Pneumonia

Pneumonia - pneumonia; A group of diseases characterized by inflammation of the parenchymal, or primarily parenchymal, respiratory, part of the lungs; Are divided into croupier (share) and focal. Isolation of acute interstitial and chronic pneumonia is controversial. In the domestic literature of recent years, chronic pneumonia is attributed to recurrent inflammation of the lungs of the same localization involving all structural elements of the lung and the formation of pneumosclerosis.

Etiology, pathogenesis. Inflammation of the lungs is an etiologically heterogeneous disease in the occurrence of which various bacteria play a role: pneumo-, staphylo- and streptococci, Klebsiella pneumonias, Pfeiffer's wand, sometimes E. coli, proteus, hemophilic and smelnoynaya sticks, causative agent of Ku fever - rickettsia Burneta, legionella, Wand plague, some viruses, mycoplasmas, fungi. Viral-bacterial associations can play an important role in the onset of the disease. A new group of pathogens of pneumonia was discovered - bacteroides, which for a long time were considered to be a non-pathogenic flora of the oral cavity. Pneumocyst, acinobacteria, aspergillus, aeromonas and branhamella, considered only as frequent agents of nosocomial (hospital) pneumonia, can cause "home" pneumonia. Chemical and physical agents - exposure to light chemicals (gasoline, etc.), thermal factors (cooling or burning), radioactive radiation - as etiologic factors usually combine with infectious. Pneumonia may be the result of allergic reactions in the lungs or the manifestation of a systemic disease (interstitial pneumonia in connective tissue diseases).

Pathogens penetrate into the lung tissue by bronchogenic, hematogenous and lymphogenous pathways, usually from the upper respiratory tract, usually in the presence of acute or chronic foci of infection and from infectious foci in the bronchi (chronic bronchitis, bronchiectasis). An important role in pathogenesis is played by violations of the protective mechanisms of the bronchopulmonary system and the state of humoral and tissue immunity. The survival of bacteria in the lungs, their reproduction and distribution along the alveoli, largely depend on their aspiration with mucus from the upper respiratory tract and bronchi (which is favored by cooling), from the excessive formation of edematous fluid, enveloping in croupous (pneumococcal) pneumonia, a whole or a few parts Lungs Simultaneously, possible immunological damage and inflammation of the lung tissue due to the reaction to the antigenic material of microorganisms and other allergens. Viral infection, itself causing inflammation of the upper respiratory tract and bronchus, and in some cases pneumonia, more often favors the activation of bacterial infection and the emergence of bacterial focal or lobar pneumonia. The appearance of bacterial pneumonia usually at the end of the 1st or at the beginning of the second week of respiratory viral disease corresponds to a significant decrease in the bactericidal activity of the alveolar-macrophagic system of the lungs. Chronic pneumonia can occur as a result of unresolved acute pneumonia with the slowing and stopping of resorption of exudate in the alveoli and the formation of pneumosclerosis, inflammatory-cell changes in the interstitial tissue, often of an immunological nature (lymphocytic and plasma cell infiltration). The long-term course of acute pneumonia, their transition to a chronic form is facilitated by immunological disorders caused by a repeated respiratory viral infection, chronic infection of upper respiratory tract (chronic tonsillitis, sinusitis, etc.) and bronchial tubes, metabolic disorders in chronic alcoholism, diabetes, etc.

Symptoms and course depend on the etiology, nature and phase of the flow, the morphological substrate of the disease and its prevalence in the lungs, as well as complications (pulmonary suppuration, pleurisy, etc.).

Croupous (pneumococcal) pneumonia usually begins acutely, often after cooling: the patient experiences a tremendous chill; Body temperature rises to 39-40 degrees C, less often to 38 or 41 degrees C; The pain of aspiration on the side of the affected lung is enhanced by coughing, at first dry, later with a "rusty" or purulent viscous sputum with an admixture of blood. A similar or less violent onset of the disease is possible in the outcome of an acute respiratory illness or against a background of chronic bronchitis. The condition of the patient, as a rule, is heavy. Skin covers are hyperemic and cyanotic. Breathing from the very beginning of the disease is rapid, superficial, with swelling of the wings of the nose. Herpes labialis etnasalis is often noted.

