PNEUMONIA (pneumonia; grech, pneumon easy) — the disease combining big group various on an etiology, a pathogeny and the morphological characteristic exudative inflammatory is more often infectious, processes in lungs with preferential defeat of their respiratory departments. On a wedge, to a current and morfol, to the changes happening in pulmonary fabric distinguish acute and chronic P.
- 1 the ACUTE PNEUMONIA
- 1.1 The etiology
- 1.2 The factors contributing to developing of an acute pneumonia
- 1.3 A pathogeny
- 1.4 Experimental pneumonia
- 1.5 Pathological anatomy
- 1.6 The clinical picture
- 1.7 Radiodiagnosis
- 1.8 The differential diagnosis
- 1.9 Treatment
- 1.10 Rehabilitation
- 1.11 The forecast
- 1.12 Prevention
- 1.13 Features of an acute pneumonia at children
- 2 CHRONIC PNEUMONIA
- 3 Tables
the ACUTE PNEUMONIA
In a basis of the first classification of the acute P. developed by K. Rokitansky (1842) it was put morfol. the principle, and P. differed depending on localization and the sizes of pneumonic infiltrate. In 1937 Bullova (G. The m of Bullowa) offered the acute P.'s classification based on etiol, the principle. The classification developed Hoeg-glinom (R. Hegglin, 1969) which is constructed by the etiopatogenetichesky principle is abroad eurysynusic and allocates P. etiologies of a disease, primary and secondary with the instruction. In the USSR the acute P.' classification offered by N. S. Molchanov in 1962 and approved by the XV All-Union congress of therapists is accepted. In this classification allocate following acute P.: on an etiology (bacterial, virus and ku-rickettsial; The Items caused by chemical and physical irritants; mixed); on kliniko-morphological features (parenchymatous croupous and parenchymatous focal, intersticial, mixed); on a current (ostrotekushchy, long). However this classification did not include mycoplasmal and allergic P. Besides, in the section characterizing acute P. on kliniko-morphological features the intersticial P. which is almost not found at adults which diagnosis is based on data rentgenol, researches that creates conditions for acute P.'s hyper diagnosis at patients with changed rentgenol, the drawing of lungs is specified. In 1978 classification of acute P. in which these defects were eliminated was offered O. V. Korovina. In it distinguish: on an etiology — bacterial (with the indication of the activator), virus (with the indication of the activator), mycoplasmal and rickettsial (with the indication of the activator), allergic, caused by physical and volumetric factors, mixed, is not specified-ache;;;;;;;;; on a pathogeny — primary and secondary; on morphological features — croupous and focal; on a current — ostrotekushchy and long. However the exception of intersticial P.'s classification admits yet not all pulmonologists. In classification acute P. is subdivided on primary and secondary. The disease which arose at the person with a respiratory organs healthy before and in the absence of diseases of other bodies and systems which led to P. or promoting its emergence is considered primary acute P. Secondary acute P. arises against the background of hron, diseases of a respiratory organs (hron, bronchitis, a tumor, etc.) as a complication inf. diseases, including viral respiratory diseases, diseases of cardiovascular system with stagnation in a small circle of blood circulation, hron, diseases of various bodies and systems (kidneys, the hemopoietic system etc.) reducing resistance to an infection as a complication of operations and injuries.
Acute P. meets quite often. So, by data A. A. Korovina (1976), patients with acute P. make 9 — 13% of number of patients in therapeutic departments, and patients with focal P. (73 — 77%) prevail.
Acute P. is a polietiolo-gichny disease. Bacterial p the viral (virus and bacterial) infection which causative agents are characterized expressed pneumotracks-nostyyu is the main reason for P. In recent years the frequency of mycoplasmal, rickettsial, fungal and other types of the Item increased. At the same time development of the acute P. which is directly not connected with primary infection is possible. It is P. from influence of various physical and volumetric factors (aspiration, medicinal, beam, etc.).
Kliniko-mikrobiologichesky and kliniko-immunological comparisons and pilot studies allowed to divide the microorganisms which are most often allocated from bronchial contents on degree of their potential ability to cause inflammatory process in lungs on three groups: pathogenic (Streptococcus pneumoniae, Haemophilus influenzae), uslov-Ho-naToreHHbie (Staphylococcus aureus. Streptococcus haemolyticus, Pseudo-monas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Proteus sp. and other enterobakteriya) and nonpathogenic (Staphylococcus epidermidis, Streptococcus viridans, Streptococcus anhaemolyticus, etc.).
Among bacterial activators of acute P. the leading role belongs to a pneumococcus (Streptococcus pneumoniae). It is confirmed not only bacterial, a research of a phlegm, but also results serol, researches. Especially often the pneumococcus is allocated at patients at the very beginning of a disease before purpose of antibacterial therapy. According to various researchers, the specific weight of a pneumococcus among other activators P. in an etiology of acute pneumonias fluctuates from 70 to 96%.
In recent years the frequency of allocation from a phlegm of patients with an acute pneumonia of Haemophilus influenzae increased.
Frequency of staphylococcus among other activators of acute P. at adults is small and makes, according to Venta (H. Wenta, 1975), 0.4 — 5%. In 3 — 8% of cases acute P.'s activators, according to Deyvid-son (M. of Davidson, 1976) and Finlenda (M. of Finland, 1976), gram-negative enterobakteriya, especially Klebsiella pneumoniae stick and a pyocyanic stick (Pseudomonas aeruginosa) are.
The frequency of P. caused by opportunistic microorganisms which increased for the last 10 — 15 years, many researchers explain with the irrational use of antibacterial agents bringing To to dysbacteriosis (see) and superinfections (see). The items caused by opportunistic microorganisms of Pseudomonas aeruginosa, Escherichia coli, Proteus sp., quite often are a consequence of a hospital infection.
At aspiration pneumonia along with the aspirated material (e.g., the emetic masses, vaseline, gasoline) in quality etiol, a factor anaerobic microflora can act.
P. caused by various fungi, generally the sorts Candida meet. Increase of cases of this form of a disease is also connected with broad use of antibacterial agents. In 3 — 8% of cases of acute P. viruses are a cause of illness. Generally it is influenza viruses, is much more rare — a parainfluenza, adenoviruses, myxoviruses, picornaviruses, reoviruses or a combination of various viruses. On E. V. Ermakov (1979) observations, flu A1 was complicated by P. at 11,2% of patients, and flu A2 — at 14,9%. However primary intersticial influenzal P. proceeding at adults it is good-quality without infiltrative changes in a pulmonary parenchyma, by most of researchers it is not estimated as P., and is considered as intersticial reaction of a lung to an influenzal infection. Possibility of virus P. without participation of other microorganisms is disputed by many researchers; most of them considers an acute respiratory viral infection as one of the major contributing factors to emergence of acute P. which development is a consequence ekzo-and an endogenous bacterial infection.
In some cases the activator P. are chlamydias (see. Ornithosis ).
The mycoplasmal nature of acute P. authentically is established in 6 — 20%, in the conditions of the closed collectives sometimes to 52% of cases. At the same time at 70% of sick P., the caused Mycoplasma pneumoniae, participation in pathological process of viruses and microbic agents is found. Apparently, independent Mycoplasma pneumoniae value in development of pneumonia in adults is small and in most cases these microorganisms take part in development of inflammatory process as excite l and-assotsianty.
Acute P. can accompany and complicate various inf. diseases (whooping cough, measles, chicken pox, a tularemia, a brucellosis, a hay fever, a malignant anthrax, sap, plague, scarlet fever, salmonellosis, a typhoid) at which P. can be caused by the specific activator given inf. diseases or the joined bacterial or virus agents. Items can be caused also by helminths during their migration, napr, ascarids.
Depending on the infectious and parasitic agents who caused an acute pneumonia, A. P. Kazantsev (1979) divides pneumonia on: 1. Bacterial pneumonia: a) pneumococcal, b) staphylococcal, c) streptococcal, d) the pneumonia caused by other bacterial agents (Klebsiella, Pseudomonas, Neisseria, Escherichia, etc.), e) specific pneumonia at the general infectious diseases (a typhoid, salmonellosises, scarlet fever), g) pulmonary forms of zoonotic diseases (a tularemia, plague, a brucellosis, leptospirosis, a malignant anthrax, sap). 2. Viral pneumonia: a) influenzal, b) parainfluenza, c) adenoviral, d) respiratory and syncytial and virus, e) the pneumonia caused by other viruses (chicken pox, measles, herpes, etc.). 3. Ornitozny pneumonia. 4. Rickettsial pneumonia (pulmonary forms of a Q fever). 5. The pneumonia caused by a mycoplasma. 6. The pneumonia caused by fungi (Candidiasis of lungs, histoplasmosis of lungs, an aspergillosis, the Coccidioidosis). 7. The pneumonia caused by migration of helminths. 8. The mixed pneumonia caused by action of several etiological factors (virus and bacterial, virus mik about plasma and so forth).
Acute P.' emergence can directly be not connected with primary implementation of an infection. E.g., at P. from influence of volumetric and physical factors the infection joins for the second time. In such P.' etiology various injuries of bronchial tubes and lungs by physical or chemical agents and secondary infection with the microbes and viruses living in an organism, a thicket in a pharynx, upper airways and quite often being opportunistic are combined (staphylococcus, colibacillus, etc.).
Acute P. can arise at a gas poisoning of suffocating type, from steam inhalation of various irritating substances, at household poisonings hlorofosy and a thiophos (toxic P.). Aspiration even of small amounts of gasoline, kerosene, ligroin, oil, fats of mineral, plant or animal origin, and also gastric contents can lead to acute P. at alcoholic intoxication and during an anesthesia.
Often P. arises at a burn injury, especially burns of respiratory tracts. According to N. S. Molchanov, V. V. Stavskoy (1971),P. at burns of the II—IV degree is observed in 38% of cases. The «cold pneumonia» («perfigeration of lungs») described during the Soviet fpn-lyandskogo of the conflict and during the Great Patriotic War are known.
At use of radiation therapy there can be acute P. caused by radiation (a synonym beam pneumonia).
The medicinal allergy can be followed by an acute pneumonia. E. Ya. Severova (1969) observed acute P. at 7,3% of patients, and A. F. Bilibin (1974) — at 4,1% of patients with an allergy to pharmaceuticals.
The allergic P. known under the name «exogenous allergic alveolites» develop as a result of the damage caused by activation of immune mechanisms on effect of exogenous allergens. A role of exogenous allergens the most various substances (e.g. carry out, disputes of fungi, antigens of house dust, medicines, etc.), to-rye get to an organism in the inhalation way with inhaled air. The disease develops usually after long contact with a source of allergen, is shown by an indisposition, fever, a fever, and also cough and other symptoms characteristic of dysfunction of lungs (see. Exogenous allergic alveolites ).
The factors contributing to developing of an acute pneumonia
To emergence acute, especially focal contribute with P. various hron, diseases of lungs (hron, bronchitis, the Pneumoconiosis, bronchial asthma, a mucoviscidosis, nonspecific pulmonary syndromes at general diseases) and inborn defects of bronchial tubes and lungs. At all these diseases stability of a respiratory organs in relation to various inf is reduced. to agents. Smoking can also contribute to acute P.'s emergence, especially at smokers, patients hron, with bronchitis.
Aspiration of a foreign body, with the subsequent development of an atelectasis, with disturbance of drainage and ventilating function of an affected area of a lung, creates the conditions promoting P.'s emergence in a zone of an atelectasis. Cancer of a bronchial tube quite often is complicated by P. in a zone of defeat.
Dysfunction of external respiration in the postoperative period, especially after abdominal operations, connected with the oppressing effect of anesthetics, disturbance of mobility of a diaphragm, a hypodynamia, the phenomena of stagnation in lungs, creates favorable conditions for development of postoperative Items. Experience of the Great Patriotic War showed a significant role of an injury in P. Otmechalos's emergence increase in frequency of P. at wounds of a breast (18%), a stomach (35,8%), a skull (17,5%). After a craniocereberal injury of P. developed in the first days on the party opposite to wound that N. S. Molchanov and V. V. Stavskaya (1971) explain with neurohumoral mechanisms of their emergence.
Acute P.' emergence is promoted by inflammatory diseases of subordinate clauses (okolonosovy, T.) bosoms of a nose, at the same time nasal breath is broken that promotes accumulation of the infected secret in bronchial tubes. Patol, changes in paranasal sinuses with acute P. occur at patients by 2,5 times more often than at healthy, including sinusitis — by 3,6 times, bilateral antritises make 1/3 all defeats Highmore's (maxillary, T.) bosoms.
The dysfunction of an epiglottis which is quite often arising at epileptic seizures and other diseases of a nervous system contributes to P.'s development. Disorder of regulation of bronchial tubes and vessels of lungs, disturbance of a functional condition of the respiratory and tussive centers at patients with nevrol, diseases promote penetration of an infection and development of inflammatory process in lungs.
At a circulatory unefficiency, a long bed rest and forced situation (on one side or to back at myocardial infarctions, fractures, etc.) the weakened patients quite often have a stagnation in lungs, hypoventilation, is broken drenazhnat function of bronchial tubes that promotes emergence acute the Item. The inborn and acquired immunodeficiency (see. Immunological insufficiency ), multiple myeloma (see) also contribute to repeated P. U of the elderly and weakened people with the broken allocation of a bronchial secret and its delay in basal segments, with hypoventilation of lungs focal P. can develop, it is preferential in basal segments of lungs. Alcoholism contributes to P.'s emergence hron: croupous P. at suffering hron, is observed by alcoholism twice more often than at the persons who are not taking alcohol and proceeds much heavier. Treatment by immunodepressive and cytostatic means, reducing immunol, protective mechanisms, promotes acute P.
Zabolevayemost's emergence by acute P. depends on season. The greatest number of patients of croupous P. are the share of fall, winter and spring. Communication of emergence of acute P. with overcooling was noted by N. S. Molchanov and V. V. Stavska (1971). Negative influence of overcooling on a respiratory organs is connected not only with decrease in the general body resistance of an infection, but also with local changes — disturbance of drainage function of respiratory tracts owing to changes in a mucous membrane of a trachea and bronchial tubes.
three ways of penetration into lungs of activators P. Are possible: bronchogenic, apparently, the most widespread, hematogenous and lymphogenous. The bronchogenic way of penetration is observed at aspiration of a contagium. It is promoted by various inborn and acquired defects of elimination (removal) of agents: disturbances of mukotsiliarny clearance, defects of surfaktantny system of a lung (see Lungs, physiology, Surfactant), insufficient phagocytal activity of neutrophils and alveolar macrophages, changes of local and general immunity, tracheobronchial dyskinesia, disturbance of passability of bronchial tubes, pleural unions with disturbance of mobility of a lung, dysfunction of a diaphragm, decrease in a tussive reflex, etc. Along with int-rakanalikulyarny (on respiratory tracts) distribution of inflammatory process also contact distribution of microbes at the expressed exudation of serous liquid which carries bacteria is possible, getting through a time in interalveolar partitions. The combination of both types of distribution inf is quite often observed. process in lungs. Hematogenous distribution of microbes is proved in cases of a traumatosepsis. According to S. S. Vail (1946), in some cases P.'s emergence at wounded in a thorax lymphogenous spread of an infection in connection with limfangiity takes place.
In 1925 A. N. Rubel put forward the allergic theory of a pathogeny of acute P. which was widely adopted and recognition. According to this theory pneumonic process takes place two phases: reflex giperergicheskuyu and infectious and allergic. Under the influence of overcooling or other environmental factors immunobiological equilibrium between a macroorganism and microbes inhabiting a respiratory organs changes. Pulmonary fabric is sensibilized in relation to bacteria, as leads to development of the local and general allergic reaction which is the cornerstone
of P. Bolshinstvo of researchers considers that focal and croupous P.'s pathogeny is various. Unlike focal P. which is expression of norms - and gipergichesky reaction of an organism on inf. the agent, croupous P. is considered as manifestation of giperergichesky reactivity. The sensitization to these or those microorganisms is available both at croupous, and at focal P., however the level of specific immunity is higher at croupous P.'s patients that is connected with more considerable antigenic irritation and a host defense. According to V. V. Nikolayevsky (1979), preservation of a sensitization to microbic agents and after treatment is characteristic of patients with a long current of acute P. that can promote maintenance of inflammatory process in lungs.
In the analysis of a condition of T - and V-systems of immunity (see. Immunity ) the certain changes connected with features a wedge, currents of the Item are revealed. The smallest changes of these systems are noted at patients with a favorable current of focal P. V cases of a long current of focal P. the maintenance of T-cells, their functional activity and amount of immunoglobulins in blood serum decreased. At croupous P.'s patients the expressed changes of both systems of immunity which are shown considerable change of number of T - and V-cells (reduction of T-cells and increase in B-cells), were observed by reduced reaction to phytohemagglutinin and high content of immunoglobulins. The analysis of frequency of circulation of cell-bound immune complexes in blood of patients allowed to establish that at croupous P. cell-bound immune complexes are available in an acute phase of a disease almost for all patients, at focal — is slightly more rare. It was suggested that circulation of cell-bound immune complexes in blood of patients of acute P. within two-three weeks from the beginning of a disease testifies to intensity of the immune processes directed to bystreyshy removal of antigen from an organism of the patient and promotes more bystry recovery. Lack of cell-bound immune complexes at the beginning of a disease in the presence of a long antigenemiya can be considered as manifestation of insufficiency of immunity. At patients with a long current of acute P. dominance of the antigens circulating in blood over antibodies and considerable changes in system of a complement is noted. It is suggested that at absence a wedge, effect in the course of treatment acute P.'s patients almost always have expressed autoimmune changes or sharp oppression of mechanisms of nonspecific reactivity.
Acute P.'s emergence, features of its current and an outcome substantially depend on a condition of mechanisms of nonspecific protection of bronchial tubes and lungs, to-rye interfere with hit in airways and lungs of microbes, viruses, foreign debris and clear a respiratory organs of the got activators, dust, etc. So, disturbance of closing of an entrance to a throat with an epiglottis, an insufficient smykaniye of phonatory bands, a reduced tussive reflex, disturbance of motor function of bronchial tubes, the expressed bronchospasm or obturation of bronchial tubes promote P.'s emergence, worsen its current, creating conditions for its transition in hron, a form. A specific place in acute P.'s pathogeny is held by dysfunctions of a ciliate epithelium of bronchial tubes, change of chemical structure and rheological properties of a bronchial secret (see. Bronchial tubes, physiology ). The reduced and diskoordiniro-bathing function of cilia lowered or the increased viscosity and the elasticity of a bronchial secret increased or the reduced its quantity lead to decrease in mukotsiliarny clearance and progressing of acute P.'s patients by acute P. U cellular mechanisms of anti-infectious protection of bronchial tubes and lungs are broken: phagocytal activity of alveolar macrophages and neutrophils is reduced that leads to intracellular parasitizing of microbes and viruses, dissimination and progressing of inflammatory process in lungs. These disturbances can precede acute P., especially at persons, many years of smokers, with hron, bronchitis, a pneumosclerosis, but they can develop also in the course of formation of an inflammation in bronchial tubes and lungs. It is especially characteristic of an acute respiratory viral infection which oppresses humoral and cellular mechanisms of immunity, breaks function and a structure of a ciliate epithelium, drainage function of bronchial tubes and mukotsiliarny clearance. Viruses, getting into epithelial cells of upper respiratory tracts and bronchial tubes, cause their necrosis. The struck epithelial cells are exfoliated, and the deepitelizi-rovanny surface of airways, especially at the broken mukotsiliarny clearance and reduced phagocytal activity of neutrophils and alveolar macrophages, is infected and inflames that the Item creates conditions for emergence and progressing acute.
