Bronchiectasis disease clinic. Timely treatment of bronchiectasis of the lungs will save you from complications. Gymnastics for breathing

Bronchiectasis is a pathological process of bronchial expansion in its separate area, accompanied by a change in the structure of the organ and its main function. Most often, the disease is acquired in nature, developing against the background of already existing pathological changes. It is important to remember that bronchiectasis is a chronic condition that tends to progress. Therefore, patients with this diagnosis should be under constant medical supervision. What is this disease and how to reduce the risk of complications? Let's consider all these questions in detail.

Forms of the disease

Before talking about methods of treating bronchiectasis, it is necessary to establish its type. Usually, when making a diagnosis, the cause of the pathology, the duration and severity of the course of the disease are taken into account.

Traditionally, bronchiectasis is an acquired pathology that occurs as a complication of chronic inflammatory processes in the bronchi and lungs. But in medical practice, there are also congenital forms of the disease, due to the genetic structure of the bronchial wall.

Depending on the cause that provoked the development of bronchiectasis, the following forms of the disease are distinguished:

1. Atelectatic. It is characterized by uniform damage to the bronchi with simultaneous atelectasis (decline) and an increase in the volume of the lower lobes of the lungs. The inflammatory process is also localized in the lower lobe of the bronchial segment. The lung tissue in this form of the disease becomes porous, resembling a honeycomb in its structure.
2. Destructive. This form is also called saccular bronchiectasis, which develops as a result of the formation of a purulent focus of inflammation in the bronchi. With the progression of the disease, suppuration of large areas of the bronchi and adjacent tissues is noted, followed by their melting.
3. Postbronchitis. A form of the disease that develops as a result of dystrophy of the bronchial walls with a long course of chronic bronchitis. It is also possible to develop against the background of purulent acute bronchitis.
4. Poststenotic. The narrowing of the lumen of the bronchi leads to the accumulation of a large amount of mucous content, which provokes atony (decreased tone) of the walls. This leads to the development of this form of bronchiectasis.
5. Retention. This type of disease is caused by a decrease in the tone of the bronchial wall and its stretching due to the progression of the chronic form of deforming bronchitis. Somewhat less often, pathological changes in the walls are due to the accumulation of a large amount of thick mucus in cystic fibrosis.

Depending on the severity, the following forms of the disease are distinguished:

• mild - the patient feels well during the remission period, no more than two exacerbations during the year;
• moderate severity - a slight violation of respiratory functions and a decrease in working capacity, up to five exacerbations during the year;
• severe - rare and short periods of remission, serious respiratory failure, high risks of complications.

The main causes of the disease

The causes of bronchiectasis are very diverse. The first is an infection. Bacterial microflora, various viruses, mycobacteria (tuberculous and non-tuberculous), fungal infections can provoke the development of the disease.

A special role in the development of bronchiectasis is played by the existing congenital and chronic diseases of the internal organs, the state of immunodeficiency:

• congenital diseases of the immune system, characterized by a decrease in the production of antibodies and a violation of the functions of immune cells;
• secondary immunodeficiency acquired as a result of organ transplantation, after chemotherapy or HIV infection;
• congenital pathologies of the respiratory system;
• changes in the structure of the bronchi due to the growth of connective tissue, the ingress of a foreign body, an increase in lymph nodes or the growth of neoplasms;
• gastroesophageal reflux, aspiration of stomach contents into the respiratory tract;
• inhalation of toxic substances, including drugs, gases, chemicals;
• as a complication of inflammatory processes in the intestines, connective tissue diseases (rheumatoid arthritis or systemic lupus erythematosus) and various respiratory pathologies;
• allergic bronchopulmonary aspergillosis (an infectious disease of allergic etiology caused by fungal microflora).

Often, the identified cause of the pathology requires the appointment of specific treatment. Therefore, a thorough examination is the key to a successful recovery.

According to statistics, in 30-55% of cases, the cause of bronchiectasis is unknown.

Symptoms of the disease

In periods between exacerbations, bronchiectasis practically does not manifest itself. From this, the identification of pathology by any signs during periods of remission is impossible. The only thing that can bother the patient is a periodic cough with a meager separation of mucopurulent secretion. Quite often there is an absolutely asymptomatic course.

Against the background of such a clinical picture, relapse is felt extremely acutely. The main symptoms of bronchiectasis of the lungs during exacerbations:

1. Weakness in the body, headaches, loss of appetite, fever within 37.5 0 and other signs of general intoxication of the body.
2. Dyspnea. This symptom is due to the deformation of important organs of the respiratory system and, as a result, the loss of the ability to fully perform its function.
3. Wet cough with mucopurulent sputum. Attacks of a productive cough are recorded mainly in the morning after sleep or in the supine position on the side, opposite from the affected area of ​​the organ. Depending on the amount of pus present in the discharge, the color of sputum may vary from colorless and light yellow to dark yellow or dark green. Usually, during periods of exacerbation, sputum in bronchiectasis is separated in large quantities, and the daily volume can be up to 200 ml.
4. Hemoptysis. The slight presence of blood streaks in sputum clots indicates a rupture of small capillaries with a hysterical cough. If the amount of blood has increased sharply, this indicates pulmonary bleeding. The condition requires immediate hospitalization.
5. Intense pain behind the chest.

The long course of the disease eventually leads to the development of cardiopulmonary insufficiency, manifested by blue tip of the nose, lips and fingers.

Diagnosis of the disease

Diagnosis of the disease in adults and children, in addition to a general examination of the patient, without fail includes a general blood test and a biochemical study. In the process of collecting an anamnesis, the fact of previously transferred infections is established, after which there are periodic complaints about the separation of purulent sputum. Frequent diagnoses of pneumonia, localized in the same area, are also a reason to suspect bronchiectasis.

Conventional X-ray examination for suspected bronchiectasis is not informative enough. And to establish the cause of damage to the bronchial tree, it is recommended to use the method of multiaxial computed tomography.

The main diagnostic method for assessing the degree of the disease and the viscosity of the purulent secretion is bronchoscopic examination. Bronchoscopy for bronchiectasis allows not only to take a secret for further research, but also helps to sanitize the bronchi. This method is used not only to diagnose the disease, but also to monitor the success of the treatment.

