PNEUMONIA

PNEUMONIA - a large group of different in the etiology, pathogenesis and morphological characteristics of inflammatory, more often infectious, processes in the lungs with a predominant lesion of their respiratory departments. In this acute infectious inflammatory process is localized in the alveoli and interstitial lung tissue. The "home pneumonia" (out-of-hospital) and "hospital" (nosocomial), developing after 2 days or more after admission of the patient to a hospital for another reason, are distinguished according to the place of origin of the disease, and hence the most probable spectrum of pathogens.

The main cause of pneumonia is bacterial and viral-bacterial infection. The leading role among the "home" pathogenic bacterial pathogens belongs to pneumococci, streptococci, hemophilic rod. The frequency of pneumonia caused by pyogenic cocci, gram-negative rods and anaerobic microorganisms (staphylococcus, legionella, protea, E. coli, etc.) increased, which is associated mainly with the widespread use of antibacterial drugs, leading to dysbiosis and superinfection. The main pathogens of nosocomial pneumonia are gram-negative microorganisms and staphylococci. The causative agents of pneumonia may also be fungi, viruses (more often influenza viruses, less often parainfluenza, adenoviruses, myxoviruses, reoviruses, etc.), mycoplasmas, rickettsia, chlamydia.

The pathogenesis of pneumonia depends on the properties of the pathogen (its pathogenicity, the ability to isolate exo- and endotoxins), the ways it penetrates and the site of implantation, as well as the state of the macroorganism. More often, pathogens fall into the lungs by a bronchogenic route, less often hematogenous and lymphogenic. The spread of infection through the bronchial tree is facilitated by the disturbance of the evacuation and secretory function of the bronchi that arise under the influence of microbes or their toxins, the defeat of their ciliated epithelium.

Perhaps the development of pneumonia, not directly associated with primary infection. For example, it can be caused by physical and chemical factors: exposure to ionizing radiation, inhalation of asphyxiating agents, aspiration of gasoline (petrol pneumonia), kerosene, oil, etc. In these cases, the infection joins later. There are also allergic pneumonia, proceeding as an exogenous allergic alveolitis.

The degree of manifestation of general manifestations of the disease and symptoms of lung damage in pneumonia is different and is largely associated with etiological factors.

Croupous pneumonia is characterized by a sudden onset, marked by symptoms of intoxication (body temperature 39 - 40 ° C in combination with chills and sweating, weakness, headache , "body aches", sometimes delirium , etc.), cough - dry on the first day of illness , And then with sputum ("rusty", mucopurulent), chest pain (due to involvement in the pathological process of the pleura), increasing with breathing, coughing (so the patient often lies on the side of the lesion). With the localization of the inflammatory process in the lower parts of the lungs and lesions of the diaphragmatic pleura, the pain can irradiate into the abdominal cavity, simulating the picture of the acute abdomen. Often the patient has hyperemia of the cheek on the side of the lesion, herpetic eruptions on the lips, swelling of the wings of the nose during breathing. Breathing shallow, rapid

Up to 30 -40 in 1 min. Tachycardia, lowering blood pressure, acrocyanosis is possible. On the 2-3rd day of the disease there are signs of pulmonary tissue infiltration: dullness of the percussion sound corresponding to the segment or lobe of the lung, pronounced increase in vocal tremor and bronchophonia, bronchial or hard breathing; As a rule, the noise of friction of the pleura is determined. At the end of the first - the beginning of the second day and during the resorption of the infiltrate in auscultation of the lungs, crepitation and finely bubbling wet wheezing can be determined. X-ray reveals a uniform, intense darkening occupying the segment, several segments or a fraction of the lung. In the blood, the number of leukocytes is significantly increased. As the inflammatory process resolves, signs of pulmonary infiltration decrease. The febrile period lasts 5 to 9 days, the temperature decreases critically or lytically (see Fever).

