Internal illnesses. Pneumonia (lecture notes)

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Internal illnesses. Pneumonia (lecture notes)

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LECTURE No. 22. Pneumonia

Pneumonia is an acute infectious and inflammatory process in the lungs with the involvement of all structural elements of the lung tissue and obligatory damage to the alveoli of the lungs.

Etiology. Pneumonia in all cases is caused by gram-positive or gram-negative microflora. With immunodeficiency pneumonia, Pneumocystis carinii, Cytomega-lovirus, Herpes simplex, and fungi are found. With aspiration pneumonia, anaerobic microorganisms are detected.

Pathogenesis. With community-acquired pneumonia, an airborne route of penetration is observed - inhalation of small drops or aspiration of the secret of the upper respiratory tract containing microorganisms. There is damage to the endothelium of the tracheobronchial tree with a violation of mucociliary clearance and mucociliary barrier. Violated the functioning of macrophages, the secretion of lysozyme and interferon.

RџSЂRё nosocomial pneumonia the cough reflex is suppressed, the mucous membrane of the tracheobronchial tree is damaged during surgery and mechanical ventilation, and there is a sharp decrease in general and local immune defense against the background of immunosuppressive therapy.

Classification. Pneumonia by type is divided into community-acquired, or home, outpatient (acquired outside the hospital), nosocomial, or hospital, nosocomial (acquired in a medical institution), aspiration, in persons with severe immunity defects (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

According to the severity of the course, the following pneumonias are distinguished:

1) mild degree: mild intoxication (consciousness is clear, fever up to 38 ° C, tachycardia up to 90 beats per minute, blood pressure is normal), shortness of breath is slight on exertion, not at rest, on the x-ray - the lesion is small;

2) moderate degree: moderate intoxication (clear consciousness, mild euphoria, sweating, weakness, fever up to 39 ° C, tachycardia up to 100 beats per minute, moderate decrease in blood pressure), shortness of breath at rest (number of breaths up to 30 per minute), on X-ray - severe infiltration of the lung tissue;

3) severe degree: severe intoxication (temperature up to 39-40 ° C, weakness, blackout, delirium, tachycardia more than 100 beats per minute, collapse), shortness of breath at rest (30-40 breaths per minute), cyanosis, extensive infiltration on x-ray, complications of pneumonia are frequent. According to the prevalence of pneumonia are lobar, segmental, right-sided, left-sided.

Clinic. high tide It is marked by an acute onset: chills, headache, chest pain when breathing, fever, dry cough, later "rusty" sputum appears. Herpes labialis (nasalis), hyperemia of the cheek on the side of the lesion, swelling of the wings of the nose may appear. When breathing, the affected half of the chest lags behind the healthy one. Percussion determined pulmonary sound with a tympanic tinge. Auscultatory listening to the weakening of vesicular breathing, gentle initial crepitus - crepitus "indux", pleural friction rub.

В compaction stages there is a cough with purulent sputum, persistent fever, shortness of breath, chest pains when breathing and coughing, mental agitation up to psychosis, Herpes, cheek flushing, skin icterus, sclera. Increased voice trembling, bronchophony. Percussion determined dull sound. Bronchial breathing, pleural friction rub are auscultated.

В resolution stages there is a productive cough, a large amount of sputum, body temperature drops. Percussion is determined by dullness with a tympanic shade. Harsh breathing, rough crepitus - "redux" crepitus, sonorous moist rales are auscultated.

Additional diagnostic study. A general blood test is performed (leukocytosis, an increase in ESR), where leukocytosis is detected more than 10-12x10⁹/_л indicates a high probability of a bacterial infection, more than 25x10⁹/_л and leukopenia below 3x10⁹/_л are unfavorable diagnostic features. In a biochemical blood test, dysproteinemia is determined. In arterial blood, hypoxemia is determined with a decrease in oxygen below 60 mm Hg. Art., which is a prognostically unfavorable sign.

Gram-stained bacterioscopy and culture of sputum obtained by deep coughing, determination of antigens, polymerase chain reaction (the method is promising, but cannot be recommended for widespread practice). The pleural fluid is examined (in the presence of pleural effusion - counting leukocytes with a leukocyte formula, determining pH, LDH activity, protein content, Gram smear, culture for aerobes, anaerobes, mycobacteria). Fiberoptic bronchoscopy is also performed with a quantitative assessment of microbial contamination (to exclude pulmonary tuberculosis) and chest x-ray.

Complications. Complications may be pulmonary (pleural effusion, pleural empyema, destruction (abscess formation) of lung tissue, acute respiratory distress syndrome, acute respiratory failure) and extrapulmonary (toxic shock, secondary bacteremia, sepsis, pericarditis, myocarditis, nephritis).

Differential diagnostics. Should be carried out with thromboembolism in the pulmonary artery system, exudative pleurisy, focal tuberculosis, acute abdomen, acute myocardial infarction.

Treatment. The treatment of pneumonia provides for an active and early effect on the pathogen, the use of rational antibacterial therapy, anti-inflammatory treatment through the complex use of physiotherapy and medications (NSAIDs), the elimination of toxemia, the correction of impaired functions of the lungs and other systems (rehabilitation), pathogenetic and symptomatic therapy. Bronchodilators are used in combination with mucolytics to improve the drainage function of the lungs (ambroxol, mucodin, bromhexine, bronchicum, etc.); with bronchial obstruction - bronchodilator drugs with anticholinergic action (atrovent, berodual). Patients are shown early therapeutic breathing exercises (with a decrease in temperature to subfebrile and the absence of hemodynamic disorders), physiotherapy (microwave field on the area of the pneumonic focus) in the absence of contraindications (abscess formation, hemoptysis, suspicion of a tumor or specific process, the presence of severe cardiac pathology). At the end of the course of antibiotic therapy, in the absence of contraindications from the gastrointestinal tract, NSAIDs (non-steroidal anti-inflammatory drugs) are prescribed.

Antibacterial therapy with non-severe pneumonia, it can be completed upon reaching a stable temperature normalization (within 3-4 days); the duration of treatment is usually 7-10 days, with mycoplasma and chlamydial pneumonia - up to 14 days, with staphylococcal or gram-negative pneumonia - from 14 to 21 days, with legionella - 21 days.

Criteria for the sufficiency of antibiotic therapy are body temperature below 37,5 ° C, no intoxication, no respiratory failure, no purulent sputum, normalization of blood counts: leukocytes below 10_л, neutrophils below 80%, young below 6, no negative dynamics on the radiograph.

In severe pneumonia, a two-stage method of using antibiotics is used, the transition from parenteral to oral administration should be carried out as soon as possible, taking into account the clinical condition. The best option is to use two dosage forms of one antibacterial drug.

Transition Criteria (on average 2-3 days after the start of treatment) the following: normalization of temperature (below 37,5 ° C) in two consecutive measurements with an interval of 8 hours, decrease in dyspnea, no impairment of consciousness, positive dynamics of other symptoms of the disease, no violations of gastrointestinal absorption , patient consent to oral treatment.

Flow. The course of the disease can be acute, protracted and chronic. Pneumonia should resolve in 3-4 weeks. Pneumonia that does not resolve for more than 4 weeks and ends in recovery is considered protracted. Long-term (over 8 weeks), chronic inflammatory process in sclerotically altered and (or) carnifying lung tissue with formed irreversible changes in the bronchial tree according to the type of local chronic bronchitis and clinical manifestations of recurrent inflammation in the same affected part of the lung refers to chronic pneumonia .

Forecast. In the absence of complications, the prognosis is favorable, and in the presence of complications, it is determined by them.

Prevention. Preventive measures include the following: hardening of the body, smoking cessation, dispensary observation, vaccination with a 23-valent pneumococcal vaccine S. pneumoniae (all persons over 65 years of age, without immunological disorders, younger than 65 years of age in the presence of severe concomitant diseases).

Author: Myshkina A.A.

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