Differential diagnosis of pneumonia. Pneumonia: complex and unresolved issues of diagnosis and treatment

Book: “Diseases of the respiratory organs VOLUME 2” (N.R. Paleev; 1989)

Chapter 2. Acute pneumonia.

Diagnosis of lung diseases remains an urgent task. At present, even in specialized centers, the number of post-mortem discrepancies in diagnoses ranges from 4 to 7% [Pilipchuk N. S., 1983].

According to the differential diagnostic commission of VNIIP from the USSR, the diagnosis of acute pneumonia, established in polyclinics, is not confirmed in half of the patients [Kokosov A. N. et al., 1986]. Yu. A. Panfilov et al. (1980) point to the following differential diagnostic tasks:

• 1) delimitation of pneumonia from extrapulmonary diseases;
• 2) differentiation of pneumonia from other respiratory diseases;
• 3) differentiation of pneumonia according to various criteria (etiology, primary or secondary nature, extent of the lesion, course, complications, etc.).

Acute pneumonia should be distinguished from diseases of the cardiovascular system associated with stagnation in the pulmonary circulation. A differential sign of congestive rales in the lungs is their variability with a change in body position. Certain diagnostic difficulties arise when distinguishing between hypostasis and hypostatic pneumonia.

Edema of the interstitial tissue of the lung and concomitant atelectasis, with hypostasis, can cause a shortening of the percussion sound, especially in the presence of a small hydrothorax. Therefore, when recognizing hypostatic pneumonia, one should take into account the appearance in the posterior lower sections of light respiratory noises with a bronchial tint or even bronchial breathing; increased bronchophony, a sudden deterioration in the patient's condition and an increase in body temperature.

The differential diagnosis between focal pneumonia and pulmonary embolism is of particular importance for everyday therapeutic practice. The threat of thromboembolic complications increases sharply in phlebothrombosis and thrombophlebitis of various localization, in the acute period of myocardial infarction, in chronic heart diseases with the formation of heart failure and cardiac arrhythmias, after fractures of long tubular bones, in persons who are forced to stay on strict bed rest for a long time, in postoperative period, etc.

Thromboembolism of small branches of the pulmonary artery, which proceeds clinically as atypical pneumonia, is characterized by a sudden, often paroxysmal onset of shortness of breath or dyspnea with severe pain in the chest, often delayed (for 3-5 days) fever without preceding chills; the absence of severe intoxication at the onset of the disease, even at high temperature, hemoptysis with reddish sputum discharge.

The signs of overload of the right parts of the heart and the degree of hypoxemia detected in some cases do not correspond to the volume of infiltration in the lungs and are observed even in its absence.

Ictericity in thromboembolism of small branches of the pulmonary artery is not accompanied by intoxication and liver damage. Percussion and auscultatory symptoms (shortening of percussion sound in a limited area, hard breathing and moist rales, pleural friction noise or signs of pleural effusion) are nonspecific and are not significant in differential diagnosis.

An important role is played by an x-ray examination that reveals a bulging of the pulmonary cone, a sharp expansion and chopping of the lung root, regional disappearance or weakening of the vascular pattern, discoid atelectasis and a high standing of the diaphragm on the side of the lesion. After a few days, signs of a pulmonary infarction can be ascertained.

Typical darkening in the form of a triangle with an apex directed towards the root of the lung is rare. Usually darkening has the form of a strip, "rocket" or "pear", often with the involvement of the pleural membranes and the presence of both exudative and adhesive phenomena. Typically, the formation of new focal shadows against the background of ongoing antibacterial treatment. Hemogram changes are nonspecific. Of the biochemical indicators, an increase in the level of lactate dehydrogenase and bilirubin is important, while the activity of glutamate dehydrogenase remains within the physiological limits.

In patients with acute respiratory viral infection, it is necessary to exclude pneumonia by physical and necessarily X-ray methods of investigation with increased dyspnea, chest pain, cough, an increase in the amount of sputum and especially a change in its nature, an increase in malaise, fever. One of the first symptoms of pneumonia at the end of a viral infection is the second wave of fever.

Diagnosis of viral, mycoplasmal, or rickettsial pneumonia always requires a chest X-ray.

Differentiation of acute pneumonia and bronchogenic cancer requires in-depth X-ray, bronchoscopic and multiple cytological studies, especially in older men with recurrence of acute pneumonia in the same area of ​​the lung.

It is important to take into account the presence on the lateral radiograph of a pronounced shadow superimposed on the root of the lung, the discrepancy between the severity of dyspnea and the volume of pulmonary infiltration, the development of a dry cough before an increase in body temperature, hemoptysis with "unmotivated" chest pain.

Differential diagnosis of acute pneumonia and infiltrative pulmonary tuberculosis sometimes presents significant difficulties, especially when pneumonia is localized in the upper lobes of the lungs and tuberculous lesions in the lower lobes.

It should be borne in mind that the acute onset of the disease occurs with pneumonia twice as often. This corresponds to the symptoms of intoxication, the rapid development of shortness of breath, cough with sputum, chest pain. For infiltrative tuberculosis, a gradual or asymptomatic onset of the disease and the absence of the effect of conventional antibiotic therapy are more indicative.

Leukocytosis with a shift of the leukocyte formula to the left and an increase in ESR are more characteristic of pneumonia, lymphocytosis - tuberculosis. The most important diagnostic value is the detection of Mycobacterium tuberculosis in sputum, while the results of the Mantoux test do not always help the correct recognition of the pathological process.

Thus, according to our observations, a positive tuberculin test was recorded in 39.2% of patients with pneumonia, and a negative one - in 13.3% of patients with tuberculosis.

Sometimes tuberculous lobitis with an acute onset of the disease is mistakenly regarded as lobar lobar pneumonia. The anamnesis, the timing of the regression of the infiltrate during treatment, have a differential diagnostic value. Even more often, another form of tuberculosis is mistaken for croupous pneumonia - caseous pneumonia, which can begin acutely, with chills and manifest itself as a change in percussion sound, bronchial breathing, rusty sputum and the corresponding x-ray picture.

However, the sputum soon becomes greenish, purulent; especially sonorous rales are heard; hectic fever, night sweats, signs of lung tissue decay are noted; Mycobacterium tuberculosis is cultured.

In differential diagnosis, predisposing probable factors of tuberculosis should be taken into account [Kornilova 3. X., Yurchenko L. N., 1986]. The first group of factors includes frequent and prolonged colds, diabetes mellitus, alcoholism, smoking, silicosis, treatment with glucocorticoids, the second group includes contact with a patient with tuberculosis, previous tuberculosis, positive tuberculin test, lack of effect from nonspecific antibiotic therapy, detection of Mycobacterium tuberculosis and others

X-ray signs systematized by A. I. Borokhov and P. G. Dukov (1977) and reflected in Table. 2.8. It is necessary to emphasize the importance of X-ray examination in the lower lobe localization

tuberculosis. At the same time, a focal structure of blackout with calcified inclusions and foci of dissemination around the main pathological focus is revealed on the lateral tomogram [Vorokhov A. I., Dukov P. G., 1977]. Occurring differential diagnostic difficulties justify the recommendations of R. Hegglin (1965), according to which each pulmonary process must be considered tuberculous until its belonging to another group of diseases is absolutely identified.

Complications of acute pneumonia.

Viral-bacterial pneumonia is often accompanied by acute bronchitis, tracheitis, laryngitis, sinusitis, otitis media. These pathological processes can be considered rather as accompanying acute pneumonia, rather than complicating its course.

The most frequent complications of acute pneumonia are those or other violations of the respiratory system. These include primarily serous-fibrinous or purulent pleurisy. Pleural effusion is noted on average in 40% of patients with bacterial pneumonia.

It has been established that the longer the patient did not seek medical help after the onset of symptoms of the disease, the more likely he was to develop a pleural effusion. In 10-15% of patients with acute pneumonia, a slight pleural effusion is observed, which is rapidly absorbed with adequate therapy. Each patient with croupous pneumonia develops dry pleurisy.

Such forms of pleurisy were not considered by E. M. Gelshtein and V. F. Zelenin (1949) as a complication of lobar pneumonia. A complication, in their opinion, is the accession to pneumonia of a significant serous-fibrous effusion at the height of pneumonia (parapneumonic pleurisy) or after a crisis (metapneumonic pleurisy). Empyema was observed by them in approximately 2% of patients.

Suppurative processes in the lung tissue occur on average in 2.5-4% of patients with acute pneumonia [Fedorov B.P., Wol-Epshtein G.L., 1976; Gogin E. E., Tikhomirov E. S., 1979]. The clinical picture of these complications is reflected in the chapter "Abscess and gangrene of the lung". A complication of destructive processes in the lungs are, in turn, spontaneous pneumothorax and pyopneumothorax.

In severe pneumonia in patients with chronic obstructive bronchitis (especially in elderly and senile patients), with a massive, confluent nature of the inflammatory process and lung tissue destruction, acute respiratory failure may develop, associated with a drop in oxygen tension in arterial blood (Po2) or an increase in tension carbon dioxide in it (Pco2), or by both shifts together.

Based on this, hypoxemic and hypercapnic forms of acute respiratory failure are distinguished, although both types of disorders can be simultaneously observed in the same patient, but one of them usually dominates.

Hypercapnic form of acute respiratory failure with a rise in the level of Pco2 above 40 mm Hg. Art. develops mainly with severe respiratory disorders, respiratory depression and previous chronic obstructive pulmonary diseases.

The first signs of acute respiratory failure are confusion and impaired consciousness, sometimes psychotic disorders (especially in people who abuse alcohol), an increase in sinus tachycardia and the appearance of new arrhythmias, arterial hypertension or, conversely, hypotension, distal tremor, increased cyanosis and sweating. With the threat of this complication, and even more so its development, regular monitoring of arterial blood gas parameters is necessary.

Arterial hypoxemia, hypercapnia and metabolic acidosis, combined with severe intoxication and alveolar hypoventilation, create conditions for the formation of pulmonary edema in viral or massive confluent pneumonia.

Usually this complication occurs suddenly, but sometimes there is a prodromal period in the form of a feeling of pressure behind the sternum, anxiety, dry cough, feeling of lack of air. The patient takes the position of orthopnea; breathing is difficult, requires physical effort, severe shortness of breath; tachycardia; bubbling breath with (excretion of white, yellowish or pink frothy sputum; percussion sound over the lungs with a tympanic tinge; a lot of wet rales of various sizes are heard.

On radiographs, inhomogeneous blackouts are determined initially in the lower sections with a gradual filling of all lung fields.

Acute cor pulmonale is observed with confluent total pneumonia. The risk of developing acute cor pulmonale, as well as acute respiratory failure, increases when pneumonia develops against the background of chronic obstructive bronchitis, emphysema, and bronchial asthma.

Characterized by increased dyspnea, cyanosis and tachycardia, acute enlargement of the liver, swelling of the jugular veins, electrocardiographic signs of overload of the right heart.

In severe croupous pneumonia (especially against the background of cerebral atherosclerosis or chronic alcoholism), intoxication psychoses may develop during a critical drop in body temperature; small pulse.

Septic complications of acute pneumonia are extremely difficult, especially infectious-toxic (septic) shock. Croupous pneumonia (especially left-sided) can be complicated by purulent pericarditis and mediastinitis. Staphylococcal, rarely streptococcal and pneumococcal pneumonias can sometimes cause septic endocarditis.

The septic process in bacterial pneumonia may result in the development of secondary purulent meningitis. With mycoplasmal pneumonia, meningoencephalitis occasionally occurs, with influenza - encephalitis. There are also infectious-toxic lesions of the liver, kidneys and urinary tract, joints, salivary glands.

Infectious-allergic myocarditis can be with all types of pneumonia; with septic complications, an infectious-toxic lesion of the myocardium joins this. In the clinical picture of the general infectious process, the symptoms of myocarditis in most cases are secondary. However, in some cases, myocarditis can be severe, complicated by progressive heart failure and lead to death [Sumarokov AV, Moiseev VS, 1978].

Treatment of pneumonia It must be early, rational, individual and complex. Components of the medical complex: fight against infection and intoxication; activation of the body's defenses; normalization of disturbed functions of organs and systems; acceleration of regenerative processes.

The complex of therapeutic measures K. G. Nikulin (1977) proposes to subdivide depending on the stage of the pneumonic process:

• 1) bacterial aggression;
• 2) clinical stabilization;
• 3) morphological
• 4) functional recovery.

At the stage of bacterial aggression and stabilization of the process, antibiotic therapy should be the main one.

Patients with acute pneumonia are subject to treatment in a hospital, although bed rest for an uncomplicated course is prescribed only for a period of fever.

Treatment at home is possible with a mild course of the disease and carrying out therapeutic measures in full. After normalization of body temperature, the patient is allowed to walk and serve himself.

At the same time, proper patient care has not lost its importance to date (a spacious room, good lighting and ventilation). The bed should be with a fairly firm mattress, which is comfortable for the patient and facilitates his examination. Cool air is maintained in the ward, which improves sleep, deepens breathing and stimulates the mucociliary function of the bronchial tree.

Oral care and plentiful (up to 2.5-3 liters per day) drink (fruit drinks, liquid fruit, berry, vegetable juices) are necessary, with diuresis of at least 1.5 liters per day. The diet of a patient with pneumonia during a feverish period consists of a variety of easily digestible foods containing a sufficient amount of proteins, fats, carbohydrates, trace elements, and vitamins.

Antibacterial therapy

Antibacterial therapy should be:

• 1) early and course, taking into account the nature of the pathological process and the patient's condition;
• 2) directed against an established or suspected agent;
• 3) adequate for the choice of the drug (pharmacokinetics and pharmacodynamics) acceptable doses (single and daily) and method of application;
• 4) correctable during treatment, depending on the clinical effect, the sensitivity of the pathogen and the possible side effects of the drug.

The severity of the patient's condition determines the choice of an antibacterial drug of a bactericidal type of action and the possibility of its intravenous administration. Early etiotropic therapy mainly with one (in accordance with the etiology) drug gives the same immediate and long-term results as long-term treatment with combinations of antibacterial agents without taking into account the etiology of the disease.

When establishing an early etiological diagnosis, combinations of antibacterial agents are required only for pneumonia caused by gram-negative bacteria (Klebsiella, Pseudomonas aeruginosa, Proteus, etc.), with the association of pathogens and the absence of one antibiotic that affects all pathogenic agents, resistance of the pathogen to several antibiotics, as well as with in order to overcome the emerging resistance of microorganisms in case of need for long-term treatment with antibiotics.

It should be borne in mind that the acquired resistance in microorganisms depends on the duration of use and the breadth of action of the antibiotic, on the type of microorganism and the type of antibiotic. Naturally, bacteriological examination of sputum with a quantitative calculation of the content of microorganisms in 1 ml increases the accuracy of the etiological diagnosis of pneumonia, and the determination of the antibiogram contributes to the choice of a therapeutic drug.

Therapy with a drug selected according to epidemiological and clinical and radiological data without bacterioscopic, bacteriological, immunological confirmation of the etiology remains largely empirical.

Adequate etiotropic therapy provides a decrease in body temperature after 2-3 days, after which treatment is continued at an effective dose for 3-4 days of a fever-free state with the possible withdrawal of the drug when the leukogram normalizes or, according to most authors, after 6 days of normal body temperature. The presence of residual infiltration of the lung tissue after 5-6 days of normal temperature is not an obstacle to the abolition of the antibacterial drug.

Accounting for the belonging of an antibiotic to a certain chemical group excludes the use of the same type of drugs and allows you to rationally switch from one group to another when toxic or allergic reactions occur.

For example, if a patient is allergic to penicillins, they can be treated with macrolides due to the different chemical structure of the core of these medicines. It should be emphasized that with the development of resistance to an antibiotic from a certain chemical group, resistance to other drugs of this group also arises.

There is also cross-resistance between antibiotics of different chemical groups, for example, between erythromycin and levomycetin, semi-synthetic penicillins (methicillin, cloxacillin) and cephaloridine.

The type of antibiotic action - bacteriostatic or bactericidal - is essential. The acute course of the inflammatory process, the serious condition of the patient, signs of suppression of natural immunity dictate the need for the use of drugs of a bactericidal type of action. The type of action is also taken into account in combination therapy with antibiotics. It is irrational to combine a bactericidal and bacteriostatic drug.

The spectrum of action of the antibiotic determines the choice of the drug depending on the etiology of the disease, i.e. the nature of the microorganism. It is natural, for example, for pneumonia caused by pneumococcus (gram-positive microorganism), to use a drug from the group of antibiotics with an average spectrum of action on gram-positive microorganisms.

At the same time, one should not forget about the possible resistance of microorganisms to antibiotics of each group. Therefore, the antibiotic is prescribed taking into account this very important factor determining the success of treatment. Different colonies of microorganisms may differ in sensitivity to the antibiotic.

This must be taken into account when analyzing the results of therapy, when incomplete effectiveness can be overcome by increasing the concentration of the antibiotic in the blood. In principle, an antibiotic dose is considered adequately effective if a blood concentration of 2-3 times the minimum inhibitory concentration (MIC) can be achieved.

However, the use of broad-spectrum antibiotics (i.e., those that affect gram-positive and gram-negative cocci) is not always justified. So, with resistance to benzylpenicillin in a patient with staphylococcal pneumonia, one can resort to methicillin or oxacillin, drugs that are not inactivated by staphylococcus penicillinase.

In order to solve practical issues of antibacterial tactics, one should keep in mind the degree of sensitivity of microorganisms to the agent chosen for treatment. Distinguish resistance in biological and clinical terms.

Biological resistance means that higher concentrations of antibiotics are required to control a microorganism of a given species or strain than other species or strains of the same microorganism. In clinical terms, resistance is defined as the inability to create a therapeutic concentration of the drug in the focus of infection due to the peculiarities of its pharmacokinetics or toxicity.

So, if pneumonia is complicated by pleural empyema and confirmed by the study of the sensitivity of the pathogen to penicillin, intramuscular and intravenous administration of this drug will be ineffective, since its concentration in the pleural cavity will be only 20-30% of its content in the blood. With abscess formation, the content of the antibiotic in the focus decreases due to the pyogenic membrane.

This barrier is overcome by the influence of the antibiotic into the focus of infection through a catheter inserted into the drained bronchus. Thus, the method of administration of an antibiotic or other agent is a matter of therapeutic tactics and is justified by the need to create an effective concentration in the pneumonic focus.

In pulmonology, the following methods of drug administration are used: inside, intramuscular, intravenous, intratracheal, transtracheal, iotrabronchial and transthoracic. The indication for intravenous administration of antibiotics is the need to quickly create a high concentration of the drug in the blood. If multiple infusions and prolonged administration of antibiotics are necessary, a permanent catheter is placed in the jugular or subclavian vein.

The transthoracic method of using drugs is indicated in the presence of large abscess cavities located superficially. It is possible to simultaneously use several methods of administration, for example, intravenous, intramuscular and intrabronchial in sanation bronchoscopy in patients with severe staphylococcal pneumonia [Gembitsky E. V. et al., 1982].

A measure of the sensitivity of microorganisms to antibiotics in laboratory conditions is the minimum concentration of an antibiotic calculated per 1 ml of nutrient medium, which retards the growth of the causative agent of the disease under stationary conditions of the experiment.

Under clinical conditions, the division of microorganisms into more sensitive and resistant should be carried out on the basis of the compliance of the minimum inhibitory concentration of the antibiotic, determined in the laboratory, with the concentration of the drug created in the blood, urine, bile, and organ tissues when non-toxic doses are administered.

For practical purposes, it is recommended to divide microorganisms according to the degree of sensitivity to antibiotics into 4 groups. The first group includes sensitive microorganisms; regardless of the severity of the disease they cause, the commonly used doses of antibiotics are sufficient to achieve a therapeutic effect.

The second group includes moderately sensitive microorganisms; to achieve a therapeutic effect in the disease caused by them, increased doses of the antibiotic are needed. The third group includes weakly sensitive microorganisms; the therapeutic effect in these cases can be achieved with a high concentration of the antibiotic in the focus of infection, in particular, the introduction of the drug directly into the focus of inflammation.

The fourth group includes resistant microorganisms; in this situation, the therapeutic effect cannot be achieved with this antibiotic.

The minimum inhibitory concentrations of antibiotics according to the sensitivity groups of microorganisms are presented in Table. 2.9.

There are natural, primary and acquired resistance of a microorganism to an antibacterial agent. The natural (natural) resistance of bacteria to a particular antibacterial agent is specific

feature of a microorganism, its biological essence. As a result, the microorganism reacts only to certain antibiotics and does not react to others (for example, E. coli is naturally resistant to penicillin).

Acquired resistance of microorganisms occurs during antibiotic treatment. The mechanism of this resistance and the rate of its occurrence are different. In clinical practice, the problem of resistance of staphylococci, as well as a number of gram-negative microorganisms (Klebsiella, Proteus, Salmonella, etc.) is currently particularly relevant.

At the same time, the rate of emergence of acquired resistance should be taken into account. Rapidly developing resistance to streptomycin, erythromycin, kanamycin; slowly - to chloramphenicol, penicillin, tetracycline, gentamicin, lincomycin.

Therefore, a categorical recommendation to change antibiotics during long-term treatment every 7-10 days cannot always be accepted [G. B. Fedoseev, I. M. Skipsky, 1983]. It must be emphasized that the emergence of rapid resistance can be prevented by the simultaneous use of 2-3 drugs.

If it is necessary to replace the drug, it is necessary to take into account the possibility of cross-resistance not only within one group of antibiotics, but also between groups.

Cross-resistance is observed in the following groups:

• 1) tetracyclines (among themselves);
• 2) tetracycline and levomycetin (for gram-negative flora);
• 3) aminoglycosides (kanamycin, neomycin, gentamicin) and streptomycin (but not vice versa);
• 4) erythromycin, oleandomycin, lincomycin;
• 5) erythromycin, chloramphenicol;
• 6) methicillin and cephaloridine;
• 7) penicillin and erythromycin (partial resistance).

A combination of antibiotics is used to improve the effectiveness of therapy. But this should not be a simple pile of drugs.

The combined use of antibiotics has its own strict indications:

• 1) unknown bacteriological nature of the infection;
• 2) the presence of mixed flora;
• 3) severe diseases that are not amenable to the influence of a certain antibiotic;
• 4) persistent infections.

According to S. M. Navashin and I. P. Fomina (1982), combined antibiotic therapy should be based on knowledge of the mechanism of action and the spectrum of antibiotics, the characteristics of the pathogen, the nature of the course of the pathological process and the patient's condition.

To prevent polypharmacy, the use of combination antibiotic therapy should be justified every time (Table 2.10). Using the synergy of action of various drugs, it is sometimes possible to prevent or reduce a side effect by reducing the dose of each antibiotic.

Analyzing the general provisions of adequate combined antibiotic therapy for acute pneumonia, it should be noted that antibiotics in combination with sulfonamides are used for pneumonia caused by Klebsiella, Pseudomonas aeruginosa, various mixed infections, as well as actinomycosis, plague, listeriosis.

In all cases, the combination of sulfonamides (especially prolonged action) with antibiotics does not increase the therapeutic effect, but increases the risk of adverse reactions [Navashin S. M., Fomina I. P., 1982].

In acute pneumonia, early antibiotic therapy is started before the pathogen is isolated and its antibiogram is determined. The choice of the initial antibacterial agent is based on epidemiological data, clinical and pathogenetic and clinical and radiological features of the disease, taking into account the patient's history before the development of acute pneumonia.

Until an etiological diagnosis is established, antibiotic therapy remains empiric in nature. With regard to bacterial pneumonia, this difficulty is overcome to some extent by the study of a Gram-stained sputum smear. The main pathogens isolated in various clinical forms of pneumonia are given in Table. 2.11.

In our country, the most famous scheme for choosing an antibiotic for acute pneumonia of unknown etiology, proposed by S. M. Navashin and I. P. Fomina (1982). Antibiotics have been identified for each form of acute pneumonia

the first and second stages (Table 2.12). Instead of cephalothin, you can use kefzol (cefazolin, cefamezin) or other drugs from the cephalosporin group.

For staphylococcal etiology of acute pneumonia, first-generation cephalosporins are preferred because they are most resistant to staphylococcal penicillinase.

The causative agents of acute pneumonia that occurs in a previously healthy person are usually considered viruses, pneumococci, mycoplasma and legionella. In this regard, the treatment of such patients most often begins with penicillin (at an average dose of up to 6,000,000 units / day intramuscularly).

The drug of choice is erythromycin (0.25-0.5 g orally every 4-6 hours or 0.4-0.6 g, sometimes up to 1 g / day intravenously), especially effective for mycoplasma or legionella pneumonia

research institutes. The development of destructive processes in the lung tissue makes it advisable to use cephalosporins: cephaloridine (ceporin) up to 6 g / day, cefazolin (kefzol) 3-4 g / day or cephaloxime (claforan) up to 6 g / day intramuscularly or intravenously by drip. With intramuscular injection of 1 g of klaforan, its content in sputum reaches 1.3 μg / ml, 20-130 times higher than the MG1K of possible pathogens.

Certain difficulties arise in the treatment of acute pneumonia in pregnant women, in elderly and senile people, as well as in the development of secondary pneumonia in people hospitalized for other diseases.

In the first case, natural and semi-synthetic penicillin, erythromycin, fusidine and lincomycin are considered the drugs of choice; in the second, semi-synthetic penicillins (in particular, ampicillin 2-4 g / day intramuscularly); in the third case, two options for empirical antibiotic therapy are provided.

If a limited pulmonary infiltrate is found, the most likely causative agents of pneumonia are aerobic gram-negative microorganisms (Klebsiella, Escherichia coli, Pseudomonas aeruginosa) or staphylococcus aureus.

Such patients are prescribed a combination of antibiotics from the group of cephalosporins and aminoglycosides. If improvement is observed within 72 hours, then this therapy is continued for 2 weeks.

In the absence of effect and the impossibility of invasive diagnosis of the etiology of pneumonia, the ongoing therapy is expanded by including drugs aimed at legionella (erythromycin), pneumocystis (biseptol) and fungi (amphotericin B).

In the second variant of empirical antibiotic therapy, used in patients with diffuse infiltrate in the lungs, Bactrim is immediately added to the combination of antibiotics of cephalosporins and aminoglycosides.

Empiric antibiotic therapy with a favorable course of the disease should continue until the patient's body temperature is stable. When using penicillin, cephalosporins or erythromycin, its duration is usually at least 10 days.

The severe course of the disease makes it necessary to carry out antibiotic therapy until the complete resorption of infiltrative changes in the lungs. At the same time, the preservation of radiological changes with the complete normalization of the patient's well-being cannot serve as an indication for the continuation of antibiotic therapy. In Legionnaires' disease, treatment with erythromycin lasts 21 days.

It should be noted that the use of broad-spectrum antibiotics and the combination of antibacterial agents that affect both the pathogenic and non-pathogenic flora of the patient pose a threat of the emergence of resistant species of microorganisms or the activation of saprophytes, which under normal conditions do not affect the lungs.

It is known that the prescription of excessive doses of antibiotics can cause pulmonary superinfection with persistent fever. To avoid this, it is desirable to use antibacterial agents in the smallest effective doses; at the same time, one should strive for monotherapy, which is preferred in modern pulmonology [Sergeyuk E. M., 1984].

Combined antibiotic therapy is recognized as justified in cases of severe disease requiring immediate treatment without an etiological diagnosis.

Rational antibiotic therapy, unlike empirical therapy, is determined by the etiological orientation, taking into account the pharmacokinetics and pharmacodynamics of the prescribed drug (Table 2.13). Approximate doses of antibacterial drugs in the treatment of acute pneumonia are given in Table. 2.14.

Penicillins and cephalosporins are currently the main antibacterial drugs used in medical practice in general, including in the treatment of acute pneumonia. This is due to their high activity against

shenii microorganisms and minimal compared with other antibiotics, toxicity. These groups of antibiotics are generally characterized by a bactericidal type of action, high activity against gram-positive and gram-negative microorganisms, and good tolerance even with prolonged use.

If the "old", traditionally applied

For antibiotics (benzylpenicillin, streptomycin, tetracycline, levomycetin), the frequency of isolation of resistant strains is 40-80%, then for semi-synthetic penicillins and cephalosporins it varies within 10-30% [Navashin S. M., Fomina I. P., 1982] .

In the class of penicillins, penicillinase-resistant drugs (methicillin, oxacillin and dicloxacillin), resistant to the action of staphylococcal penicillinase, and broad-spectrum drugs - ampicillin, ampiox (a combined form of ampicillin with oxacillin), carbenicillin are distinguished.

Cephalosporin preparations are distinguished by a wide spectrum of antibacterial action, resistance to staphylococcal penicillinase, high activity against benzylpenicillin-resistant penicillinase-forming staphylococci; when using these agents, incomplete cross-allergy with penicillins is possible.

When developing therapeutic tactics, it must be taken into account that oxacillin and dicloxacillin have pronounced lipophilic properties and acid stability, which is associated with their good absorption and efficiency when taken orally.

Methicillin is destroyed by gastric acid, therefore, it is effective only when administered parenterally. In relation to penicillinase-forming staphylococcus, the activity of oxacillin and dicloxacillin is 5-8 times higher than the activity of methicillin.

Dicloxacillin is 2-4 times superior to oxacillin and methicillin in terms of activity against benzylpenicillin-sensitive and resistant strains of staphylococci, therefore it is used in much lower doses (2 g, in severe cases no more than 4 g), while oxacillin have to appoint 6-8 g or more.

All three penicillinase-stable penicillins are characterized by lower (compared to benzylpenicillin) activity against staphylococci that do not form penicillinase, as well as pneumococci and group A streptococci; therefore, in pneumonia caused by these pathogens, benzylpenicillin remains the antibiotic of first choice.

At the same time, none of the penicillinase-stable penicillins is ineffective in pneumonia caused by the so-called methicillin-resistant multi-resistant staphylococci. For therapeutic practice, the possibility of cross-allergy to these three drugs is essential.

A group of semi-synthetic broad-spectrum penicillins is represented by ampicillin, carbenicillin and ampiox. Ampicillin has established itself as a highly effective agent in the treatment of pneumonia.

Most strains of Proteus, Escherichia coli and Haemophilus influenzae are sensitive to it. Ampicillin is highly active (at the level of benzylpenicillin) against pneumococci and group A streptococci.

Compared with other penicillins, it has the most pronounced activity against enterococci.

However, ampicillin, like benzylpenicillin, does not act on penicillinase-forming staphylococci. When isolating penicillinase-negative staphylococci, preference should be given to benzylpenicillin.

Ampicillin is also ineffective in diseases caused by (3-lactamase-producing strains of Escherichia coli, Proteus, Enterobacter and Klebsiella. The absence of the effect of ampicillin in diseases caused by Pseudomonas aeruginosa is due to the natural resistance of these microorganisms to this antibiotic.

The antibacterial effect of ampicillin is enhanced when combined with aminoglycosides (kanamycin, gentamicin) and oxacillin.

Ampioks - a combined preparation of ampicillin and oxacillin - is used as a means of rapid action in the form of injections and inside. The drug is active against penicillinase-forming staphylococci, streptococci, Escherichia and Haemophilus influenzae, Proteus and is especially indicated for microbial associations before obtaining the results of the antibiogram.

Significant activity against Pseudomonas aeruginosa, all types of Proteus and some bacteroids has carbenicillin. It acts on other gram-negative microorganisms in the same way as ampicillin. The drug is indicated primarily for the destruction of lung tissue caused by Pseudomonas aeruginosa, Proteus of all kinds and ampicillin-resistant strains of Escherichia coli.

Despite its wide spectrum of activity, carbenicillin is inferior to other antibiotics in the treatment of pneumonia caused by gram-positive pathogens. The combination of carbenicillin with penicillinase-resistant penicillins, as well as with gentamicin, is considered one of the optimal methods for the treatment of secondary pneumonia.

