sufficient stabilization of inflammatory process and at trace amount of a phlegm. For removal of flash of inflammatory process and fight against purulent intoxication the postural drainage and bronchoscopic sanitation with a careful toilet of a bronchial tree, catheterization of purulent cavities, suction of pus, washing, administration of proteolytic enzymes and antibiotics have major importance. In certain cases at the obliterated pleural cavity I. S. Kolesnikov, B. S. Vikhriyev (1973) recommend abscesses in L. to punktirovat and sanify through a chest wall. Additional actions which can exert beneficial influence on removal of purulent intoxication and improvement of the general condition of the patient are inhalation of aerosols of proteolytic enzymes and antibiotics, intravenous drop injections of 1% of solution of calcium chloride on 500 ml 2 — 3 times a week, transfusions of blood, plasma, proteinaceous drugs, and also good nutrition with enough proteins and vitamins, respiratory gymnastics. Usually vigorous treatment allows to prepare the patient for operation during 2 — 3 weeks. If significant improvement does not come, purulent cavities in L. it is necessary to drain in the operational way or to undertake, despite the increased risk, a radical operative measure.
At suffering from tuberculosis L. before operation for elimination of flash, the greatest possible stabilization and an otgranicheniye of tubercular process happens specific antitubercular treatment is necessary. Depending on the general condition of the patient, a form of tubercular process, a phase of a disease and efficiency of the carried-out therapy ways and duration of such treatment widely vary. On average it proceeds 2 — 3 months and is usually carried out not in surgical, and in a ftiziatrichesky hospital.
Features of the general anesthesia
Absolute majority of operations on L. and bronchial tubes carry out in the conditions of operational pheumothorax. On the course of operations there can be a need of long and broad opening or full crossing of bronchial tubes, at the same time widely apply methods of the combined general anesthesia in the conditions of a total mioplegiya and artificial ventilation of the lungs (see. Artificial respiration ). Special value at operations on L. and bronchial tubes get methods of the artificial ventilation of the lungs (AVL) and an intubation.
Danger of flowing of pus, a phlegm, blood from the struck departments of L. in healthy it is especially big at big and multiple cavities in L. (abscesses, cavities, the suppurated cysts), bronchiectasias, empyemas of a pleura with bronchopleural fistulas. Such patients have a preoperative bronkhoskopiya with a toilet of a bronchial tree, situation on a stomach with an inclination of the head end of the operating table down, frequent suctions through an endotracheal tube can be insufficient for maintenance of free passability of respiratory tracts and prevention of infection of healthy departments of L. At operations during pulmonary bleeding a blood coagulation in respiratory tracts with threat of fatal asphyxia is possible.
Specific requirements to the general anesthesia during operations on L. and bronchial tubes prevention of paradoxical breath and a flotirovaniye of a mediastinum, an action for prevention of hit of pus, blood, a phlegm in healthy departments of L are. and maintenance of free passability of respiratory tracts, ensuring adequate ventilation during opening and crossing of bronchial tubes. For this purpose during intervention carry out IVL with endotracheal or endobronchial intubation (see). Introduction anesthesia (see) carry out intravenous administration of barbiturates or use of the combined methods of induction. After introduction muscle relaxants (see) make an intubation of a trachea, bronchial tube or a separate intubation of bronchial tubes. Enter the thick probe for prevention of regurgitation of its contents and simplification of anatomic orientation in position of a gullet into a stomach. As insuffliruyemy general anesthetics at a stage of maintenance of an anesthesia use Ftorotanum, constant boiling mixture, metoksifluran and nitrous oxide in a flow of oxygen (see. Inhalation anesthesia ). The general anesthesia is carried out with the help neyroleptanalgeziya (see). IVL carry out devices. In some cases (at considerable resistance in an inspiratory phase and during the opening of a gleam of respiratory tracts when in them the surgeon periodically closes an opening a tupfer or a finger) pass to manual ventilation of L. During the general anesthesia and operation as required periodically suck away a phlegm from respiratory tracts a catheter which is entered through an endotracheal tube. Such technique provides performance of the majority of operations on L.
For prevention of hit of light bodies from the struck departments of L. in healthy apply an intubation of a primary bronchus («a one-pulmonary anesthesia»), a separate intubation of bronchial tubes, drainage and blockade of a bronchial tube.
Intubation of a bronchial tube of healthy L. interferes with flowing of light bodies from the L struck in healthy. Thus struck with L. does not participate in breath and decreases in volume that facilitates performance of a resection. For an intubation of a bronchial tube use rather long endotracheal tube with a short inflatable cuff. It is convenient to intubate the right primary bronchus Gordon's tube — Green with a special side opening for the right superlobar bronchial tube. Provision of a tube and extent of dissociation of L. prior to operation control auscultation, and after opening of a pleural cavity — a palpation and overseeing by a condition of L. and the movements of a mediastinum according to a breath and an exhalation.
Most often apply a dvukhprosvetny tube of Karlens to a separate intubation of bronchial tubes. The end of this tube is established in the left primary bronchus, advancing a tube before fixing of its right-hand spur on bifurcation of a trachea (fig. 70).
Advantage of use of dvukhprosvetny tubes before method of an intubation of a bronchial tube of the healthy party is the possibility of aspiration of light bodies from a bronchial tube of the deleted L., and a shortcoming — relative narrowness of gleams and impossibility of use for patients of early and younger children's age.
At partial resections of L. use of a separate intubation of bronchial tubes by means of dvukhprosvetny tubes allows to prevent flowing of light bodies in bronchial tubes on the healthy party and at the necessary moments to stop ventilation of L. on the party of an operative measure. The last is especially important at the bronchopleural fistulas passing large volumes of gas-narcotic mix and complicating carrying out effective IVL. For simplification of surgical manipulations it is possible to connect channels of a dvukhprosvetny tube to two various narcotic devices or to the channel of the operated party to connect the connector with an adjustable gleam and to ventilate L. on the party of operation by the smaller volume of gas-narcotic mix — the so-called managed collapse of a lung offered by G. I. Lukomsky and M. A. Vishnevskaya (1964). Before processing of a primary bronchus the tube is tightened or replaced usual odnoprosvetny.
Drainage of a bronchial tube is carried out by preliminary, prior to the beginning of the general anesthesia, introductions of the managed catheter to the bronchial tube draining cavities in L. Zatem make an intubation of a trachea and continue an anesthesia. Through a catheter continuously suck away contents of purulent cavities without the termination of IVL; this technique is offered by M. B. Dribinsky with sotr. (1959).
Blockade of a bronchial tube of the deleted L. carry out a catheter with an inflatable cylinder (a bronchus blocker, fig. 71) or a gauze tamponade at a bronkhoskopiya. Apply both of these ways seldom since they are a little reliable and can be followed by dangerous disturbances of ventilation in cases of shift of a cylinder or a tampon.
At all operations on L., regardless of a method of an intubation, it is important during operation the toilet of a trachea and bronchial tubes which is carried out by suction of liquid contents from a trachea and bronchial tubes. The catheter for suction shall have trailer and several side openings. Through a tee with one open knee the catheter is connected to rather strong sucking-away device. During introduction of a catheter the open knee of a tee interferes with evacuating. After carrying out a catheter on sufficient depth the open knee of a tee is closed a finger and the catheter is slowly removed from a tube. Such technique reduces traumatization of a mucous membrane of respiratory tracts, edges always to some extent takes place at suction through a catheter. The procedure of suction, as a rule, connected with the termination of ventilation of L., shall not proceed more than 1 — 1,5 min. Consider that suction shall not last more than that time, on a cut the anesthesiologist can hold own breath.
During operation there can periodically be a need for inflating of H.p. build-up of pressure in respiratory tracts to 30 — 40 cm w.g. Build-up of pressure is especially important for definition of intersegmental borders, check of passability of bronchial tubes, identification of damages of pulmonary fabric, control of tightness of a stump of a bronchial tube and a bronchial anastomosis, and also for a raspravleniye of atelektazirovanny sites L. at the end of operation.
At bronchial tubes operations the best conditions for ensuring gas exchange and performance of intervention are created by an intubation of a primary bronchus of the opposite side.
On bronchial tubes of the right side it is more convenient to operate at an intubation with Karlens's tube, Macintosh's tube — Literdela or an odnoprosvetny tube, the end a cut can be moved from a trachea to the left primary bronchus and back. At operations on bronchial tubes of the left side enter into the right bronchial tube a usual odnoprosvetny tube or Gordon's tube — Green.
At patients with wide bronchopleural fistulas, and first of all with fistulas of primary bronchi, after a pneumonectomy prior to carrying out the general anesthesia it is necessary to tampon well a residual pleural cavity for prevention of dumping of gas-narcotic mix through fistula. Use of bronchus blockers for closing of fistulas is inexpedient. At wide bronchopleural fistulas, especially on the right, the intubation of the left primary bronchus is sometimes connected with considerable technical difficulties. The trachea at such patients is usually bent and displaced to the right, the left bronchial tube departs under a big corner, and the tube is easily entered only into fistula. In similar cases dense and elastic odnoprosvetny tubes with a big bend are necessary. The head of the patient is taken away to the right, the tube is turned a bend to the left and slowly advanced so that its cut slid on the left wall of a trachea.
At patients with fistula of a stump of the left primary bronchus at access to bifurcation of a trachea by a right-hand torapotomiya it is necessary to squeeze the only right L. V these cases for maintenance of adequate gas exchange it is necessary to carry out an intensive hyperventilation within 5 — 7 min., and then to pass to superficial manual ventilation.
Complexity of carrying out the general anesthesia and inevitable breaks in IVL at a number of operations on L. and bronchial tubes cause need of elektrokardioskopichesky control and a periodic research of an acid-base state and blood gases. In more dangerous situations also elektroentsefalografichesky control is shown.
After operations on L. and bronchial tubes perhaps bystry recovery of consciousness, adequate independent breath and a tussive reflex is necessary. These factors have essential value for a favorable current of the next postoperative period.
Features of anesthesia at children
Carrying out the general anesthesia at children has a number of features (see. Inhalation anesthesia, Anaesthesia). At operations on L. they are defined by hl. obr. anatomo-fiziol. characteristics of system of a respiratory organs. Respiratory tracts at children narrow, and their passability is easily broken at a plentiful sialosis, receipt from L. phlegms, especially purulent. The narrowness of a throat and trachea does not allow to apply dvukhprosvetny endotracheal tubes of Karlens and other special tubes to a separate intubation of bronchial tubes and their dissociation. Therefore the intubation of a trachea at children is made, as a rule, a usual smooth, semi-curved odnoprosvetny tube (see the Intubation). At the age of children up to 7 — 10 years use of tubes with inflatable cuffs which injure voice folds during an intubation is contraindicated and promote developing of hypostasis of a throat and trachea after an anesthesia, especially long. From methods of dissociation of bronchial tubes it is rational to apply only one — an intubation of a bronchial tube of healthy L. advance in it an odnoprosvetny tube with a short cut. At the same time it must be kept in mind that at small children bronchial tubes depart from a trachea almost under an identical corner, and it is technically easier to carry out a tube to the left primary bronchus, than at adults. At the same time the small length of primary bronchi causes ease of shift of a tube up and down, something breaks dissociation of bronchial tubes, or leads to overlapping of the mouth of an upper lobar bronchus and switching off from breath of an upper share of L. In this regard during an intubation of a bronchial tube and on the course of operation systematic control, hl is necessary. obr. auskultativny, behind ventilation of an upper share of L. on not operated party.
During the general anesthesia the dead space shall be most reduced. IVL carry out so that respiratory volumes exceeded their size at spontaneous breath. In cases of obstructive pathology pressure, under the Crimea moves gas-narcotic mix, sometimes it is necessary to raise considerably — to 50 — 60 cm w.g.
Complications of the general anesthesia during operations on L. and bronchial tubes can be flowing of light bodies in bronchial tubes of healthy departments and disturbance of gas exchange in the presence of bronchopleural fistulas and broad opening of bronchial tubes. A careful toilet of a tracheobronchial tree through an endotracheal tube, an intubation of a bronchial tube of healthy L., a separate intubation of bronchial tubes dvukhprosvetny tubes minimize probability of these complications.
At development of the phenomena of pulmonary insufficiency after extensive interventions on L. (a pneumonectomy, a lobectomy) in the next postoperative period there can be a need for the prolonged IVL.
Technology of surgeries
For successful performance of operations on L. a number of conditions is necessary. Operating rooms shall be equipped with automatic respirators for an anesthesia, are equipped by otsasyvatel, to have a surgical diathermy for cuts an electroknife and coagulations of the bleeding vessels. From tools dilators of wounds of a chest wall, a saw are important for a section of a breast (wire, vibration, circular, ultrasonic), deep rigid and soft mirrors for assignment of a diaphragm, L. and hearts, nippers for capture of L. and pleurae, long tweezers, scissors, clips and needle holders, dissectors, staplers of UO and MOUSTACHE with tantalic brackets, tweezers with an atraumatic notch, atraumatic needles of various sizes. Also tools for a resection of edges, including bandbox nippers, raspatories and costal nippers of Zauerbrukh for the I edge are necessary.
