Chronic bronchitis auscultation percussion. Acute simple bronchitis. Emphimatous type of disease

To understand what auscultation is and for what purpose it is carried out, you need to know - this is a special research method, which consists in listening to sound phenomena (tones, noises, rhythm) that occur in the body. Experts divide this study into two types: direct auscultation (when the doctor puts his ear to the patient's body) and indirect (using a special device - a stethoscope). Nowadays, direct auscultation is not used in modern medicine, since indirect auscultation is more preferable because of its informativeness and high sensitivity.

Auscultation when listening to the chest reveals respiratory noises mainly on inspiration, but the assessment of breathing on exhalation is no less important, so the doctor will certainly analyze both of these indicators.

The purpose of auscultation is to identify and describe murmurs, as well as bronchophony over the surface of the lungs.

Classification of breath sounds

What are breath sounds? This term in medicine is usually called sound phenomena that occur during the act of breathing.

Basic breath sounds:

• Vesicular (or alveolar) breathing is a low-frequency breath noise, determined by auscultation of healthy lungs. In its sound, it very distinctly resembles the sound "ffff". In adults with a thin chest, the noise of this breath is defined as louder when inhaling and more extended when exhaling.

• Bronchial breathing (it is also called laryngo-tracheal) - is characterized by a higher timbre that occurs due to air turbulence in the trachea and larynx. Reminiscent of the rough sound of "xxx", it is determined by inhalation and exhalation, while the exhalation is heard more strongly than the inhalation. Bronchial breathing differs from vesicular breathing in greater volume, a special timbre, and also in that this noise is longer in the exhalation phase than in inspiration. If bronchial breathing is heard in any other part of the chest, except for the lung zone, this should always be alarming and serve as a signal for a more thorough examination.
• Hard breathing. During auscultation, the doctor can listen to coarser (compared to vesicular breathing) inhalation and exhalation. Harsh breathing is characteristic of acute bronchiolitis and chronic bronchitis.

With pathological changes (bronchitis, pleurisy, tracheitis), which are associated with the functioning of the respiratory system, additional noises are added to the main noises - various wheezing, crepitus. High-quality, attentive listening allows you to set the timbre, depth, location and duration of the pathological noise that has arisen.

Additional noises:

• pleural friction noise usually characterizes dry pleurisy. It also occurs with metastases to the pleura, severe dehydration of the body;
• crepitus is a common breath noise that occurs when multiple alveoli are disconnected at the same time. The sound of crepitus is similar to crackling or rustling of cellophane or rubbing fingers against the hair near the ear;
• moist rales. They appear when the air flow passes through a special secret. At the same time, a low-viscosity liquid foams, tiny bubbles appear and burst on its surface.

Auscultation in acute bronchitis

If acute bronchitis is suspected, breathing can be uniform and uneven, sometimes hard, and exhalation is most often elongated. Wheezes - wet and dry, have a different caliber and timbre, depending on the involvement of smaller and larger bronchi in the inflammatory process. When the infection affects the small bronchi and bronchioles, wheezing may be absent altogether.

How is auscultation performed?

As you know, the purpose of this examination is to identify and describe noises in the respiratory system, bronchophony over the area of ​​​​the lungs. Auscultation of the lungs, determination of auscultation points is usually carried out in a sitting position, standing, and also lying down (if the patient is too weak). Auscultation is carried out in front, in the lateral section and behind. To get reliable results, the patient must breathe deeply.

After carefully listening to the lungs, the doctor can evaluate its results:

• the identity of the main noise at symmetrically located points;
• the main type of noise that is heard at all points of auscultation;
• the presence of side uncharacteristic noise and determining its location.

Types of wheezing in bronchitis

Wheezing is called abnormal breath sounds.. They are distinguished by the mechanism of occurrence and sound sensations. Divided into dry and wet.

Wet rales

Usually, moist rales appear when fluid (secretion or blood) accumulates in the bronchi, which foams with the flow of incoming air. Bubbles on its surface burst and are perceived by the ear as moist rales. If fluid has accumulated in the bronchi or bronchioles, then fine bubbling rales are determined when listening (with bronchopneumonia, bronchiolitis).

If the liquid secret or blood is in the walls of the bronchi of medium or large caliber, then medium bubbling or large bubbling rales are heard (with bronchitis, pulmonary edema, bronchiectasis, abscess).

Dry wheezing

They usually occur in case of bronchial obstruction (spasm or compression of the bronchus, accumulation of viscous sputum or mucus in it). Buzzing dry rales are always formed in large bronchi, and whistling - in bronchioles and bronchi of small caliber. With bronchitis, dry whistling rales can be determined over the entire surface of the lungs. Dry rales are characterized by great volatility, since they can either increase, or disappear, or decrease in a short period of time and in the same area.

Permanent dry rales over a certain area of ​​the lung field are of great diagnostic value, because they are a symptom of an inflammatory focus or neoplasm in the lung.

Bronchophony

This is the name of a special type of auscultation, during which the patient pronounces words containing the letters “p” and “h” in a whisper at the request of the doctor. If the words are easily defined, then we are talking about lung compaction or the presence of cavities. Such symptoms most often indicate the presence of bronchial asthma. In a healthy person, in this study, rustling or quiet sounds are heard, that is, there is no bronchophony.

Despite the great importance of auscultation in the diagnosis of bronchitis, modern medicine replaces it with improved, hardware diagnostic methods. The result of auscultation may have some inaccuracies. Therefore, a mandatory study, shown to all patients with complicated bronchitis, is radiography, which is carried out in two planes. Quite effective modern special research methods are: computed tomography, bronchography, angiography, pleurography, bronchoscopy (examination of the upper respiratory tract using a bronchoscope), thoracoscopy and others.

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Acute bronchitis

Most often, acute bronchitis develops as a result of a viral or bacterial infection against the background of cooling, less often against the background of irritating effects of physical and chemical factors.

Clinical manifestations

The clinical picture of acute bronchitis consists of symptoms of general intoxication and symptoms of bronchial damage.

In the first 2-3 days, body temperature rises, but often remains normal. Occurs:

• general weakness,
• chilling,
• muscle pain in the back and limbs,
• runny nose,
• hoarse voice,
• tickling in the throat.

Cough at first dry, rough, with scanty viscous sputum. On the 2nd-3rd day of the illness, there are sore sensations behind the sternum, which are aggravated by coughing.

As the process spreads along the bronchi, the symptoms of irritation of the upper respiratory tract weaken, and the process, as it were, moves in a downward direction, the cough comes from the depths, expectoration becomes easier, sputum is excreted in greater quantities, acquires a mucopurulent character.

The percussion sound above the lungs is not changed, auscultation reveals hard vesicular breathing and, depending on the nature of the sputum (liquid or viscous), inaudible wet or dry, usually diffuse rales are heard. With a viscous secret in the large and medium bronchi, the rales are low, buzzing, in the presence of a secret in the small bronchi or with swelling of the mucous membrane, the rales are high, whistling.

A number of features of the clinical symptomatology of acute bronchitis is determined by the state of the function of external respiration and impaired bronchial patency (obstructive and non-obstructive bronchitis).

At obstructive bronchitis small bronchi are affected. Bronchial obstruction is caused by:

• increased tone of the bronchial muscles,
• swelling of the mucous membrane and hyperproduction of mucus.

The specific significance of these factors in patients is different, but the leading role in the mechanisms of impaired bronchial patency is played by neuro-reflex factors, manifested by bronchospasm. Reflexes can come from irritation by the pathological process of the interoreceptors of the bronchi and upper respiratory tract. The swelling of the mucous membrane depends on the degree of its hyperemia and the severity of the inflammatory edema. The delay of the secret depends on its viscosity.

A patient with obstructive bronchitis may feel short of breath during normal physical activity, sometimes even at rest. It is noted:

• varying degrees of lengthening of the expiratory phase,
• with percussion of the chest, a sound with some tympanic shade,
• hard, vesicular breathing
• wheezing wheezing, more constant on exhalation.

Sometimes wheezing has to be detected by listening to the patient in a standing position, lying down, with forced exhalation. Patients in this group often have a paroxysmal cough, after which shortness of breath occurs for a while.

Restoration of bronchial patency in acute bronchitis is observed at different times.

From instrumental studies, violations of bronchial patency are reliably and with great completeness detected by the method of pneumotachometry and the study of forced vital capacity using spirography.