In severe pneumonia, obviously mixed flora, or the impossibility of identifying it, cephalosporins are the drugs of choice. First-generation cephalosporins (cephalothin, cephaloridine) are active against gram-positive and gram-negative cocci, most rod-shaped microorganisms.

Cephalosporins of the next generations are distinguished by more pronounced activity and a wider spectrum of action. Cefuroxime is superior in activity to cephalothin and cephaloridine against Klebsiella, Proteus and other microorganisms; cefotaxime is characterized by even higher activity. In severe pneumonia with lung tissue destruction, cefuroxime is the drug of choice for monotherapy.

One of the leading places in the treatment of pneumonia caused by gram-negative rods (Ps. aeruginosa, Proteus) or their associations with gram-positive cocci is occupied by aminoglycosides. After a single intramuscular injection of gentamicin at a dose of 80 mg, 89.7% of the dose taken is released in 24 hours; while most of the drug (80% of the administered dose) is excreted in 8 hours.

These data determine the threefold administration of the daily dose of the drug. With a daily dose of 240-320 mg of gentamicin, a good effect is achieved in 71.4% of patients, a satisfactory one - in 28.6% [Zamotaev I.P. et al., 1980].

If it is necessary to expand the spectrum of action or enhance the bactericidal effect, aminoglycosides are used in combination with semi-synthetic penicillins or cephalosporins. Such combinations are usually prescribed before establishing a bacteriological diagnosis and determining the antibiogram of the pathogen, based on the expansion of the spectrum of action, including the alleged pathogens. The drugs are used in medium, rather than maximum doses, which helps to reduce the frequency of side effects.

In connection with the nephrotoxicity of cephaloridine and gentamicin and the risk of summation of this effect in their combination, it is advisable to combine gentamicin with cefazolin.

Kanamycin is also a broad-spectrum antibiotic - the second drug in the treatment of purulent-inflammatory pulmonary diseases caused mainly by gram-negative microorganisms resistant to other antibiotics, or by a combination of gram-positive and gram-negative microbes.

Of the tetracycline drugs used in the treatment of pneumonia, doxycycline (a semi-synthetic derivative of oxytetracycline) is of particular interest. The drug is active against most gram-positive and gram-negative microorganisms and has an exceptional duration of action.

The antibiotic is rapidly absorbed from the gastrointestinal tract and remains in high concentration in biological fluids and tissues during the day.

With normal kidney function, 1 hour after taking 0.1 g of doxycycline, the concentration of the drug in the blood serum reaches 1.84 μg / ml, increases after 2-4 hours and remains at a high level (2.8 μg / ml) up to 12 hours [ Zamotaev I.P. et al., 1980]. On the first day, the drug is prescribed at 0.1 g every 12 hours in the following days at 0.1 g / day. When using doxycycline in the treatment of acute pneumonia, a cure is observed in 64.1% of patients, an improvement in 28.1% [Slivovsky D., 1982].

Lincomycin is indicated for the treatment of acute pneumonia caused by gram-positive microorganisms resistant to other antibiotics (staphylococci, streptococci, pneumococci), as well as for allergies to penicillin group drugs.

The use of lincomycin may be accompanied by severe side effects. In this regard, the drug should not be prescribed if other less toxic antibiotics are effective. Lincomycin-resistant pneumococci, viridans, and pyogenic streptococci are rare. At the same time, in the course of treatment, the development of resistance of staphylococci to the antibiotic is possible.

After 6-10 days of therapy with lincomycin, 20% or more strains of staphylococci resistant to its action are sown, therefore, long-term use of the antibiotic requires constant monitoring of the sensitivity of the pathogen.

Fusidin is an alternative drug against staphylococci, including those resistant to other antibiotics. The maximum concentration of the drug in the blood is reached 2-3 hours after its ingestion and remains at the therapeutic level for 24 hours.

In case of staphylococcal lung destruction, especially caused by methicillin-resistant strains, it is recommended to use combinations of fusidine with methicillin, erythromycin, novobiocin, rifampicin.

Rifampicin is a broad-spectrum antibiotic with bactericidal activity against Gram-positive microorganisms and Mycobacterium tuberculosis.

In acute pneumonia, the drug is prescribed primarily in cases where the disease is caused by multiresistant staphylococci [Pozdnyakova VP et al., 1981; Navashin S. M., Fomina I. P., 1982].

Treatment with rifampicin should be carried out under close observation and control of the antibiogram, since resistant strains of bacteria can appear relatively quickly with its use. The duration of treatment is set individually depending on the severity of the disease.

Erythromycin is the main treatment for legionella pneumonia and an alternative drug for pneumococci, streptococci, staphylococci, rickettsiae. Erythromycin has predominant activity against coccal forms of microorganisms, including strains of staphylococci resistant to penicillin, tetracycline, streptomycin and other antibiotics.

For most sensitive microorganisms, the antibiotic MIC ranges from 0.01-0.4 µg/ml. The sensitivity limit for erythromycin is determined by the average concentration of the antibiotic in the blood and is 3-5 μg / ml.

After a single oral administration of 500 mg of the antibiotic, its maximum concentration in blood serum (0.8-4 μg / ml) is observed after 2-3 hours, and after 6-7 hours it decreases to 0.4-1.6 μg / ml. Erythromycin may be the drug of choice for the outpatient treatment of pneumonia in people under 40 years of age who cannot obtain sputum for microscopy.

Levomycetin is used as the main remedy (along with tetracycline drugs) for Curickettsia pneumonia. In other cases, it is rarely prescribed as the first drug for the treatment of acute pneumonia due to possible side effects.

The drug is effective against a number of gram-positive and gram-negative microorganisms, including those resistant to penicillin and ampicillin. With mixed aerobic and anaerobic microflora, a combination of levomycetin with an antibiotic aminoglycoside is recommended. In case of anaerobic infection, metronidazole is also included in the complex of drugs.

Sulfanilamide preparations have not lost their significance in the treatment of acute focal pneumonia of mild and moderate severity (especially pneumococcal etiology).

Their use has expanded with the introduction into clinical practice of prolonged preparations (sulfapyridazine, sulfamonomethoxine, sulfadimethoxine, etc.), as well as a combination of sulfamethoxazole with trimethoprim (bactrim), which provides an antibacterial effect comparable to that of antibiotics.

When using sulfonamides, interruptions in treatment should not be allowed; taking drugs should be continued for 3-5 days after the elimination of the main symptoms of the disease.

The duration of the course of treatment is on average 7-14 days. To prevent side effects in the treatment of sulfonamides, prophylactic vitamin therapy is prescribed.

When sulfonamides are combined with erythromycin, lincomycin, novobiocin, fusidine and tetracycline, antibacterial activity is mutually enhanced and the spectrum of action is expanded; when combined with rifampicin, streptomycin, monomycin, kanamycin, gentamicin, nitroxoline, the antibacterial effect of the drugs does not change.

It is not advisable to combine sulfonamides with nevigramone (antagonism is sometimes noted), as well as ristomycin, chloramphenicol and nitrofurans due to a decrease in the total effect [Pyatak OA et al., 1986].

The rationality of combining sulfonamides with penicillins is not shared by all authors [Gogin E. E. et al., 1986].

The most widespread in modern clinical practice is Bactrim (biseptol), a combination drug containing 400 mg (800 mg) of sulfamethoxazole and 80 mg (160 mg) of trimethoprim in one tablet.

The drug is rapidly absorbed; its maximum concentration in the blood is observed 1-3 hours after ingestion and persists for 7 hours. High concentrations are created in the lungs and kidneys. Within 24 hours, 40-50% of trimethoprim and about 60% of sulfamethoxazole are released.

In a number of patients, the use of nitroxoline, which has antibacterial activity against gram-positive and gram-negative microorganisms and is effective against certain fungi of the genus Candida, is shown.

With the joint appointment of nitroxoline with nystatin and levorin, a potentiation of the effect is observed. Nitroxoline cannot be combined with nitrofurans.

For the prevention and treatment of candidiasis with prolonged use of antibiotics, as well as for the treatment of visceral aspergillosis, levorin is prescribed orally and in the form of inhalations. Amphotericin B is highly active against many pathogenic fungi.

A characteristic feature of amphotericin B in comparison with other drugs is its effectiveness in deep and systemic mycoses. Apply the drug intravenously or inhalation.

Thus, the basis for the success of antibacterial therapy is the observance of its principles: the timely administration and etiotropy of the chemotherapeutic effect, the choice of the most effective and least toxic drug, taking into account the pharmacokinetic characteristics of the drug, dynamic control of the sensitivity of microorganisms to the drugs used.

Of considerable importance for the prevention of toxic and allergic complications of antibiotic therapy and the normalization of the body's immunological reactivity is also the timely cancellation of antibacterial drugs.

Nonspecific therapy

In severe croupous or viral-bacterial pneumonia and its complication by acute destruction of the lung tissue, active detoxification therapy is necessary.

For this purpose, intravenous drip transfusions of rheopolyglucin (400-800 ml / day), gemodez (200-400 ml / day), one-group hyperimmune (antistaphylococcal, antiproteus, antipseudomonal) plasma are performed (at the rate of 4-5 ml / kg for 10- 12 days).

Severe dehydration and a tendency to develop acute vascular insufficiency serve as the basis for the transfusion of protein, as well as 5 or 10% albumin solution. In case of arterial hypotension with distinct peripheral signs of collapse, 60-90 mg of prednisolone or 100-250 mg of hydrocortisone are injected intravenously in 200-400 ml of isotonic sodium chloride solution.

Along with this, 1-2 ml of cardiamine or 10% sulfocamphocaine solution are administered parenterally. If necessary, cardiac glycosides are also used (0.5 ml of a 0.06% solution of corglycone or a 0.05% solution of strophanthin 1-2 times a day intravenously).

Progressive right ventricular failure in combination with hemoptysis, increasing thrombocytopenia and an increase in the content of fibrinogen in the blood plasma makes it necessary to use heparin (up to 40,000 - 60,000 IU / day) in combination with antiplatelet agents (dipyridamole 0.025 g 3 times a day), xanthinol nicotinate according to 0.15 g 3 times a day, pentoxifylline 0.2 g 3 times a day or 0.1 g intravenously drip in isotonic sodium chloride solution 2 times a day.

Non-steroidal anti-inflammatory drugs also act as antiplatelet agents (acetylsalicylic acid - 0.25-0.5 g / day, indomethacin - 0.025 g 3 times a day); the same drugs are used as antipyretic and analgesic for pain syndrome caused by pleural lesions.

With hemoptysis, codeine preparations are indicated, with pulmonary bleeding - parenteral administration of 1 ml of a 1% solution of morphine.

Dry unproductive cough, exhausting the patient and disturbing sleep, becomes an indication for the appointment of non-narcotic antitussive drugs (glaucine 0.05 g, libexin 0.1 g or tusuprex 0.02 g 3-4 times a day), which do not depress breathing, do not inhibit intestinal motility and do not cause drug dependence.

At the heart of attacks of dry painful cough with a scanty separation of very viscous sputum may be bronchospasm, inflammatory swelling of the bronchial mucosa and hypersecretion of bronchial glands with the formation of bronchial obstruction syndrome.

It is assumed that the phenomena of bronchial obstruction are accompanied by the activation of cholinergic mechanisms against the background of adrenergic imbalance [Yakovlev VN et al., 1984].

In these cases, drugs with a bronchodilatory effect are shown: eufillin (5-10 ml of a 2.4% solution intravenously), atropine (inhalation of fine aerosols), as well as salbutamol, fenoterol (Berotek), atrovent or berodual, produced in an aerosol package with dosing valve for use as a personal inhaler.

In the resolution phase of pneumonia, solutan has a clear bronchodilator and expectorant effect (10-30 drops orally 2-3 times a day after meals or 12-15 drops in 10-15 ml of isotonic sodium chloride solution in the form of inhalations).

Enduring importance in the syndrome of bronchial obstruction has oxygen therapy. To soothe and mitigate dry cough in the early days of acute pneumonia, inhalations of bicarbonate or sodium chloride (warm fog-type aerosols), as well as eucalyptus, turpentine or thymol essential oils, which have a bronchodilatory, expectorant and antiseptic effect, are used.

If sputum is difficult to expectorate, reflex drugs that stimulate expectoration are prescribed (terpinhydrate, sodium benzoate, thermopsis, marshmallow, licorice, elecampane, thyme, anise and other medicinal plants), and with increased sputum viscosity, resorptive drugs (mainly 3% potassium iodide solution , which is taken 1 tablespoon 5-6 times a day after meals or with milk).

In addition, mucolytic agents that thin sputum are used: acetylcysteine ​​(mucosolvin) in inhalations, bromhexine (bisolvone) orally (4-8 mg, i.e. 1-2 tablets 3-4 times a day), proteolytic enzymes (trypsin, chymotrypsin , chymopsin), ribonuclease or deoxyribonuclease inhalation in the form of fine aerosols.

With the ineffectiveness or insufficient effectiveness of the above drugs and obstruction of the bronchi with a mucous or purulent secret, therapeutic bronchoscopy is indicated with the evacuation of the contents of the bronchial tree and washing the bronchi with a 0.1% solution of furagin, repeated therapeutic bronchoscopy is necessary for obstructive atelectasis and the development of acute lung abscess.

Among the nonspecific local protective factors in pneumonia, the function of neutrophilic granulocytes and alveolar macrophages is important. Their phagocytic activity increases under the influence of lysozyme and interferon.

It was found that interferon at a dilution of 1:8 or 1:16 enhances phagocytosis and metabolic activity of peripheral blood granulocytes, while a low (1:32) or too high (1:2) dilution does not significantly affect these indicators [Chernushenko E V. et al., 1986].

The use of 3 ampoules of interferon per inhalation (a course of 10-12 inhalations) provides a more rapid increase in the interferon reaction of leukocytes and an improvement in clinical, laboratory and radiological parameters.

For non-specific effects on the immunobiological properties of the body and increase the reactivity of the patient, aloe, FiBS, and autohemotherapy are used.

We often use FiBS 1 ml subcutaneously once a day (for a course of 30-35 injections). To accelerate regeneration, methyluracil is prescribed 1 g 3-4 times a day for 10-14 days. With purulent intoxication and slow reparation in malnourished patients, it is possible to use anabolic agents (nerobol sublingually 5 mg 2 times a day for 4-8 weeks; retabolil 1 ml 1 time in 7-10 days, 4-6 injections).

With a prolonged course of pneumonia, glucocorticoids are indicated against the background of treatment with antibacterial agents. B. E. Votchal (1965) in these cases recommended prescribing prednisolone at a daily dose of 30-40 mg for a period of 5-7, less often 10 days with rapid withdrawal of the drug.

Physical methods of treatment can accelerate the resolution of inflammatory infiltrates, reduce intoxication, normalize lung ventilation and blood circulation in them, mobilize protective processes, achieve analgesic and desensitizing effects.

Physiotherapy should not be prescribed during a period of severe intoxication, with a serious condition of the patient, body temperature above 38 ° C, congestive heart failure, hemoptysis.

During the period of active inflammation, simultaneously with early antibacterial pharmacotherapy, an electric field of ultrahigh frequency (UHF) is applied to the focus area in the lung. At the same time, exudation in tissues decreases, capillary circulation is actively restored, and swelling of inflamed tissues decreases.

Under the influence of the UHF electric field, the vital activity of bacteria decreases, local phagocytosis increases, the creation of a leukocyte shaft and the delimitation of the focus of inflammation from healthy tissues are accelerated.

The power of the UHF electric field for the treatment of adults is 70-80 - 100 watts. Procedures lasting 10-15 minutes are carried out daily. The course of treatment is 8-10-12 procedures.

During the period of resorption of pronounced infiltrative phenomena, preference is given to microwave therapy - the effect of a microwave electromagnetic field of radiation.

Microwaves have an anti-inflammatory effect by changing blood circulation in tissues, stimulate regenerative processes, increase the synthesis of glucocorticoids in the adrenal cortex, cause slowing and deepening of breathing, reduce ventilation-perfusion disorders and tissue hypoxia.

The use of microwaves in acute pneumonia leads to an acceleration in the resolution of infiltrative changes in the lungs, restoration of the function of external respiration and tissue metabolism, positive immunological changes, and a reduction in the number of complications.

During treatment, a cylindrical emitter with a diameter of 14 cm is placed above the focus of inflammation with a gap of 5-7 cm, usually behind or on the side of the chest.

For bilateral pneumonia, a rectangular emitter is used and placed above the right and left half of the chest (emitter power - 30, .40, 50 W; exposure time -15 min).

Procedures are prescribed daily for treatment in a hospital and every other day for treatment in a clinic. The course of treatment - 10-12 procedures.

Electromagnetic waves of the decimeter range (UHF) favorably affect the course of protracted pneumonia. To enhance the therapeutic effect during UHF therapy, it is advisable to include the projection of the roots of the lungs and the adrenal glands in the area of ​​influence, and not just the area of ​​inflammation.

During treatment, a rectangular emitter is placed with a gap of 3-5 cm transverse to the spine from the back at the level of the IV-VIII thoracic vertebrae (I field), and then at the level of the IX thoracic-III lumbar vertebrae (II field).

An output power of 35-40 W is used, acting for 10 minutes on each field, daily or 2 days in a row, followed by a one-day break per week, for a course of 10-15 procedures.

The impact on one field is indicated for prolonged pneumonia with subfebrile condition, increased bronchopulmonary pattern, according to radiographs, but the absence of pronounced disturbances in the function of external respiration.

When normalizing body temperature or maintaining a slight subfebrile condition, 3-5 sessions of erythemal ultraviolet irradiation are prescribed. Then, if necessary, spend 6-8 sessions of inductothermy.

An integral flux of ultraviolet rays with a wavelength of 180-400 nm is used. This therapeutic method is based on an active hyposensitizing effect, an effect on vitamin D synthesis, and an increase in erythropoiesis.

Ultraviolet radiation has an anti-inflammatory effect as a non-specific irritant due to the release of biologically active substances in the skin and stimulation of metabolic processes in tissues.

Inductothermy differs from UHF in that under the action of a magnetic field, changes occur mainly in conductive tissues (blood, lymph, parenchymal organs, muscles).

The observed significant thermal effect in these tissues is due to the appearance of Foucault eddy currents. Inductothermia leads to a generalized increase in blood and lymph circulation, a significant relaxation of smooth and striated muscles, an increase in metabolism, an increase in the synthesis of glucocorticoids in the adrenal glands and a decrease in their binding by transcortin.

In the treatment of inductothermia in patients with pneumonia, separation noticeably improves and the viscosity of sputum decreases, bronchospasm decreases, and the ventilation and drainage function of the bronchi is restored. However, the active influence of the magnetic field on the hemodynamics of the pulmonary circulation sometimes leads to pain in the region of the heart. This negative reaction is quickly eliminated when the procedures are cancelled.

Inductothermia is prescribed during the resolution of acute pneumonia. The impact is carried out by an inductor - a cable or a disk with a diameter of 20 cm. The inductor is placed on the chest from behind with the capture of its left or right half or on the subscapular region on both sides.

The strength of the anode current is 160-180-200 mA, the duration of the procedure is 10-15-20 minutes. Treatment is carried out daily in a hospital or every other day in a clinic; for a course of 10-12 procedures.

Amplipulse therapy is used to improve the drainage function of the bronchi in patients with prolonged pneumonia with abundant but poorly separated sputum (often against the background of obstructive bronchitis).

The impact is carried out paravertebral at the level of IV-VI thoracic vertebrae, a variable mode is used. The course requires 10-12 procedures.

Thermal remedies (paraffin, ozocerite, mud) should be prescribed to eliminate the residual effects of acute or prolonged pneumonia. The application is made on the interscapular region or the right half of the chest in front every other day. Mud temperature 38-42 °С, paraffin - 52-54 °С, ozocerite - 48-50 °С. The duration of the procedures is 15-20 minutes. The course of treatment consists of 10-12 procedures.

Electrophoresis of medicinal substances is used at the stage of resorption of inflammatory changes in the lung tissue or to eliminate individual symptoms (relieving pain in pleural adhesions, improving sputum separation, reducing bronchospasm).

For this purpose, medicinal ions of calcium, magnesium, aloe extract, iodine, heparin, eufillin, lidase, etc. are used. For electrophoresis, either ready-made solutions are taken, or a single dose of the drug is dissolved in distilled water or in a buffer solution.

A pad with a medicinal substance is placed on the projection of the pathological process or in the interscapular region, the second pad is placed on the anterior or lateral surface of the chest. Gasket size 100-200 cm2; current density 0.03-0.05 mA/cm2, exposure time 15-30 min. Procedures are prescribed every other day or daily courses of 10-15 procedures.

Aeroionotherapy is used in the recovery period or in the period of incomplete remission [Kokosov A. N., 1985]. The method of exposure to air ions is remote. The number of air ions per procedure is 150-300 billion, the duration of the procedure is 5-10-15 minutes. Procedures are prescribed daily or every other day. The course of treatment requires 10-15 procedures.

Therapeutic physical culture with a set of breathing exercises is a means of rehabilitation therapy.

It should be emphasized the importance of early inclusion in the complex of therapeutic measures of respiratory gymnastics.

Therapeutic exercises should be started on the 2-3rd day after the normalization of body temperature or its decrease to subfebrile figures.

Moderate tachycardia and shortness of breath are not contraindications for therapeutic exercises, since the dosage of physical activity, the nature and number of exercises in classes are chosen taking into account these factors. In the classes, exercises are used that increase the respiratory mobility of the chest and stretch the pleural adhesions, strengthen the respiratory muscles and muscles of the abdominal process.

The localization of the process in the lungs is also taken into account. During bed rest, simple low-intensity gymnastic exercises for arms and legs are prescribed; exercises for the body are performed with a small amplitude of movement.

Breathing exercises are carried out without deepening the breath. During the treatment and training period, the schemes of procedures for therapeutic exercises and an approximate set of physical exercises are built taking into account the regimen established for the patient (half-bed, ward, general hospital).

Timely appointment and full implementation of a complex of therapeutic exercises provide a more complete restoration of the functional state of the respiratory and cardiovascular systems. The use of therapeutic physical culture in elderly patients is especially important.

Our observations have shown that through careful, gradual training, it is possible to restore the function of external respiration during their stay in the hospital, to teach these patients the correct respiratory act, the ability to make fuller use of the capabilities of their respiratory apparatus. After discharge from the hospital, it is recommended to continue physical therapy classes.

Sanatorium-and-spa treatment of people who have had acute pneumonia is often carried out in the conditions of local out-of-town medical institutions.

A good effect gives sanatorium-resort treatment in low mountains, in forest areas, on the southern coast of Crimea. Yu. N. Shteingard et al. (1985) developed a two-stage treatment of patients with acute pneumonia with early rehabilitation in the conditions of a sanatorium-resort institution and the use of peat applications on the area of ​​​​the approximate projection of the lesion (temperature 40-42 ° C, exposure 15-, 30 minutes, 10-12 procedures per course, scheduled every other day).

Referring patients for rehabilitation on the 3rd-4th day of stable temperature normalization, the authors reduced their stay in the hospital by 2-4 times.

REHABILITATION, DISPENSERIZATION AND MEDICAL AND LABOR EXAMINATION

Therapeutic and preventive measures to restore the health of people who have had acute pneumonia include 3 types of rehabilitation:

• 1) medical (rehabilitation treatment);
• 2) professional (labor rehabilitation);
• 3) social (retraining, employment, use of residual working capacity, etc.).

Medical rehabilitation consists of 3 stages:

• 1) clinical (hospital or polyclinic, outpatient clinic);
• 2) sanatorium-resort (sanatorium; sanatorium-dispensary; suburban rehabilitation center; resort-type research institution);
• 3) polyclinic-dispensary observation.

Despite the harmony of the system, many specific issues of rehabilitation have not yet been finally resolved. The criteria for selecting patients, the rationale for rehabilitation treatment complexes, the method of monitoring the effectiveness of the therapy, the terms of rehabilitation, the criteria for the transition of acute pneumonia to protracted and chronic forms need to be clarified.

Medical rehabilitation in its full or incomplete volume is necessary for all patients with a protracted course of acute pneumonia, complications and the threat of transition to a chronic course.

Leading tasks of the clinical stage of rehabilitation are the achievement of medical and, if possible, vocational rehabilitation.

The criteria for successful completion of the clinical stage of rehabilitation can be considered:

• 1) the absence of clinical symptoms of the inflammatory process and the normalization of the patient's well-being;
• 2) radiological signs of elimination of infiltrative changes;
• 3) restoration of indicators of bronchial patency of the gas composition of the blood;
• 4) normalization of hemogram parameters (with the exception of ESR).

The second stage of rehabilitation - sanatorium, in country boarding houses or outpatient clinic (if it is impossible to have sanatorium treatment or aftercare in a country hospital). The objectives of this stage of rehabilitation are:

• 1) full functional restoration of the respiratory system;
• 2) increase in nonspecific resistance of the organism;
• 3) complete morphological restoration of organs;
• 4) elimination of chronic foci of infection in the body.

The leading means of rehabilitation at this stage are the therapeutic regimen, exercise therapy and massage, physiotherapy, diet therapy, vitamin and enzyme therapy, and only if necessary, other medications.

A significant role in this period is assigned to the fight against chronic foci of infection. According to V. I. Tyshetsky et al. (1982), the need for a rehabilitation bed (out-of-town aftercare hospital, sanatorium, resort) per 10,000 people over 14 years of age with an average length of stay in a rehabilitation pulmonological bed of 24.5 days is 1.6 beds.

The third stage of rehabilitation - outpatient follow-up. Improving measures are aimed at increasing nonspecific resistance, maintaining the mucociliary function of the bronchi, sanitation of focal infection.

Polyclinic dispensary observation should last for 3 months in relation to persons with clinical and radiological recovery after acute pneumonia and for 1 year with prolonged and recurrent forms of pneumonia.

Purposeful planned differentiated implementation of measures of primary and secondary prevention of pneumonia corresponds to the allocation of 4 groups of dispensary observation:

• 1) persons at risk of developing nonspecific lung diseases;
• 2) persons in the period of pre-illness;
• 3) patients with acute nonspecific lung diseases and convalescents;
• 4) patients with chronic nonspecific lung diseases [Chuchalin A. G., Kopylev I. D., 1985].

The set of primary prevention measures in the 1st dispensary group consists in improving the working conditions, eliminating discomfort at the workplace and in the home, and maintaining a healthy lifestyle. Particular attention should be paid to the following activities:

• 1) smoking cessation,
• 2) the fight against alcohol abuse;
• 3) promotion of hardening and physical culture,
• 4) prevention and timely treatment of respiratory viral infections,
• 5) professional orientation of adolescents and appropriate employment of employees;
• 6) social and hygienic prevention,
• 7) personal hygiene skills.

Dispensary observation is carried out until the risk factors for the development of nonspecific lung diseases are eliminated at least once a year. A minimum of research includes an X-ray examination of the chest cavity, a clinical blood test, an assessment of the function of external respiration [Chuchalin A. G., Kopylev I. D., 1985].

One of the publicly available ways to prevent acute pneumonia is to improve the health of people in the second dispensary group. At the same time, special attention is paid to persons with impaired nasal breathing and chronic foci of infection (rhinitis, deviated septum, tonsillitis, sinusitis, etc.), persons with a history of allergic diseases, as well as those who have had acute viral infections within a year.

The same group should include persons with pulmonary metatuberculous changes, but already deregistered for this disease, pleural adhesions, metapneumonic or post-traumatic pneumosclerosis, congenital and acquired pathology of the bronchopulmonary and thoracophrenic apparatus.

Recovery is carried out according to an individualized comprehensive plan with the consultation or participation of an otorhinolaryngologist, pulmonologist, immunologist, allergist, dentist, phthisiatrician, sometimes a dermatologist, thoracic surgeon, physiotherapist.

Clinical examination in this group is carried out at least once a year, after which the subject is observed in the first group for another year.

Convalescents after acute pneumonia, which make up the 3rd group of dispensary observation, are recommended to be divided into persons with a favorable cyclic course of the inflammatory process (subgroup A) and persons with a protracted and complicated course of the disease (subgroup B).

Dispensary observation of patients of subgroup A is carried out for 3 months with a frequency of visits after 2 weeks, 1.5 and 3 months after discharge from the hospital or going to work.

The examination program is minimal and includes a clinical blood test, a general urinalysis, a study of the function of external respiration, fluorography or radiography in 2-3 projections (lung fluoroscopy), consultation with an otolaryngologist, dentist.

When making a conclusion about the recovery of the patient for another year, it should be observed in the first group.

Subgroup B should be under observation for a year and examined after 1.5; 3, 6, 12 months from the start of observation. At the first visit, the same studies are shown as in the uncomplicated course of the disease. Additional studies are prescribed after consultation with a phthisiatrician or thoracic surgeon.

At subsequent visits, the examination program may include a morphofunctional assessment of the bronchial tree (bronchoscopy, lung tomography), assessment of the severity of the inflammatory process, immunological status, bacteriological and virological examination.

Upon recovery, these patients are transferred to the second dispensary group. If the implementation of the treatment plan for 12 months did not provide stabilization of the process, it is necessary to make a conclusion about the transformation of the disease into a chronic form and transfer the patient to the fourth group of dispensary observation.

In acute pneumonia, all patients are temporarily disabled. The duration of temporary disability depends on a number of factors: the term of appeal, the timeliness of diagnosis and hospitalization, the age of the patient, the nature and severity of pneumonia, the presence of concomitant diseases, the etiology of the process, etc.

Thus, the results of our observations showed that the duration of temporary disability in patients hospitalized on the 10th day and later was 45.2 + 1.25 days compared to 23.5 ± 0.95 days among those hospitalized during the first 3 days of illness.

According to Yu. D. Arbatskaya et al. (1977), the period of temporary disability for people over 50 years old was 31 days, and for people under 30 years old - only 23 days. In the studies of Yu. A. Panfilov et al. (1980), these figures were almost identical (32.5 days in patients older than 50 years and 24.6 days in patients 20-30 years old).

The duration of temporary disability in acute pneumonia increases with concomitant diseases (especially chronic obstructive bronchitis, pulmonary emphysema) and severe inflammation.

When discharging patients who have had acute pneumonia for work, one should be guided by the criteria for recovery and rehabilitation. At present, it is recognized as necessary to distinguish 2 groups of convalescents after acute pneumonia.

The first group includes persons who were in the hospital until complete recovery and were discharged to work with the normalization of the clinical and radiological picture, laboratory and biochemical data. Convalescents of this group are under dispensary observation for 3 months and during this period they are examined 3 times: 2 weeks, 1 and 2 months after discharge.

Under unfavorable working conditions, convalescents of this group should be employed by the VKK for various periods (1-2 months). Such an expert decision should be made in relation to patients working as foundry workers, moulders, steelworkers, furnace workers, drivers, workers at a construction site, in agriculture, etc.

The 2nd group includes persons discharged with residual effects of acute pneumonia and in need of rehabilitation using out-of-town aftercare hospitals, dispensaries and sanatoriums and subsequent dispensary observation.

Forecast. With timely and accurate diagnosis, rational treatment, acute pneumonia ends with recovery, usually by the end of the 3-4th week from the onset of the disease. The reverse development of the clinical symptoms of pneumonia with its favorable course occurs by the 7-14th day. X-ray signs of inflammation disappear on the 2-3rd week. However, in 25-30% of patients, acute pneumonia acquires a protracted course [Silvestrov V.P., Fedotov P.I., 1986].

In some patients, clinical and radiological signs of an ongoing inflammatory process may persist for up to 6 months. With long-term (up to 3-4 years) observation of convalescents, it was found that acute pneumonia ends in complete recovery in 91.9% of patients, contributes to the progression of previous chronic bronchitis in 2.7%, causes the development of chronic bronchitis in 4.9% and takes chronic course in 1.2% [Polushkina A.F., Gubernskova A.N., 1977].

Prior to the introduction of antibiotics into clinical practice, mortality in acute pneumonia reached 9-38% [Tushinsky M. D. et al., 1960]. Currently, it is about 1% [Molchanov N. S., Stavskaya V. V., 1971]. Mortality is especially high in viral-bacterial and staphylococcal pneumonia in elderly debilitated people.

The prevention of acute pneumonia is inextricably linked with the development and improvement of broad nationwide health measures, including the improvement of the environment, labor protection, the improvement of technology and industrial sanitation, and the improvement of the material well-being of the population.

At the same time, the prevention of acute pneumonia means strengthening the skills of collective and personal hygiene among the population, engaging in physical culture and sports, hardening the body, eradicating bad habits, preventing and timely adequate treatment of influenza and other viral respiratory infections.

In differential diagnosis, it is important to distinguish pneumonia from diseases such as tuberculosis, lung cancer, and pulmonary embolism.

The course of some forms of tuberculosis in the initial stage is very similar to the clinical picture of bacterial pneumonia. However, it should be remembered that the onset of tuberculosis is almost asymptomatic. Patients complain of fatigue, slight malaise (as a result of intoxication), coughing, sweating. At this stage, X-ray examination of the lungs is already obvious.

Bacterial pneumonia is characterized by a pronounced onset with chills, fever above 38.5 degrees. The skin of such a patient is dry and hot, and sweating is observed only at the time of the crisis. Sputum with pneumonia - with air bubbles, more viscous than with tuberculosis.

Tuberculosis on an x-ray looks like clear rounded polymorphic foci, more often in the upper lobe. A blood test for pneumonia reveals pronounced leukocytosis, and for tuberculosis - lymphopenia and moderate leukocytosis. Microbiological examination of sputum detects Mycobacterium tuberculosis.

Only 5% of TB patients benefit from broad-spectrum antibiotic treatment. Therefore, if the symptoms of pneumonia in a person last more than 2 weeks, then the diagnosis should be clarified. It's probably tuberculosis. However, broad-spectrum anti-tuberculosis drugs are not recommended for empiric treatment of pneumonia.

2. Differential diagnosis of pneumonia and lung cancer

Cough, sputum, pain and hemoptysis may accompany the germination of metastases in the pleura. Up to this point, lung cancer is asymptomatic, but can be detected on an x-ray. In this case, peripheral cancer is located more often in the anterior upper lobes of the lung, its contours are radiant.

Cancer cells can germinate in other organs or appear in the lungs as metastases.

For more details on the differences between acute pneumonia, tuberculosis and lung cancer, see the table:

3. Differential diagnosis of pneumonia and pulmonary embolism (PE)

Prolonged bed rest after surgery, femoral neck fractures, with atrial fibrillation can lead to thrombophlebitis of the lower extremities. The consequence is often pulmonary thromboembolism. In young women, this problem sometimes occurs after taking oral contraceptives.

The characteristic features of TELA, in addition to the background, are:

• · cyanosis;
• shortness of breath;
• arterial hypotension;
• tachycardia.

When listening, the doctor detects a pleural friction rub and weakened breathing. X-ray shows a triangular shadow, and perfusion radioisotope scanning - ischemic "cold" zones. In this case, there is an acute overload of the right side of the heart.

Clinical diagnosis

Based:

• - complaints of paroxysmal cough with scanty purulent sputum difficult to separate for about 2 days, an increase in T to 38.0 OS for about 2 days, pain in the left side of the chest, runny nose, shortness of breath when walking, general weakness, headache;
• - medical history: considers himself ill since 12.04.16. The disease is associated with hypothermia during military exercises. 04/13/16 after the onset of a dry paroxysmal cough and weakness, he turned to the medical clinic at the place of service, from where he was sent for a consultation with a pulmonologist of the LRCH.
• - data of an objective study: the general condition of moderate severity, due to intoxication, nasal breathing is difficult, with comparative percussion, dullness of percussion sound to the left of the angle of the scapula downwards, during auscultation, breathing is hard, sharply weakened in the lower lateral sections on the left, single moist small bubbling rales are heard on the left , heart rate - 95 beats / min, blood pressure - 90/60 mm Hg;
• - data of additional research methods:

Clinical blood test 14.04.16.

Conclusion: The blood test revealed leukocytosis, a shift of the leukocyte formula to the left, an increase in ESR, which indicates an acute inflammatory process.

Overview P-gram of the OGK dated 04/14/16: on the left in S 9, 10 of medium intensity, inhomogeneous darkening with fuzzy contours. The roots are reinforced. The shadow of the heart without features.

Conclusion: left-sided pneumonia S 9, 10.

Ultrasound of the pleural cavity from 18.04.16.

Conclusion: in the pleural cavities on both sides of the free fluid is not determined.

General analysis of sputum from 19.04.16. Conclusion: sputum revealed leukocytes (indicating infection), erythrocytes, alveolar macrophages (indicating that the lower parts of the respiratory system are affected), which indicates the presence of an infectious inflammatory process in the lung tissue.

You can make a clinical diagnosis:

Primary: Acute community-acquired left-sided lower lobe pneumonia S9-10, moderate severity.

Companion: -

Complications: ODN 0 degree.

Various diseases that affect the respiratory system are very similar to each other, have a high likelihood of complications, and are a health hazard. Differential diagnosis of pneumonia allows you to establish the cause that provoked the inflammatory process, which makes it possible to make the treatment as competent and productive as possible.

The differential diagnosis of pneumonia is established on the basis of a research method that involves the stepwise exclusion of diseases with similar symptoms. During the study, the doctor must collect the maximum possible amount of reliable information regarding the lifestyle, reactions and individual characteristics of the patient's body.

Differential diagnosis is carried out according to the following algorithm:

• First, the symptoms are identified, on the basis of which the most likely diagnoses are selected.
• After collecting the diagnoses, a detailed description of the disease is made and the leading variant is determined.
• The third stage involves comparing the most appropriate diagnoses. To exclude a probable variant, the diagnostician must make a deliberate analysis of all the information received.

Differential diagnosis should be carried out in cases where the patient suffers from any lung diseases, or he has signs of various concomitant ailments of the respiratory tract and other organs that can distort the symptoms and significantly complicate the process of establishing a diagnosis.

Features of the course of the disease

Pneumonia is an acute focal infiltrative disease that affects the lung tissue and covers both individual areas and various segments, including the entire organ. Most often, hemophilic bacilli, pneumococci and intracellular bacteria (such as legionella, mycoplasmas and) provoke the onset of the disease. Pneumonia is diagnosed according to instrumental and laboratory criteria, which include the following signs:

• the presence of pleural murmurs;
• dull percussion sounds in certain areas;
• increased trembling of the vocal cords;
• pain syndrome localized in the chest area;
• wet or dry cough;
• intoxication;
• febrile state, accompanied by high body temperature.

Pneumonia is confirmed by a number of additional studies that reveal the presence of sputum in the tests, darkening in the lung tissue, accelerated ESR and other negative changes.

Differentiation between pneumonia and lung cancer

Differential diagnosis of pneumonia includes a number of tests that can detect cancerous damage to the medium and small bronchi. The clinical picture combines various signs, among which it is worth highlighting the following:

• shortness of breath, accompanied by hemoptysis;
• pain syndrome in the chest area;
• fever and cough.

In obstructive bronchitis, similarly, there is an increase in sputum volume, as well as increased shortness of breath and an increase in coughing fits. However, such symptoms occur mainly in the initial stages, indicating that the local process has managed to spread to the surrounding tissues. Some of the main signs of cancer can be called:

• Pain syndrome in the shoulder area, which indicates the growth of cancer in the area of ​​​​the cervical-brachial plexus.
• Constricted pupil, confirming the fact that the sympathetic ganglion is involved in the process.
• If metastases affect the nerve nodes, there are difficulties with swallowing.

According to the results of laboratory studies, with pneumonia, a strong increase in the level of leukocytes and ESR can be observed. There is a noticeable increase in the roots of the lungs, and the affected area has a uniform appearance, while the edges look blurry. In cancer, the reaction to antibiotics is most often absent, the level of leukocytes is within the normal range, and the ESR is not very elevated.

Differentiation of tuberculosis and pneumonia

Signs of tuberculosis and bacterial pneumonia have very similar manifestations, since both diagnoses are a bacterial lesion of the lung tissue. Tuberculosis can provoke an inflammatory process in the lungs when other pathogens are added to the Koch stick. You can distinguish this disease from pneumonia by the following signs:

• The onset of the disease is usually accompanied by acute bouts of dry cough and fever.
• Tuberculosis is accompanied by a pronounced and permanently progressive intoxication of the body.
• Pain in the chest area is rare.
• Shortness of breath occurs in case of severe damage to the internal tissues of the lungs.
• There is no response of the body to antibiotic treatment.

With tuberculosis, changes in respiratory function are rarely observed. Laboratory analyzes show indicators of ESR and leukocytes within the normal range. On the x-ray, changes are observed that affect the upper lobes and have clear contours.

Advanced forms of bronchitis have a number of similar symptoms with pneumonia. If the focus of an infectious lesion passes to the alveoli from the bronchi, one disease may well flow into another. The doctor should first of all pay attention to such signs as: the presence of purulent mucus in the sputum, cough, fever.

Under the age of two, it manifests itself in the form of crepitus, fine bubbling rales and increased deformation of the vascular pattern. Bronchiolitis shares a number of features with pneumonia, but it can be distinguished by the absence of infiltration, harsh breathing, and a percussion sound that has a boxy tone.

Course of pneumonia and lung abscess

Lung abscess often occurs after pneumonia. Signs of the resulting abscess may not be visible on the x-ray, which greatly complicates the diagnosis. The most common manifestations of an abscess are a weakened respiratory function, temperature jumps and severe pain in the affected area.

Pulmonary embolism is easily confused with pneumonia, but PE is accompanied by signs of lung tissue damage, severe dyspnea, tachycardia and cyanosis, as well as a decrease in blood pressure by 15–25%. Differential diagnosis of pneumonia in the presence of thromboembolism is based on a detailed study of the results of tests and the history of previous diseases of the lungs and other internal organs.

PE often develops after surgery, abuse of hormonal contraceptives and other medications. It can provoke pneumonia and oppression of lung tissues.

Etiology of pneumonia and pleurisy

can develop as an independent disease, or be caused by pneumonia. As a result of the disease, the pleural fluid sweats out into the area that delimits the pleural sheets from the lungs.

It is problematic to detect the disease using standard diagnostic methods, since obvious signs of pleurisy are most often absent. An x-ray of the lungs shows foci that periodically change their own dislocation, which is not observed in the case of pneumonia. When present, or patients usually suffer from rapid weight loss and prolonged coughing, which is accompanied by spitting up of blood.

The course of echinococcosis

This pathology is expressed in the form of the formation of a specific cyst in the lungs. Over a long period, the lesion can proceed without obvious signs, but subsequently the patient begins to worry about:

• permanent feeling of weakness;
• nausea;
• high fatigue.

The echinococcal bladder, increasing in size, leads to squeezing of neighboring tissues, which leads to shortness of breath, pain localized in the chest area, and coughing up blood.

A large cyst provokes an external deformation, in which difficulties with respiratory function are observed in the affected part. If it breaks through the tissues of the bronchi, the patient suffers from, accompanied by the release of translucent, cloudy sputum.

Fibrosing alveolitis is a pathological process in which the respiratory vesicles are damaged. The disease begins gradually, people working in hazardous industries and smokers are most susceptible to it. The main signs of the disease are the presence of shortness of breath and cough, accompanied by a small amount of sputum, lethargy, fatigue and pain localized in the chest area.

Fibrosing alveolitis is accompanied by such signs as, and crepitus. Radiography allows you to determine the position and dimensions of small focal shadows, usually localized in the lower lobes.

Differential diagnosis of pneumonia is carried out in various systemic diseases of an autoimmune nature. With this disease, the formation of pulmonary infiltration occurs, in which the upper sections of the respiratory tract and other internal organs are affected. The first signs are expressed in the form of fatigue and weakness, after which the patient is disturbed by pain localized in the joints and muscles. The pathological process in the lungs is accompanied by:

• shortness of breath;
• expectoration of blood;
• tracheitis;
• pharyngitis;
• sinusitis;
• chronic runny nose.

Systematic lung disease provokes the occurrence of skin vasculitis, polyneuritis, nephritis and stomatitis. X-rays can reveal the presence of nodular opacities, pleural effusion, and massive or focal infiltration. The disease is accompanied by damage to the upper respiratory tract, joint and muscle pain, as well as fatigue and weakness.

In the lungs, foci of infiltration occur, which are detected with the help of. In most cases, the disease provoked by ascaris proceeds without pronounced symptoms, however, many patients experience: cough with yellow sputum, profuse night sweats, headache, malaise and other signs.

Differential diagnosis of pneumonia in such cases is carried out with pulmonary infarction, pneumonia and tuberculosis. In the clinical picture, there is a hidden onset, after which there is a constant increase in dry cough, accompanied by a small amount of sputum. A functional study of the lungs usually demonstrates the presence of obstructive changes.

Clarification of the diagnosis

The primary diagnosis of pneumonia is established on the basis of a radiograph. Since some types of pneumonia do not show radiological changes at the initial stages of development, it is necessary to differentiate pneumonia based on the results of complex studies.

Computed tomography of the lungs is prescribed in cases where, according to the results of ultrasound and radiography, it was not possible to obtain enough information to establish the correct diagnosis and assess the risks of complications.

This analytical method allows you to establish the presence of initial infiltrative deviations, when radiography is not yet able to provide the necessary information to make the most likely verdict. Thus, it is possible to identify a disease at any stage only with the help of differential diagnosis.

Among respiratory pathologies, an infectious lesion of the lower respiratory tract, known as pneumonia or pneumonia, is quite common. It occurs in people of all ages, from newborns to the elderly. And it is extremely important to correctly diagnose the disease. It is known that 20% of medical conclusions are erroneous, and twice as many cases are detected only a week after the onset of pulmonary pathology. Therefore, the differential diagnosis of pneumonia is of utmost importance at any stage of medical care.

Based on the origin of the changes, they can be infectious-inflammatory, tumor, allergic or ischemic. The clinical picture of the infiltrative syndrome begins to emerge from the identified complaints. But, unfortunately, they are not specific. Common symptoms that are characteristic of many of the diseases listed above include:

• Cough.
• Difficulty breathing (shortness of breath).
• Excretion of sputum.
• Pain in the chest (when inhaling and coughing).

The last sign is characteristic only for those processes that are localized superficially - closer to the pleural sheets. Indeed, in the lung tissue itself there are no sensitive receptors, the irritation of which could cause pain. Unpleasant sensations will arise or increase on inhalation and during coughing, which indicates the involvement of the pleura. This allows you to distinguish respiratory pathology from cardiovascular (angina pectoris, heart attack) and digestive (peptic ulcer, diaphragmatic hernia, cholecystitis, pancreatitis).

Complaints are subjective. But clinical examination reveals objective signs. Of the physical symptoms that occur with pulmonary infiltration, it is worth noting the following:

1. Lag of one half of the chest in respiratory movements.
2. Intensification of voice trembling.
3. Percussion sound is shortened or dulled.
4. Changed breathing (weakened, bronchial).
5. Pathological noises (wheezing, crepitus).

It should be noted that the clinical signs are determined by the size of the infiltrate, its nature and localization. The most important is the prevalence of the pathological process in the lung tissue, on the basis of which infiltrates are:

• Segmental and equity.
• Focal.
• rounded.

Pronounced physical symptoms, as a rule, are observed with rather large focal changes, and conditions in which the outflow of exudate is difficult or the productive component predominates (tumors, granulomatous changes) are manifested only by a weakening of breathing.

Pulmonary infiltration syndrome is observed not only in patients with pneumonia, but accompanies many diseases of the respiratory system.

Diagnosis Criteria

Pneumonia is an acute focal infiltrative disease of the lung tissue of infectious and inflammatory origin, which covers a separate area, several segments or the entire lobe of the organ.

The diagnosis of pneumonia consists of clinical and laboratory-instrumental criteria. The first are the following:

1. Fever over 38 degrees and general intoxication.
2. Dry or wet cough.
3. Respiratory-related chest pain.
4. Increased voice trembling.
5. Dullness of percussion sound in a certain area.
6. Auscultatory phenomena (small bubbling rales, crepitus, pleural murmurs, bronchial breathing).

But, as it has already become known, similar signs are also characteristic of other diseases with pulmonary infiltration syndrome. Therefore, pneumonia is confirmed through additional studies. Their results are the remaining criteria:

• Changes in the picture of peripheral blood (leukocytosis over 10 g / l with a stab shift and toxic neutrophilic granularity, accelerated ESR).
• Darkening of lung tissue on x-ray.
• Identification of the pathogen in the analysis of sputum.

This is quite enough to verify the diagnosis of uncomplicated pneumonia, the treatment of which is carried out on an outpatient or inpatient basis. An important place is given to the x-ray picture. It is she who allows you to visually assess the infiltrate in the lungs: its size, location, shape, contours, structure. In addition, there are criteria for a severe course that must be taken into account when examining a patient. These include:

• Respiration rate over 30 per minute.
• Body temperature is above 40 or below 35 degrees.
• Blood pressure below 90/60 mm. rt. Art.
• Heart rate over 125 beats per minute.
• Disturbed consciousness.
• Leukocytosis more than 20 g/l or leukopenia less than 4 g/l.
• Anemia (hemoglobin content less than 90 g/l).
• Changes in the gas composition of the blood (saturation below 90%, partial pressure of oxygen less than 60%).
• Increased plasma creatinine concentration.
• Infiltration extended to more than one lobe.
• The development of complications (infectious-toxic shock, pleurisy, pulmonary destruction).

If at least one of the above signs is present in the clinical picture, then pneumonia is regarded as severe and requires increased attention from medical personnel. But the diagnostic program may include other research methods, on the basis of which the pathology is differentiated:

1. Biochemical blood test (with the progression of chronic pathology).
2. Serological tests (with an atypical course, in debilitated patients who use drugs).
3. Cytological analysis of sputum (for smokers with experience and people with other risk factors for oncology).
4. Computed tomography (with lesions of the upper lobe, lymph nodes, suspected abscess, recurrent and prolonged pneumonia, ineffectiveness of antibiotics).
5. Bronchoscopy (for biopsy).
6. Angiopulmonography (in case of suspected thromboembolism).

Thus, examination of a patient with pulmonary infiltration and a preliminary diagnosis of pneumonia is not an easy task. The doctor will need to use all his experience, clinical thinking and the ability to analyze information obtained by additional methods.

To make a diagnosis of pneumonia, clinical and laboratory-instrumental criteria should be taken into account.

Features of the flow

Before considering other diseases, a differential diagnosis of pneumonia of various origins should be made. If, according to the above criteria, the doctor's assumption is confirmed, you should understand what is the source of the problem. And this can be done even taking into account the information obtained during the clinical examination. The probable symptoms of various pneumonias are shown in the table:

A frequent cause of the atypical course of pneumonic infiltration is the weakening of the general protective mechanisms, which is characteristic of patients with comorbidities and immunodeficiency states. They have a disease with its own characteristics:

• There is no fever.
• Physical symptoms are mild.
• Extrapulmonary manifestations predominate.
• Typical changes in peripheral blood are not observed.
• The results of radiography also differ from the classical picture (less revealing).

Considering all these points, one can assume the nature of pulmonary changes, even without the results of specific laboratory diagnostics indicating the causative agent of pneumonia. This is important, because at first (before obtaining a cultural analysis), empirical therapy of the disease with broad-spectrum drugs is carried out, but if the search boundaries are narrowed, then the effectiveness of treatment will become much higher.

Tuberculosis

The first disease with which it is necessary to differentiate pneumonia is tuberculosis. Possessing a high medical and social relevance, the problem has reached the level of an epidemic, which leads to an attentive attitude to it. Typical inflammatory changes in the lungs should be distinguished from several variants of tuberculosis:

• Infiltrative.
• Focal.
• Caseous pneumonia.
• Tuberculomas.

Lung injury caused by Koch's bacillus (mycobacterium) is characterized by a polymorphism of symptoms with a wide variability in severity and prevalence. Manifestations of tuberculosis are non-specific, among them the following are common:

• Prolonged cough (with or without phlegm).
• Hemoptysis.
• Shortness of breath and chest pains.
• Fever (mostly subfebrile).
• Excessive sweating (especially at night).
• Weakness and fatigue.
• Emaciation.

The disease can begin acutely (with caseous pneumonia), but more often gradually. The course of tuberculosis is undulating, with periods of subsiding inflammatory changes. But the pronounced nature of inflammation leads to severe intoxication and the rapid development of pathology. Patients have a history of factors that contribute to infection: contact with the patient, alcoholism, malnutrition, chronic diseases. Clinical signs are divided into general intoxication and local (thoracic).

The results of laboratory and instrumental studies are of decisive importance in the diagnostic process. Tuberculin tests (Mantoux and Koch) reveal hypersensitivity reactions and a turn (a positive result after a previous negative). Mycobacteria are detected in sputum by microscopy or culture. A special role in verifying the nature of the tuberculous process is played by radiography, which allows you to identify such changes in lung tissue:

• Darkening with fuzzy edges located behind the collarbone (cloudy infiltrate).
• Limited shadow without clear contours, inhomogeneous, medium intensity (rounded infiltrate).
• Single shadows up to 10 mm in diameter, of low intensity, without clear contours and with a tendency to merge (focal process).
• A shadow resembling a triangle in shape, the apex of which is facing the pulmonary root, with a blurred upper border (periscissuritis).
• Lobar darkening of small or medium severity, inhomogeneous structure with a clear lower edge (lobite).
• Intense shadow in the entire lobe, homogeneous, without clear contours, in the center of which areas of enlightenment are formed (caseating pneumonia).
• Focal darkening of a rounded shape with clear contours and medium intensity, inside which, during decay, a sickle-shaped enlightenment (tuberculoma) is formed.

Thus, tuberculosis has forms that are suitable for differential diagnosis of both caseous and focal pneumonia. In the unaffected areas of the lung or on the opposite side, small foci are often formed - screenings. This is due to broncho-lymphatic dissemination of mycobacteria from the decay zone (cavern). And the lack of effect from traditional antibacterial treatment further confirms the tuberculous origin of the changes.

The tuberculous process very often disguises itself as pneumonic infiltration, which requires a thorough examination for the specificity of the process.

Lung cancer

In pneumonia, differential diagnosis must necessarily be carried out with central and peripheral lung cancer. The first develops from large and medium bronchi, and the second develops from their small ones (starting from the segmental). In the clinical picture, there are various signs that are combined into local and general. Local symptoms of the pathological process include:

• Cough.
• Hemoptysis.
• Dyspnea.
• Pain in the chest.
• Fever.

The temperature rises as a result of the development of obstructive pneumonitis, which is also accompanied by an increase in sputum volume, increased cough and shortness of breath. But these symptoms are observed at the initial stage. Then there are signs that indicate the prevalence of the local process and damage to surrounding tissues:

1. Dizziness, fainting, headaches - with compression of the superior vena cava.
2. Violation of swallowing (dysphagia) - with metastases in the lymph nodes of the mediastinum.
3. Hoarseness of voice (dysphonia) - with damage to the recurrent laryngeal nerve.
4. Horner's syndrome (narrowing of the pupil, drooping of the upper eyelid, retraction of the eyeball) - involvement in the process of the VI sympathetic ganglion.
5. Pencost syndrome (pain in the shoulder) - the germination of cancer in the cervicobrachial plexus.

General signs are the result of tumor intoxication and metastasis of the tumor by the hemato- and lymphogenous route to other organs. Characterized by exhaustion (up to cachexia), bone pain, neurological symptoms, etc.

The radiological picture of the central cancer is quite poor. At first, until the tumor overlaps the lumen of the bronchus, it does not come to light in any way. Then there are signs of atelectasis - a homogeneous and intense darkening of a triangular shape with clear contours. The mediastinum is displaced to the affected side. But peripheral cancer on the x-ray is detected quite well. It is defined as a rounded, non-homogeneous and medium-intensity shadow with wavy edges and strands projecting outward ("rays"). Often you can see the "path" leading to the pulmonary root. Cancer may be accompanied by the formation of a cavity, but it does not contain fluid, which distinguishes the tumor process from abscessing pneumonia.

The diagnosis of malignancy is confirmed by bronchoscopy with aspiration of the contents or by direct biopsy. Further cytological or histological examination makes it possible to establish the nature of the process.

With lung cancer, many of the signs characteristic of pneumonia are found. But there are also characteristic features that allow us to assume the correct diagnosis.

Obstructive atelectasis

If air stops flowing into the alveoli through the bronchus, they collapse. In addition to cancer, foreign bodies of the respiratory tract, a breakthrough of caseous masses from the zone of tuberculous decay, blockage with sputum in violation of drainage can lead to obstructive atelectasis. Patients complain of difficulty in breathing, dry hacking cough, which soon becomes excruciating. The lung may decrease in size, lagging behind in breathing. There are signs of ventilation insufficiency: retraction of the intercostal spaces, participation of auxiliary muscles, pallor and cyanosis of the skin.

During a physical examination, the percussion sound is shortened over the atelectasis zone, breathing is weakened, the boundaries of cardiac dullness are shifted towards the lesion. Radiologically, a homogeneous shadow is determined, covering the area associated with the obstructed bronchus (lobule, segment, lobe). The intercostal spaces are narrowed, the mediastinum is displaced in the direction of atelectasis. There are no laboratory data on the infectious process.

Pulmonary infarction

Pulmonary infarction is a consequence of arterial thromboembolism. Factors predisposing to such damage will be: prolonged immobilization of the limbs, varicose veins and phlebitis, overweight, old age, estrogen therapy. The process develops sharply, sometimes with lightning speed. The main clinical signs of pulmonary embolism are:

• Shortness of breath and chest pains.
• The appearance of blood in the sputum.
• Paleness of the skin with a grayish tint.
• Cyanosis of the upper half of the body.
• Bulging of the neck veins.
• Decreased blood pressure.
• Pulse increase.

There is a pathological pulsation in the epigastric region, fine bubbling rales are determined above the infarction area. On the pulmonary artery, a systolic murmur and an accent of the second heart sound are heard, and at the xiphoid process of the sternum, the so-called gallop rhythm.

X-ray reveals a wedge-shaped infiltration, facing the apex to the root of the lung. Its structure is homogeneous, the contours are fuzzy, and the intensity is moderate. Additionally, the bulging of the pulmonary artery trunk is determined, the cardiac shadow expands to the right, the dome of the diaphragm is raised, and the pulmonary root is deformed.

Specific signs are visible on the electrocardiogram: deviation of the electrical axis, a high S wave in the first standard lead, and a deep Q in the second. Dopplerography determines the increase in pressure in the pulmonary artery, but the main criterion for the diagnosis will be changes in angiopulmonography. These include the expansion of the lumen of the vessel and the lack of contrast below the site of obturation.

Pulmonary infarction in arterial thromboembolism is a dangerous condition that requires differential diagnosis with bronchopneumonia.

Fibrosing alveolitis

Similar moments in the clinical picture are found in fibrosing alveolitis. This is a process that diffusely affects the respiratory vesicles and interstitium of the lungs. The disease is relatively rare, but the course is especially severe. The onset of alveolitis is gradual. People who work in dusty conditions (wood chips, bird fluff, dry excrement, coal, asbestos, metal) and smokers are more susceptible to it.

The main symptoms of the disease are severe shortness of breath and cough with a small amount of sputum. Characterized by pain in the chest, fatigue and decreased performance, arthralgia and myalgia, fever. There are signs of hypoxic changes in the tissues: the fingers take the form of drumsticks, and the nails become like watch glasses. The wall of the alveoli becomes increasingly rigid due to fibrosis, which progressively increases respiratory failure.

Auscultation over the lungs is determined by crepitus, dry rales and hard breathing. Percussion sound is shortened. When x-rays are determined by small-focal shadows, localized, as a rule, in both lower lobes. A drop in the diffusion capacity of the alveoli is detected during functional tests (spirometry, peak flow).

Echinococcosis

Wegener's granulomatosis

With pneumonia, a differential diagnosis is also carried out with systemic diseases of an autoimmune nature. Among them, Wegener's granulomatosis is to be considered. It is characterized by the formation of multiple pulmonary infiltrates, lesions of the upper respiratory tract and other organs. The disease begins with general symptoms (weakness and fatigue), then pain in the muscles and joints joins.

Lung damage occurs with hemoptysis and shortness of breath, pleurisy may occur. Changes in the upper respiratory tract are runny nose, sinusitis, pharyngitis and tracheitis. The systemic nature of the disease manifests itself in the form of skin vasculitis, stomatitis, nephritis, iridocyclitis, pericarditis, polyneuritis. X-ray in the lungs are determined nodular darkening, focal or massive infiltration, atelectasis, pleural effusion.

The systemic nature of the lesion in Wegener's granulomatosis is confirmed by a variety of extrapulmonary manifestations.

Pneumonia in childhood

Clinical manifestations of pneumonia in children are determined by several aspects: boys are most often ill; the younger the child, the more severe the inflammation of the lungs; worse prognosis for prematurity, rickets, malnutrition, diathesis. At an early age, pneumonia often occurs against the background of SARS, whooping cough, measles. As a rule, in children it begins gradually - with catarrhal symptoms: runny nose, sneezing, dry cough. Then signs of intoxication join in the form of lethargy, loss of appetite, capriciousness, drowsiness. There is shortness of breath, periodic apnea, the ratio of breathing and pulse changes.

For bronchopneumonia in children under one year old, percussion signs are not characteristic, but fine bubbling rales and crepitus appear. Lobar and segmental infiltration is accompanied by bronchial breathing and shortening of the sound over the pathological focus. Radiologically at an early age, small rounded shadows are determined against the background of an enhanced and deformed vascular pattern.

Pneumonia in childhood must be differentiated from bronchiolitis, which has similar clinical features. But in this case, the results of the physical examination are radically different:

1. Percussion sound with box tone.
2. Hard breathing.
3. Scattered small bubbling rales.
4. Strengthening of the vascular pattern.
5. No infiltration.

Segmental pneumonia requires differentiation from pulmonary edema in SARS. The latter is more common after 2 years of age. Respiratory failure is rare, and physical signs are rather sparse. On the radiograph, extensive shadows of a homogeneous structure are determined, which, as a rule, are localized in the right lung. But when examined in dynamics, they disappear after a few days. The peripheral blood picture confirms the viral origin of the pathology (leukopenia, lymphocytosis).

Thus, pneumonia requires a qualitative differential diagnosis with other conditions in which pulmonary infiltration syndrome can be observed. The doctor analyzes any information - clinical symptoms, laboratory and instrumental signs. And only after a comprehensive analysis, a conclusion is made in favor of a particular disease.

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The need for differential diagnosis stems from common errors in the diagnosis of acute pneumonia, especially at the prehospital stage.

In at least 30-40% of patients, pneumonia is not recognized during the initial examination, and both overdiagnosis and underdiagnosis are observed with approximately the same frequency.

The main reason for such unsatisfactory diagnosis is the late appeal of patients for medical care.

In the hospital, according to pathoanatomical studies, pneumonia remains unrecognized in approximately 5% of patients.

As you know, differential diagnosis is carried out according to the leading syndrome. In the differential diagnosis of pneumonia, it is advisable to consider radiologically determined infiltration of the lung tissue (pulmonary infiltrate) as the leading syndrome. In those rare cases when X-ray examination is not performed for various reasons, differential diagnosis can be carried out according to the syndrome of clinically determined pulmonary infiltration: increased voice trembling and bronchophony in a limited area, dullness of percussion sound, hard or bronchial breathing, local crepitus (listening to local wet rales).

An infiltrate is a tissue area that has an accumulation of cellular elements that are usually not characteristic of it (inflammatory, eosinophilic, cancerous, lymphoid, leukemic, etc.), characterized by an increase in volume and increased density. In accordance with this, inflammatory, for example, with pneumonia and tuberculosis, cancerous, eosinophilic, leukemic infiltrates, infiltrates with malignant lymphomas, etc. are distinguished.

Thus, parenchymal changes in the lung tissue in pneumonia are only one of the options for pulmonary infiltrate. Infiltration is defined on the radiograph as a darkening of the lung tissue, which is not always easy to distinguish from other processes. Therefore, the list of diseases with which it is necessary to carry out a differential diagnosis is expanding due to these processes (atelectasis of a lobe or segment, pulmonary infarction, congestion in the lungs).

In the differential diagnosis of pneumonia, the doctor faces the following tasks:

1) delimitation of pneumonia from other respiratory diseases;

2) differentiation of pneumonia from extrapulmonary diseases with manifestations in the lungs;

3) conducting a differential diagnosis among the pneumonias themselves in order to establish (at least presumably) the etiology of the disease, since pneumonia caused by various microorganisms are different nosological forms and require appropriate etiotropic treatment.

Differential diagnosis of lobar (segmental) pneumonia with other diseases of the respiratory system

Differential diagnosis with tuberculous lobitis and caseous pneumonia

In favor of tuberculous lobitis testify:

1) heterogeneity of darkening on the radiograph with the presence of denser formations and areas of enlightenment (better seen on the tomogram), and especially focal shadows, both dense and soft, due to lymphogenous and bronchogenic seeding of the lung tissue surrounding the infiltrate;

2) more frequent absence of leukocytosis and neutrophilic shift to the left in peripheral blood;

3) detection of mycobacterium tuberculosis in sputum (research should be repeated - up to 3-5 times, especially if the upper lobe is affected);

4) the lack of effect of treatment in the "set" terms for pneumonia.

More significant differences with lobar pneumococcal pneumonia have caseous pneumonia - one of the most severe forms of pulmonary tuberculosis, the frequency of which has increased dramatically in recent years due to the deterioration of social conditions.

Unlike pneumococcal, caseous pneumonia has severe and constant sweating, especially at night (with pneumococcal lobar pneumonia, sweating appears only during a crisis or when the disease is complicated by abscess formation), distinct symptoms of intoxication, usually there is no severe pain in the chest; after a few days from the onset of the disease, a large amount of greenish, purulent sputum begins to separate (with pneumococcal pneumonia, after a short period of separation of rusty sputum, mucous sputum is separated in a small amount); hectic fever is noted (does not happen with pneumococcal pneumonia); during auscultation, usually by the end of the first week of the disease, moist rales of increased sonority are determined.

X-ray examination of the lungs and sputum analysis are of decisive importance for the diagnosis. Caseous pneumonia radiographically from the first days of the disease is characterized by inhomogeneous darkening of the lobe of the lung (less often 1-2 segments), which consists of merging large, flaky infiltrative foci with emerging areas of enlightenment due to rapidly advancing decay.

Within a few days, numerous fresh caverns with bay-shaped outlines and a wide zone of inflammatory changes around are formed at the site of these areas. A rapid transition of the process to the adjacent lobe or to another lung is characteristic, with the seeding of these departments, followed by the rapid development of new confluent foci with their disintegration.

The tuberculous nature of the pulmonary process is confirmed by the detection of Mycobacterium tuberculosis in the sputum.

It is much more difficult to make a differential diagnosis of Friedlander's and caseous pneumonia. As mentioned earlier, Friedlander's pneumonia, as well as caseous, is characterized by a more frequent lesion of the upper lobe, early development of multiple destructions in the lungs, and a severe course.

Differentiation is carried out according to the above features of radiological changes and the results of the analysis of sputum and other biological substrates (bronchial secretion, swabs from the larynx, bronchial washings, gastric contents) for Mycobacterium tuberculosis. Of additional importance is the consideration of the dynamics of the pulmonary process under the influence of the therapy.

Differential diagnosis with obstructive pneumonitis

Differential diagnosis of subsegmental pneumonia with other respiratory diseases

Differential diagnosis with ARVI and infiltrative pulmonary tuberculosis

The accession of pneumonia is evidenced by the worsening of the general condition of the patient on the 3-7th day from the onset of acute respiratory viral infections, the appearance of a second wave of fever, increased shortness of breath and cough with a significant amount of sputum discharge, identification of local changes in the lungs: an area with increased voice trembling and bronchophony, dullness of percussion sound, hard breathing or breathing with a bronchial tone, against which crepitus and moist rales are heard.

Listening to dry and moist rales symmetrical on both sides in the lungs is explained by the presence of acute bronchitis as a manifestation of an acute respiratory viral infection and does not directly indicate pneumonia. The diagnosis is confirmed by x-ray examination, which reveals infiltrative changes in the lungs.

Subsegmental (rarely segmental) pneumonia must also be differentiated from infiltrative pulmonary tuberculosis, primarily with the most common rounded infiltrate, as well as cloud-like infiltrate and periscissuritis, which refers to tuberculous infiltrate located along the large or small interlobar fissures.

Let's name the main differences between infiltrative pulmonary tuberculosis and pneumonia:

1. More gradual and less noticeable onset of the disease. The acute onset of the disease is more often observed with cloud-like infiltrates, periscissuritis and lobitis, but they account for 10-20% of all infiltrative forms of pulmonary tuberculosis.

2. Absence or slight severity of the syndrome of intoxication and catarrhal phenomena. In particular, the cough in patients is not pronounced and has the character of "coughing". Often, with infiltrative tuberculosis, the first clinical symptom is hemoptysis, which appears as a “thunder in the blue” and already indicates the disintegration of the infiltrate.

3. More often upper lobe localization or in the VI segment of the lower lobe (subsegmental pneumonia is more often localized in the basal segments of the lower lobes).

4. Frequent detection of pallor of the face, profuse sweating at night, good tolerance for elevated body temperature (the patient often does not feel its increase), poor percussion and auscultatory data (single moist rales are heard more often, usually after coughing). The expression of G. R. Rubinshtein (1949) that in tuberculosis (more precisely, with its infiltrative form) “a lot is seen (meaning in an X-ray examination) and little is heard” remains relevant to this day.

5. As a rule, a normal or slightly increased number of leukocytes with a tendency to lymphocytosis. However, even with subsegmental pneumonia, an increase in leukocytes is absent in almost half of the patients. Therefore, only the detection of leukocytosis above 12x10 9 /l with a pronounced shift of the leukocyte formula to the left and erythrocyte sedimentation rate (ESR) above 40 mm/h may be indicative of pneumonia.

6. Indications for contact with a patient with tuberculosis.

X-ray examination, detection of Mycobacterium tuberculosis in sputum, and in some cases bronchoscopy are of decisive importance for differential diagnosis. X-ray differences between subsegmental confluent pneumonia and tuberculous infiltrate are shown in Table 6.

The unconditional proof of the tuberculous process is the detection of Mycobacterium tuberculosis in sputum, especially in repeated studies. Mycobacteria are more often determined using fluorescent microscopy and bacteriological method. The effectiveness of simple bacterioscopy, which is more often used in medical institutions, is low.

Even if 1 ml of sputum contains 30,000 mycobacteria, positive results do not exceed 30%. Hence the expediency of repeated (up to 4-5 times or more) studies. The same facts indicate that the negative results of a simple bacterioscopy cannot serve as a basis for excluding tuberculosis.

Table 6. Radiological differences between subsegmental pneumonia and infiltrative tuberculosis

Differential diagnosis with lung cancer and malignant lymphoma

Central cancer develops from the epithelium of large bronchi, more often segmental, less often lobar and main bronchi. It is accompanied by a cough with sputum, hemoptysis, an x-ray examination reveals a tumor node, which, due to its low density, is poorly contoured on a conventional x-ray (better visible on a tomogram). With endobronchial growth, it quickly leads to hypoventilation and atelectasis and is clinically often manifested by recurrent obstructive pneumonitis.

In connection with segmental or lobar obscuration, such processes must be distinguished, first of all, from pneumococcal and other lobar and segmental pneumonias. With exobronchial tumor growth, bronchial obstruction does not occur for a long time. Such a tumor reaches a considerable size and, due to the peribronchial branched growth on the radiograph, gives an expanded root with uneven outer contours like “rays of the rising sun” or “janitor's broom”.

The need for differential diagnosis with pneumonia arises only when the tumor is complicated by paracancrous pneumonia. After antimicrobial therapy, the basal darkening only decreases in size due to the resorption of pneumonia, retaining the characteristic appearance described above after treatment.

More important is the differential diagnosis of subsegmental pneumonia with peripheral lung cancer, which on the radiograph gives an infiltrative shadow of a rounded shape. The main differential diagnostic differences between these diseases are shown in Table 7.

Peripheral lung cancer is prone to decay with the formation of a cavity in the tumor. With this variant of peripheral cancer, differential diagnosis is carried out with abscessing pneumonia.

Table 7 Differences between subsegmental pneumonia and peripheral lung cancer

Significant differences exist in the x-ray picture. The walls of the cavity, formed by a decaying tumor, are usually thick with an uneven, bay-shaped inner surface; the cavity itself is located eccentrically and, as a rule, does not contain liquid contents. With abscesses, the cavity is located centrally, usually has a horizontal level of fluid and an uneven but clear internal contour.

Of the other malignant neoplasms with which it is necessary to differentiate pneumonia, one should name malignant lymphomas - lymphosarcoma and especially pulmonary lymphogranulomatosis. This does not mean the most common primary lesion of lymphogranulomatosis of the intrathoracic lymph nodes, in which the differential diagnosis is carried out according to the syndrome of enlarged lymph nodes, but the primary lesion of the bronchopulmonary tissue.

In these cases, the growth of a specific granuloma often begins in the bronchial wall and, with endobronchial growth, leads to bronchial obstruction, atelectasis, and recurrent obstructive pneumonitis. But more often, the granuloma, growing, sinks into the lung tissue and leads to the formation of a polycyclic tumor of considerable size, which radiologically gives a picture of the infiltrate. In this regard, the disease often proceeds under the guise of pneumonia.

The similarity is enhanced by the presence of a cough with a small amount of sputum and such signs of lymphogranulomatosis as fever, neutrophilic leukocytosis with stab shifts, which in this situation are perceived as "evidence" of pneumonia. Against pneumonia, the clarity of the peripheral contours of blackout, the lack of improvement, and even the tendency of the infiltrative shadow to increase, despite the ongoing antimicrobial therapy, speak. The diagnosis is confirmed with the help of a puncture biopsy and with the appearance of extrapulmonary signs of lymphogranulomatosis.

Differential diagnosis with chronic pneumonia and allergic lung lesions

Subsegmental (rarely segmental) pneumonia must be differentiated from exacerbation of chronic pneumonia. Unlike "acute" in chronic pneumonia:

1) in the anamnesis there are indications of the repeated nature of inflammation with localization in the same areas of the lung, the undulating course of the disease with alternating periods of exacerbation (usually during the transitional season) and remission;

2) during auscultation, the sonorous nature of moist rales draws attention (explained by increased resonance due to pneumosclerosis);

3) in X-ray examination, infiltration is determined against the background of pneumosclerosis, which is better documented as infiltrative changes decrease under the influence of treatment.

Allergic lesions of the lungs, with which it is necessary to differentiate pneumonia, proceed in the form of:

1) eosinophilic pulmonary infiltrate (ELI), also called volatile ELI, simple pulmonary eosinophilia or Loeffler's syndrome (described by Loeffler in 1932);

2) prolonged pulmonary eosinophilia;

3) allergic pneumonitis;

4) allergic alveolitis.

The need to exclude allergic processes in the lungs is dictated by the objectives of treatment, since the prescription and especially persistent use of antibiotics in allergic processes not only has no effect, but leads to a deterioration in the condition and often to death.

The differences from pneumonia are:

1) the absence or weak severity of clinical manifestations in ELI (cough, percussion and auscultatory data), for example, single dry and intermittent small bubbling moist rales are heard only occasionally;

2) mucous sputum, in a small amount, contains eosinophils, Charcot-Leiden crystals;

3) normal (rarely subfebrile) temperature.

The most characteristic signs of eosinophilic pulmonary infiltrate are blood eosinophilia (more than 8-10, more often 20-50, sometimes up to 70%) with a normal or slightly increased number of leukocytes and the detection of a homogeneous infiltrative opacification of significant size without clear external boundaries, more often round in shape , resembling a tuberculous rounded or cloudy infiltrate. The infiltrate is more often located in the upper parts of the lung, sometimes several infiltrative shadows are determined.

Characteristically rapid, after 3-4, rarely 5-7 days, the disappearance of the infiltrate. It is believed that if the infiltrate persists for more than 10 days, then the diagnosis of ELI becomes doubtful. However, some authors allow the duration of eosinophilic pulmonary infiltrate up to 4 weeks. The protracted course of eosinophilic pulmonary infiltrate is explained by the permanent intake of an allergen into the body, for example, by continuing to take the “guilty” drug, and is morphologically characterized by the development of allergic vasculitis. In this regard, in all cases when ELI develops against the background of drug treatment, drug withdrawal is recommended.

At prolonged pulmonary eosinophilia (PLE)(synonym - eosinophilic pneumonia), described by Carrington in 1969, infiltrates in the lungs and eosinophilia in the peripheral blood persist for more than 1 month. Persons of middle age, mainly women are ill. Clinical symptoms are more pronounced than with EIL: moderate fever, cough with sputum, shortness of breath, symptoms of intoxication, dullness of percussion sound, moist rales are observed.

A blood test reveals slight leukocytosis and eosinophilia, although the latter is less pronounced than with ELI, and in some cases is absent, which makes it difficult to differentiate from pneumonia. Lung biopsy specimens show eosinophilic infiltration of the alveoli and interstitial tissue. DLE can be an independent pathological process, but often it turns out to be the debut or one of the manifestations of systemic allergic, including autoimmune diseases, such as polyarteritis nodosa.

Allergic pneumonitis, also called pneumonia-like allergic lung disease, is more often a sign of a drug-induced disease, although it can also develop when exposed to other allergens. Allergic pneumonitis is a localized process in the lungs, often unilateral, which, according to clinical and radiological data, cannot be distinguished from pneumonia. Often the pleura is affected with the possible development of effusion.

The idea of ​​​​the allergic nature of the pulmonary process is suggested by:

1) the development of the disease against the background of taking medications (more often drugs of the penicillin series, sulfonamides, cephalosporins, furazolidone, furadonin, adelfan, dopegyt, vitamin B 1, cocarboxylase and many others);

2) the presence of other clinical manifestations of allergies (skin rashes, asthmatic bronchitis, conjunctivitis, etc.);

3) the presence of moderate blood eosinophilia in some patients;

4) ineffectiveness of antibiotic therapy;

5) improvement after elimination of contact with the suspected allergen, for example, after the withdrawal of the "guilty" drug. To clarify the diagnosis, some authors recommend provocative, for example, intradermal allergic tests, as well as various methods for detecting drug allergies in vitro (leukocyte migration inhibition reaction, lymphocyte blast transformation reaction).

Allergic pneumonitis often overlaps with normal pneumonia. In these cases, at the beginning of the disease, antibiotics have a certain effect, but then the reverse development of the process stops, despite the change in the antibiotic (antibiotics); moreover, the process spreads to neighboring parts of the lungs, and sometimes destructive changes develop and hemoptysis appears, which is explained by hemorrhagic vasculitis and impaired microcirculation.

Pulmonary destruction in allergic pneumonitis develops due to aseptic necrosis and, unlike abscessing pneumonia, its formation is not preceded by the separation of purulent sputum with a smell, and the cavity itself initially does not contain liquid. In the future, its secondary infection often occurs with the formation of an abscess.

Allergic pneumonitis can be suspected based on the above signs. The most important argument in favor of allergic pneumonitis is the improvement after the abolition of antibiotics and the appointment of glucocorticoids.

Pneumonia must be differentiated from acute forms of alveolitis (bronchioloalveolitis). Recall that alveolitis is divided into idiopathic fibrosing alveolitis (ELISA), exogenous allergic alveolitis (EAA) and toxic fibrosing alveolitis (TFA).

With ELISA, the etiology of the disease is unknown; having begun, it steadily progresses, leading to diffuse pneumosclerosis, a decrease in the respiratory surface, pulmonary and pulmonary heart failure.

EAA is an allergic reaction (type III according to Gell and Coombs) from the respiratory organs to the effects of various allergens. The source of EAA can be thermophilic actinomycetes contained in moldy hay (“farmer’s lung”), antigens of various fungi (“brewers’ lung”, “cheese makers’ disease”, allergic aspergillosis, etc.), components of cotton, hemp, flax (byssinosis - cotton allergy ), animal hair (“lung of furriers”), waste products of birds with antigenic properties, especially excrement, which are in large quantities in the form of dust in the air of rooms where birds are kept (“lung of the poultry breeder”, in particular “lung of the pigeon breeder”), various medicines (antibiotics, sulfonamides, cordarone, trypsin, chymotrypsin, streptase, urokinase and other enzymes, pituitrin, radiopaque preparations, etc.).

These substances often cause EAA when inhaled into the body, less often - orally or parenterally. Among the various forms of EAA, "farmer's lung", "poultry's lung" and drug-induced allergic alveolitis are more common. Manifestations of EAA occur 4-8 hours after the allergen enters the body.

TFA develops as a result of exposure to the alveoli of various toxic substances: irritating gases (hydrogen sulfide, chlorine, ammonia, etc.), metals in the form of vapors, fumes (manganese, mercury, zinc, etc.), plastics, herbicides. TFA can be caused by various drugs, such as nitrofuran derivatives (furadonin, furazolidone), sulfonamides, cytostatic agents (chlorbutin, cyclophosphamide, methotrexate, myelosan, azathioprine, vincristine, etc.), anaprilin, and many others.

The acute form of alveolitis, which proceeds almost the same in all variants of the disease, is almost always mistaken for pneumonia at first. Common symptoms for both diseases are: acute onset in most patients with fever up to 38-40 ° C, the appearance of shortness of breath, cough, chest pain (in some patients), aggravated by deep inspiration; crepitus and fine bubbling rales in the lungs, neutrophilic leukocytosis with a shift to the left, aneosinophilia. However, in 40-45% of patients, the disease begins gradually with the onset of shortness of breath, dry cough, and fatigue.

Doubts about the diagnosis of "pneumonia" appear in the analysis of subjective and objective clinical symptoms. Attention is drawn to the great intensity of dyspnea and its steadily progressive nature, which in most patients is accompanied by acrocyanosis or general cyanosis. In a number of patients, signs of right ventricular hypertrophy and its decompensation appear quite early due to pulmonary hypertension: expansion of the boundaries of the heart to the right, accent and splitting of the II tone on the pulmonary artery, liver enlargement, symptoms of overload of the right heart on emission computed tomography (ECG).

Cough in acute alveolitis is usually dry and only in 20-25% of patients is accompanied by the separation of a small amount of mucous sputum. The diagnosis of "pneumonia" does not correspond to the data of a physical examination: indefinite and variable percussion changes (often a percussion tone with a box shade, sometimes not changed or somewhat shortened), over all fields of the lungs, mainly in the lower sections, crepitus is heard (due to damage to the alveoli) and small bubbling moist rales (due to damage to the bronchioles).

At first, in the exudative phase of the disease, gentle crepitus is heard, then, as lung fibrosis develops, voiced crepitus (sclerosyphonia) is heard. Crepitus and small bubbling wet rales are heard in 75% of patients.

Radiographically, in contrast to bacterial pneumonia, the diffuse nature of the pulmonary process is determined: a sharp increase in the pulmonary pattern with a predominance of interstitial edema, against which infiltrative changes in the form of flakes, small-focus blackouts or large areas of infiltration, mainly in the lower sections of the lungs, are determined in all parts of the lungs, frosted glass type. It is somewhat more difficult to distinguish non-bacterial pneumonia (mycoplasmal, chlamydial) from alveolitis by the x-ray picture. Here it is necessary to evaluate the entire clinical picture, as well as the dynamics of pulmonary changes under the influence of treatment.

Differential diagnosis also takes into account:

1) the discrepancy between moderately severe intoxication, on the one hand, and the prevalence of lung damage, on the other;

2) lack of effect and even progression of the pulmonary process against the background of antimicrobial therapy;

3) a history of allergy to various substances and drugs, which can be observed with EAA, and exposure to compounds that can have a toxic effect on the respiratory tract (to exclude TFA);

4) the presence of extrapulmonary signs of allergy (skin rashes, angioedema, allergic rhinitis, conjunctivitis), which may indicate EAA.

The diagnosis of alveolitis is confirmed by cytological methods in the study of lung tissue biopsies (the method of choice is an open lung biopsy) and lavage fluid.

Differential diagnosis of pneumonia with diseases of other organs and systems

Common signs of hypostasis and pneumonia are the presence of shortness of breath, cough with a small amount of sputum, dullness of percussion sound in the lower sections (with hypostasis due to swelling of the interstitial tissue), listening to crepitus and moist rales. With hypostasis, wheezing is determined on both sides, although they are often heard mainly on the right, but, most importantly, there is a variability of wheezing with a change in body position and with deep breathing (their decrease and even complete disappearance).

Distinctive signs of pneumonia, including pneumonia against the background of hypostasis (hypostatic pneumonia) from isolated hypostasis are a sudden deterioration in the patient's condition, increased shortness of breath, cough, fever (in these cases, even a temperature of 36.9-37 ° C can indicate the addition complications, since hypothermia is characteristic of heart failure), some increase in bronchophony, the appearance in the lower back sections of the lungs of hard breathing or breathing with a bronchial tone, the asymmetric nature of wheezing. An essential role in the diagnosis is given to X-ray examination.

Damage to the lungs in DCTD (pneumonitis), in particular with systemic lupus erythematosus and rheumatoid arthritis, can be mistaken for pneumonia. In both diseases, there is a cough, shortness of breath, pain in the chest during breathing, fever, dullness of percussion sound above the lower parts of the lungs, with auscultation - hard or weakened breathing, moist, mostly finely bubbling rales of various sonority. Similar to pneumonia can be with DZST and radiographic changes: increased pulmonary pattern in the lower and middle sections of the lungs, against which infiltrative foci are determined.

The main differences between pneumonitis and pneumonia are: the presence of signs of CTD, the ineffectiveness of antimicrobial therapy, the virtual absence of sputum separation, the high standing of the diaphragm and bilateral symmetrical changes in the lungs with the presence of focal mesh enhancement and deformation of the pulmonary pattern, as well as unilateral or bilateral discoid atelectasis located parallel to the diaphragm and associated both with damage to the lungs and the diaphragmatic pleura, positive dynamics under the influence of glucocorticosteroids.

Pulmonary infarction is usually the result of thromboembolism of medium-sized branches of the pulmonary artery. The cause of embolism is often thrombophlebitis (phlebothrombosis) of the lower extremities and small pelvis, which developed after childbirth and surgical interventions, especially on the organs of the small pelvis. A pulmonary infarction can also develop as a result of local thrombosis in the pulmonary arteries in people with heart defects, hypertension, coronary heart disease with severe heart failure, in patients with neoplasms of various localization, in people who are on bed rest for a long time.

Pulmonary embolism (PE) begins suddenly with shortness of breath, which can reach the degree of suffocation and is accompanied by diffuse cyanosis. Approximately half of the patients, along with this, have pain in the chest (behind the sternum, in the back or lateral sections), 1/3 of the patients have hemoptysis. The presence of severe and acute dyspnea, not adequate to the extent of the lesion (at first, even without detectable changes in the lungs), often in combination with vascular insufficiency, the absence or mild severity of symptoms of intoxication and febrile reaction in the first 1-2 days of the disease can serve as hallmarks of pulmonary embolism from pneumonia.

During this early period, distinct physical changes in the lungs may not be detected, and an x-ray examination reveals an increase in the transparency of the lung tissue in the affected area with regional disappearance or weakening of the vascular pattern. Along with this, it is at the onset of the disease that the syndrome of acute pulmonary heart develops when a larger branch or several segmental arteries are affected.

Clinically, this is manifested by an increase in cardiac impulse, an accent of the II tone over the pulmonary artery, and a Graham-Still diastolic murmur. On the radiograph, a bulging of the pulmonary cone, a sharp expansion and chopping of the roots of the lung are revealed. The ECG reveals changes of the S 1 Q 3 type, that is, a deep S wave in I and a deep Q wave in standard leads III, as well as an increase in the ST segment and the appearance of a negative T wave in standard lead III, while in I and II standard assignments the ST segment is displaced down.

With the development of a lung infarction (usually by the end of 1-3 days), dullness of percussion sound is determined, more often in the subscapular region, weakened breathing, a small amount of dry and wet rales, quite often pleural friction noise. X-ray in typical cases (when capturing one segment of the lung), a homogeneous darkening of a triangular shape is detected with the base facing the pleura, and the apex facing the gates of the lung. Sometimes the opacification may be in the form of a linear horizontal shadow over the diaphragm, pear-shaped or rocket-shaped with frequent involvement of the pleura with exudate and pleural adhesions.

In contrast to pneumonia, with a pulmonary infarction, an increase in body temperature is of a “delayed” nature and develops only as infarct pneumonia develops, usually 2–4 days after embolization. Distinguishing infarct pneumonia from pneumonia of a different nature due to the similarity of the clinical and radiological picture is possible only when taking into account the dynamics of the development of the disease and the presence of background diseases that can lead to pulmonary embolism or local thrombosis of the pulmonary artery.

It should be borne in mind that thrombophlebitis of the deep veins of the legs and especially the pelvic veins is not always recognized clinically. Radiologically with infarct pneumonia, it is often not possible to delimit the infarct zone from peri-infarction inflammation. In such cases, the shadow of a lung infarction in the form of a uniform sharply defined blackout is detected only after the resolution of perifocal infiltration (after 1-2 weeks of treatment), it persists for another 1-3 weeks, after which the infarction resolves or is replaced by pneumosclerosis.

Lung scans can be used to differentiate between PE and pneumonia. The absence of changes on the scan testifies against PE, while a positive result, reflecting a decrease or absence of perfusion, does not allow us to judge the nature of the disease, since it is observed not only in PE, but also in pneumonia and a number of other diseases. According to indications, angiopulmonography is performed.

The nature of differential diagnosis with other diseases is often determined by extrapulmonary symptoms (syndromes) of the pneumonia itself or its complications. Among them, according to our data, the pseudo-abdominal syndrome, which develops due to damage to the diaphragmatic pleura when pneumonia is localized in the lower lobe, has the greatest practical significance.

The presence of severe pain in the upper abdomen, often nausea and vomiting, high body temperature, leukocytosis with a neutrophilic shift to the left explains why it is sometimes mistaken for an "acute abdomen" and the patient is subjected to unnecessary surgery. Correct diagnosis is facilitated by the identification of symptoms of pneumonia, which is possible only with an impartial (that is, according to the generally accepted plan) clinical examination of the patient. Significant differences are also symptoms from the abdomen.

With pneumonia, abdominal pain is reflected in nature and is observed in the absence of peritonitis. In this regard, the tension of the abdominal muscles is expressed indistinctly, indistinctly, and, most importantly, is of a non-permanent nature, significantly decreasing up to complete disappearance when the patient's attention is distracted. In contrast to the "acute abdomen", with dynamic observation, the abdominal syndrome does not increase with pneumonia.

Pneumonia due to developing hypoxia and intoxication often leads to exacerbation ischemic heart disease (CHD), especially often to the appearance (sometimes for the first time) of cardiac arrhythmias (paroxysmal tachycardia or paroxysmal form of atrial fibrillation, polytopic extrasystoles). Doctors correctly associate these rhythm disturbances with coronary artery disease, but pneumonia, which served as their provocateur, is often not diagnosed. This is also facilitated by the fact that secondary pneumonia in patients with cardiovascular diseases usually proceeds without fever, and worsening of the condition, the appearance (or increase) of shortness of breath, cough, wet rales in the lungs is associated with the development of left ventricular failure due to IHD and arrhythmia. X-ray examination plays an important role in the diagnosis of pneumonia.

The presence of severe pain in the chest with left-sided pneumococcal pneumonia dictates the need to exclude myocardial infarction, an increase in severe pneumonia of the liver with a violation of its functions - acute hepatitis or exacerbation of chronic hepatitis, irritation of the meninges (meningism) in some forms of pneumonia is a reason to exclude meningitis.

If the patient first comes under the supervision of a doctor with the development of complications such as respiratory distress syndrome (RDS) and infectious-toxic shock (ITSH), then the differential diagnosis is based on these syndromes. At the same time, to confirm the connection between RDS and pneumonia, the doctor must exclude other variants of RDS (with sepsis, chemical poisoning, etc.) and hemodynamic pulmonary edema. Physical and radiological signs of pneumonia will come to light only after a few days, as the pulmonary edema is eliminated.

TSS is also observed not only in pneumonia, but also in many other bacterial infections. Its connection with pneumonia is much easier to establish in the initial stages of shock, when its signs (general anxiety, alternating with mental retardation, shortness of breath, nausea, vomiting, tachycardia, moderate hypotension) do not mask the symptoms of pneumonia. With the progression of TSS, when hypothermia, pulmonary edema, oliguria, hypoxic ECG changes resembling heart attacks develop, the presence of pneumonia can only sometimes be assumed on the basis of a careful study of the anamnesis and the absence of other reasons for the development of shock. In most cases, pneumonia is not diagnosed at this stage of TSS, and the origin of the shock itself is often associated with myocardial infarction.

Opportunities for differentiating pneumonias by etiology

In rare cases, a lobar (segmental) lesion can be observed with staphylococcal infiltrate and confluent pneumonia of another bacterial etiology (“pseudo-lobar” pneumonia), which have an insufficiently defined clinical and radiological picture and course. In these cases, the probability of establishing an etiological diagnosis without special laboratory tests is much lower.

From non-lobar and non-segmental pneumonia, it is necessary, first of all, to strive to isolate mycoplasma and chlamydial pneumonia according to clinical and radiological data. This is of great practical importance due to the peculiarities of the etiotropic treatment of these pneumonias.

Radiologically, they are characterized by the presence of infiltrative changes in the form of spotty or subsegmental (rarely larger) opacities against the background of a diffuse enhancement of the lung pattern, and an increase in the lung pattern in the first 1-2 weeks of the disease precedes the development of infiltrative changes. These features of the X-ray picture, if they are identified and properly assessed, can serve as a starting point for differential diagnosis.

Similar radiological changes can also be observed in viral-bacterial pneumonia, in which viral intoxication leads to toxic edema of the interstitial tissue with increased pulmonary pattern, and bacterial pneumonia leads to infiltrative changes. However, according to clinical and laboratory parameters, viral-bacterial pneumonias practically do not differ from other bacterial pneumonias and, as a rule, can be distinguished from mycoplasmal and chlamydial pneumonias.

Clinically, mycoplasma and chlamydial pneumonia are characterized by the presence of extrapulmonary manifestations, the scarcity of the physical picture from the lungs, the long course of the disease, including the febrile period, a normal or slightly increased number of leukocytes, and often the group nature of the disease.

Although there are some differences between mycoplasma and chlamydial pneumonia, for example, the development of the disease with symptoms acute respiratory disease (ORZ) and the presence of a painful, debilitating cough in mycoplasmal pneumonia and the development of the disease without a previous acute respiratory syndrome and the almost constant presence of hepatolienal syndrome in chlamydial pneumonia, but without special laboratory studies it is not possible to reliably distinguish between these two forms of pneumonia. However, this does not affect the nature of therapeutic measures, since the etiotropic therapy of mycoplasma and chlamydial pneumonia is the same.

In other forms of subsegmental pneumonia, the etiology of the disease is presumably established taking into account the place of occurrence, the clinical and radiological picture, the course of the disease, the epidemiological situation, age, the nature of background diseases and the effect of the therapy.

In all cases, it is necessary to strive for etiological diagnosis by laboratory methods.

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