BRONCHOSTENOSIS

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BRONCHOSTENOSIS (bronchostenosis; a bronchial tube[s] + grech, stenosis narrowing) — the pathological narrowing of a gleam of a bronchial tube resulting from inflammatory, fibrous or cicatricial processes in its wall, growth of the benign or malignant tumor which is localized in a bronchial tube or out of it and also owing to hit in a gleam of a bronchial tube of a foreign body.

The etiology and a pathogeny

B. develops at hron, a hypertrophic, obliterating endobronchitis or tuberculosis of a bronchial tube as a result of a sharp hypertrophy, hypostasis and infiltration of a mucous membrane of a bronchial tube.

At endobronchial development of a tumor of B. accrues gradually, breaking ventilation of a lung. Accession of an infection leads to development of inflammatory process in bronchial tubes and a lung and to disturbance of drainage function of bronchial tubes.

At tumors of a mediastinum, an aortic aneurysm, an exudative pericardis and other ekstrabronkhialny processes of B. results from a mechanical prelum of a bronchial tube. B. develops at long stay of a foreign body in a bronchial tube that is followed by an inflammation of its wall and narrowing of a gleam with the subsequent disturbance of ventilation.

Acute development of B. is caused most often by hit in a bronchial tube of a foreign body. Hron, B.'s development is called by damage of the bronchial tube or its prelum from the outside. The foreign body which got into a bronchial tube can play a role of the valve passing air only at a breath; difficulty of an exhalation leads to development of emphysema in the respective site of a lung. At a considerable stenosis passing of air is broken also at a breath that leads to development of an atelectasis. At long B. and incomplete closing of a gleam of a bronchial tube below the place of a stenosis the bronchiectasia can develop.

Long existence of pathological process in a wall of a bronchial tube leads to a fibrous and cicatricial stenosis. At morphological studying of drugs of lungs with cicatricial stenoses of large bronchial tubes the atrophy mucous and a submucosa, cartilaginous tissue and quite often mucous glands with substitution by their fibrous fabric is characteristic. Allocate concentric, pristenochny and false cicatricial B.

the Clinical picture

the Clinical picture depends on an etiology, localization (in a large or small bronchial tube), degrees of manifestation, duration of existence of B. and existence of the existing inflammatory changes both in bronchial tubes, and in pulmonary fabric.

During the listening of lungs on side of the narrowed bronchial tube breath is weakened or is absent; at a breath the pressure whistling murmur better listened in interscapular space is heard. A characteristic sign of B. is cough, at a long stenosis — cough with a mucopurulent phlegm. The developed complications from lungs cause the corresponding wedges, symptoms.

The diagnosis

the Diagnosis is based on the anamnesis, data of a bronkhoskopiya and X-ray inspection. Results of gisto-cytologic researches of the material received at a bronkhoskopiya and catheterization of a bronchial tube are subject to visual or radiological correction.

These bronkhoskopiya. At B. of an inflammatory etiology the sharp hyperemia and hypostasis of a mucous membrane of a bronchial tube is found. In the presence of a foreign body note the plentiful granulations of bright red color bleeding at touch by a suction and a tupfer; the foreign body maybe is not visible. At long stay of a foreign body in a gleam of a bronchial tube fibrous process, granulations more pale with a yellow-white shade develops. Such bronchoscopic picture needs to be differentiated with a cancer tumor. Development of limited infiltrates with a hyperemia and a sharp thickening of a wall of bronchial tubes is characteristic of tubercular B. Often ulcerations in a mucous membrane and the friable bleeding granulations which especially plentifully expand around fistulas of a wall of a bronchial tube at bronkhozhelezisty tuberculosis are found.

At cicatricial B. a mucous membrane of bronchial tubes pale, dim, with whitish sites. The prelum of a bronchial tube from the outside can not be followed by changes in a mucous membrane, but at disturbance of bronchial passability the inflammatory phenomena and a picture of bronchitis of various intensity, as a rule, are found. If the artery is the reason of a compression of a bronchial tube, then the expressed pulsation of a bronchial wall in the place of narrowing is found.

Radiodiagnosis it is based on data of roentgenoscopy with functional trials, a X-ray analysis by beams of the increased rigidity, tomographies and bronchographies. The radiological symptomatology of B. consists of direct symptoms which characterize a condition of a bronchial tube at the level of a stenosis, and indirect signs reflecting secondary changes of lungs and bodies of a mediastinum.

Fig. 1. Different types of a bronchostenosis (the scheme from roentgenograms): 3 — a foreign body in a bronchial tube (a water-melon stone); 2 — adenoma of a bronchial tube; 3 — a symptom of «dagger» at cancer of a lung; 4 — a stenosis of a bronchial tube at chronic pneumonia; 5 — a midlobar syndrome. Shooters point to localization of pathological process.

Direct symptoms depend substantially on an etiology and a pathogeny of a stenosis. So, at the stenosis caused by aspiration of a foreign body on roentgenograms (fig. 1, 1) the additional shadow against the background of a little changed bronchial tube is found, walls to-rogo are elastic and have smooth outlines (see. Foreign bodys , radiodiagnosis). If B. is caused by slowly growing benign intra bronchial tumor (adenoma, fibroma, a gamartoma), then against the background of an expanded gleam of a bronchial tube the oval or roundish shadow (fig. 1, 2) adjoining the wide basis one of its walls is found; the bronchial tubes located distalny tumors, as a rule, are expanded and deformed because of is long the current secondary inflammatory process. If the benign tumor completely obturirut a gleam of a bronchial tube, then his stump reminds a bell with gradually extending caliber and the concave line of break, camber turned proksimalno. Infiltrative growing tumor causes gradual narrowing of a gleam of a bronchial tube, walls to-rogo become rigid and have the uneven, jagged outlines; at B. caused by cancer of a lung the so-called symptom of «dagger» (fig. 1, 3) is characteristic. At hron, the pneumonia which is followed by the expressed phenomena of cirrhosis, B. is characterized by usually big extent and deformation of the next bronchial tubes (fig. 1, 4). At a so-called midlobar syndrome (fig. 1, 5) sometimes it is difficult to establish B.'s character since the X-ray pattern of a stump of a bronchial tube can correspond as hron, pneumonia with fibroatelektazy, and to the central cancer of a lung.

Indirect symptoms of B. depend hl. obr. from extent of disturbance of passability of bronchial tubes and usually come to light at damage only of large bronchial tubes (main, share, zone). However set of indirect signs quite often allows to suspect B.'s localization that defines a further technique of a research for detection of direct symptoms.

Disturbances of bronchial passability in the x-ray image were studied by Jackson in detail (Ch. Jackson, 1865 — 1958), and then S. A. Reynberg and his school.

Extents of disturbance of passability of bronchial tubes

Fig. 2. Scheme of three main types of a bronchostenosis. Various extents of narrowing of a bronchial gleam (as an example spherical foreign bodys of different caliber are represented): 1 — a through partial bronchostenosis; 2 — the valve bronchostenosis causing valve swelling of pulmonary fabric; 3 — the full bronchostenosis causing a full atelectasis of pulmonary fabric; and — a gleam of a bronchial tube in an inspiratory phase; — a gleam of a bronchial tube in an expiratory phase. Shooters specify the direction of an air stream at breath.

Distinguish three extents of disturbance of passability of bronchial tubes.

First degree it is characterized rather small reduce niy a gleam of a bronchial tube: at a breath air is freely included into a lung, and at an exhalation comes out it (fig. 2, 2); reduction of amount of the air passing through the narrowed bronchial tube leads to hypoventilation of a lung. Radiological it is shown by insignificant or moderate decrease in transparency of the pulmonary field, especially at the beginning of a breath, a nek-eye lag of the corresponding half of a diaphragm, sometimes emergence of the small spotty shadows of small intensity displaying the lobular atelectases which are formed in a plashchevidny layer of a lung. At B. of a large bronchial tube the tolchkoobrazny shift of bodies of a mediastinum in the struck party on a breath is observed (see. Goltsknekhta-Jacobson symptom ).

Second degree disturbances of bronchial passability — valve, or valve, the stenosis — is characterized by considerable narrowing of a gleam of a bronchial tube (fig. 2, 2). Ventilation becomes unilateral: in an inspiratory phase when the gleam of a bronchial tube increases on average by one third of diameter, air gets into a lung, and in an expiratory phase when the bronchial tube is fallen down, it does not leave back. The valve swelling of a lung which radiological is shown increase in the pulmonary field, increase in its transparency, low standing and small mobility of the corresponding half of a diaphragm is caused. In an expiratory phase when the sore lung remains blown up, and healthy it is fallen down, the median shadow is displaced towards the last; on a breath when the healthy lung is filled with air and intrathoracic pressure is relatively counterbalanced, the median shadow is returned to the place. Some authors call the shift of a median shadow in an expiratory phase in the healthy party the return symptom of Goltsknekht — Jacobson.

Third degree disturbances of bronchial passability it is characterized by full obturation of a gleam of a bronchial tube and the termination of ventilation of the respective site of easy (fig. 2, 3). The air which is contained in it resolves within several hours; there comes Obturatsionny atelectasis (see). Radiological reduction of the pulmonary field, its intensive blackout, high standing and an immovability of a dome of a diaphragm is noted; the median shadow is with firmness displaced towards defeat. At stenoses of lobar and segmental bronchi there is hypoventilation, swelling or an atelectasis in the corresponding share or a segment. Stenoses of small bronchial tubes a long time can be compensated by development of collateral ventilation.

The forecast

the Forecast in many respects is defined by duration, degree and an etiology B. Full long obturation of a bronchial tube, as a rule, leads to irreversible processes in pulmonary fabric. At small disturbance of bronchial passability it is possible to count on recovery of function of a lung after elimination of a stenosis. The short-term impassability of a bronchial tube caused by a foreign body usually is not followed by effects, however is long the existing B. at preservation of ventilation can lead to development of bronchitis with the subsequent destruction of bronchial walls and development of bronchiectasias (see). The bad forecast at B. caused by malignant tumors.

Treatment

Treatment depends on an etiology B. The inflammatory processes in a wall of a bronchial tube causing narrowing of its gleam are subject to conservative therapy in combination with local endobronchial impact on pathological process: a bronkhoskopiya with aspiration of contents of bronchial tubes, administration of medicinal substances, removal of granulations, their cauterization etc.

of B., caused by a foreign body, it is possible to eliminate by its extraction. Inflammatory changes in a wall of a bronchial tube, as a rule, disappear after that.

At B. of the tumoral nature make a pneumonectomy; at adenoma of a bronchial tube at early stages the bronchotomy or a resection of the site of a bronchial tube with the subsequent imposing of an interbronchial anastomosis is shown that allows to keep the functioning part of a lung. Plastic surgery can be executed also at limited cicatricial or inborn stenoses of large bronchial tubes. At a prelum of a bronchial tube from the outside elimination of the reason of a compression recovers the broken bronchial passability.


Bibliography: Bogush L. K., etc. The Kliniko-morfologichesky characteristic of the cicatricial stenosis of large bronchial tubes at adults connected with a tubercular bronchadenitis, Grudn. hir., No. 6, page 66, 1971, bibliogr.; JI and p and N and A. A. Tuberkulez of bronchial tubes. M, 1961; Lukomsky G. I., etc. Bronchology, M., 1973, bibliogr.; Disturbances of bronchial passability, under the editorship of S. A. Reynberg, M., 1946, bibliogr.; Petrovsky B. V., Perelman M. I. and Kuzmichev of A. P. Rezektion and plastics of bronchial tubes, M., 1966, bibliogr.; Rosen-shtraukh L. S. Value of collateral ventilation at cancer of a lung, Grudn. hir., No. 6, page 94, 1961; Sokolov Yu. N. and Rozenshtraukh L. S. Bronchography, M., 1958, bibliogr.; The III are about in B. K. The bronchial tree is normal p of pathology, M., 1970, bibliogr.; F with Ι-βο η V. of Chest roentgenology, Philadelphia, 1973, bibliogr.; Huzly A. u. Bohm F. Bronchus und Tuberkulose, Stuttgart, 1955.

V. P. Filippov; L. S. Rozenshtraukh (rents.).

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