The pathogenesis of pneumonia. Pneumonia

I Introduction

II Etiopathogenesis

III Clinic

IV Diagnostics

V Differential Diagnosis

VI Principles of treatment

Bibliography

I Introduction

The first mention of inflammation in the respiratory sections of the respiratory tract was given by Celsus, and later, due to the accumulation of clinical experience with a detailed description by Willis in 1684, brought doctors closer to understanding pneumonia as an independent disease. Isolation by Rokitansky (1842) of two morphological variants of pneumonia: lobar and bronchopneumonia, then the discovery by Roentgen (1895) of the possibility radiodiagnosis created the basis for the classification and diagnosis of pneumonia, which are also used by modern clinicians. The problem of diagnosis and treatment of pneumonia is one of the most urgent in modern therapeutic practice.

In Russia, more than 1.5 million people are observed annually by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. In Russia, according to official statistics, at least 400,000 new cases are registered annually. In developed countries, the incidence of pneumonia ranges from 3.6 - 16 per 1000 people, and according to the statistics of DMP No. 1, 8%. Men predominate among patients with pneumonia. They make up from 52 to 56% of patients, women from 44 to 48%.

Purpose: to analyze the prevalence of the disease in Dagestan and Russia.

Task: to learn how to make a differentiated diagnosis and be able to provide assistance and prevention.

II Etiopathogenesis

Pneumonia is inflammatory disease lungs, predominantly of an infectious nature with damage to the alveoli.

Classification of pneumonia:

1. By etiology:

– bacterial;

- viral;

- rickettsial;

- mycoplasma;

- fungal;

- mixed.

2. According to clinical morphological features:

- parenchymal (croupous, lobar, pleuropneumonia);

- parenchymal (focal, lobular, bronchopneumonia);

- interstitial.

3. Localization and extent:

- unilateral;

- bilateral.

4. Gravity:

- extremely heavy

- heavy;

– moderate;

- light and abortive

5. Downstream:

– acute;

- protracted

Etiopathogenesis:

In children, in most cases, the etiology of pneumonia is infectious. Most often, acute pneumonia occurs in a child suffering from SARS, in the first week of illness. Viral infection, preceding pneumonia, reducing the immunological reactivity of the body and causing necrotic changes in the epithelium respiratory tract, preparing the way for layering infection.

The entrance gate is the upper respiratory tract. Perhaps 3 ways of penetration into the lungs of the pathogen: bronchogenic, hematogenous, lymphogenous.

The microorganism entering the small bronchioles causes an inflammatory process involving the alveolar tissue. Under the influence of microorganisms and their toxins, cell damage occurs, the permeability of cell membranes increases and vascular wall and there is swelling of the interstitial tissue, which contributes to the formation of exudate in the alveoli. Edema and infiltration contribute to the occurrence of upper respiratory failure, shortness of breath occurs with a reduced depth of breathing. Pathological changes in the lung tissue in croupous pneumonia takes place in 4 stages:

1. The stage of the tide, which is characterized by hyperemia of the lung tissue, inflammatory edema. The stage lasts from 1 to 3 days;

2. The stage of "red hepatization" is characterized by sweating into the alveoli of erythrocytes.

3. The stage of "gray hepatization" is characterized by sweating of leukocytes into the alveoli. Duration from 2 to 6 days.

4. Stage of resolution, which is characterized by the resorption of ukssudate.

III Clinic

Pulmonary manifestations of pneumonia:

- shortness of breath;

- cough;

- sputum production (mucous, mucopurulent, "rusty")

- pain when breathing;

- local clinical signs (dullness of percussion sound, bronchial breathing, crepitant wheezing, pleural friction noise);

– local radiological signs(segmental and lobar shading).

Extrapulmonary manifestations of pneumonia:

- fever;

- chills and sweating;

- headache;

- cyanosis;

- skin rash, mucosal lesions;

- changes in the blood (leukocytosis, shift of the formula to the left, increased ESR).

Children are characterized by an increase in body temperature of 38-39 degrees C, manifestations of intoxication: worsening general condition, headache, loss of appetite, sleep disturbance, pallor of the skin, vegetative-vascular disorders (sweating, marble skin pattern, cold extremities during high temperature bodies). The cough is often wet. Expressed shortness of breath at rest, in children older than 3 years, it is sometimes observed only with physical activity. When the pleura is involved in the process, a “short” (superficial) cough occurs, pain in the side increases with deep breathing and coughing. Pneumonia is characterized by fine bubbling and crepitating rales over the lesions. Blood changes are noted: leukocytosis, neutrophilia with a shift of the formula to the left, increase in ESR. Children in the first year of life in the clinic are dominated by symptoms of intoxication (anxiety or lethargy, refusal to eat, pallor and "marbling" of the skin), respiratory failure (shortness of breath with swelling of the wings of the nose, cyanosis of the nasolabial triangle). Hypoxia and acidosis develop rapidly. Cardiovascular disorders join: tachycardia, deafness of heart sounds, there is a disorder in the functions of the gastrointestinal tract (vomiting, regurgitation, loose stools).

With croupous pneumonia, the disease begins acutely, pronounced signs of intoxication appear, body temperature is 39-40 degrees Celsius, chills, chest pain increases with breathing. The patient's face is haggard, cyanotic lips, herpes on the lips. Lag in breathing of the affected half chest, percussion sound is shortened, crepitus is heard. On the second day of illness, "rusty" sputum appears. In the stage of resolution, the condition of patients gradually improves, dullness of percussion sound decreases, crepitus begins to be heard again, and then breathing becomes vesicular. X-ray examination: segmental or lobar obscuration of the lungs.

With focal pneumonia - beginning the disease cannot be established, since it often develops against the background of bronchitis. Most characteristic symptoms are: cough, fever, shortness of breath, there is a lag of the "sick" half of the chest in the act of breathing. In the presence of a large focus of inflammation, dullness of percussion sound is determined, with auscultation - hard breathing, against its background, moist rales and crepitus. The onset of the disease is not acute, a gradual increase in temperature to 39 degrees Celsius, persistent cough with mucopurulent sputum. X-ray studies: darkening corresponding to the focus of inflammation.

Chronic pneumonia - signs of intoxication are often absent, malaise, fatigue, loss of appetite are less common. Cough is the main symptom of the disease. Dry cough often occurs at the beginning of an exacerbation of the disease, later becomes wet. With extensive lesions in the acute phase, sputum is usually purulent or mucopurulent. On percussion, dullness of percussion sound is determined, hard breathing is heard. Auscultation revealed medium and fine bubbling rales.

Complications of pneumonia:

Pulmonary complications:

- parapneumonic pleurisy;

- pleural empyema;

- abscess and gangrene of the lung;

- broncho-obstructive syndrome;

- pleurisy, bronchitis.

Extrapulmonary complications:

– infectious-toxic shock;

- sepsis (often with pneumococcal pneumonia);

- meningitis, meningoencephalitis;

– DIC syndrome;

- acute respiratory failure;

- acute cardiovascular failure.

Risk Factors for Pneumonia :

– age (children and the elderly);

- smoking (tobacco smoke reduces the respiratory protection mechanism);

– chronic diseases lungs, heart, kidneys;

- immunodeficiency states;

- heart failure.

IV Diagnostics

Based on the results of X-ray and laboratory-instrumental studies. One of the important methods is x-ray examination, multi-projection fluoroscopy, tomography, radiography are carried out. With long-term non-absorbable pneumonia, when it is necessary to distinguish the inflammatory process from malignant tumor use bronchography. On the basis of clinical, and mainly radiological data, the doctor must indicate the number of affected segments (1 or more), lobes (1 or more), one- or two-sided lesion.

V Differential diagnosis

Pneumonia is differentiated from influenza, SARS, especially if they are accompanied by bronchitis. In addition, in some cases, pneumonia must be differentiated from acute appendicitis, peritonitis, acute bronchiolitis, tuberculosis.

The main guidelines for the etiological diagnosis of pneumonia.

Pneumonia - acute infection lung parenchyma.

The main causative agent of pneumonia in children - pneumococcus, up to 6 months, may be atypical flora: chlamydia.

Children older than 6 months to 6 years: 80% of cases of pneumococcus, Haemophilus influenzae, Staphylococcus aureus, there may be atypical flora: mycoplasma, rhinovirus, parainfluenza, influenza virus, RSV, adenovirus.

School-age children: pneumococcus.

Fungal pneumonia is more common in children with IDS, there may be pneumocystis pneumonia.

Pathogenesis. The main route of penetration of microbes is bronchopulmonary with subsequent spread of the infection to the respiratory sections. There may be a hematogenous route of spread, as well as lymphogenous, but very rarely. Once in the respiratory bronchioles, the infectious agent spreads beyond them, causing inflammation in the lung parenchyma (i.e. pneumonia). With the spread of bacteria and edematous fluid through the pores of the alveoli within the same segment, segmental pneumonia occurs, and with a more rapid spread, lobar (croupous) pneumonia occurs. In the same place, regional The lymph nodes. On radiographs, this is manifested by the expansion of the roots of the lung. Oxygen deficiency progresses. Changes in the central nervous system, cardiovascular system, gastrointestinal tract develop, metabolic processes are disturbed, and DN progresses.

Predisposing factors, taking into account the anatomical and physiological characteristics of the respiratory system.

anatomical and physiological features of the bronchopulmonary system (insufficient differentiation of acini and alveoli, poor development of the elastic and muscular tissue of the bronchi, abundant blood supply and lymphatic supply to the lung tissue → significant exudation and spread of the pneumonic process develops, ↓ protective function of the ciliated epithelium of the bronchi, weakness of cough shocks → delay secretion in the respiratory tract and reproduction m / o, narrowness of the lower respiratory tract → stenosis and obstruction of the respiratory tract, morphofunctional immaturity of the central nervous system, lability of the respiratory and vasomotor centers)

immaturity of cellular and humoral immunity;

genetically determined factors (hereditary predisposition, hereditary diseases);

second hand smoke;

early age;

unfavorable social aspects;

the presence of anomalies of the constitution, rickets, chronic eating disorders.

Children up to 1 year of age are hospitalized necessarily in a hospital for treatment, regardless of severity.

Classification.

Clinic.

Diagnostic criteria:

- Intoxication syndrome(fever, lethargy, loss of appetite).

- Respiratory catarrhal syndrome(dry painful cough, changing to productive with purulent / rusty sputum; shortness of breath of a mixed nature).

- A specific syndrome for pneumonia is a syndrome of local physical changes (pneumonic infiltration): local increase in voice trembling, dullness of percussion sound (or dullness), GC may be swollen, one half of the chest in the act of breathing, hard or bronchial breathing, crepitus (accumulation of exudate in the alveoli), small bubbling moist rales

- infiltrative shadows on the radiograph, having fuzzy outlines;

- changes in general biochemical analysis inflammatory blood.

- there may be a syndrome of toxicosis of 1-3 degrees in the course of the disease

- there may be a respiratory failure syndrome of a restrictive type, which occurs due to the impossibility of a full expansion of the alveoli when air enters them, freely passing through the respiratory tract. The main causes of restrictive respiratory failure are diffuse damage to the lung parenchyma.

Respiratory failure I degree characterized by the fact that at rest or not it clinical manifestations, or they are expressed insignificantly. However, moderate dyspnea, perioral cyanosis, and tachycardia appear with mild exertion. Blood oxygen saturation is normal or can be reduced to 90% (RO 2 80-90 mm Hg), MOD is increased, and MVL and respiratory reserve are reduced with some increase in basal metabolic rate and respiratory equivalent.

With respiratory failure II degree at rest, moderate dyspnea is noted (the number of breaths is increased by 25% compared to the norm), tachycardia, skin pallor and perioral cyanosis. The ratio between pulse and respiration has been changed due to the increase in the latter, there is a tendency to increase blood pressure and acidosis (pH 7.3), MVL (MOD), respiratory limit are reduced by more than 50%. Blood oxygen saturation is 70-90% (RO 2 70-80 mm Hg). When giving oxygen, the patient's condition improves.

With respiratory failure III degree breathing is sharply accelerated (by more than 50%), cyanosis with an earthy tinge is observed, sticky sweat. Breathing is superficial, blood pressure is reduced, the respiratory reserve drops to 0. MOD is reduced. Blood oxygen saturation is less than 70% (RO 2 less than 70 mm Hg), metabolic acidosis is noted (pH less than 6.3), hypercapnia is possible (RCO 2 70-80 mm Hg).

Respiratory failure IV degree- hypoxemic coma. Consciousness is absent; breathing arrhythmic, periodic, superficial. Observed general cyanosis (acrocyanosis), swelling of the jugular veins, hypotension. Blood oxygen saturation - 50% and below (RO 2 less than 50 mm Hg), RCO 2 more than 100 mm Hg. Art., pH is 7.15 and below. Oxygen inhalation does not always bring relief, and sometimes causes a deterioration in the general condition.

Features of pneumonia in children

- preceded viral infection

- acute onset, pronounced intoxication syndrome

- always short of breath

- objectively, percussion sound with a box tone, auscultatory more often breathing is hard, wheezing is moist, medium and finely bubbling diffuse.

Tendency to atelectasis;

Tendency to protracted flow;

Tendency to destructive processes;

Interstitial pneumonia is more often recorded in young children.

Treatment.

Bed rest until general condition improves.

Nutrition - complete, enriched with vitamins.

Antibiotic therapy.

Now there are soluble tablets of amoxiclav (solutab) that are convenient for children.

The starting antibiotic, given the etiology of pneumonia in older children, should be an antibiotic penicillin series(ampicillin, ampioks, oxacillin, carbinicillin), in the absence of effect - change to 1-3 generation cephalosporins, aminoglycosides. If mycoplasmal or chlamydial etiology is suspected - macrolides (erythromycin, sumamed, rovamycin).

• Antiviral if viral etiology. Ribavirin, rimantadine.

Expectorant therapy - bromhexine, mukaltin, ambroxol.

• Antipyretic - parcetamol.

Herbal medicine - decoctions of elecampane, thyme, coltsfoot, oregano, licorice root, ledum)

Vitamin therapy is indicated for prolonged or severe, complicated course of acute renal failure.

Biological products (lacto-, bifidumbactrin, bactisubtil) are indicated if the child receives several courses of antibiotics.

Physiotherapy. A) Inhalation with soda, saline-soda solutions. B) Heat treatment (ozocerite and paraffin applications). C) Massage, gymnastics, postural drainage, vibration massage.

Prevention comes down to the prevention of any respiratory viral infection (hardening, which helps to increase the child's cold endurance, vaccination during an epidemic, interferon prophylaxis, chemoprophylaxis). There are data in the literature on the high efficacy of pneumococcal and hemophilia vaccines for children older than 2 years. For the prevention of nosocomial pneumonia, hospitalization of patients in boxed wards, frequent ventilation of the wards, wet cleaning, personnel hygiene, elimination of the unreasonable use of "prophylactic" courses of antibiotics, and infection control are necessary.

Dispensary observation. Under dispensary observation the child is 10-12 months old. Children under 3 months old are examined 2 times a month in the first 6 months of convalescence, up to a year - 1 time per month. Children 1-2 years old - 1 time in 1.5-2 months, over 3 years old - 1 time per quarter.

Pneumonia is an infection of the lungs. It is characterized by the development of the process of inflammation in the tissue of the organ. Its nature may be viral, bacterial, fungal or other. Every year, about 500 thousand people around the world are diagnosed with pneumonia, 1.5% die due to the disease. The lethal outcome occurs due to incorrect diagnosis, when the disease is confused with other disorders and the wrong treatment is carried out.

For timely diagnosis it is important to know about the etiology and pathogenesis of pneumonia.

Course of the disease

The pathogenesis of pneumonia is based on the defeat of the lungs by an infectious agent. Usually, pathogenic microflora enters different parts of the lung through the bronchi - this is the broncho-organ route.

The hematogenous route of infection is also common. Such inflammation of the lungs occurs as a complication of sepsis or other infections.

The lymphogenous pathway is through the lymph. It is due to the activation of the microflora of the lungs.

Classification

There are specific types of pneumonia in accordance with the following groups:

• causes of development;
• duration of symptoms;
• type of pathogens;
• the way the microbe enters the lungs;
• focus of pathology and its prevalence.

Every kind inflammatory process characterized by characteristic features and symptoms. In this regard, in order to correctly identify the violation and prescribe treatment, the specialist first diagnoses the type, establishes the pathogenesis of pneumonia.

The severity of the pathological process to a greater extent affects the duration of therapy for pneumonia:

1. Mild form - therapy is implemented within 5 - 10 days.
2. Moderate severity - treatment takes 1 - 2 weeks.
3. Severe form - requires mandatory inpatient treatment for 2 - 3 weeks.

Etiology

Pneumonia is characterized by a large number reasons that can provoke its development. Inflammation can be non-infectious or infectious. The disease develops in isolation or as a complication of the primary disease. Bacterial infection is the most common among all provoking factors. It occurs on its own or is a complication of a viral or bacterial-viral infection.

The main causative agents of pneumonia include:

• Gram-positive pathogens: most often pneumococci - in 70 - 95%, staphylococci - no more than 5%, streptococci - 2.5%.
• Gram-negative enterobacteria: Pseudomonas aeruginosa, rod-shaped intestinal bacterium.
• Mycoplasma - from 6 - 20% of cases.
• Viruses, these can be adenoviruses, influenza, herpetic virus - these lesions account for 3-8%.
• Fungi - candida, yeast, etc.

Non-infectious causes include:

• Inhalation of poisonous substances belonging to the asphyxiating type is kerosene, oil, gasoline, chlorophos.
• Chest injuries - blows, bruises, compression.
• The influence of allergens - dust, pollen, pet hair, some medicines.
• Organ burns respiratory system.
• Radiation therapy, which is implemented for the treatment of cancerous tumors.

Factors that increase the risk of infection should also be identified. For children it is:

• hereditary violation of the immune system;
• intrauterine asphyxia or oxygen starvation fetus;
• congenital pathologies of the heart or lungs;
• hypotrophy;
• birth trauma;
• pneumopathy.

For teenagers:

• smoking;
• the presence of chronic infectious foci in the nasopharynx or nasal cavity;
• caries;
• acquired heart defects;
• poor immune function, and therefore frequent bacterial and viral infections.

In adults, pneumonia etiologies include:

• chronic respiratory pathologies of the lungs and bronchi;
• smoking and alcohol abuse;
• decompensated stage of heart failure;
• diseases of the endocrine system;
• drug addiction, in particular inhalation of the drug through the nose;
• immunodeficiency, which includes HIV and AIDS;
• prolonged forced stay in a lying position, for example, after a stroke;
• complication after chest surgery.
• prolonged forced stay in a lying position, for example, with a stroke;
  as a complication after surgical operations on the chest.

Epidemiology

AT modern world pneumonia occupies the 4th - 6th place in terms of death. The incidence of persons after 60 years is very high. Men are slightly more likely to suffer from this pathology.

The main risk factors are:

• hypothermia;
• age group after 60 years;
• smoking - cigarette smoke contributes to the disruption of the proper functioning of the cilia, it thickens sputum and inhibits the immunity of macrophages, impairs the production of immunoglobulin;
• primary, secondary immunodeficiency;
• periods after surgery, especially when the surgery involved the chest or upper abdomen;
• frequent contact with rodents and birds.

Favorable prognosis in the treatment of pneumonia in most cases depends on the effectiveness of antibiotics and the correct selection of drugs, its dosage. Proper diagnosis and appropriate treatment guarantee recovery in 3 to 4 weeks.

If you start the pathological process, then complications arise, a protracted form develops, characterized by high risks of death.

Everyone should understand that pneumonia is a serious and dangerous disease which takes a long time to heal. To prevent the development of such a condition, it is necessary to properly organize the microclimate in the house, maintain the immune system and pay enough attention to the state of health.

Pneumonia is an acute infectious and inflammatory process that occurs in the lungs and affects their respiratory sections - bronchioles, alveolar ducts and sacs. The danger of the disease lies in the high likelihood of complications from bronchitis and pleurisy to sepsis or acute heart failure. The pathogenesis of pneumonia depends on the route of penetration of pathogens into the human respiratory system.

Etiology of the disease

Pneumonia can develop in the human body as an independent disease or occur against the background of an existing inflammation of the upper respiratory tract. There are many reasons that can cause this pathology of the lungs. They are divided into two large groups - infectious and non-infectious factors..

The etiology of pneumonia of infectious origin involves the impact on humans of bacteria, viruses and fungi. The most common causative agents of the disease are the following microorganisms:

• Gram-positive bacteria. Pneumococci are the cause of pneumonia in 70-90% of cases, the mass fraction of staphylococci in the total number of cases of the disease is up to 5%, and streptococci - no more than 3%.
• Gram-negative microorganisms. The most common representatives of this group, causing damage to the lower respiratory tract, are various enterobacteria, Friedlander's bacillus, Pseudomonas aeruginosa. They account for 3 to 8% of cases.
• viral agents. Among the most common pathogens of pneumonia, herpes, influenza, measles, and adenoviruses are distinguished. Often they are activated during the cold period and affect children's organisms with weakened immunity.
• Fungi. Representatives of this species - candida and dimorphic fungi penetrate the organs of the respiratory system and develop in them with a sharp decrease immune function organism.
• Mycoplasma. Pathogen atypical form pneumonia is Mycoplasma pneumoniae. This microorganism is found in 10-20% of patients.

Among the factors of non-infectious origin, the following causes of pneumonia are distinguished:

1. Mechanical damage to the chest - bruises, fractures, blows, squeezing.
2. Thermal damage to the organs of the respiratory system - burns or severe cooling.
3. Exposure to allergens - dust, some medicines, plant pollen.
4. Inhalation of vapors of toxic substances.
5. Radiation therapy used in the treatment of cancer.

Experts identify the following factors that can contribute to the development of pneumonia in adult patients:

• chronic diseases of the upper respiratory tract;

• gastrointestinal and other diseases that cause aspiration of the contents of the oropharynx into the lungs;
• immunodeficiency states;
• general weakness of the body, accompanied by smoking, taking alcohol and drugs;
• heart failure;
• prolonged bed rest, causing a violation of the drainage function of the bronchi, stagnation of air in the lungs.

The mechanism of the development of the disease

In the pathogenesis of pneumonia, three ways of penetration of microflora into the organs of the respiratory system are distinguished:

1. Bronchogenic - by inhalation of air containing pathogenic organisms or by their aspiration from oral cavity or nasopharynx. Infection of the respiratory system is possible as a result of surgical interventions, for example, bronchoscopy.
2. Hematogenous - microorganisms that cause the development of pneumonia penetrate the respiratory system through circulatory system. This is possible with intrauterine infection of the fetus, sepsis, or the introduction of narcotic drugs intravenously.
3. Lymphogenous - the causative agents of the disease penetrate the lymph, with the current of which they spread throughout the body. This variant of infection penetration is less common than others, since it involves chest injuries.

The impetus for the development of pneumonia with the penetration of pathogens into the respiratory sections of the lungs is the weakening barrier function alveoli against the background of a general decrease immune system organism.

As a result of the entry of pathogenic microorganisms into the respiratory tract, one of the listed methods leads to the development of an inflammatory process, which is characterized by the following stages:

• Growth of colonization of the pathogenic bacterium. In case of violation of the integrity of the upper layer of the epithelium of the bronchi and dysfunction of the mechanism of production of mucous secretion, pathogenic microorganisms penetrate deep into the cells and actively multiply, which is accompanied by the release of toxins. This entails the development of an inflammatory process in the bronchi.
• Spread of inflammation. The defeat of the alveoli over time leads to the appearance of areas of collapse of the lung tissue, which causes a cough to clear the airways of mucus. However, due to the blockage of the bronchial passages, healthy parts of the organ are exposed to infection, and the inflammatory process progresses.
• Activation of the immune system. Enter the site of infection blood cells, the purpose of which is the fight against pathogenic organisms. The inflammatory process continues to develop, which is accompanied by the appearance of pain in the patient's head, tachycardia.
• exudate formation. As a result of the accumulation of mucus in the alveoli and the spread of the inflammatory process, the oxygen exchange between the tissues of the lungs and blood vessels worsens. The consequence of this phenomenon is the development of respiratory and oxygen deficiency. In severe cases, heart failure may occur.

Features of the occurrence of pneumonia in children

AT childhood pneumonia develops more often than in an adult, which is associated with the imperfection of the immune system and insufficient development of the respiratory system. Often, pneumonia occurs against the background of other diseases of the respiratory system - bronchitis, respiratory viral infections, tonsillitis.

The mechanism of the course of pneumonia in children is as follows:

• as a result of ARVI, mucous contents accumulate in the bronchi;
• due to the impossibility of removing mucus during coughing, the quality of lung ventilation deteriorates;
• viruses and bacteria accumulate in non-ventilated areas of the body, develop and multiply, which contributes to the development of pneumonia.

Experts identify the following risk factors for pneumonia in children:

• fetal hypoxia during fetal development;
• lesions in the process of labor activity;
• hereditary immunodeficiency;
• congenital pathologies of the structure of the respiratory system;
• the presence of cystic fibrosis.

Among adolescents, young men and women with acquired heart defects, weakened immunity, and the presence of chronic foci of infection in the sinuses are at risk.

The clinic of pneumonia is characterized by a combination of syndromes of pathological functioning of various organs and systems:

• intoxication of the body is manifested by headaches, general weakness, lack of appetite, pallor of the skin;
• the presence of inflammation is reflected in an increase in body temperature, the occurrence of chills, changes in blood counts;
• inflammatory processes in the lungs are characterized by the occurrence of wheezing, coughing with sputum.

In severe pneumonia, there may be symptoms of involvement of other body systems - jaundice, diarrhea, signs of kidney failure, changes in blood pressure and heart rhythms.

Diagnosis and treatment

To diagnose pneumonia, the specialist performs the following manipulations: listening to the patient's chest with a stethoscope, determining body temperature, performing a blood test.

Diagnostics also includes instrumental examination methods:

• chest x-ray;
• computed tomography;
• bronchoscopy;
• study of the pleural fluid.

Treatment of pneumonia is carried out in a hospital medical institution and consists of a set of procedures:

• the appointment of drugs that promote sputum discharge;
• reception medicines that eliminate the causative agent of infection;
• performing physiotherapy procedures;
• diet compliance.

The prognosis for recovery from pneumonia depends on many factors: the age of the patient, the type of pathogen, the state of the human immune system, and the timeliness of the start of treatment. An unfavorable outcome is most often observed with a severe course of the pathology, complicated by reduced immunity and bacterial resistance to antibiotic therapy.

734 0

Chronic pneumonia is a recurrent inflammatory process in the lungs of an infectious nature, which is the result of unresolved "acute pneumonia" and occurs in the same area of ​​the lungs against the background of limited pneumosclerosis.

social significance

Due to frequent exacerbations of chronic pneumonia, it gives significant losses due to temporary disability. With the occasionally observed development of secondary chronic bronchitis and COPD, and in the presence of secondary bronchiectasis - chronic abscess formation, permanent disability (disability) may develop.

The mortality rate in CP has not been studied. Death can occur with a pronounced exacerbation of the disease, especially in the presence of severe concomitant diseases.

Etiology

In our opinion, chronic pneumonia often develops as a result of viral-bacterial, mycoplasmal, viral-mycoplasmal and mycoplasmal-bacterial "acute pneumonia", characterized by a more severe and protracted course, a weakening of the general and local resistance of the body, and with mycoplasmal pneumonia - and a tendency to autoimmune reactions.

One of the reasons for the transition of "acute pneumonia" to chronic should be called various defects in treatment, in particular, late started and prematurely stopped treatment, irregular treatment, prescription of antibiotics in small doses and without taking into account the sensitivity of the causative agent to them. At the stage of prolonged pneumonia and during its transition to chronic pneumonia, superinfection or a change in the pathogen often develops, which requires correction of antibiotic therapy. Underestimation of this factor contributes to the development of CP.

For rational therapy it is important to know which microbes caused this exacerbation of CP. It has been established that the infectious agents responsible for the occurrence of chronic pneumonia and for the development of individual exacerbations of the disease often do not coincide.

Presumably, the nature of the microflora that caused the exacerbation is judged by clinical and radiological data, taking into account the epidemiological situation, but these questions have not been developed in relation to CP. In all cases, whenever possible, use laboratory methods etiological diagnosis of exacerbation of the disease, which completely coincide with those in "acute pneumonia".

Pathogenesis

In this case, it is necessary to single out two kinds of factors: those that precede the onset of "acute pneumonia", which turned into chronic, and those that arise in the course of "acute pneumonia". The significance of previous local and general changes is assessed depending on how much they contribute to the transition of the "acute pneumonia" that has arisen against this background into a chronic one. In the case of a significant increase in the transition compared to the control group of patients, the participation of these changes in the pathogenesis of chronic pneumonia is recognized.

These pathogenic factors include the following:

1. Anatomical and functional changes in the bronchopulmonary apparatus and pathology of the upper respiratory tract. Of primary importance is chronic bronchitis, which, due to the constant presence of an infection depot in the bronchi and a violation of the protective and cleansing function of the bronchi, contributes not only to the onset, but also to the further progression of CP.

A significant role in the pathogenesis of CP also belongs to local pneumosclerosis, which remains after past illnesses, especially tuberculosis. The “acute pneumonia” that arose against the background of pneumosclerosis is poorly absorbed. This is due to damage to the bronchi and impaired blood and lymph circulation in the area of ​​pneumosclerosis, which prevents the penetration of antibiotics into the pneumonic focus.

The pathogenetic role of diseases of the upper respiratory tract ( chronic sinusitis, more often sinusitis, as well as rhinitis, pharyngitis, tonsillitis, adenoids) is explained by the fact that these processes are a constant depot of the infection that penetrates the lungs through the bronchogenic route, as well as a violation of nasal breathing and a deterioration in pulmonary ventilation. Malformations contribute to the development of chronic pneumonia lung development(simple and cystic lung hypoplasia, desontogenetic bronchiectasis, etc.), as well as hereditary diseases such as cystic fibrosis and deficiency in 1-antitrypsin.

The unfavorable outcome of "acute pneumonia" is facilitated not only by the previous bronchitis, but also by the violations of bronchial patency that often occur in the course of "acute pneumonia".

2. Decreased local protective factors. The mechanisms of nonspecific protection of the bronchi and lungs are associated with the presence of complement, lysozyme, interferon, lactoferrin and nonspecific inhibitors of some viruses in the bronchial secretion. Cellular mechanisms of nonspecific protection of the bronchi and lungs are provided primarily by alveolar macrophages. Of particular importance in the protective reactions of the respiratory organs is given to local immunity, which consists of humoral, primarily secretory IgA, and cellular (sensitized T-lymphocytes) factors.

With prolonged pneumonia and with initial bronchial lesions, the mechanisms of nonspecific and immunological protection of the respiratory organs are disrupted, which contributes to the development of CP.

3. Decreased systemic mechanisms of nonspecific and immunological protection. The nature of these disorders in prolonged pneumonia is discussed in the 3rd chapter. With the development of CP, immunological disorders increase, but retain the same direction. The main violation is a decrease in the number and functional activity of T-lymphocytes, especially T-killers, while the activity of T-suppressors is often increased.

4. Development of autoimmune processes. For the first time, autoantibodies to the lung tissue and their pulmonocytotoxic effect were revealed by A.I. Borokhov (1973); further studies have confirmed these data. In the development of autoimmunization in CP, the role of infection is not excluded, since the commonality of antigenic determinants of lung tissue and some microorganisms that cause "acute pneumonia" is shown.

Other factors also take part in the pathogenesis of chronic pneumonia: toxemia and hypoxemia, impaired microcirculation in the area of ​​inflammation, a decrease in glucocorticoid and an increase in mineralocorticoid functions of the adrenal cortex.

pathological anatomy

At this stage, there is still no reason to talk about CP, since in many patients postpneumonic pneumosclerosis is a complete process, does not impair the quality of life of patients, and can be an accidental X-ray finding.

CP is evidenced by the development of repeated pneumonia against the background of pneumosclerosis. Strictly speaking, it is not the first acute pneumonia that leads to the formation of pneumosclerosis that passes into chronic pneumonia, but the repeated “acute pneumonia” that developed against the background of pneumosclerosis and is often distant from the first by a long light interval.

The morphological substrate of chronic pneumonia is a chronically current and periodically aggravated inflammatory process in the interstitial tissue against the background of limited pneumosclerosis.

Along with the development of local pneumosclerosis, chronic pancreatitis is naturally manifested by inflammatory changes in the bronchial tree according to the type of deforming bronchitis in the affected area. Thus, when making a diagnosis of CP, it is not necessary to note limited pneumosclerosis and segmental bronchitis, since they are included in the mandatory morphological substrate of CP.

Anatomical changes in chronic pneumonia depend on the phase of the disease. Distinctive feature phase of exacerbation is the presence of exudative changes in the alveoli; along with this, there is an exacerbation of bronchitis in the affected area and an increase in inflammatory changes in the interstitial tissue. However, even in the phase of remission, morphological changes, apparently, are not limited to the presence of pneumosclerosis.

In our opinion, the elements of inflammation in the interstitial tissue (“smoldering” inflammatory process) persist in the remission phase. These changes, combined with segmental, often deforming bronchitis, which is accompanied by the constant presence of an infection in the bronchi, create conditions for periodic exacerbations and progression of CP.

Classification

Table 1. Classification of chronic pneumonia

Primary CP develops in the absence of a previous pathology in the bronchopulmonary and immunological systems of the body (when making a diagnosis, the word “primary” is omitted). Secondary CP is formed against the background of malformations of the bronchi and lungs, metatuberculous pneumosclerosis, foreign bodies and bronchial tumors, bronchoadenitis, cystic fibrosis, primary and secondary immunodeficiency states

To determine the degree of activity of the inflammatory process, the severity is taken into account clinical signs, radiological abnormalities (length of infiltrative changes), temperature reaction (febrile, subfebrile, normal), changes erythrocyte sedimentation rate (ESR)(more than 40, 20-40, less than 20 mm/h).

By the nature of the course, we distinguish chronic pneumonia with rare exacerbations (up to two times a year), with frequent exacerbations (more than twice a year) and continuously recurring, when remissions are very short-term and not fully expressed.

Bronchiectasis in CP are secondary. Characteristics of secondary bronchiectasis and their differences from bronchiectasis are given in the chapter "Bronchiectasis". Complications of CP include secondary chronic diffuse bronchitis and chronic obstructive pulmonary disease (COPD), which, in turn, is associated with the development of chronic cor pulmonale and pulmonary heart disease.

Similarly, if there is a complication of bronchiectasis, it is possible to develop hemoptysis and general amyloidosis with kidney damage with an outcome in chronic kidney failure. However, we do not include these "complications of complications" in the classification of CP.

In patients with chronic pneumonia without secondary diffuse bronchitis and COPD, pulmonary insufficiency, even with an exacerbation of the process, as a rule, does not exceed grades I-II, and chronic pulmonary heart does not develop.

In addition to these characteristics, it is recommended to indicate the localization of the process (by lobes and segments) in the diagnosis.

An example of a diagnosis

Chronic pneumonia (with frequent exacerbations) with localization in the basal segments on the left in the stage of severe exacerbation (pneumococcal etiology) with secondary cylindrical and fusiform bronchiectasis in segments 8 and 9. Complications: respiratory failure (RD) I.