According to A. A. Korovin (1976), patofiziol, virus influenzal P.' mechanisms are connected with disturbance of filtrational and secretory function of pulmonary fabric under the influence of influenzal intoxication. The strengthened absorption from blood of toxic products is followed by damage of a vascular membrane and emergence of nonspecific proliferative reaction to an interstitium. At the malignant course of flu because of a hyperpermeability of blood vessels patol, process quickly passes to alveoluses, causing hemorrhagic the Item.
The influenza virus and bacterial antigens can reduce local resistance of a lung to an infection, suppressing phagocytal activity of neutrophils. Staphylococcal antigen and an influenza virus inhibit phagocytosis in an acute phase P. Perhaps, incompleteness of phagocytosis is one of the reasons of insufficient efficiency of antibacterial therapy
of P. Uroven of a lysozyme, a complement and beta lysines the acute period of P. at most of patients considerably reflects character of a current of P. V in blood increase in their level is noted that reflects mobilization of nonspecific protective mechanisms. During the subsiding a wedge, manifestations of an acute inflammation in lungs at patients different levels of these factors of nonspecific protection were revealed: from datum level of all three indicators at patients with a favorable current of acute P. before moderate and sharp oppression — at its long current.
At acute P.'s patients, according to Baryeti and Gaydos (M. of Bariety, A. Gajdos, 1964), note compensatory and adaptation changes in the maintenance of the microelements which are taking part in transport of oxygen, tissue respiration, processes of desintoxication and a reparation. At the height of acute P. concentration of iron in an organism is increased that can be regarded as the defense reaction directed to normalization of oxidation-reduction processes. Increase in activity of a karboangidraza in blood and increase in content of zinc in an organism probably are also the defense reaction connected with the arisen deficit of oxygen; increase in content of cobalt at acute P.'s patients, apparently, has protective and adaptive value and promotes stimulation of an immunogenesis. The expressed disturbances of exchange of copper, its endogenous deficit observed at acute P. are caused, probably, by the fact that copper is the catalyst of many biol, processes and is a part of a number of oxidizing enzymes. All these changes can be considered as one of links of a pathogeny acute P.
Odnim from mechanisms of a pathogeny of acute P. increase in permeability of capillaries is that is especially expressed at patients of the croupous P. complicated by abscessing. According to increase in permeability of capillaries at P. activity of lizosomalny enzymes increases in blood serum that is connected with increase in permeability of lizosomalny membranes under the influence of bacterial toxins. In the course of treatment permeability of capillaries decreases.
Inflammatory process in lungs at acute P.'s patients leads originally to disintegration, and then synthesis of collagen what increase in content of oxyproline in blood and urine according to the level of activity of inflammatory process in lungs testifies to. During the subsiding of inflammatory process further increase in oxyproline is explained, apparently, by strengthening of processes of a new growth of connecting fabric.
At acute P.'s patients local strengthening haemo coagulating and oppression of fibrinolitic activity is noted that is one of the mechanisms promoting an otgranicheniye of a zone of an inflammation. At acute P. in blood the level of fibrinogen increases, its fibrinolitic activity decreases; at the same time concentration of free heparin increases that leads to compensatory hypocoagulation. At some patients with a heavy current of acute P. the fibrinosis is combined with thrombocytopenia. It is connected with intravascular aggregation of thrombocytes and development of the platelet embolisms, at a part of patients which are coming to the end with development of local hemorrhagic necroses of pulmonary fabric. Allocation by the collapsing thrombocytes of serotonin and thromboplastic substances strengthens a vasospasm and loss of fibrin.
The neurotrophical frustration arising in lungs and bronchial tubes exert impact on P.'s emergence. Immediate effect of contagiums on various parts of the nervous system at their hematogenous distribution is established and influence of irritations of the vegetative and other highest centers of a nervous system transferred on interoretseptorny ways at injury by pathogenic microorganisms of a mucous membrane of upper airways and bronchial tubes. According to K. A. Shchukarev (1953), in acute P.'s development an important role is played by impact of a bacterial flora on the interoretsep-even device of respiratory tract, with emergence of disturbances in bronchial tubes and lungs of the reflex nature.
Experimental pneumonia — artificially caused at a lab. animals pneumonia. It is reproduced for studying of various parties of a pathogeny and patol, P.'s anatomy of the person, and also for testing of various means for its prevention and treatment.
Acute inf. process in a respiratory organs rather easily is caused by introduction to an animal of various microorganisms, usually pathogenic for the person (viruses, bacteria, mycoplasmas, fungi and protozoa), aerosol, intranasal, intratracheal and an intrabronkhi-alny way. At introduction of the most pathogenic microorganisms animal, sensitive to these activators, inf. process in lungs arises rather easily without additional influences. In this case on the manifestations it is identical to P. of the person.
At introduction of low-pathogenic activators or a suspension of microorganisms, pathogenic for the person, to an animal, unreceptive to them, patol, process in a respiratory organs is slight. It is caused by the fact that at normally functioning protective mechanisms of a bronchial tree the most part of bacteria and fungi is rather easily brought out of respiratory tracts. In this regard it is necessary or to enter very large number of microorganisms, or to add any substance complicating removal of microorganisms, napr, polyvinyl alcohol, arabic gum etc. Conditions for acute P.' emergence of the same etiology can be created by preliminary injury of a mucous membrane of respiratory tracts by chemical substances or physical. factors. Perhaps also disturbance of drainage mechanisms of a bronchial tree by introduction on a long term to respiratory tracts of an animal foreign body, binding of a bronchial tube etc. Disturbance of drainage mechanisms of a bronchial tree, and also other changes of a respiratory organs promoting P.'s emergence are observed at various damages of the central or peripheral nervous system at animals. In all these cases P.'s development is connected with penetration of a bacterial flora from an oral cavity, a nasopharynx, upper respiratory tracts in respiratory departments of lungs and the subsequent its reproduction.
For receiving the most expressed P. it is possible to use additional impacts on a macroorganism (radiation, administration of hormones, in particular corticosteroids, etc.). The role of these factors is shown in relation to virus, bacterial P. and a pneumocystosis clearly. At mature animals without additional influences experimental P. proceeds as local process more often; at newborns, and also at suppression of lymphoid system or at especially high pathogenicity of the activator — as a generalized infection with defeat of many bodies, first of all kidneys, a liver and a brain.
Thus, in an experiment it can be caused as the defeat of a respiratory organs caused by high-pathogenic activators, reminding primary P. of the person at exogenous infection, and caused by low-pathogenic microflora similar with autoinfektsionny. In the latter case various previous changes as respiratory organs, and extra pulmonary have major importance (nervous, immune and other systems) that is observed at the person at secondary
P. P.' development can be caused in an experiment by introduction to pulmonary fabric of chemical substances (toxic agents, acids, lipids etc.) or the substances possessing the damaging action connected with temperature (hot water etc.). It is natural that defeats in these cases are not identical P. at the person, nomogenous, and can serve only for studying of some parties of their pathogeny.
On localization and volume of damage of lungs distinguish the following forms P.: share, or lobar, P. — at defeat of the whole lung lobe (in this case apply the term «lung fever»); focal P. — at defeat of a part of a segment, the whole segment or several segments of lungs. Because at focal P. also bronchial tubes usually are surprised, as a synonym the term «bronchial pneumonia» is used. Inflammatory process at focal P. is more often localized in the lower lung lobes, especially on the right, sometimes happens bilateral. In case of merge of a number of the centers an impression about defeat of the whole share is made (tsvetn. fig. 1) that pseudo-lobar P. is designated by the term (e.g., at P. caused by Friedlander's stick). At localization patol, changes in easy P.'s stroma call intersticial or interstitial; such changes, however, seldom happen inflammatory true, as a rule, these are limfogistiotsitarno-plazmotsi-tare, the perivascular and peribronchial infiltrates which are local manifestation immunol are more often. reactions. At defeat in the basic of respiratory departments of lungs pathoanatomical allocate alveolites — the form P. which is characterized by the expressed changes of alveolotsit.
In addition to differentiation in sootvot stviya with localization and volume of changes, P. are classified depending on an etiology (virus, bacterial, mycoplasmal p etc.), the nature of morphological manifestations of inflammatory reaction at the time of the research (leukocytic, fibrinous, serous etc.).
Macroscopically bacterial P.'s centers can have different character depending on a stage of process. At early stages of a disease from a cut surface a large amount of rather turbid foamy liquid flows down; clearly there are no defined centers of consolidation yet. In the heat of process the airless centers of consolidation from several millimeters to tens centimeters in size in the diameter, most often gray color are visible. In case of impurity to exudate of fibrin a cut surface of the pneumonic center fine-grained, in other cases — smooth. If to exudate erythrocytes are added, P.'s centers become gray-red, red and even dark red. At late stages of a disease at a rassasyvaniye of an exudate lungs gain usual color, however for some time remain flabby.
In the most part of cases alterativny the component of an inflammation is expressed poorly. In the beginning only the plethora of textural features of a lung in which bacteria are and breed is noted. Soon there is clearly an expressed phase of exudation which begins with sweating in a cavity of alveoluses of a blood plasma — serous liquid; then the escalating amount of neutrophilic leukocytes joins it. At receipt in the center of an inflammation of coarse-dispersion blood proteins there is a loss of fibrin (fig. 1). Proliferative changes in the majority of acute bacterial P. are expressed slightly. In that case when bacteria, in particular staphylococcus or streptococci, form a significant amount of toxins, there is a necrosis of cells of exudate and pulmonary fabric, permeability of blood vessels sharply increases.
Depending on a type of the activator of bacterial P. character morfol, changes significantly changes.
At pneumococcal P., in particular at its heaviest option — croupous P., process begins with development of the small center of the serous inflammation which is located usually in back or in posterolateral departments of lungs where pneumococci contain (fig. 2, a). Patol. process extends first of all in the contact way and very quickly takes a considerable part of a lung — the whole share and even several share. Macroscopically the lung is increased in volume, its fabric is sharply edematous and full-blooded. These changes carry the name of a stage of inflow.
Further in exudate the amount of neutrophilic leukocytes increases, quite often along with fibrin serous and purulent exudate gradually fills gleams of alveoluses (fig. 2, b); the last reach at the same time the sizes, to-rye they have on a breath; pneumococci are englobed by leukocytes at this time and disappear. During the progressing of a disease more expressed disturbances decide on border on not changed fabric of body. On a section the lung of gray color with a fine-grained or smooth surface, on a consistence reminds a liver (a gray gepatization of a lung). At patients with a hyperpermeability of vessels a large number of erythrocytes therefore the lung gains gray-red or dark red color (a red gepatization of a lung) joins exudate.
During recovery there is a rassasyvaniye of an exudate; macroscopically during this period lungs are characterized by the lowered lightness and elasticity.
At focal pneumococcal P. similar changes, but with smaller degree of manifestation are noted.
Staphylococcal P. has a number of features. At early stages of a disease around accumulations of stafilokokk there is serous or serous and hemorrhagic exudate with small nefiat 33 BME impurity, t is more often. 19 1495 trofilny leukocytes. Further the centers of an inflammation gain characteristic zonal structure. Their center contains many stafilokokk, there are necrotic changes (fig. 3, a), around sites of a necrosis leukocytes collect, to-rye englobe staphylococcus. In peripheral sites of the pneumonic center of an alveolus contain fibrinous or serous exudate, in Krom there are no bacteria. At heavy disease (staphylococcal destruction of lungs) in places of accumulations of stafilokokk on a considerable extent there is a destruction of pulmonary fabric. Macroscopically in lungs the multiple small, quite often merging centers abscessing the Item come to light. They red or dark red color with yellowish-gray sites of fusion in the central part. Later here the abscesses accepting sometimes hron, a current form. At distribution inf. process on a pleura and its destructions there is a message between an abscess cavity, bronchial tubes and a pleural cavity, develops pyopneumothorax (see). Sometimes as a result of destruction of a wall of a bronchial tube and penetration of air into an interstitium there is intersticial emphysema.
Streptococcal P. has many common features from staphylococcal. However in hard cases it is characterized by bigger degree of a necrosis of cells of exudate and pulmonary fabric, and also more expressed lymphogenous generalization of process.
The necrosis of cells of exudate and pulmonary fabric, especially in the center of the pneumonic center where accumulations of bacteria are visible is also typical for P. caused by a sinegioyny stick. On the periphery of the center the expressed disturbances of blood circulation are noted.
The centers of P. caused by Friedlander's stick can have share character. Exudate, and also the phlegm allocated to patients have muciform character as Friedlander's stick has mucous capsules; because of the small content of fibrin a cut surface of a lung usually smooth. Also formation of extensive infarktoobrazny necroses of pulmonary fabric in connection with thrombosis of vessels of a lung is characteristic. Macroscopically pneumonic centers of grayish-pink or are more rare than gray color, is frequent with red sites of hemorrhages.
The acute P. caused by other bacteria (a stick of an influenza, escherichias) morphologically remind focal pneumococcal
Local complications of acute bacterial P. (abscess, gangrene of a lung) are most often caused by stratification of consecutive infection (staphylococcal, fuzospirokhetozny, etc.).
If bacterial P. comes to an end with recovery, there is a rassasyvaniye of exudate — at first serous liquid, and then cells. Leukocytes break up and are partially englobed by alveolar macrophages, to-rye, besides, take part in a rassasyvaniye of fibrin. A part in it is played also by proteolytic enzymes of leukocytes. Further alveolar macrophages as well as other components of exudate, are brought out of lungs with a phlegm or on limf, to ways.
Defeat of an epithelium of a mucous membrane of respiratory tracts and alveolotsit is most characteristic of P. at acute viral respiratory infections (flu, a parainfluenza, respiratory and syncytial and adenoviral). Intracellular reproduction of viruses is resulted by damage of these cells with development of dystrophic and necrotic changes. At the favorable course of a disease in several days in them there are reactive changes in a type of consolidation of cytoplasm around the site of damage — fuchsinophil inclusions) (fig. 3,6). Along with it moderately expressed inflammatory changes of a mucous membrane of respiratory tracts with dominance of disturbances of blood circulation in the form of a plethora of vessels, sweating of serous liquid in a gleam of alveoluses and small hemorrhages are observed. Also small accumulations neutrophylic, leukocytes and alveolar macrophages are noted. As a result of disturbance of education surfactant (see) there are small atelectases (see), mostly incomplete — diste-lektaza (fig. 3, c) that compensatory focal expansion of alveoluses in other sites easy is especially expressed at children of early age, and also. Macroscopic changes at the same time are insignificant and consist in the basic in a catarrh of respiratory tracts and education in lungs of small sites of consolidation of dark red or cyanotic color. The most characteristic feature of virus P. is giant-cell transformation of the struck epithelial cells.
At flu the struck cells increase in volume a little, in case of rejection turn into the large one-nuclear cells considerably exceeding by the sizes ordinary alveolar macrophages (fig. 3, d). Subauriculate growths, sosochkovidny outgrowths of a mucous membrane are typical for a parainfluenza. At a respiratory and syncytial infection they are even more expressed. At adenoviral P. there is a formation of large one-nuclear cells (giant-cell metamorphoses of alveolotsit), and also the expressed accumulation of exudate (fig. 3, e). At recovery there is a regeneration of an epithelium of respiratory tracts. In the beginning the undifferentiated flattened epithelial cells which are located usually in several rows come to light (fig. 3, e), to-rye further are differentiated.
Virus P. is followed by a circulatory disturbance and dystrophic changes in other bodies. At the weakened patients generalization of an infection with reproduction of viruses out of lungs is possible.
The changes similar with morfol, changes at virus P., are observed at mycoplasmal P. — respiratory mycoplasmosis (see. Mycoplasmal infections ). For it also typically intracellular reproduction of the activator (fig. 4) though it is possible also extracellular. Defeats have desquamative P.'s character at very moderate macroscopic changes (tsvetn. fig. 3 — 5; 6 — 10).
Pneumomycoses (see), including. Candidiasis of lungs, differ from bacterial P., as a rule, hron, a current. In this regard, in addition to acute inflammatory changes of the lungs reminding bacterial education inf is observed. granulomas (see. Granuloma ).
Pneumocystic P. (see. Pneumocystosis ) differs from all other P. in accumulation of a large number of activators in alveoluses in the absence of exudative reaction and more expressed, preferential plazmotsitarny infiltration of interstitial fabric.
The clinical picture
the Lung fever begins, as a rule, suddenly, often with a tremendous fever, there is a stitch amplifying at deep breath, cough and also short wind, dry cough, feeling of weakness, a headache; temperature rises to 39 — 40 °. The patient is a little excited, sometimes raves. The stethalgia at breath and cough happens such strong that the patient is forced to hold the breath and to suppress cough. At P.'s localization in basal segments of lungs and involvement in process of a diaphragmal pleura pain can irradiate in an abdominal cavity or be localized there, simulating an acute disease of bodies of a stomach (an acute appendicitis, perforative peritonitis, etc.). In the first days of a disease symptoms, characteristic of croupous P., appear: a hyperemia of cheeks, sometimes it is preferential on the one hand, the relevant party of an inflammation, inflating of wings of a nose at breath, herpetic rashes on lips. Elderly people and persons with pathology of cardiovascular system have a cyanosis of lips, cheeks, lobes of ears, trailer phalanxes of fingers of hands. Shallow breathing, is speeded up to 30 — 40 in 1 min. On the party of defeat lag of a thorax at breath and participation in breath of intercostal muscles is noted. With 2 — the 3rd day the scanty viscous vitreous mucous phlegm, sometimes with impurity of blood begins to separate. Further, in 2 — 3 days, the phlegm gets a brown-red, rusty shade. The quantity of a phlegm usually does not exceed 50 — 100 ml a day. In the days preceding P.'s permission the quantity of a phlegm increases, it becomes more liquid and easier separates.
Physical signs at croupous P. depend on a stage and prevalence of process. In the first day of a disease at a typical current of croupous P. it is possible to note a peculiar tympanic shade of a percussion sound over the struck lung lobe that is connected with reduction of elasticity of pulmonary fabric because of the beginning inflammatory hypostasis of a zone of defeat. In the course of accumulation of exudate in alveoluses, reduction of lightness of affected areas and their consolidation the tympanic shade of a percussion sound gradually is replaced by obtusion. Respiratory noise at the very beginning of a disease remains vesicular, but is a little weakened because of shallow breathing in connection with strong pain. By the end of the first, the beginning of second day at auscultation at height of a breath, and sometimes only after cough crepitation (crepitatio indux) is listened. Sometimes because of frequent and shallow breathing it is not possible to listen to crepitation at croupous P.'s patients. Except crepitations (see) over a zone of defeat it is possible to listen small-bubbling wet and dry rattles (see). Voice trembling (see) and bronchophony (see) at the initial stage of a disease do not change. In 2 — 3 days in process of emigration of uniform elements of blood through a vascular wall and accumulation of fibrin in alveoluses, upon transition to a stage of a gepatization, obtusion becomes more intensive, excursions of the lower bound of a lung on the party of defeat decrease, and in the field of obtusion bronchial breath is listened. With the advent of bronchial breath initial crepitation disappears. In a stage of a gepatization strengthening of voice trembling and a bronchophony is defined, the pleural rub is quite often listened (see. Respiratory noise, table ).
During the fluidifying of exudate and resuming of aeration of alveoluses the dullness decreases, bronchial breath weakens and again crepitation (crepitatio redux) appears. In the course of a rassasyvaniye of exudate bronchial breath becomes rigid, and then vesicular (see. Vesicular breath ), disappear the shortened percussion sound, the strengthened voice trembling and a bronchophony. Sometimes in a stage of permission over a zone of pneumonic infiltrate ringing small-bubbling rattles appear.
Changes in lungs at croupous P.'s patients usually are followed by dry pleurisy, there is vypotny pleurisy much less often (see). In this regard croupous P. is called also a pleuropneumonia. Besides, changes in a healthy lung, a cut emfizematozno sometimes are found extends.
From cardiovascular system from the very beginning of a disease the tachycardia reaching 100 — 120 blows in 1 min. is noted, and the long increase of pulse which is followed by decrease in the ABP is pointed to the heavy current croupous by P. Inogda the extent of relative cordial dullness to the right at the expense of the right auricle and a right ventricle increases, and the emphasis of the second tone on a pulmonary trunk due to build-up of pressure in a small circle of blood circulation appears.
At croupous P. there are functional changes of digestive organs. Nausea, vomiting, lack of appetite and a delay of a chair can disturb the patient. Language at the same time dry, is laid over, the stomach is blown up. At a heavy current of croupous P. sometimes there are abnormal liver functions, there is an ik-terichnost of scleras and skin, the liver increases in sizes, becomes painful.
Changes from a nervous system are noted at all patients of croupous P. and depend on weight of its current. At an easy current of croupous P. they are shown by a headache, sleeplessness, and at a severe disease excitement, nonsense appear. At the persons having alcoholism symptoms of acute psychosis develop: patients jump from a bed, try to leave, jump out in a window. Sometimes from the very beginning of a disease at patients Meningeal symptoms develop (see. Meningism ): stiff neck, Kernig's sign, hyperesthesia of skin, stupefaction, severe headache, etc.
Duration of the feverish period, duration and expressiveness of subjective and objective signs are very variable and depend on a type of the activator, reactivity of an organism of the patient and treatment. Body temperature, having reached in several hours of high figures, there can be high several days, then critically decrease (during 12 — 24 hours) or lytically (for 2 — 3 days).
Despite early purpose of effective antibacterial therapy, croupous P. keeps a number of symptoms, typical for this disease: considerable weight of a current, massive segmented, sometimes lobar damage of lungs, frequent involvement in inflammatory process of a pleura (pleuropneumonia), a high leukocytosis with a neutrocytosis and a deviation to the left. At the same time croupous P. after introduction to a wedge, practice of antibiotics began to proceed much easier. Intoxication is less expressed, character of a temperature curve changed: temperature of constant type with critical falling, characteristic of classical option of a current of croupous P., occurs only at 1/3 patients, the lytic type of decrease in a tekhmperatura with an average duration of feverish period of 9 — 10 days prevails, and at certain patients during recovery repeated rises in temperature are possible. Less expressed to steel Physical signs of croupous P.: every fifth patient has no shortening of a percussion sound, bronchial breath and crepitant rattles, recurrence in emergence of the physical signs reflecting change characteristic of croupous P. morfol, changes in lungs. There are such heavy displays of intoxication as acute vascular insufficiency, nonsense, hallucinations less often.
In blood at croupous P. the leukocytosis, hl is noted. obr. at the expense of neutrophils, to-rye make 80 — 90%, the maintenance of band neutrophils increases to 6 — 30%, sometimes a deviation to the left to young forms and even myelocytes. Toxic granularity of neutrophils is characteristic; the inclusions which are painted in blue color — Knyazkov's little bodies — Business appear in more hard cases in their cytoplasm (see. Leukocytes ). The maintenance of eosinophils and basophiles decreases, comes to light a moderate monocytosis. At a heavy current of croupous P. eosinophils completely disappear from blood; the lymphopenia and thrombocytopenia which is combined with increase in level of fibrinogen, coagulability of blood at the same time are noted raises (these changes at patients with the expressed hemorrhagic syndrome are clearer). ROE is considerably accelerated.
At croupous P. all indicators characteristic of an acute phase of an inflammation are sharply changed (C-reactive protein appears, the ratio of protein fractions of blood changes, contents sialine to - t, a gaptoglobina, etc. increases). In a phlegm, especially prior to antibacterial therapy, it is possible to find pneumococci. At a research of urine the proteinuria, sometimes a cylindruria and a microhematuria quite often comes to light that is caused by toxic defeat of a parenchyma of kidneys.
Acute inflammatory process of e of lungs is followed by increase in glucocorticoid and mineralokortikoidny activity of bark of adrenal glands. The maintenance of free 17 oxycorticosteroids in a blood plasma and Aldosteronum in daily amount of urine is considerably increased in an acute phase P., in the course of subsiding of an inflammation it gradually decreases.
Croupous P.'s patients have considerable dysfunctions of breath: vital capacity of lungs, maximal ventilation of lungs are reduced, the minute volume of breath and the relation of residual volume to the total capacity of lungs are increased. At 2/3 patients distensibility of lungs and the maximum rate of volume flow of a breath and exhalation decrease. Disturbances of bronchial passability at acute P. come to light at 38 — 72% of patients, at 75% of patients the hidden disturbances of bronchial passability are possible. According to N. S. Molchanov and V. V. Stavskaya (1971), as a rule, there is no accurate dependence between changes of ventilating ability of lungs and kliniko-morphological features of a disease.
Changes on an ECG depend on age of the patient and a condition of a myocardium to a disease. At elderly people at croupous P.'s disease decrease in a voltage, a negative tooth of T in II and III assignments, the shift of an interval of S T below isoelectric level is sometimes noted. In hard cases there can be a disturbance of a cordial rhythm because of disturbance of conductivity, premature ventricular contraction and even a ciliary arrhythmia.
Focal pneumonia. Focal P.'s clinic depends on an etiology, the contributing factors, age of the patient, his state, associated diseases. As a rule, focal P. begins sharply, body temperature increases to febrile figures, there is cough with a phlegm which has serous character in the first days of a disease. Perhaps subacute beginning with a prodromal stage and subfebrile temperature. Most often patients at the same time complain of cough with a mucous or slime-hundred-purulent phlegm, sometimes with impurity of blood (in the form of streaks). Patients are disturbed various character and intensity of a stethalgia and under a shovel, by the general weakness, headaches, sometimes short wind.
Degree of respiratory insufficiency depends on the size of the pneumonic center, existence accompanying bronchitis of emphysema of lungs and diseases of cardiovascular system. Bolp in a breast are often connected with developing of pleurisy.
At timely begun and correctly picked up treatment duration of fever at most of patients does not exceed 3 — 5 days. At elderly people and the weakened patients focal P. can proceed at a standard and subfebrile temperature.
Physical data at focal P. differ in big variability and depend on an arrangement (superficial or deep) and prevalence of inflammatory process (tab. 1). The centers of the small sizes located it is central or is superficial, are not followed by changes of voice trembling and a percussion sound. Irrespective of the size of the centers in the presence of bronchitis or the accompanying pleurisy dry rattles and a pleural rub can be listened.
Increase in number of patients with erased and even an asymptomatic current focal the Item is noted.
At focal P. the moderate leukocytosis is noted only at a half of patients. The accelerated ROE, reduction or disappearance of eosinophils are more characteristic neutrophylic shift to the left. At the expressed phenomena of intoxication the proteinuria, a microhematuria and a cylindruria can be observed. At patients from focal P. the vital capacity of lungs and maximal ventilation are reduced, the minute volume of breath, the relation of residual volume to the total capacity of lungs are increased. 23% of patients have no convincing wedge, focal P.'s signs, and the diagnosis is made on the basis rentgenol, data.
Features of a clinical course of an acute pneumonia of various etiology. At the description of features a wedge, acute P.'s currents depending on etiol, a factor it is reasonable to allocate pneumonia of an infectious and noninfectious etiology.
Pneumonia of an infectious etiology can be caused by bacteria, viruses, fungi and to accompany various inf. to diseases.
Pneumococcal P. most often proceeds as croupous or focal P., a wedge which characteristic is stated above.
The item, Haemophilus influenzae called by a stick, quite often arises at patients with hron, bronchitis, bronchiectasias, malignant tumors, and also at patients with flu. At the same time hl are surprised. obr. lower shares of lungs. The centers of defeat can merge, taking all share. Peribronchial spread of an infection, defeat of an epithelium of an epiglottis, bronchial tubes and bronchioles is characteristic that is followed by a severe cough. The leukocytosis with a deviation to the left is observed approximately at a half of patients.
Staphylococcal P. (staphylococcal destruction of lungs) with a heavy fulminant current is observed at children, elderly people, and also at the patients weakened by various infections or accompanying hron, by diseases. Primary bronchogenic staphylococcal P. begins sharply, often against the background of or after flu. There are a high temperature, the consciousness sometimes confused, short wind, thorax pain, cough with a gnoynokrovyanisty phlegm. Weight of a current, expressiveness of an asthma and cyanosis often do not correspond to originally revealed size of the inflammatory center in a lung. Against the background of a dullness and the weakened vesicular breath over a zone of defeat wet small-bubbling rattles soon begin to be listened. Staphylococcal P.'s feature is early (on 2 — the 3rd day of a disease) emergence thin-walled, free of an exudate, the inflated cavities. Further there are necrotic cavities with a fluid level, septic fever, accrues intoxication, the purulent phlegm is allocated. The configuration and number of necrotic cavities in a lung can quickly change. Quite often there is a break of a purulent cavity in a pleural cavity with formation of a pyopneumothorax.
At secondary hematogenous staphylococcal P. the disease proceeds without expressed a wedge, symptoms in the beginning. Later a nek-swarm time the condition of the patient considerably worsens, appear high fever with tremendous oznoba, short wind, thorax pains, dry cough, accrues respiratory insufficiency (see). At auscultation the weakened vesicular breath alternates with amphoric, wet rattles are listened. The pneumorrhagia and break of suppurative focuses in a pleural cavity with education is quite often observed pyopneumothorax (see).
Streptococcal P. meets seldom and in most cases is a complication of measles, whooping cough, flu, and also various acute respiratory or hron, diseases. Bronchogenic spread of an infection leads to emergence of the small pneumonic centers within one segment and to bystry spread of an infection on all lung with formation of the drain centers (tsvetn. fig. 2). Hl are surprised. obr. lower shares of lungs. Streptococcal P. begins sharply with the fever, repeated oznob expressed to intoxication, stitches and cough with department liquid with streaks of blood of the phlegm containing a large number of streptococci. The disease in 50 — 70% of cases is complicated by vypotny pleurisy. Symptoms of pleurisy appear on 2 — the 3rd days of a disease. The liquid serous or serous and hemorrhagic exudate contains a large number of microorganisms. Auskultativny symptomatology scanty. The dullness is quite often caused by vypotny pleurisy. The high leukocytosis with the expressed deviation to the left is characteristic. In 10 — 15% of cases bacteremia is found.
The presumable diagnosis of streptococcal P. can be made at patients at whom focal P. quickly was complicated by vypotny pleurisy. This diagnosis is confirmed by detection of streptococci in a phlegm and becomes undoubted at release of pure growth of a streptococcus from blood or from pleural liquid. Retrospectively the diagnosis can be confirmed on dynamics of credits
of streptolysin O. P., caused by Klebsiella pneumoniae stick, develops at elderly people more often, and also at alcoholics. The heavy course, progressing of inflammatory changes with distribution on a lung lobe, developing of abscesses of a lung (see) and empyemas of a pleura are characteristic (see. Pleurisy ).
The item, caused by a pyocyanic stick (Pseudomonas aeruginosa), occurs preferential at the weakened patients after heavy operations, and also at persons, is long and inexpedient treated by antibiotics. The disease proceeds hard, with tendency to dissimination and abscessing, quite often becomes complicated piogshevmotoraksy. The diagnosis is confirmed on the basis of detection of the activator in tracheobronchial contents.
Collibacillary P. in the 70th yuda began to meet considerably more often. The acute P. caused by colibacillus develops generally at patients with malignant tumors, a diabetes mellitus, a heart and renal failure, serious illnesses of a nervous system, a pneumosclerosis. Such P. promotes emergence prolonged treatment by corticosteroids, anti-metabolic means, penicillin, tetracycline or the combined treatment by antibiotics. The disease begins sharply or gradually. Sometimes first manifestation ostroprotekayushchy collibacillary II; is collapse (see). More often the lower shares of lungs are surprised, at the same time fever, cough are noted. The phlegm of patients contains a large amount of colibacilli, bacteremia occurs at 15 — 20% of patients. Abscessing comes seldom.
The item, caused by Proteus (Proteus sp.), begins always imperceptibly, proceeds with moderate fever, an insignificant leukocytosis, often abs tsedirut.
Viral influenzal pneumonia depending on terms of emergence of P. after flu, divides allocations from a phlegm and washout from bronchial tubes of these or those viruses and bacteria, existence in blood serum of antiviral and antimicrobic antibodies and dynamics of their credits on virus (primary influenzal), and also virus and bacterial or bacterial postgrippal (secondary influenzal).
Primary influenzal P. is characterized bystry, within several hours, by temperature increase, the expressed symptoms of intoxication, a severe headache, dizziness, all body pain, especially in muscles of hands and legs, an adynamia. Sometimes patients feel a congestion and dryness in a nose, a pharyngalgia during the swallowing. Cough dry or with a small amount of a serous phlegm in which sometimes contains dtrimes blood. There can be nasal bleedings. The expressed asthma with diffusion cyanosis is characteristic.
Physical data differ in a big variety and variability.
At percussion often define symptoms of acute swelling of lungs: tympanites, low arrangement of edges of lungs, reduction of absolute cordial dullness. Define small shortening of a percussion sound according to the invaded zone and expansion of a root of a lung on the struck party. At auscultation breath rigid, unstable scanty dry rattles are listened, sometimes there is a lot of dry and wet rattles. In certain cases percussion and auskultativny signs are expressed poorly or are absent. Often between a wedge, and rentgenol, influenzal P.' signs observe discrepancy. So, at expressed rentgenol, signs of pneumonic infiltration there are no its Physical manifestations or, on the contrary, at patients with clinically expressed P.'s signs roentgenoscopic and radiographic define only small expansion of radical shadows and lag of excursions of a diaphragm. According to N. S. Molchanov (1971), is more often than others back segments of upper shares, apical and back basal segments of the lower shares are surprised. At the beginning of a disease tachycardia is expressed, the ABP raises a little in the first days of a disease, and then decreases.
At a blood analysis approximately at one third of patients of influenzal P. find a leukopenia. At extensive infiltrative changes the leukocytosis with a neutrocytosis and a deviation to the left is found more often. Reduction or lack of eosinophils in blood, a lymphopenia, increase in number of monocytes, reticuloendothelial and plasmocytes are characteristic of influenzal P. At 25 — 30% of patients the proteinuria, a hamaturia and a cylindruria comes to light. At an electrocardiographic research at a part of patients signs of diffusion toxic damage of a myocardium come to light: lengthening of an interval of PQ, low voltage or expansion of the QRS complex, low two-phase or negative tooth of T.
At influenzal P. there can be defeats of a nervous system (encephalitis, meningitis, neuritis and neuralgia). cardiovascular system (myocarditis) and ENT organs (otitis, sinusitis). Formation of cylindrical bronchiectasias, dry cavities — so-called influenzal cavities is possible.
Most hard hemorrhagic influenzal P. proceed, to-rye begin sharply with rise in temperature to 39 — 41 °, quickly accruing heavy asthma, cyanosis, emergence bloody, sometimes a foamy phlegm and can be followed by a collapse, a loss of consciousness, meningism (see). Heavier disease is observed during the developing of influenzal pneumonia at patients hron, bronchitis, emphysema of lungs, coronary heart disease.
Secondary influenzal P. of a virus and bacterial or bacterial origin arise usually in 4 — 5 days after a disease of flu. Before secondary influenzal P.'s emergence at some patients body temperature decreases, symptoms of intoxication and catarral changes of upper respiratory tracts and bronchial tubes decrease, but then the general state worsens again, symptoms of steam appear - or postgriipozny P. U of other patients secondary influenzal P. is direct continuation of flu. Elevated temperature which remains a long time and reaches high figures is characteristic of secondary P. Development of the new centers of an inflammation is followed having repeated temperature increase, deterioration in health, emergence of pristupoobrazny cough with allocation of a mucous or mucopurulent phlegm, sometimes with impurity of blood. There are short wind, cyanosis, in lungs shortening of a percussion sound, strengthening of voice trembling, dry and wet, preferential small-bubbling is defined, rattles, there can come abscessing.
In blood at secondary influenzal P. the lymphopenia, a monocytosis, an eosinopenia and acceleration of ROE are noted a moderate leukocytosis with a deviation to the left. At some patients the insignificant proteinuria and a cylindruria comes to light. Sometimes expressed a wedge, and Physical signs of secondary P. are absent.
Acute P. can arise against the background of the acute respiratory disease caused by viruses of a parainfluenza, adenoviruses, respiratorno - from an intsiti of l ny viruses.
At P.'s parainfluenza usually develops in late terms of a disease, and focal P. are localized preferential in the lower shares of lungs, segmented — is preferential in segments of the right lung. From a phlegm of patients of parainfluenza P. in 50% of cases pneumococci are allocated, is more rare — staphylococcus, at a part of patients — a bacterium in combination with the causative agent of a mycoplasmal infection. P.'s accession is followed by an aggravation of symptoms of the patient, temperature increase to high figures, short wind, cyanosis, emergence or strengthening of cough. At some patients cough is followed by thorax pains and expectoration of mucopurulent character, sometimes with impurity of blood. Over a zone of pneumonic infiltration shortening of a percussion sound, rigid breath, wet and dry rattles are noted, the pleural rub is sometimes listened. In blood the leukocytosis is observed.
P.'s emergence at an adenoviral infection is followed by fervescence, sometimes to febrile figures, increase of the phenomena of intoxication, short wind and cyanosis, emergence physical and rentgenol, signs of the Item. Acute P.'s symptoms are combined with symptoms of an adenoviral infection: rhinitis (see), nasopharyngitis, tonsillitis (see), laryngotracheitis (see. Laryngitis ), bronchitis (see). At some patients it is noted conjunctivitis (see). From a phlegm of patients streptococci, pneumococci, staphylococcus are allocated. At a half of patients the quantity of leukocytes exceeds 10 — 15 thousand
P. at a respiratory and syncytial viral disease arises in the first days of a disease against the background of the moderate phenomena of intoxication: fevers, headache, dizziness, feeling of weakness. Cough, cold and conjunctivitis is sometimes noted. The item is localized preferential in the lower shares of lungs, to a thicket happens unilateral. At sick P.' half has drain, focal, segmented or share character. At 1/3 patients from a phlegm golden plazmokoaguliruyushchy staphylococcus, a pneumococcus is allocated, at a part of patients connection of a disease with a mycoplasmal infection is established. At a blood analysis in the first days of a disease the leukocytosis is defined.
The acute beginning, bystry rise in temperature to 39 — 40 °, the expressed phenomena of intoxication in the absence of signs of damage of upper airways is characteristic of the acute P. caused by the activator of an ornithosis. Physical and rentgenol, P.'s signs appear on 2 — the 5th day from the beginning of a disease. By the end of the first week at most of patients the liver and a spleen increases. The feverish period proceeds from 1 to 4 week. In the period of reconvalescence palindromias are possible, on 3 — 5th week of a disease there can be late myocardites, the astenisation of the patient remaining up to 2 — 3 months is often observed. The leukopenia and considerable acceleration of ROE are noted. A certain diagnostic value has identification of contact with birds (wavy popugaychik, pigeons, ducks).
Mycoplasmal P. are caused by Micoplasma pneumonia (see. Mycoplasmal infections ) also are characterized by dominance in the first days of a disease of the general phenomena of intoxication (fever, a fever, an adynamia, muscular pains, etc.) which expressiveness increases to 5 — to the 7th day of a disease. Fever at mycoplasmal P. differs in the wrong character and 8 — 9 days proceed. The main symptom of a disease is progressively amplifying cough. In the beginning cough dry, then develops mucous, sometimes a purulent phlegm. At most of patients symptoms of laryngitis are expressed, pharyngitis (see) and tracheitis (see). The physical symptomatology scanty, is limited to emergence of rigid breath in the absence of a dullness, dry and occasionally wet rattles. The quantity of leukocytes in blood normal or is a little increased, the small band shift and considerable acceleration of ROE is noted.
The acute beginning, the expressed toxicosis, intermittent fever with repeated oznoba and pouring sweats are characteristic of Ku-rickettsial P. Patients complain of cough, a severe headache, pain in eyeglobes, a sleep disorder, disorder of consciousness is sometimes observed. The dermahemia of the person and neck, bradycardia, increase baking of a spleen is defined. Data of a physical research of lungs scanty.
Infectious diseases, such, as measles (see), whooping cough (see), typhus (see. Typhoid , Sapropyra ), a paratyphoid (see. Paratify ), tularemia (see), malignant anthrax (see), brucellosis (see), plague (see), can be complicated by acute P. of a bacterial etiology; P. caused specific inf meet. activator.
At brucellous P. cough with a phlegm, a pneumorrhagia, thorax pains, an osiplost of a voice is noted. Radiological the infiltrative changes which are localized in a radical zone of a lung or peribronkhialno come to light. The item is followed by a leukocytosis, in a phlegm find causative agents of a brucellosis.
P. at plague differs in extremely heavy current. On the foyer of the expressed symptoms of intoxication there is cough with the bloody, foamy phlegm containing a large number of causative agents of plague. Physical signs of P. at patients with plague are expressed poorly.
The item, caused by an anthracic stick, arises after a short incubation interval, begins sharply. There is a fever, body temperature rises to 39 — 40 °. Cold, cough, pains and feeling of constraint in breasts, a photophobia, dacryagogue, a hyperemia of a conjunctiva are observed. The phenomena of intoxication accrue: weakness, headache, dizziness, nausea, vomiting, pouring sweat, nonsense, spasms; The ABP falls. Sites of consolidation of pulmonary fabric are defined by Perkutorno, dry and wet rattles are listened. The heavy current of P. is followed by the phenomena of a fluid lungs and vypotny pleurisy. At cough the foamy phlegm with impurity of blood is allocated (the phlegm collected in bank during the standing sometimes takes a form of «crimson jelly»). Find anthracic sticks in a phlegm. The exudate in a pleural cavity has hemorrhagic character. Anthracic P.'s current extremely heavy.
At primary pulmonary form of the tularemia arising at aspiration infection, inflammatory process develops in lungs, with preferential damage of bronchial tubes (bronkhitichesky option) or a pulmonary parenchyma (pneumonic option). The item at a tularemia begins sharply: temperature increases, there are short wind, cough, there can be thorax pains. Except pneumonic infiltrates increase bronchopulmonary (root) likhmf is noted. nodes. At auscultation dry, kregshtiruyushchy and wet small-bubbling rattles are defined. The item at a tularemia quite often lasts two months and more, differs in tendency to a recurrence and complications in the form of bronchiectasias, abscesses, pleurisy and gangrene of lungs. For diagnosis use biol, and serol. methods, an intracutaneous test with tularin (see. Tularemia ).
Pneumonia of a noninfectious etiology develop under the influence of physical, volumetric and other disturbing factors of the environment, at some diseases (Leffler's syndrome, rheumatism, etc.).
At Leffler's syndrome (see. Lefflera syndrome ) one of frequent the wedge, P.'s manifestations is a combination of infiltrates in pulmonary fabric with an eosinophilia in blood.
Items can arise at patients with diffusion diseases of connecting fabric. Rheumatic P. develop at II and III degrees of activity of rheumatism. Are characteristic of rheumatic P. the expressed fever, cough with allocation of a bloody phlegm, the thorax pains amplifying at cough and deep breath, the accruing short wind, tachycardia, cyanosis at some patients are noted attacks of suffocation. Preferential lower shares of lungs are surprised, is more often than right. Physical data depend on localization and the size of pneumonic infiltrate. Wet small-bubbling rattles, a pleural rub are defined, shortening of a percussion sound is more rare. At bacterial, a research the phlegm at most of patients is sterile, sometimes from it allocate nonpathogenic and opportunistic flora. On an ECG at rheumatic P. increase of signs of a hypertrophy and overload of a right ventricle comes to light. In blood the moderate leukocytosis, band shift of a leukocytic formula and acceleration of ROE is noted. The combination of hypercoagulation to oppression of anticoagulative mechanisms and vascular defeats creates conditions for a thrombogenesis (histologically in lungs find blood clots and hemorrhages). Functional researches of a respiratory organs reveal dominance of disturbance of ventilation of restrictive type.
P.'s frequency at burns of the II—IV degree, according to N. S. Molchanov and V. V. Stavskaya (1971), makes 38%. Burn P. can be divided on primary, directly connected with a burn of respiratory tracts, and secondary: aspiration, atelectatic, hypostatic and septiko-toksiche-skiye. Burns of respiratory tracts result from inhalation of a hot air and steam and also necks, about-goraniyem a hair at an entrance to a nasal cavity, patol, changes of a mucous membrane of a nasal cavity and a mouth, an aphonia, an asthma which in hard cases has expiratory character because of narrowing of a gleam of small bronchial tubes and bronchioles are followed by burns on the face. Primary P. at a burn injury usually are followed by development of a fibrinous and necrotic tracheobronchitis and bronchiolitis, obstruction of bronchial tubes, have as правило^ drain character and often are complicated by a pulmonary heart (see. Pulmonary heart ). The main role in P.'s development is played by associations of microorganisms, preferential the autoinfection extending bronkhogenno. Secondary P.'s accession worsens the course of a burn disease (see Burns). Drain P. at a burn disease usually lead to acute pulmonary and heart failure and quite often are a cause of death.
Beam pneumonia (a synonym a beam pneumonitis) develops owing to a local or systemic effect of ionizing radiation during the performing radiation therapy concerning the tumors which are located in other cavity, a breast cancer and other diseases. Beam P. can be shown in the form of local beam reaction in the site of the lung which underwent radiation and also in the form of early or late complications. P.'s manifestations depend hl. obr. from a dose of radiation and the sizes of the irradiated site of a lung. Signs beam P. appear in several weeks after the end of radiation therapy in the form of an asthma which gradually accrues of the dry cough amplifying at loading and deep breath. Some patients owing to the accompanying beam esophagitis have complaints to a dysphagy. Temperature is usually normal. Shortening of a percussion sound, weakening of breath and wet rattles over a zone of pneumonic infiltration can objectively be defined. ROE is accelerated. Functional changes have preferential restrictive character.
In more hard cases beam P. proceeds with temperature increase, cough, short wind, stethalgias. Beam P. can accept hron, a current with development of a pneumosclerosis and cicatricial shift of a mediastinum. On this background the pulmonary heart quite often develops. Emergence of a «spontaneous» pneumosclerosis in late terms after radiation is manifestation undetected, clinically compensated the beam Item.
Features a wedge, aspiration P.'s currents depend on character of aspirirovanny material. Petrol pneumonia is preceded by aspiration of gasoline at its careless suction by a mouth through a rubber tube. After aspiration there is a pristupoobrazny painful, followed by the phenomena of a bronchospasm cough with the phlegm sometimes containing impurity of blood. Cough proceeds 20 — 30 min. Then the state improves and there comes so-called stage of latency duration apprx. 6 — 8 hours after which appear a severe cough with a phlegm, sometimes rusty color, the severe pains in a thorax amplifying at cough again. Symptoms of intoxication are observed: a headache, dizziness, frustration of a dream, euphoria, the general weakness, an eructation gasoline, nausea, vomiting, pains in epigastric area, sometimes confusion of consciousness. Some patients have phenomena very similar to a symptom complex acute abdomen (see), cholecystitis (see) that is probably connected with irritation of a diaphragmal pleura. In especially heavy, cases develops shock (see). The aggravation of symptoms of patients is followed by fervescence to 38 — 39 °. The hyperemia of the person, sometimes cyanosis, tachycardia, short wind is noted. In lungs in the first day of a disease expressed patol, changes at objective inspection do not come to light. On second day and later the site of the shortened percussion sound comes to light, the weakened or rigid breath, wet small-bubbling rattles, sometimes a pleural rub is defined in the same place. More often average and lower shares of the right lung are surprised that it is connected with features of an anatomic structure of the right primary bronchus and ease of hit in it aspirirovanny liquid.
Penetration of gasoline from lungs in a circulatory bed can lead to development of toxic hepatitis, focal nephrite, gastritis, to damage of a myocardium and c. N of page. In blood the leukocytosis with a deviation to the left, a lymphopenia, an eosinophilia, considerable acceleration of ROE is noted. At active treatment on 2 — the 3rd day the state improves, temperature to 4 — to the 5th day of a disease decreases. The disease lasts on average 3 — 4 weeks. By the end of term of treatment in a hospital, despite a top general condition and normalization of the lungs given a physical research, at a considerable part of patients strengthening of the pulmonary drawing, consolidation of roots of lungs radiological come to light. The increased petrol P.' tendency to transition in hron, a form is noted.
Most hard P. after aspiration of emetic masses, gastric contents at persons in alcohol intoxication proceeds, during an anesthesia or soon after its termination, during epileptic seizures, in coma of various etiology, at patients with bulbar frustration. Aspiration of food particles can happen at tumors, strictures and diverticulums of a gullet, a reflux esophagitis, phrenic hernia, tracheobronchial fistulas and other diseases.
Aspiration of acid gastric contents leads to a fluid lungs (see), to acute hemorrhagic P.'s development, emergence bronchospasm (see). Contents of a stomach can cause obturation small, and sometimes and average bronchial tubes. Along with gastric contents the bacterial flora from a nasopharynx and a gullet gets into bronchial tubes that promotes development of the Item. Aspiration P.'s localization substantially depends on a pose in which there was a patient at the time of aspiration: if the patient sat, the lower shares of lungs, especially on the right are surprised, in a prone position — except the lower shares back segments of upper shares of lungs often are surprised. The item after aspiration of contents of a stomach begins sharply, is followed by sharp rise in temperature, emergence of the expressed asthma, severe, pristupoobrazny cough with allocation of a bloody phlegm, the phenomena of a bronchospasm. Over a zone of defeat at the same time shortening of a percussion sound, the weakened breath is defined that it is probably connected with development of atelectases, wet small-bubbling and dry rattles are defined. In blood the neutrophylic leukocytosis with shift is observed to the left.
Hit in respiratory tracts of food particles without impurity of a gastric juice leads to moderately expressed inflammation in lungs. The item at the same time arises, as a rule, imperceptibly, proceeds is long, with the repeated recurrence caused by repeated aspirations and the piyevmoskle-rose and a pneumofibrosis comes to the end with development in a zone of pneumonic infiltration. Repeated flashes of acute P. after aspiration of the crushed food without impurity of gastric contents can lead to emergence chronic the Item. This diagnosis in some cases presents considerable difficulties, especially when the patient does not know about aspiration of food.
Aspiration of blood and the infected material wounded in a face, and also patients at upper airways operations leads to the aspiration P. which is characterized by a heavy current. As-pirirovannaya blood is a good medium for microorganisms that promotes development of the Item.
Lipoid pneumonia can develop at inhalation of fats and oils (exogenous lipoid P.) and at fatty embolisms of lungs (endogenous lipoid P.). Exogenous lipoid P. can arise at aspiration of the liquid paraffin applied as a purgative and to an instillation in Nov. Cases of inhalation of diesel oil at various emergencies are described. Aspiration of fish oil, vegetable oil and milk food is possible that it happens to a thicket at children during their feeding. The disease proceeds asymptomatically, patients of complaints do not show, and P. comes to light accidentally at rentgenol. research on an occasion of other disease. Carefully collected anamnesis allows to establish that the fit of coughing with suffocation after an unsuccessful proglatyvaniye of food or reception of medicine took place. At accession of consecutive infection suppuration in a zone of pneumonic infiltrate can develop.
Hypostatic (congestive) pneumonia arises especially often in lower parts of the right lung at the phenomena hypostatic, congestive, a plethora (tsvetn. fig. 3). It is quite often observed at patients with a serious illness of cardiovascular system (heart diseases, an ischemic disease, a cardiosclerosis, etc.), at the expressed heart failure and the phenomena of stagnation in a small circle of blood circulation. Besides, hypostatic P. can arise at the weakened patients, forced is long to lie on spin (e.g., after operations, after wounds). In addition to stagnation of blood and a fluid lungs, essential value of century P.'s development has an incomplete raspravleniye of alveoluses, especially in nizhnezadny departments of lungs, as a result of shallow breathing, and also a delay of a secret in alveoluses and bronchial tubes that is substantially connected with weakening of tussive movements. P.'s emergence at these patients is also promoted by disturbance of protective mechanisms of bronchial tubes and lungs.
Hypostatic P. develops gradually and is characterized by a sluggish current and erased a wedge, symptomatology. Against the background of the general serious condition of the patient narastadot weakness, short wind and cough with a small amount of a phlegm. Body temperature remains normal or increases to subfebrile figures. Physical signs of P. come to light not always because of weakness of breath and difficulty of inspection of such patients. At a part of patients it is possible to define a dullness and against the background of the weakened breath to listen wet small - and srednepuzyrchaty rattles. At rentgenol, a research pneumonic infiltrates of focal character come to light. The moderate neutrophylic leukocytosis is sometimes noted. In a phlegm of patients at whom hypostatic P. arose against the background of heart disease so-called cells of cordial defects can be found (see. Phlegm ).
In postoperative P.'s emergence the contributing factors which appeared as a result of an operational injury have major importance. According to N. S. Molchanov and V. V. Stavskaya (1971), the centers of a hyperemia, hemorrhages or a necrosis, atelectases which arose in lungs in connection with an operational injury, strengthening of bronchial secretion, heart attacks of a lung owing to an embolism of pulmonary vessels, dysfunction of bronchial tubes and lungs (reduction of depth of breath with decrease in lightness of pulmonary fabric, disturbance of passability of bronchial tubes at the expense of a spasm and hypostasis, decrease in force of tussive movements and braking of evakuatorny function of bronchial tubes), disturbance of blood circulation in lungs with development of stagnation of blood can be such factors. In most cases postoperative P. have focal character and their wedge, manifestations depend on character of the contributing factors and features of a pathogeny.
After operations on bodies of belly and chest cavities, a backbone often arise atelectatic to P. Ety disturbance of phrenic and chest types of breath owing to a chrevosecheniye or thoracotomies promotes that leads to disturbance of evakuatorny function of bronchial tubes, decrease in bronchial passability, emergence atelectases (see) various degree of manifestation and extent. Patients complain a pas difficulty of breath, an asthma and pains in the field of the made operation at breath. Their body temperature is increased, cough with a purulent phlegm develops. At an objective research — immobilization of bottom edges of lungs, high standing of a diaphragm, especially on the right, a dullness and a large number small - and srednepuzyrchaty rattles over a zone of obtusion. The leukocytosis with a deviation to the left develops.
The infarctive P. (heart attack pneumonia) developing as a result of an embolism of pulmonary vessels is observed at patients after operation rather seldom. Physical signs of focal P. are shown at these patients against the background of a wedge, pictures of a heart attack of a lung (see. Lungs ), are followed by fever and moderately expressed leykotsitozol!. Find a dullness in most of patients, usually over a back basal segment of one of lungs, weakening of breath, a small amount of dry and wet rattles, a pleural rub. In several days on the party of defeat signs of accumulation of liquid in a pleural cavity can appear. At an extensive thromboembolism of a pulmonary artery (see the Embolism of a pulmonary artery) there are symptoms of acute pulmonary hypertensia which can lead to a syndrome of an acute pulmonary heart (see). Intercurrent P. in the postoperative period have generally focal character and on a wedge, to a picture differ from the described earlier focal Items a little.
Complications at croupous P. meet more often than at focal. According to V. I. Struchkov (1961), suppurations at croupous P. arise in 2.6% of cases, and at focal — in 1,2%.
Introduction to a wedge, practice of antibiotics led to reduction of number of purulent complications of acute P. by 2 — 3 times. However in 60 — the 70th, on M. I. Perelman (1979) observations, the tendency to further reduction of number of these complications is not noted; their frequency according to various data reaches 1,8 — 13%.
Complications in the acute period of croupous P. are most often connected with the dysfunctions of cardiovascular system caused by a hypoxia and intoxication. Before use of antibiotics for croupous P.'s patients during crisis the vascular collapse as a result of toxic paresis of vazomotor quite often developed. It was followed by sharp decline of forces, a black-out, cyanosis with a grayish shade of skin, a cold snap of extremities, frequent and small pulse, falling of the ABP, strengthening of an asthma.
One of important diagnostic methods of P. is rentgenol, the research. Carry out hl. obr. multiprojective roentgenoscopy (see), X-ray analysis (see), the superexhibited pictures, tomography (see), functional trials of Valsalva (attempt of an exhalation through a nose at the clamped nostrils and a mouth) and Müller (attempt of a breath at the closed glottis). Additional techniques — bronchography (see), sounding of bronchial tubes, the angiography is more rare (see. Angiopulmonografiya ) — are applied at prolonged, it is long not allowed P. when there is a need of carrying out differential diagnosis with processes of other origin, first of all with malignant tumors. Rentgenol, a picture reflects the main stages of development of a stage of inflow by croupous P. V in an affected area of a lung insignificant decrease in transparency and strengthening of the pulmonary drawing at the expense of a plethora of vessels is noted. If the affected area is less than share, these changes come to light hardly. The expressed decrease in transparency of the respective site of a lung on intensity reminding a picture of an atelectasis (fig. 5) is characteristic of a stage of a gepati-zation. Total P. meet very seldom, are characterized by full blackout of all pulmonary field. The croupous P. occupying the sites located lengthways interlobar cracks is much more often observed (peristsissuralny P., or peristsissurita), to-rye are located in the depth of pulmonary fabric. In this regard Physical data at peristsissurita are very poor, and in some cases at all are absent that sharply increases value rentgenol, researches in their diagnosis. Interlobar cracks come to light better in side projections therefore at peristsissurita the picture is most demonstrative on side roentgenograms. Existence of a shadow of the irregular extended shape which has one clear, rectilinear boundary which is corresponding to an interlobar pleura, and another indistinct, gradually passing into not changed pulmonary field (fig. 6) is characteristic of a neristsissurit. Peristsissurit can accompany one interlobar crack, but quite often passes from a slanting crack to horizontal; this sign allows to distinguish a shadow at a peristsissurita from the segmented blackout which is not going beyond a share. The tomography in a side projection is quite often applied to identification small on prevalence of peristsissurit. The current of peristsissurit is more favorable, than share Items. Their outcomes in most cases also differ from widespread processes in lack of complications and a full rassasyvaniye with recovery normal rentgenol, pictures, except for a reinforced interlobar pleura.
The stage of permission of croupous P. radiological is shown by decrease in intensity of a shadow and its fragmentation. After P.'s rassasyvaniye strengthening of the pulmonary drawing on site of the former blackout remains during 3 — 4 weeks. For specification of substrate of this phenomenon Valls's tests lions and Müller are applied. During the conducting test of Valsalva the pulmonary drawing becomes poorer owing to increase in intra pulmonary pressure and vasoconstriction; at Müller's test the pulmonary drawing amplifies thanks to overflow of vessels blood. The pulmonary drawing during the conducting tests considerably does not change if anatomic substrate patol, process is growth of connecting fabric, napr, at a pneumosclerosis. Along with changes of pulmonary fields expansion and homogenization of a shadow of the corresponding root of a lung is noted; these changes are usually observed during 3 — 4 weeks after a rassasyvaniye of the inflammatory phenomena in pulmonary fabric. The pleura on the party of defeat almost always is reinforced. In some cases liquid in a pleural cavity is defined (pleuropneumonia); at a small amount of liquid its identification is promoted by a research of the patient on a lateroskopa in situation on a sick side (see. Polyposition research ). At basal P. mobility of a dome of a diaphragm on the party of defeat, as a rule, decreases. At the favorable course and a full rassasyvaniye of inflammatory process rentgenol, the picture is normalized on average in 1 — 1,5 month. Distinguish the abscessing P. from the most often found complications: radiological against the background of blackout one or several cavities containing the liquid and gas divided by horizontal border (fig. 7) come to light.
