X-ray diagnosis of pneumonia. Pneumonia in children Viral pneumonia X-ray diagnostics

X-ray diagnosis of nosocomial pneumonia

I.E. Tyurin

Hospital-acquired pneumonia (HP) is an inflammatory process in the lower respiratory tract and lung tissue that occurs in a hospital setting 48 hours or more after hospitalization.

The true incidence of HP is unknown, which is due to the difficulties of their intravital diagnosis, differences in the interpretation and classification of clinical data, and the impossibility of autopsy in all patients who died in the hospital. Approximate estimates show that HP develops in 0.5-5.0% of patients in hospitals, and in intensive care units (ICUs) - in 15-20%. Mortality in GP reaches 20-50%.

Diagnosis of HP is associated with objective difficulties. The development of pneumonia can be assumed in any patient with an increase in body temperature or the appearance of respiratory complaints, which serves as the basis for x-ray of the lungs and sputum analysis. Changes in the lung tissue detected on radiographs can be directly or indirectly due to pneumonia. The diagnostic criteria for HP are:

1) the appearance of fresh focal-infiltrative changes in the lungs on radiographs;

2) the presence of at least two signs:

Fever >39.3°C;

Bronchial hypersecretion;

Ra02/Ryu2*<240 мм рт. ст.;

3) the presence of at least two signs:

Tachypnea, crepitus/moist rales, bronchial breathing or cough;

Leukopenia (<4,0 х 109/л) или лейкоцитоз (>12.0 x x 109/l) with stab shift (>10%);

The appearance of purulent sputum / bronchial secretions (microscopy with a magnification of x100 reveals more than 25 polymorphonuclear leukocytes in the field of view).

These criteria are not always effective. On the one hand, fever, sputum hypersecretion, and infiltrative changes in the lungs may not be associated with the development of pneumonia. On the other hand, GP can be masked by other clinical symptoms, and signs of pneumonia are not always detected by radiography. However, radiography, and in

Igor Evgenievich Tyurin - professor, head. Department of Radiation Diagnostics, Radiation Therapy and Medical Physics of the RMAPE.

* PaO2 - oxygen pressure in arterial blood; PIO2 is the fraction of oxygen in the inhaled gas mixture.

recent years and computed tomography (CT) are important methods for diagnosing HP.

The main tasks of X-ray examination:

Identification of pneumonic infiltration, assessment of the localization and prevalence of the pathological process;

Differential diagnosis of the identified changes, the maximum narrowing of the differential diagnostic range of causes that cause clinical symptoms or radiographic changes, and (if possible) the determination of the etiological factors of pneumonia;

Determination of tactics for further examination, including indications for invasive diagnostic procedures;

Assessment of the dynamics of the inflammatory process, identification of complications and residual changes after pneumonia.

The effectiveness of solving each of these problems largely depends on the specific clinical situation, the etiology and pathogenesis of the inflammatory process in the lungs, and the chosen method of radiological examination.

Methods of X-ray examination

Radiography

The main radiation method for diagnosing pneumonia is radiography. Identification of new infiltrative or focal changes on radiographs with appropriate clinical symptoms becomes an important argument in favor of the diagnosis of pneumonia. Therefore, any clinical suggestion of a possible GP is an unconditional indication for an X-ray examination.

If a patient with suspected HP can be taken to an x-ray room, then the study is performed on a stationary x-ray machine. It is optimal to carry out radiography in the vertical position of the patient's body (standing or sitting) in two mutually perpendicular projections - the anterior straight line and the right side. This allows you to study the state of the organs of the chest cavity under physiological conditions, with a delayed breath, with an adequate focal length.

If the condition of the patient with HP does not allow such a study, radiography is performed on the table of the X-ray machine, with the patient lying on his back. As a result, a radiograph is obtained in direct posterior projection (the x-ray tube is above the patient, and the film cassette is behind the patient). This

the picture can be supplemented by radiography in a lateral projection with a horizontal course of x-rays - a laterogram (the patient is still lying on his back, the x-ray tube is located on the side of the chest, the film cassette is pressed to the opposite side). Laterograms are of great importance in assessing the state of the chest organs in patients in serious condition, allowing you to confidently detect fluid in the pleural cavities, distinguish atelectasis from pneumonic infiltration, and evaluate the location of medical devices (tubes, drains, catheters, etc.) inside the chest cavity.

Much more often, patients with HP cannot be delivered to the X-ray room due to the severity of the condition, artificial lung ventilation (ALV), other medical or organizational reasons. In this case, the X-ray examination is performed outside the X-ray room, usually in the ICU. Radiography is performed using a mobile X-ray machine. The patient lies in bed, lying on his back strictly horizontally (in the patient's sitting position, the diaphragm shifts upward and covers a significant part of the lung fields, hiding changes in the posterior costophrenic sinuses). Fears that in a horizontal position on the back more often no fluid is detected in the pleural cavity is not true. The cassette is placed under the patient's back, the X-ray tube is located above him. If necessary, a laterogram of the chest can also be performed: the patient remains in the supine position, the tube and the film cassette are located on the sides of him.

Radiography in the ward requires coordinated actions of the radiologist and ICU staff, and also has a number of features and limitations. Most mobile X-ray machines are inferior in power to stationary counterparts. Because of this, radiography is performed with a greater exposure, leading to dynamic blur from contractions of the heart and pulsation of large vessels. When examined in the supine position, the heart and large vessels of the mediastinum, located near the anterior chest wall, are at a distance from the film cassette, and therefore there is an effect of geometric blur and projection magnification. This is exacerbated by the short focal length, since it is almost impossible to position the X-ray tube at a height of 150 cm above the patient. As a result, the median shadow turns out to be much larger than in the pictures in the anterior projection, creating a false impression of the pathology of the heart and blocking a significant part of the lung fields. The lack of cooperation in severely ill patients should also be taken into account (the inability to hold the breath while inhaling at the time of exposure). Recommendations for eliminating these shortcomings are given in some manuals on X-ray diagnostics.

CT scan

In recent years, CT has been increasingly used in the diagnosis of HP. The study is performed according to the standard

technique, in the position of the patient on his back with his hands behind his head, at the height of a calm, delayed breath. In a serious condition of the patient, the study can be carried out with the arms down, however, this leads to the appearance of artifacts from the bones of the limbs.

Of exceptional importance is the possibility of CT in patients on mechanical ventilation. To do this, the CT room must be equipped with an oxygen and nitrous oxide supply for ventilation during the diagnostic procedure. Modern CT machines are usually equipped with an automatic syringe, allowing CT angiography to be performed, even on critically ill patients. This possibility is of decisive importance in the differential diagnosis of pneumonia and pulmonary infarction in pulmonary embolism (PE).

X-ray signs of HP

X-ray semiotics of HP differs little from that in community-acquired pneumonia. The inflammatory process in the lung tissue is characterized by three main types of infiltrative changes: alveolar (pleuropneumonia), focal (bronchopneumonia) and interstitial (interstitial pneumonia).

The alveolar type of infiltration is characterized by the appearance of an airless area of ​​the lung tissue of a homogeneous structure, in the zone of which air gaps of the bronchi are clearly visible - a symptom of “air bronchography” (Fig. 1). The pathological process occupies one or two segments, rarely spreads to a large part of the lobe and even the neighboring lobe. The site of infiltration with a wide base faces the costal, interlobar or diaphragmatic pleura, where its density is greatest. The interlobar pleura is concave towards the airless area, since the volume of the affected lobe is somewhat reduced due to hypoventilation. Changes are more often localized in the back or outer part of the lung lobe and gradually decrease towards the anterior or inner (basal) parts of it.

The focal (bronchopneumonic) type of infiltration is characterized by the presence in the lungs of an area of ​​compaction of a heterogeneous structure, consisting of numerous polymorphic, predominantly large centrilobular foci with fuzzy contours, often merging with each other (Fig. 2). Foci and small infiltrates are located peribronchially, peribronchiolarly, around small intralobular bronchi, the gaps of which can be seen on high-resolution CT. The zone of infiltration extends to one or more segments, a lobe or several adjacent lobes of the lung. In the altered area, gaps of segmental and smaller bronchi, their sharply thickened walls, and vessels with fuzzy contours are visible.

The third type of infiltration is characterized by the appearance in the lung of one or more areas of interstitial infiltration of the ground glass type (Fig. 3). Unlike alveolar infiltration, against the background of compacted lung tissue, not only air gaps of the bronchi are visible, but

Rice. 1. Condition after resection of the right mammary gland and chemotherapy, hospital right-sided lower lobe pneumonia, alveolar type of infiltration. On the survey radiograph (a), axial section (b), reformations in the direct (c) and lateral (d) projections, alveolar infiltration is detected in the 1X-X segments of the right lung. Bronchial lumens are clearly visible in the compaction zone.

Rice. 2. B-cell lymphoma, right-sided pneumonia, focal type of infiltration. Axial sections (a, b) show multiple peribronchial infiltration foci in the middle and lower lobes of the right lung.

Rice. 3. Lymphogranulomatosis, bilateral pneumonia, interstitial type of infiltration. On the survey radiograph (a), there is a decrease in the airiness of the right lung, the disappearance of the normal contours of the cardiac shadow on the right, and the expansion of the roots of the lungs. Axial section (b) reveals an interstitial type of infiltration (“ground glass”) in the middle lobe of the right and lower lobe of the left lung.

Rice. 4. Lymphogranulomatosis, left-sided lower lobe pneumonia. On the roentgenogram (a), the expansion of the median shadow to the right is determined due to the increase in the lymph nodes of the anterior mediastinum, fluid in the right pleural cavity, and expansion of the shadow of the heart. Axial section (b) reveals fluid in the right pleural cavity and compression atelectasis of the lower lobe of the right lung, in which bronchial air gaps are visible. On reformations in direct (c) and lateral (d) projections, pneumonic infiltration is detected in the lower lobe of the left lung.

and elements of the pulmonary pattern - the walls of the bronchi, interlobular and intralobular septa and vessels. The contours of these structures, as a rule, are indistinct, vague.

The advantage of CT in the diagnosis of pneumonia is the earlier detection of infiltrative changes in the lung tissue, especially when they are small (foci) or low density (ground glass). Therefore, the diagnosis of small-focal and interstitial GPs today is largely the prerogative of CT (Fig. 4).

Another specific advantage of CT is the identification of the symptom "Inge-In-LuC" - "blossoming tree". It reflects the expansion of small intralobular bronchi when they are filled with bronchial

Rice. 5. Compression fracture L5, right lower lobe pneumonia. Symptom "1gee-1n-bucT. In the X segment of the right lung, at a distance of 2-3 mm from the mediastinal pleura, multiple small U-shaped and U-shaped structures are defined - enlarged intralobular bronchi filled with a secret.

secret (pus, caseous masses or other pathological contents). The detection of a U-shaped or U-shaped expansion of small bronchi is the main symptom of the bronchogenic spread of the process in the lung tissue (it is most often based on pneumonia - Fig. 5).