Acute bronchitis in the elderly when small bronchi are involved in the process, it is difficult. Due to impaired bronchial patency and senile emphysema, breathing becomes frequent and superficial, shortness of breath and diffuse cyanosis appear. On the part of the central nervous system, at first there is anxiety, agitation, which later turns into apathy and drowsiness. Heart sounds are muffled, pulse is quickened. Respiratory failure may be accompanied by cardiac failure.

The course of acute bronchitis, especially when small bronchi are affected, can be complicated by pneumonia both due to infection of atelectasis, and due to the transition of inflammation into the interstitial tissue of the lung. The general condition of the patient worsens, there is chills, fever, increased cough, purulent sputum, shortness of breath may appear. Complications of small-focal pneumonia are especially frequent in the elderly and the elderly. The percussion sound over the lungs becomes shortened or with a tympanic shade, breathing is hard vesicular, localized moist small bubbling rales are heard, bronchophony is often increased. Neutrophilic leukocytosis is noted in the blood, ESR is accelerated.

Diagnostics

The diagnosis of acute bronchitis does not cause difficulties and is established taking into account the etiological factor according to the leading signs, the most important of which are:

1. cough,
2. sputum department,
3. listening in the lungs of dry and (or) moist rales against the background of hard breathing.

X-ray diagnostics acute bronchitis is limited to the recognition of functional disorders associated with a violation of the ventilation capacity of the bronchi due to their spasm, swelling of the mucous membrane and retention of bronchial secretions.

On plain radiographs and electro-roentgenograms against the background of general swelling of the lungs, focal or lamellar atelectasis, and sometimes small areas of pneumonia, complicating acute bronchitis, can be seen. Respiratory mobility of the diaphragm is limited.

Forecast

The prognosis for acute bronchitis is usually favorable.

In most cases, especially in the catarrhal form, the disease ends in recovery with the restoration of the normal state of the walls and lumen of the bronchi. In some cases, especially with violations of bronchial patency, the acute process becomes chronic. In cases of purulent bronchitis, after recovery, a fibrous thickening of the bronchus wall may remain, often with a narrowing of its lumen.

With a pronounced and predominant lesion of the small bronchi (bronchiolitis), the outcome of acute bronchitis may be the overgrowth of the lumen of the bronchi with connective tissue - bronchitis obliterans. A similar outcome is often observed in acute chemotoxic bronchitis (after inhalation of acid fumes, phosgene, chlorine, diphosgene, etc.), as well as in bronchitis against the background of certain viral infections (measles, influenza).

Temporary disability depends on the degree of damage to the bronchial wall (with endobronchitis it is short, with panbronchitis it can reach several weeks) and on the extent of the lesion, which determines the degree of functional impairment (with catarrhal bronchitis without obstruction, the duration of temporary disability usually does not exceed 5-7 days, with obstructive - increases to 2-3 weeks).

Treatment

Treatment of acute bronchitis should be early, taking into account the etiology and pathogenesis of the disease. With viral and bacterial bronchitis, often developing with epidemic respiratory infections (influenza, parainfluenza, etc.), etiotropic therapy is carried out, as well as pathogenetic and symptomatic treatment of bronchitis itself.

A patient with acute bronchitis should observe bed rest, avoid cooling, but stay in a ventilated room with non-cold, fresh air.

For pain in the chest:

• mustard plasters on the sternum, interscapular region,
• circle jars,
• warm compresses,
• mustard foot baths.

With a dry painful cough at the beginning of the disease, antitussives are used - codeine, codterpin, dionin. Since the strengthening of sputum separation and with difficult expectoration, the appointment of antitussives is contraindicated; during this period, expectorants are prescribed, for example, an infusion of thermopsis (0.6 or 1.0 per 200.0), 1 tablespoon every 2-3 hours.

In cases of bronchial obstruction, bronchodilators are individually selected - ephedrine, atropine, belladonna preparations, antastman, theofedrine, eufillin in suppositories.

With purulent sputum, sulfonamides or antibiotics are indicated. It is rational to prescribe the latter in the form of aerosols 2-3 times a day. In cases of broncho-bronchiolitis, antibiotic therapy with sulfonamides or antibiotics is combined with the appointment (for adults) of 30-40 mg per day of prednisolone (or equivalent doses of triamcinolone, dexamethasone) for a period of 5-7 days, usually until the disappearance of high-pitched dry rales in the lungs. With such a duration of use, hormones can be canceled immediately, but in cases of a longer course of therapy, they are canceled gradually.

Cardiovascular remedies are indicated in the presence of affections of the heart, especially in the elderly. In these cases, oxygen therapy is also very effective.

In order to restore impaired blood circulation in the mucous membrane of the bronchi, trachea and nasopharynx in catarrhal bronchitis, if tuberculosis is excluded, quartz irradiation of the chest surface with one biodose of 400-600 cm 2 daily is prescribed.

Diathermy of the chest area or inductotherapy on the interscapular region is appropriate for deeper bronchitis.

Prevention

Prevention of acute bronchitis consists in hardening the body, observing the rules of hygiene at the workplace and at home, in carrying out anti-influenza vaccination.

Timely and persistent treatment of infections of the upper respiratory tract is important: rhinitis, tonsillitis, sinusitis, pharyngitis. A person with bronchitis should be isolated at home. It is recommended that people in contact with a sick person with bronchitis wear masks.

Obstructive bronchitis

Obstructive bronchitis- diffuse inflammation of the bronchi of small and medium caliber, proceeding with a sharp bronchial spasm and progressive impairment of pulmonary ventilation. Obstructive bronchitis is manifested by cough with sputum, expiratory dyspnea, wheezing, respiratory failure. Diagnosis of obstructive bronchitis is based on auscultatory, x-ray data, the results of a study of the function of external respiration. Therapy for obstructive bronchitis includes the appointment of antispasmodics, bronchodilators, mucolytics, antibiotics, inhaled corticosteroid drugs, breathing exercises, and massage.

Obstructive bronchitis

Bronchitis (simple acute, recurrent, chronic, obstructive) constitute a large group of inflammatory diseases of the bronchi, different in etiology, mechanisms of occurrence and clinical course. Obstructive bronchitis in pulmonology includes cases of acute and chronic inflammation of the bronchi, occurring with a syndrome of bronchial obstruction that occurs against the background of mucosal edema, mucus hypersecretion and bronchospasm. Acute obstructive bronchitis often develop in young children, chronic obstructive bronchitis - in adults.

Chronic obstructive bronchitis, along with other diseases that occur with progressive airway obstruction (emphysema, bronchial asthma), is commonly referred to as chronic obstructive pulmonary disease (COPD). In the UK and the US, COPD also includes cystic fibrosis, bronchiolitis obliterans, and bronchiectasis.

Causes of obstructive bronchitis

Acute obstructive bronchitis is etiologically associated with respiratory syncytial viruses, influenza viruses, type 3 parainfluenza virus, adenoviruses and rhinoviruses, and viral-bacterial associations. In the study of bronchial flushing in patients with recurrent obstructive bronchitis, DNA of persistent infectious agents - herpesvirus, mycoplasma, chlamydia - is often isolated. Acute obstructive bronchitis occurs predominantly in young children. The most susceptible to the development of acute obstructive bronchitis are children who often suffer from acute respiratory viral infections, who have a weakened immune system and an increased allergic background, and a genetic predisposition.

The main factors contributing to the development of chronic obstructive bronchitis are smoking (passive and active), occupational risks (contact with silicon, cadmium), air pollution (mainly sulfur dioxide), deficiency of antiproteases (alpha1-antitrypsin), etc. The risk for the development of chronic obstructive bronchitis includes miners, construction workers, metallurgical and agricultural industries, railway workers, office workers associated with printing on laser printers, etc. Men are more likely to develop chronic obstructive bronchitis.

The pathogenesis of obstructive bronchitis

The summation of genetic predisposition and environmental factors leads to the development of an inflammatory process, which involves the bronchi of small and medium caliber and peribronchial tissue. This causes a violation of the movement of the cilia of the ciliated epithelium, and then its metaplasia, the loss of ciliated cells and an increase in the number of goblet cells. Following the morphological transformation of the mucosa, a change in the composition of the bronchial secretion occurs with the development of mucostasis and blockade of the small bronchi, which leads to a violation of the ventilation-perfusion balance.

In the secret of the bronchi, the content of nonspecific factors of local immunity, which provide antiviral and antimicrobial protection, decreases: lactoferin, interferon and lysozyme. Thick and viscous bronchial secretion with reduced bactericidal properties is a good breeding ground for various pathogens (viruses, bacteria, fungi). In the pathogenesis of bronchial obstruction, an essential role belongs to the activation of cholinergic factors of the autonomic nervous system, which cause the development of bronchospastic reactions.

The complex of these mechanisms leads to swelling of the bronchial mucosa, hypersecretion of mucus and spasm of smooth muscles, i.e., the development of obstructive bronchitis. If the component of bronchial obstruction is irreversible, one should think about COPD - the addition of emphysema and peribronchial fibrosis.

Symptoms of acute obstructive bronchitis

As a rule, acute obstructive bronchitis develops in children of the first 3 years of life. The disease has an acute onset and proceeds with symptoms of infectious toxicosis and bronchial obstruction.

Infectious-toxic manifestations are characterized by subfebrile body temperature, headache, dyspeptic disorders, and weakness. Leading in the clinic of obstructive bronchitis are respiratory disorders. Children are worried about a dry or wet obsessive cough that does not bring relief and worsens at night, shortness of breath. Pays attention to the inflation of the wings of the nose on inspiration, participation in the act of breathing of the auxiliary muscles (muscles of the neck, shoulder girdle, abdominals), retraction of the compliant parts of the chest during breathing (intercostal spaces, jugular fossa, supra- and subclavian region). For obstructive bronchitis, an elongated whistling exhalation and dry (“musical”) rales, audible at a distance, are typical.

The duration of acute obstructive bronchitis is from 7-10 days to 2-3 weeks. In case of recurrence of episodes of acute obstructive bronchitis three or more times a year, they speak of recurrent obstructive bronchitis; if symptoms persist for two years, a diagnosis of chronic obstructive bronchitis is established.

Symptoms of chronic obstructive bronchitis

The basis of the clinical picture of chronic obstructive bronchitis is cough and shortness of breath. When coughing, a small amount of mucous sputum is usually separated; during periods of exacerbation, the amount of sputum increases, and its character becomes mucopurulent or purulent. The cough is persistent and accompanied by wheezing. Against the background of arterial hypertension, episodes of hemoptysis may occur.

Expiratory dyspnea in chronic obstructive bronchitis usually joins later, however, in some cases, the disease may debut immediately with dyspnea. The severity of shortness of breath varies widely: from sensations of lack of air during exercise to severe respiratory failure. The degree of shortness of breath depends on the severity of obstructive bronchitis, the presence of an exacerbation, and comorbidities.

Exacerbation of chronic obstructive bronchitis can be triggered by a respiratory infection, exogenous damaging factors, physical activity, spontaneous pneumothorax, arrhythmia, the use of certain medications, decompensation of diabetes mellitus, and other factors. At the same time, signs of respiratory failure increase, subfebrile condition, sweating, fatigue, myalgia appear.

The objective status in chronic obstructive bronchitis is characterized by an extended exhalation, the participation of additional muscles in breathing, remote wheezing, swelling of the neck veins, and changes in the shape of the nails (“watch glasses”). With an increase in hypoxia, cyanosis appears.

The severity of the course of chronic obstructive bronchitis, according to the guidelines of the Russian Society of Pulmonologists, is assessed by FEV1 (forced expiratory volume in 1 second).

• I stage chronic obstructive bronchitis is characterized by an FEV1 value exceeding 50% of the standard value. At this stage, the disease has little effect on the quality of life. Patients do not need constant dispensary control of a pulmonologist.
• II stage chronic obstructive bronchitis is diagnosed with a decrease in FEV1 to 35-49% of the standard value. In this case, the disease significantly affects the quality of life; Patients require regular follow-up with a pulmonologist.
• III stage chronic obstructive bronchitis corresponds to an FEV1 of less than 34% of the expected value. At the same time, there is a sharp decrease in tolerance to stress, inpatient and outpatient treatment is required in the conditions of pulmonology departments and offices.

Complications of chronic obstructive bronchitis are pulmonary emphysema, cor pulmonale, amyloidosis, respiratory failure. To make a diagnosis of chronic obstructive bronchitis, other causes of shortness of breath and cough must be excluded, primarily tuberculosis and lung cancer.

Diagnosis of obstructive bronchitis

The program of examination of persons with obstructive bronchitis includes physical, laboratory, radiological, functional, endoscopic studies. The nature of physical data depends on the form and stage of obstructive bronchitis. As the disease progresses, voice trembling weakens, a boxed percussion sound appears over the lungs, and the mobility of the lung edges decreases; auscultatory revealed hard breathing, wheezing with forced exhalation, with exacerbation - wet rales. The tone or number of wheezing changes after coughing.

X-ray of the lungs allows to exclude local and disseminated lung lesions, to detect concomitant diseases. Usually, after 2-3 years of obstructive bronchitis, an increase in the bronchial pattern, deformation of the roots of the lungs, and emphysema are detected. Therapeutic and diagnostic bronchoscopy for obstructive bronchitis allows you to examine the bronchial mucosa, collect sputum and bronchoalveolar lavage. Bronchography may be required to rule out bronchiectasis.

A necessary criterion for the diagnosis of obstructive bronchitis is the study of the function of external respiration. The data of spirometry (including with inhalation tests), peak flowmetry, pneumotachometry are of the greatest importance. Based on the data obtained, the presence, degree and reversibility of bronchial obstruction, pulmonary ventilation disorders, and the stage of chronic obstructive bronchitis are determined.

In the complex of laboratory diagnostics, general blood and urine tests, blood biochemical parameters (total protein and protein fractions, fibrinogen, sialic acids, bilirubin, aminotransferases, glucose, creatinine, etc.) are examined. In immunological tests, the subpopulation functional ability of T-lymphocytes, immunoglobulins, CEC is determined. Determination of CBS and blood gases allows you to objectively assess the degree of respiratory failure in obstructive bronchitis.

Microscopic and bacteriological examination of sputum and lavage fluid is carried out, and in order to exclude pulmonary tuberculosis, sputum analysis by PCR and AFB is performed. Exacerbation of chronic obstructive bronchitis should be differentiated from bronchiectasis, bronchial asthma, pneumonia, tuberculosis and lung cancer, pulmonary embolism.

Treatment of obstructive bronchitis

In acute obstructive bronchitis, rest, plenty of fluids, air humidification, alkaline and medicinal inhalations are prescribed. Etiotropic antiviral therapy is prescribed (interferon, ribavirin, etc.). With severe broncho-obstruction, spasmolytic (papaverine, drotaverine) and mucolytic (acetylcysteine, ambroxol) agents, bronchodilator inhalers (salbutamol, orciprenaline, fenoterol hydrobromide) are used. To facilitate the discharge of sputum, percussion massage of the chest, vibration massage, massage of the back muscles, and breathing exercises are performed. Antibacterial therapy is prescribed only when a secondary microbial infection is attached.

The goal of the treatment of chronic obstructive bronchitis is to slow down the progression of the disease, reduce the frequency and duration of exacerbations, and improve the quality of life. The basis of pharmacotherapy of chronic obstructive bronchitis is basic and symptomatic therapy. Smoking cessation is a must.

Basic therapy includes the use of bronchodilators: anticholinergics (ipratropium bromide), b2-agonists (fenoterol, salbutamol), xanthines (theophylline). In the absence of the effect of the treatment of chronic obstructive bronchitis, corticosteroid drugs are used. Mucolytic drugs (ambroxol, acetylcysteine, bromhexine) are used to improve bronchial patency. The drugs can be administered orally, in the form of aerosol inhalations, nebulizer therapy or parenterally.

When layering the bacterial component during periods of exacerbation of chronic obstructive bronchitis, macrolides, fluoroquinolones, tetracyclines, b-lactams, cephalosporins are prescribed in a course of 7-14 days. With hypercapnia and hypoxemia, oxygen therapy is an obligatory component of the treatment of obstructive bronchitis.

Forecast and prevention of obstructive bronchitis

Acute obstructive bronchitis responds well to treatment. In children with an allergic predisposition, obstructive bronchitis may recur, leading to the development of asthmatic bronchitis or bronchial asthma. The transition of obstructive bronchitis to a chronic form is prognostically less favorable.

Adequate therapy helps to delay the progression of obstructive syndrome and respiratory failure. Unfavorable factors that aggravate the prognosis are the elderly age of patients, comorbidities, frequent exacerbations, continued smoking, poor response to therapy, and cor pulmonale.

Measures for the primary prevention of obstructive bronchitis include maintaining a healthy lifestyle, increasing overall resistance to infections, improving working conditions and the environment. The principles of secondary prevention of obstructive bronchitis involve the prevention and adequate treatment of exacerbations to slow down the progression of the disease.

Bronchitis

Bronchitis is an inflammatory disease of the bronchi with a predominant lesion of their mucous membrane. Bronchitis is one of the most common diseases of the respiratory system and often occurs with simultaneous damage to the upper respiratory tract - the nose, nasopharynx, larynx and trachea. According to the localization of the process, tracheobronchitis (damage to the trachea and main bronchi), bronchitis (medium and small bronchi are involved in the process) and capillary bronchitis, or bronchiolitis (bronchioles are affected) are distinguished. According to the course of the disease, acute and chronic bronchitis are distinguished.

Acute bronchitis usually has an infectious etiology. Overwork, exhaustion, nervous and physical stress contribute to the development of the disease. Cooling and inhalation of cold air play an essential role; in some cases they play the main etiological role.

Acute bronchitis proceeds in isolation or is combined with nasopharyngitis, laryngitis and tracheitis. In some cases, acute bronchitis can result from exposure to physical and chemical irritants.

The pathological process in acute bronchitis is usually limited to the mucous membrane; in severe cases, it spreads to the deep layers of the bronchial wall. There are plethora of the mucous membrane, its swelling and swelling due to inflammatory infiltration. Exudate appears on its surface, first sparse serous, and then abundant serous, mucopurulent or purulent; the epithelium of the bronchi is exfoliated and, together with leukocytes, is excreted with sputum. In some diseases (flu) exudate may be hemorrhagic. In small bronchi and bronchioles, exudate can fill the entire lumen.

Acute bronchitis begins with a general malaise, runny nose, and sometimes unpleasant sensations in the throat. A cough appears, at first dry or with scanty sputum, then it intensifies, diffuse pains in the chest join, sometimes muscle pains. Body temperature is normal or elevated (not higher than 38 °). Percussion can not detect pathology. On auscultation, wheezing and buzzing rales scattered over the entire chest. X-ray (not always) you can catch the strengthening of the shadows of the root of the lungs.

In some cases, acute bronchitis is accompanied by a violation of bronchial patency, which can lead to impaired function of external respiration (respiratory failure).

In the study of blood - a moderately accelerated ROHE, a slight leukocytosis and a stab shift in the leukocyte formula.

A more severe course is observed with bronchiolitis, or capillary bronchitis, which can develop primarily or as a result of the spread of the inflammatory process from large and medium bronchi to small and smallest. It most often occurs in young children and the elderly. The fulfillment of the lumen of the bronchioles with an inflammatory secret causes a violation of the function of external respiration. The clinical picture of bronchiolitis is a cough with difficult to separate mucopurulent sputum, sometimes shortness of breath, the pulse is quickened, the body temperature is elevated. With percussion - over some sections of the box, and over others - a shortened percussion sound. Auscultatory-abundant dry and moist rales of various calibers. Bronchiolitis is often complicated by pneumonia (see) and lung atelectasis. Often pulmonary and sometimes heart failure develops. The duration of acute bronchitis is 1-2 weeks, and bronchiolitis is up to 5-6 weeks.

The prognosis for acute bronchitis is favorable; with bronchiolitis, especially in children and the elderly, more severe; the most serious - with the addition of pneumonia.

The treatment is complex: etiological, symptomatic and aimed at increasing the body's resistance. Bed rest is shown, a full-fledged diet containing a sufficient amount of vitamins, plentiful hot drinks (up to 1.5 liters of liquid per day in the form of tea with raspberry jam or hot milk with sodium bicarbonate), inhalations with a 2% solution of sodium bicarbonate, mustard plasters, circular jars, codeine, dionine, expectorants (for example, dry thermopsis extract, 0.05 g 2 times a day), sulfa drugs (sulfadimezin or etazol, 0.5 g 4 times a day for 3-4 days) and, if indicated, antibiotics ( penicillin every 4-6 hours for 150,000-250,000 IU). With bronchiolitis - antibiotics, as well as cardiovascular agents.

Prevention of acute bronchitis: hardening and strengthening of the body in order to make it less susceptible to harmful external influences (cooling, infections, etc.), elimination of external irritating factors (dust, toxic substances, etc.), in the presence of diseases of the nasopharynx - their thorough treatment.

Chronical bronchitis may occur as a consequence of acute (with insufficiently active treatment) or develop independently; often accompanies diseases of the cardiovascular system, kidneys, etc. The main etiological factors of chronic bronchitis: an infection that enters the bronchi from the upper respiratory tract for a long time; irritation of the bronchial mucosa by various physical and chemical agents (dust, smoke, smoking, etc.). A significant role is played by a change in the body's resistance under the influence of previous diseases, cooling, etc.

Changes are observed not only in the mucous membrane, but also in the deep layers of the bronchus wall and often even in the surrounding connective tissue. In the initial stages, there is plethora and thickening of the mucous membrane with inflammatory infiltration and the release of abundant serous-purulent exudate; in the future, it is possible to detect in the mucous membrane separate areas of excess tissue growths or, conversely, its thinning. With the progression of the process, there is an excessive growth of the submucosal layer and the muscular membrane, followed by the death of muscle fibers, the development of connective tissue in their place, as a result of which bronchiectasis can form (see Bronchiectasis).

The main symptom of chronic bronchitis is a dry cough or with mucopurulent sputum (more often). With the defeat of the large bronchi, the cough is dry, often comes on with attacks. Another form of chronic bronchitis, characterized by a relatively small cough, but with the separation of a large amount of mucopurulent sputum (100-200 ml per day), is more often observed with damage to the medium and small bronchi. With percussion of the lungs, a tympanic sound is often found, especially in the lower back sections of the lungs. Auscultation determines hard breathing and whistling and buzzing wheezing; sometimes in the lower back sections there are inaudible moist rales. With fluoroscopy - enhanced pulmonary pattern, more clearly expressed at the root. With the progression of the process as a result of inflammatory infiltration, as well as reflex influences, the lumen of the bronchus narrows, bronchial patency is disturbed, which causes a violation of the function of external respiration. As a result, cyanosis of the lips, asthma attacks (sometimes of a protracted nature), shortness of breath during movements, i.e., symptoms indicating pulmonary and heart failure, may join the described symptoms. The course of chronic bronchitis is long, periods of remission alternate with periods of exacerbations. The latter are characterized by a deterioration in general well-being, an increase in cough, an increase in the amount of sputum discharge, an increase in body temperature up to 38 °, a greater severity of symptoms detected by physical and instrumental methods of research. The long course of chronic bronchitis leads to the development of emphysema (see), bronchiectasis and pneumosclerosis (see). Persistently recurrent bronchitis that occurs with asthma symptoms (suffocation attacks, excessive wheezing, their sudden appearance and disappearance, the presence of eosinophils in the sputum) is called asthmatic. Asthmatic bronchitis is usually relieved by ephedrine.

The prognosis for chronic bronchitis is favorable, but a complete cure usually does not occur.

Treatment during an exacerbation is the same as for acute bronchitis. In cases of accession of pulmonary and heart failure - oxygen therapy, treatment with cardiac drugs, etc. During the period of remission, therapeutic exercises, spa treatment are indicated (climatic - seaside, mountain and forest resorts).

Prevention, in addition to the measures mentioned in the description of acute bronchitis, comes down to the careful treatment of acute bronchitis.

Bronchitis (bronchitis; from the Greek. bronchos - breathing tube) - an inflammatory process in the bronchi with a primary lesion of the mucous membranes. Bronchitis is often combined with damage to the upper respiratory tract, and with a long course - with damage to the lung. Bronchitis is one of the most common diseases of the respiratory system.

Etiology. In the etiology of bronchitis, bacterial (pneumococcus, streptococcus, staphylococcus, etc.) and viral (influenza, etc.) infections, toxic (chemical) effects and intoxication with toxic substances (chlorine, organophosphorus and other compounds), some pathological processes (uremia ), as well as smoking, especially at a young age, work in dusty areas. As a rule, a secondary infection joins the action of these harmful factors. An essential role in the etiology of bronchitis belongs to disorders of blood and lymph circulation in the respiratory system, as well as disorders of nervous regulation. The so-called predisposing factors include cooling, slight vulnerability of the pharyngeal lymphatic ring due to chronic rhinitis, pharyngitis, tonsillitis, overwork, trauma, etc.

A variety of etiological factors and clinical manifestations makes it difficult to classify bronchitis. So, there is their division into primary and secondary (when bronchitis develops against the background of other diseases - measles, influenza, etc.); superficial (the mucous membrane is affected) and deep (all layers of the bronchial wall are involved in the process up to the peribronchial tissue); diffuse and segmental (according to the prevalence of the process); mucous, mucopurulent, purulent, putrefactive, fibrous, hemorrhagic (according to the nature of the inflammatory process); acute and chronic (according to the nature of the course). According to the state of the function of external respiration, bronchitis is distinguished with and without impaired bronchial patency and ventilation. According to the localization of the process, tracheobronchitis is distinguished (the trachea and trunks of the main bronchi are affected), bronchitis (medium and small bronchi are involved in the process), bronchiolitis (the process is extended to the smallest bronchi and bronchioles).

What is auscultation for bronchitis and what data does it provide

The need for auscultation in bronchitis is one of the weighty reasons that makes the patient go to the doctor. If you can bring down the temperature or take expectorant drugs without the help of a doctor, then listening to the state of the respiratory tract is beyond the power of an unqualified specialist. An experienced doctor, by the nature of wheezing and the place of their localization, will make an accurate diagnosis and prescribe the correct treatment, so the appearance of a cough is a reason to see a doctor.

Breath sounds

The movement of air through the respiratory tract, as well as the opening of the lumen of the bronchi and alveoli, is accompanied by a certain noise. Distinguish between healthy breath sounds and pathological additional sounds- wheezing, crepitus, pleural friction sound.

The main (healthy) breath sounds include:

1. Alveolar respiration. A characteristic sound is heard in every healthy person. It occurs when the alveoli expand and elastic stretch their walls due to filling with air during inspiration. It has a soft blowing sound that does not stop throughout the act of inhalation. A similar sound is also heard at the initial stage of exhalation, when the walls of the alveoli begin to contract back. Minor changes from the generally accepted idea of ​​​​alveolar noise can be considered normal and be a consequence of physiology (in people with asthenic physique, children). In such patients, the same changes are heard in both lungs.
2. bronchial. Heard louder than alveolar. This is due to the rapid and swirling movement of air in the larynx and trachea. On exhalation, such noise lasts longer than when air is inhaled. Normally, this type of noise should only be heard in certain areas.

Additional sounds that appear in pathological conditions:

1. Wet rales. A typical symptom of bronchitis, which is often heard by all doctors. A wheezing and gurgling sound occurs when the inhaled air passes through the bronchial secretions.
2. Crepitus. The simultaneous opening of many alveoli sounds like a crackling or rustling.
3. Pleural friction. Occurs with inflammation in the pleural region and dehydration of the body.
4. hard breathing. Often heard in bronchiolitis. This type is accompanied by a rough and intensified both inhalation and exhalation.

Changes in respiratory sounds in acute bronchitis

Alveolar respiration can both increase during the inflammatory process and weaken. In a pathological condition, a change can appear both on the entire lung, and on some part of it. Sometimes the noise is heard more strongly, in other cases it is absolutely not audible.

The quality of the noise during alveolar breathing depends on the number of alveoli, the elasticity of their walls, the speed and completeness of filling with air, the duration of inspiration. The weakening of breathing is caused by atrophy of the alveoli and the resorption of the partitions that separate them. This leads to the formation of large areas that are less elastic and do not fall off on exhalation.

Obstructive bronchitis, mucosal edema and bronchospasm provoke increased alveolar breathing on expiration. This is due to the difficulty of passing air through the respiratory tract and the tension of the walls of the alveoli.

Harsh breathing is considered to be increased noise during the inhalation and exhalation phases. The inflammatory process in bronchitis leads to an uneven narrowing of the elastic walls of the bronchioles, which occurs quite sharply.

Auscultation procedure

With the help of a phonendoscope, the doctor listens to the airways in various locations - behind, in front and from the side. The purpose of auscultation is to identify noises and determine their nature. You can listen while lying down, standing and sitting.

Alveolar breathing is best heard with a phonendoscope in front of the chest or in the region of the shoulder blades. The patient must take a deep breath.

During auscultation, the doctor pays attention to the symmetry of the noise and the identity of the main types.. In addition, he carefully listens to pathological sounds in various localizations. If unusual sounds are detected, additional methods of diagnostics of the respiratory system or the results of a blood test may be required.

An experienced doctor always qualitatively and attentively listens to different parts of the respiratory tract. He can determine the location, timbre, depth, and duration of noise that should not normally be present.

Types of wheezing

Pathological noises that appear in respiratory diseases and are absent in a healthy state are called wheezing. There are such types:

1. Wet rales. Characteristic gurgling sounds occur when air enters the respiratory tract, when sputum accumulates in them. With bronchitis, they are medium or large bubbles. At the same time, the patient is worried about a hoarse cough, and the doctor recommends pharmacy or folk expectorants for bronchitis. The lung cavity itself to some extent amplifies the sound of moist rales. If they are localized in the lower parts of the lungs, the doctor may suspect pneumonia. If the sound is well heard under the scapula, the presence of tuberculous infiltrate is likely.
2. Dry wheezing. Occur when the patency of the bronchi is impaired. Whistling rales in the lungs and over their entire surface are clearly audible in bronchitis and bronchopneumonia. In large bronchi, the sound resembles a buzzing, in smaller bronchi - a whistle. Its audibility can change - periodically the sound weakens or disappears, and then intensifies. In bronchial asthma, a total narrowing of the bronchial lumen is observed and dry rales are heard along the entire length of the respiratory tract. With bronchitis, the narrowing is uneven, so pathological noise can only be diagnosed in certain areas. More serious diseases, such as tuberculosis, are accompanied by focal obstruction.

Bronchophony

A kind of auscultation, when the doctor listens not to clean breathing, but to sounds during a conversation. The patient is asked in a whisper to pronounce words that contain the letters "p" and "h". In a healthy person, the sounds are quiet, and there is no bronchophony. The accumulation of fluid impairs the conduction of sound, and the compaction of the lung tissue improves it.

Diagnosis of the respiratory system by auscultation has its drawbacks., one of which is the presence of an error. If an inflammatory process is suspected, additional diagnostic methods are often prescribed - x-ray, bronchography, bronchoscopy, and others.

The main direction in the treatment of respiratory diseases is the purification of the respiratory tract from accumulated sputum and the relief of breathing. For this, expectorants and sputum thinners are used. Powders and syrups that thin sputum are allowed for children from a very early age. Such drugs have a high safety profile and help prevent severe complications and further spread of the infection.

Video about lung auscultation

In the video, the doctor explains what the procedure is and how it is performed.

To understand what auscultation is and for what purpose it is carried out, you need to know - this is a special research method, which consists in listening to sound phenomena (tones, noises, rhythm) that occur in the body. Experts divide this study into two types: direct auscultation (when the doctor puts his ear to the patient's body) and indirect (using a special device - a stethoscope). Nowadays, direct auscultation is not used in modern medicine, since indirect auscultation is more preferable because of its informativeness and high sensitivity.

Auscultation when listening to the chest reveals respiratory noises mainly on inspiration, but the assessment of breathing on exhalation is no less important, so the doctor will certainly analyze both of these indicators.

The purpose of auscultation is to identify and describe murmurs, as well as bronchophony over the surface of the lungs.

Classification of breath sounds

What are breath sounds? This term in medicine is usually called sound phenomena that occur during the act of breathing.

Basic breath sounds:

• Vesicular (or alveolar) breathing is a low-frequency breath noise, determined by auscultation of healthy lungs. In its sound, it very distinctly resembles the sound "ffff". In adults with a thin chest, the noise of this breath is defined as louder when inhaling and more extended when exhaling.

• Bronchial breathing (it is also called laryngo-tracheal) - is characterized by a higher timbre that occurs due to air turbulence in the trachea and larynx. Reminiscent of the rough sound of "xxx", it is determined by inhalation and exhalation, while the exhalation is heard more strongly than the inhalation. Bronchial breathing differs from vesicular breathing in greater volume, a special timbre, and also in that this noise is longer in the exhalation phase than in inspiration. If bronchial breathing is heard in any other part of the chest, except for the lung zone, this should always be alarming and serve as a signal for a more thorough examination.
• Hard breathing. During auscultation, the doctor can listen to coarser (compared to vesicular breathing) inhalation and exhalation. Harsh breathing is characteristic of acute bronchiolitis and chronic bronchitis.

This is the name of a special type of auscultation, during which the patient pronounces words containing the letters “p” and “h” in a whisper at the request of the doctor. If the words are easily defined, then we are talking about lung compaction or the presence of cavities. Such symptoms most often indicate the presence of bronchial asthma. In a healthy person, in this study, rustling or quiet sounds are heard, that is, there is no bronchophony.

Despite the great importance of auscultation in the diagnosis of bronchitis, modern medicine replaces it with improved, hardware diagnostic methods. The result of auscultation may have some inaccuracies. Therefore, a mandatory study, shown to all patients with complicated bronchitis, is radiography, which is carried out in two planes. Quite effective modern special research methods are: computed tomography, bronchography, angiography, pleurography, bronchoscopy (examination of the upper respiratory tract using a bronchoscope), thoracoscopy and others.

Bronchitis - a disease characterized by inflammation of the bronchi with a primary lesion of their mucous membrane. Bronchitis is one of the most common respiratory diseases. There are acute and chronic bronchitis, which are independent nosological forms.

Acute bronchitis

Acute bronchitis is based on inflammation of the bronchial mucosa, usually caused by respiratory viruses, which can be secondarily attached to the microbial flora (streptococci, pneumococci, Haemophilus influenzae, etc.). Often it is observed with influenza, measles, whooping cough and other diseases; sometimes becomes chronic. Often acute bronchitis is combined with tracheitis, laryngitis, nasopharyngitis.

In some cases, the terminal sections of the bronchial tree are predominantly affected, bronchiolitis occurs. Predisposing factors include hypothermia, smoking, alcohol consumption, chronic focal infection in the nasopharyngeal region, impaired nasal breathing, chest deformity. Acute bronchitis can also occur when exposed to physical (cold or hot air) or chemical (irritating gases) factors.

The damaging agent penetrates into the bronchi mainly with inhaled air. It is also possible for the damaging agent to penetrate through the bloodstream (hematogenous route) or through the lymphatics (lymphogenic route). Usually, edema and hyperemia of the bronchial mucosa develop with the formation of a mucous or mucopurulent secret. In severe cases, necrotic changes in the epithelium of the bronchi can be observed, followed by rejection of the epithelial cover. As a result of inflammatory changes, as well as bronchospasm, sometimes there are violations of bronchial patency, especially when small bronchi are affected.

Bronchitis of infectious etiology often begins against the background of acute rhinitis and laryngitis. The onset of acute bronchitis is manifested by malaise, a burning sensation behind the sternum (with damage to the trachea). The main symptom of bronchitis is a cough (dry or wet). In acute bronchitis, the cough is predominantly paroxysmal in nature, accompanied by a burning sensation or soreness behind the sternum or in the throat. Sometimes a paroxysmal cough is so intense that it is accompanied by a headache. Patients are concerned about weakness, chilling, fever up to 37-38 ° C, headache, muscle pain. There are no percussion changes.

On auscultation of the lungs, hard breathing, scattered dry rales are noted. Changes in the blood are minimal. X-ray inconstantly revealed increased lung pattern and blurring of the roots of the lungs. After 2-3 days from the onset of the disease, a small amount of viscous sputum appears, the cough becomes less painful, and the state of health improves. The illness usually lasts 1-2 weeks, but the cough can last up to 1 month.

In acute bronchitis, there may be a violation of bronchial patency, the main clinical manifestation of which is a paroxysmal cough, dry or difficult to separate sputum, accompanied by a violation of lung ventilation. There is an increase in shortness of breath, cyanosis, wheezing in the lungs, especially on exhalation and in a horizontal position. Acute bronchitis with impaired bronchial patency tends to protracted course and transition to chronic bronchitis.

Severe and protracted course of bronchitis should be differentiated from the development of pneumonia, in which there is a dullness of percussion sound over the affected area, moist rales are heard.

Topographic percussion data depend on the prevalence of the lesion and may not change with a small area of ​​compaction.

Auscultation: basic breath sounds.

With focal compaction, mixed (broncho-vesicular) breathing is noted, since normal lung tissue is located around the focus of compaction.

Auscultation: Adverse breath sounds.

Dry and wet small bubbling sonorous rales are heard, because with focal compaction, the inflammatory process is also present in the bronchi;

Wet rales are characterized as sonorous, since the inflammatory compaction of the lung tissue around the bronchi contributes to better conduction of moist rales arising in them to the surface of the chest.

Chest X-ray (Fig. 2): In the lungs, multiple foci of different size and intensity are found (the diameter of the foci is at least 1-1.5 cm). Reinforced drawing of the lungs due to their plethora and peribronchitis. Small pneumonic foci are not always recognized.

Examination of IFD: See examination of the function of external respiration in the syndrome of infiltrative compaction

Blood analysis: Reduction or disappearance of eosinophils. ESR acceleration. In some cases, the disease proceeds with a normal number of leukocytes.

Complications:

Acute respiratory failure;

Syndrome of fluid in the pleural cavity;

Air cavity syndrome in the lung (lung abscess);

Focal pneumosclerosis (fibrosis).

Reliable signs of focal syndrome are:

q dullness of percussion sound;

q wet sonorous fine bubbling rales;

broncho-vesicular breathing.

II . Air cavity syndrome in the lungs

The air cavity in the lungs is a localized cavitary process that communicates with the bronchus.

The formation of a cavity in the lung occurs as a result of:

abscessing pneumonia;

With tuberculosis (cavity);

The collapse of a cancerous tumor;

Bronchiectasis (bronchiectatic cavity);

Cystic lesion of the lungs (congenital air cyst);

With aspiration of foreign bodies;

With chest wounds;

During operations on the respiratory tract.

With the syndrome of an air cavity in the lungs, patients have both signs of compaction of the lung tissue and abdominal symptoms.

5 prerequisites for detecting a cavity in the lungs:

1. The cavity in the lungs must be at least 4 cm in diameter;

2. The cavity should be located near the chest wall;

3. The lung tissue surrounding the cavity must be compacted;

4. The walls of the cavity should be thin;

5. The cavity must communicate with the bronchus and contain air.
Main complaints:

Cough with the release, usually purulent, sputum in large quantities ("full mouth"), unpleasant odor, sometimes fetid (due to putrefactive flora), a daily amount of 500 ml or more;

A strong separation of sputum is observed at a certain (drainage) position of the body. For example: when the patient is positioned on the right side (bronchiectasis or a cavity containing pus is located in the left lung);

An increase in body temperature on a large scale;

sweating;

Anorexia (loss of appetite);

Weight loss.

General inspection

On examination, it is not possible to identify any changes specific to this syndrome. With a long-term abscess or cavity, it is possible

emaciation of the patient due to infectious intoxication.

Chest examination:

Often there is a lagging of the affected half of the chest during breathing.

Palpation:

1. In the projection of the cavity, an increase in voice trembling is determined;

2. Kryukov's symptom - pain on palpation along the intercostal spaces (with a subpleural location of the cavity).

Comparative percussion:

1. A dull-tympanic percussion sound is determined above the cavity;

2. With a large cavity - a sound with a metallic tint;

3. If the cavity communicates with the bronchus through a narrow opening, with strong percussion, you can get "the noise of a cracked pot."

Auscultation:

Basic breath sounds: Breathing over the cavity is bronchial or less often "amphoric".

Adverse breath sounds: Resounding moist large bubbling rales are heard, which may disappear due to sputum closing of the lumen of the bronchus and reappear after coughing.

Bronchophony: increased bronchophony is observed on the side of the lesion.

X-ray signs of an air cavity in the lungs. Limited enlightenment of a rounded shape, usually against the background of the surrounding darkening. Inside the cavity, the horizontal level of the liquid is determined, which shifts with a change in the position of the patient's body.

The formation of an air cavity in the lung (lung abscess) mainly depends on the ability of the pathogenic infection to secrete the appropriate enzymes and toxins, leading to necrosis of the lung tissue.

In the development of a lung abscess, two periods are distinguished:

1. The period of abscess formation (before the opening of the abscess).

2. The period of cavity formation (after opening the abscess)

Lung abscess: First period

The period of abscess formation (before its opening). Duration - 2-3 weeks (average 7-10 days).

Complaints:

Chills, fever (often hectic), profuse sweat;

Dry cough, chest pain;

Bad breath (foetor ex ore);

General increasing weakness;

Weight loss.

General inspection:

In the initial period, during a general examination, no special deviations are detected.

Chest examination: Lag of the affected half

chest in the act of breathing (with a sufficiently extensive zone of infiltration).

Palpation:

Kryukov's symptom

Profuse sweating (hyperhidrosis)

Can be reinforced (extensive area of ​​infiltration)

With a deep location of the abscess is not changed.

Comparative percussion: dullness of percussion sound is determined (with a sufficiently extensive zone of infiltration).

Auscultation: basic breath sounds. AT Weakened vesicular breathing is heard with the appearance of a bronchial shade.

Auscultation: side breath sounds.

Copious amount of voiced moist rales (in a limited area).

Rubbing noise of the pleura (with subpleural location of the abscess)

Bronchophony: Increased bronchophony over the emerging abscess.

Blood test: H eutrophilic leukocytosis 15,000-25,000 with a shift to the left, toxic granularity of neutrophils. Sharp acceleration of ESR up to 50-60 mm/hour.

X-ray examination chest: massive infiltration is detected in the form of a homogeneous darkening with fuzzy boundaries.

Lung abscess: second period.

After opening the abscess with the formation of a cavity.

The beginning of the period - from the moment of opening the abscess to the discharge of sputum through

Severe cough with purulent sputum "full mouthful" (from 50 ml to 1

l or more);

Decrease in temperature, which remains subfebrile for quite a long time;

Improved appetite;

Feeling better.

Percussion

1. Tympanic sound (with a large superficial cavity);

2. Wintrich's symptom (if the cavity is connected / fistulous tract / with a large bronchus, then during percussion the tone of the tympanic sound will change).

Auscultation: Basic breath sounds.

Breathing over the cavity is bronchial or less often amphoric.

Adverse breath sounds.

Large bubbling sonorous moist rales are heard (above the zone

defeat).

Sputum (visual assessment):

Smell: fetid.

Colour: dirty brown.

Quantity: from 50 ml to 1 liter or more.

When standing for a long time: 3 layers:

1. Upper - a layer of foamy serous fluid;

2. Middle layer of purulent sputum with a lot of saliva;

3. Lower - greyish thick pus with crumbly tissue detritus.

Sputum (microscopy):

A large number of leukocytes, erythrocytes;

Elastic fibers;

Cholesterol crystals;

Fatty acid crystals or Dietrich balls (fatty epithelium).

X-ray examination of the chest after opening the abscess characteristic is the presence of a limited darkening of a rounded shape against the background of pneumonic infiltration with a horizontal level of liquid.

bronchiectasis

Of fundamental clinical importance is the division of bronchiectasis into:

1. primary (congenital) or bronchiectasis. Primary bronchiectasis occurs in childhood and adolescence, characterized by the formation of infected bronchiectasis without persistent causal relationships with chronic respiratory diseases.

2. secondary. Secondary bronchiectasis develops as a result of various respiratory diseases (bronchitis, pneumonia).

Bronchiectasis is a regional expansion of the bronchi, exceeding the lumen of the unchanged bronchus by two or more times, and their deformation.

According to the anatomical form, bronchiectasis is divided into:

Cylindrical;

Saccular;

mixed;

racemose;

Fusiform;

Varicose.

Complaints (without exacerbation):

1. Cough with mucopurulent and purulent sputum that occurs with

characteristic regularity in the morning upon awakening and in the evening upon

going to bed;

2. Hemoptysis;

3. Slimming;

4. Quick fatigue;

5. Decreased ability to work.

Complaints (with exacerbation):

-Fever;

Pain in the chest (with the development of perifocal pneumonia);

sweating;

Headache;

Bad appetite.

Disease history:

1. Postponed (repeated pneumonia) in childhood;

2. Frequent bronchitis, acute respiratory infections.

General inspection:

The patient's lag in physical development (during the formation of bronchiectasis in childhood);

Puffiness of the face;

Nails in the form of watch glasses;

Examination of the chest.

Emphysematous form of the chest (especially with atelectatic bronchiectasis)

Comparative percussion:

Box sound (with severe emphysema).

Tympanic sound (with large bronchiectasis).

Dullness of percussion sound (with perifocal pneumonia).

Topographic percussion:

Low location and reduced mobility of the lower edges of the lungs.

Auscultation: basic breath sounds:

Weakened vesicular breathing (in the presence of emphysema);

Harsh breathing (in the presence of concomitant bronchitis).

Auscultation: side breath sounds:

Dry and wet (small bubbling and medium bubbling) wet rales (above the area of ​​bronchiectasis), stable localization of wet rales.

Blood analysis:

1. Leukocytosis with neutrophilic shift to the left (with exacerbation);

2. Accelerated ESR;

3. Anemia.

Biochemistry of blood:

Dysproteinemia (decrease in albumin content;

Increase in alpha-2 globulins, fibrin;

The presence of hypoalbuminemia, which may be an early sign of liver amyloidosis.

Analysis of urine. P roteinuria, persistent presence of protein in the urine may indicate kidney damage (renal amyloidosis).

In Phlegm a large number of neutrophils, elastic fibers are found, there may be erythrocytes.

radiography;

Computed tomography (CT);

Bronchography.

X-ray examination:

1. Increasing the transparency of the lung tissue;

2. Strengthening of the lung pattern;

3. Cellularity of the lung pattern;

4. Deformation of the vascular pattern;

5. Peribronchial fibrosis in the affected segments, atelectasis.

More informative computed tomography of the lungs, made in the corresponding projections and at different depths, at which clearly a honeycomb pattern of the lesion is revealed.

Bronchography.

Directed bronchography is a reliable method

diagnosis of bronchiectasis.

The drawing of normal bronchi is compared

with a "winter tree", and the pattern of the bronchi in bronchiectasis - with a "tree with foliage" or altered bronchi take the form of a chopped tree or a bunch of twigs.

Saccular bronchiectasis: distal parts look swollen

(“a tree with leaves”).

Cylindrical bronchiectasis. They give a picture of a chopped tree.

FVD study: restrictive or restrictive-obstructive

ventilation disorders.

Fibrobronchoscopy:

Clarification of the location and type of bronchiectasis (cylindrical, saccular) helps to identify the source of bleeding

Fibrobronchoscopy reveals:

atrophic;

Hypertrophic;

Edema-hypertrophic changes in the bronchial mucosa;

Pus in their lumen.

III. C-m lesions of the bronchial tree. Bronchitis.

The bronchial tree lesion syndrome is characterized by a diffuse, bilateral lesion of the bronchial tree and proceeds with a violation of the drainage function of the bronchi, hypersecretion of mucus and a change in the mucous membrane (endobronchitis) or the entire wall of the bronchi (panbronchitis).

However, bronchitis in the lungs can be local or segmental. So, with focal pneumonia with a protracted course, local or segmental (isolated) bronchitis is formed over time at the site of infiltration or the affected area. In these cases, we are not talking about the syndrome of lung damage, but about local or segmental bronchitis.

Striking examples of damage to the bronchial tree are bronchial asthma, COPD (chronic obstructive pulmonary disease) and bronchitis, when the process is diffuse and bilateral.

Bronchitis is divided into acute and chronic. Acute bronchitis: this is an inflammatory process in the trachea, bronchi or bronchioles, characterized by an acute course and diffuse reversible damage mainly to the mucous membrane. Usually, the inflammatory process stops within a few weeks, and the affected mucous membrane of the respiratory tract is completely restored.

Acute bronchitis is most often one of the clinical stages of acute respiratory infections (acute respiratory diseases), much less often - an independent disease

By origin, OB can be primary and secondary.

The latter often occurs against the background of infectious diseases (measles, whooping cough, etc.) or acute circulatory and metabolic disorders (uremia, jaundice, etc.).

In most cases, AB is an infectious disease.

Complaints/

If OB is a consequence of acute respiratory infections, then it is preceded by: runny nose (rhinitis), sore throat and sore throat when swallowing (pharyngitis, tonsillitis), hoarseness (laryngitis), burning, soreness or “scratching” behind the sternum (tracheitis). Patients complain at this time of malaise - general weakness, weakness, loss of appetite, muscle pain in the back and limbs, chilling.

A cough usually appears dry or with sputum difficult to separate. After 2-3 days, the cough becomes wet with the separation of mucous or mucopurulent sputum.

On general examination and examination of the chest pathology is not detected.

Percussion - a clear pulmonary sound. Auscultatory - hard breathing is detected. Adverse breath sounds are dry rales of various heights and timbres.

1. Blood test are usually within the normal range. Occasionally, a slight leukocytosis (9.0-11.0 9 /l) or a slight increase in ESR (15-20 mm/hour) is detected.

2. X-ray examination - there are no deviations from the norm. In rare cases, some increase in the pulmonary pattern can be detected.

CHRONICAL BRONCHITIS

Classification of bronchitis.

1. By the nature of the inflammatory exudate:

catarrhal;

Purulent.

2. Changes in the function of external respiration:

obstructive;

Non-obstructive.

3. With the flow:

Remission;

Aggravation.
Complaints:
1. Cough - after waking up - in the morning;

2. Sputum at the beginning with mucous sputum, later - mucopurulent and purulent sputum;

1. Shortness of breath - at first insignificant, and then with little physical exertion (obstructive bronchitis).

1. Non-obstructive chronic bronchitis.

Bronchitis is one of the most common diseases. Both acute and chronic cases rank high among respiratory pathologies. Therefore, they require high-quality diagnostics and treatment. Summarizing the experience of leading experts, relevant clinical recommendations on bronchitis are created at the regional and international levels. Compliance with the standards of care is an important aspect of evidence-based medicine, which allows you to optimize diagnostic and therapeutic measures.

None of the recommendations can do without considering the causes of the pathology. It is known that bronchitis has an infectious and inflammatory nature. The most common causative agents of the acute process are viral particles (influenza, parainfluenza, respiratory syncytial, adeno-, corona- and rhinoviruses), and not bacteria, as previously thought. Outside of seasonal outbreaks, it is possible to establish a certain role for other microbes: whooping cough, mycoplasmas and chlamydia. But pneumococcus, moraxella and Haemophilus influenzae can cause acute bronchitis only in patients who have undergone surgery on the respiratory tract, including tracheostomy.

Infection plays a crucial role in the development of chronic inflammation. But bronchitis at the same time has a secondary origin, arising against the background of a violation of local protective processes. Exacerbations are provoked mainly by the bacterial flora, and the long course of bronchitis is due to the following factors:

1. Smoking.
2. Professional hazards.
3. Air pollution.
4. Frequent colds.

If during acute inflammation there is swelling of the mucous membrane and increased production of mucus, then the central link of the chronic process is the violation of mucociliary clearance, secretory and protective mechanisms. The long course of the pathology often leads to obstructive changes, when due to thickening (infiltration) of the mucosa, sputum stagnation, bronchospasm and tracheobronchial dyskinesia, obstacles are created for the normal passage of air through the respiratory tract. This leads to functional disorders with further development of pulmonary emphysema.

Bronchitis is provoked by infectious agents (viruses and bacteria), and acquires a chronic course under the influence of factors that violate the protective properties of the respiratory epithelium.

Symptoms

Assume pathology at the initial stage will allow the analysis of clinical information. The doctor evaluates the anamnesis (complaints, onset and course of the disease) and conducts a physical examination (examination, auscultation, percussion). So he gets an idea of ​​the symptoms, on the basis of which he makes a preliminary conclusion.

Acute bronchitis occurs on its own or against the background of SARS (most often). In the latter case, it is important to pay attention to the catarrhal syndrome with a runny nose, perspiration, sore throat, as well as fever with intoxication. But pretty soon there are signs of bronchial damage:

• Intense cough.
• Expulsion of scanty mucous sputum.
• Expiratory dyspnea (difficulty exhaling predominantly).

Even chest pains may appear, the nature of which is associated with muscle strain during a hacking cough. Shortness of breath appears only with the defeat of the small bronchi. Percussion sound, as well as voice trembling, are not changed. Auscultation reveals hard breathing and dry rales (buzzing, whistling), which become moist during the resolution of acute inflammation.

If the cough lasts more than 3 months, then there is every reason to suspect chronic bronchitis. It is accompanied by sputum discharge (mucous or purulent), less often it is unproductive. At first this is observed only in the morning, but then any increase in the frequency of breathing leads to expectoration of the accumulated secret. Shortness of breath with prolonged exhalation joins when obstructive disorders appear.

In the acute stage, there is an increase in body temperature, sweating, weakness, the volume of sputum increases and its purulence increases, the intensity of cough increases. The periodicity of chronic bronchitis is quite pronounced, inflammation is especially activated in the autumn-winter period and with sudden changes in weather conditions. The function of external respiration in each patient is individual: in some, it remains at an acceptable level for a long time (non-obstructive bronchitis), while in others, shortness of breath with ventilation disorders appears early, which persists during periods of remission.

On examination, one can notice signs indicating chronic respiratory failure: chest expansion, pallor of the skin with acrocyanosis, thickening of the terminal phalanges of the fingers (“drumsticks”), changes in nails (“watch glasses”). The development of cor pulmonale may indicate swelling of the legs and feet, swelling of the jugular veins. Percussion with simple chronic bronchitis does not give anything, and obstructive changes can be assumed from the box shade of the sound received. The auscultatory picture is characterized by hard breathing and scattered dry rales.

It is possible to assume bronchitis by clinical signs that are revealed during a survey, examination and using other physical methods (percussion, auscultation).

Additional diagnostics

Clinical recommendations contain a list of diagnostic measures that can be used to confirm the doctor's assumption, determine the nature of the pathology and its causative agent, and identify concomitant disorders in the patient's body. On an individual basis, such studies can be prescribed:

• General blood analysis.
• Blood biochemistry (acute phase indicators, gas composition, acid-base balance).
• Serological tests (antibodies to pathogens).
• Analysis of swabs from the nasopharynx and sputum (cytology, culture, PCR).
• Chest X-ray.
• Spirography and pneumotachometry.
• Bronchoscopy and bronchography.
• Electrocardiography.

The study of the function of external respiration plays a key role in determining violations of bronchial conduction in a chronic process. At the same time, two main indicators are evaluated: the Tiffno index (the ratio of forced expiratory volume in 1 second to the vital capacity of the lungs) and peak expiratory flow rate. Radiologically, with simple bronchitis, only an increase in the pulmonary pattern can be seen, but prolonged obstruction is accompanied by the development of emphysema with an increase in the transparency of the fields and a low standing diaphragm.

Treatment

Having diagnosed bronchitis, the doctor immediately proceeds to therapeutic measures. They are also reflected in the clinical guidelines and standards that guide specialists when prescribing certain methods. Drug therapy is central to acute and chronic inflammation. In the first case, the following drugs are used:

• Antiviral (zanamivir, oseltamivir, rimantadine).
• Expectorants (acetylcysteine, ambroxol).
• Antipyretics (paracetamol, ibuprofen).
• Antitussives (oxeladin, glaucine).

The last group of drugs can be used only with intense hacking cough, which is not stopped by other means. And it should be remembered that they should not inhibit mucociliary clearance and be combined with drugs that increase mucus secretion. Antibiotics are used only in cases where the bacterial origin of the disease is clearly proven or there is a risk of developing pneumonia. In the recommendations after bronchitis there is an indication of vitamin therapy, immunotropic drugs, giving up bad habits and hardening.

Acute bronchitis is treated with medications that affect the infectious agent, disease mechanisms, and individual symptoms.

The treatment of chronic pathology involves various approaches during the period of exacerbation and remission. The first direction is due to the need to sanitize the respiratory tract from infection and involves the appointment of such medications:

1. Antibiotics (penicillins, cephalosporins, fluoroquinolones, macrolides).
2. Mucolytics (bromhexine, acetylcysteine).
3. Antihistamines (loratadine, cetirizine).
4. Bronchodilators (salbutamol, fenoterol, ipratropium bromide, aminophylline).

Drugs that eliminate bronchospasm occupy an important place not only during exacerbation, but also as a basic therapy for chronic inflammation. But in the latter case, preference is given to prolonged forms (salmeterol, formoterol, tiotropium bromide) and combined drugs (Berodual, Spiolto Respimat, Anoro Ellipta). In severe cases of obstructive bronchitis, theophyllines are added. Inhaled corticosteroids, such as fluticasone, beclomethasone, or budesonide, are indicated for the same category of patients. Like bronchodilators, they are used for long-term (basic) therapy.

The presence of respiratory failure requires oxygen therapy. The set of recommended measures also includes influenza vaccination to prevent exacerbations. An important place in the rehabilitation program is occupied by individually selected breathing exercises, high-calorie and fortified diet. And the appearance of single emphysematous bullae may suggest their surgical removal, which favorably affects the ventilation parameters and the condition of patients.

Bronchitis is a very common disease of the respiratory tract. It occurs in acute or chronic form, but each of them has its own characteristics. Methods for diagnosing bronchial inflammation and methods for its treatment are reflected in international and regional recommendations that guide the doctor. The latter were created to improve the quality of medical care, and some have even been put into practice at the legislative level in the form of relevant standards.