The next obligatory item is the collection of material for bacteriological examination. Sputum culture makes it possible to establish the presence of pathogenic microflora in the bronchi. The constant localization of bacterial microorganisms in the lower parts of the broncho-pulmonary system leads to a chronic course of the inflammatory process, the constant production of purulent secretions and, as a result, deformation of the organ. Sputum analysis is carried out both at the stage of diagnosis and during treatment.

Additionally, an assessment of the function of external respiration can be carried out, which allows to determine the degree of narrowing of the lumen of the bronchi to prevent the occurrence of possible shortness of breath or bronchospasm.

Features of treatment

Treatment of bronchiectasis is a complex process aimed at reducing the frequency of relapses of the disease and alleviating the patient's condition.

Medical therapy

Traditionally, antibacterial drugs are used to suppress the activity of pathogenic microorganisms and stop the inflammatory process. In severe cases, antibiotics are given intravenously to the patient..

Antiseptics help in the rehabilitation of the focus of inflammation, and mucolytics thin the purulent secret, facilitating the process of its removal. The most effective treatment method is bronchoscopy, during which the remains of the mucous contents are first removed, and only then the drug is administered. For mucolytic agents, it is preferable to use inhalation routes of administration using a nebulizer.

During periods of remission, it is advisable to conduct immunomodulatory therapy. With an exacerbation of a disease characterized by the accumulation of a large amount of purulent sputum, the use of immunostimulating drugs is not effective.

Hygiene measures

Timely removal of purulent secretion from the bronchi greatly facilitates the patient's condition. Therefore, respiratory hygiene is an important step in successful treatment.

Hygiene measures can be carried out actively or passively. Active hygiene - sanitation of the focus of inflammation by bronchoscopy, followed by the introduction of drugs into the bronchial cavity. Passive hygiene is a set of procedures aimed at facilitating sputum discharge. Among them:

• vibration massage in the chest area;
• special breathing exercises;
• positional drainage (using correct body position).

Purulent sputum comes out most effectively when the patient lies on the side opposite to the bronchiectasis. If the process is localized in the lower part of the lung, the patient's torso should be tilted down. When localized in the upper sections, it is recommended to take a semi-elevated position.

Surgery

Surgical intervention in the treatment of bronchiectasis is carried out:

• according to vital indications (pulmonary bleeding, pneumothorax, gangrenous inflammation of the lung);
• with a specified secondary nature of the disease;
• with low effectiveness of ongoing drug therapy.

Patient selection is very strict. This is especially true for patients at an early age, in whom the formation of bronchiectasis is due to a genetic imperfection of the bronchial wall. Most likely, after surgery, bronchiectasis in children will progress again. And due to the smaller volume of the respiratory surface, it will be harder to leak than before the operation.

Patient Care

Patients with bronchiectasis require meticulous care. And most often people with medical education are involved in its provision. The nursing process for bronchiectasis is:

• hygiene procedures;
• compliance with the clinical recommendations of the attending physician;
• collecting information about the patient's condition, recording all vital signs (including body temperature, volume of collected sputum, etc.);
• change in the spittoon for sputum deodorizing solution;
• regular ventilation in the room or in the patient's room;
• assistance in conducting positional drainage.

If the patient began to spit up blood, in order to prevent the development of pulmonary hemorrhage, the nurse must immediately inform the attending physician about the deterioration. Before the arrival of the doctor, you must:

1. Help the patient to take the correct position - sublime.
2. Prohibit any physical activity.
3. Prepare hemostatic drugs.

Additionally, wiping the skin with a damp material may be required.

Possible risks and complications

Bronchiectatic lung disease is a progressive disease that, in the absence of full medical intervention, can lead to serious consequences. The main complications of bronchiectasis:

• pulmonary hemorrhage;
• lung abscess - a destructive process characterized by the formation of a limited cavity filled with purulent contents;
• gangrenous lesion of the lung - an extensive lesion of the lung without a clear localization of the purulent-inflammatory process;
• bronchial obstruction syndrome - difficulty breathing caused by a violation of air permeability;
• pneumothorax - spontaneous rupture of the affected areas of the lung and air entering the pleural cavity;
• sepsis - toxic damage to organs due to the penetration into the blood of waste products of bacterial microflora;
• amyloidosis - dysfunction of one of the organs caused by the deposition of protein compounds.

For children, this disease is dangerous for developmental delay, both mental and physical.

Forecasts

Bronchiectasis has a chronic progressive course. The disease is incurable. However, the rate of progression of the pathology, the extent of damage to the pulmonary system, the frequency of relapses and the severity of the course of the disease will largely depend on the patient himself. Significantly improve the patient's condition and slow down the process of lung damage will help early diagnosis, full treatment and regular examinations.

Patients with bronchiectasis should undergo preventive examinations at least twice a year.. It is advisable to conduct a complete diagnosis even with persistent remission. Computed tomography of the lungs and radiography are mandatory. The latter makes it possible to exclude the possibility of developing complications that threaten the patient's life.

Preventive actions

Prevention of exacerbations in bronchiectasis is an important component of treatment. To this end, it is recommended:

• timely treatment of all diseases of the broncho-pulmonary system, even if we are talking about a banal respiratory infection;
• take immunostimulating drugs during periods of remission;
• observe thorough hand hygiene, use protective equipment and limit the time spent in crowded places during epidemics;
• vaccinate against influenza and pneumococcal infection on time(usually from early October to mid-November).

Despite the fact that bronchiectasis is a pathology that causes irreversible changes in one of the most important human organs, you can live with it and even enjoy this life. The main thing is to diagnose the disease in a timely manner. Therefore, do not neglect the need to seek qualified help. Sometimes an hour of wasted time can save you full health.

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General information

Bronchiectasis (bronchus + Greek ectasis - expansion) is a persistent (irreversible) expansion of the bronchi with pronounced structural changes and functional inferiority of their walls.

Bronchiectasis is a disease that arose in childhood, the morphological substrate of which is bronchiectasis, followed by their infection and the development of a chronic purulent inflammatory process in them (purulent endobronchitis).

In addition to bronchiectasis as an independent nosological form, also called primary bronchiectasis, there are secondary bronchiectasis, which are a complication of other diseases of the bronchopulmonary system: chronic bronchitis (it is characterized by the development of bronchiolectasis), chronic pneumonia, lung abscess, tuberculosis, tumors, foreign bodies and cicatricial processes in the bronchi.