Evaluation of X-ray data

Despite the obvious advantages of CT, at present, the primary and often the only method of radiation examination of patients with suspected HP is radiography of the lungs in the ward. The above disadvantages of radiography using ward X-ray machines have important consequences in relation to the detection of changes in the lungs, including HP.

Radiography is not as accurate a technique for recognizing HP as in cases of community-acquired pneumonia. This is due to objective technological difficulties in obtaining a high-quality image of the organs of the chest cavity outside the X-ray room and changes in physiological conditions during X-ray examination.

HP often occurs against the background of already existing changes in the chest cavity - atelectasis, pleurisy, cardiogenic pulmonary edema, or acute respiratory distress syndrome (ARDS). The differentiation of these processes with pneumonia according to X-ray data is difficult and often impossible at all.

It is known that the main radiographic sign of any pneumonia, including hospital pneumonia, is the occurrence of one or more areas of compaction (synonyms: infiltration, decreased airiness, shading) of the lung tissue. In patients with community-acquired pneumonia, the first x-ray examination is usually performed a day or more after the onset of respiratory complaints (after contacting a medical institution). In patients with suspected HP, a completely different situation is possible: the appearance of fever, respiratory complaints, and changes in blood tests may serve as a reason for emergency X-rays. In this case, the time between the onset of clinical manifestations and radiography can be calculated in hours and even minutes. There is no exact information in the literature about how quickly pneumonic infiltrates become visible on radiographs, however, the existence of a latent period is generally recognized, the duration of which from the onset of the disease reaches 10-24 hours. Performing radiography during this period of time is fraught with a false negative conclusion about the absence of pneumonia. This is of fundamental importance, for example, when there is a discrepancy between the autopsy data and the results of radiography performed a few hours before the death.

Special care must be taken in interpreting radiographic data in immunocompromised and neutropenic patients. In one of the studies among 175 patients with neutropenia on the background of antitumor

Left therapy revealed 70 episodes of pneumonia, diagnosed clinically - no changes on radiographs. In 27 of 70 patients, infiltration was recorded on follow-up radiography over time. At the same time, in 25 out of 57 patients who died, signs of pneumonia were detected only at autopsy.

Delayed changes on radiographs can occur not only in patients with neutropenia, but also in functional defects in granulocytic germ cells observed in patients with diabetes mellitus, alcoholism, and uremia. Conflicting data exist regarding how inadequate hydration affects the diagnosis of pneumonia. One way or another, but the interpretation of X-ray data should take into account the fact that HP may not have typical radiographic signs, especially at the onset of the disease. CT, and especially high-resolution CT, can help in diagnosis, which allows earlier and more accurate detection of minimal changes in the lung tissue.

Of particular difficulty is the X-ray diagnosis of HP against the background of other pathological changes in the chest cavity - preceding or occurring simultaneously with HP. These processes include pulmonary edema. aspiration of blood and gastric contents, pulmonary infarction in PE, ARDS, idiopathic pulmonary fibrosis, lung tissue damage in systemic diseases, pleurisy and atelectasis. All of these diseases can mimic pneumonia or hide inflammatory changes behind manifestations of another pathological process. The more common the previous changes are, the less likely it is to diagnose pneumonia on x-ray. CT can also provide some help here, especially when this study reveals obvious signs of one of the diseases (PE and concomitant pulmonary infarction, pleurisy in the absence of changes in the lung tissue, etc.).

It is especially difficult to diagnose HP in patients on mechanical ventilation. The detection of pneumonia in the setting of ARDS remains an unsolved problem. Comparison of X-ray data, performed shortly before death, with autopsy data showed that the overall accuracy of X-ray symptoms does not exceed 68%. The only predictor of pneumonia against the background of ARDS with a reliability of more than 60% was the symptom of “air bronchography”. The most specific, albeit infrequent, sign is an underlined contour of the interlobar pleura, to which an airless area of ​​\u200b\u200blung tissue is adjacent.

In general, the specificity of radiography in the diagnosis of pneumonia against the background of ARDS usually does not exceed 27-35% in comparison with autopsy data and bronchial secretions. A study in 40 patients with clinical symptoms of pneumonia that arose in the ICU and infiltrative changes in the lungs detected by radiography showed that the overall

www.atmosphere-ph.ru

Rice. 6. Condition after gastric extirpation, left ventricular failure, pulmonary edema. On the radiograph in direct projection (a) there is a bilateral decrease in the transparency of the lung fields, an expansion of the median shadow. Axial sections in the mediastinal window (b) and in the pulmonary window (c, d) in the right pleural cavity show a large amount of free fluid, compression atelectasis of the lower lobe of the right lung (b, c). Diffuse changes in the lungs due to alveolar edema (d).

The radiographic accuracy was 52%, but decreased to 42% with the development of ARDS (the diagnosis of pneumonia was confirmed by examination of bronchial secretions and bronchoalveolar lavage). Interestingly, the use of clinical information to assess changes in radiography led to an additional decrease in the information content of radiological examination due to the increase in false positive and false negative conclusions.

The same group of authors investigated the possibilities of CT in the diagnosis of pneumonia in 31 patients with ARDS. Of the 16 patients in whom CT did not reveal pneumonic infiltration, in 13 pulmonary infection was also excluded according to bronchoscopy with examination of bronchial secretions. The study showed that the use of CT is of little value in detecting pneumonia against the background of ARDS, but it is extremely important in ruling out this pathological condition.

Differential Diagnosis

An important task of X-ray examination is the most accurate assessment of the identified changes in the chest cavity. The principles of differential diagnosis of HP with other pathological processes in the lungs do not differ from those in community-acquired pneumonia and are detailed in the relevant guidelines. It is only necessary to take into account that the main tool for differential diagnosis, as a rule, is a conventional radiograph in direct posterior projection, performed in the ICU. Other Methodological Techniques Used to Evaluate Outpatients

pneumoniae (fluoroscopy, polypositional examination, tomography) are not applicable here. In this regard, the importance of the availability and rational use of CT for examining resuscitation patients with a suspected nosocomial infection increases significantly (Fig. 6). This possibility should be provided in each multidisciplinary hospital already at the design stage of the CT room and ICU.

Equally important is the assessment of the etiological factor of HP. A review of modern literature shows that with the most thorough microbiological examination of sputum, the detection of the causative agent of pneumonia is possible in no more than 30-70% of patients. In patients in the ICU, and even more so on mechanical ventilation, the frequency of identification of pathogens may be higher due to the more frequent use of invasive procedures to obtain material, but even here the result is not always guaranteed. X-ray data can be of some help, but these possibilities should not be overestimated. X-ray examination does not allow to establish the etiology of the inflammatory process, with the exception of lung lesions on the background of immunodeficiency caused by pneumocystis infection, invasive aspergillosis, tuberculosis (with a typical picture). In other situations, X-ray and CT data help to distinguish between groups of pathogens, such as bacteria and viruses. Despite the possibility of significant similarities between bacterial and viral pneumonias, in most patients with bacterial pneumonias, the radiological picture is characterized by the appearance of local alveolar infiltration in the form of large areas (lobar, segmental, subsegmental) or peribronchiolar (centrilobular) foci. For a viral infection, diffuse, often bilateral lesions are more characteristic in the form of a combination of small foci, reticular changes, and ground-glass infiltration areas. It is important to emphasize that the etiological diagnosis within each of these groups is practically difficult to implement. For example, it is usually not possible to distinguish between bacterial pneumonia caused by typical gram-positive organisms and "atypical" bacterial pneumonia caused by mycoplasmas or chlamydia on x-ray. This is convincingly shown in patients with community-acquired pneumonia and is completely true for patients with HP.

The prognostic value of X-ray examination in GP is estimated inconsistently. It is known that the usual x-ray signs, such as the intensity of the seal shadow, the structure and type of infiltration, have little effect on the outcome of the disease. The only exception to this rule may be the involvement of several lobes of the lungs in the pathological process, which significantly worsens the prognosis of HP. >

You can find the list of references on our website www.atmosphere-ph.ru

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

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

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

Introduction
Diagnosed by x-rays, pneumonia is traditionally assessed, first of all, quantitatively: the volume of the lesion, the intensity of inflammatory infiltration are reflected. The risk of acute respiratory distress syndrome (ARDS) is expressed as the number of lung quadrants affected. In many manuals, articles, reviews, the X-ray picture is named among the leading criteria for diagnosing severe pneumonia, viral-bacterial pneumonia, viral pneumonia, ARDS, however, the wording in the "Changes in the lungs" section is very scarce - "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 identify the features of the x-ray picture in patients with viral-bacterial pneumonia. To develop criteria for a qualitative assessment of the radiological picture in patients with a pulmonological profile, to use them in predicting the risk of ARDS.

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

This scale is syndromic, the specification of syndromes is included in the tasks of the descriptive part of the analysis of an x-ray (or CT). To evaluate each criterion, 3 degrees are provided (0, 1, 2), additional transition states are allowed (0–1, 0–2, 1–2). The final assessment for all 4 criteria is supposed to be expressed not as a sum of points (quantitative approach), but as a combination of values ​​of 4 criteria. When choosing a value for the 1st criterion - “impaired pneumatization”, not only obvious signs of emphysema or the phenomenon of atelectasis of the lung tissue were taken into account, but also intermediate conditions in the form of hyperair or hypoair, 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-tuberculous ones. Bronchiectasis (3rd criterion along with interstitial lesions) are chronic changes, but an exacerbation stage is possible, bronchiectasis can be combined with bronchiolectasis and bronchiolitis. Under the syndrome of interstitial lesions, we mean any thickening of the interstitium (here we also include small-focal dissemination), requiring treatment or mandatory x-ray monitoring in dynamics. The structure of the site 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 has been used in the analysis of radiographs of the lungs of patients with a pulmonological profile. and the above criteria.
When using the TPLS criteria to assess the x-ray picture of the lungs in patients with a pulmonological profile, we reflected: asymmetry of pneumatization of the lung fields and the degree of inspiration during the picture, including in dynamics; the presence of local chronic changes as evidence of past, as a rule, inflammatory lung diseases; 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, polysegmentally, which is more typical for the viral component of pneumonia.
In our hospital during the epidemic season of 2009-2010. (influenza H1N1), patients diagnosed with pneumonia were treated in pulmonology departments No. 1 and 2, infectious departments No. 1 and 2, and the department of thoracic purulent surgery. Severe viral-bacterial pneumonia was diagnosed in 54 patients (including 17 pregnant women), these patients were treated in the pulmonary and general intensive care units, 28 (51.9%) people were on artificial lung ventilation (ALV), incl. 7 pregnant. The study group was represented by 54 patients, including 18 (33.3%) men and 36 (66.7%) women. The average age is 35 years (from 15 to 55 years).
All patients had a history of acute respiratory disease. The number of days spent in intensive care, 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 serious condition. All had bilateral infiltrates in the lungs at the time of admission. All patients underwent X-ray of the lungs, CT was performed in 20 patients. The duration of stay in our hospital in most patients reached 2 months. The onset of clinical manifestations of viral-bacterial pneumonia accounted for an average of 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. Signs of ARF developed, as a rule, within 24 hours. ARDS was diagnosed in 37 cases.
In 2009–2010 in the analysis of CT radiographs of the lungs of patients with viral-bacterial pneumonia, the following observations were made: “frozen picture”, a very slow change in the x-ray picture during studies in dynamics for 1–2 weeks; a small degree of inhalation on a lung scan in all patients; bilateral polysegmental lung disease in 46 (85.1%) patients. In all patients, lung damage was asymmetric, there were large intense infiltrates. Absence of pleurisy - in most patients, isolated cases of pleurisy of small volume - in 5 (9.2%) patients. Pneumothorax - in 8 (28.6%) of 28 patients on mechanical ventilation (Fig. 1 and 2).
Lung radiographs: either non-specific with bilateral opacities (inflammatory infiltrates) or showing a combination of interstitial lesions and inflammatory infiltrates, in the latter case a small number of patients had small infiltrations but still had ARDS. Bilateral infiltrates were observed equally often in the upper and lower sections (Fig. 3).
CT scan of the lungs: 2 signs are characteristic - consolidation ( infiltration, filling the lumen of the alveoli with a pathological substrate) of the lung tissue and "frosted glass" ( a sign of alveolitis, thickening of the walls of the alveoli). Consolidation with a tendency to the peribronchial location in most patients prevails over ground glass. Less often - chaotic areas of consolidation. Subpleural consolidation - in all patients (Fig. 4-6).