Prior to the use of antibiotic therapy, high temperature was maintained for an average of a week, falling sharply (critically); Under the influence of antibacterial drugs there is a gradual (lytic) decrease in temperature. The thorax lags behind in the act of breathing on the side of the affected lung, the percussion of which, depending on the morphological stage of the disease, reveals blunted tympanitis (tidal stage), pulmonary shortening (stage of red and gray curing), and pulmonary sound (resolution stage). Depending on the staged nature of the morphological changes, auscultation is accompanied by enhanced vesicular respiration and crepitatio indux, bronchial respiration and vesicular or weakened vesicular breathing, against which the crepitatio redus is heard. In the phase of custody, enhanced vocal tremor and bronchophoria are determined. Due to the uneven development of morphological changes in the lungs, percussion and auscultatory patterns can be variegated. Due to the defeat of the pleura (parapneumonic serous-fibrinous pleurisy), a pleural friction noise is heard. At the height of the disease, the pulse is rapid, mild, corresponds to a lowered blood pressure. It is not uncommon to muffle the I tone and accent the II tone on the pulmonary artery. Characterized by neutrophilic leukocytosis, and occasionally hyperleukocytosis. The absence of leukocytosis, especially leukopenia, can be a prognostically unfavorable sign. Increases ESR. Radiographic examination determines the homogeneous shading of the entire affected part or part of it, especially on the side radiographs. X-rays can be inadequate in the first hours of the illness. Atypical flow is more common in people with alcoholism.

Similarly, pneumococcal can occur staphylococcal pneumonia. More often, however, it flows more heavily, accompanied by destruction of the lungs with the formation of thin-walled air cavities, lung abscesses. With the phenomena of severe intoxication, staphylococcal (usually multifocal) pneumonia occurs, complicating the viral infection of the bronchopulmonary system (viral-bacterial pneumonia). The frequency of viral-bacterial pneumonia significantly increases in the epidemic of influenza. For this type of pneumonia is characterized by a pronounced intoxication syndrome, manifested by hyperthermia, chills, flushing of the skin and mucous membranes, headache, dizziness, severe dyspnea, hemoptysis, tachycardia, nausea, vomiting. In severe infectious-toxic shock, vascular insufficiency develops (BP 90-80, 60-50 mmHg, pale skin, cold extremities, the appearance of sticky sweat). With the progression of intoxication syndrome, cerebral disorders, increased heart failure, heart rhythm disturbances, development of shock lung, hepatorenal syndrome, DIC syndrome, toxic enterocolitis are revealed. Such pneumonia can lead to a rapid fatal outcome.

Severe course is also observed in pneumonia caused by pneumonia (Friedlander's stick); Occurs relatively rarely (more often with alcoholism); Lethality reaches 50%. Characteristic of the polydole spread with more frequent than in pneumococcal pneumonia, involvement of the upper lobes. Sputum is often jelly, viscous, but can be purulent or rusty. Typically, the formation of abscesses and the complication of the empyema.

Focal pneumonias, bronchopneumonia arise as complications of acute or chronic inflammation of the upper respiratory tract and bronchi, in patients with stagnant lungs, severe, exhausting diseases, post-operative period, fat embolism in traumas, thromboembolism. The disease can begin with chills, but not as pronounced as with lobar pneumonia. Body temperature rises to 38-38.5 degrees C, rarely higher. Appears or intensifies cough, dry or with mucopurulent sputum. Possible pain in the chest when coughing and inhaling. With a focal focal (usually staphylococcal) pneumonia, the condition worsens: severe dyspnea, cyanosis; Shortening of pulmonary sound; Breathing can be strengthened vesicular with foci of the bronchial, foci of small- and medium bubbling rales are heard Radiographically there are bullae and foci of abscess formation. Often observed "blurred" clinical picture of the disease. For viral, Kurikettsioznaya and mycoplasmal pneumonia, there is a discrepancy between pronounced intoxication (fever, headache and muscle pain, severe malaise) and absence or weak expression of respiratory symptoms. On the roentgenogram (sometimes only on a tomogram), lobular, subsegmental and segmental shadows are revealed, and the lung pattern is enhanced. Common and focal focal, especially staphylococcal, pneumonia are accompanied by neutrophilic leukocytosis, an increase in ESR. Viral, rick-ketsiosis and mycoplasmal pneumonia are usually not accompanied by leukocytosis, sometimes leukopenia is observed. In patients with ornithous pneumonia, hepatolyenal syndrome is possible.

Chronic pneumonia may include lung disease with a limited (segment, proportion) repetitive inflammation of the bronchopulmonary system, more often as a manifestation of the carnification of acute pneumonia. Clinically characterized by a periodic increase in body temperature, usually to subfebrile digits, increased coughing with increased mucopurulent sputum, sweating, often dull pain in the chest on the side of the lesion, occasionally shortening of the percussion sound over the projection of the affected lung, increased vesicular breathing and small bubbling rales. In the presence or addition of chronic bronchitis and emphysema of the lung, shortness of breath is noted, first with exercise, then at rest, often with an expiratory nature. The percussion sound becomes boxed, vesicular breathing weakens, dry, rattling rales are heard along with the foci of wet wheezes. Changes in physical examination are also aggravated with the development of bronchiectasis (persistent foci of wet wheezing), sometimes a chronic abscess (amphoteric respiration, large bubbling wet rales). Exacerbation of the disease may be manifested neutrophilic leukocytosis, increased ESR, acute phase reactions (increased sialic acids, increased C-reactive protein, dysproteinemia, etc.). In instrumental studies, the centers of pneumonic infiltration in the period of exacerbation are combined with fields of pneumosclerosis, inflammation and deformation of the bronchi, less often with their expansion (bronchiectasis) and the presence of cavities in the parenchyma (abscess).

A frequent complication of pneumonia is exudative pleurisy (see). Usually it is weakly expressed and has no clinical significance, but with an increase in exudate or its suppuration acquires a leading importance in the clinical picture. A serious complication is the abscess of the lungs (see). Staphylococcal destruction of the lung can be complicated by rupture of the cavity and the development of spontaneous (usually valvular) pneumothorax (see) or pyopneumothorax (see). Among extrapulmonary complications, acute vascular (collapse) and heart failure are of the greatest importance. They occur in patients with a common (usually multi-lobe) process with late hospitalization and ineffective treatment, often against the backdrop of chronic diseases of the cardiovascular system (coronary artery disease and heart defects, arterial hypertension). Acute pneumonia can be complicated by focal nephritis, much less often - diffuse glomerulonephritis. Lesion of the liver of prilobarnoy pneumonia is sometimes manifested by jaundice, which can be a consequence of hemolytic immune anemia, in particular with mycoplasmal pneumonia. Rare complications were pericarditis, endocarditis, meningitis.

In diagnosis, it is taken into account that shortening of percussion sound in focal pneumonia usually does not occur, but vesicular breathing is sometimes noted with bronchial foci, crepitus, small and medium bubbling rales, focal shadows better detected on radiographs (sometimes on tomograms). To establish the etiologic diagnosis, sputum or swabs from the pharynx (and sometimes flushes from the larynx and bronchi) are examined for the beginning of the treatment for bacteria, including mycobacterium tuberculosis, viruses, mycoplasma pneumonia and rickettsia. Assuming a viral or rickettsial etiology of the disease can be due to a discrepancy between acute emerging infectious-toxic phenomena and minimal changes in the respiratory organs during direct examination (radiographically identify focal or interstitial shadows in the lungs).

In the differential diagnosis of pneumonia, a carefully collected history is crucial. In acute bronchitis and exacerbation of chronic bronchitis, unlike pneumonia, intoxication is less pronounced, roentgenologically no shadows are detected. With complication of chronic bronchitis with bronchopneumonia, resolution of pneumonia (but not always bronchitis!) Under the influence of treatment should be regarded as evidence of pneumonia transferred; On the contrary, persistently determined physical symptoms and peribronchotic pneumosclerosis can be interpreted as evidence of chronic pneumonia upon completion of its exacerbation. For those who deny chronic pneumonia as a special nosological form, the situation described can be regarded as acute pneumonia that has arisen and resolved on the background of chronic bronchitis with post-pneumonic pneumosclerosis.

The onset of tuberculous exudative pleurisy can be as acute as pneumonia; Shortening of percussion sound and bronchial breathing above the area collapsed to the root of the lung can simulate shared pneumonia. Errors can be avoided with careful percussion, which reveals the dull sound and weakened breathing from dullness (with empyema, weakened bronchial breathing!). Differentiation is assisted by an X-ray in the lateral projection (intense shadow in the axillary region) and pleural puncture followed by examination of the exudate. In contrast to neutrophilic leukocytosis in case of lobar (less often focal) pneumonia, the hemogram in exudative pleurisy of tuberculous etiology is usually not changed. Unlike share and segmental pneumonia with tuberculous infiltrate or focal tuberculosis, usually less acute onset; Pneumonia under the influence of nonspecific therapy is resolved in the next 1.5 weeks, while the tuberculosis process does not lend itself so quickly even to tuberculosis therapy.

Severe intoxication with high fever with mildly expressed physical symptoms is typical for miliary tuberculosis, which requires its differentiation with fine focal pneumonia. Acute pneumonia and obstructive pneumonitis in bronchogenic cancers can begin acutely against the backdrop of apparent well-being, often after cooling chills, fever, chest pain are noted, but coughing with obstructive pneumonitis is more often dry, paroxysmal, and later with the separation of a small amount of sputum and hemoptysis; In unclear cases, only bronchoscopy allows you to clarify the diagnosis.

Treatment of pneumonia with mild and favorable conditions can be performed at home, but most patients need inpatient treatment. For emergency indications, patients with shared and other pneumonias and expressed infectious-toxic syndrome are hospitalized. At the height of the disease, bed rest is shown, a mechanically and chemically sparing diet with restriction of table salt and a sufficient number of vitamins, especially A and C. With the disappearance or significant decrease in the effects of intoxication, the regime is extended, physical therapy is prescribed, in the absence of contraindications (heart disease, digestive organs) Patient transferred to a diet number 15.

Immediately after taking sputum, smears or rinses for bacteriological examination, etiotropic therapy is started, which is carried out under the control of clinical efficacy, in the following - taking into account the sown microflora and its sensitivity to antibiotics. Patients younger than 30 years with a mild course of pneumonia and the absence of chronic diseases can be prescribed long-acting sulfonamides (sulfapiridazine, suppy-monomethoxin, sulfadimethoxin 1-2 g for the first dose once a day, up to 0.5-1 g in the following days for 5-7-14 days). In contrast to the rapidly absorbed from the intestine of sulfapiridazine and sulfamonomethoxin, the maximum concentration in the blood of sulfadimethoxin is observed after 8-12 hours. Therefore, concomitantly with sulfadimethoxin, 2 g of short-acting norsulfazol-sulfanylamide should be administered in two divided doses at intervals of 3 hours. Norsulfazole in the same dose can be prescribed 3-4 hours before taking sulfapiridazine or sulfadimethoxin 0.5-1 g once a day. Sulfalen - sulfonamide of superlong action with a half-life period of 65-84 h from the body is taken in a dose of 0.2 g once a day or once 2 g per week. Sulfanilamides should be used in the acute period and within 3-5 days after the disappearance of the symptoms of the disease. It is recommended to take them dissolved in 1/2 cup water or 1-2% solution of sodium hydrogencarbonate on an empty stomach, 30-40 minutes before meals and not earlier than 3-5 hours after eating. If the drug is poorly soluble (sulfadimethoxin, sulfapiridazine), the tablet should be thoroughly chewed and washed down with plenty of water. The combined preparation containing sulfamethoxazole and trimetroprim, bactrim (biseptol), which acts on gram-positive and gram-negative microbes, has a more pronounced bactericidal action. Assigning 2 tablets (for severe pneumonia, 3 tablets) 2 times a day for 1-2 weeks, you can achieve a good effect.

For moderate and severe forms of pneumonia (especially those caused by staphylococcus and Klebsiella pneumonia) antibiotics of all groups are used. Penicillin (preferably benzylpenicillin sodium salt) remains effective at daily doses from 6 000 000 to 30 000 000 units in 0.5-1% solution of novocaine or isotonic sodium chloride solution; The drug is administered in equal doses v / m or IV every 3-4 h (sometimes intratracheally once a day). It should be borne in mind that large doses of penicillin can pose a threat of superinfection with penicillin resorption flora. Intravenous administration of antibiotic allows obtaining in 2-3 times a large concentration of the drug in the blood in a short time than with intramuscular injection.

With penicillin-resistant forms of pneumonia, more often caused by strains of staphylococcus producing penicillinase, semisynthetic penicins - methicillin sodium salt (1 g at 4-6 h IM, 10-12 g / day), oxacilpine sodium salt (0 , 25-0.5 g per reception, up to 3-8 g / day, depending on the severity of pneumonia or 1.5-3 g / day IM), and with pneumonia caused by gram-negative microbes (Klebsiella pneumonia, Pfeif- Ferric, E. coli) -Ampicillin trihydrate (0.5 g every 4-6 h inwards with an increase in the daily dose in severe pneumonia to 6-10 g) or ampicillin sodium salt (0.5 g / m, IV drip Or spray every 4 hours, up to 10 g / day). Cephalosporins (strings 1-2 g 2-3 times a day IM or IV, including drip, intratracheal or en-doberonhial, into the pleural cavity), unlike penicillin, are resistant to staphylococcal penicillinade, which makes them especially Effective for staphylococcal pneumonia. The combination of penicillin with streptomycin, as a rule, is not applied due to the high frequency of streptomycin-resistant forms of microbes, but in cases of "freelander" pneumonia streptomycin sulfate (0.5-1 g i / m 2 times a day) is usually effective. Streptomycin, 0.5 g 2 times a day, is combined with penicillin and also acts on Pfeiffer's wand.

Tetracyclines as broad spectrum agents are effective for pneumonias caused by the virus of ornithoies, mycoplasma pneumonia, and rickettsia of Burnett, for administration of tetracycline, oxytetracycline dihydrate (0.25-0.5 g 4 times daily), and metacycline hydrochloride Rondomycin) in capsules (0.3 g twice a day), intramuscularly, intratracheally (endobronchially) and into the pleural cavity - tetracycline hydrochloride and oxytetracycline hydrochloride (each 0.1 g in 2.5-5 ml or 20 ml 0 , 5-1% solution of novocaine 1-3 times a day.) In severe pneumonia, intravenous administration of tetracycline drugs: glycocycline (0.25-0.5 g 1-2 times a day), morphocycline (0.15- 0.3 g 2-3 times a day.) Erythromycin (0.25-0.5 g every A-6 h for 1 hour before meals) or erythromycin ascorbate (0.1-0.2 g IV 2-3 times to 1 g / day) and oleandomycin phosphate (0.25-0.5 g 4 times a day and 0.1-0.25-0.5 g 3-4 times a day IM or in / C) are also effective for various etiologic forms of pneumonia, including staphylococcal, penicillin-resistant. Their therapeutic effectiveness is even more increased in combination with tetracycline (oletetrin or tetraoleane 0.25-0.5 g4 orally or 0.1 g IM 2-3 times or 0.25-0.5 g 2-4 times On the day in / in jet or drip) and morphocycline (oper-morphocycline in 0.25 g 2-3 times a day in / in). Of the aminoglyco-311DOV in pneumonia, kanamycin is preferred (0.5-1 g / m2 / day) and gentamicin sulfate (40-80 mg IM / 3 times a day). Other antibiotics are also used (levomycetin, lincomycin, ristomycin, rifampicin, etc.), as well as nitrofuran derivatives: furazoline 0.1 g 3-4 times a day, furagin soluble in 300-500 ml 0.1% solution (0, 3-0.5 g) IV drip for 3-4 hours daily or every other day.

The effectiveness of sulfonamides and antibiotics for pneumonia is usually detected by the end of the first day of treatment, but not later than 3 days of their use; After this period, in the absence of a therapeutic effect, the prescribed drug should be replaced by another one. But in cases of positive effect, it is desirable to change the drug (drugs) every 5-6 days. Antibacterial therapy is controlled by clinical and paraclinical methods both for evaluating its effectiveness and for detecting intolerance (especially drug allergy and hemocytodeptic-repressive action).

In severe viral-bacterial pneumonia, often due to the interaction of the influenza virus and staphylococcus, in addition to intravenously administered broad-spectrum antibiotics, the introduction of a specific donor anti-influenza gamma globulin of 3-6 ml is shown, if necessary, again every 4-6 hours, in the first 2 Day of illness. Also used detoxication (gemodez, etc.).

With severe tachycardia, a decrease in systolic pressure to 100 mm Hg. Art. And lower patient pneumonia prescribed strophanthin (0.05% solution of 0.25-0.5 ml iv once a day), cordiamine (2 ml IM or iv 3-4 times a day), Sulphocamphocaine (2 ml IM / 10% solution 2-4 times a day). With severe dyspnea and cyanosis, long-term inhalations of moistened oxygen are prescribed. With pneumonia, which develops against the background of chronic obstructive bronchitis, lung emphysema, oxygen concentration should not exceed 30%, and its inhalation is controlled by the study of acid-base balance. Use unmedicated physiotherapy (circular banks, paraffin wax, ozocerite, mud), after normalizing the body temperature, short-wave diathermy, the electric field of UHF, etc. can be assigned. In severe acute and exacerbation of chronic pneumonia complicated by acute or chronic respiratory insufficiency, the patients are placed in Intensive care wards; Can be carried out bronhoskopichesky drainage, with arterial hypercapnia - assisted artificial ventilation. With the development of pulmonary edema, infectious-toxic shock and other severe complications, the treatment of patients with pneumonia is conducted jointly with the reanimatologist.

Outpatients discharged from a hospital during a period of clinical recovery or remission should be taken under medical supervision. For rehabilitation, they can be sent to local sanatoria. Patients with chronic pneumonia without pronounced suppuration and pulmonary heart disease of II - III stage in the remission phase can be referred to treatment in the resorts of the Southern coast of Crimea, mountain climatic resorts of the Caucasus, Altai, sanatoriums of the Moscow region, Primorye, Siberia, etc.

The prognosis for pneumonia has significantly improved since the beginning of the use of antibacterial agents. But it remains serious with staphylococcal and "freelander" pneumonias, with frequently recurring chronic pneumonia complicated by obstructive process, respiratory and pulmonary heart failure, as well as when pneumonia occurs in people with severe cardiovascular diseases and other systems. The mortality from pneumonia in these cases remains high.