The cause of the development of secondary bronchiectasis can also be malformations of the lungs (cystic hypoplasia, tracheobronchomegaly, etc.), genetically determined diseases (cystic fibrosis, immobile cilia syndrome), as well as primary immunodeficiency states.

With bronchiectasis as an independent nosological form of the disease, which caused the development of bronchiectasis, (see below) "remained in the anamnesis", and the main, and often the only manifestation of the pathological process is purulent endobronchitis in the cavities of the dilated bronchi. With secondary bronchiectasis, signs of a purulent-inflammatory process in the cavities of the dilated bronchi are superimposed on the clinical picture of the underlying disease and, as a rule, do not have a dominant value.

In the International Classification of Diseases of the X revision, bronchiectasis as an independent disease is designated by the code J 47. This document also includes congenital bronchiectasis, which has the code Q 33.4, which is used only in children of the first two years of life.

social significance

Since the 60s of the last century, there has been a decrease in the incidence of bronchiectasis, which is explained by a decrease in the frequency of childhood infections, especially measles and whooping cough, and the success of the treatment of acute bronchopulmonary diseases, primarily pneumonia in children, which is mainly associated with the development of bronchiectasis.

Bronchiectasis contributes to the structure of mortality, as well as temporary and permanent disability, although these issues are not reflected in the literature. A lethal outcome can occur with an exacerbation of the disease, especially with severe perifocal pneumonia and impaired bronchial drainage with delayed sputum separation, which sharply increases the syndrome of purulent intoxication. An unfavorable outcome can also occur when complicated by a metastatic brain abscess, purulent meningitis, septicopyemia, pulmonary hemorrhage, as well as with the development of secondary systemic amyloidosis and secondary chronic obstructive pulmonary disease (COPD).

With an exacerbation of the disease, as well as with the development of complications, the patient is unable to work. With frequent exacerbations of bronchiectasis (more than 2-3 times a year), in the presence of a syndrome of severe purulent intoxication in the periods between exacerbations, the release of a large amount of purulent sputum, periodically occurring "temperature candles" (incomplete remissions), persistent disability is determined.

Persistent disability also occurs when complicated by pulmonary heart failure, secondary amyloidosis with kidney damage and the development of chronic renal failure, as well as after extensive resections of the lungs with the development of severe respiratory failure.

Etiology and pathogenesis

An additional (sometimes main) value in the development of atelectasis is the collapse of the lung tissue due to a violation in connection with pneumonia of the activity of the surfactant - a special lipoprotein complex that provides the necessary level of surface tension of the alveolar membrane.

In the area of ​​atelectasis, the drainage function of the bronchi is impaired, which leads to a delay in secretion, activation of infection and the development of purulent endobronchitis distal to the obturation level. The purulent process further spreads to all layers of the bronchial wall, causing degeneration of smooth muscles and cartilaginous elements and their replacement with scar tissue. As a result, the bronchi lose their normal elasticity and become functionally defective.

In conditions of functional inferiority of the bronchi, the following pathogenetic factors lead to their expansion:

1. Increased intrabronchial pressure when coughing and stretching of the bronchi with accumulated sputum.

2. Increased, due to a decrease in lung volume due to atelectasis, negative intrathoracic pressure, especially in the inspiratory phase. The difference in pressure in the bronchi, which are associated with atmospheric air, and intrathoracic pressure has an expanding effect on the bronchi.

It is believed that these factors can cause the formation of bronchiectasis only in childhood (up to 10-12 years), when the normal formation of the bronchi has not yet completed. The nature of the bronchopulmonary infection also matters: bronchiectasis often develops after pneumonia associated with measles, whooping cough, viral and bacterial infection, in which pronounced lesions of the bronchial tree are observed. Most authors also believe that a congenital inferiority of the bronchial wall (insufficient development of smooth muscles, elastic and cartilaginous tissues) is a contributing factor for the formation of bronchiectasis.

Some authors allow the formation of bronchiectasis in early childhood only due to congenital inferiority of the bronchial wall (desontogenetic bronchiectasis). Such bronchiectasis, according to these authors, develops without connection with past pneumonia, impaired bronchial patency, and purulent-destructive changes in the bronchial wall.

The resulting bronchial extensions are persistent and persist after the elimination of bronchial obstruction. Violation of sputum evacuation leads to the persistence of chronic inflammation in them, which periodically worsens under the influence of adverse factors.

The progression of the pathological process in bronchiectasis goes, first of all, along the path of development of secondary diffuse bronchitis, which is initially reversible and may disappear after removal of the lung section affected by bronchiectasis. If a radical operation is not performed or is performed late, then chronic diffuse bronchitis progresses. Some patients (approximately 20% of cases) develop chronic obstructive bronchitis and COPD with the development of respiratory failure, and then chronic cor pulmonale, followed by its decompensation.

The progression of the process can also lead to the formation of new bronchiectasis as a result of purulent sputum flowing into intact bronchi with the development of purulent bronchitis with persistent bronchial obstruction. So, with a primary lesion of the basal segments, as a result of this mechanism, a secondary lesion of the bronchi in the reed segments may develop.

The data presented here relate to the etiology and pathogenesis of bronchiectasis as such. In addition, in order to prescribe adequate antibiotic therapy, the doctor needs to know the etiology of this exacerbation, which is judged by the results of laboratory tests, mainly by bacteriological examination with an assessment of the antibiogram of the purulent contents of bronchiectasis. Exacerbations are more often caused by gram-negative flora (Klebsiella, Proteus, Pseudomonas, Haemophilus influenzae, etc.), somewhat less often - by staphylococcus, pneumococcus, streptococcus or mixed microflora.

Classification

1. Disease form:

A) mild (bronchitis);
b) "dry" (bleeding);
c) pronounced (classical).

2. Localization of the process by shares and segments.

3. Type of ectasias (according to bronchography): saccular, cylindrical, fusiform, mixed.

4. Phase of the process: exacerbation, remission.

5. Complications: pneumonia, hemoptysis, pulmonary hemorrhage, aspiration abscess in the unaffected area of ​​the lung, metastatic brain abscess, pleural empyema, meningitis, septicopyemia, secondary chronic diffuse bronchitis, secondary systemic amyloidosis.

Examples of the formulation of a clinical diagnosis

1. Bronchiectasis, severe (classic) form, saccular bronchiectasis in segments VII-VIII on the left, exacerbation phase. Secondary chronic purulent obstructive bronchitis, exacerbation phase. Respiratory failure (DN) I.

2. Bronchiectasis, "dry" form, predominantly cylindrical bronchiectasis in the X segment on the right, exacerbation phase. Complication: profuse pulmonary bleeding.

Clinic and diagnostics

In a significant number of patients, the disease is initially manifested by a cough with a small amount of sputum (bronchitis form of the disease), against this background there is a tendency to catch colds and periodic exacerbations of the disease, which often occur under the diagnosis acute respiratory viral infection (SARS), exacerbation of chronic bronchitis or chronic pneumonia.

With a pronounced (classic) form of the disease, the main complaint during the period of exacerbation is a cough with the separation of a significant amount (from 30-50 to 200-300 ml or more per day) of purulent sputum.

Clinical signs of abdominal syndrome are revealed:

1) sputum separation with a full mouth, mainly in the morning;

2) dependence of sputum separation on body position; this is due to the fact that the pathologically altered mucous membrane in the dilated bronchi loses its sensitivity and the cough reflex occurs only when sputum enters the unaffected bronchi;

3) sometimes an unpleasant odor from sputum, which indicates putrefactive decomposition of sputum when it stagnates in bronchiectasis.

When standing, the sputum is divided into two layers: the upper, which is an opalescent liquid with a large admixture of saliva, and the lower, consisting entirely of purulent sediment. It is the volume of this sediment that characterizes the intensity of purulent inflammation. Unlike a lung abscess, there are no elastic fibers in the sputum in bronchiectasis.

In some patients (approximately 30%), hemoptysis and pulmonary hemorrhage are observed. Hemoptysis refers to the secretion (coughing up) of blood with sputum. Pulmonary hemorrhage is coughing up clear blood from the respiratory tract or lungs. There are small (up to 100 ml), medium (up to 500 ml) and large, profuse (more than 500 ml) pulmonary bleeding.

Hemoptysis and pulmonary bleeding can be observed in any form of the disease (on average, in 25-30% of patients), and in the "dry" form of bronchiectasis, they are the only manifestation of the disease. Pulmonary bleeding usually occurs after heavy physical exertion or overheating. The immediate cause of bleeding and hemoptysis is the rupture of altered vessels in the wall of bronchiectasis.

With extensive lesions and with a complication of the disease with secondary diffuse obstructive bronchitis (COPD), shortness of breath is observed. Pain in the chest of a pleural nature can be with an exacerbation of the disease due to reactive dry pleurisy. As a rule, during an exacerbation of the disease, symptoms of intoxication are revealed: general weakness, malaise, sweating.

An increase in body temperature during exacerbation is more pronounced (up to 38.5-39 ° C) in the first years of the disease, which, apparently, is associated not only with suppuration in bronchiectasis, but also with pneumonia in the parenchyma preserved around them. In the future, the parenchyma around the bronchiectasis is destroyed and exacerbations of the disease are almost entirely due to a suppurative process in the cavities of the dilated bronchi; the temperature increase in these cases rarely exceeds 38 ° C.

In the remission phase of the disease, the cough and the amount of sputum discharge decrease, the manifestations of intoxication decrease, and body temperature normalizes. However, there is a clear connection between the general condition of the patient and the temperature reaction with the state of the drainage function of the bronchi; with a delay in the separation of sputum, intoxication increases, and the body temperature rises (temperature "candles").

An objective examination in approximately 30-40% of patients reveals changes in the terminal phalanges of the fingers in the form of "drumsticks" and nails in the form of "watch glasses". This symptom, associated with purulent intoxication, is more common with a long course of the disease.

Above the affected area of ​​the lung, usually in the posterior lower sections, a dullness of the percussion sound is determined or, in the presence of dry cavities, a tympanic percussion sound (there may be no changes during percussion); more characteristic is the listening in this area against the background of hard breathing of sonorous and rather persistent medium and large bubbling moist rales, which are compared with "machine-gun crackling". After expectoration of sputum, and especially after the elimination of the exacerbation of the disease, the number of moist rales decreases until it disappears completely.

The auscultatory picture changes dramatically when the bronchi are blocked with a viscous secret. In such cases, breathing and wheezing over the affected area are not heard and begin to be determined only after the discharge of sputum or therapeutic lavage of the bronchi.

With an exacerbation of bronchiectasis, leukocytosis, a neutrophilic shift to the left, deviations of acute phase blood parameters are often observed; natural increase erythrocyte sedimentation rate (ESR). With severe purulent intoxication, a number of patients develop hypo- or normochromic anemia (posthemorrhagic or myelotoxic).

On the roentgenogram of the chest organs, made in frontal and lateral projections, an area of ​​enhanced and deformed lung pattern is revealed, covering 1-2 segments or an entire lobe, less often more extensive in area, and the affected sections are reduced in size due to pneumofibrosis.

Against the background of fibrosis, a cellular pulmonary pattern is often found. Contrary to previous ideas, the cells do not correspond to the cavities of the dilated bronchi, but are areas of emphysema against the background of pneumosclerosis. Only in very rare cases, on the x-ray, it is possible to detect directly bronchiectasis in the form of thin-walled cavities, sometimes with a liquid level.

Structural changes in the affected area of ​​the lungs can be more reliably judged from the data of multiaxial X-ray superexposed and tomographic studies.

These changes are more often found in the lower lobe on the left and in the middle lobe on the right. On a direct roentgenogram, the left lower lobe, reduced in volume, is almost completely “hidden” behind a heart displaced to the left; its structure is clearly visible only on the left lateral radiograph.

Similarly, a direct radiograph cannot be used to judge changes in the lower lobe on the right, especially if it is reduced in volume (represented as a small triangular darkening adjacent to the mediastinum). The middle lobe is clearly visible on the right side image in the form of a clearly defined strip up to 2-3 cm wide, running obliquely from the root of the lung to the anterior costophrenic sinus.