The puncture of a lung is made from diagnostic or to lay down. purpose. The main indication to a diagnostic puncture is need of receiving material from patol. the center for tsitol, and gistol, researches. Contraindications to a diagnostic puncture are localization patol, the center in the field of a root L., emphysema of L., existence of the only functioning L., suspicion of intra pulmonary aneurism or echinococcal cyst. The transthoracic puncture is done under a local infiltration anesthesia and X-ray television control. Dia can use a usual syringe needle 140 — 150 mm long with outside. 0,9 — 1,1 mm, a needle with the jagged or split Silvermen's (fig. 72 and 73) end. Puncture of L. after opening of a pleural cavity do by a usual syringe needle. During transthoracic to lay down. the puncture of abscess or a cavity through a needle or a trocar can enter a thin catheter which is fixed to skin into a purulent cavity and use for systematic sanitation of abscess or a cavity by suction, washing and administration of medicines.
Standard quick access for operations on L. rather wide intercostal section is. Depending on position of the patient on the operating table and localization of a section it is accepted to distinguish front, side and back quick access. The thoracotomy (see) is made by B IV, V or the VI mezhreberye. A number of surgeons use crossing of edges and their resection only at back access or in cases of need of expansion of a surgery field. At operations on elements of a root L. or single-step bilateral interventions on L. sometimes apply a median sternotomy to access (see. Mediastinotomy ).
The most widespread operations on L. are pneumonectomy (see), a plevropnevmonektomiya (see. Pleurectomy ), lobectomy (see), segmentectomy (see) and atypical pneumonectomy, decortication of a lung (see). More rare operations are removal of not parasitic and parasitic cysts of L. (a cystectomy, an ekhinokokkektomiya), removal of a foreign body and opening of abscess — pneumotomy (see), opening of a cavity — cavernotomy (see), drainage of abscess or a cavity through a chest wall (an abstsessostomiya, a cavernostomy).
The special equipment is used to removal of echinococcal cysts of L. Obychno an ekhinokokkektomiya make after suction of contents of a cyst. For this purpose the cyst is punktirut the thick needle connected to the sucking-away system in the beginning. All liquid is sucked away. Pulmonary fabric over a cyst is cut an electro-knife. Widely open the fibrous capsule, delete a kutikulyarny cover with its contents, take in bronchial fistulas (see) and cavity of the fibrous capsule. For reduction of danger of a secondary invasion at accidental hit in a wound of echinococcal liquid it is possible to enter at once after suction of a small amount of liquid into a cyst for several minutes 1 — 2% solution of formalin, and a cavity of the fibrous capsule after sewing up of bronchial fistulas to grease 2% with solution of formalin in glycerin. Sewing up of the big cavities formed by the fibrous capsule in L., presents considerable difficulties and quite often leads to wrinkling and rough deformation of L. In order to avoid these negative moments A. A. Vishnevsky (1956) offered a way of processing of the fibrous capsule. The essence of a way consists in what edges of widely opened fibrous capsule partially otpreparovyvat and cut for the purpose of transformation of a deep cavity into most flattened. Then edges of the capsule and wound of L. sheathe on a circle a blanket catgut seam. After that the inner surface of the fibrous capsule becomes as if a part of an outer surface of L. Bronchial fistulas take in. Ekhinokokkektomiya by the described technique is especially shown at big cysts. In cases of cysts of the smaller sizes the «ideal» ekhinokokkektomiya, i.e. removal of a cyst with the unimpaired kutikulyarny cover is rational. Over a cyst an electroknife cut pulmonary fabric. Then a scalpel very carefully cut the fibrous capsule, without damaging a kutikulyarny cover. Small build-up of pressure in system of the narcotic device as if squeeze out not opened echinococcal cyst through a section in the fibrous capsule. It is possible to remove also successfully a cyst, without raising, and lowering intra pulmonary pressure. The cavity of the fibrous capsule is taken in, paying special attention to closing of bronchial fistulas.
In process of more and more early production of operations for an echinococcosis of L. and improvement of the surgical ideal equipment the ekhinokokkektomiya at cysts of the small and average sizes gains bigger distribution. Ekhinokokkektomiya together with the fibrous capsule is inexpedient since reproduction of a parasite happens only in a cavity of a kutikulyarny cover, and the fibrous capsule of the activator does not contain. Removal of a share of L., and furthermore two shares or even all L. at patients with an echinococcosis has very limited indications: secondary suppurative processes around a cyst, pulmonary bleedings, suppuration of the multiple cysts located in one share or in one
L. U of patients with several echinococcal cysts in one L. the single-step ekhinokokkektomiya — «ideal» or with preliminary suction of contents of cysts is shown. Possibly and a combination of these two methods in the course of removal of various cysts. At bilateral cysts make consecutive operations of removal of cysts from one, and then and second L. A usual interval between operations 2 — 3 months. Single-step removal of cysts from both L. it is not recommended because of bigger operational risk.
True recurrence of an echinococcosis of L. after operation develop less than at 1% of patients. A false recurrence — cases when the being available small cysts during operation were not revealed and removed is occasionally observed. An average lethality after operations for an echinococcosis of L. makes about 3%, but in a number of clinics during the last time it is considerably reduced and is in limits of 0,5-1%.
Patients within 2 — 4 days after operation shall be in the intensive care unit equipped with the control and diagnostic equipment, devices for long IVL, systems for constant supply of oxygen through nasal catheters. Existence of vacuum installations is very important for the dosed suction of air and liquid through the drainages entered into a chest cavity. Except specially designed systems and regulators, for dosing of vacuum also simple system from two large bottles with a manometrical tube in one of them is widely used (fig. 74). In department there has to be the round-the-clock possibility of a research of gas composition of blood, rentgenol, control of a condition of bodies of a chest cavity, transnasal catheterization of a trachea and bronchial tubes, a bronkhoskopiya.
In the first days after operation it is necessary to provide sufficient anesthesia. Long peridural anesthesia Trimecainum is most effective (see Anesthesia local).
After all operations on L. it is very important to provide good expectoration of a phlegm, and after resections of L. — bystry raspravleniye of its rest. For achievement of these purposes the main preventive and to lay down. actions are massage of a thorax, respiratory gymnastics, an early rising (in 1 — 2 days after operation), transnasal catheterization of a trachea and bronchial tubes, constant suction of liquid and air from a pleural cavity through drainages (see. Aspiration drainage ). According to indications in specialized institutions use devices of artificial cough (see. Cough artificial ).
At low funkts, indicators and tendency to hypersecretion of bronchial slime apply microtracheostomy (see). For this purpose during operation or in the first days after it, having pierced with a trachea is slightly lower than a cricoid, into a gleam it is entered a thin chlorvinyl tube, by edges, irritating a mucous membrane of a trachea, causes a tussive reflex, and also serves for administration of the drugs liquefying a phlegm and antibiotics. An effective remedy for suction of a phlegm and clots which can get into bronchial tubes during operation is the transnasal bronkhofibroskopiya. At the developed acute pulmonary insufficiency are shown tracheostomy (see) and artificial respiration (see).
The drainages entered into a pleural cavity after a lobectomy delete on 2 — 4 days when the lung completely finishes and in a pleural cavity will not remain liquid and gas. It is necessary to Punktirovat a pleural cavity for removal of the accumulating exudate after a pneumonectomy only according to indications: at complaints of the patient to constraint in breasts and an asthma, the shift of a mediastinum in the healthy party, at excess accumulation of exudate. It is inexpedient to delete liquid from a pleural cavity without indications since it promotes its further accumulation. The patient at the same time loses a lot of protein, salts and liquid. The liquid collecting in a pleural cavity after a pneumonectomy is necessary substrate for its obliteration.
In the postoperative period much attention needs to be paid to prevention of pulmonary, pleural and cardiovascular complications. It is necessary to struggle with paresis went. - kish. a path and an acute gastrectasia (often observed at damage of a vagus nerve) since high standing of a diaphragm considerably complicates breath and cordial activity. Quite frequent tromboembolic episodes in the postoperative period force to watch carefully a condition of coagulant and anticoagulative system of blood, especially at corpulent and elderly patients with cardiovascular diseases in the anamnesis. Serious complications after operations on L. bronchial fistulas (see) and an empyema of a pleural cavity are (see. Pleurisy ).
See also Respiratory system .
Comparative anatomy, embryology, anatomy, histology — Adyshirin-Zada E. A. It is normal of relationship of pulmonary and bronchial veins also at disturbance of a pulmonary blood-groove, Arkh. annate., gistol, and embriol., t. 57, No. 7, page 73, 1969; Antipchukyu. Item and Gibradze T. A. To comparative morphology of blood vessels of lungs, Tbilisi, 1973; In e y e of l E. R. Morfo-metriya of lungs of the person, the lane with English, M., 1970; Zhedenov V. N. Lungs and heart of animals and person, M., 1961; The Lung is normal, under the editorship of I. K. Yesipova, Novosibirsk, 1975; Linberg B. E. Anatomic premises to topical diagnosis of pulmonary diseases, Owls. medical, No. 9, page 4, 1948; L about m about in M. F. and Nepomnyashchy L. M. Lungs, additional share of an unpaired vein, Novosibirsk, 1971, bibliogr.; P about d d at-ny I. G. Embryonic development of pulmonary veins, Arkh. annate., gistol, and embriol., t. 64, No. 3, page 49, 1973, bibliogr.; Palikar And. and Ghali P. The bronchopulmonary device, structure and mechanisms is normal also at pathology, the lane with fr., Novosibirsk, 1972, bibliogr.; Selivanova L. M. To evolutionary and age morphology of bronchial arteries, Arkh. annate., gistol, and embriol., t. 45, No. 8, page 55, 1963, bibliogr.; Serova E. V. Surgical anatomy of lungs, M., 1962, bibliogr.; Speransky V. S. Pulmonary zones and segments in the sravnitelnoanatomichesky relation, Arkh. annate., gistol, and embriol., t. 43, No. I, page 29, 1962, bibliogr.; Resident of Veliky Ustyug of the island N. V. and Shishkin G. S. Quantitative elektronnomikroskopichesky studying of resprfatorny departments of lungs, in the same place, t. 70, No. 1, page 33, 1976; Surgical anatomy of a breast, under the editorship of. And. N. Max names-kova, page 219, L., 1955; Anatomy of the developing lung, ed. by J. L. Emery, L., 1969; Angus G. E. a. Thuri-b e with k W. M. Number of alveoli in the human lung, J. appl. Physiol., v. 32, p. 483, 1972; B o y d e n E. A. The mode of origin of pulmonary acini and respiratory bronchioles in the fetal lung, Amer. J. Anat., v. 141, p. 317, 1974; Harris P. a. Heath D. The human pulmonary circulation, its form and function in health and disease, Edinburgh — N. Y., 1977, bibliogr.; H a y e k H. The human lung, N.Y., 1960; K i lb urn K. H. Functional morphology of the distal lung, Int. Rev. Cytol., v. 37, p. 153, 1974; O’ R a-hillyR. Boyden of E.A. The timing and sequence of events in the development of the human respiratory system during the embryonic period proper, Z. Anat. Entwickl. - Gesch., Bd 141, S. 237, 1973; Rosario E. J. a. o. The architecture of the alveolar wall, an ultrastructural study in man, Cardiovasc. Res. Cent. Bull., v. 12, p. 13, 1973; Sarrazin R., Voog R.et D at o n J. F. Contribution a l’etude des lymphatiques du poumon, Poumon, t. 30, p. 289, 1974.
Physiology — Dembo A. G. Insufficiency of function of external respiration, L., 1957, bibliogr.; Zilber A. P. Regional functions of lungs, clinical physiology of irregularity of ventilation and blood-groove, Petrozavodsk, 1971, bibliogr.; Komro D. G. idr. Lungs, clinical physiology and functional trials, the lane with English, M., 1961, bibliogr.; Navratil M., Kadlec To. and D and at S. Patofiziologiya's m of breath, the lane from Czeches., M., 1967, bibliogr.; Physiology of breath, under the editorship of L.L.Shik, etc., page 4, L., 1973; Bouhuys A. Breathing, physiology, environment and lung disease, N. Y., 1974; With o t e s J. E. Lung function, Oxford, 1975, bibliogr.; Handbook of physiology, ed. by M. B. Yisscher, sec. 3-Respiration, v. 1, Washington, 1964; Sanderson R. J. a. o. Morphological and physical basis for lung surfactant action, Resp. Physiol., v. 27, p. 379, 1976; U 1 m e r W. T., Rei-chel G. u. Nolte D. Die Lungenfunk-tion, Physiologie und Pathophysiologie, Methodik, Stuttgart, 1976, Bibliogr.
Methods of a research — Bogolyubov V. M. Radio isotope diagnosis of heart diseases and lungs, M., 1975, bibliogr.; Bogush L. K. both ares about in and the p I. A. Biopsiya in pulmonology, M., 1977, bibliogr.; Lindenbraten L. D. and Naumov L. B. Radiological syndromes and diagnosis of pulmonary diseases, M., 1972; Fundamentals of pulmonology, under the editorship of A. N. Kokosov, page 24, etc., M., 1976, bibliogr.; Rozenshtra-ukh L. S., Rybakov N. I. and M. G Vanner. Radiodiagnosis of diseases of a respiratory organs, M., 1978; Fridkin V. Ya. Anatomo-funktsional-nye of a basis of the radiological image of lungs, M., 1963, bibliogr.; Functional researches of breath in pulmonary practice, under the editorship of H. N. Kanayeva, L., 1976, bibliogr.; B. K spheres. Radiodiagnosis of cancer of lung, M., 1974, bibliogr.; F e 1 s about n B. Chest roentgenology, Philadelphia, 1973; Lung cells in disease, Proc. Brook Lodge Conf., ed. by A. Bouhuys, Amsterdam a. o., 1976; Pulmonary diagnostic techniques, ed. by T. L. Petty, Philadelphia, 1975; Rup-p e 1 G. Manual of pulmonary function testing, St Louis, 1975; Special procedures in chest radiology, ed. by S. S. Sagel, Philadelphia, 1976; Teschendorf W., Anacker H. u. ThurnP. Rontgeno-logische Differentialdiagnostik, Bd 1, T. 1, Stuttgart, 1975; .Wright F. W. The radiological diagnosis of lung and mediastinal tumors, L., 1973, bibliogr.
Pathology — Amosov H. M. Sketches of thoracic surgery, Kiev, 1958; Anichkov M. N. and Vigdorchi to I.V., Medical emergencies in pulmonology, M., 1975, bibliogr.; Atanasyanl. And., Rybakova N. I. and Poddub-ny B. K. Metastatic tumors of lungs, M., 1977, bibliogr.; The atlas of chest surgery, under the editorship of B. V. Petrovsky, t. 1, page 97, 105, M., 1971; B akulev A. N. and To about l of e with N and to about in and R. S. Surgical treatment of purulent diseases of lungs, M., 1961, bibliogr.; Diseases of system of breath, the lane with polsk., under the editorship of T. Gar-oinsky, Warsaw, 1967; Bochka-r e in M. V. and To and sh to and N P. N. Gistoplaz-moz, Chisinau, 1977; Wagner E. A. The closed injury of a breast of peace time, M., 1969, bibliogr.; about N e, the Getting wounds of a breast, M., 1975, bibliogr.; Vakhidov V. V. and And with l and m of EC about in E. S. Ekhinokokkoz of lungs, Tashkent, 1972; In and N of N of e r M. G. and Sh at l at shopping mall about M. L. Spherical formations of lungs, Sverdlovsk, 1971, bibliogr.; In and sh-N of e in with to and y A. A. and Sh r and y e r M. I. Field surgery, M., 1975; To War of Page. Cytologic diagnosis of lung cancer, the lane with polsk., Warsaw, 1970, bibliogr.; Purulent diseases of a pleura and lungs, under the editorship of P. A. Kupriyanov, page 183, L., 1955; Yesipova I. K. Pathological anatomy of lungs, M., 1976, bibliogr.; Zilber A. P. Artificial ventilation of the lungs at acute respiratory insufficiency, M., 1978; Kolesnikov I. S. and In and x-r and ev B. S. Abscesses of lungs, L., 1973, bibliogr.; Kolesov A. P. and d river. About the mechanism of slight gunshot injuries, Surgery, No. 5, page 54, 1975, bibliogr.; Boxes V. I., Kartashov V. M. and Blinova R. V. Iglovaya biopsy of lungs, Sverdlovsk, 1972, bibliogr.; To r and e in with to and y N. A. O of histologic classification of cancer of lung, Vestn. USSR Academy of Medical Sciences, No. 3, page 15, 1976; The Krakow N. I., Kolesnikov R. of Page and P and in about in and r about in and G. M. Inborn aoteriovenozny fistulas, page 144, M., 1978; To r about f t about N of J. and Douglas A. Diseases of a respiratory organs, the lane with English, M., 1974; The Lung in pathology, under the editorship of I. K. Yesipova, Novosibirsk, 1975, bibliogr.; Medicinal treatment of patients with cancer of a lung, under the editorship of I. V. Kasyanenko, Kiev, 1977, bibliogr.; M of az and ev P. N., Sarkisov D. S. and Adamyan A. A. Peripheral cancer of a lung, Tashkent, 1977, bibliogr.; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 9 — 10, M., 1950 — 1952; The Jail with to and I am N. V. The closed injuries of lungs, L., 1971, bibliogr.; Petrovsky B. V., Perelman M. I. and Koroleva N. S. Tracheobronchial surgery, M., 1978; Potter E. Pathological anatomy of fruits, newborns and children of early age, the lane with English, M., 1971; Cancer of a lung, under the editorship of B. E. Petersona, M., 1971, bibliogr.; Rodionov V. V. Surgery of cancer of lung, M., 1970, bibliogr.; The guide to a pulmonary ofurgiya, under the editorship of I. S. Kolesnikov, h. 416, L., 1969; The Guide to pulmonology, under the editorship of N. V. Putov and G. B. Fedoseyev, L., 1978, bibliogr.; Spasokukotsky S. I. Surgery of purulent diseases of lungs and a pleura, M. — L., 1938. bibliogr.; Strukov A. I. and Kodolova I. M. Chronic nonspecific diseases of lungs, M., 1970; V.P's Pods. Purulent diseases of lungs and pleura, L., 1967, bibliogr.; V. I. pods, Ox-E P-matte. L. and Sakharov V. A. Malformations of the easy person, M., 1969; Fedorov B. P. and Ox-E p Matte. L. Abscesses of lungs, M., 1976, bibliogr.; Surgery of parasitic diseases, under "an edition of I. L. Bregadze and E. N. Wangqiang, page 7, M., 1976, bibliogr.; Stern R. D. and Kireeva S. G. Pulmonary alveolar proteinosis, Arkh. patol., t. 36, century 2, page IX, 1974, bibliogr.; Carcinoma of the bronchus, ed. by T. J. Dee-ley, L., 1971; Haupt R. Narbenkrebs der Lunge, Lpz., 1973, Bibliogr.; Morgan K. G. a. Seaton A. Occupational lung diseases, Philadelphia, 1975, bibliogr.; S e y d e 1 H. G., C h an i t A. a. G m e 1 i with h J. T. Cancer of the lung, N. Y., 1975; Shields T. W. Bronchial carcinoma, Springfield, 1974, bibliogr.; Spencer H. Pathology of the lung, v. 1 —-2, Oxford, 1977; S at 1 1 an A. Lungen-krankheiten, Bd 1 — 2, Lpz., 1978, Bibliogr.; V a s s i 1 k o s P. Cytopathologie des cancers broncho-pulmonaires, Berne, 1976.
L. at children — Children's thoracic surgery, under the editorship of V. I. Struchkov and A. G. Pugachev, M., 1975, bibliogr.; Dmitriyev M. L., Pugachev A. G. and N. L Kushch. Sketches of purulent surgery at children, page 256, M., 1973; Isakov Yu. F., Stepanov E. A. and Geraskinv. I. The guide to thoracic surgery at children, M., 1978, bibliogr.; To l and m and N with to and y V. A. Surgical pathology of lungs at children, M., 1975, bibliogr.; To l and m to about in and the p I. G. An intensive care and surgical treatment of nonspecific diseases of lungs at children, M., 1975, bibliogr.; L and - about in S. L. and Sh and r I am e in and K. F. Purulent diseases of lungs and a pleura at children, L., 1973, bibliogr.; Lindenbraten D. S. and Lindenbraten L. D. Radiodiagnosis of diseases of a respiratory organs at children, L., 1957, bibliogr.; P about to and the Central Committee and y M. R. Urgent pulmonology of children's age, L., 1978; Rokitsky M. R. and In and N I am A. A N. Clinic, diagnosis and treatment of staphylococcal destructions of lungs at children, Kazan, 1974, bibliogr.; Chronic nonspecific diseases of lungs at children, under the editorship of K. F. Shiryaeva, L., 1978, bibliogr.
N. V. Putov, A. A. Ovchinnikov; V. I. Geraskin, S. M. Krivorak, L. M. Roshal (it is put. hir.), V. D. Glebovsky (physical.), 3. V. Vorobyova, I. P. Zamotayev, A. I. Ishmukhametov (mt. issl.), I. K. Yesipova (stalemate. An.), I. I. Kagan, S. S. Mikhaylov (An.), L. D. Lindenbraten (rents.), M. I. Perelman (damages, inflammatory processes, operations), I. A. Perez-legin (I am glad.), B. E. Peterson (PMC.), M. L. Shulutko (inflammatory processes).