Focal pneumonias (for example, heavy focal and drainage) can start suddenly and accompanied by severe intoxication, high fever, coughing, shortness of breath, chest pain and similar physical changes, just like croupous pneumonia. In other cases, intoxication can be expressed bluntly, the disease begins subacute, body temperature subfebrile or normal (in weakened patients), the clinical picture is dominated by signs of bronchitis. The percussion sound with small-focal pneumonia is not changed, with larger foci blunting can be determined, especially clearly expressed in drain pneumonia. The degree of amplification of vocal tremor and bronchophonia is proportional to the size of the focus. Breathing with small-focal pneumonia is slightly stiff, with large-focal and drainage - very hard with bronchial shade. Crenation with focal pneumonia is rare. Characterized by finely bubbling rales , in the presence of bronchitis - dry rales . In the case of pleurisy, there is a pleural friction noise. Radiographically darkening of lung tissue with small-focal pneumonia is absent, with other focal pneumonia, the shading is not uniform, of varying intensity, does not completely occupy the affected segments. In blood for bacterial focal pneumonia, leukocytosis of different degrees is determined, with viral pneumonia - leukopenia .

The severity of acute pneumonia depends on the severity of intoxication, respiratory failure, the vastness of the lesion, the presence of destruction of lung tissue and complications.

Complications in the acute period of croupous and focal pneumonia can be associated with the destruction of vital organs by microbial toxins and the products of the disintegration of lung tissue. These include: infectious-toxic (septic) shock , acute respiratory and heart failure, pulmonary edema, myocarditis , pericarditis , endocarditis , psychoses , disorders of the blood coagulation system and anemia . There are purulent complications: pleurisy , empyema of the pleura, abscess and gangrene of the lung, sepsis , meningitis . According to various authors, they are observed in 1.8-13% of patients, and equally common in patients with croupous and focal pneumonia.

In elderly and elderly people, an erased (atypical) course of pneumonia is possible, in which severe complications can occur (purulent pleurisy , pericarditis). In people with chronic alcoholism, pneumonia often occurs with signs of CNS damage (confused consciousness, disorientation , etc.), up to the development of coma; Frequent complications are acute cardiovascular insufficiency and lesion of the organs of the gastrointestinal tract (acute cholecystitis , pancreatitis , thrombosis of the mesenteric arteries, gastrointestinal bleeding).

Features of the clinical course of pneumonia of different etiology. Pneumococcal pneumonia is characterized by an acute onset with high fever and tremendous chills, coughing with the separation of typical "rusty" sputum, weakened breathing and local small- bubbling rales , often hearing the pleural friction noise.

Staphylococcal pneumonia with a severe fulminant course is observed in children, after the viral infections suffered in hospital patients weakened by various chronic diseases. Bronchogenic staphylococcal pneumonia arises sharply. In the first 2 days of illness, high body temperature, chills, confusion are noted. On the 2nd -3rd day there are signs of a defeat of the respiratory organs: a cough with the separation of purulent sputum of yellow or brown, sometimes hemoptysis, dyspnea , pain in the chest , change in percussion sound over the lesion, weakened or bronchial breathing, wet wheezing in the lungs . As a result of the spread of the process, X-ray reveals extensive polysegmentary sites of pulmonary tissue infiltration, often with concomitant pleurisy, and after 5-7 days, on the background of infiltration, annular dry air cavities with liquid level are detected, the configuration and quantity of which change rapidly. The condition of patients worsens during this period, the signs of intoxication become worse, the fever acquires septic character, the amount of purulent sputum increases. The abscess of the lung can be heard so-called amphoric breathing.

Hematogenous staphylococcal pneumonia, unlike bronchogenic pneumonia, occurs in the first days more benignly, without significant clinical symptoms. Only when necrosis, abscesses appear in the infiltration zone, are marked signs of intoxication, high fever , tremendous chills, and the symptoms of respiratory failure increase. The most frequent complications of staphylococcal pneumonia are lung abscesses, pyopneuromotorax, pulmonary hemorrhage, sepsis may develop.

Mycoplasmal pneumonia is characterized by a gradual onset with a prodromal period (malaise, sore throat, dry cough). Chills, dyspnea , pleural pain, as a rule, absent. Physical data can be scarce, sometimes mycoplasmal pneumonia occurs with severe bronchitis, often accompanied by bronchospasm, a constant symptom is dry cough , scanty mucous sputum appears on the 10th -12th day of the disease. Characterized by extra-pulmonary symptoms - pain in the muscles of the back and thighs, conjunctivitis, myocarditis, anemia . With pneumonia due to respiratory viruses, lesions of various parts of the upper respiratory tract are observed.

Congestive, or hypostatic pneumonia, which occurs with stagnation in the lungs in patients with severe cardiovascular disease (heart disease, ischemic heart disease), weakened patients, or in those who are forced to lie on their back for a long time (for example, after operations) develops Gradually, without the expressed fever and signs of intoxication. More often the pathological process is localized in the lower parts of the right lung. The physical changes are fuzzy. Decisive in diagnosis is an x-ray study. Laboratory manifestations of the activity of the inflammatory process (leukocytosis, neutrophil shift, increase in ESR, etc.) are minimal.

Aspiration pneumonia develops when acidic stomach contents or food particles enter the airways during vomiting, gastroesophageal reflux, during or immediately after general anesthesia, against a background of epileptic seizure and coma of various etiologies. Aspiration of food particles contribute to myasthenia gravis , scar strictures, tumors , esophageal diverticula, diaphragmatic hernia, etc. Gastric juice causes chemical damage to the bronchial mucosa and inactivates the surfactant (anti-teleleptatic factor). The protective reflex arising in aspiration in the form of coughing and deep breathing contributes to the penetration of aspirated masses into small bronchi and bronchioles and may be the cause of the development of pulmonary edema. Aspiration into the bronchial tree leads not only to the development of the inflammatory process, but also to the appearance of partial (or total) bronchospasm and lung atelectasis. The severity of these changes depends on the irritating effect of the aspirated masses (for example, ethyl alcohol has a strong irritant effect). Aspiration pneumonia often develops in the lower lobe of the right lung. The clinical picture depends on the nature of the aspirated material, the depth of its penetration, the amount of bacterial flora that has entered the bronchi from the nasopharynx and esophagus. Acute shortness of breath , tachycardia , cyanosis . At auscultation, the weakened (due to atelectasis) or hard breathing, sonorous damp and deaf wheezing are heard. Symptoms of bronchial obstruction are more pronounced when they get gastric juice and ethyl alcohol. Inflammatory changes in aspiration of food are less pronounced than with the migration of gastric contents, often only one or more segments of the lungs are involved in the process. A characteristic feature of pneumonia due to aspiration of food particles is their long, recurrent course. Signs of intoxication, the indices of activity of the inflammatory process are minimal, and infiltrative changes are not subjected to reverse development for a long time. Aspiration pneumonia can lead to the appearance of pneumosclerosis (often with the formation of bronchiectasises), abscess and gangrene of the lung. When aspirating food, abscesses form slowly, imperceptibly, and do not open for a long time in the bronchi. Early development of the destruction of lung tissue is characteristic when the content of aspirated masses of ethyl alcohol.

Gasoline pneumonia develops 2-8 hours (less often after 2 days) after aspiration of gasoline. The onset of the disease, as a rule, is characterized by the appearance of sharp pain in the chest, more often on the right, amplifying during movements. There are signs of intoxication (headache, dizziness , weakness), there may be chills, an increase in body temperature to 38 - 39 ° C. Breathing becomes superficial, frequent (up to 40 or more in 1 min), cyanosis appears, the thorax on the side of the lesion lags sharply when breathing. In the first day, auscultatory and percussion signs of pneumonia are absent. On the 2nd -3th day signs of pulmonary insufficiency (cyanosis, dyspnea) increase and physical changes appear: shortening of percussion sound, weakened or hard breathing, wet wheezes and friction of the pleura. In the blood already at the end of the first day, there is leukocytosis , a stab-shift, lymphopenia, an increase in ESR. For gasoline pneumonia is characterized by a rapid positive dynamics. Already by the end of 3-4 days the state of health improves, the temperature decreases or normalizes, dyspnea , cyanosis disappear. Sometimes there are complications: pulmonary hemorrhage, lung abscess , exudative pleurisy . Radiographically, 1 to 2 hours after the onset of pain in the chest, it is possible to detect an intense, uniform (as with croupous pneumonia) darkening; As a result of atelectasis, the affected parts of the lung can be reduced in size, compacted, the mediastinal organs are displaced to the sore side, and on the healthy side, signs of emphysema are revealed. X-ray changes can persist up to 20-30 days.

Treatment . Patients with pneumonia, as a rule, should be treated in the hospital, especially if pneumonia occurs against the background of chronic bronchial and lung diseases, as well as in the elderly and senile age.

Patients with severe pneumonia complicated by infectious-toxic shock, acute respiratory, cardiovascular and renal insufficiency, as well as with deep disturbances of acid-base equilibrium and coagulation system require treatment in an intensive care unit.

Patients must comply with bed rest during the entire period of fever and intoxication, but they should not lie still in bed. It is necessary to periodically change position, sit down, actively cough phlegm, collecting it in a jar with a tight-fitting lid. The room in which the patient is located should be systematically ventilated. Of great importance is the careful care of the skin and oral cavity. Food should be high-calorie, rich in vitamins, mechanically and chemically sparing. You need an abundant warm drink: tea with raspberries, mineral water, cranberry juice, warm milk with soda and honey. It is very important to monitor the function of the intestine and prevent the development of flatulence and constipation.

Etiotropic therapy consists mainly in the use of antibacterial agents. The appointment of antibiotics should be early, should not wait for isolation and identification of the causative agent of pneumonia. Antibacterial drugs should be used in sufficient (average therapeutic) doses, at intervals such that a constant therapeutic concentration of the drug is created and maintained in the blood and in the lung tissue. It is not recommended to simultaneously use bactericidal and bacteriostatic drugs.

Prior to the isolation of the pathogen of pneumonia, antibacterial therapy is carried out taking into account the epidemiological situation, the clinical picture of the disease, suggesting its etiology. If it is difficult to determine the etiology of the disease in the case of "home" pneumonia, antibiotics with a broad spectrum of action that penetrate well into the lung tissue (semisynthetic penicillins in combination with beta-lactamase inhibitors, cephalosporins II-III generation) should be prescribed. In the future, antibiotic therapy is corrected by bacteriological examination of sputum or bronchial contents and the results of antibioticograms. To avoid the emergence of resistance of microorganisms to antibiotics and reduce the risk of allergic reactions, it is necessary to replace the drugs after 7 to 10 days. To etiotropnyh means used for the treatment of patients with acute pneumonia, include sulfanilamide preparations. More often prescribed drugs prolonged action (sulfadimetoksin, biseptol, etc.) in conventional doses. The duration of their intake should not exceed 7-10 days.

The main pathogenetic agents used for the treatment of patients with acute pneumonia include drugs whose action is aimed at restoring the drainage function of the bronchi: theophylline preparations - retafil, teopek, etc .; Drugs that dilute sputum - acetylcysteine , bromhexine (bisolvon), etc .; Expectorants - thermopsis, potassium iodide, ammonium chloride, mucaltin, althea root, licorice root, plantain leaf, etc .; Drugs that improve microcirculation in the lungs - heparin , quarantil, trental, nicotinic and acetylsalicylic acid; Detoxifying agents - hemodez, isotonic sodium chloride solution, 5-10% glucose solution. Antihistamines (dimedrol, suprastin , etc.) and anti-inflammatory drugs, such as antipyrine , amidopyrine , are also used . With prolonged course of pneumonia in severe cases, corticosteroid hormones are prescribed for the doctor's prescription. According to the indications, anti-inflammatory and analgesic agents (diclofenac, ibuprofen, etc.), analeptics (camphor, sulphocamphocaine , cordiamine), oxygen therapy, diuretics (lasix, furosemide , etc.) are used.

In the treatment of congestive pneumonia, developing against a background of heart failure, the leading drugs are cardiac glycosides, diuretics. Along with this antibacterial, bronchodilators, expectorants are shown. Correction of disorders of acid-base state, therapeutic exercise is necessary. The main role in the complex treatment of aspiration pneumonia belongs to drugs that promote the restoration of normal bronchial patency. When aspiration bronchoscopy is mandatory. In gasoline pneumonia, along with antibacterial, antihistamine, bronchodilator drugs should be prescribed prednisolone . Preserve local importance in the arsenal of therapy for patients with pneumonia local distractions: cans, mustard, mustard wraps. After the normalization of body temperature and the disappearance of signs of intoxication, it is advisable to expand the regime, the appointment of physiotherapeutic methods of treatment (diathermy, inductothermy, microwave currents, UHF, sinusoidal modulated currents, pneumomassage of the thorax).

In the complex treatment of pneumonia, an important role belongs to physiotherapy. Its main means are physical exercises that activate blood and lymph circulation, contribute to the normalization of impaired pulmonary ventilation, accelerate the process of resorption of the inflammatory focus, prevent the formation of pleural adhesions, improve the outflow of sputum, strengthen the respiratory musculature, increase the mobility of the chest. Classes of physiotherapy exercises are prescribed after lowering the body temperature to normal or persistent subfebrile and with the reverse development of the inflammatory process in the lung. At first, elementary gymnastic exercises for limbs, a trunk with a small amplitude, breathing exercises in the prone position are recommended. After 3 - 4 days, the exercises are already performed in the initial sitting position. When the patient's condition improves, the exercises are performed mainly in the standing position while standing, increasing the number of exercises for the upper to the lower limbs, trunk, complicating the breathing exercises, to prevent the formation of pleural adhesions, exercises that increase the mobility of the chest are introduced. Along with therapeutic gymnastics, walking is combined with respiratory movements, both on average and at a fast pace. After discharge from the hospital, we recommend rowing, skiing, short-term tourism, sports games (volleyball, badminton, tennis) in a sanatorium.

Treatment should be carried out before recovery: normalization of patients' well-being, elimination of clinical, laboratory and roentgenological signs of inflammation. The discharge of patients from the hospital, even with a slight residual infiltration of the lung tissue and with minimal signs of activity of the inflammatory process, creates a threat of recurrence, the transition of an acute inflammatory process to a chronic inflammation with the development of pneumosclerosis. After discharge from the hospital, treatment should continue in the conditions of specialized rehabilitation departments, in sanatoriums and dispensaries. The complex of rehabilitation measures includes therapeutic gymnastics, climatotherapy, nutrition, non-medicament methods of treatment (inhalation, acupuncture, etc.). Patients with acute pneumonia should be under clinical supervision for 6-12 months.

The prognosis with timely initiated and rational therapy in most cases is favorable, recovery occurs at the end of the 3rd - the beginning of the 4th week of the disease. Prolonged flow of pneumonia is most often caused by late started and inadequate treatment, predisposing factors are concomitant diseases of the respiratory system, foci of chronic infection, occupational hazards, and smoking .

Prevention is based on the observance of common sanitary and hygienic principles (working conditions, ventilation, fighting dust, smoking, adequate nutrition, isolation of infectious patients, etc.). It is necessary to timely and adequate treatment of diseases, which are accompanied by lung damage. Important is the hardening, sanation of foci of chronic infection.