Focal P. radiological is shown by existence of a set of the small sites of blackout located most often in both pulmonary fields; the sizes of these focal shadows in most cases do not exceed 1 cm that corresponds to the sizes of pulmonary segments. Tops of lungs in most cases are not surprised. Outlines of focal shadows indistinct, their intensity is small (fig. 8, a). Because of the coming hyperemia of tissue of lung the pulmonary drawing amplifies. Shadows of roots of lungs extend and homogenized. In places of the greatest concentration of the centers reaction of a pleura in the form of a thickening is noted; quite often in a pleural cavity the exudate, mostly in a small amount comes to light. Mobility of a diaphragm is often limited. For focal P., as well as for the majority of acute inflammatory processes in lungs, bystry dynamics rentgenol, pictures is characteristic: in 5 — 7 days there are essential changes, and in 1,5 — 2 weeks the centers in most cases resolve. Because the centers at this type of P. arise not at the same time, their rassasyvaniye occurs also gradually. Depending on the sizes of the centers it is accepted to distinguish 3 types of focal P.: macrofocal P. at which diameter of inflammatory focuses is equal to about 1 cm (meets most often), sredneochagovy (to dia. 6 — 8 mm) and melkoochagovy (to dia. 3 — 5 mm). Along with these forms at which the sizes of the centers do not exceed 1 szh in some cases the so-called drain P. which is characterized by existence of large focuses, to dia meets. 2 — 3 cm and more (fig. 8,6): sometimes drain focuses occupy the whole segments, and in some cases even shares, imitating rentgenol, croupous P. Sravnitelno's picture a rare form of focal P. is miliary dissimination at which diameter of the centers does not exceed 1 — 2 mm (fig. 8, c).
Supporters of recognition of acute intersticial P. as forms P. believe that the most characteristic rentgenol, its sign is strengthening and deformation of the pulmonary drawing on cellular type (fig. 8, d). These changes are more expressed in average and especially lower parts of lungs; more often they are observed in both lungs though at the beginning of a disease can come to light only in one lung, usually in its nizhnemedialny department. The pulmonary drawing loses the radial orientation and gains mesh character; small cells of this grid display the interstitium surrounding a separate acinus and larger pulmonary segments which diameter reaches 1,5 cm. Mesh or cellular character of the pulmonary drawing allows to distinguish an inflammation and infiltration of an interstitium from a plethora of vessels of lungs and stagnation in a small circle of blood circulation, to-rye can also cause strengthening of the pulmonary drawing, however the last at the same time keeps the radial direction. In especially hard cases for differential diagnosis the functional trial of Valsalva at which height the pulmonary drawing owing to increase in alveolar pressure becomes poorer is applied, and at infiltration of an interstitium remains without changes. Shadows of roots of lungs at intersticial P. in most cases become nonstructural and tyazhisty, without noticeable increase in sizes. Reaction of a pleura is almost constant: it is considerably condensed, sometimes it is possible to reveal a small amount of liquid in a pleural cavity. The excursion of a diaphragm at height of inflammatory process is quite often limited. At further development of P. the small infiltrative shadows displaying secondary involvement in process of tissue of lungs (an acinus and segments) often join intersticial changes focal, and sometimes. Intensity of these shadows is usually small, they seldom merge among themselves. Rentgenol, changes can be observed during 2 — 3 weeks. During the subsiding of an inflammation focal and infiltrative shadows resolve in the beginning, and their involution occurs from the periphery to the central departments. Disintegration of the centers and infiltrates is observed rather seldom. Strengthening and deformation of the pulmonary drawing, consolidation of a pleura, a tya-zhistost of roots remain is longer. At a favorable current of intersticial P. rentgenol. the picture can be normalized completely.
P.'s etiology quite often defines features it rentgenol, manifestations. At staphylococcal P. one is observed or several inflammatory focuses of the averages or the large sizes which are quite often located in both lungs are more often. Outlines of these focuses indistinct, intensity of shadows increases in process of increase in their sizes, the tendency of these focuses to merge and the subsequent disintegration is characteristic — against the background of blackout the sites of an enlightenment testimonial of fusion of pulmonary fabric appear (fig. 8, e). At a research in an orthoposition in these sites horizontal fluid levels are found. At good drainage the amount of liquid quickly decreases and cavities gain rounded shape. Quite bystry dynamics rentgenol, changes is characteristic of this type of P. During rather short time (one-two weeks, sometimes slightly more) it is possible to observe emergence of infiltrates, their disintegration, transformation of cavities of disintegration into thin-walled cysts. In the subsequent the cavities formed as a result of disintegration are deformed, can decrease in sizes and on site the former inflammatory infiltration the picture of the pneumosclerosis which is quite often passing into cirrhosis develops. Very frequent complication of staphylococcal P. is vypotny pleurisy, most often purulent. After elimination of pleurisy in most cases there are massive shvarta, rebernodiafragmalny sine are quite often obliterated. Further there can be sites of calcification of a pleura in the form of the separate densely located grains of various size.
Rentgenol, septic metastatic P.'s picture differs in a number of features. Non-simultaneity of emergence in both lungs various by the sizes and a form of inflammatory infiltrates concerns to them, to-rye have the expressed tendency to disintegration. Radiological these sites take a form of a cavity (abscess) with availability of liquid and air, divided by horizontal border (fig. 8, e). These abscesses are quickly enough cleared, turning into the thin-walled air cysts remaining a long time after liquidation of the Item. Air cysts can be deformed in the subsequent as a result of growth of connecting fabric, turning into slit-like cavities, to-rye in some cases cicatrize. At height of development of septic P. the pulmonary drawing is strengthened because of the raised krovenapolneniye of vessels of lungs. Roots of lungs are moderately expanded, their structure usually is not differentiated. All development cycle of septic metastatic P. in the x-ray image from emergence of the first infiltrates before elimination of inflammatory process and formation of air cysts lasts on average 2 — 3 weeks. One of characteristic features of this P. is diversity rentgenol, pictures: availability of fresh infiltrates in one sites of lungs, cavities of disintegration — in others, the cleared cysts — in the third is at the same time noted. Lack of synchronism in development of pneumonic focuses is explained by the fact that a hematogenous drift of purulent emboluses from primary center (an anthrax, a furuncle, the osteomiye-lytic center, etc.) occurs repeatedly and each similar wave is followed by emergence of new infiltrates while earlier arisen focuses undergo the transformations described above by this time.
The expressed hyperplasia bronchopulmonary limf, nodes is characteristic of adenoviral P. At this stage there can be low-intensive shadows of infiltrates which rassasyvaniye occurs slowly.
Rentgenol, rickettsial P.'s picture differs in early emergence of infiltrates of various sizes, hl. obr. in outside departments of pulmonary fields; the expressed reaction of roots of lungs is absent. Liquid in a pleura is found rather seldom. Rassasyvaniye of infiltrates begins on the 2nd week of a disease and 3 — 5 weeks last. Emergence of new infiltrates is not typical and meets only in very hard cases. Rickettsial P.'s transition to a chronic form is noted seldom.
Rentgenol, manifestations of P. caused by activators of a tularemia, a brucellosis, a malignant anthrax are various; sharp expansion of roots of lungs at the expense of a hyperplasia bronchopulmonary limf, nodes is characteristic of these processes. Quite often shadows of roots get polycyclic contours. Diphtheritic P. is characterized by existence of the intersticial and focal changes revealed against the background of the increased transparency of pulmonary fields. Dissiminations are characteristic of pertussoid and clumsy P. melkoochagovy, sometimes miliary, focal shadows larger are more rare; usually these changes are followed by the phenomena of a bronchiolitis and inflation of certain sites of lungs.
At the aspiration P. arising owing to hit in respiratory system of a large amount of blood, emetic masses, pieces of food etc. radiological note emergence of the massive blackout which is usually localized in nizhnezadny departments of the lower shares of lungs, more often on the right. Because infiltrates at aspiration P. tend to disintegration, against the background of blackout the sites of an enlightenment having the horizontal lower bound are often visible. The break of the necrotic centers in a pleural cavity with education is in certain cases noted pyopneumothorax (see). If aspirirovanny masses obturirut a gleam of a lobar bronchus, P. gains atelectatic character (see above).
The hypostatic P. developing against the background of developments of stagnation in lungs can be defined radiological first of all on the basis of such symptoms of stagnation as increase in caliber of pulmonary veins, expansion and homogenization of shadows of roots, existence of an exudate in pleural cavities, increase in the sizes and change of a configuration of a shadow of heart. On this background there are indistinctly outlined focal or infiltrative shadows sometimes merging among themselves. At the weakened patients these blackouts are visible usually in the lower shares of lungs.
Infarctive P. in typical cases radiological is shown by triangular blackout which top is directed to a root of easy (fig. 9). However the similar picture is visible only in certain projections. In other cases the shadow at infarctive P. can be a rounded or oval shape. Infarctive P.'s focuses can be multiple; in certain cases they are found in both lungs.
The differential diagnosis
Croupous P. is differentiated with the diseases which are followed by infiltrative changes of pulmonary fabric it is especially frequent with infiltrative and pneumonic forms of a pulmonary tuberculosis, and first of all from lobar caseous P. (see. Tuberculosis of a respiratory organs) . The increased perspiration is characteristic of suffering from tuberculosis lungs; skin of the patient of croupous P. in an acute phase of a disease dry and hot. The phlegm at tubercular P. may contain impurity of blood, but does not happen such sticky and evenly impregnated with air traps as a phlegm at croupous P.'s patients Besides, the phlegm of TB patients does not contain pneumococci or other activators of croupous P. Nedomoganiye and increased fatigue are usually noted long before tubercular P.'s emergence; the indisposition before croupous P. can be absent or appear all some days before the beginning of a disease. Expressiveness of intoxication at tubercular P. is very variable while at most of patients of croupous P. symptoms of intoxication are sharply expressed from the first day of a disease. The pain at breath caused by the accompanying pleurisy is expressed at tubercular P. is moderately and most often localized in interscapular area; at croupous P. it most often arises in a side, according to a projection of basal segments of the lower shares, to-rye are surprised most often. TB patients show less complaints, cannot designate day of a disease, and sometimes do not consider themselves patients at all; changes in lungs at them for the first time reveal at rentgenol, inspection. The leukopenia or a moderate leukocytosis without the expressed deviation to the left, unlike croupous P.'s patients of whom they are characteristic the expressed leukocytosis, a deviation to the left to young forms and considerably the accelerated ROE are characteristic of tubercular P.'s patients.
Need of carrying out differential diagnosis of bacterial or virus focal P. with infiltrative and pneumonic tuberculosis, primary tubercular complex and reinfection of pulmonary tuberculosis at adults arises in cases of not allowed P. U of patients with tubercular defeat in the anamnesis there can be outbreaks of pulmonary tuberculosis, the phenomenon of tubercular intoxication which in an acute phase of a disease is expressed in most cases more weakly, than at bacterial to the Item. Results of physical inspection depend on size and localization of infiltrate and do not give reliable justification for the differential diagnosis of the compared diseases. The greatest informational content for the differential diagnosis data rentgenol have, inspections. Tubercular infiltrates have usually round or oval form and more accurate contours, than pneumonic. Along with the fresh centers it is possible to find in tubercular P.'s patients radiological and old petrifikata, and tomographic — in early stages the outlined disintegration. Positive tuberkulinovy tests (see. Tuberculinodiagnosis ) and especially their increase at a repeated research confirm existence at the patient of a tuberculosis infection. Bronkhoskopiya allows to find sometimes the fistular courses and cicatricial changes of a wall of bronchial tubes, characteristic of tuberculosis. Fibrobronkhoskopiya with carrying out a biopsy for tsitol, and bacterial, researches in 89,7% of cases allows to specify the diagnosis. The tubercular etiology of P. becomes undoubted if in contents of bronchial tubes and in a phlegm of the patient find mycobacteria of tuberculosis.
Differential radiodiagnosis of staphylococcal P. in the presence of cavities in lungs should be carried out with multiple abscesses of lungs, cavernous tuberculosis, caseous the Item. Bystry dynamics patol, process is characteristic of staphylococcal P.
At elderly people, especially at smokers, the malignant tumor of a bronchial tube (parakankrozny P.) needs to carry out the differential diagnosis between croupous P. and pneumonia in a zone of an atelectasis distalny. This type of P. is, as a rule, shown by unilateral infiltrative blackout which sizes depend on the extent of the hypoventilated zone of a lung (see Lungs, tumors). The blackout caused by croupous P. differs from an atelectasis in the fact that the volume of an affected area (a segment, a share) does not decrease as at an atelectasis, and keeps the sizes (in certain cases even increases a little) therefore contours of blackout are rectilinear or are even slightly convex (at an atelectasis they are bent). Besides, existence against the background of blackout of transparent air strips of bronchial tubes (fig. 10) that is not observed at an atelectasis is characteristic of croupous P. Preservation of lightness of large and average bronchial tubes leads to the fact that intensity of blackout at P. decreases from the periphery to the center that is not characteristic of an atelketaz. In many cases the blackout caused by parakankrozny P. blocks a shadow of a tumor and complicates diagnosis of basic process. Patients with a malignant tumor of a bronchial tube are often disturbed by severe, pristupoobrazny cough, sometimes with the phlegm containing blood; their asthma, stethalgias, a febricula are observed. The item in the field of an atelectasis can be resistant to antibiotics or show tendency to recuring in the same sites of a lung therefore not allowed or repeatedly recurrent P., especially at elderly people, shall be the indication for a careful bronkhol. the research including a bronkhoskopiya with a fence of contents of bronchial tubes for tsitol, researches and a biopsy, a bronchography and a tomographic research.
Recurrent focal P. can be a complication of adenomas of a subsegmental bronchus, to-rye a long time proceed asymptomatically (see. Bronchial tubes, tumors ). In the subsequent cough, at a half of patients — a moderate pneumorrhagia develops. The bad rassasyvaniye and P.'s recuring are explained by the accruing deterioration in ventilation of the struck segment in connection with growth of a tumor. The main confirmation of the diagnosis of adenoma of a peripheral bronchial tube are data bronkhologichesky and tsitol, researches.
Krupnofokusny focal P. on rentgenol, can remind a picture pulmonary metastasises of malignant tumors of various bodies. The main distinguishing character of P. is bystry involution patol, process. It is extremely difficult to distinguish miliary focal P. from cancer dissimination in some cases, and at a single research often it is impossible. Bystry dynamics, lack of defeats of other bodies speaks well P.
Inogda it is necessary to carry out differential diagnosis of P. with bronkhioloalveolyarny cancer of a lung, at Krom several roundish shadows in a lung radiological come to light. Merging, they can make an impression croupous P. Bronkhioloalveolyarny cancer of a lung can remind in certain cases and focal P. Primerno at a half of patients tumoral process the long time proceeds asymptomatically. In later stages cough, in the beginning dry, and then productive, with allocation of a plentiful mucous phlegm, short wind, fever and pains develops at breath (in cases of defeat by a tumor of a pleura). The accruing infiltration in a lung, accession of pleural changes and the phenomena of intoxication, lack of effect of antibacterial therapy shall be a reason for carrying out careful bronkhologichesky and rentgenol, researches of lungs. Focal P. can
sometimes be early pulmonary manifestation of a lymphogranulomatosis and dominate in a wedge, a picture of this disease (see. Lymphogranulomatosis ).
The differential diagnosis of focal P. with heart attack of a lung (see) the wedge, courses of a heart attack of a lung of which sudden emergence of a stethalgia, asthma and pneumorrhagia without intoxication and temperature increase in the presence of possible sources of a pulmonary thromboembolism (thrombophlebitis, heart disease etc.), and also on data rentgenol, researches is characteristic is based on features. Only set of signs gives the chance to distinguish focal P. from a heart attack of a lung.
There can be a need for carrying out differential diagnosis of focal P. with eosinophilic pulmonary infiltrates (see. Lefflera syndrome ), which emergence is not followed by intoxication and temperature increase; at a repeated rentgenol, control it is possible to state bystry (in 5 — 8 days) disappearance of eosinophilic infiltrates. Their emergence is connected with an invasion ascarids and is followed by an eosinophilia of blood.
Treatment of patients of acute P. shall be timely and complex. Acute P.'s patients shall be treated in a hospital. Treatment is admissible at home only at observance of all rules of the stationary mode and treatment. The requirement of need of hospitalization especially concerns to patients at whom acute P. arose against the background of hron, bronchitis and others hron, diseases of bronchial tubes and lungs, and also to patients of advanced and senile age. Defective, overdue treatment even at an easy current of acute P. can bring to its long current and formation hron, pneumonia.
Treatment of patients of acute P. includes corresponding to lay down. mode, balanced diet, medicinal therapy (etiotropic, pathogenetic and symptomatic means), physiotherapeutic treatment.
The patient shall observe a bed rest during the entire period of fever and intoxication, however it is periodically recommended to change situation, to sit down and actively to cough up a phlegm. The phlegm should be collected in bank with densely closed cover. The room in which there is a patient, it is necessary to air well. Careful care of skin and an oral cavity is of great importance.
Food shall be caloric, vitamin-rich, easily assimilable. In the first days of a disease at high fever and the expressed phenomena of intoxication it is better to give it in a liquid or semi-fluid look. Liquid is entered in the form of broth, fruit juice, mineral water.
Before purpose of antibacterial therapy it is necessary to take a phlegm for bacterial, researches, however treatment needs to be begun, without waiting for allocation and identification of the activator, and also definition its antibiotiko-grams. It is necessary that treatment was carried out under a wedge, and if it is possible, bacterial, control (definition of sensitivity of microflora of a phlegm to antibiotics in the course of treatment). Antibacterial agents shall be applied in sufficient doses and with such intervals that in blood and pulmonary fabric was created and supported to lay down. concentration of drug.
The most effective is causal antibacterial treatment. The choice of an antibiotic taking into account sensitivity of bacteria to the appointed drug is especially important in connection with a wide spread occurance of antibiotic-resistant strains of microorganisms. Approximate etiol, diganoz at a part of patients it can be put taking into account features of clinicoradiological data. Bystry approximate bacterial, can promote the diagnosis microscopy of the smears of a phlegm painted across Gram. In need of immediate purpose of antibacterial agents (before definition antibiotiko-grams of the activator) it is necessary to give preference to the bactericidal antibiotics of a broad spectrum of activity having ability of good diffusion in pulmonary fabric (semi-synthetic Penicillin, cephalosporins). In the subsequent antibacterial therapy korrigirutsya by data antibiotikogram-we and the wedge, currents is appointed taking into account features. For the choice of an effective dose, optimum intervals and ways of administration of antibacterial agents it is necessary to consider results of a research of the minimum overwhelming concentration of drug for the allocated activator. At the choice of an antibiotic contraindications to its appointment, napr, allergic reactions to the previous administrations of drug, etc. shall be considered.
Identification of the activator P., its sensitivity to antibiotics and the minimum overwhelming concentration of drug allows to appoint the most effective individual therapy. At P. caused by pneumococci penicillin (benzylpenicillin) is most effective. To the Penitsillinazoustoychi-Vyya semi-synthetic Penicillin (Oxacillinum, Methicillinum, etc.), drugs of a broad spectrum of activity (ampicillin, etc.) and tetracycline drugs concede to it in activity concerning pneumococci. At acute streptococcal P. which arises as a complication of acute respiratory viral diseases more often the most effective antibiotic is also penicillin. In cases of the staphylococcal nature of a disease the semi-synthetic Penicillin steady against the penicillinase developed by staphylococcus are shown, and at semi-synthetic penicillin resistance of stafilokokk the positive take is yielded by a combination of lincomycin to gentamycin or Fusidinum with lincomycin or rifampicin. At P. caused by Haemophilus influenzae stick it is reasonable to appoint ampicillin, and at resistance to it — tetracyclines, levomycetinum. The most effective at sick P.' treatment, the caused Klebsiella pneumoniae stick, are streptomycin, Kanamycinum or gentamycin in combination with levomycetinum or tetracyclines. For treatment of P. caused by a pyocyanic stick (Pseudomonas aeruginosa) gentamycin or its combination with karbenitsilliny is recommended. At detection of anaerobic flora appoint penicillin, lincomycin or levomycetinum. It is reasonable to carry out mycoplasmal P.'s treatment by antibiotics of a wide range — drugs of tetracycline group, levomycetinum. The patient with virus, especially influenzal, P. appoint a combination of antibiotics of a broad spectrum of activity and semi-synthetic penicillin.
In an acute phase P. it is recommended to appoint at the same time two antibiotics or one antibiotic in combination with sulfanamide drug. The dose and number of at the same time appointed antibiotics depend on weight of a current and prevalence of process. Data on doses, terms and ways of introduction of the antibiotics which are most often used for treatment of pneumonia, feature of their use and possible complications are provided in table 2. For the purpose of prevention of accustoming to antibacterial agents and reduction of danger of allergic reactions it is recommended to change drugs in 7 — 10 days. The issue of duration of antibacterial therapy shall be resolved individually.
Purpose of 2 — 3 antibacterial agents in the maximum doses preferential intravenously is recommended to patients with extremely heavy current of P., polysegmented distribution of infiltration.
Transdermal catheterization of a trachea and bronchial tubes is applied to achievement of long and continuous impact of pharmaceuticals on inflammatory process at patients with a long current of acute P. (see. Mikrotrakheostomiya ) with introduction of antibiotics, mucolytic and other means directly in a zone of badly resolving pneumonic center. With the same purpose it is possible to carry out medical and diagnostic bronkhoskopiya during which of bronchial tubes delete mucous and purulent traffic jams and wash out them solutions of broncholitic means, proteolytic enzymes, alkalis, vitamins, a hydrocortisone, and at the end of the procedure enter antibacterial agents.
At treatment of patients of acute P. antibiotics should be combined with sulfanamide drugs which purpose is possible from the very beginning of acute P. (tab. 3). At a stage of recovery antibiotics cancel, leaving streptocides. Along with antibiotics and streptocides it is possible to use phytoncidal drugs (inhalations of solutions of juice of garlic, onions, a St. John's Wort, etc.), the most reasonable during the subsiding of the acute phenomena. At a stage of the beginning recovery it is possible to treat sulfanamide drug and phytoncides, and then, having cancelled streptocide, to finish sanitation of active inflammatory process in lungs with phytoncides.
Antibacterial therapy is combined with the antiinflammatory and hyposensibilizing means, such as acetilsalicylic to - that, by chloride or a gluconate of calcium, Pipolphenum, Suprastinum. At a sluggish rassasyvaniye of infiltrate and the accompanying bronchospasm apply short courses small doses of Prednisolonum. Corticosteroid drugs in high doses are appointed the patient with the expressed phenomena of intoxication and bronchial obstruction, with extensive infiltrative changes in lungs and in the absence of accurate positive dynamics from antibacterial therapy.
A fundamental unit of pathogenetic therapy is recovery of bronchial passability and a bronchial drainage. For this purpose at treatment of all patients of acute P. it is reasonable to apply the broncholitic, liquefying slimes and expectorants (an Euphyllinum, Theophedrinum, ephedrine, etc.). The good action expectorating and liquefying slime solution of potassium iodide, a root of a mallow, Mucaltinum, Acetylcysteinum, Bisolvon, a thermopsis, terpin hydrate, a leaf of a plantain, hot milk with soda and honey and other means possess. At strong N unproductive cough appoint antibechics, to-rye do not reduce department of a phlegm (libexinum). The great value is attached to an aerosoltherapy with use of broncholitic mixes in a combination with various microbicides (phytoncides, sometimes streptocides), alkaline and oil solutions, honey.
At a long current of P. and its complication abscessing the crucial role in treatment is played by recovery of an effective bronchial drainage (see Lungs) that is carried out at bronchoscopic sanitation. The heavy current of P. with short wind and cyanosis is the indication to performing oxygen therapy (see). Use of oxygen at treatment of patients at whom acute P. arose against the background of emphysema of lungs, of a pneumosclerosis is especially necessary and can become the reason of heavy respiratory insufficiency (see). At a heavy current of P. of t especially when thrombocytopenia is combined with a fibrinosis that leads to development of local hemorrhagic necroses of fabrics, continuous anticoagulating therapy using heparin is recommended that improves not only a current, but also an outcome of a disease since prevents the disturbance of microcirculation arising owing to thrombosing of vessels of a small circle of blood circulation.
A big role, and at staphylococcal P. with destruction it is decisive, play the methods of treatment directed to increase and recovery of immune mechanisms of protection. For this purpose at P. of a staphylococcal etiology carry out massive immunization by hyperimmune anti-staphylococcal plasma or staphylococcal antitoxin. Very effectively for treatment of patients with a heavy current of P. repeated administration of hyperimmune, polyvalent gamma-globulin.
Treatment of patients of acute P. shall be directed to recovery of nonspecific resistance of an organism. For this purpose appoint the polyvitamins including ascorbic to - that, thiamin, etc. Biogenic stimulators and adaptogenny means are used (an aloe, tinctures of a root of a ginseng, an eleuterokokk, a magnolia vine, Pantocrinum, an apilak, pentoxyl, methyluracil, anabolic steroids). The positive effect from use in complex treatment of patients of acute P. of an aerosol of the concentrated leukocytic interferon is described. At a long current of acute P. hemotransfusions and an autohemotherapy are shown. For stopping of pains, to-rye often disturb croupous P.'s patients, apply analgetics.
At the accompanying pathology of heart, especially at elderly, and also at a heavy current of P. means for prevention and treatment are appointed heart failure (see). Keep the value in an arsenal of therapy of patients of acute P. the local distracting procedures: banks, mustard plasters, mustard packs, to-rye appoint from the first days of a disease.
Physiotherapeutic methods of treatment make an integral part of complex therapy and P.'s prevention and increases in protective immune processes in an organism of the patient are applied for the purpose of acceleration of a rassasyvaniye of inflammatory infiltrates, reduction of the phenomena of intoxication, improvement of ventilation of the lungs and blood circulation in them.
With 3 — day after acute P.'s beginning would appoint aerosols and electrical aerosols of antibiotics, streptocides and phytoncides. In the presence of a viscous secret in bronchial tubes before inhalation of antibiotics and streptocides it is reasonable to carry out inhalations of proteolytic enzymes (trypsin, chymotrypsin, chemical opsin). Besides, aerosols and electrical aerosols of bronchial spasmolytics, corticosteroids, the hyposensibilizing means are applied.
Lech. the effect increases at a combination of inhalations to an electrotherapy. Antiinflammatory and antiallergenic action at P. is inherent in electric field of the ultrahigh frequency (UVCh) in the constant and pulse modes, an inductothermy to the harmonic modulated currents (HMC), decimeter waves (DMV) by means of which influence a projection of the inflammatory center, area of roots of lungs at bilateral process, and also area of a projection of adrenal glands. The electrotherapy exerts beneficial effect on all forms of immunity. Impact on the center of an inflammation influences local immunity, and impact on area of adrenal glands stimulates emission of steroid hormones, increases dissociation of a proteinaceous and steroid complex. During the carrying out an electrotherapy the level of immunoglobulins, autoantibodies goes down, iyespetsifichesky reactivity of an organism increases.
At acute P. in the period of an exudative and infiltrative inflammation, during the abscessing in the period of permission and at P. with bronchiectasias (at safety of drainage function of bronchial tubes) apply electric field of UVCh (see. UVCh-therapy ). In the absence of pus use of microwaves of santimetrovolnovy range is possible (see. Microwave therapy ), UF-radiations (see. Ultraviolet radiation ). In the period of permission of an inflammation it is most shown inductothermy (see), expectorative, to reduction of a bronchospasm and recovery of ventilating and drainage function of bronchial tubes. At a stage of a rassasyvaniye of the inflammatory phenomena and for elimination of separate symptoms of a disease (pain at pleural commissures, difficulty of department of a phlegm, etc.) appoint an electrophoresis of pharmaceuticals (see. Electrophoresis, medicinal ); for this purpose use drugs of magnesium and copper, a lidaza, an Euphyllinum, heparin, ascorbic to more often - that, Gumisolum, extract of an aloe, etc. In a phase of recovery carry out an aero ionotherapy (see. Aeroionization ).
Sanatorium treatment is shown at croupous or focal P. in the period of an absolute recovery and during the recovery period. Treatment is carried out in the local pro-thinned-out sanatoria, in climatic resorts of the Southern coast of the Crimea, low - and middle mountains (Kislovodsk), and also in steppe climate to warm season. In the recovery period after croupous and focal P. the thalassotherapy is shown (see. Climatotherapy , Thalassotherapy ), under the influence of which function of adrenal glands is normalized, function of external respiration, bronchial passability, a hemodynamics, thermoadaptation improve.
In balneological resorts (see. Balneoterapiya ) such patient appoint balneoprotsedura and mud cure. Hydrogen-sulfide and carbonic waters possess antiinflammatory action, increase protective forces of an organism. Apply mud applications, an electrophoresis of mud solutions on a projection of roots of lungs, induktotermogryaz, grya-8evy compresses (see. Mud cure ). Inhalations of radon have analgesic and antiinflammatory effect on a mucous membrane of bronchial tubes and tissue of lungs. At appointment balneoprotsedur or to lay down. dirt function of external respiration improves, microcirculation and a resorption of inflammatory infiltration amplify.
The physiotherapy exercises are widely used in complex therapy of sick Items. Under the influence of systematically carried out physical exercises ventilation of the lungs increases, improve also a lymphokinesis in lungs and a pleura, function of external respiration, becomes stronger respiratory muscles and mobility of a thorax increases. Physical exercises warn a number of complications in lungs and a pleural cavity (commissures, an atelectasis, emphysema, etc.), secondary deformations of a thorax. Specially picked up initial (drainage) positions give the chance to considerably improve drainage function of bronchial tubes and promote removal from bronchial tubes and alveoluses of slime, a phlegm. During the occupations of LFK there is a training of a diaphragm, development of diaphragmal respiration. The movements of a diaphragm promote strengthening of inflow of a venous blood from an abdominal cavity to heart, facilitating its work, favorably influence digestion. Improvement of oxygenation of blood during the performance of breathing exercises normalizes exchange processes in bodies and fabrics of all organism.
Lech. gymnastics appoint after decrease in temperature to normal or at a rack subfebrile, at involution of inflammatory process in lungs (by data a wedge., rentgenol, and lab. inspections) and in the absence of the expressed phenomena of cardiovascular insufficiency. As contraindications serve the acute stage of the disease or an aggravation accompanying hron, inflammatory process, sharp exhaustion of the patient.
From various means and the LFK forms are applied morning a gigabyte. the gymnastics to lay down. gymnastics (individual or group), drainage provisions, corrective gymnastics, and also massage, walks in the fresh air, elements of sports (volleyball, badminton, etc.). Actions appoint Zti taking into account a functional condition of the patient and the period of a disease.
At acute P. the patient who is on a bed rest appoint simple gymnastic exercises of small intensity for hands and legs, exercises for a trunk are carried out with a small amplitude of movements. Breathing exercises carry out without deepening of breath, i.e. without increase in mobility of a thorax on the party of defeat for a shchazheniye it is time a zhenny lung. It is necessary to pay attention to an urezheniye of breath. Initial positions for exercises lying or semi-sitting with highly lifted headboard. Duration of occupations is 10 — 12 min. In process of improvement of a condition of the patient carries out exercises from the initial position sitting, and upon transition to the ward mode — from a standing position; during this period the number of exercises for upper extremities and a trunk increases. Also breathing exercises improving ventilation of the struck departments of lungs are applied; the exercises increasing mobility of a thorax (inclinations, turns) to-rye in combination with respiratory are also used for the prevention of formation of pleural commissures; walking; exercises with objects. Time of occupations of 20 — 25 min. At the free mode increase number of the all-developing exercises for all muscular groups, appoint exercises with stuffed balls, maces, dumbbells, exercises on shells (wall bars, a bench). Time of occupations of 25 — 30 min. Along with to lay down. gymnastics it is possible to use walks, walking in combination with the respiratory movements on average speed.
After an extract from a hospital the patient is recommended to continue studies of LFK since the complete recovery of function of respiratory and cardiovascular system does not come by this time yet. In sanatorium conditions include in occupations sports exercises (walking, skis, rowing etc.), games (badminton, volleyball, table tennis).
In complex therapy of patients with an acute pneumonia of LFK it is successfully applied in combination with a fiziobalneolecheniye in a certain sequence; so, e.g., remedial gymnastics it is reasonable to give classes prior to thermal electroprocedures and an oxygenotherapy and after an aerosoltherapy with an interval of 1 — 2 hour
As it is very difficult to check completion of inflammatory process in lungs, patients shall be under dispensary observation within 6 — 12 months after recovery. Medical examination (see) includes performing rehabilitation therapy. The main role in a complex of rehabilitation actions belongs to lay down. to physical culture, physiotherapeutic procedures and good nutrition. It is reasonable to carry out treatment in specialized rehabilitation departments, sanatoria and dispensaries. The complex of rehabilitation actions includes an aerosoltherapy broncholitic mixes in combinations with microbicides (phytoncides, sometimes streptocides), inhalations of alkaline and oil solutions. The smokers who had acute P. shall stop smoking.
At timely and rational treatment both croupous, and focal acute P. usually by the end 3 — comes to an end 4th week with recovery. Criteria of recovery at P. are normalization of health and a condition of patients, elimination a wedge., laboratory and rentgenol, signs of inflammatory process in lungs. At a favorable current involution the wedge, P.'s symptoms occurs to 7 — to the 14th day. Rentgenol, signs of an inflammation disappear on 2 — - 3rd week. Together with tekhm more than in 70% of cases a wedge, and rentgenol, recovery at acute P. does not match elimination morfol, disturbances. The termination of treatment even at insignificant residual infiltration of pulmonary fabric creates threat of recuring, transition of acute inflammatory process in chronic with development in the subsequent pneumosclerosis (see). By data A. F. Polushkina (1977), long, within 3 — 4 years, overseeing by convalescents at acute P. showed that the absolute recovery came at 93,9% of patients, chronic P. was created at 1,2% of patients, at 4,9% of patients for 6 — 8 months it was not possible to liquidate symptoms of bronchitis; acute P. caused progressing in 2,7% of patients being available earlier hron, bronchitis.
Dispensary observation for had acute P. showed that the residual phenomena of acute P. (rigid breath, dry rattles, peribronchial and perivascular infiltration, changes biochemical, indicators of blood) can remain a long time, at some patients up to 6 months and more then there occurs recovery. According to V. P. Silvestrov (1979), acute P. gets a long current from every fourth patient. Out of time begun and incorrectly carried out treatment, change immunobiol, reactions in the course of a disease can be the reasons of a long current of acute P.; also associated diseases of a respiratory organs (hron, bronchitis, diseases of upper respiratory tracts), focal infection (hron, tonsillitis, sinusitis, cholecystitis, etc.), various professional harm, smoking contribute to a long current. Acute P. often gains long character from the weakened patients, especially advanced age, and also from the persons having associated diseases. V. P. Silvestrov (1979) considers that associations of activators, especially virus and bacterial, promote transition of acute inflammatory process in lungs in long.
Among pathogenetic links long P. changes of rheological properties of contents of bronchial tubes, a microbic allergy and an autoserotherapy consider a toxaemia, an anoxemia, disturbances of drainage function of bronchial tubes. At different stages of a disease this or that pathogenetic mechanism can be the leader.
The factors stated above promoting the long course of a disease contribute also to development hron. P. O acute P.'s transition in chronic can be spoken at absence, despite treatment, positive kliniko-rentgenol. loudspeakers, emergence of signs of a sclerosis of pulmonary fabric and the local deforming bronchitis and repeated aggravations. Preservation of these or those symptoms of a disease after 6 — 8 weeks and more after acute P.'s beginning is not criterion of transition of acute P. in chronic since the long current of P. in most cases comes to the end with recovery.
The rational therapy of patients of acute P. including a stage of rehabilitation treatment and dispensary observation leads to the fact that acute P. passes in hron, a form less often.
The lethality at P. depends on weight of a current, the previous state of health, features of treatment and fluctuates, according to various data, from 0,005 to 4,6%. The lethality at influenzal P. among the weakened elderly people is especially high, newborn, sick with heavy accompanying hron, diseases. The forecast of the diseases which were complicated by P. (plague, a malignant anthrax, measles, whooping cough, etc.), depends on weight of a basic disease and a current of P. which complicated them
Preventive actions at acute P. are based on carrying out the general a dignity. - a gigabyte. actions (the mode of work, airing of rooms, fight against dust content, good nutrition, isolation of the diseased etc.), and also on personal prevention. Personal prevention includes a systematic hardening of an organism (see. Hardening ), protection from overheatings and overcoolings, systematic exercises and tourism, sanitation of the centers of an infection (hron. tonsillitis, sinusitis, carious teeth, cholecystitis, etc.). Timely performance protivoepid, actions, including vaccination against flu of a pas, treatment of acute respiratory diseases, tracheitises and bronchitis is of great importance. Strict observance of the mode ordered by the doctor at diseases is necessary, to-rye can be complicated by pneumonia. Acute P.'s prevention at the patients having chronic legochna mi diseases is especially important (hron, bronchitis, bronchiectasias, bronchial asthma); they shall be on the dispensary account in a pulmonary office of policlinic.
Features of an acute pneumonia at children
Items at children have a number of differences from the same diseases at adults. It is caused first of all by features of a structure of a respiratory organs at children. Cartilages of a throat, a trachea and bronchial tubes at children of the first months and even years of Life soft, the mucous membrane friable, is rich with blood vessels and is rather poor in elastic fibers and mucous glands. These features, on the one hand, result in inferiority of protective mechanisms of a bronchial tree, and with another — cause easier emergence at children of the stenotic phenomena in respiratory tracts. By data A. I. Strukova (1960), at children of the first months of life is much sharper, than at adults and children of more advanced age, the segmented structure of lungs is expressed. Rather wide intersegmental connective tissue layers (fig. 11) interfere with contact distribution of inflammatory process. Therefore at children of chest and early age croupous pneumococcal P. develops extremely seldom.
Patients of early children's age easily have expressed hemodynamic disturbances in lungs caused by imperfection of regulatory systems. Formation of hyaline membranes is explained by these disturbances, and also a hyperpermeability of blood vessels, to-rye cause certain features of a current of P. in connection with sharply expressed phenomena of respiratory insufficiency.
Children have less alveolus, than at adults, and Interalveolar partitions are much richer with a friable connecting and adenoid tissue, circulatory and limf, vessels, н© is poorer in elastic fibers. It causes easier development of vascular frustration and promotes emergence of atelectases (see). Structural features of interstitial tissue of lung cause more expressed intersticial reaction which is that in an interstitium, especially around bronchial tubes and blood vessels, at repeated development of an acute respiratory infection of any etiology arise very widespread lympho-histiocytic plazmotsitarnye infiltrates. They are local manifestation immunomorfol. reactions, though are designated quite often by the term «intersticial pneumonia». Similar changes arise at other diseases of lungs with a long current, napr, at pneumocystosis (see). Features of structure of a microcirculator bed at children promote frequent defeat of a respiratory organs and distribution of any microorganisms, especially viruses and mycoplasmas, out of limits of a respiratory organs with the subsequent emergence of the centers of an infection, first of all in kidneys, intestines, a liver and a brain. In these bodies there are defeats essentially similar on features of reaction with observed in a respiratory organs.
Certain features at children exist in ways of infection and localization of inflammatory changes. In the antenatal period at infection respiratory viruses get into an organism of a fruit through a placenta gemato - gene transplatsentarno. At the same time there are centers of an inflammation which are localized generally in respiratory departments of lungs and also in a liver and kidneys. Damage of upper airways in this case arises for the second time and is observed less often.
On the current and an outcome of a disease, in addition to virulence of the activator, the great influence is exerted by a condition of protective forces of a macroorganism, tension of reactions of specific and nonspecific immunity, a type of the activator, existence of inborn malformations.
The newborn child can have a pre-natal item, i.e. developed at a fruit in the last days of pregnancy. K. A. Sotnik the ova observed pre-natal P. at 11,6% of the newborns (full-term and premature) who came on treatment to department of pathology of newborns. Mostly it is focal P. (bronchial pneumonia) and, in exceptional cases, croupous (share) Items. Infestants are microorganisms of vaginal flora, most often streptococci, staphylococcus, colibacillus, is more rare pneumococci. Pre-natal P.'s emergence is connected with diseases of the pregnant woman and an infection at the time of delivery. The contributing moment of development of pre-natal P. is the premature or early bursting of waters, and also long childbirth. Contagiums at pre-natal P. most often extend bronchogenic and are more rare in the hematogenous way. In P.'s development an important role is played by the disturbance of placental blood circulation leading to asphyxia which causes quite deep respiratory movements of a fruit with aspiration of amniotic waters. At gistol, a research of lungs at the died children in similar cases find amniotic liquid in alveoluses, bronchioles and bronchial tubes, and also leukocytic infiltration in alveoluses and alveolar partitions. Sometimes P. of the mixed type developing as a result of bronchogenic and hematogenous spread of an infection meets.
A clinical picture
Klin, pre-natal P.'s symptoms are expressed poorly. Disorders of breath and attacks of asphyxia are most often observed. The beginning of a disease, as a rule, happens acute though at premature children of P. can develop gradually and slowly. At children note a hyperexcitability, concern, a sleep disorder or slackness, an adynamia, muscular weakness, decrease fiziol, reflexes. Fervescence is possible, however premature children can have it normal or even lowered. Quite often note a loss of appetite, vomiting and vomiting. Breath frequent (to 80 in 1 min.), superficial, uneven, «groaning». During a breath there are retractions of pliable departments of a thorax, an exhalation long. Emergence of foam from a mouth and a nose is possible. Around a mouth cyanosis is usually observed, and at heavy disease quite often note the general cyanosis. Cough is frequent, times painful; at children with a hypotrophy or at premature it can have character of a tussiculation. Over lungs the tympanic shade of a percussion sound is defined, it is possible to find obtusion over the center of defeat with a long exhalation in some patients. Rattles are dry, non-constant, on 2 — the 3rd day of a disease small-bubbling wet rattles appear, to-rye can be listened only at rather deep breath. Note tachycardia, however at premature children emergence of bradycardia and arrhythmia is possible. The ABP at the full-term newborns in the first days of a disease is usually a little raised. Cardiac sounds are, as a rule, muffled or deafs. The stomach is blown up, soft, the liver is quite often increased and acts from under edge of a costal arch on 2 — 3 cm. In blood the leukocytosis with a moderate deviation to the left is usually observed, the accelerated ROE, the metabolic or mixed acidosis, quite often comes to light the expressed anoxemia (see. Hypoxia ).
The adverse obstetric anamnesis, a birth trauma, asphyxia at the time of delivery, disturbance of feeding, anemia, hypovitaminosis, a hypotrophy and other factors promote a heavy current of P. at the child and to a possible lethal outcome.
At premature children owing to immaturity of pulmonary fabric and an underdevelopment of elastic elements intersticial focal fibroziruyushchy P. can develop (see. Wilson — Mikiti a syndrome ).
At children of chest and early children's age with not burdened premorbidal background acute P. proceeds rather easily. The disease usually begins sharply: the child becomes whimsical, irritable, refuses food, body temperature increases to 38 — 39 °, there are cold, cough, small increase of breath, tachycardia is noted. In the first day of a disease in lungs, except a bandbox shade of a percussion sound, any changes usually it is not noted.
On 2 — the 3rd day of a disease the state worsens, temperature keeps on high figures, cough and short wind amplifies. At breath wings of a nose are inflated, retractions of pliable departments of a thorax, lag of one half of a thorax appear. Skin is pale, around a mouth cyanosis, visible mucous membranes also tsianotichna is noted. Over lungs against the background of a bandbox sound at silent percussion it is possible to find the centers of shortening of a sound, breath with a rigid shade, small-bubbling rattles, sometimes crepitation are listened here. Pulse is frequent, its filling can be a little reduced, cardiac sounds are a little muffled. The stomach is soft, participates in breath, the liver acts from under edge of a costal arch on 3 — 4 cm. Quite often in this period of a disease children have a vomiting (especially after a fit of coughing), liquid excrements.
At timely begun treatment the condition of the patient quickly improves also on 5 — the 7th day of a disease a wedge, manifestations disappear. Gradually, during 5 — 6 weeks, the functional condition of all bodies and systems is normalized.
The item at children with anomalies of the constitution, especially at children with exudative and catarral and limfatiko-hypoplastic diathesis (see. Status thymicolymphaticus , Exudative and catarral diathesis ), proceeds hard, is followed by attacks of a severe cough, development of an asthmatic syndrome and often gets a long and recurrent current. Children with a hypotrophy have II—III degrees (see. Hypotrophy ) The item is characterized by a sluggish and long current against the background of standard or subfebrile temperature with scanty a wedge, and rentgenol. manifestations. In such cases development of sepsis or P.'s transition in hron, a form is possible. Rickets (see) at children of early age is an adverse premorbidal background. Deformation of a thorax, deterioration in ventilation of the lungs and hemodynamic disturbances are factors of «the increased risk» for emergence of P. which in these cases has tendency to a long recurrent current. The acute P. developing against the background of hron of pneumonia, proceeds with the expressed intoxication, respiratory and cardiovascular insufficiency.
At children of the first years of life depending on a disease-producing factor nek-ry features in a wedge are possible, a picture and P. Krayne's current hard proceed at children staphylococcal and mixed influenzal and staphylococcal by P. Bystro toxicosis, slackness, an adynamia accrue, emergence of spasms, vomitings, liquid excrements is possible. Acute respiratory and cardiovascular insufficiency develops: integuments pale with a gray or cyanochroic shade, the expressed short wind, tachycardia, a liver and a spleen are increased. For staphylococcal P. education in a lung of air-vessels — bulls is pathognomonic (pnevmotsela) which number and the sizes can change. The most severe form of staphylococcal P. is staphylococcal destruction of lungs of which purulent infiltration of pulmonary fabric and formation of abscesses is characteristic. In this case deterioration in already serious general condition of the patient is noted: slackness, apathy, anorexia increase, body temperature increases, skin gets an earthy shade, dryness of mucous membranes is noted, features are pointed, an asthma with participation of auxiliary muscles in the act of breath amplifies. Pulse becomes frequent, small filling; cardiac sounds are muffled. Over abscess the percussion sound is shortened, mixed wet rattles are listened. After opening of abscess in a bronchial tube typical signs of existence of a cavity appear: amphoric breath, sonorous wet rattles with a metal shade, timpanichesshsh a shade of a percussion sound over a cavity. The patient coughs up a large number of a purulent phlegm with off-flavor. Children of early age swallow a phlegm therefore at them it is possible to see pus in emetic masses; at the same time development of staphylococcal damages of intestines is sometimes observed. After opening of abscess the condition of the patient gradually improves, temperature decreases a little, the phenomena of intoxication decrease. Especially hard the huge («sagging») abscesses at children of the first months of life proceed. Such patients have the general state extremely heavy, symptoms of intoxication, legochnoserdechny insufficiency, paresis of intestines are sharply expressed.
Crucial importance in diagnosis of abscesses and bulls belongs rentgenol. to a research. During formation of abscesses on the roentgenogram intensive limited homogeneous blackout is visible, and after their break in a bronchial tube there are one or several cavities which are usually located on the periphery of le» - whom and having a horizontal fluid level. Clearer idea of the sizes and the location of abscesses is promoted by a tomographic research of lungs.
After the postponed staphylococcal P. in lungs, as a rule, there are considerable fibrous changes. Thin-walled cavities sometimes can remain for a long time. At some children pneumonia forms hron, (see below).
At influenzal P. the heavy current with the expressed toxicosis and dysfunctions of a nervous system and bodies of blood circulation is observed. The catarral phenomena in upper respiratory tracts in similar cases happen minimum. Items of a parainfluenza etiology are characterized by toxicosis, an adynamia, a hyperplasia tracheal and bronchopulmonary limf, nodes. At adenoviral P. the expressed catarral phenomena in upper respiratory tracts and a conjunctiva, cough, cyanosis, short wind, disturbance of breath, abundance of rattles in lungs are observed (see. Adenoviral diseases ). Respiratory sintsitial-nye P. differ in considerable toxicosis, painful cough, attacks of asphyxia, emergence of atelectases, drain centers of an inflammation, development of a pulmonary heart.
Nek-ry features a wedge, pictures are observed at plazmotsellyu-lyarny (see. Pneumocystosis ) and mycoplasmal P. (see. Mycoplasmal infections ). Fungal P. more often happen secondary as manifestation of generalized process to a fungal infection of an oral cavity (the milkwoman, stomatitis), skin, intestines, urinary tract and other bodies.
The most frequent complication of P. at children of early age is purulent and catarral otitis (see). At the same time the aggravation of symptoms of the child is noted, body temperature increases, there are vomiting, concern, the dream, appetite worsens, increase occipital and mastoidal limf, nodes and morbidity is noted during the pressing on a trestle. The diagnosis is confirmed at an otoskopiya.
At the abscessing form P. there can be purulent pleurisy (see), pyopneumothorax (see), purulent mediastinitis (see) and pericardis (see). A terrible complication is sepsis (see) and its purulent manifestations — meningitis (see), purulent arthritises (see), osteomyelitis (see), etc. At early children's age at P. as a result of full or partial bronchial obstruction the atelectasis or obturatsionny can develop emphysema of lungs (see).
takes the Important place in P.'s diagnosis at children carefully collected anamnesis. During the collecting anamnestic data first of all it is necessary to find out on what background the real disease proceeds, i.e. to learn about features of development and food of the child, to specify the postponed diseases, existence of allergic reactions (in particular, on antibiotics).
At survey of the patient it is necessary to pay attention to indirect signs of P.: coloring of skin, mucous membranes, existence of cyanosis, participation in the act of breath of auxiliary muscles, tension of wings of a nose, retraction of mezhreberiya, supraclavicular and subclavial poles, etc. At a research of a thorax Physical data hmonut to be very scanty. Sometimes the only find are the wet rattles disseminated through all thorax or concentrated in one area. At rentgenol, a research of lungs in the first days of a disease the increased transparency of pulmonary fields, strengthening of the vascular drawing is noted, the centers of infiltration appear a bit later, to-rye a thicket are observed in medial departments of lungs. Quite often (especially at premature newborn children) segmented and polysegmented atelectases of pulmonary fabric or emphysema come to light. The last is more characteristic of children of early age. Shadows of a various form, localization and density radiological are found in more senior children in lungs. It is possible to establish increase and consolidation of one or both roots of lungs from which the shadows which are gradually dissipating in a pulmonary parenchyma fanlikely disperse. Occasionally the shadow can be only on the periphery, without being connected with a root of a lung. Dense, homogeneous and clearly limited shadows meet seldom. Sometimes it is possible to establish participation in inflammatory process of a pleura in the form of kostalny or interlobar pleurisy.
Treatment of children, sick P., is carried out taking into account age, a form of a disease and weight of its current. Newborns and children of the first months of life shall be hospitalized in specialized departments with observance of the conditions of isolation excluding cross infection. Children of more advanced age at rather easy current of P. and existence of good living conditions can be left at home, but due leaving and daily medical (medical and sisterly) observation and treatment shall be provided to them.
The child shall be in the light, well aired spacious chamber or the room (not less sq.m on one patient) with air temperature 20 — 22 ° for full-term and 23 — 24 ° — for premature children. The head of the child should be raised, the clothes shall not complicate breath. It is periodically desirable to change position of the child — to overturn, take on hands, etc. For fight against a hypoxia at heavy P. to the child masks, etc. allow to breathe the moistened oxygen in special tents or by means of a catheter. Oxygen moves in mix with air in concentration of 40 — 60%. Sessions of an oxygen therapy lasting 20 — 40 min. repeat 5 — 10 times e a current of days. The good effect renders use of mix of oxygen with helium in the ratio 2: 1, and also use of oxygen in a pressure chamber under supertension (see. Barotherapy ). Use of aerosols of mucolytic drugs (Acetylcysteinum, fibrinolysin, chymotrypsin, Mucomystum, etc.), bronchial spasmolytics (an Euphyllinum, ephedrine) promotes fluidifying and more active evacuation of a secret from bronchial tubes, to improvement of bronchial passability.
For the purpose of elimination of intra bronchial obstructive impassability it is shown bronkhoskopiya (see).
For reduction of toxicosis and improvement of function of c. the N of page, bodies of blood circulation, breath and urination intravenously or intramusculary enter solutions of an Euphyllinum, Korglykonum or strophanthin, cocarboxylase, lasixum, ascorbic to - you. The good effect renders intravenous administration of native plasma and an injection of gamma-globulin. Administration of antistaphylococcal plasma, antistaphylococcal gamma-globulin is shown to staphylococcal P.'s patients.
In complex treatment use is of great importance antibiotics (see) taking into account sensitivity to them of microflora, their side effect and individual portability. The good therapeutic effect is rendered by semi-synthetic Penicillin (Oxacillinum, Methicillinum, ampicillin), lincomycin, Cefaloridinum, Sigmamycinum, Ristomycinum, etc., to-rye enter parenterally or in 3 — 4 times a day, a course of treatment of 7 — 10 days. If in 3 — 4 days after an initiation of treatment the positive effect is absent, it is necessary to apply other antibiotic. In hard cases appoint two antibiotics strengthening action of each other. Newborns and children of early age cannot enter the antibiotics having ototoksichesky effect (streptomycin, Monomycinum, etc.). At virus P. apply leukocytic interferon which solution is dug in in a nose or enter into respiratory tracts in the form of inhalations.
It is necessary to provide a balanced diet of patients: children of the first months of life shall receive chest women's (maternal or donor) milk. In the absence of women's milk preference should be given to acid milk mixes. In the acute period of P. at the expressed toxicosis it is possible to reduce amount of food on 1/3 in comparison with age norm of the healthy child (see. Feeding of children ). In similar cases the missing amount of liquid, carbohydrates and protein fill with purpose of solution of Ringer, 5% of solution of glucose, isotonic solution of sodium chloride, a reopoliglyukin, Haemodesum, 5% of solution of globulin inside or intravenously. During the day the child needs to enter liquids (inside and parenterally) 150 — 180 ml/kg.
At sick P. a polyhypovitaminosis therefore purpose of the polyvitamins improving exchange processes is necessary is noted (redoxons, D, E, a complex of vitamins of group B, etc.). In the period of reconvalescence carry out physiotherapeutic procedures, massage, fortifying treatment. The obligatory element of complex treatment and rehabilitation at P. at children — to lay down. physical culture. At children of LFK plays especially important role as means of fight against respiratory insufficiency and consequently, with a hypoxia. Long P. at threat of transition is of great importance of LFK in cases it in hron, a form. LFK is shown at all stages of treatment of acute P., it can be applied since 1 — 1,5-month age. At children of chest age a technique to lay down. gymnastics is under construction on the principles of use of instinctive reflexes. Bases of such reflex exercises were developed by A. F. A tour with sotr. In the LFK complex together with reflex exercises massage is widely used (see). Gradually along with reflex passive and active exercises by means of which the general influence on an organism, a respiratory organs is carried out are applied, and also problems of formation at the child of independent movement skills are solved. Lech. the gymnastics and massage are made on a special massage table at air temperature in the room not lower than 20 °. Lech. 2 times a day are recommended to carry out gymnastics and massage. Duration of the procedure fluctuates depending on a stage of a disease and age from 3 — 5 to 10 — 15 min.
At P.'s treatment at children of more advanced age widely apply gymnastic exercises with objects (balls, gymnastic sticks, etc.), to-rye allow to influence selectively certain muscular groups and a respiratory organs (breathing exercises), and also imitating exercises and games.
P.'s prevention at children includes the actions increasing body resistance of the child: the correct breastfeeding, the prevention of hypovitaminoses and anemias, prevention of viral diseases, treatment of diseases of ENT organs, holding the tempering actions (air bathtubs, massage, hydrotherapeutic procedures).
Chronic P. is result not completely cured acute by the Item. By data V NI R1 of pulmonology, number of patients of chronic P. does not exceed 4% among inpatients with diseases of a respiratory organs, and according to KA billiard pocket (Kaluza, 1972), Veks and Wasserman (R. of Wex, F. J. Bassermann, 1973) - 1-2%.
According to the definition developed in the All-Russian Research Institute of pulmonology, chronic P. represents, as a rule, the localized process which is an outcome of not cured completely acute P., morfol which substrate is the pneumosclerosis or carnification of pulmonary fabric, and - also irreversible changes in a bronchial tree as a local hron, the bronchitis which is clinically shown in repeated flashes of inflammatory process in the struck part of a lung. All provisions of this definition are essentially important. So, the lokalizovannost of process distinguishes chronic P. from diffusion diseases of lungs, such as bronchitis (see), emphysema of lungs (see). Obligatory communication of chronic P. with acute indicates the main line of its pathogeny and delimits from primary hron. diseases. The instruction on the fact that substrate of a disease is the pneumosclerosis (see) draws a distinction between chronic P. and chronic diseases which cornerstone destruction, suppuration in patol, the cavities which resulted from disintegration of a pulmonary parenchyma or a bronchiectasia is. At last, mentioning of a recurrence of an inflammation in an affected area of a lung excludes from the concept «chronic pneumonia» the asymptomatic localized pneumosclerosis which is not a disease, and purely morphological or rentgenol, a phenomenon, a form of treatment from some patol, processes and injuries.
Until recently was considered that chronic P.'s patients make more than a half of all stationary pulmonary patients. The reason that chronic P.'s frequency was significantly overestimated were considerably conditional criteria of definition of transition of acute P. in hron, a form (residual clinicoradiological manifestations in 6 — 8 weeks later began diseases). Besides, numerous researches PI. V. Davydovsky (1937), A. T. Hazanova. (1947), A. I. Strukova and PI. M. Kodolova (1970), based preferential on studying of drugs of the lungs deleted apropos hron, nonspecific diseases, revealed the general morfol, changes (an inflammation, carnification, a pneumosclerosis, emphysema) which are expression of stereotypic nonspecific reaction of pulmonary fabric to these or those disturbing factors. These observations induced morphologists, and then and clinical physicians to consider that hron, nonspecific diseases of lungs represent this or that form of chronic P. which began to be considered as a special nosological form.
From the middle of the 50th ideas of so-called staging of a current of the chronic P. beginning with not resolved - sya P. further progressing from a limited pneumosclerosis and bronchitis before destruction of pulmonary fabric began to develop and bronchiectasias (see). Further in so-called Minsk (1964) and the Tbilisi (1972) classifications of chronic P. staging of its development began to be understood even more widely — "from rather small on the volume and extent of defeat of the changes of pulmonary fabric taking a segment or a share before the diffusion process in bronchopulmonary fabric with bronchiectasias, respiratory, and then and heart failure leading to death of the patient. So widely treated chronic P. actually included almost all main forms hron, nonspecific pathology of lungs, such as bronchitis, emphysema, bronchiectasias, hron, abscess etc. The exaggeration of a role of an infection in an etiology of bronchial asthma brought to that, as this disease was considered as if as an element or chronic P. Odnako's complication as showed researches, acute P.'s transition in hron, a form against the background of not changed to this bronchial tree and not followed by abscessing occurs extremely seldom, according to N. V. Elypteyn (1971), A. N. Gubernskova (1978), E.A. Rakova (1979) — in 1 — 2% of cases. Besides, long dynamic overseeing by patients could not confirm natural transition of chronic P. with existence of a local pneumosclerosis in bronchiectasias or destruction of a pulmonary parenchyma, and also transformation of local process what P., in generalized defeat with development of total bronchial obstruction and a pulmonary heart is.
The main and the most often meeting hron, nonspecific disease of lungs resulting in disability and the death of patients is hron, bronchitis (see), etiologically not connected with acute P.
and quite often exerting the defining impact on emergence and the adverse course of acute inflammatory processes in pulmonary fabric. Thus, chronic P. has no that value in pulmonary pathology, a cut was given it in the past. However such treatment hron. The item is divided not by all scientists. In particular, in pediatrics a bit different approach to this disease is accepted (see below).
The etiology and a pathogeny
As chronic P. is a direct consequence inf. inflammations of a lung, its etiology corresponds to acute P. Vopros's etiology about the reasons causing incomplete permission of acute inflammatory process in pulmonary fabric and its transition in hron, a form, it is studied insufficiently. Obviously, an essential role is played at the same time by the irreversible damage of a quantity of the structural elements of pulmonary fabric alternating with viable structural elements (the disseminated necrosis, on terminology S. S. Girgolava, 1956), arising during the acute inflammatory process proceeding without massive destruction of pulmonary fabric. In a result in easy develops pneumosclerosis (see), being morfol, chronic P. Intensivnost's substrate of the damaging action inf. a factor on pulmonary fabric depends both on pathogenicity of microorganisms, and on reactivity of the patient. Any factors reducing reactivity of the patient (senile age, intoxication, including virus, alcoholism, hypovitaminosis, etc.), can promote, according to N. S. Molchanov and V. V. Stavskaya (1971), to acute P.'s transition in hron, a form. As an essential role in the damaging operation of activators on fabric is played also by duration of their influence, essential value has untimely and inadequate treatment of patients acute the Item. In many cases the bronchitis which is sharply complicating drainage and aeration function of bronchial tubes in a zone of an acute inflammation is defining in chronic P.'s pathogeny accompanying hron. So, according to L. G. Soboleva (1979), acute P.'s transition to chronic was observed almost only at the patients who earlier had obstructive bronchitis (see).
The irreversible changes developing in a lung upon acute P.'s transition in chronic, hypersecretion of slime in departments of a bronchial tree with the broken drainage function and also disturbance of a raspravleniye and aeration of alveoluses in a zone of pneumosclerous changes cause decrease in resistance of an affected area of a lung concerning adverse, in particular infectious, influences. In the respective sites of pulmonary fabric there are repeated flashes of an acute inflammation, to-rye in some cases can lead to progressing of a pneumosclerosis and disturbance of respiratory function. And yes and more often the reason of an aggravation of chronic P., according to L. A. Vishnyakova (1978), are the pneumococcus and Pfeyffer's stick, to-rye quite often become more active under the influence of the postponed viral infection, overcooling and other adverse factors. As a result of an aggravation inf. process there are repeated local flashes of an inflammation, to-rye are observed preferential in a bronchial tree or in pulmonary fabric (bronkhitichesky and parenchymatous types of an aggravation, according to A. V. Alekseenko, 1980).
The pathological anatomy
the Struck part of a lung at chronic P. is usually reduced in volume and covered with unions. On a section pulmonary fabric is represented condensed. Walls of bronchial tubes are rigid. The gleam of bronchial tubes contains a mucopurulent secret. Microscopically to a greater or lesser extent the expressed phenomena of a pneumosclerosis come to light: fibrosis of an interstitium with signs of an inflammation. In other cases carnification of alveoluses as a result of the organization of a fibrinous exudate prevails; sometimes carnification develops in the form of the large centers which form comes nearer to spherical (spherical chronic P.). Sites of an intersticial sclerosis and carnification can alternate with the centers of a peri-fok of lny emphysema. Walls of bronchial tubes are thickened at the expense of fibrosis. In mucous and submucosal layers the phenomena hron, inflammations with characteristic reorganization of an epithelium are noted (reduction of number of cells of a ciliary epithelium, dominance of scyphoid cells, sometimes a metaplasia of a cubic ciliary epithelium in multilayer flat).
Depending on dominance of these or those morfol, changes chronic P. is subdivided on intersticial (with dominance of a sclerosis of a peribronchial interstitium) and karnifitsiruyushchy (with dominance of carnification of alveoluses). Depending on prevalence distinguish focal (more often karnifitsiruyushchy), segmented, share and total (with damage of all lung) chronic P. Ukazyvayut also localization of changes (on shares and segments) and a phase of process (an aggravation, remission). At the stated definition hron. The items «Minsk» and «Tbilisi» of classification lose the value.
A clinical picture
acute P.'s Transition in hron, a form is stated in the absence of a positive rentgenol, dynamics, despite prolonged and intensive treatment, and, above all at repeated flashes of inflammatory process in the same site of a lung where took place acute the Item. The terms which passed since the beginning of a disease cannot serve as criterion of development in chronic P.'s patient as elimination of clinicoradiological manifestations of acute P. can last many months, and sometimes and over a year. Patients at chronic P. complain generally of cough, stethalgias on the party of defeat, is rare on a pneumorrhagia, fervescence, weakness, perspiration. Expressiveness of these symptoms depends on a stage (an aggravation or remission) in which the patient is inspected.
At chronic P.'s aggravation the health of patients worsens. There is a weakness, perspiration. Cough arises or amplifies, and the phlegm quite often gains purulent character. Sometimes the patient is disturbed by thorax pains on the party of defeat. Body temperature increases to subfebrile or febrile figures. Data of a physical research (a dullness, small-bubbling and crepitant rattles) can remind acute P., and radiological in a zone of a pneumosclerosis fresh infiltrative changes of pulmonary fabric appear. At so-called bronkhitichesky type of an aggravation on the roentgenogram only strengthening of the pulmonary drawing due to peribronchial infiltration can be noted. In blood the moderate leukocytosis comes to light, the accelerated ROE, and also shifts biochemical, tests, characteristic of an aggravation of inflammatory process is noted (a hypoalbuminemia, increase alfa-2-, beta and gamma-globulins, fibrinogen, sialine to - t, a gaptoglobina). During the subsiding of an aggravation biochemical tests are normalized more slowly, than a wedge, indicators.
During remission of the complaint of patients of chronic P. can be scanty or be absent at all. Unproductive cough, preferential is in the mornings characteristic, at a satisfactory general condition and health. Data of a physical research are also poor. Sometimes in a zone of defeat it is possible to define a dullness and not plentiful rattles. At macrofocal karnifitsiruyushchy chronic P. complaints and changes of data of a physical research, except change of a percussion sound, most often are absent.
Chronic P. or its aggravation in most cases is confirmed at rentgenol, a research, at Krom reduction of the relevant department of a lung and strengthening of the pulmonary drawing due to changes of an interstitium is noted. At karnifitsiruyushchy chronic P. the intensive, rather accurate shadows similar to a peripheral tumor, quite often high standing of the corresponding dome of a diaphragm, an obliteration of pleural sine, commissural process in a pleura of various intensity can be observed. At a bronchography — rapprochement of bronchial branches, roughness of their contours and irregularity of filling in the field of defeat (the deforming bronchitis). Bronchoscopic the endobronchitis expressed in the corresponding share or a segment, but sometimes extending out of their limits is found catarral (in the period of an aggravation sometimes purulent). At a spirografi-chesky research (see. Spirography ) find, as a rule, restrictive disturbances of ventilation, and in case of the accompanying obstructive bronchitis — disturbance of bronchial passability.
the Greatest practical value differential diagnosis hron has the differential diagnosis. Items with cancer of a lung (see) (patients with cancer of a lung sometimes a long time are observed with the wrong diagnosis of chronic P. therefore do not receive the corresponding treatment). In cases of the dragged-out or recurrent process in a lung, in particular at elderly men and smokers before making chronic P.'s diagnosis, it is necessary to exclude first of all the tumor stenosing a bronchial tube and causing the phenomena so-called obturatsionny, or parakankrozny, the Item. The large peripheral focal shadows found at rentgenol a research, most often are tumors, but can represent also sites of carnification. The diagnosis is made on the basis of dynamics rentgenol, a picture which at cancer is represented negative. The final diagnosis in most cases manages to be established by means of special methods: bronkhoskopiya with a biopsy, a transbronchial or transthoracic biopsy patol, the center, regional limf, uzlovt bronchographies. At impossibility to specify the diagnosis these methods in the absence of the general contraindications to an operative measure showed a thoracotomy (see) with establishment of the diagnosis on the operating table and the subsequent performance of intervention of appropriate volume.
Differential diagnosis of chronic P. and hron, bronchitis is carried out on the basis of absence at bronchitis of the acute beginning of a disease, and also local changes at physics by flax, radiological and endoscopic researches. Are characteristic of bronchitis diffusion of defeat, are quite often observed a wedge, and rentgenol. symptoms of emphysema and typical functional changes (obstructive disturbances of ventilation, pulmonary and pulmonary heart).
Bronchiectasias (see) unlike chronic P. meet at younger age; more plentiful department of a phlegm, and also typical bronchiectasias revealed at a bronchography with disturbance of passability of the branchings located distalny is characteristic of them.
Hron, abscess of a lung (see) the wedge, differs in a picture of pulmonary suppuration from chronic P. typical; radiological at abscess in survey pictures, tomograms or at a bronchography against the background of a pneumosclerosis the cavity comes to light.
Certain difficulties quite often arise at chronic P.'s differentiation and some forms of a pulmonary tuberculosis (see. Tuberculosis of a respiratory organs ). Absence at the beginning of a disease of signs of acute nonspecific process, preferential superlobar localization of defeat, a petrifikata in pulmonary fabric and bronchopulmonary (root) limf, nodes, revealed at rentgenol, a research is characteristic of the last. The diagnosis of tuberculosis is confirmed by a repeated research of a phlegm on a mycobacterium, conducting skin tuberkulinovy tests, and also data serol, methods of a research. It must be kept in mind also a possibility of development of chronic P. on site of a metatuberculous pneumosclerosis.
Treatment, the forecast and prevention
chronic P.'s Treatment in the period of an aggravation shall be in principle same, as well as at acute the Item. Because most often aggravations are caused by a pneumococcus and Pfeyffer's stick, antibacterial therapy is performed generally by means of drugs of a penicillinic and tetracycline row, and also erythromycin in sufficient dosages. Duration of use of antibacterial agents depending on efficiency fluctuates from 1 to 4 week. In case of insufficient efficiency the players of antibiotics are changed taking into account results of crops of a phlegm on special environments which is recommended to be made before prescription of antibiotics, and also taking into account results immunol, researches of the patient. At chronic P.'s treatment it is recommended to use endotracheal and endobronchial sanitation with careful washing of the struck departments of a bronchial tree of 3% solution of hydrosodium carbonate and the subsequent introduction in them of antibiotics, broncholitic and mucolytic means. A part at treatment of aggravations of chronic P. is played by purpose of the antiinflammatory and hyposensibilizing means (acetilsalicylic to - you, 10% of solution of calcium chloride intravenously, Dimedrol). In the period of an aggravation hron. Items use local UF-radiation, electric field of UVCh in the continuous mode. At a subacute current of an aggravation appoint an inductothermy (see), microwaves of decimeter range, during the subsiding of an aggravation — electric field of UVCh in pulsed operation (see UVCh-therapy), an electrophoresis using pharmaceuticals (see the Electrophoresis., medicinal), an aero ionotherapy (see. Aeroionization ). At a prolonged aggravation against the background of hron, bronchitis, bronchiectasias (in the absence of pus), at early manifestations of a pulmonary heart, at a bronchospasm the harmonic modulated currents are recommended (see. Impulse currents ).
Chronic P.'s treatment during remission represents a package of measures, directed to the prevention of an aggravation. Chronic P.'s patients shall stay on the constant dispensary registry in pulmonol, an office of policlinic. They need rational employment (in the conditions excluding sharp temperature variations, production air pollution etc.). Courses of antirecurrent therapy and treatment in night dispensaries, specialized sanatoria are shown. In the period of remission apply the general UF-radiation to prevention of an aggravation (see. Ultraviolet radiation in physical therapy), heliation (see), pulse electric field of UVCh, an electrophoresis using pharmaceuticals, hydropathic procedures (rubdown, douche), bathtubs — oxygen, narzan, chloride sodium, turpentine (see. Balneoterapiya , Bathtubs , Balneotherapy ), thalassotherapy (see). Treatment of the focal infection which is localized in paranasal sinuses, in teeth is carried out.
As morfol, chronic P.'s basis are irreversible changes in bronchopulmonary fabric, the disease in principle cannot be cured by means of conservative methods of treatment. Nevertheless systematically carried out treatment in most cases allows to support a condition of the patient at the satisfactory level with preservation of working capacity.
At frequent aggravations and small efficiency of antirecurrent therapy it is possible to raise a question of use of operational methods of treatment. The pneumonectomy is possible preferential at persons of young and middle age at rather accurately delimited process and lack of the general contraindications to operative measures on bodies of a thorax.
The main measure of prevention of chronic P. is the prevention, early detection, and also timely and rational treatment of acute Items. The persons suffering hron. Items, shall be under dispensary observation.
Features of chronic pneumonia
Chronic P. at children occurs at children quite often. Most of domestic pediatricians (S. M. Gavalov, 1968; S. V. Rachinsky, 1971; N. N. Rozinova, 1974; S.Yu. Kaganov, 1979, etc.) include bronchiectasias in chronic P.'s concept, allocating respectively special bronkhoektatichesky option of chronic P. that is explained with pathogenetic communication of both states with acute P., difficulties 'Their differential diagnosis at children during formation of bronchiectasias and existence of a large number of transitional forms. At the same time most part of domestic surgeons (A. P. Kolesov, 1951; G. A. Boykov, 1973; V. R. Yermolaev, 1974; N. V. Putov, 1977), and also many foreign researchers consider bronchiectasias as an independent nosological form.
At children chronic P. forms generally in the first 3 years of life, most often as a result of an adverse current of acute P. Zatyazhnoye, and further hron, segmented or polysegmented P.' current — result of disturbance of drainage function of bronchial tubes (that conducts to a ginoventilyation or an atelectasis), development of a local purulent bronchitis, infection bronchopulmonary limf, nodes or destruction of pulmonary fabric at acute destructive processes. More rare heavy viral infections (measles, whooping cough), aspiration of foreign bodys or metatuberculous are chronic P.'s reason pneumosclerosis (see). In development hron. bronchopulmonary process the premorbidal background of the child, disturbance of resistance of an organism, including as a result of inborn pathology of an immunogenesis is of great importance.
Pathomorphologic changes at chronic P. at children are characterized by existence local hron. bronchitis, bronchiectasias, atelectases, sclerous changes in the struck department of lungs. Often the cellular lymphoid infiltrates squeezing small pneumatic ways develop. In post-stenotic departments diyetelektaza, atelectases or sites of emphysema are formed. Chronic P. at children — dynamic morfol, process, at Krom is possible to track the beginning of an inflammation and gradual formation of a pneumosclerosis.
Chronic P. at children proceeds rather easily due to reduction of number of patients with classical clinic of bronchiectasias that allowed to allocate small forms of a disease and bronkhoektatichesky option. At small forms of a disease the subfebrile temperature, cough with allocation of a mucopurulent or purulent phlegm (20 — 30 ml per day) are noted only in the period of an aggravation. Sometimes at wet cough there is no phlegm at all. At oron-hoektatichesky option, irrespective of the period of a disease, bystry fatigue, constant cough with a purulent phlegm which quantity in the period of an aggravation increases are observed. At children with hron. The item is late physical development, it is often noted hron. focal infection in a nasopharynx. At inspection of the patient over the struck segments define shortening of a percussion sound. Auskultativno listens small and srednepuzyrchaty wet rattles. In the period of an aggravation the number of rattles increases, at small forms of a disease during remission rattles can be absent.
Rentgenol, chronic P.'s picture is characterized by strengthening and deformation of the pulmonary drawing, reduction of separate segments of a lung in volume, a thickening of walls of bronchial tubes. In the period of an aggravation peribronchial infiltration or infiltration of pulmonary fabric is observed. At small forms patol, process no more than 1 — 5 segments are surprised, and bronkhografichesk the deforming bronchitis or moderate cylindrical bronchiectasias is defined. At bronkhoektatichesky option of chronic P. contrasting reveals cylindrical, meshotchaty bronchiectasias. Process is more often localized in segments of the lower share and a uvula of the left lung, in the lower or average shares on the right.
Bronchoscopic at small forms of chronic P. the local purulent or mucopurulent endobronchitis is defined. At bronkhoektatichesky option of chronic P. an endobronchitis always purulent and prevalence exceeds it the volume of a zone of defeat in pulmonary fabric. By the beginning of remission at small forms of chronic P. the purulent endobronchitis manages to be liquidated by conservative methods of treatment, but it with firmness remains at bronkhoektatichesky option.
The phase of a course of process (an aggravation, remission) is defined on the basis a wedge, pictures, mikrobiol, and tsitol, researches of a phlegm (qualitative and quantitative test of microbic flora and viruses, determination of amount of neutrophilic leukocytes and cells of a bronchial epithelium), datas of laboratory (acceleration ROE, a neutrophylic leukocytosis, positive C-reactive is white to, increase in quantity ag-and az globulins, a gaptoglobin, sialine to - t in blood serum).
Function of external respiration — one of the main criteria at assessment of disease severity. At small forms of chronic P. there are insignificant obstructive disturbances in the period of an aggravation, during remission these disturbances disappear. At bronkhoektatichesky option of chronic P. the combined obstructive and restrictive disturbances of breath are noted. For definition of ventilation and a pulmonary blood-groove functional radiological methods of a research are perspective (see Lungs, methods of a research). At heavy disease and total defeat by purulent process of top and bottom respiratory tracts it is necessary to exclude inborn immunological insufficiency (see).
The differential diagnosis is carried out with a pulmonary form mucoviscidosis (see), the infected anomalies of lungs — simple and cystous hypoplasias, sequestration of a lung (see Lungs, malformations), recurrent bronchitis (see), local functional dyskinesia of bronchial tubes, a pulmonary tuberculosis (see Tuberculosis of a respiratory organs), a metatuberculous or metapnev-monichesky segmented pneumosclerosis (see).
Chronic P.'s treatment in the period of an aggravation is identical to treatment acute to the Item. Much attention is paid to endobronchial sanitation, recovery of drainage function of bronchial tubes, antibacterial therapy taking into account a type of the activator, normalization immunol, reactivity, sanitation of the centers of an infection in an oral cavity and a nasopharynx. After treatment in a hospital the sanatorium therapy and dispensary observation is necessary. At inefficiency of conservative therapy the question of operational treatment is raised.
Chronic P.'s forecast rather favorable thanks to the organization of system of dispensary observation and treatment, and also achievements of pulmonary surgery.
Chronic P.'s prevention at children includes antenatal protection of a fruit (see), natural feeding of children (see), hardening (see), active treatment of the long and complicated forms of an acute pneumonia.
Table 1. DATA of the PHYSICAL RESEARCH of PATIENTS AT FOCAL PNEUMONIA, VARIOUS ON PREVALENCE (N. S. Molchanov, V. V. Stavskaya, 1971)
Table 2. DOSES, TERMS AND WAYS of INTRODUCTION of the ANTIBIOTICS (are PRESENTED ON GROUPS) which are MOST OFTEN USED FOR TREATMENT of PNEUMONIA, FEATURE of THEIR USE AND POSSIBLE COMPLICATIONS (V. P. Silvestrov and soavt., 1979)
Table 3. DOSES, TERMS AND WAYS of ADMINISTRATION of SULFANAMIDE DRUGS. The MOST OFTEN USED FOR TREATMENT of PNEUMONIA, FEATURE of THEIR USE AND POSSIBLE COMPLICATIONS (V. P. Silvestrov and soavt., 19 79)
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