Thus, the most common variants on the TPLS scale were TPLS 2002, TPLS 2012, less often variants TPLS 2001, TPLS 2011. Taking into account the greater information content of lung CT compared with traditional radiographs, the TPLS variant can be refined according to the results of CT. As a rule, the syndrome of interstitial lesions, identified on traditional radiographs, corresponded to a combination of mild peribronchial consolidation and small areas of “ground glass” polytopic localization on CT scan of the lungs (i.e., a combination of symptoms of parenchymal compaction of the lung tissue was observed). ARDS corresponded to the TPLS 2002 and TPLS 2022 variants (radiographs of the chest organs were mainly analyzed, since CT was limited by the severity of the patients' condition).
In the dynamics of all patients, both radiographs and CT scans of the lungs showed the absence of a complete restoration of the normal radiographic picture: all of them retained compacted interlobular septa, linear fibrosis/atelectasis, areas of consolidation, but in a much smaller volume (Fig. 7 and 8).

At the onset of the disease and by the time of discharge, the airiness of the lung 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 the interalveolar septa) or severe hypopneumatization (absence full breath).
Among all patients who had pneumonia during the 2009–2010 epidemic season, there was no absolutely similar CT picture, despite the same CT symptoms. When comparing CT images in patients with viral-bacterial pneumonia diagnosed with ARDS and without ARDS, we did not reveal a significant difference in the ventral-dorsal lung tissue density gradient. The ventral-dorsal gradient on CT examination is clearly expressed in patients with manifestations of heart failure. In addition, patients with heart failure on CT 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 of 2015–2016. we met 12 cases of viral-bacterial pneumonia, not all of them confirmed H1N1 influenza, however, all patients had a history of acute respiratory disease and a similar radiological picture. In the study group of 12 patients, 8 (66.7%) men and 4 (33.3%) women. The average age is 51 years (from 28 to 79 years). When examining the first images, one can speak of a dubious, but still probable picture of pneumonia or bilateral pneumonia of a small volume. At the control study after 3-6 days (X-rays or CT scans of the lungs), bilateral large-volume polysegmental pneumonia with several infiltrates is observed. There are no large lobar high-intensity infiltrates. The parts of the lungs below the level of the tracheal bifurcation are predominantly affected. According to the results of CT, the volume of the lesion is much larger than according to x-rays, 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 8th–12th day; no “frozen picture” was noted. Pleurisy and cases of ARDS were not identified.
According to the TPLS scale in the initial x-ray examination TPLS 000 (0-1), i.e. doubtful infiltration in a small volume, in the control study TPLS 002 (0-2) or TPLS 2012. Against the background of the regression of pneumonia TPLS 000 (1-2 ), i.e. medium volume infiltration, transient changes are present. The most characteristic variant of viral-bacterial pneumonia for the epidemic season of 2015-2016. – TPLS (0–2)002, i.e. the degree of inhalation is moderately affected, 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-bacterial pneumonia in the epidemic season of 2015-2016. we have 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-bacterial pneumonia in the 2009-2010 epidemic season. more often observed in women, with a high incidence in pregnant women.
3. For viral-bacterial pneumonia, concomitant pleurisy is not typical.
4. "Frozen picture" on lung images 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 the lung tissue on x-rays form, along with the 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 radiography and CT, there is no tendency to damage the basal 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 disorders.
7. Viral and bacterial pneumonia of the epidemic seasons of 2009–2010. and 2015–2016 have a similar radiographic picture, but for pneumonia in 2015–2016. a long course is not typical, there are no cases of ARDS, a violation of lung excursion is less pronounced, large high-intensity infiltrates are not characteristic, a lesion of mainly the lower parts of the lungs is detected.
Based on the results of work with patients with a pulmonological profile, in particular with patients with viral-bacterial pneumonia, we put forward several hypotheses.
1. Background chronic changes in the lungs, perhaps not only an indicator of "abnormality", but also an indicator of the "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 volume 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. It is possible that with 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 the lung tissue and reduce the gradient between different parts of the lungs compared with the density of the lung tissue 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 bilateral polysegmental lung damage, a “frozen” x-ray picture, a high risk of developing ARDS, and residual post-inflammatory changes.
Perhaps it is advisable to use the criterion of the absence of dynamics - the "frozen picture" - to be used for classification within the group of viral-bacterial pneumonias.
In our opinion, the prospects for diagnosing viral-bacterial pneumonia and predicting the risk of ARDS are largely associated with the improvement of the leading method, the 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 features during dynamic observation.

Pneumonia is an inflammation of the lungs that occurs due to the presence of a large number of pathogens in the body. For example, illness can be caused due to 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 areas of tissue in the lungs. X-rays help to more effectively monitor the patient's condition. So, for example, when infected with bacteria, viruses or fungi, it is not advisable to treat the patient with antibiotics.

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

X-rays should be done with symptoms that are reliably established. So, for example, in the presence of wheezing in a patient, an x-ray may be offered. But in laboratory tests, the reliability of the method is reduced. 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, since it all depends on the cause of the disease and the volume of the affected areas.

In addition to these symptoms, one can also distinguish a high temperature, reaching 40 degrees Celsius. Dry cough is replaced by a wet cough with purulent sputum. There is pain in the chest 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 croupous or focal pneumonia, you need to re-X-ray.

Contraindications for referral for radiography should be minimal, except for pregnant women. In their position, radiography is done, observing the following rules: lead aprons are used, a smaller amount is given for the procedure, and the number of studies is reduced. A radiograph is a negative with blackouts that show foci of inflammation, they are depicted in white.

The foci are small-focal, reaching no more than 3 mm, while medium-sized foci can be no more than 8 mm. As for large-focal ones, they are found with sizes from 8 to 12 mm, and focal ones are more than 12 mm. In addition, blackouts 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, so these are subtotal spots. If the intensity is greater, then the airiness of the lung tissue is less. Shading is fuzzy and non-uniform.

On x-ray with croupous pneumonia, you can see a large darkening with medium intensity. Darkening may be on one or both lungs. Croupous pneumonia can be caused by provoking Frindler's wand. This disease is severe and can lead to death.

Croupous pneumonia on x-rays

On x-rays, croupous pneumonia can be recognized by a change in the physiological lesion of the domes of the diaphragm, there are shadows on one or both sides, the mediastinum is advancing 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 detect, especially in the initial stages. An infiltrate is a seal that forms in a tissue or organ. Its occurrence depends on the accumulation of cell elements, 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 lung pattern in a certain area, the presence of shadows in the picture, the presence of pleurisy. In addition, due to infiltration, an increase in the root occurs. 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 infiltrate can lead to lobar inflammation.

Therefore, it is very important to diagnose immediately.

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

Infiltrates no more than 2 mm. Lymph nodes in the mediastinum are very poorly visible. If only the shadows disappear, then the distortion of the radiograph remains for a while. Due to the high density of the damaged area, the structure of the root and the pattern of the lungs overlap. Most often, swelling of the lung tissue occurs. This leads to difficulties during diagnosis.

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

Features of the x-ray sim in this disease reflects the foci of enlightenment and darkening, based on the blockage of the bronchi. The disease occurs due to the ingestion of the contents of the stomach into the bronchi.

In places of violation of the passage, the occurrence of atelectasis is observed. Looking at the picture, they can be seen in a triangular shape. The dome of the diaphragm will rise, and the mediastinum will shift to the affected side.

With inflammation due to staphylococcus aureus, the picture shows a limited seal, which is one-sided. Somewhere after the second day, in extreme cases after the fifth, when the disease appears dry and airy bullae containing fluid and air. Bullae in the lungs are such formations that look like air bubbles in the tissue of the lungs. Sometimes, you can find another name for this phenomenon, for example, bleb or cyst. Although they are still bull options. The thickness in the lung tissue changes in this case, so it is often difficult to determine the exact number of infiltrates in the picture.

In the case of interstitial pneumonia in an adult, changes in the picture are noticeable. An expanded root after radiography is a basal 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 classified as another group, atypical. This is due to the fact that they have their own characteristics, in addition, they differ in diagnosis and treatment methods. With a disease due to the ingress of fungi, in most cases, people with HIV infection are observed, 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 causes include chest injuries, diseases of the internal organs, severe stress or deficiency of the immune state, smoking and alcohol abuse. In addition to them, diseases of this type can be caused by oncological diseases, swallowing disorders, or an age exceeding 60 years.

Features of X-ray diagnostics of various types of pneumonia

Symptoms of pneumonia are partially similar to manifestations 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! An 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 other pathologies with similar symptoms, but also to control treatment, identify possible complications in a timely manner, and establish the effectiveness of therapy. It is mandatory 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 structure of the lungs;
• to avoid 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 is used with shielding aprons.

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

Unambiguous signs of pneumonia on x-rays are darkening of some part of the lung field.

Focal shadows or a common, confluent decrease in transparency are detected. Fuzzy blurry contours are characteristic.

Allocate inflammation of the lungs:

• Focal (a small area of ​​\u200b\u200blung tissue is affected);
• Segmental (one or more segments are involved in the process);
• Equity (croupous, exciting share);
• Total (damage to the entire lung).

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

The results of the study in various types of pneumonia

Fundamentally different radiographs for pneumonia of different types: focal bronchopneumonia, croupous lobar and interstitial.

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

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

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 area of ​​damage.

Croupous inflammation goes through several stages.

If you do an x-ray at the very beginning (stage of hot flashes), then if you have 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 on the affected side.

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

Pathology during this period is as follows:

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

Croupous pneumonia always proceeds with a reaction of the pleura. With the formation of an effusion, a darkening is observed in the pleural fissure.

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

With adequate therapy of 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 typical:

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

Features of changes in childhood

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

The most characteristic signs of the disease in a child:

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

It is necessary to monitor the child's condition, to direct therapeutic measures for the complete restoration of not only the affected lung tissue, but also the accompanying local bronchitis, the signs of which remain on the X-ray for a long time.

Features of radiodiagnosis of atypical pneumonia

Atypical pneumonia is distinguished not only by the presence of atypical pathogens (Klebsiella, mycoplasma, chlamydia), but also by the characteristics of the manifestations. First of all, this is the predominance of signs of respiratory failure (feeling of lack of air) over the symptoms of inflammation (low temperature, slight cough).

X-ray picture depends on the pathogen. Main features:

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

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

Thus, the use of radiography in pneumonia helps to establish a diagnosis in a timely manner, to determine the form of the disease. This allows you to differentiate therapy, avoid the development of complications and prevent a threat not only to health, but also to the life of the patient.

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

X-ray of the lungs with pneumonia (pneumonia) is a diagnostic method that a modern medical clinic cannot do without. The lack of x-rays is acutely felt by the village outpatient clinics and feldsher-obstetric stations. Medical workers who work in them have to treat pneumonia "in the blind."

Inflammation of the lungs is provoked 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 dynamically monitored during treatment.

How effective is a chest x-ray for pneumonia?

X-ray of the lungs with pneumonia is as effective as x-ray diagnostics are prescribed in a timely manner. If an x-ray examination is used in the detection of wheezing in a person, but with normal laboratory tests, the statistical reliability of the method decreases. In this situation, the results of the x-ray do not reveal inflammation of the lungs. Wheezing causes bronchitis or a cold.

The possibilities of x-rays for pneumonia are extensive, but they make the study necessary when identifying clinical symptoms that, with a high degree of certainty, indicate pneumonia.

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, and an increase in the number of leukocytes is traced in laboratory tests.

If a person is found to have croupous or focal pneumonia, repeat x-rays are ordered to track changes in "bad" shadows with treatment.

A specific indication for an x-ray of the lungs is a serious suspicion of an inflammatory process in the lung tissue or another dangerous disease. To take a picture of a person, you need to take into account the harm and benefit from the examination. Only if the benefit of x-ray exposure outweighs the harm, you can do x-rays.

There are no contraindications to the study. 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 is doing 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 radiograph, it can not be detected, since in the initial stages the disease is characterized by the appearance of small infiltrates. However, a qualified radiologist may suggest an inflammatory process in the lung tissue even in the absence of infiltrates by indirect x-ray symptoms:

X-ray for pneumonia

Pneumonia, due to its prevalence and increase in the incidence rate, can be considered one of the most important problems of 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 undertaken by patients, causing resistance to antibiotics in pathogens of pneumonia.

Due to the fact that the diagnosis of pneumonia cannot be based on characteristic clinical signs, since all symptoms and complaints often indicate a whole range of pathological processes in the lungs, radiography 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-rays can become a determining factor in choosing treatment tactics.

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 blackout on the x-ray. Pathological processes occurring in the lung structures often do not allow a clear clinical picture of the course of the disease, 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 tissues to the negative impact of some external factor:

The morphological cause of the long course of the disease can be considered a violation of regenerative functions in the area of ​​inflammation, leading to the formation of foci of fibrosis and the release of intraalveolar exudate. In this case, there is a violation of the blood supply to the lung tissue, accompanied by the formation of blood clots, air microembolism and general intoxication of the body caused by the release of toxic substances by pathogenic microorganisms.

Radiological evaluation 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 lung pattern and roots of the lungs, a darkening or enlightenment that forms against the background of the lung field. The reasons for darkening, mainly, is 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 lung 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, indicating the presence of pneumonia, the following signs can be observed:

• complete loss of transparency of the lung tissue (total darkening of the lung field);
• blackout of one or more lobes of the lung (subtotal blackout);
• opacity within one segment of the lung (limited opacity).

However, all these evaluation criteria, with equal probability, may indicate a whole group of lung diseases (lung 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 you to track dynamic changes in the state of the lungs in accordance with the stages of the spread of the pathology and evaluate the body's response to ongoing therapy.

Stages of pneumonia in the picture

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

high tide

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. On the x-ray, you can see an increase in the intensity and clarity of the lung pattern, a slight darkening of the lung 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 supply, resembles a lattice (honeycomb 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 minor differences from stage 1, expressed in a decrease in the severity of the lung pattern with its simultaneous enlargement and increased darkening of the lung fields (ground glass effect). It is possible to determine the stage of the disease, at the initial stages of development, only by being able to compare images taken with an interval of 1-2 days.

Gray hepatization stage

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 radiography, a significant darkening of the fields is noted, against the background of which the bronchi not affected by the pathological process look like bands of enlightenment. Free fluid is well visualized when taking pictures with the patient in the “lying on the affected side” position. 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. X-ray signs of recovery can be considered a decrease in the intensity or area of ​​blackout, a change in the lung pattern at the site of the lesion (the disappearance of large elements and the formation of small ones).

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

Atypical forms of pneumonia

In addition to the generally recognized radiographic signs, pneumonia may 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 has developed against the background of immunodeficiency or malnutrition. The characteristic manifestations of KP 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 tissues, the formation of curdled masses (caseinification) and the formation of cavities (one large or several small). It is possible to determine the CP on an 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-rays are defined as round or semicircular formations in the lung wall 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 severe darkening of the upper parts of the lungs and cavernous focal lesions of the lower lobes.

Pneumocystis pneumonia

Pneumocystis pneumonia (PP) is a fungal disease transmitted in a manner similar to a respiratory infection. In the vast majority of cases, the disease is characterized by a latent course, not accompanied by any manifestations of the disease. However, in immunocompromised individuals, PP occurs in a severe form accompanied by severe respiratory failure. On the radiograph, PP looks like a bilateral symmetrically located lung lesion, expressed in the loss of transparency of the basal sections.

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

SARS

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

An X-ray image in mycoplasmal 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 lung pattern and darkening in the areas of parenchyma infiltration. Blackouts can occupy one lobe of the lung, or maybe its entire surface. In 20% of cases, blackouts can be focal in nature and be multiple or single. However, the intensity of the shading can be so slight that when X-rays are taken with older equipment, the image may not show abnormalities.

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

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

When diagnosing AP, regardless of what result the X-ray showed, it is advisable to resort to an examination using computed tomography. This technique allows you to get a photo and video image made in various modes and avoid the appearance of areas hidden from view.

As a rule, radiography in pneumonia is able to provide enough 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 disease and reduce the percentage of deaths.

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

X-ray of the lungs in 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 croupous pneumonia

X-rays in lobar pneumonia are characterized by the following syndromes:

1. Extensive (total) decrease in the transparency of the lung tissue.
2. Subtotal darkening - with the localization of inflammation within one or two lobes of the lungs.
3. 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 are also observed in: atelectasis, lung cancer, pleurisy, tuberculous pneumonitis, pulmonary infarction.

An 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.

X-ray photo for pneumonia: in the stage of gray hepatization (a), after resolution (b)

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

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

1. Enrichment and strengthening of the lung pattern.
2. Reduced or normal transparency of the lung fields.
3. Expansion of the root of the lung on the side of the lesion.

A change in the lung pattern occurs due to an increase in blood supply against the background of a decrease in the functional capacity of the lung tissue. A chest x-ray in this situation looks like a grid. True, such changes are observed only in the localization of the inflammatory focus.

With an increase in airiness, the lung fields on the radiograph become transparent. Morphological sections of the tissue at the stage of the tide indicate that the alveoli become red due to bleeding, but this sign cannot be fixed radiologically.

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

X-ray of the lungs in the stage of gray hepatization

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

1. Decreased transparency of lung fields in the area of ​​inflammatory lesions.
2. The appearance of intense shadows corresponding to the size of the damaged tissue.
3. Against the background of massive darkening, the strips of enlightenment show the visualization of the trachea and bronchi, which are not affected by inflammation.
4. Expansion of the root on the side of the pathology.
5. Compaction of pleural sheets in the area of ​​inflammation.
6. Effusion in the pleural fissure with the addition of pleurisy.

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

Photo: radiograph of left-sided hilar pneumonia. The arrows indicate the deformation of the lung pattern and the absence of the root structure (a). 2 months after pneumonia, fibrous cords formed against the background of inflammation - carnification (b)

Stage of resolution of pneumonia on x-ray

On the radiograph with pneumonia in the resolution stage, the following signs are observed:

1. Decreased shading intensity.
2. Reducing the size of the shadow.
3. Root extension.
4. Enrichment of the lung pattern (many small elements per unit area) at the site of the existing focus of inflammation.

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

What do the complications of pneumonia look like on the pictures?

Complications of pneumonia - abscesses, exudative and fibrinous pleurisy, periscissuritis also have their own radiological manifestations in the lung images.

What does an abscess look like on an x-ray?

Skiological picture of an abscess on a radiograph:

• enlightenment cavity;
• indistinct rounded contour with perifocal inflammatory foci;
• the level of darkening in the decay projection due to infiltration;
• disappearance of the horizontal level during abscess drainage.

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

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

Skiological symptoms of pleurisy in the pictures

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

• darkening of the lower pulmonary field due to infiltrative fluid;
• upper oblique boundary of Sokolov-Damuazo-Ellis;
• shift of the mediastinum to the opposite side.

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

• clarity of the contour of the interlobar fissure;
• 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 considers a classic example of X-ray diagnosis of pneumonia against the background of croupous inflammation. There are other forms of the disease (focal, segmental, lobar), in which the above X-ray syndromes are only partially expressed.

Version: Directory of Diseases MedElement

Viral pneumonia, not elsewhere classified (J12)

Pulmonology

general information

Short description

Viral pneumonia is a variant of pneumonia, which was previously called atypical. In the past, all pneumonias were called atypical if the bacterial pathogen could not be detected by bacteriology and if the pneumonia did not respond to antibiotic treatment.

Clinical manifestations various viral pneumonias practically do not differ from each other and from mixed viral-bacterial pneumonias, which makes only clinical diagnosis impossible. However, accurate and early diagnosis of the etiological agent is important, as in some cases it determines the need for specific antiviral therapy and the rejection of empirical antibiotic therapy.
The viral causative agent of pneumonia, even at the present time, cannot be detected in 50-80% of patients with characteristic symptoms.

Etiology and pathogenesis

Both DNA and RNA viruses cause viral pneumonias. Most common:
- Adenoviridae (adenoviruses);
- Coronaviridae (coronaviruses);
- Bunyaviridae (arboviruses), e.g. Hantavirus;
- Orthomyxoviridae (orthomyxoviruses), such as the influenza virus;
- Papovaviridae (polyomaviruses), eg JC virus, BK virus;
- Paramyxoviridae (paramyxoviruses) - parainfluenza virus (PIV), respiratory syncytial virus (RSV), human metapneumovirus (hMPV), measles virus;

Picornaviridae (picornaviruses) - enteroviruses, Coxsackie virus, ECHO virus, enterovirus 71, rhinoviruses;
- Reoviridae (rotavirus);
- Retroviridae (retroviruses) - human immunodeficiency virus, human lymphotropic virus type 1 (HTLV-1).

The reasons community-acquired viral pneumonia: influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, coronavirus, rhinoviruses and human metapneumovirus.

For immunocompromised patients etiological factors are also:
- herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2), also called human herpes virus type 1 (HHV-1) and human herpes virus type 2 (HHV-2);
- herpes viruses types 6, 7, 8;
- Varicella zoster virus (VZV);
- cytomegalovirus (CMV);
- Epstein-Barr virus (EBV).

The age of the patient and the state of his immune status suggest a likely causative agent of viral pneumonia (presented below in descending order of importance).

Viruses that commonly cause pneumonia in children include:

- influenza viruses A and B;
- parainfluenza virus;
- adenovirus;
- human metapneumovirus;
- coronavirus;
- measles virus (in unvaccinated children).

Viruses commonly causing pneumonia in immunocompetent adults:
- influenza viruses A and B;
- adenovirus;
- respiratory syncytial virus;
- parainfluenza virus;
- coronavirus;
- Varicella zoster virus.

Viruses that commonly cause pneumonia in immunosuppressed patients include:
- cytomegalovirus;
- herpes simplex virus;
- flu;
- respiratory syncytial virus;
- parainfluenza virus;
- adenovirus;
- Varicella zoster virus.

A complete understanding of the pathophysiology and pathogenesis of viral diseases does not currently exist. After infection, most respiratory viruses tend to replicate in the epithelium of the upper respiratory tract and may secondarily infect the lungs by spreading through secretions or blood. Severe pneumonia can lead to extensive consolidation (up to sublobar, bilateral) foci of pneumonia. Some patients have had bloody effusions and diffuse alveolar lesions.

Epidemiology

Viruses cause 13-50% of community-acquired pneumonias as the sole pathogen and 8-27% of cases in mixed bacterial-viral infections. The reported incidence of viral pneumonia has increased over the past decade, which seems to reflect improvements in diagnostic methods (mainly PCR) on the one hand, and on the other hand indicates a growing population of immunocompromised patients.

Influenza virus types A and B account for more than 50% of all community-acquired viral pneumonias in adults. Influenza virus is the most serious etiological factor for the development of pneumonia in elderly patients.

Studies have shown a different frequency of other viruses causing community-acquired pneumonia: RSV - 1-4%, adenoviruses - 1-4%, PIV - 2-3%, hMPV - 0-4%, coronavirus - 1-14% of diagnosed cases of pneumonia with typed pathogen.

RSV is the most common etiology of viral pneumonias in infants and children. In addition, RSV is an increasingly important pathogen in the elderly. It is the second most frequently cited cause of pneumonia in the elderly (causing 2-9% of hospital admissions and the majority of pneumonia deaths in the US in this population).
Parainfluenza infections are the second most common viral illness, after RSV infections, in infants.
Adenovirus accounts for 10% of the causes of pneumonia in children. Various serotypes of adenoviruses are essentially responsible for continuous epidemics of acute respiratory diseases in closed communities (recruits, students, kindergartens, orphanages, nursing homes).

Factors and risk groups

- infants and elderly patients;
- infants without breastfeeding;
- pregnant women (flu viruses, chickenpox, measles);
- immunocompromised patients (HIV infection, congenital immunity defects, organ recipients, patients receiving immunosuppressive therapy);
- patients with a burdened premorbid background (malformations and diseases of the pulmonary and cardiovascular systems);
- people in closed teams;
- socially disadvantaged groups of the population (malnutrition, non-observance of hygiene rules, etc.).

Clinical picture

Clinical Criteria for Diagnosis

Fever, chills, rhinitis, myalgia, headache, asthenia, non-productive cough, physical signs of pneumonia.

Symptoms, course

Clinical manifestations of viral pneumonia vary significantly depending on the pathogen, age of patients, the state of their immune system, premorbid background. Premorbid background - the state of the body that precedes and contributes to the development of the disease
and others.

Common symptoms of all viral pneumonias:
- fever;
- chills;
- rhinitis;
- myalgia Myalgia - muscle pain
;
- headache;
- asthenia Asthenia (syn. asthenic syndrome) - a condition manifested by increased fatigue and exhaustion with extreme instability of mood, weakening of self-control, impatience, restlessness, sleep disturbance, loss of the ability for prolonged mental and physical stress, intolerance to loud sounds, bright light, strong odors
;
- unproductive cough (in older people, the cough may not be pronounced).
Thus, the symptoms of viral pneumonia are the same as those of bacterial pneumonia, although chest pain is less common in viral pneumonia and does not correlate with the degree of lung involvement.

Diagnostics

Recommended chest x-ray in two projections in patients with suspected pneumonia for the following purposes:
- confirmation of the diagnosis;
- identification of complications (for example, pleurisy Pleurisy - inflammation of the pleura (the serous membrane that covers the lungs and lines the walls of the chest cavity)
);
- differential diagnosis with viral bronchitis and bronchiolitis (which prevents the unreasonable use of antibiotics).

There are no radiological signs to distinguish between pneumonia of various etiologies.

General radiological symptoms of viral pneumonia:

1. Radiographic signs of pneumonia in influenza are similar to those described for other respiratory viral infections. Peribronchial infiltrates are usually seen. Diffuse interstitial infiltrate Infiltrate - a tissue area characterized by an accumulation of cellular elements that are usually not characteristic of it, an increased volume and increased density.
seen in people with severe disease.
The so-called "bird flu" is characterized by "spotty" diffuse and / or interstitial infiltrates with a tendency to consolidate, as well as the possible development of acute respiratory distress syndrome, pleurisy, spontaneous pneumothorax Pneumothorax is the presence of air or gas in the pleural cavity.
.
Pneumonia in swine flu is characterized by patchy alveolar opacities in the basal regions.

2. RSV pneumonia is usually characterized by heterogeneous bilateral alveolar infiltrates and interstitial changes (similar to influenza).

3. Adenovirus pneumonia usually occurs with diffuse, bilateral and heterogeneous ground-glass infiltrates (on high-resolution computed tomography), detected more often in the lower lobes. It can also present with lobar consolidation, which is uncommon in viral pneumonias.

4. Parainfluenza pneumonia manifests itself poorly. Infiltrates in the lungs are interstitial or mixed alveolar-intestinal, depending on the stage of the process.

5. Metapneumovirus pneumonia is characterized by both unilateral and bilateral infiltrative process with an equal number of interstitial and interstitial-alveolar infiltrates.

6. Coronavirus pneumonia is characterized by foci of consolidation, especially pronounced on the periphery and in the subpleural regions of the lower zones.

7. Pneumonia in varicella infection. X-ray signs are not visible to the naked eye. Fluffy, reticular or nodular infiltrates are sometimes noted, which progresses rapidly. Pleural effusion may be seen An effusion is an accumulation of fluid (exudate or transudate) in the serous cavity.
and enlargement of peripheral lymph nodes. Radiographic changes are most noticeable during the peak of the lesions and disappear rapidly with clinical improvement. Consequences are visualized as small, diffusely scattered, punctate calcifications, which can be detected by radiography in individual patients.

8. Herpes simplex virus can cause patchy lesions that start as small nodules in the center of the lobe. As the disease progresses, the nodules coalesce to form extensive centrilobular infiltrates.

9. Cytomegalovirus pneumonia can proceed according to two scenarios:
- multifocal or miliary Miliary - millet-like, small (like millet) multiple painful foci
changes that are characterized by discrete spherical lesions (4 mm in diameter);
- diffuse interstitial pneumonitis with interstitial edema and varying degrees of fibrosis Fibrosis is the growth of fibrous connective tissue, which occurs, for example, as a result of inflammation.
.

10. Hantavirus pneumonia is characterized by interstitial edema with rapid development of central, "dense" alveolar infiltrates and (possibly) pleurisy. The central localization of infiltrates makes it possible to distinguish it from acute respiratory distress syndrome, in which the changes are shifted to the periphery of the lungs.

High resolution computed tomography recommended in doubtful cases and for differential diagnosis with other processes. A characteristic symptom is the "ground glass" symptom.

Pulse oximetry Pulse oximetry (oxygemometry, hemoximetry) is a non-invasive method for determining the degree of blood oxygen saturation. The method is based on a spectrophotometric method for assessing the amount of hemoglobin in the blood
is essential in infants and elderly patients as it provides the earliest, simplest and fastest non-invasive way to confirm and dynamically evaluate respiratory failure.

Laboratory diagnostics

The development of diagnostic methods has led to a significant improvement in the ability to detect viruses in the respiratory tract. However, detection of viral pathogens does not always mean active disease. For example, the detection of herpes viruses can only mean their carriage, without the development of an active disease. Similarly, respiratory syncytial virus and cytomegalovirus can be found among other known (including bacterial) pathogens in healthy carriers.

Virological tests in most cases are the basis of an etiologically accurate diagnosis. Rapid test kits (panels) for antigen detection can provide results within hours, making them useful in emergency rooms. The sensitivity and specificity of these kits range between 80% and 95%. The greatest role, in addition to ELISA tests (ELISA), is played by PCR PCR - polymerase chain reaction
and immunofluorescent reactions.

Broncho-Alveolar Lavage Samples Lavage - flushing a body cavity (such as the colon or stomach) with water or a medicinal solution
, and lung tissue samples obtained in other ways can be studied using cytological and histological methods.
Intranuclear inclusions are often present in cells infected with DNA viruses.
Cytoplasmic inclusions are usually present in cells infected with RNA viruses.
Cytomegalovirus infection is characterized by cells of the "eye of an owl", which are large cells with basophilic intranuclear inclusions surrounded by a zone of enlightenment.
Virus inclusion detection is diagnostic, although this method has low sensitivity. Thus, the absence of intracellular inclusions does not always rule out infection or active disease.

Cultural method.Viral pneumonia can be diagnosed by isolation and identification of the pathogen in culture. Identification of the virus is made taking into account the characteristic cytopathic changes and direct and reverse reactions of immunofluorescence. This method is not beneficial for RSV, hMPV and coronavirus infection for various reasons.

Differential Diagnosis

1. Bacterial pneumonia. Differential diagnosis of bacterial and viral pneumonia is carried out in the first place. It is of great difficulty, given the relatively low percentage of pathogen detection in community-acquired pneumonia and a significant number of mixed bacterial-viral pneumonias. The need for differential diagnosis is dictated by the need to use antibiotic therapy for bacterial pneumonia and its complete unreasonableness for viral ones.

2. Viral bronchitis and bronchiolitis(especially in infants and those with chronic obstructive pulmonary disease).

Complications

1. Viral pneumonia can cause disability from interstitial fibrosis. Some adenoviruses (serotypes 2, 3, 7, and 21) have been associated with other serious chronic illnesses (after acute respiratory illness), including irreversible atelectasis Atelectasis is a condition of the lung or part of it in which the alveoli contain little or no air and appear to be collapsed.
, bronchiectasis Bronchiectasis - expansion of limited areas of the bronchi due to inflammatory-dystrophic changes in their walls or anomalies in the development of the bronchial tree
, obliterating bronchiolitis and unilateral compaction of the lungs.
It is estimated that 14-60% of these children will suffer some form of lung injury later on. Children hospitalized with an RSV lower respiratory tract infection are at greater risk of developing asthma later in life.

2. Development of acute respiratory distress syndrome.

3. Myocarditis (are a rare complication for most viral pneumonias).

4. Hematogenous dissemination of infection in immunocompromised patients.

5. Complications associated with bacterial superinfection Superinfection - re-infection with a new infectious disease in the setting of an unfinished infectious disease caused by another microorganism, usually resistant to the drug that was used to treat the primary infection
.

Treatment abroad

Lecture for doctors "Radiation diagnosis of pneumonia". The lecture for doctors is conducted by the Scientific Clinical Center of Russian Railways.

Pneumonia (pneumonia) is a group of acute local infectious-inflammatory diseases of different etiology, pathogenesis and morphological characteristics, which are characterized by focal lesions of the respiratory sections (alveoli, bronchioles) of the lungs with intra-alveolar exudation, confirmed by physical and radiological examination, and are accompanied by varying degrees of febrile reaction 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 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 senile 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 (AP) 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 Therapists. It contains the following headings.

Etiology:

Bacterial (indicating the pathogen);

Viral (indicating the pathogen);

Ornithoses;

Rickettsial;

Mycoplasma;

Fungal (indicating the species);

mixed;

Allergic, infectious-allergic;

undetermined etiology.

Pathogenesis:

Primary;

Secondary.

Primary OP is an independent acute inflammatory process of predominantly infectious etiology. Under the secondary understand pneumonia that occurs as a complication of other diseases (diseases of the cardiovascular system with circulatory disorders in the small circle, chronic diseases of the kidneys, blood systems, metabolism, infectious diseases, etc.) or developing against the background of chronic diseases of the respiratory system (tumor, bronchiectasis and etc.), etc.

Clinical and morphological characteristics:

Parenchymal - croupous, focal;

Interstitial.

The division into focal and croupous AP is valid only for 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 can contribute to the overdiagnosis of interstitial pneumonia.

Localization and extent:

Unilateral;

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

Extremely heavy;

heavy;

Medium severity;

Light and abortive. Flow:

Acute;

Lingering.

It was proposed to consider such a course of AP as protracted, in which its complete resolution did not occur within 4 weeks, which is not true, 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 group of pneumonia pulmonary inflammations of another origin (immune, toxic, allergic, eosinophilic, etc.), for which it is advisable to use the term "pneumonitis" in order to avoid terminological confusion.

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

Due to 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.

Intrahospital acquired (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, finely bubbling rales. In Russia, the term "SARS" was used several years ago to refer to the severe acute respiratory syndrome (SARS) caused by the coronavirus and spreading under certain epidemic conditions. The causative agent of acute respiratory syndrome, labeled as SARS-CoV, belongs to the group Coronavirus. Animals (cats, dogs) serve as its source; the disease is transmitted from person to person.

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

Hospital-acquired (nosocomial) include those pneumonia that developed within 48-72 hours or more after the patient was admitted to the hospital for another disease. The main causes leading to the development of nosocomial pneumonia most often are surgeries, mechanical ventilation, various endoscopic procedures and previous treatment with broad-spectrum antibiotics.

Pneumonia that develops 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. The role of gastroesophageal reflux has increased in the occurrence of aspiration pneumonia.

Etiology

In 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 Chlamydia psittaci and Klebsiella (Friedlander's stick).

Nosocomial (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 immunocompromised patients, 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 detected in such patients during a blood test, then the pathogens 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 atypically occurring pneumonia - Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Legionella pneumophyla and Coxiella burnetti.

During the period of the 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 bacterial microflora remains the main etiological factor that determines the clinical picture, severity and outcome of the disease.

Pathogenesis

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

Hematogenously, the pathogen enters the lungs with pneumonia that develops as a complication of sepsis and infectious diseases, as well as with pneumonia of thrombotic etiology. Lymphogenic distribution

The development of infection with the development of the disease is noted only with injuries of the chest.

There is also an endogenous mechanism for the development of inflammation of the lung tissue, due to the activation of the microflora of the lungs. 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. After adhesion, the next stage in the development of inflammation 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 that take part in the local inflammatory reaction occurs. In the development of subsequent stages of inflammation, invasion and intracellular persistence of microorganisms, as well as the production of endo- and exotoxins by them, 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 (the elderly and children), smoking, chronic diseases of the lungs, heart, kidneys and gastrointestinal tract, immunodeficiency states, contact with birds, rodents

Rice. 1-1. The pathogenesis of pneumonia

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

In addition to infection, 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 body (suppression of phagocytosis, 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, contribute to the production of antibodies, which are fixed mainly on the cells of the mucous membrane of the respiratory tract. Here, the antigen-antibody reaction occurs, which leads to tissue damage and the development of an inflammatory process.

If there are common antigenic determinants of microorganisms and lung tissue or if 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, the protracted course of pneumonia is often due to associations of microorganisms (see Fig. 1-1).

Clinical painting

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

Syndrome of general intoxication: general weakness, fatigue, headaches and muscle pain, shortness of breath, palpitations, pallor and loss of appetite.

Syndrome of general inflammatory changes: feeling hot, chills, fever, changes in acute-phase blood parameters (leukocytosis with a shift of 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 (coughing, sputum, shortening of percussion sound), increased voice trembling and bronchophony, changes in the frequency and nature of breathing, the occurrence of wet rales 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;

Accession of an asthmatic component.

In severe pneumonia (viral or massive confluent 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 the 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 confluent total pneumonia - acute pulmonary heart, DIC and sepsis.

On 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 variant of the onset and course of the process.

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

Cough can be dry (in the initial period of lobar pneumonia, throughout the disease with interstitial pneumonia) or with sputum (mucous, mucopurulent, purulent, bloody).

"Rusty" sputum is characteristic of croupous pneumonia, and bloody viscous - for pneumonia caused by Klebsiella (Friedlander's wand). Purulent bloody sputum is one of the signs of pneumonia of streptococcal etiology. With the release of bloody sputum, viral pneumonia can occur. Persistent, sometimes paroxysmal cough with a small amount of mucopurulent sputum is noted with mycoplasmal pneumonia. In addition, they are characterized by a sensation of "soreness" in the throat.

Hemoptysis is one of the characteristic features of pneumonia in pulmonary mycoses. 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 a disease of streptococcal etiology. With the localization of pneumonia in the lower parts of the lungs and the involvement of the diaphragmatic pleura in the process, the pain can radiate into the abdominal cavity, resembling a picture of an acute abdomen. If the upper or lower reed segment of the left lung is involved in the process, 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 characteristic of ornithosis and mycoplasmal 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. Acute onset with chills is more typical for bacterial pneumonia, primarily for croupous (pneumococcal) pneumonia. The disease usually begins suddenly with a tremendous chill and increased

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 serious patient (except for patients with influenza), since the clinical picture is not yet accompanied by symptoms of pneumonia.

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

When studying the anamnesis, 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, hemoblastoses, receiving chemotherapy, immunosuppressants and (or) suffering from 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 occurring with atypical symptoms, the epidemiological history is important: contact with birds (domestic or decorative) - sources Chlamydia psittaci, rodents; travel (for example, Legionella can be found in water in hotel air conditioning systems). Pay attention to group outbreaks of febrile diseases in closely interacting groups.

The atypical course of pneumonia is characterized by fever, headache and the appearance of an 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 is periodically paroxysmal in nature and disrupts sleep.

Aspiration pneumonia is characterized by a gradual onset, an increase in body temperature, a cough with purulent sputum, the most common 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 prone position) of the right lung, a protracted course with the development late purulent complications in the form of lung abscess or pleural empyema.

If you suspect the development of pneumonia in a patient who is in the hospital for another disease, you should be aware of the risk factors for the development of nosocomial (nosocomial) pneumonia. These include the patient's stay in intensive care units or intensive care units, mechanical ventilation, tracheostomy, bronchoscopic studies, 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 often develop.

Aspiration pneumonia occurs in severe alcoholism, epilepsy, in patients who are 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 proportion of various pathogens in 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 first stage of diagnostic search it is possible to assume pneumonia, but it is impossible to make a final 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 a severe concomitant disease, 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, consisting of the following symptoms:

Lagging of the affected side of the chest during breathing;

Shortening of 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.);

Occurrence of pathological respiratory noises (wet voiced small bubbling rales and crepitus).

The nature of breathing can change in different ways. In the initial stage of croupous pneumonia, it can be weakened, with an extended exhalation; in the hepatization phase, along with an increase in the dullness of the percussion sound, bronchial breathing is heard; 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 constant symptoms of focal pneumonia are hard breathing and moist, ringing fine bubbling rales. In some cases (for example, with central hilar pneumonia), physical data are presented very poorly, and recognition of the disease is possible only after an X-ray examination.

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

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

connection to pneumonia of the allergic / asthmatic component) during auscultation, a lot of bass and treble dry rales, which are not characteristic of the inflammatory infiltration syndrome, come to the fore. Molds (urticaria, allergic rhinitis, eosinophilic infiltrate, Quincke's edema) have the most pronounced sensitizing effect.

Physical examination helps to detect other pulmonary complications of pneumonia: pleurisy (rubbing noise of the pleura or percussion dullness without breath sounds) and lung abscess (dullness and a sharp weakening of breathing in the first phase, dull tympanitis, amphoric breathing and moist medium 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 help establish the etiological diagnosis:

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

Local enlargement of lymph nodes (especially axillary and supraclavicular) suggests a lung tumor and perifocal pneumonia;

Fungal pneumonias are combined with lesions of the mucous membranes, skin and nails;

Hepatolienal syndrome and slight jaundice are characteristic of ornithosis and Kurikketsial pneumonia;

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

The most important is the detection of signs that confirm or reject the existence of pneumonia; clarifying the nature and specificity of the pathogen; indicating the severity of the inflammatory process; clarifying the state of the immunological reactivity of the organism; 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 radiography in two projections, carried out in dynamics, help (taking into account the clinical picture) to diagnose pneumonia.

Sometimes, by the nature of radiological changes, it is possible with a certain degree of probability to judge the pathogen that caused the disease. Staphylococcal pneumonias are distinguished by a clear segmentation of lung lesions with the involvement of several segments in the process (in 60% of cases - bilateral lesions). Their characteristic radiological sign is the formation of multiple cavities in the lungs of the pneumocele type on the 5-7th day from the onset of the disease, and later - necrotic cavities containing fluid.

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

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

X-ray examination can detect an effusion in the pleural cavity, sometimes not determined using physical methods. Often it is formed with streptococcal pneumonia, as well as with a disease caused by Pfeiffer's stick, localized in the lower lobe, and in two-thirds of patients involving more than one lobe.

Focal pneumonia is often distinguished 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 hilar pneumonia. In such cases, computed tomography (CT) is recommended to clarify the diagnosis. It is also carried out for the diagnosis of pneumonia occurring with severe clinical signs, but without clear radiological 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 exacerbation (the 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 serve as evidence of the breakdown of lung tissue (cancer, tuberculosis, abscess). With mycosis 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 bacterioscopy (microscopy of Gram-stained sputum smears), it is possible to determine gram-negative or gram-positive microorganisms living in the bronchi already on the first day of the patient's stay in the hospital (it is important to consider when choosing antibiotics).

Bacteriological examination of sputum (bronchial washings) 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-

tested using a 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, an increase in ESR, an 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 the ESR in these cases is not changed.

In severe pneumonia, repeated sputum cultures are performed, the results of which can help determine 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) in the complication of IE helps to detect pericardial effusion or bacterial colonies on the heart valves;

Indicators of the function of external respiration 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 an etiological diagnosis belongs to the correct assessment of the epidemiological situation in combination with the clinical picture of the disease and X-ray data. Assistance in this case 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 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 flow;

The presence of complications;

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

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

The treatment activities are listed below.

Therapeutic regimen and rational nutrition.

Medical treatment:

Etiotropic;

pathogenetic;

Symptomatic.

Physiotherapeutic effect.

Dispensary supervision.

Therapeutic regimen and rational nutrition

Patients with pneumonia are subject to hospitalization. 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 proper care at home. In other cases, you can organize a hospital at home. Be sure to observe bed rest during the entire period of fever and intoxication. At the same time, the patient needs plenty of fluids, rich in vitamins and proteins.

Medical treatment

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

opinion. The main method of treating pneumonia is antibiotic therapy, which is prescribed empirically until the results of bacteriological examination are obtained. Its results become known 2–3 days after sampling and in most cases do not have a significant impact 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, in the appointment of which three main conditions must be observed:

Starting treatment as early as possible, without waiting for the isolation and identification of the pathogen, focusing in the choice of dosing regimen on the features of the clinical picture and radiographic data;

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

Monitoring the effectiveness of treatment through clinical observation and, if possible, bacteriological examination.

Of all antibacterial agents, antibiotics are the most effective, which are chosen taking into account the characteristics of the possible pathogen and the patient's tolerance to the drug. With gram-positive microflora, the appointment of semi-synthetic penicillins and cephalosporins is preferable, with gram-negative - fluoroquinolones, aminoglycosides and imipenem (imipenem + cilastatin). Patients with a 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. Objective response includes assessment of fever, symptoms, laboratory findings, and radiographic changes. The average dynamics of these parameters is presented in Table. 1-4.

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

Table 1-4.

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

Treatment of Community Acquired Pneumonia

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

Group I - age less than 60 years, no comorbidities;

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

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

Conducting antibiotic therapy in patients of group I

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

Conducting antibiotic therapy in patients of group II

The drugs of choice are amoxicillin + clavulanic acid (0.625 g orally 3 times a day or 1.0 g 2 times a day), cefuroxime (0.5 g orally 2 times a day). Alternative drugs: levofloxacin (orally 0.5 g 1 time per day), moxifloxacin (orally 0.4 g 1 time per day) or ceftriaxone (intramuscularly 1.0-2.0 g 1 time per day).

Macrolides should be preferred for 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 their ingestion.

Antibacterial therapy in stationary conditions

Medical treatment in the 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 units 4-6 once a day), cefotaxime (intravenously or intramuscularly, 1.0-2.0 g 2-3 times a day), ceftriaxone (intravenously or intramuscularly, 1.0-2.0 g 1 time per day), cefuroxime (intravenously or intramuscularly at 0.75 g 3 times a day). Alternative drugs: levofloxacin (intravenously at a dose of 0.5 g 1 time per day) or moxifloxacin (intravenously at a dose of 0.4 g 1 time per 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 intravenously 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: combination of levofloxacin (0.5 g IV 1-2 times a day), or moxifloxacin (0.4 g IV 1 time per day), or ofloxacin (0.4 g IV 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 1 time per day).

Parenterally drugs are administered within 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 multiresistant gram-negative bacteria (including Pseudomonas aeruginosa), staphylococci, and anaerobes. Treatment of nosocomial pneumonia with antibacterial agents depends on the presence or absence of concomitant risk factors. The duration of the use of antibacterial drugs is determined individually. In the treatment of nosocomial (nosocomial) pneumonia, taking into account the most common pathogens (Pseudomonas aeruginosa, Staphylococcus aureus), III-IV generation cephalosporins resistant to the action of β-lactamase, fluoroquinolones and imipenem come first.

Antibacterial treatment of nosocomial pneumonia occurring in patients without concomitant 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 of 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 1 time per day), moxifloxacin (intravenously at a dose of 0.4 g 1 time per day), a combination of cefepime (intravenously at a dose of 1.0-2.0 g 2 times a day day) with amikacin (intravenously at a dose of 15-20 mg/kg 1 time per day) or gentamicin (intravenously at a dose of 3-5 mg/kg 1 time per day).

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

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

2 times a day), or meropenem (intravenously at a dose of 0.5 g 3-4 times a day) in combination with amikacin (intravenously at a dose of 15-20 mg/kg 1 time per day) or vancomycin (intravenously at a dose of 1.0 g 2 times a day). Alternative drugs: aztreonam (intravenously or intramuscularly at a dose of 0.5-2.0 g 2-3 times a day), or levofloxacin (intravenously at a dose of 0.5 g 1 time per day), or moxifloxacin (intravenously at a dose of 0, 4 g 1 time per day), or a combination of amikacin (intravenously at a dose of 15-20 mg/kg 1 time per 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 at 3-5 mg/kg of body weight 1 time per day).

Treatment of aspiration pneumonia

Aspiration pneumonias are 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 (intravenously, 1.2 g

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 (0.5 g IV 3-4 times a day) or meropenem (0.5 g IV 3-4 times a day). A good effect is provided by intravenous administration of clindamycin (0.3-0.9 g 3 times a day). The duration of antibiotic therapy for aspiration pneumonia is determined individually.

Treatment of pneumonia in immunodeficiency states

Treatment of pneumonia in combination with severe immunity defects should be carried out only in a hospital setting. In patients with immunodeficiency conditions, the choice of antibiotic therapy largely depends on the origin of the pathogen. The most common regimen is the appointment of aminoglycosides in combination with modern cephalosporins. In AIDS patients with the development of pneumonia caused by Pneumocystis carinii, The accepted treatment regimen is 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 doses). Duration of treatment - 21 days.

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

4 times a day), furazidin (intravenous drip, 300-500 ml of a 0.1% solution per day; 3-5 infusions per course). If antibiotics are ineffective,

success in using quinoxaline derivatives (hydroxymethylquinoxaline dioxide).

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

In case of 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 prolonged pneumonia, immunomodulatory agents are used (interferon preparations, azoximer bromide, thymus extract).

With staphylococcal pneumonia, passive immunization is carried out with staphylococcal toxoid.

To restore bronchial patency, bronchodilators and agents that thin bronchial secretions (ingestion of acetylcysteine, ambroxol, bromhexine, hot alkaline drink) are used. Bronchodilators are preferably administered by inhalation: adrenomimetic (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 magnolia vine, liquid extract of Eleutherococcus) are prescribed.

Patients who may have a disease of viral etiology are recommended to administer anti-influenza human immunoglobulin and antiviral drugs (riboverin, ganciclovir, etc.). On an outpatient basis, inhalations of phytoncides are used (garlic and / or onion juice, 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.); with difficult sputum discharge - expectorants (infusion of thermopsis grass, marshmallow root, etc.) and mucolytic drugs (marshmallow medicinal herb extract, ambroxol, acetylcysteine). In case of poor tolerance to high body temperature, antipyretics are indicated (metamisole sodium, acetylsalicylic acid). Patients with concomitant pathological changes in the cardiovascular system (especially the elderly), as well as in severe cases of the disease, are prescribed injections of camphor, procaine + sulfocamphoric acid.

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

Intravenous administration of glucocorticoids is recommended for patients with severe pneumonia, severe intoxication and infectious-toxic shock.

Physiotherapy impact

In the treatment of patients with pneumonia, distracting procedures (jars, mustard plasters, mustard wraps) are used, which, at a low body temperature, are carried out 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 (LFK).

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

dispensary observation

Recovery Criteria:

Good health and general condition of the patient;

Persistent normalization of body temperature;

Elimination of clinical, laboratory and radiological signs of pneumonia.

Forecast

Pneumonia is one of those diseases that, as a rule, end 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 start and usefulness of antibiotic therapy, the state of the body and other reasons.

All patients with a widespread inflammatory process, a prolonged course of pneumonia, impaired functions of external respiration and the immune system, as well as with complicated pneumonia, should be referred to a rehabilitation department for aftercare and restoration of morphological and functional parameters.

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

Prevention

Preventive measures are aimed at carrying out general sanitary and hygienic measures (working regime, the fight against dust, gas contamination, overheating and hypothermia, ventilation of premises, isolation of the sick, 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.

The prevention of pneumonia in patients suffering from chronic pulmonary diseases is especially important. For them, anti-influenza vaccination is considered mandatory, and, if possible, immunization with a vaccine to prevent pneumococcal infections.

Strict adherence to the regimen and other doctor's prescriptions for diseases that can be complicated by pneumonia (MI, stroke, condition after surgery, etc.) is necessary.

In 3% of cases, chronic inflammation is noted. Chronic pneumonia or chronic pneumonia(CP) - 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 manifesting repeated outbreaks of the inflammatory process in the affected part of the lung. The morphological substrate of CP is pneumosclerosis and (or) carnification of the lung tissue, as well as irreversible changes in the bronchial tree according to the type of local bronchitis, often with deformity and the development of bronchiectasis in the future. Due to the widespread and successful use of antibacterial drugs for the treatment of infectious processes in the lower respiratory tract, CP is currently rarely recorded.

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

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

Currently, the main criterion for the transition of prolonged 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 talk about the transition of prolonged pneumonia into a chronic form.

Etiology. CP is an inflammatory disease of infectious origin, so 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 a viral infection in the transition of an acute inflammatory process to a chronic one is especially great.

Pneumonia, in the occurrence of which the leading role belongs to viruses, leading to destructive processes, ends 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 stable and prone to slow regression.

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 area 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 into 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 impedes 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 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.), which suppress the overall 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 was noted. Antipulmonary antibodies have a pulmonocytotoxic property, which is 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. There remain areas of carnification, which later serve as a place of recurrence of the inflammatory process.

The process is not limited to the parenchyma of the lungs, but goes to the interstitial tissue, bronchi and blood vessels. In this regard, the inflammatory-sclerotic process (pneumosclerosis) is considered to be the morphological substrate of CP, 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 become deforming with the subsequent development of bronchiectasis.

The process never becomes diffuse, so the severity of functional disorders of the respiratory and circulatory systems in the pulmonary circulation is negligible. In this regard, the development of respiratory (pulmonary) insufficiency and cor pulmonale, even with extensive foci of chronic pancreatitis, is rarely recorded.

Rice. 1-2.

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

Inflammatory infiltration;

Local pneumosclerosis.

Broncho-obstructive syndrome and respiratory failure syndrome are optional signs that can occur at different stages 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 HP. In the bronchiectasis form, along with focal pneumosclerosis, there are also bronchiectasis (CP with bronchiectasis). Not all doctors recognize this form (N.R. Paleev, 1985).

N.V. Putov, in addition to the 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 complain, and radiologically there may be intense, fairly well-defined shadows that must be differentiated from signs of a peripheral tumor.

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

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

Pain in the chest on the affected side;

Shortness of breath on exertion;

Increase in body temperature;

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

Complaints are most vivid and numerous with severe exacerbation. The amount of sputum increases, it becomes purulent. After joining the broncho-obstructive syndrome, along with the productive, there is a hacking paroxysmal cough with difficult sputum production.

In CP without bronchiectasis, the occurrence of hemoptysis always indicates the activity of the process and, as a rule, is slightly expressed. Hemoptysis is usually noted in the bronchiectasis form of CP, as it is one of the generally recognized symptoms of bronchiectasis.

In the event of an exacerbation of the process, chest pain often occurs or intensifies on the side of the inflammatory process: a constant feeling of heaviness worries (most often at the angle of the shoulder blade). Drawing stabbing pain may be aggravated by breathing (involvement of the pleura in the process). Body temperature is often subfebrile, rarely febrile. Exacerbation is accompanied by severe sweating, severe weakness and loss of appetite.

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

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

There are no indications of pneumoconiosis, tuberculosis, sarcoidosis and other diseases accompanied by similar clinical signs in the anamnesis in patients with CP (their existence in the anamnesis 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 can 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 the lung tissue in the process);

Dullness or shortening of percussion sound;

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

If the pleura is involved in the process, then listen to the pleural friction rub. With broncho-obstructive syndrome, expiratory lengthening and dry wheezing are noted. The latter also occur when an asthmatic (allergic) component is added to CP, the development of which is one of the main and serious complications of the disease at present. The development of respiratory failure is accompanied by shortness of breath at rest, cyanosis and tachycardia. Outside of an exacerbation of CP, clinical signs are scarce: in a limited area, moist, unvoiced fine bubbling rales are heard.

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

Make a final diagnosis of CP based on radiological signs of local (segmental or lobar) pneumosclerosis, endoscopic signs of local bronchitis, exclusion of diseases that have 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. The infiltrative type is characterized by focal darkening against the background of variously expressed interstitial changes (pneumosclerosis) and adhesive pleurisy (interlobar, paramediastinal adhesions, infection of the costophrenic sinuses). The peribronchial type is distinguished by changes around the segmental bronchi in the form of concentric clutches or strands parallel to the bronchus in combination with signs of focal pneumosclerosis (heavy and deformed lung 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, radiological 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 Hamman-Rich syndrome. Results are decisive in differential diagnosis.

MSCT.

Bronchography is performed before surgery to clarify the nature and extent of bronchial damage.

Data from bronchoscopic examination 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 the uncomplicated form of CP, as a rule, restrictive violations are determined.

The detection of a large number of neutrophils in sputum microscopy indicates the activity of the inflammatory process: the detection of eosinophils is typical for the development of an allergic (asthmatic) component that complicates the course of CP; the determination of mycobacterium tuberculosis and elastic fibers forces us to 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. When sowing sputum, the sensitivity of microflora to antibiotics is also determined.

The role of clinical and biochemical blood tests in assessing the activity of the inflammatory process is insignificant. The obtained results do not adequately reflect the degree of inflammation. Changes in acute phase parameters (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. With the activity of the process of a lesser degree, all of these indicators may be normal. The 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.

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

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

The peculiarity of complaints and the degree of their severity:

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

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

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

The active inflammatory process proceeds continuously or with frequent exacerbations. This is explained by a more pronounced 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 the general and immunological reactivity.

Less effective conservative therapy.

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

Distinct severity of clinical symptoms: weight loss, change in the shape of the nails (take the form of watch glasses) and deformity of the fingers like drumsticks. The physical changes found during the examination of the respiratory organs are also more pronounced and constancy. 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.

Complications are detected: pulmonary bleeding, spontaneous pneumothorax, signs of cor pulmonale.

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

Plain radiographs show a gross focal deformity of the lung pattern and cystic lucencies. Perhaps a volume decrease in a lobe or segment of the lung with a shift in the mediastinum towards the lesion.

On CT, areas of carnification, thin-walled cavities, and a cylindrical expansion of the draining bronchus can be identified.

On bronchograms, pathological changes in regional bronchi are detected, the segmental localization of the process and the type of bronchiectasis (cylindrical, fusiform, saccular) are specified.

Complications of HP:

Broncho-obstructive syndrome;

respiratory failure;

Chronic cor pulmonale;

Formation of an allergic (asthmatic) component;

Pulmonary bleeding;

Spontaneous pneumothorax.

Diagnostics. When establishing the diagnosis of CP, consider:

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

Re-inflammation of the same area of ​​lung tissue within the same 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 non-specific 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, Hamman-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" should reflect:

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 the exacerbation indicates the degree of activity of the process;

Complications.

Treatment. In the acute phase, treatment includes:

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

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

Treatment of complications.

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

When conducting 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 washing 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 cases of relapse caused by staphylococcus, Pseudomonas aeruginosa and other pathogens, passive specific immunotherapy with hyperimmune plasma and y-globulin should be carried out.

During exacerbation of the disease and at the stage of recovery, the use of immunomodulatory drugs is recommended: thymus extract, azoximer bromide, glucosaminyl muramyl dipeptide. Ingestion and parenteral administration of vitamin preparations, complete, protein-rich and vitamin-rich nutrition 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 the treatment is the implementation of measures aimed at restoring or improving bronchial patency.

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

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

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

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

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

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

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

BRONCHIOECTATIC DISEASE AND BRONCHIOECTASIS

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 causes the appearance of a characteristic symptom complex. In essence, they cannot be considered primary, since they usually develop as a result of childhood infectious diseases of the bronchopulmonary system, mainly of viral etiology, but their formation most likely requires the existence of a congenital defect in the bronchial wall.

At the same time, with primary bronchiectasis, there are usually signs that make it possible to distinguish an independent nosological form - bronchiectasis. With it, there is no significant involvement of the lung tissue in the pathological process, and exacerbations of the disease proceed mainly according to the type of exacerbation of purulent bronchitis without infiltration of the lung parenchyma.

There are also secondary bronchiectasis that occurs as a complication or symptom of another disease, including chronic pneumonia and chronic deforming bronchitis. With secondary bronchiectasis, pronounced changes in the respiratory department are detected.

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

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

Inhalation damage (inhalation of toxins, irritating gases, vapors and smoke, 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 anomaly 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, relapsing polychondritis).

Other causes (allergic bronchopulmonary aspergillosis or mycosis, HIV infection, AIDS, yellow nail 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 but is a symptom of other underlying 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 the 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 the success of medical treatment. Along with this, the prevalence of secondary bronchiectasis has not decreased.

Etiology

The causes of bronchiectasis so far cannot be considered sufficiently clarified. Probably, the combination of the influence of the pathogen and the genetic inferiority of the bronchial tree plays a decisive role.

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 conditionally 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 matters;

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 the cause of exacerbations, but not the development of bronchiectasis.

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

Pathogenesis

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

The obstructive atelectasis that occurs when the bronchial patency is impaired leads to the development of bronchiectasis. Its occurrence may be facilitated by a decrease in surfactant activity (congenital or acquired, due to local inflammatory processes). In children, the causes of impaired patency of the large bronchi (and thus the formation of atelectasis) may be:

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

Prolonged obstruction of the bronchi by a dense mucous plug in acute respiratory infections.

Decreased (congenital or acquired) resistance of the bronchial walls to the action of bronchodilating forces (increased intrabronchial pressure when coughing, stretching of the bronchi with accumulated secretions, increased

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

The expansion of the bronchi and the delay in bronchial secretions 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 a violation of the cleansing function of the bronchi, degeneration of cartilage plates and smooth muscle tissue with their replacement by fibrous tissue, a decrease in resistance and ability to perform basic functions) and develop bronchiectasis.

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

The altered secret usually accumulates in the lower sections of the bronchial tree (flows freely from the upper sections under the influence of gravity). This explains the predominantly 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 (with an indication of 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 the stage of complications (III).

Clinical painting

The symptoms of bronchiectasis are extremely similar to those in the bronchiectasis form 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 first stage of diagnostic search determine attention to the occurrence of cough with sputum after childhood pneumonia, measles, whooping cough or severe influenza 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), auscultation of the lungs reveals persistent foci of moist, voiced, finely bubbling rales.

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 in 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 a direct cause of death of patients. The latter may also be pulmonary hemorrhage or chronic renal failure due to secondary renal amyloidosis.

When analyzing x-ray data for third stage of diagnostic search it must be taken into account 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 detect hemodynamic disorders in the pulmonary circulation in various forms of bronchiectasis.

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

Scanning the lungs helps to determine the pronounced violations of capillary blood flow in bronchiectasis.

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

Diagnostics

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

Clear indications of the occurrence of cough with sputum in childhood after suffering an acute respiratory illness;

Frequent outbreaks of pneumonia of the same localization;

Detection of persistent foci of moist rales during a physical examination during the period of remission of the disease;

X-ray signs of a 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 affected segments);

Process stage;

The phase of the course (exacerbation or remission);

Complications.

With 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 not possible);

In preparation for bronchography and radical surgery.

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

Impact on pyogenic microflora (through a bronchoscope, inhalation method of introducing antibacterial drugs);

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

For more information about drug treatment, see the Pneumonia section. It is necessary to sanitize the upper respiratory tract, carry out general strengthening measures and provide good nutrition.

Operative treatment is best done at a young age. Persons over the age of 45 with bronchiectasis are operated on less frequently, since by this period of life they already have complications that prevent the operation from being performed. Resection of the lobe of the lung or individual segments is carried out 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 under the condition of systematic treatment provides a long period of compensation and preservation of working capacity.

Prevention

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

View and buy books on Medvedev ultrasound: