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Pneumonia in children. X-ray for pneumonia X-ray diagnosis of chronic pneumonia

Pneumonia is an inflammation of the lungs that occurs due to the presence of a large number of pathogens in the body. For example, a disease can be caused by bacteria such as pneumococcus, streptococcus, staphylococcus, and other diseases. In addition, the causes of the disease can be intracellular pathogens, viruses and fungi.

These toxins lead to the destruction of tissue sites in the lungs. X-rays help to monitor the patient's condition more effectively. So, for example, in case of infection with bacteria, viruses or fungi, it is inappropriate to treat the patient with antibiotics.

Unfortunately, some doctors have to treat pneumonia without x-rays. This happens due to a lack of machines, especially in rural areas. Therefore, treatment without an x-ray may not be very effective.

X-rays should be taken for symptoms that are well established. So, for example, in the presence of wheezing in a patient, an x-ray may be offered. But with laboratory tests, the reliability of the method decreases. In this case, inflammation will not be detected.

Signs of pneumonia, in most cases, are weakness, headache, fatigue, muscle pain and loss of appetite. Although some signs may differ, as it all depends on the cause of the disease and the extent of the affected areas.

In addition to these symptoms, one can also distinguish a high temperature, reaching 40 degrees Celsius. Dry cough gives way to wet cough with purulent sputum. Chest pain appears when breathing or coughing. This indicates damage to the pleura.

If pneumonia has a neglected condition, then the disease is accompanied by shortness of breath, the skin becomes pale, and the area near the nose and lips becomes bluish. If most of these symptoms coincide, and when taking tests there is an increase in the number of leukocytes, an X-ray is shown. To track changes in the shadows during treatment for lobar or focal pneumonia, you need to re-x-ray.

Contraindications for X-ray referral should be minimal, with the exception of pregnant women. In their position, X-rays are taken, observing the following rules: lead aprons are used, a smaller amount is given for the procedure, and the number of examinations is reduced. An X-ray is a negative with darkening that shows foci of inflammation, they are depicted in white.

The lesions are small-focal, reaching no more than 3 mm, while medium-sized lesions can be no more than 8 mm. As for the large-focal ones, they are found with sizes from 8 to 12 mm, and focal ones more than 12 mm. In addition, opacities are divided depending on the distribution in the lungs in one segment. If there is inflammation in only one segment, then they are common.

The spots are located on several segments, which means these are subtotal spots. If the intensity is greater, then the airiness of the lung tissue is less. Blackouts are fuzzy and patchy.

On an x-ray with croupous pneumonia, you can see a large darkening with an average intensity. The blackout can be on one or both lungs. Croupous pneumonia can be contracted due to the provocation of Frindler's bacillus. This illness is difficult and can lead to death.

Croupous pneumonia on x-rays

On an X-ray, croupous pneumonia can be recognized by a change in the physiological lesion of the domes of the diaphragm, there are shadows on one or two sides, and the mediastinum moves to the site of the greatest lesion. There is a complete deformation of the pattern of the lungs.

Focal pneumonia on x-ray

As for focal pneumonia, small infiltrates appear with it, it is difficult to identify it, especially in the initial stages. An infiltrate is a seal that forms in a tissue or organ. Its occurrence depends on the accumulation of elements of cells, lymph or blood. Although focal pneumonia is characterized by a not very large increase in the number of leukocytes, high fever, wheezing.

Symptoms such as a noticeable deformation of the pulmonary pattern in a certain area, the presence of shadows in the picture, the presence of pleurisy. In addition, due to infiltration, the root increases. Focal pneumonia is difficult to diagnose.

Dark spots can be observed due to the low airiness of the lung tissue. In the first days of the disease, infiltrates are almost invisible, but very soon the shadow turns into a pneumonic focus. Although focal pneumonia is difficult to diagnose, it can still manifest itself in the pictures.

What does pneumonia look like on X-rays in children?

Inflammation in children is faster and more difficult. Even the smallest infiltration can lead to croupous inflammation.

Therefore, it is very important to make a diagnosis immediately.

In addition to this main symptom, children have other indications of the disease. Partial darkening of areas of the lungs. If the inflammation is neglected, then a high density of spots can be seen.

Infiltrates no more than 2 mm. The lymph nodes in the mediastinum are very poorly visible. If only the shadows disappear, then the deformation of the radiography persists for some time. Due to the high density of the damaged area, the structure of the root and the pattern of the lungs overlaps. Most often, the lung tissue is swollen. This leads to difficulties during diagnosis.

In addition, children have a small volume of lung tissue, but a large number of elements of the lung pattern per unit area.

Features of the X-ray sim card for this disease reflects foci of enlightenment and darkening, based on the blockage of the bronchi. The disease occurs due to the entry of stomach contents into the bronchi.

In places where the passage is disturbed, the occurrence of atelectasis is observed. Looking at the picture, they can be seen by their triangular shape. The dome of the diaphragm will rise, and the mediastinum will move to the affected side.

With inflammation due to staphylococcus, in the picture you can see a limited seal, which is one-sided. Somewhere after the second day, at least after the fifth, with the disease, dry and airy bullae appear, containing liquid and air. Bullae in the lungs are formations that look like air bubbles in the lung tissue. Sometimes, you can find another name for this phenomenon, for example, bleb or cyst. Although they are still bull variants. At the same time, the thickness in the lung tissue changes, so it is often difficult to identify the exact number of infiltrates in the image.

In the case of interstitial pneumonia in an adult, changes in the image are noticeable. An enlarged root after an X-ray is a root infiltration, this is how it looks with this inflammation. Peribronchial compaction occurs. The bronchovascular bundle expands unevenly.

The causative agents of pneumonia were listed earlier. If the disease appears due to intracellular pathogens or viruses, then these inflammations are attributed to another group, atypical. This is due to the fact that they have their own characteristics, in addition, they differ in diagnostics and methods of treatment. In case of illness due to the ingress of fungi, people with HIV infection are observed, in most cases, since they have a weakened immune system. In addition to these facts, there are others that are worth adding, since disease prevention is always effective.

Such reasons include chest trauma, internal diseases, severe stress or immune deficiency, smoking and alcohol abuse. In addition to them, diseases of this type can be caused by oncological diseases, disorders in swallowing, or age exceeding 60 years.

Features of X-ray diagnostics of various types of pneumonia

The symptoms of pneumonia are partly similar to those of other diseases of the bronchopulmonary system. Therefore, doctors are not limited to identifying complaints and features of the development of the disease, direct examination of the patient. A number of additional instrumental and laboratory studies are being carried out.

Important! X-ray of the lungs with pneumonia in order to confirm the disease is mandatory; without it, the diagnosis cannot be considered reliable.

Possibilities of using X-ray diagnostics

Radiography for pneumonia helps not only to establish a diagnosis and exclude another pathology with similar symptoms, but also to monitor the treatment, timely identify possible complications, and establish the effectiveness of therapy. It is obligatory to conduct a study in two projections.

The main objectives of the study:

to confirm the diagnosis of pneumonia, the type of disease, the extent of the lesion;
for the diagnosis of a protracted course, the effectiveness of therapy;
to control recovery and complete restoration of the lung structure;
to exclude the development of complications.

pregnancy;
extremely serious condition of the patient;
the presence of concomitant ongoing bleeding.

These contraindications are relative. If the condition requires immediate diagnosis due to a direct threat to life, then the study is still carried out. At the same time, the negative consequences are minimized as much as possible. For pregnant women, additional protection of the abdomen and pelvis with shielding aprons is used.

The disease is characterized by sweating of fluid in the alveoli, swelling of tissues, the presence of a large number of cells in them, primarily leukocytes and macrophages. It manifests itself clinically (in the form of an acute infectious inflammatory process) and radiographically.

The unambiguous signs of pneumonia on x-rays are darkening of some part of the pulmonary field.

Focal shadows or a widespread, drainage decrease in transparency are revealed. Fuzzy blurred outlines are characteristic.

Allocate pneumonia:

Focal (a small area of lung tissue is affected);
Segmental (one or more segments are involved in the process);
Lobar (croupous, exciting lobe);
Total (damage to the entire lung).

The degree of involvement of various structures of the lungs and the prevalence of the pathological process affect the prognosis of the disease and determine the tactics of treatment.

Research results for various types of pneumonia

Radiographs are fundamentally different for pneumonia of different types: focal bronchopneumonia, lobar lobar and interstitial.

It must be remembered that the changes detected by radiography lag behind the clinical manifestations in time.

Symptoms appear later and remain for a certain time after the disappearance of the manifestations. The description of the picture reflects as much as possible the height of the disease with inflammatory changes in the lung tissue and the filling of the alveoli with fluid.

With a focal process, the following are revealed:

shadows, violation of transparency in a limited area;
enlarged root of the lung (corresponds to the side of the lesion);
deformed, enhanced bronchial and pulmonary vascular pattern in the damaged area.

Croupous inflammation goes through several stages.

If you take an x-ray at the very beginning (the tide stage), then in the presence of typical symptoms (high body temperature, chills, cough, feeling short of breath, pain in the chest with a deep breath), the changes may be nonspecific.

locally enhanced pulmonary vascular pattern;
the transparency of the fields is unchanged or slightly reduced;
the root is slightly expanded from the affected side.

These changes can be missed or attributed to the phenomena of bronchitis. After several days of illness, during the transition to the stage of hepatization, all signs are already visible, indicating inflammation of the lung tissue and effusion into the alveoli.

Pathology during this period is as follows:

decreased transparency of the pulmonary field;
local sharp decrease in airiness and intense darkening;
expansion of the root on the side of inflammation;
compaction of the pleural sheets.

Croupous pneumonia always occurs with a pleural reaction. With the formation of effusion, there is a darkening in the pleural fissure.

Interstitial pneumonia affects the connective tissue around the alveolar structures and blood vessels of the lungs (interstitium). Inflammatory changes, primarily tissue edema, lead to impaired gas exchange. Key Features:

With adequate therapy for all variants of the disease, clinical manifestations are weakened, the inflammatory process in the lungs decreases.

After the onset of the resolution stage, the dynamics of changes in pneumonia is observed in the picture during the control study. Most typically:

Complete restoration of the structure of the affected lung occurs after clinical recovery. The changed X-ray picture looks for at least a month.

Features of changes in childhood

Pneumonia in a child is prone to the spread and drainage nature of the damage. Focal can quickly turn into croupous.

The most characteristic signs of the disease in a child:

After clinical recovery, changes in the vascular pattern and the root of the lung persist for the longest time.

It is necessary to monitor the condition of the child, to direct therapeutic measures for the complete recovery of not only the affected lung tissue, but also the concomitant local bronchitis, the signs of which persist on x-rays for a long time.

Features of X-ray diagnostics of atypical pneumonia

Atypical pneumonia differs not only in the presence of atypical pathogens (Klebsiella, Mycoplasma, Chlamydia), but also in the peculiarities of manifestations. First of all, this is the predominance of signs of respiratory failure (feeling of lack of air) over symptoms of inflammation (low temperature, slight cough).

The X-ray picture depends on the pathogen. The main signs are:

With timely diagnosis and adequate treatment, the effectiveness of therapy is high. However, on x-rays, changes may persist after 4 weeks.

In some cases, limited compaction of pleural and lung tissues (the outcome of inflammation) remains irreversible.

Thus, the use of radiography for pneumonia helps to establish a diagnosis in a timely manner, to determine the form of the disease. This allows for a differentiated selection of therapy, avoiding the development of complications and preventing a threat not only to health, but also to the patient's life.

X-ray of the lungs with focal, croupous and interstitial pneumonia

An X-ray of the lungs for pneumonia (pneumonia) is a diagnostic method that a modern medical clinic cannot do without. The lack of X-rays is acutely felt by village outpatient clinics and feldsher-obstetric points. The medical workers who work in them have to treat pneumonia “blindly”.

Inflammation of the lungs is triggered not only by bacterial agents, but also by fungi and viruses. Against this background, it is not always rational to use antibiotics for pneumonia. With the help of X-rays, the patient's condition can be monitored dynamically during treatment.

How effective is x-ray of the lungs for pneumonia

An X-ray of the lungs in pneumonia is as effective as X-ray diagnostics are prescribed in a timely manner. If X-ray examination is used to detect wheezing in a person, but with normal laboratory tests, the statistical reliability of the method is reduced. In this situation, chest radiographs do not show pneumonia. Wheezing causes bronchitis or colds.

The possibilities of X-rays in pneumonia are extensive, but research is needed to identify clinical symptoms that indicate pneumonia with a high degree of certainty.

Chest X-ray can be dispensed with, but this reduces the effectiveness of monitoring the timely detection and treatment of the disease.

X-ray for pneumonia - indications and contraindications

An X-ray for pneumonia is shown then, the symptoms of pneumonia are characterized by cough, chills, sputum production, and an increase in the number of leukocytes is observed in laboratory tests.

If a person is diagnosed with croupous or focal pneumonia, follow-up radiographs are ordered to track changes in the "bad" shadows during treatment.

A specific indication for an X-ray of the lungs is a serious suspicion of an inflammatory process of the lung tissue or another dangerous disease. To take a picture of a person, you need to take into account the harm and benefits of the examination. Only if the benefits of x-rays outweigh the harm, can x-rays be taken.

Contraindications to the study are not highlighted. The only limitation is pregnancy. However, if pneumonia is suspected in pregnant women, an x-ray of the lungs is done. At the same time, the staff of the X-ray room does everything possible to protect the woman's organs from radiation (lead aprons, reducing the time and number of procedures).

X-ray symptoms of focal pneumonia

Focal pneumonia is laboratory characterized by a slight increase in leukocytes, wheezing and fever. On the roentgenogram, it may not be detected, since at the initial stages the disease is characterized by the appearance of small infiltrates. However, a qualified radiologist can suggest an inflammatory process of the lung tissue even in the absence of infiltrates by indirect X-ray symptoms:

X-ray for pneumonia

Pneumonia, due to its prevalence and an increase in the growth of morbidity, can be considered one of the most important problems in world and domestic medicine. To a certain extent, this trend is explained by the spread of diseases that affect the human immune system (alcoholism, hepatitis, diabetes mellitus, HIV), as well as self-medication taken by patients, causing antibiotic resistance of pneumonia pathogens.

Due to the fact that when diagnosing pneumonia, one cannot rely on characteristic clinical signs, since all symptoms and complaints often indicate a whole spectrum of pathological processes in the lungs, X-ray can be considered a reference research method. Difficulties in diagnosis can be caused by a wide variety of signs of the course of the disease, in which pneumonia on X-ray can become a determining factor when choosing a treatment strategy.

The reasons for the development of pneumonia

Pneumonia is an inflammatory disease, accompanied by damage to all structures of the lower respiratory tract (interstitial tissue of the lungs, alveoli, bronchioles) and a characteristic darkening on the x-ray. Pathological processes in the lung structures often do not allow a clear clinical picture of the course of the disease to be drawn up, since pneumonia is not always an "independent disease".

In half of the cases, it develops as a complication of pathologies such as:

immunodeficiency;
congestive heart failure;
Chronical bronchitis.

In fact, the development of pneumonia is due to the reaction of lung tissue to the negative impact of any external factor:

The morphological reason for the long course of the disease can be considered a violation of the regenerative functions in the area of inflammation, leading to the formation of foci of fibrosis and the release of intra-alveolar exudate. At the same time, there is a violation of the blood supply to the lung tissue, accompanied by the formation of blood clots, air microembolisms and general intoxication of the body caused by the release of toxic substances by pathogenic microorganisms.

X-ray assessment criteria

X-ray manifestations of pneumonia are extremely diverse, however, as with any other pathologies of the lungs, they are based on 4 signs: a change in the pulmonary pattern and roots of the lungs, darkening or enlightenment formed against the background of the pulmonary field. The reasons for the darkening are mainly the formation of exudate or purulent contents in the alveoli.

Enlightenment is a consequence of the formation of an air cavity. Deviations in the structure of the pulmonary pattern indicate damage to the interstitial tissue, accompanied by impaired blood flow. A change in the image of the roots of the lungs indicates damage to the bronchi, lymph nodes, and the vascular system.

On an X-ray that indicates the presence of pneumonia, the following signs can be observed:

complete loss of transparency of the lung tissue (total darkening of the pulmonary field);
darkening of one or more lobes of the lung (subtotal darkening);
darkening that is within one segment of the lung (limited darkening).

However, all these evaluation criteria, with equal probability, may indicate a whole group of lung diseases (pulmonary infarction, malignant neoplasm, pleurisy, tuberculosis, atelectasis). In this regard, X-rays for pneumonia should be performed repeatedly for the purpose of diagnosis, and in accordance with the stages of the course of the disease, which will allow tracking dynamic changes in the state of the lungs in accordance with the stages of the spread of pathology and assessing the body's response to the therapy.

Stages of pneumonia in the picture

Pathological changes in the lungs during pneumonia correspond to 4 stages that characterize the body's response to the presence of the pathogen and the degree of tissue damage.

Tide stage

The duration of this stage is 12-72 hours and is characterized by an intense rush of blood to the vascular system of the lungs, a decrease in their functional activity and the formation of alveolar exudate. An X-ray image shows an increase in the intensity and clarity of the pulmonary pattern, a slight darkening of the pulmonary fields in the area of localization of pathological changes and an increase in the area of the lung root with a simultaneous loss of its structure. A picture of the chest, at the first stage of the disease, due to an increase in blood filling, resembles a lattice (cellular lung).

Red hepatization stage

The duration can take from 24 to 72 hours. At this time, there is a thickening of the interstitial tissue, which in structure begins to resemble the liver. A certain amount of blood (erythrocytes) appears in the exudate. The X-ray picture has only insignificant differences from stage 1, expressed in a decrease in the severity of the pulmonary pattern with its simultaneous enlargement and increased darkening of the pulmonary fields (the "frosted glass" effect). It is possible to determine the stage of the disease, at the initial stages of development, only by having the opportunity to compare the images taken with an interval of 1-2 days.

Stage of gray hepatization

The duration of this stage can be from 2 to 6 days. This time period is characterized by the appearance of purulent contents in the exudate. When performing X-ray, a significant darkening of the fields is noted, against which the bronchi not affected by the pathological process look like stripes of enlightenment. Free liquid is well visualized when taking pictures in the patient's position "lying on the affected side". In this case, the exudate is redistributed, forming a horizontal darkening in the form of a strip.

Resolution stage

During this period, the processes of regeneration prevail over the processes of destruction, which leads to the restoration of damaged lung tissue. Radiological signs of recovery can be considered a decrease in the intensity or area of darkening, a change in the pulmonary pattern at the site of the lesion (the disappearance of large elements and the formation of small ones).

The root of the lung remains dilated for several months. A characteristic X-ray sign after pneumonia may be cicatricial formations, in the form of shadows, elongated along the wall of the lung. There is also no horizontal shading reflecting free liquid in the cavity. Classic radiological signs of pneumonia may be less pronounced in different types of the disease (lobar, focal or segmental pneumonia).

Atypical forms of pneumonia

In addition to generally recognized radiographic signs, pneumonia can also have uncharacteristic manifestations due to atypical etiological factors that provoked the development of pathology.

Caseous pneumonia

Caseous pneumonia (CP) is a pathological condition that is either a complication of tuberculosis, or an independent disease that developed against the background of immunodeficiency or malnutrition. The characteristic manifestations of CP are not the release of exudate as a reaction to the inflammatory process, but the formation of necrotic zones.

In this case, the process of necrotization is accompanied by the melting of lung tissue, the formation of cheesy masses (caseinification) and the formation of cavities (one large or several small ones). It is possible to determine the CP on X-ray by the characteristic displacement of the organs located in the chest (mediastinal organs) towards the affected lung. Also, due to insufficient ventilation of the lung, an upward displacement of the dome of the diaphragm and a decrease in the intercostal distance are observed.

Caverns, more than 3 cm in diameter, on x-ray, are defined as round or semicircular formations in the wall of the lung with a darkened contour and enlightenment in the center. Small cavities form a picture of a destructive lesion of the lung tissue. As a rule, the lesion is observed in both lungs in the form of extensive and strong darkening of the upper parts of the lungs and cavernous focal lesions of the lower lobes.

Pneumocystis pneumonia

Pneumocystis pneumonia (PCP) is a fungal infection similar to a respiratory infection. In the overwhelming majority of cases, the disease is characterized by a latent course, not accompanied by any manifestations of the disease. However, in people with immunodeficiency, PP is severe, accompanied by severe respiratory failure. On the roentgenogram, the PP looks like a bilateral symmetrically located lesion of the lungs, expressed in the loss of transparency of the hilar sections.

At the same time, opacities have a cloud-like shape and, due to their symmetry, are called "butterfly wings". The lung affected by the PP looks like a piece of cotton on the X-ray. In some cases, infiltrates are visible, characteristic of tuberculous lesions and located in the upper lobe of the lung. Another common sign of PN on x-rays are areas of enlightenment resulting from the development of pneumothorax. For a long time, PP served as an indicator allowing the identification of AIDS patients.

SARS

The concept of "atypical pneumonia (AP)" includes several types of pneumonia caused by the following diseases:

An X-ray image for mycoplasma pneumonia (MP) at the initial stages of development has some similarities with the classical development of the disease. As a rule, there is an increase in the intensity of the pulmonary pattern and darkening in the areas of infiltration of the parenchyma. Darkening can occupy one lobe of the lung, and maybe the entire surface. In 20% of cases, blackouts can be focal in nature and be multiple or single. However, the intensity of the darkening can be so slight that when the x-ray is taken on old equipment, the image may not show abnormalities.

Chlamydial pneumonia (CP) has extremely varied radiological signs, expressed in the appearance of a “ground glass” effect on the images, characterizing interstitial damage to the lung tissue or darkening of one lobe, characterizing the formation of an infiltrate. A streak-like darkening, indicative of pleural effusion, is usually negligible or absent.

Legionella pneumonia (LP) is characterized by focal darkening, which, when repeated images are taken, with an interval of several days, show progression and merge into one continuous shadow. The appearance of free fluid in the form of a horizontal darkening strip is observed in only a third of patients. In places where the infiltrates are close to the pleura, the darkening is so intense that it can resemble a pulmonary infarction.

When diagnosing AP, regardless of what result the X-ray showed, it is advisable to resort to examination using computed tomography. This technique allows you to obtain photo and video images made in various modes and avoid the appearance of areas hidden for review.

As a rule, radiography for pneumonia can provide sufficient information to make a diagnosis. To a certain extent, this is due to the fact that at the time of going to the doctor, the patient has a detailed picture of the pathological process. However, early diagnosis of pneumonia remains the main problem, the solution of which will significantly reduce the duration of the course of the disease and reduce the percentage of deaths.

X-ray of the lungs with pneumonia: what the signs of inflammation look like on the pictures

X-ray of the lungs with pneumonia is not only a method for detecting the disease, but also a way to control the dynamics of its course during therapy. There are several forms of inflammatory changes in the lungs, depending on the area of distribution of the pathological process, the X-ray semiotics of which is different.

X-ray signs of lobar pneumonia

X-rays for croupous pneumonia are characterized by the following syndromes:

Extensive (total) decrease in the transparency of the lung tissue.
Subtotal darkening - with the localization of inflammation within one or two lobes of the lungs.
Limited darkening - infiltrative changes in the lung tissue that do not go beyond the segment.

The above symptoms are observed not only with croupous pneumonia. They can also be traced in: atelectasis, lung cancer, pleurisy, tuberculous pneumonitis, pulmonary infarction.

X-ray of pneumonia should be based on additional signs of a staged course of inflammatory changes in the lung tissue for a reliable diagnosis.

Photo of a radiograph in pneumonia: at the stage of gray hepatization (a), after permission (b)

What do the images of the lungs look like in the tidal stage with croupous inflammation

The tide stage is the initial stage of the formation of croupous pneumonia. With her, the following X-ray syndromes are observed in the pictures:

Enrichment and strengthening of the pulmonary pattern.
Reduced or normal transparency of the pulmonary fields.
Expansion of the root of the lung on the affected side.

A change in the pulmonary pattern occurs due to an increase in blood supply against the background of a decrease in the functional capacity of the lung tissue. A snapshot of the chest organs in such a situation looks like a lattice. True, such changes are observed only at the site of localization of the inflammatory focus.

With an increase in airiness, the pulmonary fields on the roentgenogram become transparent. Morphological sections of tissue at the tidal stage indicate that the alveoli become red due to bleeding, but this sign cannot be recorded radiographically.

The root of the lung becomes dilated, and its structure decreases, which is due to vascular hypertension.

Radiography of the lungs in the stage of gray hepatization

X-ray of the chest organs in the gray hepatization stage is able to record the following X-ray signs of pneumonia:

Decreased transparency of the pulmonary fields in the area of inflammatory lesions.
The appearance of intense shadows corresponding to the size of the damaged tissue.
Against the background of massive darkening of the stripe of enlightenment - visualization of the trachea and bronchi, which are not affected by inflammation.
Expansion of the root on the side of the pathology.
Compaction of the pleural sheets in the area of inflammation.
Pleural fissure effusion with pleurisy.

It is better to diagnose pleurisy when performing laterography (exposure in the position of the patient on the diseased side). In this case, free liquid will spread along the costal arch, forming a horizontal shading strip. Morphological photos at the stage of gray hepatication show the accumulation of fibrin in the alveolar cavity.

Photo: X-ray of left-sided root pneumonia. Arrows indicate deformation of the pulmonary pattern and the absence of root structure (a). 2 months after pneumonia, against the background of inflammation, fibrous cords formed - carnification (b)

Stage of resolution of pneumonia on the radiograph

On the roentgenogram with pneumonia in the resolution stage, the following symptoms are observed:

Reducing the intensity of blackout.
Decrease the size of the shadow.
Root expansion.
Enrichment of the pulmonary pattern (many small elements per unit area) at the site of the existing focus of inflammation.

An enlarged root of the lung in the stage of pneumonia resolution can be observed for several months in a row, until the anatomical structures are restored. After the healing of pleurisy, linear shadows of fibrinous layers or cicatricial adhesions may remain at the site of inflammatory foci, which impede the breathing process. These changes reflect the morphological photos of the lungs in the stage of pneumonia resolution - there is no infiltration in the alveoli, but fibrous overlays may remain.

How the complications of pneumonia look on the pictures

Complications of pneumonia - abscesses, exudative and fibrinous pleurisy, periscissuritis also have their own X-ray manifestations on lung images.

What does an abscess look like on an x-ray

Skialogic picture of an abscess on a roentgenogram:

enlightenment cavity;
fuzzy rounded contour with perifocal inflammatory foci;
the level of obscuration in the projection of decay due to infiltration;
the disappearance of the horizontal level when draining the abscess.

With abscessed pneumonia, several cavities of decay of the lung tissue can be observed, which merge with each other.

Photo of a radiograph with an abscess of the right lung after lobar pneumonia. Left - reduction of the horizontal border after drainage of the abscess

Skialogic symptoms of pleurisy in the pictures

Exudative pleurisy in the pictures is manifested by the following symptoms:

darkening of the lower pulmonary field due to infiltrative fluid;
the upper oblique border of Sokolov-Damoiseau-Ellis;
displacement of the mediastinum in the opposite direction.

Inflammation of the interlobar pleura (periscissuritis) is determined by the radiologist according to the following radiological syndromes:

clarity of the contour of the interlobar slit;
the severity of the lumen of the subsegmental bronchi with infiltration of the lungs;
expansion of the root on the side of the lesion.

The article discusses a classic example of X-ray diagnostics of pneumonia against the background of croupous inflammation. There are other forms of the disease (focal, segmental, lobar), in which the given X-ray syndromes are expressed only partially.

Many researchers prefer to divide acute pneumonic processes according to the etiological principle.

Pneumococcal pneumonia. Croupous pneumonia is the most famous.

It is characterized by an acute onset, severe course, a sequence of pathological changes. An infection that has entered the body by an aerogenic route in the presence of a number of predisposing factors (cooling, overwork, etc.) causes damage to an entire lobe of the lung or part of it. In this regard, croupous pneumonia is often called lobar pneumonia, or pleuropneumonia.

Clinically and pathoanatomically, pneumonia is characterized by a change in four stages of development.

The stage of tide, or hyperemia, is accompanied by overflow of the lung lobe with blood and expansion of capillaries, accumulation of serous fluid in the alveoli with the presence of erythrocytes and leukocytes. The duration of this stage is about a day. Radiographically, at this stage of pneumonia, there is an increase in the pulmonary pattern of the affected lobe, and by the end of 2-3 days - a slight decrease in transparency, expansion of the lung root, sometimes a linear shadow of the interlobar pleura is visible, there is a restriction in the mobility of the dome of the diaphragm. On the 2-3rd day, the stage of hyperemia passes into the stage of red hepatization. The cavities of the alveoli are filled with fibrin with an admixture of erythrocytes, leukocytes, alveolar epithelium, which leads to an increase in the volume of the lobe, its density. The pleura is thickened due to fibrin deposits. In the section, the lobe has a reddish-brown color. Erythrocytes, which are part of the contents of the alveoli, soon undergo hemolysis, and after 2-3 days the stage of gray hepatization begins. The affected lobe still remains dense, there is no hyperemia, and the section has a grayish lung tissue.

Radiographically, in the stage of red and gray hepatization, an intense shadow is determined, respectively, to the affected lobe of the lung, almost uniform in nature. Its intensity increases towards the periphery. The lobe often has the usual size, the root of the lung is expanded, its structure is lost. And with atelectasis, the proportion in size decreases. In addition, the darkening in croupous pneumonia is distinguished by two more features: first, the intensity of the shadow towards the periphery increases, while the uniformity of the shadow also increases; secondly, against the background of darkening in the medial sections, light stripes of the bronchi of large and medium caliber are visible, the lumens of which in lobar pneumonia in most cases remain free (air bronchogram) (Fig. 3.28). The adjacent pleura becomes denser, in some cases, an effusion is found in the pleural cavity. There are no radiological differences between the stage of red and gray hepatization. The stage of resolution is characterized by a gradual decrease in the intensity of the shadow, its fragmentation and reduction in size. The shadow of the root remains widened and unstructured for a long time. The same should be said about the pulmonary pattern at the site of the former hepatization: it remains enhanced for another 2-3 weeks after clinical recovery. Possible complications, unfavorable outcomes, which include the transition to abscess pneumonia with the development of bronchiectasis, cirrhosis.

Currently, segmental pneumonia is more common, localized not in all segments of the lobe. If inflammation develops in a part of the segment adjacent to the pleura (usually interlobar), then such an inflammatory process is called periscissuritis (Fig. 3.29, 3.30).

Bronchopneumonia (lobular, catarrhal, focal pneumonia). The causative agent is pneumococcus. With bronchopneumonia in inflammatory

			Rice. 3.28. Plain chest radiograph in direct projection. Extensive darkening in the right lung with air bronchogram (arrow). Croupous pneumonia of the lower lobe of the right lung.

Rice. 3.29. Plain chest radiographs of the patient (age 23) in the frontal and right lateral projections. There is a limited darkening in the anterior segment of the upper lobe of the right lung. The darkening has an average intensity in the medial part and small along the periphery, its contours are indistinct, with the exception of the lower border adjacent to the interlobar fissure. The root of the lung on the right is expanded, low-structured. There are no pathological changes in other parts of the lungs. The position of the diaphragm and mediastinal organs is normal. Right-sided acute pneumonia with a lesion of the anterior segment of the upper lobe of the right lung by the type of periscissuritis.

Rice. 3.30. The same observation as in the previous figure, but ten days after treatment. Positive dynamics is noted, the infiltrative shadow in the anterior segment of the right lung has disappeared. The compaction of the interlobar pleura on the right (between the upper and middle lobes) is preserved. Right-sided acute pneumonia of the right lung in the stage of resolution.

the process involves the lobules and the stages that pass pneumonic foci are not identical (in some foci - the tide stage, in others - hepatization, in the third - permission). Unlike croupous pneumonia, the course of the disease is less severe, the onset is gradual, body temperature rarely reaches high numbers. X-ray examination is characterized by bilateral lung damage with the presence of focal shadows corresponding to the size of the lobule (1.0 cm), with blurred contours of low or medium intensity. The largest number of foci is located in the lower parts of the lungs (Fig. 3.31). Throughout the lungs, there is an increase in the pulmonary pattern, the roots are expanded, their structure is absent. Often there is a reaction from the pleura, the development of exudative pleurisy is possible. With bronchopneumonia, the fusion of foci with the formation of large foci of inflammation is possible. Bronchopneumonia can be characterized by small focal shadows, based on the defeat of the acini. A characteristic feature of bronchopneumonia is the rapid dynamics of focal shadows during the first week, and the disappearance of the foci is observed after 10-14 days. This is the main difference from tuberculosis.

Streptococcal and staphylococcal pneumonia. They account for about 10% of all acute pneumonia. The main contingent is children, including young children and newborns. Primary staphylococcal and streptococcal pneumonia in adults can be of two types.


Rice. 3.31. Frontal projection chest radiographs: left - before treatment. Multiple medium- and large-focal shadows of low intensity with indistinct contours are determined, located in the lower parts of the lungs on both sides (arrows); on the right - two weeks after treatment, positive dynamics - focal shadows in the lower parts of the lungs are not determined. Bilateral bronchopneumonia.

In some cases, they begin acutely, with high fever, chills, severe general condition; in other cases, the clinical manifestations of the disease are more erased. In both clinical forms, there is a cough with mucopurulent sputum, often mixed with blood.

The only way to distinguish staphylococcal pneumonia from streptococcal pneumonia is by bacteriological analysis. Along with pulmonary symptoms, patients often complain of pain in the joints, lower back, and extremities. ESR increased, in the blood - leukocytosis and shift to the left.

The X-ray picture of strepto- and staphylococcal pneumonia is characterized by the presence of multiple inflammatory foci of large and medium sizes, more often in both lungs. The outlines of the foci are indistinct, the intensity of the shadows depends on their size; there is a pronounced tendency towards their merger and subsequent disintegration. In these cases, against the background of the shadows of the inflammatory foci, enlightenments appear, delimited from below by the horizontal level of the liquid. A relatively quick change in the X-ray picture is characteristic. Within 1-2 weeks (sometimes longer), you can observe the appearance of infiltrates, their decay, the transformation of decay cavities into thin-walled cysts, followed by their reduction. On one radiograph, all stages of development of pneumonic infiltrates can be detected, which gives the X-ray picture a peculiar look (Fig. 3.32).

Exudative pleurisy, often purulent, often joins. A triad of symptoms is characteristic of these pneumonia: infiltrates, rounded decay cavities, pleural exudate. Outcomes of streptococcal and staphylococcal pneumonia are different. At the site of the former infiltrates, transparency is restored, sometimes the pulmonary pattern remains enhanced for a long time. The cyst-like formations that appear after the collapse of the lung tissue can persist for several months, and sometimes for several years. In most cases, these false cysts gradually decrease, deform, shrink and leave behind areas of pneumosclerosis. In some patients, there is an increase in cysts due to valvular swelling; their rupture can lead to spontaneous pneumothorax. The shadows of the roots of the lungs, which expand and homogenize during the acute course of pneumonia, gradually take on a normal appearance. In place of the former pleural exudate, pleural moles and sinus obliteration remain. Differential diagnosis is carried out with multiple lung abscesses, caseous pneumonia, chronic pneumonia. The fast dynamics of the process aids in distinctive recognition.

Viral pneumonia. The main clinical manifestations: chest pain, cough with scanty sputum, general weakness. The temperature in most cases is subfebrile, although it can sometimes rise to high numbers. The poverty of physical data is noteworthy. The blood picture is characterized by leukopenia, sometimes lymphocytosis. The clinical feature of acute interstitial pneumonia is its resistance to sulfonamides and most antibiotics. There are 3 stages of the X-ray picture of acute interstitial pneumonia: 1) initial, tracheobronchitic, characterized by an increase in the bronchial pattern. The substrate for these changes is the inflammatory infiltration of the interstitial tissue located around the bronchi, blood vessels, acini, lobules, and segments. A significant number of shadows appear (per unit area), and their normal radial direction disappears. Intertwining in different directions, these shadows form a reticular or cellular pattern, 2) peribronchitic, in which focal shadows appear against the background of an enhanced pulmonary pattern, especially in the hilar and supraphrenic regions, and 3) pneumonic, in which focal shadows are the main element of the X-ray picture; possible large low-intensity infiltrates with indistinct outlines; there is no pleural effusion (Fig. 3.33).

The course of interstitial pneumonia is long: X-ray changes are observed for 3-6-8 weeks or more. With a favorable course, acute interstitial pneumonia completely resolves, and the normal X-ray picture is restored. With a prolonged course, compaction of the pleura and areas of pneumosclerosis can be observed as residual effects. Chronic bronchitis, diffuse pneumosclerosis, and bronchiectasis often develop.

The dynamics of the X-ray picture, sputum analysis, immunological studies help to make the correct diagnosis.

Septic pneumonia. These are acute inflammatory processes of the lungs resulting from hematogenous drift of infection from individual purulent foci (osteomyelitis, liver abscess, boil). The causative agents are staphylococci, rarely streptococci, Escherichia coli.

Groups of microbes first enter the blood stream, into the pulmonary circulation, settle in the small vessels of the lungs, causing their thrombosis, followed by the transition of the inflammatory process to the lung tissue. An inflammatory focus appears in the lung, from which the further spread of the process goes along the lymphatic pathways. Clinical manifestations of septic pneumonia are not very common, auscultatory data are scarce, and X-ray examination reveals extensive bilateral lung damage, multiple focal and infiltrative shadows. The latter have a tendency to disintegration with the formation of abscess-like cavities, without horizontal levels (Fig. 3.34).

Rice. 3.34. Plain chest radiograph in direct projection. Multiple rounded shadows with indistinct contours in the lower part of the pulmonary field on the left (arrows). On the right, in the lower part of the pulmonary field, there is a limited darkening, heterogeneous with indistinct contours, in which there are rounded enlightenments (diamond-shaped arrows). Septic pneumonia with decay cavities.

There is a rapid dynamics of X-ray changes with a slow reverse development of the disease.

CT scan. With the help of CT, it is possible at earlier stages in acute pneumonia to identify changes in the lung tissue, as well as to more accurately establish the localization and prevalence of the process. CT scan better reveals the symptom of an air bronchogram, characteristic of inflammatory seals in the lung tissue. The absence of this symptom may indicate the obstructive nature of changes in the lung or a destructive-necrotic process.

For citation: D. V. Kutkin Features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome // BC. Medical Review. 2016. No. 3. S. 144-147

The article is devoted to the peculiarities of the X-ray picture in patients with viral-bacterial pneumonia and the prediction of the risk of acute respiratory distress syndrome

For citation. D. V. Kutkin Features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome // BC. 2016. No. 3. P. 144-147.

Introduction
Pneumonia diagnosed by X-ray images is traditionally assessed, first of all, quantitatively: the volume of the lesion, the intensity of inflammatory infiltration is reflected. The risk of acute respiratory distress syndrome (ARDS) is expressed in terms of the number of lung quadrants affected. In many manuals, articles, reviews, the X-ray picture is named among the leading criteria for the diagnosis of severe pneumonia, viral-bacterial pneumonia, viral pneumonia, ARDS, however, the wording in the section "Changes in the lungs" is very scanty - "bilateral infiltrates", "diffuse lesion", "Extensive areas of consolidation." It is important to highlight the features of the X-ray picture in these conditions, to use not only quantitative, but also qualitative criteria in the work.
Purpose of the study: to reveal the features of the X-ray picture in patients with viral-bacterial pneumonia. To develop criteria for the qualitative assessment of the X-ray picture in patients with pulmonological profile, to use them in predicting the risk of ARDS.

Material and methods
This study uses observations from the 2009–2010 H1N1 influenza epidemic season and a small number of observations from the current 2015–2016 epidemic season. In order to more effectively analyze and compare the X-ray picture of the lungs, 4 criteria for qualitative assessment (including for CT) in pulmonary patients have been developed, which are designated by the abbreviation TPLS (from Latin - thorax, pulmones, lobules, substratum and Greek - syndrome) (Table 1).

This scale is syndromic, detailing the syndromes is included in the descriptive part of the X-ray image (or CT) analysis. To assess each criterion, 3 degrees are provided (0, 1, 2), in addition, transition states (0-1, 0-2, 1-2) are allowed. The final grade for all 4 criteria is supposed to be expressed not in the form of the sum of points (quantitative approach), but in the form of a combination of the values of 4 criteria. When choosing a value for the 1st criterion - "violation of pneumatization" - not only obvious signs of emphysema or the phenomenon of atelectasis of the lung tissue were taken into account, but also intermediate states in the form of hyper-airiness or hypo-airiness, deep or low degree of inspiration. Local, asymmetric chronic changes (2nd criterion), in our opinion, better reflect the chronic background, since the conclusion "pneumosclerosis" based on the general picture of the pulmonary pattern is very variable and largely depends on the quality of the image, the individual point of view of the specialist and is not always confirmed by CT results. Local chronic changes in S1 – S2 of the lungs are most often associated with post-tuberculosis. Bronchiectasis (3rd criterion along with interstitial lesion) refers to chronic changes, but an exacerbation stage is possible, bronchiectasis can be combined with bronchioectasis and bronchiolitis. By the syndrome of interstitial lesion, we mean any thickening of the interstitium (this also includes small focal dissemination) that requires treatment or mandatory X-ray control over time. The structure of the area of pathological density (4th criterion) can be represented by several components, the activity of the process implies the progression of the process without treatment.

Results and its discussion
More complete results will be obtained after the end of the current epidemic season and comparison of data for several years. At present, the experience of the 2009–2010 epidemic season was used in the analysis of radiographs of the lungs of patients with pulmonological profile. and the above criteria.
When using the TPLS criteria for assessing the X-ray picture of the lungs in patients with pulmonological profile, we reflected: the asymmetry of pneumatization of the pulmonary fields and the degree of inhalation during the image, including in dynamics; the presence of local chronic changes as evidence of the transferred, as a rule, inflammatory diseases of the lungs; the presence of signs of compaction of the interstitial component along with parenchymal infiltrates - with this combination, we assume a more severe course of the disease; localization of infiltrates from 2 sides, polysegmental, which is more typical for the viral component of pneumonia.
In our hospital during the epidemic season 2009-2010. (H1N1 influenza) patients diagnosed with pneumonia were treated in the pulmonology departments No. 1 and 2, infectious diseases No. 1 and 2, the department of thoracic purulent surgery. Severe viral-bacterial pneumonia was diagnosed in 54 patients (17 of them pregnant), these patients were treated in the departments of pulmonary and general intensive care, 28 (51.9%) people were on artificial lung ventilation (ALV), incl. 7 pregnant women. The study group is represented by 54 patients, of which 18 (33.3%) are men and 36 (66.7%) are women. The average age is 35 (15 to 55).
All patients have a history of acute respiratory disease. The number of days spent in intensive care is from 3 to 32 days, on average - 17 days. 6 patients died. Some patients were treated in other hospitals from several days to a week and were transferred to us in a serious condition. All had bilateral lung infiltrates at the time of admission. All patients underwent radiography of the lungs, CT scan was performed in 20 patients. The terms of stay in our hospital for most patients reached 2 months. The onset of clinical manifestations of viral-bacterial pneumonia occurred on average on the 3-5th day (less often - on the 8th day) from the onset of the disease. The indications for transfer to the intensive care unit were the clinical picture of rapidly progressing acute respiratory failure (ARF), ARDS. ARDS symptoms usually developed within 24 hours. ARDS was diagnosed in 37 cases.
In 2009–2010 the analysis of CT radiographs of the lungs of patients with viral-bacterial pneumonia made the following observations: "frozen picture", a very slow change in the X-ray picture during studies in dynamics within 1-2 weeks; small degree of inspiration according to the image of the lungs in all patients; bilateral polysegmental lung damage in 46 (85.1%) patients. In all patients, the lung damage was asymmetric, there were large intensive infiltrates. Absence of pleurisy - in most patients, isolated cases of small pleurisy - in 5 (9.2%) patients. Pneumothorax - in 8 (28.6%) out of 28 patients on mechanical ventilation (Fig. 1 and 2).
Radiographs of the lungs: the picture is either nonspecific - bilateral areas of darkening (inflammatory infiltrates), or shows a combination of interstitial lesions and inflammatory infiltrates, in the latter case, in a small number of patients, the volume of infiltration was small, but nevertheless there was ARDS. Bilateral infiltrates were observed equally often in the upper and lower sections (Fig. 3).
CT of the lungs: 2 signs are characteristic - consolidation (infiltration, filling the lumen of the alveoli with a pathological substrate) of lung tissue and "frosted glass" (a sign of alveolitis, hardening of the walls of the alveoli). Consolidation with a tendency to peribronchial location prevails over "ground glass" in most patients. Less often - chaotic areas of consolidation. Subpleural consolidation - in all patients (Fig. 4-6).

Thus, the most frequent options on the TPLS scale were TPLS 2002, TPLS 2012, less often TPLS 2001, TPLS 2011. Taking into account the more informative value of CT of the lungs in comparison with traditional radiographs, the TPLS option can be refined based on the results of CT. As a rule, the syndrome of interstitial lesion, revealed by traditional radiographs, corresponded on CT of the lungs to a combination of mild peribronchial consolidation and small areas of "ground glass" polytopic localization (ie, a combination of symptoms of parenchymal compaction of lung tissue was observed). The options TPLS 2002 and TPLS 2022 corresponded to ARDS (mainly chest radiographs were analyzed, since the CT scan was limited by the severity of the patient's condition).
In dynamics, both radiographs and CT of the lungs showed the absence of complete restoration of the normal X-ray picture in all patients: in all patients, compacted interlobular septa, linear fibrosis / atelectasis, and areas of consolidation remained, but in a much smaller volume (Figs. 7 and 8).

At the onset of the disease and at the time of discharge, the airiness of the pulmonary fields is diffusely reduced (we emphasize that all studies are done on the patient's inspiration), therefore, it is not always possible to determine by CT: this is "frosted glass" (a sign of alveolitis, fibrosis of interalveolar septa) or severe hypopneumatization (absence full inhalation).
Among all the patients who had pneumonia during the 2009–2010 epidemic season, there was no absolutely similar CT picture, despite the same CT symptoms. When comparing the CT picture in patients with viral-bacterial pneumonia with diagnosed ARDS and without ARDS, we did not reveal a significant difference in the ventral-dorsal density gradient of the lung tissue. The ventral-dorsal gradient in CT examination is clearly pronounced in patients with manifestations of heart failure. In addition, CT patients with symptoms of heart failure often had a symptom of mosaic perfusion, which was not found in any of the patients with viral-bacterial pneumonia and ARDS.
In observations for the epidemic season 2015–2016. we met 12 cases of viral-bacterial pneumonia, not all confirmed H1N1 flu, but all patients had a history of acute respiratory disease and a similar X-ray picture. In the study group of 12 patients - 8 (66.7%) men and 4 (33.3%) women. The average age is 51 (range 28 to 79). When examining the first pictures, we can talk about a dubious, but still probable picture of pneumonia or bilateral pneumonia of a small volume. At the control examination after 3-6 days (X-rays or CT of the lungs), bilateral polysegmental pneumonia of large volume with several infiltrates is observed. Large lobar high-intensity infiltrates are absent. Mostly the parts of the lungs are affected below the level of the tracheal bifurcation. According to the results of CT, the volume of the lesion is much larger than on X-ray images, the compaction of the lung tissue is of a parenchymal nature. Positive dynamics against the background of antibiotic treatment took place in all patients on the 8–12th day, no “frozen picture” was noted. Pleurisy and no ARDS cases have been identified.
On the TPLS scale during the primary X-ray examination TPLS 000 (0–1), that is, doubtful infiltration in a small volume, during the control study TPLS 002 (0–2) or TPLS 2012. Against the background of the reverse development of pneumonia TPLS 000 (1–2 ), i.e. infiltration of the average volume, there are transient changes. The most typical variant of viral-bacterial pneumonia for the 2015–2016 epidemic season. - TPLS (0–2) 002, that is, the degree of inspiration suffers moderately, there are no chronic changes, there is no interstitial lesion syndrome, a large volume of bilateral uneven infiltration.

conclusions
Based on observations for 2009–2010. and analysis of a small number of cases of viral and bacterial pneumonia in the 2015–2016 epidemic season. we made the following conclusions.
1. Viral-bacterial pneumonia is more common in people of working age without background chronic changes in the lungs.
2. Cases of viral and bacterial pneumonia of the 2009–2010 epidemic season. more often noted in women, with a high proportion of morbidity in pregnant women.
3. For viral-bacterial pneumonia, concomitant pleurisy is not characteristic.
4. The "frozen picture" on the images of the lungs in dynamics can be regarded as an independent criterion for viral-bacterial pneumonia and ARDS.
5. Irregularity, polytopicity, small size and different intensity of areas of parenchymal compaction (infiltration) of lung tissue on X-ray images form, along with a picture of infiltrates, a picture of interstitial lesions in viral-bacterial pneumonia.
6. Viral-bacterial pneumonia often has an asymmetric picture according to the results of X-ray and CT, there is no tendency to damage the hilar parts of the lungs, which can be used in the differential diagnosis with bilateral pneumonia after an episode of pulmonary edema in severe patients with severe hemodynamic disturbances.
7. Viral and bacterial pneumonia of the epidemic seasons of 2009–2010. and 2015–2016 have a similar radiological picture, but for pneumonia 2015–2016. a long course is not typical, no cases of ARDS have been noted, impairment of lung excursion is less pronounced, large high-intensity infiltrates are not characteristic, lesions are detected mainly in the lower parts of the lungs.
Based on the results of work with patients with pulmonary profile, in particular with patients with viral-bacterial pneumonia, we have put forward several hypotheses.
1. Background chronic changes in the lungs, perhaps not only an indicator of "abnormal", but also an indicator of "preparedness" of the lungs for repeated inflammatory diseases. It is possible that the absence of a chronic background in the lungs is a greater risk factor for viral-bacterial pneumonia than the presence of chronic changes.
2. The extent of lung tissue damage does not always play a decisive role in the occurrence of ARDS. Perhaps, with a large amount of inflammatory infiltration in the lungs, there is a TPLS value, at which ARDS rarely occurs.
3. Perhaps, during a statistical analysis over a long period, it will be possible to identify the most frequent variants of TPLS in viral-bacterial pneumonia that accompanied influenza outbreaks at different times.
4. The phenomena of mosaic perfusion can be not only a variant of pathological changes, but also evidence of the activation of the adaptive mechanisms of the surfactant system.
5. Probably, in ARDS, there is a tendency to equalize the density of lung tissue and a decrease in the gradient between different parts of the lungs in comparison with the indicators of lung tissue density in pulmonary patients without ARDS.

Conclusion
Viral-bacterial pneumonia associated with a severe course can be figuratively compared with pneumonia in the "pre-antibacterial era", which is expressed in a bilateral polysegmental lung lesion, a "frozen" X-ray picture, a high risk of developing ARDS, and residual post-inflammatory changes.
Perhaps it is advisable to apply the criterion of the absence of dynamics - a “frozen picture” - to classify within the group of viral-bacterial pneumonia.
In our opinion, the prospects for diagnosing viral-bacterial pneumonia, predicting the risk of ARDS are largely associated with the improvement of the leading - radiation method of diagnosis, which should be expressed in the analysis of X-ray images of the lungs using qualitative criteria, detailing the most characteristic signs during dynamic observation.

The X-ray picture of numerous viral pneumonias is characterized primarily by an increase in the pulmonary pattern due to edema and inflammation of the peribronchial and perivascular tissue. At the same time, the drawing retains a radial direction - from the roots of the lungs to the periphery. A similar picture can be observed with increased blood volume in the lungs. These processes can be distinguished using the Valsalva test.

When straining after a deep breath with a closed glottis, excess blood from the pulmonary vessels is "squeezed out" and the pulmonary pattern is normalized. If the reason for the strengthening of the pattern is the infiltration of interstitial tissue, as in viral pneumonia, then the pulmonary pattern remains excessive at the height of the Valsalva test.

Following the infiltration of the peribronchial and perivascular tissue, edema and inflammation of the interstitial tissue surrounding the lobules and acini occur, which leads to deformation of the pulmonary pattern, acquiring a cellular nature. After 2 - 4 days, infiltration of the pulmonary parenchyma often joins the picture of interstitial pneumonia. Along with focal changes, more extensive darkening can sometimes be observed, usually in shape and distribution that does not correspond to the lobes and segments of the lungs.

These blackouts without anatomical boundaries are characterized by a peripheral location, most often in the middle and lower zones, and differ from similar blackouts in low intensity, especially in the initial stages of development.

As the infiltration intensifies and the darkening increases, their intensity increases and approaches normal. According to N. Schinz et al. (1973), the occurrence of blackouts in viral pneumonia corresponds to stage III of the disease: stage I - tracheobronchitic, II - peribronchitic, III - pneumonic.

Against the background of a strengthened and deformed pulmonary pattern, multiple infiltrates are visible
in both lungs, without clear anatomical boundaries.

The course of viral pneumonia in most cases is rather long - 3 - 6 weeks, sometimes more. Pneumonic foci resolve first; pulmonary pattern is normalized later. The disintegration of pneumonic foci in viral pneumonia is rare, usually with a layer of bacterial flora. With a favorable course of the process, after the elimination of all manifestations of viral pneumonia, the X-ray picture can completely normalize. However, in some cases, there is a transition to chronic pneumonia.

"Differential X-ray diagnostics
diseases of the respiratory and mediastinal organs ",
L.S.Rosenstrauch, M.G. Winner

See also:

Lecture for doctors "Radiation diagnostics of pneumonia". The lecture for doctors is delivered by the Scientific Clinical Center of JSC "Russian Railways".

Pneumonia (pneumonia) is a group of acute local infectious and inflammatory diseases that differ in etiology, pathogenesis and morphological characteristics, which are characterized by focal lesions of the respiratory parts (alveoli, bronchioles) of the lungs with intraalveolar exudation, confirmed by physical and X-ray examination, and are accompanied by varying degrees of reaction severity and intoxication.

The definition emphasizes the acute nature of inflammation, so there is no need to use the term "acute pneumonia" (in the International Classification of Diseases adopted by the World Health Organization, the heading "acute pneumonia" is absent and is replaced by the term "pneumonia").

Depending on the epidemiological situation, the incidence of pneumonia in Russia ranges from 3-5 to 10-14 cases per 1000 population, and in the elderly group it can reach 30-50 cases per 1000 population per year.

Classification

In our country, for a long time, the classification of acute pneumonia (OP), proposed by E.V. Gembitsky et al. (1983). This is a modification of the classification developed by N.S. Molchanov (1962) and approved by the XV All-Union Congress of Physicians. The following headings are distinguished in it.

Etiology:

Bacterial (indicating the pathogen);

Viral (indicating the pathogen);

Ornithoid;

Rickettsial;

Mycoplasma;

Fungal (with an indication of the type);

Mixed;

Allergic, infectious-allergic;

Unknown etiology.

Pathogenesis:

Primary;

Secondary.

Primary OP is an independent acute inflammatory process of predominantly infectious etiology. Secondary pneumonia is understood as a complication of other diseases (diseases of the cardiovascular system with impaired blood circulation in the small circle, chronic diseases of the kidneys, blood system, metabolism, infectious diseases, etc.) or developing against the background of chronic diseases of the respiratory system (tumor, bronchiectasis, etc.) etc.), etc.

Clinical and morphological characteristics:

Parenchymal - croupous, focal;

Interstitial.

The division into focal and croupous OP is valid only in relation to pneumococcal pneumonia. The diagnosis of interstitial pneumonia must be approached with great responsibility. This is due to the fact that interstitial processes in the lung accompany a large group of both pulmonary and extrapulmonary diseases, which may contribute to overdiagnosis of interstitial pneumonia.

Localization and extent:

One-sided;

Bilateral (indicating the length of both localizations). Severity:

Extremely heavy

Heavy;

Medium severity;

Lungs and abortive. Flow:

Sharp;

Lingering.

It was suggested to consider a protracted course of AP, in which its complete resolution did not occur within a period of up to 4 weeks, which does not correspond to reality, since a much longer period is required for the complete resolution of pneumonia caused by staphylococcus and a number of other pathogens.

Currently, this classification is not used for a number of reasons described below.

The modern definition of pneumonia emphasizes the infectious nature of the inflammatory process and, thus, excludes from the pneumonia group pulmonary inflammations of other origin (immune, toxic, allergic, eosinophilic, etc.), for which, in order to avoid terminological confusion, it is advisable to use the term "pneumonitis".

Inflammatory processes in the lungs caused by obligate bacterial or viral pathogens (causative agents of plague, typhoid fever, measles, rubella, etc.) are considered within the framework of the corresponding nosological forms.

In connection with the need for early etiotropic treatment of pneumonia and the impossibility in most cases of timely verification of its causative agent, the European Respiratory Society (1993) proposed a working classification of pneumonia based on the clinical and etiological principle, taking into account the epidemic situation and risk factors.

Community acquired pneumonia.

Nosocomial (hospital or nosocomial) pneumonia.

Pneumonia in immunodeficiency states.

Aspiration pneumonia.

The presented grouping of clinical forms of pneumonia makes it possible to identify a certain range of pathogens characteristic of each form of the disease. This makes it possible to more purposefully carry out the empirical choice of antibacterial drugs at the initial stage of the treatment of the disease.

The general group did not include atypical pneumonia as a disease caused by atypical pathogens and having an atypical clinical picture. With such pneumonia, there is no alveolar exudation, and therefore there is no main auscultatory sign - moist voiced fine-bubbling rales. In Russia, the term "atypical pneumonia" was used several years ago to refer to severe acute respiratory syndrome (SARS) caused by a coronavirus and spreading under a certain epidemic situation. The causative agent of acute respiratory syndrome, labeled as SARS-CoV, belongs to the group Coronavirus. Its source is animals (cats, dogs); the disease is spread from person to person.

Community-acquired pneumonia is an acute infectious disease of predominantly bacterial etiology that occurs in an out-of-hospital setting, which is one of the most common forms of pneumonia and has the most characteristic clinical picture. As before, pneumonia arising in closed youth groups (schoolchildren, students, soldiers) and often having the character of an epidemic outbreak, proceed with atypical symptoms.

To nosocomial (nosocomial) pneumonia are those that developed within 48-72 hours or more after the patient was admitted to the hospital for another disease. The main reasons leading to the development of nosocomial pneumonia are most often the previous operations, artificial ventilation of the lungs, various endoscopic manipulations and previous treatment with broad-spectrum antibiotics.

Pneumonia developing against the background of an altered immune status occurs in AIDS patients, persons receiving immunosuppressive treatment, patients with systemic diseases, etc. They are classified as pneumonia in immunodeficiency states.

Aspiration pneumonia most often develops in people suffering from alcoholism and drug addiction, less often after anesthesia, with depression of consciousness. In the occurrence of aspiration pneumonia, the role of gastroesophageal reflux increased.

Etiology

With community-acquired pneumonia, in 80-90% of cases, pathogens are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae and Moraxella catarrhalis. Among the most common causative agents of pneumonia, the main one is still Streptococcus pneumoniae(Pneumococcus). In addition, it can be caused by Chlamydia psittaci and Klebsiella (Friedlander's wand).

Nosocomial pneumonia is characterized by a wide variety of etiological agents, including gram-negative microflora (enterobacteria, Pseudomonas aeruginosa, acinetobacter), Staphylococcus aureus and anaerobes.

Pneumonia in patients with an immunodeficiency state, in addition to pneumococci and gram-negative rods, often causes Pneumocystis jiroveci (Pneumocystis carinii), viruses (including cytomegalovirus - a marker of HIV infection), fungi, Nocardia spp. and mycobacteria. If neutropenia is found in such patients during a blood test, then the causative agents are most often Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa, often leading to a septic course of the disease.

Since the main cause of aspiration pneumonia is the penetration of the microflora of the oropharynx or stomach into the respiratory tract, anaerobic bacteria, gram-negative microflora and Staphylococcus aureus.

The main causative agents of atypical pneumonia are Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Legionella pneumophyla and Coxiella burnetti.

During an influenza epidemic, the role of viral-bacterial associations (most often staphylococci are found), as well as opportunistic microorganisms, increases. In viral-bacterial pneumonia, respiratory viruses play an etiological role only in the initial period of the disease: the main etiological factor that determines the clinical picture, the severity of the course and the outcome of the disease remains the bacterial microflora.

Pathogenesis

In the pathogenesis of pneumonia, the main role belongs to the effect of an infectious agent entering the lungs from the outside. Most often, the microflora penetrates into different parts of the lungs through the bronchi by aspiration (from the nasal or oropharynx) and by inhalation (along with the inhaled air). The bronchogenic route of infection is considered the main one in community-acquired pneumonia.

Hematogenously, the pathogen enters the lungs with pneumonia, developing as a complication of sepsis and infectious diseases, as well as with pneumonia of thrombotic etiology. Lymphogenous dissemination

Infection with the development of the disease is noted only with chest injuries.

There is also an endogenous mechanism for the development of inflammation of the lung tissue, due to the activation of the lung microflora. Its role is especially great in nosocomial pneumonia.

The initial link in the development of pneumonia is the adhesion of microorganisms (Fig. 1-1) to the surface of the epithelial cells of the bronchial tree, which is largely facilitated by the previous dysfunction of the ciliated epithelium and impaired mucociliary clearance. The next stage in the development of inflammation after adhesion is the colonization of epithelial cells by the microorganism. Damage to their membrane contributes to the intensive production of biologically active substances - cytokines (IL-1, 8, 12, etc.).

Under the influence of cytokines, chemotaxis of macrophages, neutrophils and other effector cells taking part in the local inflammatory reaction occurs. In the development of subsequent stages of inflammation, invasion and intracellular persistence of microorganisms, as well as their production of endo- and exotoxins, play a significant role. These processes lead to inflammation of the alveoli and bronchioles and the development of clinical signs of the disease.

Risk factors play an important role in the development of pneumonia. These include age (elderly people and children), smoking, chronic diseases of the lungs, heart, kidneys and gastrointestinal tract, immunodeficiency states, contact with birds, rodents

Rice. 1-1. Pathogenesis of pneumonia

And other animals, travel (trains, stations, planes, hotels), hypothermia and stay in a closed team.

In addition to infectious pneumonia, the development of pneumonia can be facilitated by unfavorable factors of the external and internal environment, under the influence of which there is a decrease in the general nonspecific resistance of the organism (suppression of phagocytosis, the production of bacteriolysins, etc.) and suppression of local defense mechanisms (impaired mucociliary clearance, a decrease in the phagocytic activity of alveolar macrophages and neutrophils and etc.).

In the pathogenesis of nosocomial pneumonia, the development of immune responses is often given importance. Saprophytes and pathogenic microorganisms, becoming antigens, promote the production of antibodies, which are fixed mainly on the cells of the mucous membrane of the respiratory tract. This is where the antigen-antibody reaction takes place, which leads to tissue damage and the development of an inflammatory process.

When there are common antigenic determinants of microorganisms and lung tissue or when the latter is damaged by viruses, microorganisms and toxins, leading to the manifestation of its antigenic properties, autoallergic processes develop. They contribute to a longer existence of pathological changes and a protracted course of the disease. In addition, a protracted course of pneumonia is often caused by associations of microorganisms (see Fig. 1-1).

Clinical painting

The clinical picture consists of a combination of the following main syndromes.

General intoxication syndrome: general weakness, weakness, headaches and muscle pains, shortness of breath, palpitations, pallor and loss of appetite.

Syndrome of general inflammatory changes: a feeling of heat, chills, an increase in body temperature, a change in acute phase blood parameters (leukocytosis with a shift in the leukocyte formula to the left, an increase in ESR, fibrinogen concentration, and 2 -globulins and C-reactive protein).

Syndrome of inflammatory changes in the lung tissue (the occurrence of cough, sputum separation, shortening of the percussion sound), increased vocal tremor and bronchophonia, changes in the frequency and nature of breathing, the occurrence of wet wheezing and characteristic radiological changes.

Syndrome of involvement of other organs and systems (cardiovascular system, gastrointestinal tract, kidneys, nervous system).

The severity of these disorders characterizes the severity of the course of pneumonia (Table 1-1).

The clinical picture of pneumonia depends on a number of reasons and is largely determined by the characteristics of the pathogen and the state of the macroorganism. So, in the clinical picture of atypical pneumonia, signs of general intoxication predominate, while the symptoms of bronchopulmonary syndrome fade into the background. Aspiration pneumonia is characterized by the development of purulent

Table 1-1.

destructive processes in the lungs. At various stages of the course of the disease, the clinical picture may change depending on the addition of certain complications.

Complications

All complications of pneumonia are divided into pulmonary and extrapulmonary. Major pulmonary complications:

Abscess formation; pleurisy (para- and metapneumonic), much less often - pleural empyema;

Attachment of the asthmatic component.

In severe pneumonia (viral or massive drainage bacterial pneumonia), conditions are created for the formation of pulmonary edema, the development of acute respiratory failure and distress syndrome.

Extrapulmonary complications:

Infectious-toxic shock with symptoms of acute vascular, acute left ventricular and renal failure, ulceration of the gastrointestinal mucosa and bleeding, as well as the development of disseminated intravascular coagulation (DIC) of blood at the final stage;

Infectious-allergic myocarditis;

Infective endocarditis (IE);

Pericarditis;

Meningitis or meningoencephalitis;

Anemia;

Glomerulonephritis;

Hepatitis.

In addition, with a severe course of croupous pneumonia, the development of intoxication psychoses is possible, and with draining total pneumonia - acute pulmonary heart disease, disseminated intravascular coagulation and sepsis.

It is necessary:

Identify the main complaints suggestive of pneumonia;

Assess the severity of the patient's condition;

Assume the etiology of the disease, taking into account the option of the beginning and course of the process.

The main complaints presented by patients: cough, sputum production, chest pain, aggravated by breathing and coughing, shortness of breath, impaired general well-being and fever.

The cough can be dry (in the initial period of croupous pneumonia, during the entire illness with interstitial pneumonia) or with sputum (mucous, mucopurulent, purulent mucous, bloody).

"Rusty" sputum is characteristic of croupous pneumonia, and bloody, viscous - for pneumonia caused by Klebsiella (Friedlander's bacillus). Purulent bloody sputum is one of the signs of streptococcal pneumonia. With the release of bloody sputum, viral pneumonia can occur. Persistent, sometimes paroxysmal cough with a small amount of mucopurulent sputum is noted with mycoplasma pneumonia. They also have a sore throat.

Hemoptysis is one of the characteristic features of pneumonia with mycoses of the lungs. It can also be a sign of pulmonary embolism; in this case, hemoptysis combined with pain in the side is a sign of infarction pneumonia.

Pain in the side, aggravated by deep breathing and coughing, is characteristic of pneumonia with involvement of the pleura in the pathological process (most often - for croupous pneumococcal pneumonia). The development of parapneumonic pleurisy is recorded in half of patients with pneumonia caused by Pfeiffer's bacillus, and in 30-80% of patients with streptococcal etiology. When pneumonia is localized in the lower parts of the lungs and the diaphragmatic pleura is involved in the process, pain can radiate into the abdominal cavity, resembling a picture of an acute abdomen. If the process involves the upper or lower reed segment of the left lung, then the pains are localized in the region of the heart.

In 25% of patients, the complaint of shortness of breath is one of the main ones. It is most pronounced in pneumonia that developed against the background of chronic respiratory diseases (chronic bronchitis, bronchiectasis) and heart failure. The severity of shortness of breath increases in parallel with the violation of general well-being (headache, lethargy, delirium, vomiting, etc.).

Symptoms of severe intoxication are most typical for ornithosis and mycoplasma pneumonia, often present in staphylococcal, influenza and pneumococcal (croupous) pneumonia, as well as in diseases caused by viral-bacterial associations.

The patient may be disturbed by chills and fever. An acute onset with chills is more typical for bacterial pneumonia, primarily for croupous (pneumococcal) pneumonia. The illness usually begins suddenly with tremendous chills and

body temperature to febrile. Against the general background of intoxication and febrile temperature, local symptoms are noted.

With viral pneumonia at the onset of the disease, the patient does not give the impression of a seriously ill patient (except for patients with influenza), since the clinical picture is not yet accompanied by symptoms of pneumonia.

To establish an etiological diagnosis, it is important to correctly assess the symptoms of the disease at the very beginning. Hoarseness or inability to speak is characteristic of pneumonia caused by the parainfluenza virus (children may even develop false croup). Lachrymation, pain in the eyes (symptoms of conjunctivitis), sore throat when swallowing, profuse nasal discharge (symptoms of rhinopharyngitis) without changing other parts of the respiratory tract are recorded in pneumonia caused by adenovirus. If patients with mild catarrhal symptoms in the upper respiratory tract develop bronchitis (often with an asthmatic component) and pneumonia, then it is more likely that they are caused by a respiratory syncytial virus. This disease is characterized by a low body temperature and severe symptoms of intoxication.

When examining the history, attention should be paid to concomitant diseases of other organs and systems that can affect the symptoms and course of pneumonia. So, patients with various tumor diseases, hemoblastosis, receiving chemotherapy, immunosuppressants and (or) drug addiction, are classified as a contingent in which the development of pneumonia occurs against the background of a sharp change in the immune status.

In the occurrence of pneumonia, proceeding with atypical symptoms, an epidemiological history is attached to: contact with birds (domestic or decorative) - sources Chlamydia psittaci, rodents; travel (for example, legionella can live in water in hotel air conditioning systems). Pay attention to group outbreaks of febrile diseases in closely interacting teams.

The atypical course of pneumonia is characterized by fever, headache, and unproductive cough. The defeat of the lower sections is preceded by symptoms of pathological changes in the upper respiratory tract: sore throat, loss of voice and cough, which periodically has a paroxysmal nature and disrupts sleep.

Aspiration pneumonia is characterized by a gradual onset, an increase in body temperature, a cough with discharge of purulent sputum, the most frequent lesion of the upper segment of the lower lobe (with aspiration in a semi-sitting position) or the posterior parts of the upper lobe (with aspiration in the supine position) of the right lung, a prolonged course with the development late purulent complications in the form of a lung abscess or pleural empyema.

If you suspect the development of pneumonia in a patient who is in a hospital for another disease, you should remember about the risk factors for the development of nosocomial (nosocomial) pneumonia. These include the patient's stay in intensive care units or intensive care units, artificial ventilation of the lungs, tracheostomy, bronchoscopic examinations, the postoperative period, previous massive antibiotic therapy and septic conditions. In this group of patients

levitation is extremely difficult. Complications such as pleural empyema and atelectasis are common.

Aspiration pneumonia occurs in severe alcoholism, epilepsy, in patients in a coma, in acute cerebrovascular accident and other neurological diseases, as well as in violation of swallowing, vomiting, etc.

Knowledge of these variants of the clinical course of pneumonia, taking into account the specific gravity of various pathogens for each of them, will allow, with a certain degree of probability, to carry out the etiological diagnosis of the disease already at this stage of the diagnostic search.

On the the first stage of the diagnostic search one can assume pneumonia, but it is impossible to make a definitive diagnosis, since the main symptom of the disease - the syndrome of inflammatory changes in the lung tissue - can be detected at the second stage, and in some cases - only at the third stage of the diagnostic search. Along with this, in elderly patients or with severe concomitant diseases, extrapulmonary symptoms (confusion, disorientation) may come to the fore, which should prompt the doctor to suspect the development of pneumonia at the first stage of the diagnostic search.

The most significant for the diagnosis is the existence of a syndrome of inflammatory changes in the lung tissue, which consists of the following symptoms:

Lagging of the affected side of the chest during breathing;

Shortening of the percussion sound in the area of the projection of the lesion over a greater or lesser extent;

Changes in the nature of breathing (hard, bronchial, weakened, etc.);

The occurrence of pathological respiratory noises (moist, sonorous fine-bubbling rales and crepitus).

The breathing pattern can vary in different ways. In the initial stage of croupous pneumonia, it can be weakened, with a prolonged expiration; in the hepatization phase, along with an increase in the dullness of the percussion sound, they listen to bronchial breathing; with the resolution of the pneumonic focus with a decrease in percussion dullness, breathing becomes hard. With focal pneumonia, there is no such clear dynamics of physical data. The most persistent symptoms of focal pneumonia are hard breathing and moist, ringing, small bubbling rales. In some cases (for example, with central hilar pneumonia), physical data are very scarce, and recognition of the disease is possible only after an X-ray examination.

Mycoplasma pneumoniae are distinguished by the scarcity of physical data. Severe intoxication in combination with a very small number of wheezing (profuse exudation "clogs" the bronchioles and alveoli) is noted in pneumonia caused by Klebsiella pneumonia. In interstitial pneumonia of any etiology, percussion and auscultatory data are very scarce.

In a number of cases (with pneumonia that developed against the background of chronic bronchitis, diseases caused by Pfeiffer's bacillus, as well as in the case of

compounds to pneumonia of the allergic / asthmatic component) during auscultation, a lot of bass and treble dry wheezes, which are not characteristic of inflammatory infiltration syndrome, come to the fore. The most pronounced sensitizing effect is exerted by molds (urticaria, allergic rhinitis, eosinophilic infiltration, Quincke's edema).

Physical examination helps to detect other pulmonary complications of pneumonia: pleurisy (pleural friction noise or percussion dullness without breathing noises) and lung abscess (dullness and a sharp weakening of breathing in the first phase, dull tympanitis, amphoric breathing and moist mid-bubbling rales in the second phase).

It is possible to determine the friendly involvement of organs and systems in the pathological process or complications caused by damage to other organs. In severe pneumonia, a decrease in blood pressure is often noted (a sign of vascular and heart failure).

Other symptoms can also help to establish an etiological diagnosis:

Detection of a small-spotted (as in rubella) rash in combination with lymphadenopathy is characteristic of adenovirus infection;

Local enlargement of lymph nodes (especially axillary and supraclavicular) allows one to suspect a lung tumor and perifocal pneumonia;

Fungal pneumonia is combined with damage to the mucous membranes, skin and nails;

Hepatolienal syndrome and mild jaundice are characteristic of ornithosis and Kurickettsial pneumonia;

For typical croupous (pneumococcal) pneumonia, a characteristic appearance of the patient is noted (a pale face with a febrile blush on the affected side, herpetic eruptions, swelling of the wings of the nose when breathing).

The most important is the detection of signs that confirm or deny the existence of pneumonia; clarifying the nature and specificity of the pathogen; indicating the severity of the inflammatory process; clarifying the state of the body's immunological reactivity; clarifying the degree of involvement in the process of other organs and systems and the development of complications.

The most important method to clarify the existence of pneumonia and the degree of involvement of lung tissue in the process is an x-ray examination of the chest organs. Large-frame fluorography and X-ray in two projections, carried out in dynamics, help (taking into account the clinical picture) to diagnose pneumonia.

Sometimes, by the nature of the radiological changes, it is possible, with a certain degree of probability, to judge the causative agent that caused the disease. Staphylococcal pneumonia are distinguished by a clear segmental lesion of the lungs with the involvement of several segments in the process (in 60% of cases - bilateral lesion). Their characteristic X-ray sign is the formation on the 5-7th day after the onset of the disease of multiple cavities in the lungs such as pneumocele, and later - necrotic cavities containing fluid.

Unlike true abscesses, the configuration and number of cavities change rapidly.

Lobar lesion is most often a sign of croupous pneumococcal pneumonia. Homogeneous darkening of the entire lobe or most of it, usually not corresponding to segmental division of the lung, is also recorded in pneumonia caused by Klebsiella. More often, a lesion is found in the upper lobe, predominantly of the right lung.

X-rays can detect pleural effusion that is sometimes undetectable by physical methods. It often forms with streptococcal pneumonia, as well as with a disease caused by Pfeiffer's bacillus, localized in the lower lobe, and in two-thirds of patients, more than one lobe.

Focal pneumonia is often characterized by a discrepancy between clinical and radiological data.

X-ray examination data are especially important when detecting a disease with mild auscultatory changes, which is typical for interstitial and radicular pneumonia. In such cases, computed tomography (CT) is recommended to clarify the diagnosis. It is also carried out to diagnose pneumonia with severe clinical signs, but without clear X-ray changes. CT of the lungs in this situation can detect infiltration of the lung tissue.

If necessary, differential diagnosis of pneumonia with tuberculosis and lung cancer is performed by bronchoscopy.

Bronchography allows you to detect decay cavities in the lung tissue, as well as bronchiectasis, around which infiltrative changes occur during an exacerbation (so-called perifocal pneumonia).

Sputum examination helps to clarify the etiology of the disease. A large number of eosinophils indicates allergic processes, the presence of atypical cells indicates lung cancer and perifocal pneumonia. Mycobacterium tuberculosis is found in tuberculosis; elastic fibers are evidence of the breakdown of lung tissue (cancer, tuberculosis, abscess). In case of mycotic pneumonia, along with the detection of fungi, the absence of pyogenic microflora is noted due to the inhibitory effect of the waste products of the former.

According to the data of bacterioscopy (microscopy of sputum smears stained according to Gram), it is possible to determine gram-negative or gram-positive microorganisms that live in the bronchi, already in the first day of the patient's stay in the hospital (it is important to consider when choosing antibiotics).

Bacteriological examination of sputum (bronchial lavage) before the appointment of antibacterial drugs helps to detect the pathogen and determine its sensitivity to antibiotics. The study of bronchial lavage is especially important in the diagnosis of pneumonia of pneumocystis etiology.

In the diagnosis of viral and viral-bacterial pneumonia, virological and serological studies are important.

In recent years, particular importance has been attached to the determination of antigens in urine. Antigen detection Streptococcus pneumoniae and Legionella pneumophila wire

are fed with the urease test. It can be positive even if the patient received antibiotics the day before. When examining patients who are not amenable to conventional treatment, in the case of an atypical course of the disease or the development of severe complications, all complex immunological, virological and serological methods are necessarily used.

The severity of the inflammatory process can be judged by the severity of acute phase blood parameters and the dynamics of their changes (leukocytosis with a shift in the leukocyte formula, increased ESR, increased content of α 2 -globulins, fibrinogen, CRP, sialic acids). For bacterial pneumonia, neutrophilic leukocytosis with a shift of the leukocyte formula to the left is more characteristic. ESR is increased, while the degree of its increase is determined by the prevalence and severity of the process. Viral pneumonia is distinguished by leukopenia. With ornithosis pneumonia, a significant increase in ESR is noted. For parainfluenza and adenovirus pneumonia, as a rule, a tendency to leukopenia is characteristic, but ESR in these cases is not changed.

In severe pneumonia, repeated sputum cultures are performed, the results of which can help in determining the etiology of the disease.

Laboratory and instrumental research methods are of additional importance in clarifying the degree of involvement of other organs and systems in the process and the development of complications:

ECG allows you to assess the state of the myocardium;

Echocardiography (EchoCG) for complications of IE helps detect pericardial effusion or bacterial colonies on the heart valves;

Respiratory function indicators allow assessing the state of bronchial patency.

Diagnostics

Diagnosis of pneumonia is based on the definition of the main and additional diagnostic criteria. The main criterion is the syndrome of local inflammatory infiltration of the lung tissue (clinical and radiological data). Additional criteria include:

Syndrome of general inflammatory changes;

Intoxication syndrome;

Syndrome of involvement of other organs and systems;

Existence of risk factors.

An important role in establishing the etiological diagnosis belongs to the correct assessment of the epidemiological situation in combination with the clinical picture of the disease and the data of X-ray examination. Help is provided by the results of bacterioscopy, which should be performed on the first day of the disease and interpreted taking into account clinical data.

The etiological affiliation of pneumonia, in which the properties of the pathogen are not fully expressed and there is no characteristic clinical and radiological picture, is established according to the data of bacteriological, virological and serological studies during treatment. Even using a wide range of microbiological studies, it is possible to determine the etiology of the disease in hardly half of the cases.

Conditions of occurrence (clinical and etiological classification);

Etiology (if established);

Localization and prevalence;

The severity of the course;

The presence of complications;

The phase of the flow (height, resolution, convalescence). Treatment

The principles of treating a patient with pneumonia are presented in table. 1-2. Table 1-2. Principles of treating a patient with pneumonia

The following are the treatments that are being carried out.

Therapeutic regimen and balanced nutrition.

Drug treatment:

Etiotropic;

Pathogenetic;

Symptomatic.

Physiotherapy effect.

Dispensary observation.

Therapeutic regimen and balanced nutrition

Patients with pneumonia are hospitalized. The indications for it are the age of the patient over 65 years of age with any severity of the disease, the existence of serious concomitant diseases and (or) signs of impaired vital functions of the body, as well as the lack of full-fledged care at home. In other cases, you can organize a hospital at home. It is imperative to observe bed rest during the entire period of fever and intoxication. At the same time, the patient needs an abundant drink, nutrition rich in vitamins and proteins.

Drug treatment

Carried out with the help of drugs that affect the pathogen (etiotropic therapy), various links of pathogenesis, individual signs of the disease (hypoxia, fever, cough, etc.) and developed complications

neniya. The main method of treating pneumonia is antibiotic therapy, which is prescribed empirically until the results of bacteriological research are obtained. Its results become known 2-3 days after sampling and in most cases do not have a significant effect on treatment tactics (Tables 1-3).

Table 1-3.

The end of the table. 1-3

* On the first day, a double dose of 0.5 g is prescribed.

Etiotropic treatment of pneumonia. Antibacterial drugs are used, with the appointment of which three main conditions must be observed:

The earliest possible start of treatment, without waiting for the isolation and identification of the pathogen, focusing in the choice of the dosage regimen on the features of the clinical picture and X-ray data;

Prescribing drugs in sufficient doses and at such intervals that the therapeutic concentration of the drug is created and maintained in the blood and lung tissue;

Monitoring the effectiveness of treatment using clinical observation and, if possible, bacteriological research.

Of all antibacterial agents, antibiotics are most effective, which are chosen taking into account the characteristics of the possible pathogen and the patient's tolerance of the drug. With gram-positive microflora, it is preferable to prescribe semisynthetic penicillins and cephalosporins, with gram-negative - fluoroquinolones, aminoglycosides and imipenem (imipenem + cilastatin). Patients with viral-bacterial association should be prescribed broad-spectrum antibiotics in combination with semi-synthetic and protected penicillins.

A subjective response to antibiotics is usually noted within 3-4 days from the start of treatment. An objective response includes an assessment of fever, symptoms, laboratory parameters, and radiographic changes. The average dynamics of these parameters is presented in table. 1-4.

The effectiveness of antibiotics is assessed after 2-3 days. In the absence of a clinical effect from the use of the drug within three days, it should be replaced with another, focusing, if possible, on the sensitivity of the isolated microflora. Despite the high efficiency, with

Table 1-4.

long-term antibiotic therapy, the antibacterial agent is replaced with another after 10-12 days.

Treatment of community-acquired pneumonia

Patients can be treated both on an outpatient basis and in an inpatient setting. When carrying out antibiotic therapy on an outpatient basis, two groups of patients are distinguished:

Group I - age less than 60 years, no concomitant diseases;

Group II - age over 60 years and (or) there are concomitant diseases.

As a rule, the duration of antibiotic therapy is 7-10 days.

Antibiotic therapy in patients of group I

The drugs of choice are amoxicillin (inside 0.5-1.0 g 3 times a day) or amoxicillin + clavulanic acid (inside 0.625 g 3 times a day). Alternative drugs - macrolides: clarithromycin (inside 0.5 g 2 times a day), roxithromycin (inside 0.15 g 2 times a day), azithromycin (inside 0.5 g 1 time a day), spiramycin (inside 1.5 million IU 3 times a day). If an atypical pathogen is suspected, macrolides are considered the drugs of choice, and respiratory fluoroquinolones (levofloxacin inside at a dose of 0.5 g once a day or moxifloxacin at a dose of 0.4 g once a day) can be alternative drugs.

Antibiotic therapy in patients of group II

The drugs of choice are amoxicillin + clavulanic acid (inside 0.625 g 3 times a day or 1.0 g 2 times a day), cefuroxime (inside 0.5 g 2 times a day). Alternative drugs: levofloxacin (0.5 g orally once a day), moxifloxacin (0.4 g orally once a day) or ceftriaxone (1.0-2.0 g intramuscularly once a day).

Macrolides should be given preference in cases of intolerance to β-lactam antibiotics and pneumonia, presumably caused by Mycoplasma pneumoniae and Chlamydia pneumoniae. The indication for parenteral administration of drugs is the impossibility of taking them orally.

Inpatient antibiotic therapy

Medical treatment in a hospital depends on the severity of the course of pneumonia.

Treatment of mild to moderate pneumonia. Drugs of choice: amoxicillin + clavulanic acid (intravenously, 1.2 g 3 times a day), ampicillin (intravenously or intramuscularly, 1.0-2.0 g 4 times a day), benzylpenicillin (intravenously, 2 million IU 4-6 once a day), cefotaxime (intravenously or intramuscularly at 1.0-2.0 g 2-3 times a day), ceftriaxone (intravenously or intramuscularly at 1.0-2.0 g once a day), cefuroxime (intravenously or intramuscularly 0.75 g 3 times a day). Alternative drugs: levofloxacin (intravenously at a dose of 0.5 g once a day) or moxifloxacin (intravenously at a dose of 0.4 g once a day).

After 3-4 days of treatment, when a clinical effect is achieved (normalization of body temperature, a decrease in the severity of intoxication and other symptoms of the disease), one should switch from parenteral administration of drugs to oral administration. The total duration of treatment is 7-10 days.

Treatment of severe pneumonia. Drugs of choice: a combination of clarithromycin (0.5 g intravenously 2 times a day), or spiramycin (1.5 million IU intravenously 3 times a day), or erythromycin (0.5-1.0 g orally 4 times a day) day) with amoxicillin + clavulanic acid (intravenously at 1.0-2.0 g 3 times a day) or cefepime (intravenously at 1.0-2.0 g 2 times a day), or cefotaxime (intravenously at 1.0 -2.0 g 2-3 times a day), or ceftriaxone (intravenously at a dose of 1.0-2.0 g 1 time per day). Alternative drugs: a combination of levofloxacin (intravenously 0.5 g 1-2 times a day), or moxifloxacin (intravenously at a dose of 0.4 g once a day), or ofloxacin (intravenously, 0.4 g 2 times a day ), or ciprofloxacin (intravenously at 0.2-0.4 g 2 times a day) with cefotaxime (intravenously at 1.0-2.0 g 2-3 times a day) or ceftriaxone (intravenously at a dose of 1.0- 2.0 g once a day).

Parenteral drugs are administered for 7-10 days. The total duration of treatment is 14-21 days.

Treatment of nosocomial pneumonia

When treating, it should be borne in mind that often the causative agents of the disease are multidrug-resistant gram-negative bacteria (including Pseudomonas aeruginosa), staphylococci, and anaerobes. Treatment of nosocomial pneumonia with antibacterial agents depends on the existence or absence of associated risk factors. The duration of the use of antibacterial drugs is determined individually. In the treatment of hospital-acquired (nosocomial) pneumonia, taking into account the most common pathogens (Pseudomonas aeruginosa, Staphylococcus aureus), cephalosporins of the III-IV generation, resistant to the action of β-lactamases, fluoroquinolones and imipenem, come out on top.

Antibacterial treatment of nosocomial pneumonia in patients without associated risk factors

Drugs of choice: amoxicillin + clavulanic acid (intravenously, 1.2 g 3 times a day), cefotaxime (intravenously or intramuscularly, 1.0-2.0 g 2-3 times a day), ceftriaxone (intravenously or intramuscularly in

dose 1.0-2.0 g 1 time per day), cefuroxime (intravenously or intramuscularly, 0.75 g 3 times a day). Alternative drugs: levofloxacin (intravenously at a dose of 0.5 g once a day), moxifloxacin (intravenously at a dose of 0.4 g once a day), a combination of cefepime (intravenously at 1.0-2.0 g 2 times a day) day) with amikacin (intravenously at a dose of 15-20 mg / kg once a day) or gentamicin (intravenously at a dose of 3-5 mg / kg once a day).

Antibacterial treatment of nosocomial pneumonia arising in patients with concomitant risk factors

Drugs of choice: imipenem (intravenously 0.5 g 3-4 times a day), or ceftazidime (intravenous 1-2 g 2-3 times a day), or cefepime (1.0-2.0 g

2 times a day), or meropenem (intravenously, 0.5 g 3-4 times a day) in combination with amikacin (intravenously at a dose of 15-20 mg / kg once a day) or vancomycin (intravenously, 1.0 g 2 times a day). Alternative remedies: aztreonam (intravenously or intramuscularly at 0.5-2.0 g 2-3 times a day), or levofloxacin (intravenously at a dose of 0.5 g once a day), or moxifloxacin (intravenously at a dose of 0, 4 g once a day), or a combination of amikacin (intravenously at a dose of 15-20 mg / kg once a day) with piperacillin + tazobactam (4.5 g intravenously 3 times a day) or with ticarcillin + clavulanic acid (intravenously 3.2 g 3 times a day). Instead of amikacin, gentamicin can be used (intravenously, 3-5 mg / kg body weight 1 time per day).

Aspiration pneumonia treatment

Aspiration pneumonia is almost always caused by anaerobic and / or gram-negative microflora, which requires the administration of aminoglycosides, protected penicillins in combination with metronidazole and carbapenems. Drugs of choice: amoxicillin + clavulanic acid (1.2 g intravenously)

3 times a day, or benzylpenicillin (intravenously, 2 million units 4-6 times a day) in combination with metronidazole (intravenously, 0.5 g 3 times a day). Alternative medicines: imipenem (intravenously 0.5 g 3-4 times a day) or meropenem (intravenous 0.5 g 3-4 times a day). Intravenous administration of clindamycin (0.3-0.9 g 3 times a day) has a good effect. The duration of antibiotic therapy for aspiration pneumonia is determined individually.

Treatment of pneumonia in immunodeficiency states

Treatment of pneumonia in combination with severe immune defects should be carried out only in a hospital setting. In patients with immunodeficiency states, the choice of antibiotic therapy largely depends on the origin of the pathogen. The most common regimen is the administration of aminoglycosides in combination with modern cephalosporins. In AIDS patients with the development of pneumonia caused by Pneumocystis carinii, The accepted treatment regimen is considered to be parenteral administration of pentamidine, cotrimoxazole and septrim. Treatment of Pneumocystis pneumonia is carried out with cotrimoxazole (intravenously at a dose of 20 mg / kg per day in 3-4 divided doses). The duration of treatment is 21 days.

With poor tolerance of antibiotics and high sensitivity of the isolated microflora to nitrofurans, furaltadone is prescribed (0.1 g orally

4 times a day), furazidine (intravenous drip of 300-500 ml of 0.1% solution per day; for the course - 3-5 injections). If antibiotics are ineffective, you can

successfully use derivatives of quinoxaline (hydroxymethylquinoxaline dioxide).

For the prevention of candidiasis (especially with massive and prolonged antibiotic therapy), it is recommended to use nystatin and levorin (inside 500 thousand units 4 times a day).

For pneumonia of fungal etiology, antifungal agents are prescribed: amphotericin B, itraconazole, ketoconazole, fluconazole, etc.

Pathogenetic treatment of pneumonia. To restore nonspecific resistance in severe and protracted pneumonia, immunomodulatory agents are used (preparations of interferon, azoxymer bromide, thymus extract).

With staphylococcal pneumonia, passive immunization with staphylococcal toxoid is performed.

To restore bronchial patency, bronchodilators and agents that thin bronchial secretions are used (ingestion of acetylcysteine, ambroxol, bromhexine, hot alkaline drink). Bronchodilators are preferably administered by inhalation: adrenergic (fenoterol, salbutamol) and anticholinergics (ipratropium bromide, inside - theophylline).

With a protracted course of pneumonia, the restoration of bronchial drainage with the help of bronchoscopic sanitation sometimes plays a decisive role.

To restore the body's nonspecific resistance, vitamins A, C, E, group B, biogenic stimulants and adaptogenic agents (aloe, tincture of ginseng and lemongrass, liquid extract of Eleutherococcus) are prescribed.

Patients with a possible viral etiology are recommended to administer human immunoglobulin, anti-influenza and antiviral drugs (riboverin, ganciclovir, etc.). On an outpatient basis, inhalations of phytoncides are used (juice of garlic and / or onion, prepared ex temporae, in isotonic sodium chloride solution).

Symptomatic treatment of pneumonia. With an unproductive dry cough, antitussives are prescribed (codeine, prenoxdiazine, glaucine, butamirate + guaifenesin, butamirate, etc.); for difficult sputum discharge - expectorants (infusion of thermopsis herb, marshmallow root, etc.) and mucolytic drugs (marshmallow herb extract, ambroxol, acetylcysteine). In case of poor tolerance of high body temperature, antipyretics (metamizole sodium, acetylsalicylic acid) are indicated. Patients with concomitant pathological changes in the cardiovascular system (especially the elderly), as well as in severe cases of the disease, are prescribed an injection of camphor, procaine + sulfocamphoric acid.

The existence of dyspnea and cyanosis is an indication for oxygen therapy. In case of severe intoxication and destruction of pulmonary infiltrate, detoxification treatment is performed (intravenous administration of dextran [average molecular weight 30,000-40,000], hemodez * and other solutions).

Intravenous glucocorticoids are recommended for patients with severe pneumonia, severe intoxication and infectious toxic shock.

Physiotherapy impact

In the treatment of patients with pneumonia, distracting procedures are used (banks, mustard plasters, mustard wraps), which are carried out at a low body temperature from the first days of the disease. After a decrease in body temperature, diathermy, inductothermy, microwave, UHF, etc. are prescribed to eliminate inflammatory changes. The resorption of the focus of pneumonia is facilitated by chest massage and physiotherapy exercises (exercise therapy).

Aerosol therapy using bronchodilator mixtures alone or in combination with various antibacterial drugs is used in the authorization stage.

Dispensary observation

Recovery criteria:

Well-being and general condition of the patient;

Stable normalization of body temperature;

Elimination of clinical, laboratory and radiological signs of pneumonia.

Forecast

Pneumonia is one of those diseases that, as a rule, result in complete recovery. The outcome of pneumonia largely depends on the prevalence of the inflammatory process, the existence or absence of complications, the timing of the onset and usefulness of antibiotic therapy, the state of the body and other reasons.

All patients with a widespread inflammatory process, a protracted course of pneumonia, impaired functions of external respiration and the immune system, as well as complicated pneumonia, should be sent to rehabilitation departments for follow-up treatment and restoration of morphological and functional parameters.

The period of clinical examination of patients who have had pneumonia without complications can be 6 months, in all other cases - at least a year.

Prophylaxis

Preventive measures are aimed at carrying out general sanitary and hygienic measures (work regime, combating dustiness, gas pollution, overheating and hypothermia, ventilation of premises, isolation of sick people, etc.). Personal prevention includes hardening of the body, physical education and tourism, good nutrition and sanitation of foci of infection. Timely and correct treatment of acute respiratory diseases and other anti-epidemic measures are of great importance.

Prevention of pneumonia is especially important in patients with chronic pulmonary diseases. For them, it is considered mandatory to carry out influenza vaccination, and, if possible, to carry out immunization with a vaccine to prevent pneumococcal infections.

It is necessary to strictly adhere to the regimen and other prescriptions of the doctor for diseases that can be complicated by pneumonia (MI, stroke, condition after surgery, etc.).

Chronization of the inflammatory process is noted in 3% of cases. Chronic pneumonia or chronic pneumonia(CP) is a chronic lesion of the parenchyma and interstitial tissue of the lung, developing at the site of unresolved pneumonia, limited to a segment (s) or lobes (lobes) and clinically manifested by repeated outbreaks of the inflammatory process in the affected part of the lung. The morphological substrate of CP is pneumosclerosis and (or) carnification of lung tissue, as well as irreversible changes in the bronchial tree like local bronchitis, often with deformation and development of bronchiectasis in the future. Due to the wide and successful use of antibacterial drugs for the treatment of infectious processes in the lower respiratory tract, CP is rarely recorded today.

The existence of CP is not recognized by all researchers, but it is distinguished by pathologists and a number of clinical physicians (Putov N.V., Silvestrov V.P.).

Classification. Currently, there is no CP classification that would satisfy all the requirements. The classification of CP, officially adopted in 1972, led to overdiagnosis of this disease and practically replaced all other forms of so-called chronic respiratory diseases of the lungs, in particular, chronic bronchitis, bronchiectasis and chronic obstructive pulmonary disease.

Currently, the main criterion for the transition of protracted pneumonia to chronic is rejected - the duration of the disease is 8 weeks (Silvestrov V.P., 1974). Only the absence of positive X-ray dynamics, despite the long and intensive treatment, and most importantly, the existence of repeated outbreaks of the inflammatory process in the same area of the lung, allows us to speak of the transition of protracted pneumonia into a chronic form.

Etiology. CP is an inflammatory disease of infectious origin, therefore its etiology corresponds to that of pneumonia. Although there is no microorganism that causes the chronic course of pneumonia, a different degree of significance of various pathogens in the transition of an acute inflammatory process to a chronic one has been proven.

Most often, the causative agents of the inflammatory process in CP are associations of non-bacterial (viruses, mycoplasmas) and bacterial (mainly pneumococci and Haemophilus influenzae) agents.

The role of viral infection in the transition of an acute inflammatory process to a chronic one is especially great.

Pneumonia, in which the leading role belongs to viruses, leading to destructive processes, end with the formation of fibrotic changes in the lungs.

The influenza virus damages the bronchial wall with the development of drainage and ventilation disorders, causes inflammatory changes in the interstitial tissue, which are relatively persistent and tend to slow downward development.

The influenza virus is a conductor of autoinfection, creating a favorable background for the manifestation of the pathogenic properties of a diverse opportunistic and saprophytic microflora.

A possible reason for the chronicity of the process is a defect in the development of lung tissue in the zone of acute inflammation, which contributes to the recurrence of the inflammatory process, and the colonization of the pathogen.

Pathogenesis. The immediate causes of the transition of an acute inflammatory process to a chronic one are not well understood. The following facts are considered undoubted.

In the origin of repeated outbreaks of infection in the previously affected area of the lung, the remaining changes play a role, causing a local violation of the drainage function of the bronchi. In some cases, the determining factor in the pathogenesis of CP is concomitant chronic bronchitis, which sharply complicates the drainage and aeration function of the bronchi in the area of acute inflammation.

Focal infection in the patient's body can serve as a constant source of autoinfection and sensitization of the body, expressed in the increased sensitivity of the bronchopulmonary system to various microorganisms, viruses and their metabolic products.

The prerequisites for the formation of CP are all conditions (including viral intoxication, alcohol, smoking, hypothermia, overwork, old age, etc.) that suppress the general reactivity and contribute to a change in the body's immune status and local immunity of the bronchopulmonary system. These changes are expressed in a decrease in the activity of alveolar macrophages and leukocytes, a weakening of phagocytosis, a deficiency of secretory IgA and a decrease in the concentration of bacteriolysins.

With CP, the development of autoimmune processes is noted. Antipulmonary antibodies have pulmonocytotoxic properties, which are expressed in inflammation of the interstitial tissue.

As a result of the influence of all these factors, the inflammatory process in pneumonia (Fig. 1-2) is not completely eliminated. Areas of carnification remain, which later serve as a place of recurrence of the inflammatory process.

The process is not limited to the parenchyma of the lungs, but passes to the interstitial tissue, bronchi and blood vessels. In this regard, the morphological substrate of CP is considered to be an inflammatory-sclerotic process (pneumosclerosis), leading to a decrease in the volume of the affected part of the lung and its cicatricial wrinkling. In the areas of the bronchial tree corresponding to the affected area, the phenomena of local bronchitis develop, which in the future can acquire a deforming character with the subsequent development of bronchiectasis.

The process never becomes diffuse, therefore, the severity of functional disorders of the respiratory and circulatory system in the small circle is insignificant. In this regard, the development of respiratory (pulmonary) failure and cor pulmonale, even with extensive foci of CP, is rarely recorded.

Rice. 1-2.

The clinical picture. CP is characterized by the following main syndromes:

Inflammatory infiltration;

Local pneumosclerosis.

Broncho-obstructive syndrome and respiratory distress syndrome are optional signs that can occur at different stages of the development of the disease.

There are three degrees of activity of the inflammatory process:

I degree - minimal signs;

II degree - moderate signs of exacerbation;

III degree - clinical, radiological and laboratory indicators of exacerbation are pronounced.

Depending on the prevalence of a particular syndrome, CP occurs in two main forms - interstitial and bronchiectasis.

The interstitial form of CP is characterized by the predominance of changes in the form of focal pneumosclerosis (N.V. Putov, 1984). This is the most common form of CP. In bronchiectasis, along with focal pneumosclerosis, there are bronchiectasis (CP with bronchiectasis). This form is not recognized by all doctors (N.R.Paleev, 1985).

N.V. Putov, in addition to interstitial, also distinguishes the carnifying form of CP (with a predominance of alveolar carnification). With this form of CP, patients, as a rule, do not present complaints, and radiographically intense, fairly well-defined shadows may be present, which must be differentiated from signs of a peripheral tumor.

Interstitial form of chronic pneumonia. At the first stage of the diagnostic search you can find the following complaints:

Cough, in the overwhelming majority of cases - with the release of a small amount of sputum, sometimes - hemoptysis;

Chest pain on the affected side;

Shortness of breath on exertion;

Increased body temperature;

Asthenization phenomena (weakness, headache, sweating, loss of appetite and body weight).

Complaints are most striking and numerous in severe exacerbation. The amount of sputum increases, it becomes purulent. After the addition of the broncho-obstructive syndrome, along with the productive one, a hacking paroxysmal cough with difficult sputum production occurs.

With CP without bronchiectasis, the occurrence of hemoptysis always indicates the activity of the process and, as a rule, is not significantly expressed. Hemoptysis is usually noted in bronchiectasis of CP, since it is one of the generally recognized symptoms of bronchiectasis.

In the case of an exacerbation of the process, chest pain often arises or intensifies on the side of the inflammatory process: a constant feeling of heaviness (most often at the angle of the scapula) worries. A pulling stabbing pain may increase with breathing (involvement of the pleura in the process). Body temperature is often subfebrile, rarely febrile. Exacerbation is accompanied by sharp sweating, severe weakness and loss of appetite.

In the stage of remission, complaints are few. Most often, a cough with scanty mucopurulent sputum is noted.

On the the first stage of the diagnostic search important for establishing the correct diagnosis is considered the discovery of a connection between these complaints with previously transferred pneumonia (often - a protracted course), untimely started and insufficiently completed treatment. In the absence of clear indications of the transferred disease, it is necessary to establish whether there were previously frequently recurring acute respiratory diseases. Repeated inflammation of the same area of the lung tissue can be noted.

In the history of CP patients, there are no indications of pneumoconiosis, tuberculosis, sarcoidosis and other diseases accompanied by similar clinical signs (their history requires a revision of the diagnostic concept).

On the second stage of diagnostic search it is necessary to determine the syndromes of local pneumosclerosis and inflammatory infiltration, which may be characterized by the following clinical symptoms:

Lagging behind in breathing and (or) retraction of the affected side of the chest (expressed with significant involvement of lung tissue in the process);

Dullness or shortening of the percussion sound;

Wet, ringing fine bubbling rales over the lesion, caused by local focal pneumosclerosis.

If the pleura is involved in the process, then the pleural friction noise is heard. With broncho-obstructive syndrome, prolonged expiration and dry wheezing are noted. The latter also occur in the case of an asthmatic (allergic) component joining CP, the development of which is one of the main and serious complications of the disease at the present time. The development of respiratory failure is accompanied by dyspnea at rest, cyanosis and tachycardia. Outside of exacerbation of CP, clinical signs are scant: in a limited area, moist non-voiced fine-bubbling rales are heard.

On the third stage of diagnostic search perform instrumental and laboratory studies that allow:

To make the final diagnosis of CP based on radiological signs of local (segmental or lobar) pneumosclerosis, endoscopic signs of local bronchitis, exclusion of diseases with a similar clinical picture;

Determine the degree of activity of the inflammatory process;

Determine and (or) clarify the severity of complications.

X-ray examination is of decisive importance in the diagnosis of CP and its exacerbations. With a pronounced exacerbation of the process, inflammation of the infiltrative and (or) peribronchial type is noted. For the infiltrative type, focal darkening is characteristic against the background of variously pronounced interstitial changes (pneumosclerosis) and adhesive pleurisy (interlobar, paramediastinal adhesions, infection of the costophrenic sinuses). The peribronchial type is characterized by changes around the segmental bronchi in the form of concentric couplings or cords parallel to the bronchi, combined with signs of focal pneumosclerosis (severity and deformation of the pulmonary pattern, a decrease in the volume of the affected area of the lung). There is no characteristic localization of the inflammatory process in CP.

Since a chronic focal form of pulmonary tuberculosis, chronic abscess and bronchogenic tumors have a clinical picture similar to CP, X-ray methods become crucial for differential diagnosis. X-ray examination in combination with the data of the first and second stages of the diagnostic search also makes it possible to exclude sarcoidosis of the chest organs and Hammen-Rich syndrome. The results are of decisive importance in carrying out differential diagnostics.

MSCT.

Bronchography is performed before the operation to clarify the nature and extent of bronchial lesions.

Bronchoscopic examination data significantly help:

In establishing the final diagnosis of CP, since local purulent or catarrhal endobronchitis is a bronchoscopic marker of the disease;

In the exclusion (detection) of bronchogenic cancer, manifesting a clinical picture similar to CP;

In assessing the degree of activity of the inflammatory process (according to the severity of hyperemia and edema of the mucous membrane, the nature and amount of secretion in the bronchi).

All patients with CP undergo a study of the function of external respiration (spirometry). Its results help to detect and assess the severity of broncho-obstructive syndrome and respiratory failure. In uncomplicated CP, as a rule, restrictive disorders are determined.

The detection of a large number of neutrophils by sputum microscopy indicates the activity of the inflammatory process: the detection of eosinophils is characteristic of the development of an allergic (asthmatic) component that complicates the course of CP; determination of mycobacterium tuberculosis and elastic fibers makes us reconsider the previously assumed diagnosis of CP.

Bacteriological examination of sputum helps to determine the type of microflora. A high concentration of microorganisms (more than 10 6 in 1 μl) reliably indicates its pathogenicity. Sputum culture also determines the sensitivity of microflora to antibiotics.

The role of clinical and biochemical blood tests in assessing the activity of the inflammatory process is insignificant. The results obtained do not sufficiently reflect the degree of inflammation. Changes in acute phase indicators (increased ESR, leukocytosis with a shift of the leukocyte formula to the left, an increase in the content of fibrinogen, and 2 -globulins, CRP) are noted only with severe inflammation. If the process is less active, all of these indicators may be normal. Exacerbation of the pathological process in these cases is diagnosed on the basis of a combination of clinical data, the results of X-ray examination and bronchoscopy, as well as sputum analysis.

Bronchiectatic form of chronic pneumonia. This form is distinguished on the basis of a number of features of the clinical picture.

On the the first stage of the diagnostic search note a number of diagnostic clinical signs.

The originality of complaints and the degree of their severity:

A large amount of sputum secreted (up to 200 ml per day), coming out with a "mouth full" and sometimes acquiring a putrid character (hemoptysis is often noted);

With a delay in sputum production, the body temperature becomes febrile;

Patients are worried about severe weight loss (cancerophobia often develops), lack of appetite and significant severity of symptoms of intoxication.

An active inflammatory process proceeds continuously or with frequent exacerbations. This is explained by the sharper severity of morphological changes in the focus of chronic inflammation with a significant violation of the drainage function of the regional bronchi, as well as more pronounced disorders of general and immunological reactivity.

Less effectiveness of conservative therapy.

On the second stage of diagnostic search observe a typical clinical picture.

A distinct severity of clinical symptoms: weight loss, a change in the shape of the nails (they take the form of watch glasses) and deformation of the fingers like drumsticks. Physical changes found during examination of the respiratory system are also more pronounced and persistent. You can hear not only fine, but also medium bubbling rales. With percussion, it is possible to determine the local shortening of the percussion sound.

Find complications: pulmonary hemorrhage, spontaneous pneumothorax, signs of cor pulmonale.

On the third stage of diagnostic search the most important information for diagnosis is provided by X-ray examination of patients.

On survey radiographs, gross focal deformity of the pulmonary pattern and cystic enlightenment are visible. Perhaps a volumetric decrease in the lobe or segment of the lung with a displacement of the mediastinum towards the lesion.

CT can identify areas of carnification, thin-walled cavities and cylindrical expansion of the draining bronchus.

Bronchograms reveal pathological changes in the regional bronchi, specify the segmental localization of the process and the type of bronchiectasis (cylindrical, fusiform, saccular).

Complications of CP:

Broncho-obstructive syndrome;

Respiratory failure

Chronic cor pulmonale;

Formation of an allergic (asthmatic) component;

Pulmonary bleeding;

Spontaneous pneumothorax.

Diagnostics. When establishing a diagnosis of CP, take into account:

A clear connection between the onset of the disease and previous pneumonia (less often - with an acute respiratory infection, including influenza);

Repeated inflammation of the same area of lung tissue within one segment or lobe of the lung (focal nature of the pulmonary process), physical signs of focal inflammation and pneumosclerosis (depending on the phase of the process) and nonspecific signs of inflammation (according to laboratory research methods);

X-ray (including CT) signs of focal pneumosclerosis, the existence of deforming bronchitis, pleural adhesions and local bronchiectasis;

Bronchoscopic picture of local purulent or catarrhal bronchitis;

The absence of other chronic respiratory diseases of the lungs, as well as tuberculosis, pneumoconiosis, sarcoidosis, Hammen-Rich syndrome, which cause the long-term existence of the lung tissue compaction syndrome, as well as the development of bronchiectasis.

When formulating the diagnosis of chronic pneumonia, the following should be reflected:

Clinical and morphological form of pneumonia (interstitial CP or CP with bronchiectasis);

Process localization (shares and segments);

The phase of the process (exacerbation, remission), while during exacerbation indicate the degree of activity of the process;

Complications.

Treatment. In the exacerbation phase, treatment includes:

Measures aimed at eliminating the exacerbation of the inflammatory process (antibiotic therapy);

Pathogenetic therapy (restoration of bronchial patency; the appointment of agents that increase the body's resistance);

Treatment of complications.

In principle, the treatment corresponds to that of OP, but has some peculiarities.

When carrying out antibiotic therapy, the characteristics of the pathogen should be taken into account. The course of antibiotic treatment for CP is lengthened, preference is given to the parenteral route of administration.

With the development of bronchiectasis, it is advisable to administer antibiotics locally through a bronchoscope after sanitation of the bronchi and rinsing them with hydroxymethylquinoxaline dioxide. If necessary (pronounced general signs of inflammation, a high degree of activity of purulent endobronchitis), the same drugs are additionally administered parenterally.

The use of this method of drug delivery through a nebulizer opens up the possibility of inhalation therapy using a combination of the antibiotic thiamphenicol glycinate acetylcysteinate at a dose of 250 mg with the mucolytic ambroxol.

In severe relapse caused by staphylococcus, Pseudomonas aeruginosa and other pathogens, passive specific immunotherapy with hyperimmune plasma and y-globulin should be carried out.

With an exacerbation of the disease and at the stage of recovery, the use of immunomodulatory drugs is recommended: thymus extract, azoxymer bromide, glucosaminyl muramyldipeptide. Oral and parenteral administration of vitamin preparations, complete nutrition, rich in proteins and vitamins, are necessary. With a decrease in body weight and prolonged intoxication, anabolic steroids are prescribed (intramuscular administration of nandronol, 2 ml once a week).

An important part of treatment is the implementation of measures aimed at restoring or improving bronchial patency.

To improve the drainage function of the bronchi, expectorant and mucolytic agents are prescribed, sanitation bronchoscopy is performed, postural drainage and special exercises are used in the complex of respiratory gymnastics.

In order to eliminate bronchospasm, prolonged theophylline preparations and inhaled bronchodilators (β 2 -agonists and m-anticholinergics or their combination - berodual) are prescribed. If the effect of therapeutic measures is insufficient, the complex treatment includes intra-

tracheal administration of hydrocortisone at a dose of 25 mg and other glucocorticoids. With the asthmatic component, treatment is supplemented by the appointment of inhaled glucocorticoid drugs in the form of metered-dose inhalers.

In the phase of subsiding exacerbation anti-inflammatory (meloxicam, fenspiride) and biogenic stimulants (aloe, Chinese magnolia vine, etc.) are recommended. The use of antibiotics in active endobronchitis is limited to local administration (through a bronchoscope, inhalation). During this period, breathing exercises, chest massage and physiotherapeutic procedures (UHF therapy, diathermy, inductothermy, electrophoresis of calcium chloride, potassium iodide, etc.) become important.

CP treatment in remission presupposes a set of measures aimed at preventing exacerbation, i.e. secondary prevention activities. The patient should stop smoking and constantly engage in breathing exercises. He needs rational employment, sanatorium treatment and observation in the pulmonary office of the polyclinic. A course of treatment with weakened vaccines is recommended: bronchomunal, ribomunil and bronchovaxone.

Forecast. In most cases, the prognosis is favorable for life, but patients require long-term follow-up and periodic treatment.

Prevention. The main preventive measures are prevention, early diagnosis, timely and rational treatment of pneumonia.

BRONCHEECTATIC DISEASE AND BRONCHEECTASES

Bronchiectasis is an acquired (in some cases - congenital) disease characterized by a chronic purulent process in irreversibly altered (dilated, deformed) and functionally defective bronchi, mainly in the lower parts of the lungs.

The main morphological substrate of the pathological process is primary bronchiectasis, which cause the appearance of a characteristic symptom complex. In essence, they cannot be considered primary, since they usually develop as a result of infectious diseases of the bronchopulmonary system transferred in childhood, mainly of viral etiology, but their formation most likely requires the existence of a congenital defect in the bronchial wall.

At the same time, in primary bronchiectasis, there are usually signs that make it possible to distinguish an independent nosological form - bronchiectasis. With it, significant involvement of lung tissue in the pathological process is not noted, and exacerbations of the disease proceed mainly as an exacerbation of purulent bronchitis without infiltration of the lung parenchyma.

There are also secondary bronchiectasis arising as a complication or symptom of another disease, including chronic pneumonia and chronic deforming bronchitis. With secondary bronchiectasis, pronounced changes in the respiratory tract are found.

la, corresponding to the localization of bronchiectasis, which qualitatively distinguishes them from primary bronchiectasis (Putov N.V., 1978; Paleev N.R., 1985). In addition to the above diseases, there are many more reasons that contribute to the development of bronchiectasis (bronchiectasis) in adults. The reasons for the formation of secondary bronchiectasis are listed below (Shoikhet Ya.N., 2007).

Post-infectious (abscess pneumonia, tuberculosis, adenovirus infection and other infectious diseases of the respiratory tract).

Obstructive (foreign bodies, tumors, external airway compression).

Inhalation injury (inhalation of toxins, irritating gases, vapors and fumes, including thermal damage).

Aspiration (gastroesophageal reflux, aspiration pneumonia, medical procedures).

Genetically determined bronchiectasis (cystic fibrosis, ciliary dyskinesia syndrome, Ewing's syndrome).

Congenital anomalies - dysplasia (agenesis, hypoplasia, sequestration, shunts, etc.).

Deficiency or abnormality of α 1 -antitrypsin.

Primary immune disorders (humoral defects, cellular or mixed disorders, neutrophil dysfunction).

Chronic diffuse lung diseases of known or unclear etiology (idiopathic pulmonary fibrosis, sarcoidosis, etc.).

Idiopathic inflammatory disorders (ankylosing spondylitis, inflammatory bowel disease, recurrent polychondritis).

Other causes (allergic bronchopulmonary aspergillosis or mycosis, HIV infection, AIDS, yellow nails syndrome, radiation damage).

According to the mechanisms of occurrence, secondary bronchiectasis is divided into obstructive, destructive, traction, and iatrogenic (after radiation treatment and aggressive antibiotic therapy).

Secondary bronchiectasis is not classified as bronchiectasis; it is a symptom of other major diseases.

The independence of bronchiectasis as a separate nosological form is disputed to this day (Uglov F.G., 1977). This discussion is of practical importance: the diagnosis of chronic pneumonia in patients with bronchiectasis often reassures both the doctor and the patient, as a result of which a surgeon's consultation and bronchological examination are not carried out in a timely manner and the optimal time for the operation is missed.

Since the 1970s, there has been a decrease in the incidence of bronchiectasis. This can be explained by a pronounced decrease in the number of childhood infectious diseases (whooping cough, measles) and childhood tuberculosis, as well as by the success of drug treatment. Along with this, the prevalence of secondary bronchiectasis did not decrease.

Etiology

Until now, the causes of bronchiectasis cannot be considered sufficiently clarified. Probably, the decisive role is played by the combination of the effect of the pathogen and the genetic inferiority of the bronchial tree.

An essential role in the formation of bronchiectasis is played by a genetically determined inferiority of the bronchial tree, leading to a violation of the mechanical properties of the walls of the bronchi during their infection (especially in early childhood).

Microorganisms that cause acute respiratory diseases (pneumonia, measles, whooping cough, etc.) in children can only be considered an etiological factor, since in the vast majority of patients they are completely cured.

There is a connection between the development of bronchiectasis and diseases of the upper respiratory tract:

Perhaps, in their pathogenesis, the insufficiency of the same protective mechanisms of the respiratory tract is important;

There is a constant mutual infection of the upper and lower respiratory tract.

Infectious pathogens that cause a purulent process in already altered bronchi (pneumococcus, staphylococcus, Haemophilus influenzae, etc.) can be considered as a cause of exacerbations, but not the development of bronchiectasis.

The occurrence of bronchiectasis can be caused by the weakness of the bronchial wall with congenital tracheobronchomegaly (Mounier-Kuhn syndrome), the absence of cartilaginous rings (Williams-Campbell syndrome), and recurrent polychondritis.

Pathogenesis

The most important role in the pathogenesis of bronchiectasis belongs to bronchiectasis and their suppuration.

Obstructive atelectasis arising in violation of bronchial patency leads to the development of bronchiectasis. Its occurrence can be facilitated by a decrease in surfactant activity (congenital or acquired, due to local inflammatory processes). In children, the causes of impaired patency of large bronchi (and, thus, the formation of atelectasis) can be:

Compression of compliant, and possibly congenitally defective bronchi by hyperplastic hilar lymph nodes (their hyperplasia is found in hilar pneumonia and tuberculous bronchoadenitis);

Prolonged blockage of the bronchi with a dense mucous plug in acute respiratory infections.

Decrease (congenital or acquired) of the resistance of the bronchial walls to the action of bronchodilating forces (increase in intrabronchial pressure when coughing, stretching of the bronchi with accumulating secretions, an increase in

negative intrapleural pressure due to a decrease in the volume of the atelectasized part of the lung) contributes to the persistent expansion of the bronchial lumen.

Expansion of the bronchi and delayed bronchial secretion lead to the development of inflammation. With its progression, irreversible changes occur in the walls of the bronchi (restructuring of the mucous membrane with complete or partial death of the ciliated epithelium and impaired cleansing function of the bronchi, degeneration of cartilaginous plates and smooth muscle tissue with their replacement with fibrous tissue, a decrease in resistance and ability to perform basic functions) and develop bronchiectasis.

Bronchiectasis causes a violation of the coughing mechanism, stagnation and infection of secretions in the dilated bronchi, as well as the development of a chronically current, periodically exacerbated purulent process, which serves as the second most important factor in the pathogenesis of bronchiectasis. The essence of bronchiectasis is suppuration of formed bronchiectasis.

The altered secretion usually accumulates in the lower parts of the bronchial tree (flows freely from the upper parts under the influence of gravity). This explains mainly the lower lobe localization of the pathological process.

Classification

Depending on the nature of the expansion of the bronchi, cylindrical, saccular, fusiform and mixed bronchiectasis are distinguished.

According to the prevalence of the process, it is advisable to distinguish between unilateral and bilateral bronchiectasis (indicating the exact localization by segments).

According to the clinical course, V.F. Zelenin and E.M. Gelstein (1952) distinguish three stages of bronchiectasis: bronchitis (I), severe clinical symptoms (II) and stage of complications (III).

Clinical painting

Symptoms of bronchiectasis are extremely similar to those in bronchiectasis of CP and secondary bronchiectasis of a different etiology. It is necessary to highlight only a number of features of bronchiectasis at each stage of the examination.

On the the first stage of the diagnostic search determine attention to the occurrence of cough with sputum after childhood pneumonia, measles, whooping cough or severe flu and frequent recurrent pneumonia throughout the subsequent period of life.

On the second stage of diagnostic search almost always (and during the period of remission) during auscultation of the lungs, persistent foci of moist voiced fine-bubbling rales are found.

Complications of bronchiectasis are often recorded:

Hemoptysis;

Asthmatic component;

Focal (perifocal) pneumonia;

Lung abscess;

Pleurisy (pleural empyema);

Amyloidosis of the kidneys, less often of the spleen and liver (given the effective treatment of the underlying disease, amyloidosis currently develops extremely rarely and at the later stages of the disease);

Secondary chronic bronchitis.

Secondary chronic bronchitis is usually the most common and progressive complication. It leads to the development of respiratory and pulmonary heart failure and often serves as the direct cause of death of patients. The latter may also be pulmonary hemorrhage or chronic renal failure resulting from secondary renal amyloidosis.

When analyzing X-ray data on third stage of diagnostic search it should be borne in mind that most often the basal segments of the left lung and the middle lobe of the right lung are affected.

In addition to the previously described (see "Bronchiectatic form of chronic pneumonia") methods of laboratory and instrumental diagnostics, in some cases additional studies are required.

Serial angiopulmonography helps to determine the anatomical changes in the vessels of the lungs and to detect hemodynamic disorders in the pulmonary circulation in various forms of bronchiectasis.

Bronchial arteriography can detect blood shunting through pathologically dilated bronchial-pulmonary anastomoses.

A lung scan helps to determine the pronounced disturbances of capillary blood flow in bronchiectasis.

All these research methods are carried out according to indications in the preoperative period, since they help to accurately establish the volume of the operation.

Diagnostics

The diagnosis of bronchiectasis is made when certain signs are found:

Clear indications of the onset of cough with phlegm in childhood after an acute respiratory illness;

Frequent outbreaks of pneumonia of the same localization;

Detection of persistent foci of wet wheezing during physical examination during the period of remission of the disease;

X-ray signs of gross deformation of the pulmonary pattern, as a rule, in the region of the lower segments or the middle lobe of the right lung, CT and bronchographic signs of bronchiectasis.

The formulation of a detailed clinical diagnosis includes:

Name of the disease (bronchiectasis);

Localization of the process (indicating the affected segments);

Stage of the process;

The flow phase (exacerbation or remission);

Complications.

In secondary bronchiectasis, the formulation of the diagnosis begins with an indication of the underlying disease that led to their development.

Treatment

Conservative and surgical treatment is possible. Conservative treatment is recommended for patients:

With minor or clinically mild changes in the bronchi;

With a widespread and insufficiently clearly localized process (when surgical treatment is impossible);

In preparation for bronchography and radical surgery.

The main link of conservative treatment is the sanitation of the bronchial tree, carried out by:

Effects on pyogenic microflora (through a bronchoscope, inhalation of antibacterial drugs);

Elimination of purulent bronchial contents and sputum (breathing exercises, chest massage, postural and bronchoscopic drainage, use of mucolytic agents).

For more information on drug treatment, see the section "Pneumonia". The upper respiratory tract should be sanitized, restorative measures should be taken and adequate nutrition should be provided.

Surgical treatment is best done at a young age. Persons over the age of 45 with bronchiectasis are operated on less often, since by this period of their life they already have complications that prevent the operation from being performed. Resection of the lobe of the lung or individual segments is performed with unilateral bronchiectasis. With bilateral bronchiectasis, the most affected part of the lung is removed (on one side).

Forecast

The outcome of the disease depends on the prevalence of the process and the existence of complications. Moderate damage, subject to systematic treatment, provides a long period of compensation and preservation of working capacity.

Prophylaxis

Primary prevention of the disease consists in the correct treatment of pneumonia (especially in childhood), often developing against the background of infectious diseases (measles, whooping cough, flu). Secondary prevention consists of maintaining a healthy lifestyle, treating intercurrent infectious diseases, and combating focal upper respiratory tract infections.

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