X-ray and tomography of the lungs can reveal only indirect signs of bronchiectasis, which, in combination with clinical data, make it possible to express a reasonable suspicion of the presence of this disease.

Of decisive importance for the diagnosis of bronchiectasis is a contrast study of the bronchi - bronchography. Bronchography is carried out after the exacerbation of the disease has been removed, the maximum decrease in the amount of sputum discharge, since the presence of a large amount of secretion in the bronchi prevents them from being filled with a contrast agent and makes the results of the study uninformative.

Bronchography is performed in the morning on an empty stomach. In adults, the procedure is often performed under local anesthesia. The first stage: in the sitting position, anesthesia of the nose, nasopharynx (up to the glottis) is performed with a 0.5% dicaine solution. In this case, the patient must breathe correctly: inhale through the nose, exhale through the mouth.

When inhaling, a 0.5% solution of dicaine is first instilled into the nostril, which has better patency, and then poured with a full pipette, which is evenly distributed over the mucous membrane and reaches the glottis. After 5-7 minutes, when anesthesia sets in (this is determined by a feeling of awkwardness in the throat), the catheter is advanced through the corresponding nostril to the glottis, and then, with a deep breath, it is pushed through the glottis into the trachea. This is determined by the appearance of hoarseness. 3-5 ml of a mixture consisting of 1-2 ml of a 0.5% solution of dicaine and 2-3 ml of a 10% solution of novocaine is poured into the trachea. After that, the cough goes away.

In the future, if bronchiectasis is suspected, the so-called non-directional bronchography is performed, which allows you to assess the condition of the bronchial tree as a whole, to resolve the issue of the extent of the pathological process and the volume of the upcoming operation. For this purpose, the subsequent stages of the procedure are carried out on a lateroscope. The patient is placed on the side to be examined, the catheter is passed to the middle of the trachea and 3-4 ml of the same mixture is injected through it as before.

After anesthesia of the bronchi of the lung under study, an iodine-containing contrast agent, iodolipol (iodized vegetable oil) in combination with norsulfazole, is injected through the catheter. This drug is called sulfiodol. For its preparation, 10 g of powdered non-crystalline norsulfazole is added to 30 ml of iodolipol. The mixture is thoroughly triturated until a completely homogeneous mass and 10-20 ml of sulfoyodol is injected into the respiratory tract through the catheter with a syringe. After 3-4 days, the study is carried out on the other side.

With directed or selective bronchography, anesthesia is first performed, and then contrast is injected into the lobar or segmental (and even subsegmental) bronchus using a guided catheter. This technique allows you to more reliably identify bronchoconstriction (for example, tumor) or broncho-glandular fistula in the small bronchi.

Revealed bronchiectasis can be saccular, cylindrical, fusiform and mixed; bronchiectasis is characterized by the predominance of saccular bronchiectasis. At the same time, inside the affected section (lobes, segment, group of segments), all or almost all bronchi are affected, mainly of the 4-6th order, the ends of which end blindly due to obliteration of smaller bronchi distal to bronchiectasis.

Typical is the localization of bronchiectasis in the lower lobe on the left, reed segments and the middle and lower lobes on the right. The location of bronchiectasis in the upper lobes is not typical for bronchiectasis; such bronchiectasis is secondary and is usually associated with previous pulmonary tuberculosis.

For an objective judgment about the nature of bronchiectasis, it is proposed to compare the diameter of bronchiectasis in the widest place with the diameter of the unchanged bronchus preceding bronchiectasis. With cylindrical bronchiectasis, their diameter exceeds the diameter of the previous bronchus by 10-15%, with fusiform ones - by 15-30%, with saccular ones - by more than 30%. Large bronchiectasis, located in a heap within the affected segment (s), give a picture of a "bunch of grapes" on the bronchogram. Smaller bronchiectasis emanating from the bronchi of the 7th-9th order have the shape of a rosary or beads on a bronchogram.

Bronchography makes it possible not only to establish morphological changes in the bronchial tree, but also to evaluate the functional disorders of the bronchi by the time of their release from iodolipol: in patients with bronchiectasis, it is sharply slowed down.

Thus, bronchography is the main method for diagnosing bronchiectasis. It allows you to establish the localization, prevalence and type of bronchiectasis, detect deforming bronchitis, impaired bronchial patency, evaluate functional disorders of the bronchial tree, and in some cases identify a foreign body or tumor in the bronchi.

Currently, computed tomography has been proposed as an alternative to bronchography, which also reveals bronchiectasis. However, a negative result from this study is not sufficient to rule out bronchiectasis; in these cases, as well as with the planned radical operation, bronchography should be performed. In addition, according to the results of computed tomography, it is not possible to clearly distinguish between the type of bronchiectasis.

Diagnostic bronchoscopy is used to assess the prevalence and nature of inflammation of the bronchial mucosa, sampling the contents of the bronchi for bacteriological, cytological and mycological examination, biopsy of suspicious areas of the mucosa.

With bronchoscopy, bronchiectasis located in the bronchi of the 4th-6th order and in smaller bronchi are not directly visible, since with fibrobronchoscopy only the bronchi of the 1st-3rd order (main, lobar, segmental) are clearly visible. However, bronchoscopy can reveal indirect signs of bronchiectasis: the discharge of pus from the mouths of those segmental bronchi where there are festering bronchiectasis.

In uncomplicated bronchiectasis, the violation of the function of external respiration according to the restrictive (restrictive) type is moderately expressed; with complications of chronic diffuse bronchitis, ventilation disorders are determined by a mixed or obstructive type.

Bronchiectasis is characterized by a steadily progressive, undulating course. The most common variants of progression and complications of the disease are listed above.

Saperov V.N., Andreeva I.I., Musalimova G.G.

The content of the article

Etiology, pathogenesis of bronchiectasis

Classification of bronchiectasis

Clinic of bronchiectasis

Diagnosis of bronchiectasis

The group of suppurative processes in the lungs closely adjoins bronchiectasis - bronchial expansions resulting from a combined lesion of the bronchi and lung tissue. In some cases, this disease is the main, leading, causing changes throughout the body, so it should be called bronchiectasis.

In other cases, bronchial dilatation does not represent an independent disease, but is only a consequence of various pathological processes in the bronchi and lungs - and for them the old name of bronchiectasis or bronchiectasis can be retained, although in each case it is quite difficult to draw a line between bronchiectasis and bronchiectasis.

For the first time, bronchiectasis as an independent disease was described in 1819 by Laennec, and since that time the clinical study of this disease has begun.

Causes of bronchiectasis

The name "bronchiectasis" itself does not exhaust the essence of the pathological process, since in addition to changes in the bronchi, there are changes in the lung tissue, and often the pleura.

It is necessary to distinguish between acquired and congenital bronchiectasis. Acquired bronchiectasis is much more common than congenital and usually occurs after suffering focal pneumonia of various etiologies (influenza, measles, whooping cough, etc.), especially after repeated pneumonia for a few years. However, the presence of only residual effects after focal pneumonia is still not enough for the occurrence of expansion of the walls of the bronchi; a factor contributing to the stretching of the bronchial wall is also chronic bronchitis, in which coughing shocks for months or even years contribute to the development of bronchiectasis.

The main pathogenetic factor is a decrease in the elasticity of the bronchial wall itself and an increase in its compliance; this is facilitated by an increase in expiratory pressure - in particular, when coughing.

Chronic cicatrizing inflammatory processes in the lungs around the bronchi, as well as organizing pleurisy, are of importance and influence.

Of course, in the development of bronchiectasis, a number of functional factors in the form of bronchospasm are also important.

Consequently, in the occurrence of bronchiectasis, the leading role belongs to a combination of two factors - residual effects after suffering focal pneumonia and the presence of bronchitis and peribronchitis, which change the elasticity of the bronchial walls.

pathological anatomy

It is necessary to distinguish 2 main forms of bronchial extensions - cylindrical and saccular; with cylindrical bronchiectasis, there is a uniform expansion of the bronchus, the walls of which are mostly thickened and hypertrophied; the surrounding lung tissue is normal or fibrotic. Saccular bronchiectasis usually predominantly develops in altered lung tissue; they come in various sizes - up to a chicken egg; their walls are often sharply atrophied, the surrounding lung tissue is wrinkled, atrophied. The mucous membrane of the dilated bronchi is thickened, infiltrated, and later atrophic. Vessels of the submucosal tissue are often aneurysmically dilated and can serve as a source of bleeding.

In addition to the cylindrical and saccular forms of bronchiectasis, there are also mixed forms, called fusiform; their mucous membrane is often atrophied, rarely hypertrophied, sometimes ulcerations or polypous growths appear, which serve as a source of bleeding. Around bronchiectasis there are atelectatic or emphysematous areas of lung tissue; sometimes there are separate "bronchiectatic cavities" in the wrinkled lung tissue.

Symptoms of the disease

The initial stage of bronchiectasis is often almost asymptomatic, but then the main complaint of patients is a persistent cough, often attacks. Sputum is often mixed with blood, and in some cases there may be periodic hemoptysis with the release of pure blood.

With the so-called dry bronchiectasis, even in advanced cases, sputum is usually secreted little, but hemoptysis often occurs, which makes patients seek medical help. In addition to these complaints, patients with bronchiectasis complain of periodic fever, weakness, fatigue, and sometimes shortness of breath.

On examination, fingers in the form of drumsticks and nails in the form of watch glasses are usually found on the hands and even feet, which is more often observed in the stages of severe disease; in these cases, there may be mild deformities of the chest, which is associated with the presence of pulmonary fibrosis. There may be slight cyanosis of the face and extremities. Percussion, with the exception of moderate tympanitis, due to the presence of concomitant pulmonary emphysema, does not give characteristic changes; voice trembling is often not changed. From the side of the cardiovascular system, no special deviations from the norm are observed; during periods of exacerbations, the pulse usually quickens, shortness of breath increases, cyanosis increases.

Diagnostics

The diagnosis of bronchiectasis is difficult. In addition to clinical data, radiological examination and, in particular, bronchography should be widely used.

On the x-ray, in some cases, you can see the paths corresponding to the course of the bronchi, which, in the presence of an appropriate clinical picture, makes it possible to assume the presence of cylindrical bronchiectasis. Saccular bronchiectasis often give round or oval shadows, sometimes located side by side in the form of cells resembling a honeycomb.

The most accurate results are obtained by bronchography, which has become widespread over the past 40 years. For this purpose, a contrast agent is injected into the bronchial tree - in particular, iodolipol (iodine solution in poppy seed oil), iodipine, brominol, etc.; these substances are well tolerated by patients and give good contrast in the x-ray image. Cylindrical bronchiectasis on bronchography gives wider linear shadows than normal bronchi, and saccular bronchiectasis gives round or oval shadows filled with a contrast agent.

Bronchography is one of the most accurate methods for diagnosing bronchiectasis, a very valuable addition to clinical research methods and is certainly necessary in cases when it comes to the need for surgical intervention.

The study of sputum reveals its mucopurulent nature, often with an admixture of blood. With "dry" bronchiectasis, sputum is in a small amount, but with an admixture of blood; in most cases, there is a lot of sputum - sometimes up to 0.5 liters or more; often it is three-layer, with a smell.

In the blood - neutrophilic leukocytosis, especially during an exacerbation of the disease, often a shift of the leukocyte formula to the left; ROE is usually accelerated.

Fingers in the form of drumsticks were described by Hippocrates, and they are still called Hippocratic fingers in French literature. It should be emphasized that fingers in the form of drumsticks can also be observed in other chronic respiratory diseases, chronic cardiovascular insufficiency, with prolonged septic endocarditis, and sometimes even in healthy people, but their presence is most typical for bronchiectasis.

Complications of bronchiectasis

One of the frequent complications of bronchiectasis is emphysema; due to a violation of bronchial patency, stretching of the alveoli, obliteration of blood vessels, the death of the elastic elements of the lung tissue and the disappearance of the alveolar septa with the development of pneumosclerosis occur; there is a violation of gas exchange in the lungs, which leads to the appearance of cyanosis and increased shortness of breath. In the future, in connection with the death of the alveoli and the obliteration of the blood vessels of the small circle, pulmonary heart failure occurs with all the ensuing consequences.

Often, the pleura is involved in the inflammatory process, especially with peripheral bronchiectasis, and pleural adhesions develop, which cause pain and lead to a decrease in the amplitude of respiratory movements, which, in turn, contributes to sputum stagnation and makes it difficult to remove.

A formidable complication is the development of pleural empyema.

Such a severe complication as a brain abscess is described, which occurs, apparently, by an embolic route, which, however, is not recognized by everyone.

Of the other complications, occurring in about 5-7% of cases, is the development of amyloidosis of the internal organs - in particular, amyloid nephrosis; this complication often occurs imperceptibly for the patient; it must always be kept in mind and the patient's urine carefully monitored, since the first manifestation of amyloidosis is most often the appearance of protein in the urine.

Treatment of bronchiectasis

In the initial periods of the disease, when there are still no pronounced phenomena of intoxication of the body, general hygiene measures are shown: fresh, clean air for the patient, good nutrition with a sufficient amount of proteins and vitamins, and limiting the amount of fluid administered. To facilitate expectoration of sputum, patients are recommended to take a position in which the contents of the dilated bronchi can best be emptied - position on the side, on the stomach, on the back with a raised foot end of the bed, knee-elbow position, etc. The use of antibiotics and sulfonamides during exacerbations and various symptomatic remedies.

In further periods of bronchiectasis, due to the significant development of infection in the bronchi and severe symptoms of intoxication, all the means indicated in the treatment of abscesses and gangrene of the lungs should be used. The main measures should be aimed at fighting infection and restoring bronchial patency - improving the outflow of the contents of dilated bronchi; for this purpose, intratracheal administration of antibiotics and suction of pus from the bronchi with a bronchoscope are indicated.

If you suspect the development of amyloidosis, it is necessary to widely use hepatotropic drugs (campolone, antianemin) and vitamin B13.

With unilateral bronchiectasis and the general satisfactory condition of the patient, the question of surgical treatment is raised - the surgical removal of the affected lobes or the whole lung. The experience of recent years has shown a good and stable therapeutic effect after lobectomy and pneumonectomy, especially in young people.

Prevention

To prevent the development of bronchiectasis, it is necessary to carefully treat pneumonia until it is completely eliminated and combat chronic bronchitis using both medications and various physiotherapeutic measures; climatic treatment in areas with a warm, dry climate, the fight against occupational hazards (“dusty” professions), a complete ban on smoking, physiotherapy exercises, and general hardening of the body are shown. Prevention of infections in childhood is also the prevention of bronchiectasis.

Bronchiectasis is a chronic lung disease that occurs without connection with chronic diseases of the bronchi and lungs, characterized by the formation of areas of persistent pathological expansion in the bronchial wall - bronchiectasis. This pathology appears in childhood or adolescence and persists throughout the life of the patient, causing him significant discomfort.

There is such a thing as secondary bronchiectasis - this is a complication of many chronic diseases of the bronchopulmonary system, which usually develops in adulthood and is also characterized by the formation of areas of its expansion in the bronchial wall - bronchiectasis.

Clinical manifestations, principles of diagnosis and treatment (including physiotherapeutic methods) of these two conditions are similar, so our article will focus on bronchiectasis in general.

What are bronchiectasis

So, as mentioned above, bronchiectasis is a site of pathological (that is, one that is not normally present in a healthy person) expansion of the bronchial wall. It is based on cartilaginous tissue and bronchial glands, and the elastic and smooth muscle layers that take place in the structure of the wall of a healthy bronchus are absent.

Depending on the shape and location of bronchiectasis, there are such types of them:

• cystic, or saccular (determined in the upper sections of the bronchial tree - not lower than the bronchi of the 4th order);
• fusiform, or cylindrical (located in the most remote parts of the bronchi - at the level of 6-10 of their order);
• varicose veins (visually they are, as it were, the golden mean between the previous two types of bronchiectasis, resembling outwardly veins in varicose veins).

Causes and mechanism of the development of the disease

As you have already read above, bronchiectasis can develop primarily and be secondary (that is, act as a complication). Men suffer from them 3 times more often than women. Most newly diagnosed cases of bronchiectasis occur in younger (under 5 years) and mature/elderly (from 40 to 60 years) age.

So, the reasons for the development of bronchiectasis are:

• genetic predisposition (structural inferiority of the bronchial wall due to genetic factors);
• cystic fibrosis;
• syndrome of "fixed cilia";
• deficiency in the blood of ɣ-globulins;
• congenital immunodeficiencies;
• previous childhood infectious diseases (whooping cough, measles), tuberculosis, pneumonia;
• diseases leading to blockage (obstruction) of the bronchus: cancer, foreign body, enlarged lymph node, squeezing it;
• neuropathies (particularly Chagas disease).

Sometimes the cause of bronchiectasis can not be identified - in such cases, bronchiectasis is called idiopathic disease.

Under the influence of one or another (and sometimes a complex) triggering factors, the patency of the bronchi is disturbed and atelectasis develops (the alveoli collapse, to which the clogged bronchus should supply air). Below the place of obturation (blockage), a secret accumulates, which soon becomes infected - an inflammatory process occurs, sooner or later damaging the bronchus wall and leading to its expansion.

Signs of bronchiectasis

The main sign of the presence of bronchiectasis in the bronchial tree is a cough, especially in the morning, with copious sputum. Such a cough also appears when the patient is in a certain position - leaning forward or lying on a healthy side. These positions are called drainage, because they improve the patency of the affected bronchus.

Every fourth patient pays attention to the admixture of blood in the sputum - this symptom is called "hemoptysis".

Other symptoms of the disease that occur during an exacerbation:

• an increase in body temperature (appears, as a rule, during periods of severe coughing, and disappears after sputum discharge);
• general weakness;
• fatigue;
• irritability;
• poor appetite;
• headache.

In the severe stage of the disease, shortness of breath is added to the above complaints (it indicates the formation of a cor pulmonale).

Diagnostic principles

A knowledgeable doctor will be able to suspect bronchiectasis already at the stage of collecting complaints (they are quite specific), anamnesis of life and illness (here he will pay attention to frequent, severe respiratory diseases in early childhood, the appearance of typical symptoms of bronchiectasis at the age of 5 years).

During an objective examination of the patient, the doctor's attention will be attracted by the patient's hands, or rather his fingers - their tips will be expanded and thickened, look like drumsticks, and the nails look like watch glasses.

When listening to the lungs with a phonendoscope (auscultating them) during an exacerbation of the disease, foci of moist rales that do not go away after coughing will be detected. In remission, this symptom is usually absent.

The following diagnostic methods will help confirm or refute the diagnosis:

• a general blood test (indicative only during an exacerbation of the disease - it will determine the classic signs of the inflammatory process: an increase in the number of leukocytes and neutrophils, an increase in ESR);
• general sputum analysis (leukocytosis, neutrophilia, the presence of bacteria in the test material will be detected);
• determination of the level of sodium and chloride ions - if cystic fibrosis is suspected;
• examination by an immunologist - if immunodeficiencies are suspected;
• ECG (if a cor pulmonale has already formed, signs of right ventricular hypertrophy will be determined on the film);
• survey radiography of the chest (in some patients, in the lower parts of the lungs, a kind of cellularity can be detected, which, however, is not a direct sign, but only allows one to suspect bronchiectasis);
• bronchography (the main, most informative method for diagnosing bronchiectasis; it is performed only after the main symptoms of exacerbation have been eliminated; a contrast agent is injected into the bronchial tree and x-rays are taken; the pictures show bronchial dilatations and often a symptom of a "chopped lung" (lack of contrast in areas bronchi below the place of their expansion);
• bronchofibroscopy (this study is not carried out for every patient, it is not mandatory, but it is informative enough to determine the source of bleeding and identify areas of the bronchi with endobronchitis);
• CT scan.

Treatment tactics

The complex of therapeutic measures for bronchiectasis may include:

• smoking cessation and minimizing exposure to industrial and other types of air pollutants;
• washing the bronchial tree with antiseptic solutions (using dioxidine, furatsilin and similar drugs);
• direct injection of antibiotics or sputum thinners into the bronchi;
• systemic antibiotic therapy (prescribe broad-spectrum antibiotics or, if sputum culture was performed, those drugs to which the sensitivity of the seeded colonies of microorganisms was detected);
• sputum thinners or mucolytics (ambroxol, bromhexine, acetylcysteine);
• drugs that accelerate the excretion of sputum, or expectorants (herbal preparations based on ivy, plantain);
• physiotherapy procedures (more on that below);
• surgical intervention in the amount of resection (removal) of sections of the bronchi affected by bronchiectasis (at present, such operations are performed quite rarely due to the effectiveness of conservative treatment in most cases).

Physiotherapy

is an important component of treatment for bronchiectasis. Its tasks are:

• sanitation of the bronchi (that is, the elimination of infection from their lumen);
• restoration of normal outflow of sputum from the bronchi;
• minimization of symptoms of intoxication;
• increasing the body's resistance to the effects of harmful factors;
• activation of local immunity.

Unfortunately, physiotherapy is not allowed for every patient with bronchiectasis. Contraindications to its appointment are:

• pronounced exhaustion, weakness of the patient, especially with severe forms of bronchiectasis (with a large amount of purulent sputum and hemoptysis);
• spontaneous pneumothorax;
• PE - its chronic relapsing form;
• large single lung cysts;
• bronchogenic cancer;
• postoperative tracheobronchial fistulas;
• effusion pleurisy with large amounts of pleural fluid.

The methods of physiotherapy that improve the drainage function of the bronchi include:

• postural drainage (before starting the procedure, the doctor recommends that the patient take drugs that expand the bronchi and improve the discharge of sputum from them; half an hour after that, the session begins: the patient slowly takes 5 breaths through the nose and exhales through pursed lips, then just as slowly takes a deep breath and 4 Coughs shallowly 5 times; if at the same time light tapping is performed on the chest, sputum is separated much easier);
• vibrotherapy.

In order to thin viscous sputum, ultrasonic inhalations with ambroxol and other drugs similar to it in action are used.

To reduce the severity of the inflammatory process will help:

• UHF therapy;
• inhalation of glucocorticosteroids;
• calcium chloride.

To expand the lumen of the bronchi and restore the flow of air and outflow of sputum from them, appoint:

• inhalation of bronchodilators (salbutamol, ipratropium bromide);
• ventilation with continuous positive pressure (during both inhalation and exhalation, the bronchopulmonary system is affected by increased pressure, as a result of which normal gas exchange is restored below the obstruction site).

In some cases, a patient with bronchiectasis is indicated in local sanatoriums or in climatic resorts (depending on the condition). It is recommended to the patient only when the disease is in remission and after at least 3-4 months, and in some cases even six months after surgery on the lungs. Of the physiotherapy at the resorts, aerotherapy and speleotherapy have proven themselves well.

If the disease is severe - a large amount of purulent or purulent-bloody sputum is released, there are signs of severe heart or lung failure - the patient is not sent to the sanatorium, since treatment is unlikely to significantly improve his condition, but on the contrary, it can cause complications.

Prevention

In relation to this disease, methods of both primary and secondary prevention have been developed.

To prevent the development of the disease, it is necessary to diagnose and fully treat all diseases of the bronchopulmonary system, especially the lower respiratory tract (pneumonia, bronchiolitis, bronchitis) in a timely manner. Since bronchiectasis often occurs after a child has had measles and rubella, vaccination against these infections reduces the risk of their occurrence.

The essence of secondary prevention is to slow down the progression of the disease and prevent its frequent relapses. The main measures here are to prevent the development of an inflammatory process in the bronchial tree (its timely sanitation) and to maintain a full outflow of sputum and normal air exchange.

Conclusion

Bronchiectasis can develop both in childhood and in adulthood / old age, causing significant discomfort to the patient and threatening the development of complications. It is important for the patient to consult a doctor in a timely manner, at an early stage of the disease, to find out the correct diagnosis and start receiving complex treatment, which also includes physiotherapy methods. In most cases, with this approach, the exacerbation of the disease "vanishes", its progression slows down, and the patient's quality of life improves markedly. In order to prevent re-infection of bronchiectasis (development of relapse), the patient should periodically, on the recommendation of a doctor, take courses of appropriate (anti-relapse) treatment on an outpatient basis and in a sanatorium.
Take care of your health!

Maslennikova A.V., doctor of the 1st category, talks about the methods of treatment of bronchiectasis:

Maslennikova A.V., doctor of the 1st category, talks about the complications, prognosis and methods of preventing bronchiectasis: