True croup: clinic of the disease, how it differs from the false form, differential diagnosis. True croup True croup develops when

"Croup", "acute or recurrent laryngitis/laryngotracheitis", "acute airway obstruction", "larynx stenosis" - are the above names synonymous or are they independent nosological forms? Every practitioner should be clear about what these terms mean.

Probably the most widely used, especially in pediatric practice, is the term “croup”, and the most common term is “acute airway obstruction”, but in ICD-10 the codes are given according to the “organ principle”.

So, croup (from the Scottish croup - to croak) is a syndrome of an infectious disease, always implying the presence of acute stenosing laryngitis (or laryngotracheitis, or less often laryngotracheobronchitis), accompanied by hoarseness, "barking" cough and shortness of breath, often inspiratory. That is, croup is understood as the presence of a certain syndrome with a triad of clinical symptoms: stridor - "barking" cough - hoarseness. The syndrome is formed in diseases manifested by the development of an acute inflammatory process in the mucous membrane of the larynx and trachea. Therefore, the term "croup" applies only to infectious diseases! Domestic pediatricians traditionally divide croup into “true” and “false”, depending on the level of damage to the larynx, although this division is extremely conditional, since the mucous membrane of the larynx is often involved in the process along its entire length, as well as the mucosa of the underlying parts of the respiratory tract. "True" croup develops as a result of damage to the true vocal cords (folds). The only example of a "true" croup is diphtheria croup, which proceeds with the formation of specific fibrinous changes on the mucous membrane of the vocal cords. "False" croup includes all stenosing laryngitis of a non-diphtheria nature, in which the inflammatory process is localized mainly on the mucous membrane of the subglottic (subglottic) zone of the larynx. "Acute laryngitis" has the ICD-10 code J04.0, "acute laryngotracheitis" - J04.2, "acute obstructive laryngitis" - J05, and "chronic laryngitis" and "chronic laryngotracheitis" - respectively J37.0 and J37.1 . In any case, it should be understood that acute obstruction of the upper respiratory tract (narrowing of the lumen of the larynx with respiratory disorders and the development of acute respiratory failure) is primarily an emergency condition that requires emergency diagnosis and therapy even at the prehospital stage.

This condition most often occurs in children of early and preschool age (from 6 months to 3 years, and in 34% of cases - in children of the first 2 years). Acute obstruction is associated with the anatomical and physiological features of the respiratory tract in young children: the narrowness of the lumen of the trachea and bronchi (funnel-shaped instead of cylindrical), the tendency of their mucous membrane and the loose fibrous connective tissue located under it to develop edema, the peculiarities of the innervation of the larynx, which are associated with the occurrence laryngospasm, and relative weakness of the respiratory muscles. Edema of the mucous membrane with an increase in its thickness by only 1 mm reduces the lumen of the larynx by half! The development of acute upper airway obstruction in adults is rare and is usually associated with diphtheria.

There are infectious and non-infectious causes of acute upper airway obstruction. Infectious causes include viral infections (caused in 75% of cases by influenza and parainfluenza type I viruses, as well as rhinosincitial viruses, adenoviruses, less often measles and herpes viruses) and bacterial infections (with the development of epiglottitis, pharyngeal and paratonsillar abscess, diphtheria). In this case, the mechanism and ways of transmission of the pathogen are determined by the epidemiological characteristics of the underlying infectious disease. Aspiration of foreign bodies, trauma to the larynx, allergic edema, laryngospasm can be non-infectious causes of acute upper airway obstruction.

Three factors play a certain role in the genesis of airway obstruction: edema, reflex spasm of the muscles of the larynx and mechanical blockage of its lumen by an inflammatory secret (mucus) or a foreign body (including food, vomit, etc.). Depending on the etiology, the significance of these components may be different. In practical work, in order to conduct adequate therapy and provide effective assistance to the child, it is important to be able to quickly differentiate them.

The main reason for the development of croup is an inflammatory process in the subglottic space and vocal cords (acute stenosing laryngotracheitis). The phenomenon of narrowing of the lumen of the upper respiratory tract with croup is formed sequentially, in stages, and is directly related to the reaction of the laryngeal tissue to an infectious agent, including triggering and allergic reactions. When evaluating the clinical picture, it is necessary to take into account the prevalence of edema of the inflamed mucous membrane, spasm of the muscles of the larynx and trachea, and mucus hypersecretion, since this is essential when choosing treatment tactics.

Respiratory disorders due to narrowing of the lumen of the larynx most often occur at night, during sleep, due to changes in the conditions of the lymphatic and blood circulation of the larynx, a decrease in the activity of the drainage mechanisms of the respiratory tract, the frequency and depth of respiratory movements.

The clinical picture of acute stenosis of the upper respiratory tract is determined by the degree of narrowing of the larynx, associated violations of the mechanics of breathing and the development of acute respiratory failure.

With incomplete obstruction of the larynx, noisy breathing occurs - stridor, due to the intense turbulent passage of air through the narrowed airways. With a dynamic narrowing of the airway lumen, normally soundless breathing becomes noisy (due to vibrations of the epiglottis, arytenoid cartilages, and partially vocal cords). With the dominance of edema of the tissues of the larynx, a whistling sound is observed, with an increase in hypersecretion - hoarse, bubbling, noisy breathing, with a pronounced spastic component, instability of sound characteristics is distinguished. It should be remembered that with an increase in stenosis due to a decrease in tidal volume, breathing becomes less and less noisy!

Inspiratory stridor usually occurs when there is narrowing (stenosis) of the larynx at or above the vocal cords and is characterized by noisy inspiration with retraction of compliant chest areas. Stenoses below the level of the true vocal cords are characterized by expiratory stridor with the participation of auxiliary and reserve respiratory muscles in breathing. Stenosis of the larynx in the region of the infraglottic space usually manifests itself as a mixed, both inspiratory and expiratory stridor. The absence of voice change indicates the localization of the pathological process above or below the vocal cords. The involvement of the latter in the process is accompanied by hoarseness of voice or aphonia. A hoarse, "barking" cough is typical of subglottic laryngitis. Other signs of upper airway obstruction are nonspecific: anxiety, tachycardia, tachypnea, cyanosis, neurovegetative disorders, etc. Rapid breathing and elevated body temperature with croup can lead to significant fluid loss and the development of respiratory exsicosis.

According to the severity of the narrowing of the lumen of the larynx, four degrees of stenosis are distinguished, which have significant differences in the clinical picture (see table). However, when making a diagnosis, first of all, the severity of the croup is determined, and not the severity of stenosis (the latter can be assessed with direct laryngoscopy, which is not feasible at the prehospital stage). In a comprehensive assessment of the patient's condition, factors such as participation in the act of breathing of auxiliary muscles (evidence of a significant narrowing of the airway lumen), symptoms of respiratory and cardiovascular insufficiency, depression of consciousness and persistent hyperthermia should be taken into account.

Thus, the classification of cereals is built taking into account:

• croup etiology (viral or bacterial);
• stages of stenosis of the larynx (compensated, subcompensated, decompensated, terminal);
• the nature of the course (uncomplicated or complicated - the appearance of a mixed infection due to the addition of a secondary bacterial purulent infection to the main process).
• with the development of diphtheria croup, the nature of the spread of the inflammatory process is also taken into account (it is possible to spread to the mucous membrane of the trachea, bronchi and bronchioles - the so-called descending croup).
• syndrome recurrence.

DIFFERENTIAL DIAGNOSIS

Diphtheria of the larynx

Diphtheria of the larynx is most often combined with manifestations of this infection of another localization (diphtheria of the throat or nose), which greatly facilitates the diagnosis. The main differences between diphtheria of the larynx and croup, which developed against the background of SARS, are the gradual onset and severity of the course with an increase in symptoms. The voice in diphtheria of the larynx is persistently hoarse with the gradual development of aphonia. In the treatment of laryngeal diphtheria, along with measures aimed at restoring airway patency, it is necessary to urgently administer antidiphtheria serum to the child according to the Bezredko method at a dose of 40-80 thousand IU per course of treatment, depending on the form of the disease.

Allergic edema of the larynx

Allergic edema of the larynx is not always possible to distinguish from croup of an infectious nature only on clinical grounds. Allergic edema of the larynx develops under the influence of any antigen of inhalation, food or other origin. There are no specific indications for SARS. Fever and intoxication are not typical. In the anamnesis, these children have information about certain allergic sympathies: skin manifestations of allergies, food allergies, Quincke's edema, urticaria, etc. During therapy with inhaled glucocorticoids with the addition of b2-adrenergic agonists (salbutamol - ventolin), anticholinergics (ipratropium bromide - atrovent ), combined agents (a combination of fenoterol and ipratropium bromide - berodual), and also, according to indications, antihistamines, a rapid positive dynamics of stenosis occurs.

laryngospasm

Laryngospasm occurs mainly in children of the first 2 years of life against the background of increased neuromuscular excitability, with manifestations of current rickets with a tendency to tetany. Clinically, a spasm of the larynx manifests itself unexpectedly, the child has difficulty inhaling with a characteristic sound in the form of a "rooster's cry", while fear, anxiety, cyanosis are noted .. Light attacks of laryngospasm are removed by spraying the child's face and body with cold water. It is necessary to try to induce a gag reflex by pressing on the root of the tongue with a spatula or spoon, or to provoke sneezing by irritating the mucous membrane of the nasal passages with cotton wool. If there is no effect, diazepam should be administered intramuscularly.

Epiglottitis

Epiglottitis is an inflammation of the epiglottis and adjacent areas of the larynx and pharynx, most commonly caused by Haemophilus influenzae type b. The clinical picture is characterized by high fever, sore throat, dysphagia, muffled voice, stridor, and respiratory failure of varying severity. Palpation of the larynx is painful. When examining the pharynx, a dark cherry color of the root of the tongue, its infiltration, swelling of the epiglottis and arytenoid cartilages that close the entrance to the larynx are found. The disease progresses rapidly and can lead to complete closure of the lumen of the larynx.

At the prehospital stage, it is optimal to inject an antibiotic 3rd generation cephalosporin (ceftriaxone) as early as possible. Transportation of the child to the hospital is carried out only in a sitting position. Sedatives should be avoided. You need to be prepared for tracheal intubation or tracheotomy.

Retropharyngeal abscess

Most often, a retropharyngeal abscess occurs in children under the age of three. It usually develops against the background of or after an acute respiratory viral infection. The clinical picture is dominated by symptoms of intoxication, severe fever, sore throat, dysphagia, stridor, salivation. There are no "barking", rough cough and hoarseness of voice. Expectoration is difficult because of the sharp soreness in the throat. The child often takes a forced position - with his head thrown back. Inspection of the pharynx presents significant difficulties due to the sharp anxiety of the child and the inability to open the mouth. For examination, sedative therapy is used.

Treatment at the prehospital stage is not carried out. Urgent hospitalization in the surgical department is required. In the hospital, an abscess is opened and drained against the background of antibiotic therapy.

Foreign bodies

Foreign bodies of the larynx and trachea are the most common cause of asphyxia in children. Unlike croup, aspiration occurs unexpectedly in the presence of apparent health, usually while the child is eating or playing. There is an attack of coughing, accompanied by suffocation. The clinical picture depends on the level of airway obstruction. The closer the foreign body is to the larynx, the more likely it is to develop asphyxia. This location of the foreign body is usually accompanied by the appearance of laryngospasm. The child is scared and restless. A popping sound can sometimes be heard on auscultation, indicating balloting of a foreign body.

After examining the oral cavity and entering the larynx, attempts are made to remove the foreign body by mechanically "knocking out" it. A child under 1 year old is placed face down with the head end lowered by 60 °. With the edge of the palm, he is given short blows between the shoulder blades. In children older than one year, sharp pressure with the hand on the abdomen from the midline inward and upward (at an angle of 45 °) can be effective. In older children, blows to the back alternate with a sharp squeezing of the abdomen, clasping the child with his hands from behind (Heimlich's maneuver).

If attempts to remove a foreign body using mechanical techniques are ineffective, the issue of urgent intubation or tracheotomy should be decided.

Croup treatment

Treatment of croup should be aimed at restoring the patency of the larynx: reducing or eliminating spasm and swelling of the mucous membrane of the larynx, freeing the lumen of the larynx from the pathological secret.

• Patients are subject to hospitalization in a specialized or infectious diseases hospital if it has an intensive care unit and intensive care, but treatment should begin already at the pre-hospital stage.
• The child should not be left alone, he must be calmed, taken in his arms, since forced breathing during anxiety, screaming increases the phenomena of stenosis and a sense of fear.
• The room temperature should not exceed 18°C. Effective expectoration of sputum is also facilitated by the creation in the room where the child is located, an atmosphere of high humidity (the effect of a "tropical atmosphere"), steam inhalations (isotonic NaCl solution through a nebulizer). A warm drink is shown (hot milk with soda or Borjomi).
• Etiotropic therapy is effective for diphtheria croup - the introduction of antidiphtheria serum in / m or / in.
• Antibiotics - for diphtheria croup and croup, complicated by a secondary bacterial infection.
• Dilution and removal of sputum from the respiratory tract is facilitated by expectorant and mucolytic drugs, administered mainly by inhalation, for example, ambroxol (lazolvan), etc.
• Considering the significant participation of the allergic component in the development of croup, it is advisable to include antihistamines (for example, chloropyramine (suprastin), etc.) in the complex of therapeutic measures. A randomized, double, placebo-controlled study by Gwaltney J. M. et al. showed that in the treatment of acute respiratory diseases, a combination of antipyretic, antihistamine and antiviral agents can effectively (by 33-73% compared with placebo) reduce the severity of various clinical manifestations of the disease, including the amount of mucus produced and soreness in the pharynx and larynx. In another work, the same authors demonstrated that clemastine, prescribed in the complex treatment of ARI, unlike pheniramine, only increases the sensation of dryness and perspiration in the throat. And Gaffey M. J. et al. did not note any effect from the use of terfenadine in a similar clinical situation.
• Glucocorticoids, for example, prednisolone at a dose of 3-10 mg / kg - to stop swelling of the mucous membrane of the larynx.
• Psychosedative substances - with severe spasm of the muscles of the larynx. Tranquilizers are used for planned therapy of spastic symptoms.
• Intubation and tracheostomy are indicated for the ineffectiveness of conservative therapy and for resuscitation (asphyxia, clinical death).

So, until recently, croup therapy was limited mainly to the supply of humidified air and the introduction of systemic steroids. However, given the fact that croup most often develops in young and young children, in whom both oral and injectable steroids are a serious problem, and also that the entire medical community is now striving to reduce the possible risk of side effects of systemic steroid therapy, especially promising is the use of inhaled glucocorticoids. To date, vast experience has been accumulated in the treatment of stenosing laryngitis / laryngotracheitis with budesonide inhalations (pulmicort) through a nebulizer. The effectiveness of this kind of therapy was, in particular, devoted to Ausejo et al. a meta-analysis of 24 (!) randomized controlled trials, during which, among other things, the effectiveness of inhaled budesonide and systemic dexamethasone was compared. It was shown that the use of budesonide through a nebulizer in croup compared with dexamethasone injection significantly reduced the number of cases when adrenaline was recognized as necessary (by 9%), and also affected the duration of emergency care both at the prehospital and hospital stages. . The introduction of budesonide through a nebulizer was effective in children with both mild-moderate and moderate-severe croup. Moreover, single dose inhalations (2 or 4 mg) of budesonide were significantly more effective than placebo and were comparable in efficacy to dexamethasone (0.6 mg/kg). They invariably led to the leveling of croupous symptoms and a decrease in the duration of inpatient treatment.

In order to reduce edema of the mucous membrane of the larynx, which often passes to the trachea and bronchi, and relieve spasm simultaneously with budesonide, b-adrenergic agonists can be used (salbutamol - salgim, ventolin, anticholinergics - ipratropium bromide (atrovent), a combination of b-adrenergic agonist and anticholinergic agent - berodual).

It should be noted that acute stenosing laryngotracheitis occupies a significant place in the structure of emergency calls to children. So, in Moscow last year, parents applied to the ambulance about 198 thousand times. And if we discard cases of acute respiratory infections and influenza (about 70 thousand), acute surgical pathology and trauma (58 thousand) and a group of intestinal infections (12 thousand), then out of the remaining calls, every ninth or tenth call was just about the difficult breathing of a child ( an attack of bronchial asthma or "false" croup). Moreover, if the frequency of calls for exacerbation of asthma has decreased over the past 3 years, then for croup, on the contrary, it has increased (by about 1000 cases).

In our department of hospital-replacing technologies of the Scientific Center for Children's Health of the Russian Academy of Medical Sciences, which also provides emergency care to children, over the past 2.5 years (since September 2000), 100 children (67 boys and 33 girls) aged 6 months up to 7 years old. Acute obstruction of the upper respiratory tract developed in 32 children on the background of acute respiratory viral infections, in 5 children after contact with a causally significant allergen, in 8 children on the background of acute respiratory viral infections and physical activity, in 1 child on the background of physical activity and contact with the allergen, in 54 children without visible provoking factors, including SARS. Parents of all children came to our department, considering this alternative emergency care as more effective. All children received inhalations through a nebulizer (two or three times) of budesonide (Pulmicort) at a dose of 1000 mcg, ipratropium bromide (Atrovent) at a dose of 20 drops, or a combined preparation of berodual at a dose of 10 drops for children under 6 years of age, 20 drops for children after 6 years of age. drops), mucolytic drug lazolvan (at a dose of 20 drops in isotonic NaCl solution.

The effectiveness of the first inhalation of budesonide was noted in 53% of children (within 15-25 minutes after inhalation, breathing calmed down, shortness of breath, painful unproductive "barking" cough disappeared, and anxiety decreased). 44 children needed 2-3-day courses of inhalation therapy, and only in 3 patients the effect was achieved on the 4th-5th day. Thus, budesonide, administered by inhalation through a nebulizer, can be recognized as a highly effective drug for emergency treatment of acute upper airway obstruction in children of any age, including at the prehospital stage.

L. S. Namazova, Doctor of Medical Sciences
N. I. Voznesenskaya
A. L. Vertkin, doctor of medical sciences, professor
NTsZD RAMS, MGMSU, NNPOSMP, Moscow

Literature

1. Gaffey M. G., Kaiser D. L., Hayden F. G. Ineffectiveness of oral terfenadine in natural colds: evidence against histamine as a mediator of common cold symptoms // Pediatr. Infect. Dis. J. 1988. V. 7(3) Mar. P. 223-228.
2. Gwaltney J. M. Jr., Park J., Paul R. A. et al. Randomized controlled trial of clemastine fumarate for treatment of experimental rhinovirus colds.
3. Gwaltney J. M. Jr., Winther B., Patrie J. T., Hendley J. O. Combined antiviral-antimediator reatment for the common cold // J. Infect. Dis. 2002. V. 186(2). Jul 15. P. 147-154.

Croup is a rather dangerous disease of the respiratory system, which occurs as a complication of acute infectious and inflammatory processes in the respiratory system. Due to some anatomical and physiological features of the child's body, young children are most susceptible to the development of this disease.

The main danger of croup for the health of the patient lies in the growing disorder of breathing, which appears due to the narrowing of the larynx and upper trachea. Therefore, this disease has another name - stenosing (that is, accompanied by persistent narrowing of the lumen of the organ) or laryngotracheitis.

There are two types of cereals:

• True. It develops only with diphtheria. The pathology is based on a specific fibrinous inflammation with the formation of films on the mucous membrane of the larynx (in the region of the vocal folds). The airways of a person are clogged with these films, and suffocation occurs.

• False. It is a complication of other infectious and inflammatory diseases of the respiratory system. Obstruction of the respiratory tract with this type of croup occurs mainly due to swelling of the walls of the larynx (and the same vocal folds).

False croup is the most common, so it will be the focus of this article.

Depending on the prevailing pathological changes, false croup can occur in various forms:

• in edematous, in which the patient's serious condition is caused by swelling of the respiratory tract;
• in hypersecretory, characterized by abundant formation of viscous sputum, blocking the lumen of the larynx;
• in spasmodic, caused by spasm of the respiratory system;
• in a mixed one, in which several pathological manifestations are present at once (edema and hypersecretion, edema and spasm, etc.).

Causes of croup

Croup in a child can occur against the background of the following infectious diseases:

• and in most cases.
• Ailments caused by respiratory syncytial virus and.
• Inflammatory diseases of the respiratory system of a bacterial nature.

Why do children most often develop croup?

The most susceptible to the development of false croup are children from 6 months. up to 3 years, at an older age, this syndrome is much less common. This pattern is explained by some anatomical and physiological features of the respiratory tract of the child:

What happens with croup in the airways?

An acute inflammatory process in the larynx is usually accompanied by swelling of the mucous membrane and the formation of mucus. If this edema is pronounced (especially in the narrowest part of the larynx - in the region of the vocal folds and below them), the lumen is partially blocked at first, and with the intensification of pathological changes - to a critical level, as a result of which the patient cannot breathe normally - suffocates. This is the croup. Contributes to the violation of the patency of the respiratory tract in this disease, a significant accumulation of sputum and spasm of the muscles of the larynx. Moreover, it is very important that the child's anxiety, screaming and crying only increase the spasm of the respiratory system.

Especially high is the likelihood of developing croup at night. This is explained by the following physiological phenomena: when a child lies for a long time, the outflow of blood and lymph from the tissues occurs somewhat differently (therefore, swelling increases), the drainage activity of the respiratory tract decreases (mucus accumulates in them). If at the same time there is also dry warm air in the room, which dries out the mucous membranes, the risk of respiratory disorders increases significantly.

Croup is characterized by a triad of symptoms:

• barking paroxysmal cough;
• stridor (noisy breathing), especially when the child is crying or worried;
• hoarseness of voice.

In addition, secondary signs of the disease appear - severe anxiety, rapid breathing and heartbeat, nausea, hyperthermia.

With an increase in respiratory failure, all symptoms worsen, the child's skin becomes gray or bluish, salivation increases, wheezing becomes audible already at rest, and anxiety is replaced by lethargy.

Croup diagnosis

Croup is diagnosed in a child according to a characteristic clinical picture and the presence of symptoms of an infectious and inflammatory disease of the respiratory organs. There is simply no time to conduct any additional research in such situations, since assistance to the patient must be provided immediately.

Other pathological conditions may also have symptoms similar to croup: aspiration of a foreign body (for example, parts of toys getting into the respiratory organs), allergic edema of the respiratory tract, trauma to the larynx, sudden laryngospasm, epiglottitis, and others. The approach to the treatment of these ailments is somewhat different, therefore, it is impossible to treat a child who has manifestations of airway obstruction on his own.

First aid for croup

The first thing parents should do when a child develops symptoms of croup is to call an ambulance. Then do the following (before the doctors arrive, you can try to alleviate the baby's condition):

• Take the child in your arms and calm. As mentioned above, fear and anxiety leads to increased spasm of the airways.
• Wrap the patient in a blanket and bring it to an open window or take it out to the balcony (he needs access to cold air). You can also take your child to the bathroom, which has a faucet with cool water (not hot!).
• If there is a nebulizer in the house, let the child breathe with saline or mineral water.

Important! Any steam inhalation, rubbing and other similar procedures for croup are contraindicated.

Croup treatment

Children with symptoms of croup are hospitalized. The first thing doctors should do is restore airway patency. To do this, it is necessary to reduce swelling and spasm of the larynx, as well as free its lumen from accumulated mucus. Therefore, at the pre-hospital stage, and then in the hospital, the patient undergoes the following treatment:

With the ineffectiveness of conservative therapy, tracheal intubation or tracheotomy is performed, followed by artificial ventilation of the lungs.

Since false croup most often occurs in children against the background, its development can be prevented by preventing "cold" diseases. In addition, an important role in preventing the occurrence of stenosing laryngitis is played by the correct behavior of parents with influenza and other similar ailments in a child. It is the implementation of the doctor's recommendations, the creation of comfortable conditions in the patient's room (clean, moist, cool air), drinking plenty of water, regular washing of the nose, and not advertised drugs, that can reduce the severity of pathological changes in the respiratory system.

In addition, with ARI it is not advisable to do the following: put mustard plasters, rub the patient with essential oils, give the baby citrus fruits, honey and other potential allergens. All this can cause a reflex spasm of the muscles of the larynx and provoke the development of croup.

Important: parents of children who have had croup before should definitely consult with their pediatrician about how to behave if the child has the first threatening symptoms of respiratory disorders, and what emergency medicines should be in the home medicine cabinet.

Zubkova Olga Sergeevna, medical commentator, epidemiologist

True and false croup occur against the background of the underlying disease on the 2-3rd day from the rise in temperature and the appearance of general symptoms. A similar beginning is replaced by a noticeable difference in the further course of the disease. So, the true croup is characterized by a gradual increase in the degree of obstruction of the larynx and the corresponding gradual development of respiratory disorders. In its course, a dysphonic stage is distinguished, which proceeds without signs of obstruction, stenotic and asphyxic stages. With false croup, there is no staging of the course, the degree of narrowing of the larynx changes during the day, severe obstruction develops suddenly in the form of an attack (more often at night).

The swelling of the vocal cords that accompanies true croup leads to a gradual aggravation of voice disorders (dysphonia) up to complete aphonia. Characterized by the absence of amplification of the voice during coughing, screaming or crying. At the onset of aphonia, there is a silent cough and crying. False croup is usually accompanied by hoarseness, but never leads to aphonia. The amplification of the voice during screaming and coughing persists.

During laryngoscopy in patients with true croup, catarrhal changes in the mucous membrane of the larynx (edema and hyperemia), narrowing of its lumen and characteristic diphtheria raids are detected. Often, diphtheria raids are also detected when examining the throat. They are poorly removed and often expose small ulcerative defects underneath. With false croup, laryngoscopy determines catarrhal inflammation, stenosis of the larynx and the accumulation of a large amount of thick mucus in it. Easily removable plaque may be present.

Finally, bacteriological examination of throat swabs helps to differentiate true and false croup. The detection of diphtheria bacillus 100% confirms the diagnosis of true croup.

Task Boy 13 years old

1) OAC, OAM, Bx, abdominal ultrasound, FGDS

2) Blood test within normal limits, Bx within normal limits

3) Peptic ulcer should also be differentiated from chronic pancreatitis.

4) Peptic ulcer of the duodenum, first identified on the basis of complaints

5) Drug therapy of duodenal ulcer includes measures to eradicate Helicobacter and heal ulcers (which is facilitated by a decrease in the acidity of gastric juice).

To suppress Helicobacter pylori infection, broad-spectrum antibiotics (metronidazole, amoxicillin, clarithromycin) are used, antibiotic therapy is carried out for 10-14 days. To reduce the secretory activity of the stomach, the optimal drugs are proton pump inhibitors - omeprazole, esomeprazole, lansoprazole, rabeprazole. For the same purpose, drugs that block H2-histamine receptors of the gastric mucosa are used: ranitidine, famotidine. Antacids are used as agents that reduce the acidity of gastric contents: maalox, almagel, phosphalugel, gastal, rennie. Gel antacids with anesthetics are also effective as symptomatic drugs - they relieve pain by enveloping the intestinal wall. To protect the mucosa, gastroprotective agents are used: Venter, de-nol, Cytotec (misoprostol).

With the ineffectiveness of conservative treatment or in the event of the development of dangerous complications, surgical treatment is resorted to.

Ticket number 6.

1. Respiratory failure syndrome is a pathological condition in which the external respiration system does not provide normal blood gas composition, or it is provided only by increased work of breathing, manifested by shortness of breath.

Classification.

ventilation

Diffusion

Caused by a violation of ventilation-perfusion relations in the lungs.

considering the cause of respiratory disorders:

Centrogenic (due to dysfunction of the respiratory center)

Neuromuscular (associated with damage to the respiratory muscles or their nervous apparatus),

Thoracodiaphragmatic (with changes in the shape and volume of the chest cavity, chest rigidity, a sharp restriction of its movements due to pain, for example, with injuries, diaphragm dysfunction),

And also bronchopulmonary D. n. The latter is subdivided:

to obstructive, i.e. associated with bronchial obstruction,

Restrictive (restrictive) and diffusion.

Downstream: acute, chronic.

Clinic: shortness of breath, diffuse cyanosis,

One of the approaches to the gradation of degrees of severity involves the allocation of moderate, severe and transcendental acute D. n. at pO 2 values, respectively, 79-65; 64 - 55; 54-45 mmHg st. and pCO 2 respectively 46-55; 56-69; 70-85 mmHg st., as well as respiratory coma, which usually develops at pO 2 below 45 mmHg st. and pCO 2 above 85 mmHg st.

2. Systemic lupus erythematosus. Clinical diagnostic criteria. diffuse disease of the connective tissue, characterized by systemic immunocomplex lesion of the connective tissue and its derivatives, with damage to the vessels of the microvasculature. A systemic autoimmune disease in which antibodies produced by the human immune system damage the DNA of healthy cells, predominantly connective tissue is damaged with the obligatory presence of a vascular component.

1. Criteria:

2. Rash on the cheekbones (Lupus moth).

3. Discoid rash.

4. Photosensitization.

5. Ulcers in the mouth.

6. Arthritis (non-erosive): 2 or more peripheral joints.

7. Serositis: pleurisy or pericarditis.

8. Kidney damage: persistent proteinuria more than 0.5 g/day or cylindruria.

9. CNS damage: seizures and psychosis

10. Hematological disorders: Hemolytic anemia (antibodies to erythrocytes), thrombocytopenia, leukopenia.

11. Immunological indicators: anti-DNA or anti-Sm or aPL

12. ANF increase in titer.

If 4 criteria are met, at any time after the onset of the disease, a diagnosis is made systemic lupus erythematosus.

3. Chronic gastroduodenitis. Diagnostics. differential diagnosis.

Chronic gastroduodenitis is a chronic inflammation of the mucous membrane of the antrum of the stomach and duodenum, accompanied by a violation of the physiological regeneration of the epithelium, the secretory and motor functions of the stomach.

Diagnostic criteria:

7.1. complaints and anamnesis: pain in the navel and pyloroduodenal zone; pronounced dyspeptic manifestations (nausea, belching, heartburn, less often - vomiting); a combination of early and late pain;

7.2. physical examination: syndrome of gastric dyspepsia (abdominal pain, nausea, vomiting, hyperacidism) of varying severity.

7.3. laboratory research: the presence of H.pylori;

7.4. instrumental research: endoscopic changes in the mucous membrane of the stomach and DC (edema, hyperemia, hemorrhage, erosion, atrophy, hypertrophy of folds, etc.);

E. Diagnosis --- Carried out with chronic pancreatitis, in which pain is localized to the left above the navel with irradiation to the left (sometimes girdle pain), in the analysis of blood and urine there is an increase in amylase, an increase in trypsin activity in the feces, steatorrhea, creatorrhea, with ultrasound - an increase in the size of the pancreas and a change in its echo density. With chronic cholecystitis, in which the pain is localized in the right hypochondrium, on palpation there is pain in the projection of the gallbladder, an ultrasound examination shows a thickening of the gallbladder wall and flakes of mucus in it. With chronic enterocolitis, in which pain is localized throughout the abdomen and decreases after defecation, there is bloating, poor tolerance of milk, vegetables, fruits, unstable stools, in the coprogram - amylorrhea, steatorrhea, mucus, creatorrhea, possibly leukocytes, erythrocytes, dysbacteriosis.

5. Parainfluenza(English) parainfluenza) - anthroponotic acute respiratory viral infection. It is characterized by moderately severe general intoxication and damage to the upper respiratory tract, mainly the larynx; the pathogen transmission mechanism is airborne. Etiology. The disease is caused by an RNA-containing parainfluenza virus belonging to the genus Paramyxovirus ( paramyxovirus) types 1 and 3 Rubulavirus types 2 and 4 (subfamily Paramyxovirinae, family Paramyxoviridae). 5 varieties of parainfluenza viruses are known; the first 3 cause disease in humans, PG-4 and PG-5 are harmless to humans. The main pathogen is parainfluenza virus type 3. Diagnostics. For the diagnosis of parainfluenza, PCR (with preliminary reverse transcription) and ELISA are used. Pathogenesis. The incubation period is 1-6 days (less often - less than a day). People of any age get sick, but more often children under 5 years of age (among all SARS among the adult population, the proportion of parainfluenza is about 20%, among children - about 30%). The source of infection is an infected person (with obvious manifestations of the disease or its asymptomatic course). The patient is contagious approximately 24 hours after infection. The entrance gates of infection through which the virus enters the body are the mucous membranes of the pharynx and larynx. Some of the viruses enter the bloodstream, causing symptoms of general intoxication. Clinic and treatment. With parainfluenza, the larynx is primarily affected (laryngitis and / or laryngotracheitis occurs), and then the bronchi (bronchitis and / or bronchiolitis) and, less often, the nasal mucosa (rhinitis). An increase in the incidence of parainfluenza is usually observed in spring and autumn, but cases of the disease are observed year-round. Susceptibility to parainfluenza is common (both adults and children become infected). In children, the disease is usually more severe than in adults, which is associated with the possibility of developing a false croup. The disease begins with damage to the mucous membrane of the upper respiratory tract: all patients complain of hoarseness or hoarseness of the voice (in some - up to complete aphonia), sore or sore throat, cough (initially dry, then turning into wet with the release of serous sputum; if it joins bacterial infection, purulent sputum begins to stand out). Body temperature with parainfluenza, as a rule, is low (in adults no more than 38 °, in children it may be higher) or normal. During the illness, an infectious develops, and after the illness, a post-infectious asthenic syndrome develops: weakness, fatigue, headaches and muscle pain.

The duration of the illness, if there are no complications, is on average 5–7 days. The cough may persist for up to two weeks or more.

Treatment of parainfluenza is mostly symptomatic. Patients are shown taking vitamin complexes, bed rest, warm drinks and inhalations. As needed (with severe fever above 38–38.5 °) - antipyretics. With a strong dry cough, the use of antitussives is indicated; when the cough becomes wet, antitussive drugs are replaced with expectorants. In case of bacterial bronchitis or other complications, antibiotic treatment is carried out.

Complications of parainfluenza are associated mostly with the risk of bacterial bronchitis and pneumonia. In children, the danger of parainfluenza is associated with the occurrence of false croup. The greatest attention should be paid to children with laryngitis: if there is difficulty in wheezing, which is one of the signs of false croup, you should urgently seek help from a doctor; before the arrival of the latter, hot foot baths, desensitizing agents and steam inhalations are indicated.

The prognosis of the disease, in most cases, is favorable.

1. Explain to the patient the need for the procedure and its sequence.

2. The night before, they warn that the upcoming study is being carried out on an empty stomach, and dinner before the study should be no later than 18.00.

3. Invite the patient to the probing room, seat comfortably on a chair with a back, tilt his head slightly forward.

4. A towel is placed on the patient's neck and chest, and he is asked to remove his dentures, if any. They give you a saliva tray.

5. A sterile probe is taken out of the bix, the end of the probe with olive is moistened with boiled water. They take it with the right hand at a distance of 10 - 15 cm from the olive, and with the left hand support the free end.
6. Standing to the right of the patient, offer him to open his mouth. They put an olive on the root of the tongue and ask to make a swallowing movement. During swallowing, the probe is advanced into the esophagus.

7. Ask the patient to breathe deeply through the nose. Free deep breathing confirms the presence of the probe in the esophagus and removes the gag reflex from irritation of the posterior pharyngeal wall with the probe.
8. With each swallow of the patient, the probe is inserted deeper to the fourth mark, and then another 10 - 15 cm to advance the probe inside the stomach.

9. Attach a syringe to the probe and pull the plunger towards you. If a cloudy liquid enters the syringe, then the probe is in the stomach.

10. Offer the patient to swallow the probe to the seventh mark. If his condition allows, it is better to do this while walking slowly.

11. The patient is placed on the bed on the right side. A soft roller is placed under the pelvis, and a warm heating pad is placed under the right hypochondrium. In this position, the advancement of the olive to the gatekeeper is facilitated.
12. In the supine position on the right side, the patient is asked to swallow the probe up to the ninth mark. The probe moves into the duodenum.

13. The free end of the probe is lowered into the jar. A jar and a rack with test tubes are placed on a low bench at the patient's head.

14. As soon as a yellow transparent liquid begins to flow from the probe into the jar, the free end of the probe is lowered into tube A (duodenal bile of portion A has a light yellow color). For 20 - 30 minutes, 15 - 40 ml of bile enters - an amount sufficient for research.
15. Using a syringe as a funnel, 30 - 50 ml of a 25% solution of magnesium sulfate, heated to +40 ... + 42 ° C, is injected into the duodenum. A clamp is applied to the probe for 5-10 minutes or the free end is tied with a light knot.
16. Remove the clamp after 5-10 minutes. Lower the free end of the probe into the jar. When thick, dark olive bile begins to flow, lower the end of the probe into tube B (portion B from the gallbladder). For 20 - 30 minutes, 50 - 60 ml of bile is released.

17. As soon as bright yellow bile comes out of the probe along with gallbladder bile, its free end is lowered into the jar until pure bright yellow hepatic bile is released.
18. Lower the probe into tube C and collect 10 - 20 ml of hepatic bile (portion C).
19. Carefully and slowly seat the patient. Remove the probe. The patient is given to rinse the mouth with a prepared liquid (water or antiseptic).
20. Having taken an interest in the patient's well-being, they take him to the ward, put him to bed, and provide peace. He is advised to lie down, as magnesium sulfate can lower blood pressure.
21. Test tubes with directions are delivered to the laboratory.

22. After the study, the probe is soaked in a 3% solution of chloramine for 1 hour, then it is processed according to OST 42-21-2-85.
23. The result of the study is glued into the medical history.

Task. Child 5 months Acute bronchiolitis. DN II degree

1) CBC, OAM, Chest x-ray

2) Mild anemia

3) Differential diagnoses of bronchiolitis are carried out with pneumonia.

4) Acute bronchiolitis. II degree DN based on history and Chest x-ray: there is an increased transparency of the lung fields, especially on the periphery, a low standing of the diaphragm.

5) Antibiotics are prescribed (methicillin, oxacillin, carbonicillin, kefzol, gentamicin, etc. - p. 232), since a secondary bacterial infection is possible from the first hours of the disease. The use of interferon is also shown. To reduce swelling of the mucous membrane of small bronchi and bronchioles, inhalations of a 0.1% solution of adrenaline (0.3-0.5 ml in 4-5 ml of isotonic sodium chloride solution) are used 1-2 times a day.

Oxygen therapy is shown, best of all with the use of an oxygen tent DKP-1. In its absence, oxygen is introduced using the Bobrov apparatus (for the purpose of moisturizing) every 30-40 minutes for 5-10 minutes with moderate pressure on the oxygen cushion. In order to thin the secret in the bronchi, 2% sodium bicarbonate solution, isotonic sodium chloride solution, etc. are simultaneously administered in the form of aerosols.

Ticket number 7.

1. nephrotic syndrome. Etiopathogenesis. Classification.

Nephrotic syndrome is a symptom complex, including severe proteinuria (more than 3 g / l), hypoproteinemia, hypoalbuminemia and dysproteinemia, severe and widespread edema (peripheral, abdominal, anasarca), hyperlipidemia and lipiduria.

Etiology. In about 10% of cases, nephrotic syndrome in childhood is secondary, that is, associated with some known cause, often with a systemic disease. So, nephrotic syndrome can be observed with lupus, amyloidosis, sometimes with hemorrhagic vasculitis, Alport syndrome, thrombotic microangiopathy and renal vein thrombosis.

The pathogenesis of nephrotic syndrome. In the occurrence of water and electrolyte disorders, the development of edema in nephrotic syndrome, importance is attached to the renin-angiotensin-aldosterone system, antidiuretic, as well as natriuretic hormones, kallikrein-kinin and prostaglandin systems. Loss of many proteins in the urine leads to changes in coagulation and in fibrinolysis. With nephrotic syndrome, a deficiency of anticoagulants (antithrombin III - a plasma cofactor of heparin) was established; violations in the fibrinolytic system - the content of fibrinogen increases. All this contributes to hypercoagulation and thrombosis.

In nephrotic syndrome, membranous and membranous-proliferative glomerulonephritis is most often noted, less often focal segmental glomerulosclerosis.

Classification.

I. Primary NS.

Congenital NS, familial NS:

ANS - microcystic kidneys of Oliver;

VNS Kalman.

Genuine LN ("pure" nephrosis).

NS diffuse glomerulonephritis.

NS primary amyloidosis.

II. Secondary NS.

With anomalies and diseases of the kidneys and blood vessels (chronic pyelonephritis, polycystic, nephrolithiasis, renal vein thrombosis).

With collagenoses, metabolic diseases, endocrine diseases and neoplasms.

With the introduction of vaccines, sera, allergopathy.

With prolonged and chronic infections.

With damage to the cardiovascular system.

In case of poisoning with salts of heavy metals and drug intoxication.

With secondary amyloidosis.

2. Diabetes mellitus in children. Clinical and diagnostic criteria.

SD type 1. Thirst, polyuria, weight loss.

Dry skin and mucous membranes.

Glucose level in a random blood sample 11.1 mmol/l

Glucosuria more than 1%

Acute start.

Diaper rash in the perineum, inner thighs, buttocks. Girls have symptoms of vulvitis

Liver enlargement

diabetic ketoacidosis

3. Systemic scleroderma. Classification. Diagnostics. differential diagnosis.

Systemic scleroderma (SS) is a systemic disease of connective tissue and small vessels, characterized by widespread fibro-sclerotic changes in the skin, stroma of internal organs and symptoms of obliterating endarteritis in the form of widespread Raynaud's syndrome.

Clinical classification of the scleroderma group of diseases:

1. Progressive systemic sclerosis:

diffuse;

Limited or CREST syndrome (C - calcification, R - Raynaud's syndrome, E - esophagitis, S - sclerodactyly, T - telangiectasia);

Cross (overlap) syndrome: systemic sclerosis + dermatomyositis, systemic sclerosis + rheumatoid arthritis;

Juvenile scleroderma;

Visceral scleroderma.

2. Limited scleroderma:

Focal (plaque and generalized);

Linear (such as "saber strike", hemiform).

3. Diffuse eosinophilic fasciitis.

4. Scleredema Bushke.

5. Multifocal fibrosis (localized systemic sclerosis).

6. Induced scleroderma:

Chemical, medicinal (silicon dust, vinyl chloride, organic solvents, bleomycin, etc.);

Vibration (associated with vibration disease);

Immunological ("adjuvant disease", chronic graft rejection);

Paraneoplastic or tumor-associated scleroderma.

7. Pseudoscleroderma: metabolic, hereditary (porphyria, phenylketonuria, progeria, amyloidosis, Werner and Rothmund syndromes, scleromyxedema, etc.).

Diagnostics. Diagnosis requires 2 major and at least one minor criteria.

"Big" criteria: - Sclerosis/induration. - Sclerodactyly (symmetrical thickening, thickening and induration of the skin of the fingers). - Raynaud's syndrome.

"Small" criteria: - Vascular: --- changes in the capillaries of the nail bed according to capillaroscopy; --- digital ulcers.

Gastrointestinal: --- dysphagia; --- gastroesophageal reflux.

Renal: --- renal crisis; --- occurrence of arterial hypertension.

Cardiac: --- arrhythmia; --- heart failure.

Pulmonary: --- pulmonary fibrosis (according to CT and radiography); --- impaired diffusion of the lungs; --- Pulmonary hypertension.

Musculoskeletal: --- flexion tendon contractures; --- arthritis; --- myositis.

Neurological: --- neuropathy; --- carpal tunnel syndrome.

Serological: --- ANF; --- specific antibodies (Scl-70, anticentromeric, PM-Scl).

Differential diagnosis of systemic scleroderma

Differential diagnosis of systemic scleroderma should be carried out with other diseases of the scleroderma group: limited sleroderma, mixed connective tissue disease, Buschke's scleroderma, diffuse eosinophilic fasciitis, as well as with juvenile rheumatoid arthritis, juvenile dermatomyositis.

Scleroderma-like skin changes can also be observed in some non-rheumatic diseases: phenylketonuria, progeria, cutaneous porphyria, diabetes, etc.

5. Meningococcemia. Clinic. Diagnostics. Providing emergency care at the prehospital stage. Treatment.

Meningococcemia - meningococcal sepsis.

Clinic. It starts acutely, may be accompanied by the development of meningitis, but meningitis may not be; a characteristic feature is a rash. It manifests itself in the next 6-15 hours from the onset of the disease. The rash is sometimes roseolous, but more often hemorrhagic. Hemorrhages of various sizes - from pinpoint petechiae to extensive hemorrhages. Large elements of irregular, often stellate shape, are dense to the touch, and since they “pour out” for several days, they have a different color. The rash is localized on the buttocks, on the lower extremities, less often on the hands and even less often on the face. In scrapings taken from the elements of the rash, meningococci are found. Small elements of the rash disappear without leaving a trace. At the site of significant hemorrhages, necrosis often occurs, followed by rejection of dead tissues. Without treatment with penicillin (in the past), 30-40% of patients with mepingococcemia developed arthritis with more frequent involvement of the small joints of the fingers and toes. The main sign is the pink color of the iris, then there is an injection of the vessels of the sclera and conjunctivitis. The temperature in meningococcemia is high for the first 1-2 days, then it takes on a relapsing character, but it can be high all the time, it can be subfebrile, and sometimes even normal. The fulminant form of meningococcemia begins suddenly. In the midst of complete health, a sharp chill occurs and the temperature rises to high numbers, within a few hours, hemorrhages of various sizes appear on the skin - from ordinary pegechia to huge bruises, in some places resembling cadaveric spots. The condition of the patients immediately becomes very severe, the pulse is frequent, thready, shortness of breath, vomiting are observed. Arterial pressure progressively decreases, patients fall into prostration and saddert sets in. If intensive therapy manages to prevent death, then at the site of extensive hemorrhages, which are caused by thrombosis of large vessels, necrosis develops - dry gangrene. There may be gangrene of skin areas, ears, nose, and even limbs - hands and feet. Gangrene sometimes progresses rapidly and can also lead to death. The cerebrospinal fluid is usually non-purulent and even low-cytotic, but may contain large numbers of meningococci.

With a hyperacute form of meningococcemia, the diagnosis is difficult. The rash may be in the form of ordinary hemorrhages observed in capillary toxicosis in combination with thrombopenia. The association with meningitis is rare.

Diagnostics. The diagnosis is established on the basis of the most acute development of the disease with symptoms of adrenal insufficiency, often clarified on the basis of epidemiological data and finally confirmed by the data of bacterioscopic and bacteriological studies.

In the blood with meningococcal infection, leukocytosis, neutrophilia with a shift to the left, aneosinophilia, leukocytosis with a sharp shift to the left to myelocytes are noted, in the most acute form of meningococcemia - even to promyelocytes.

Providing emergency care at the prehospital stage.

Emergency care for patients with suspected generalized form of meningococcal infection begins immediately, at home. Levomycetin sodium succinate is administered intramuscularly in a single dose of 25 thousand units per 1 kg of body weight or benzylpenicillin at the rate of 200-400 thousand units per 1 kg of body weight of a child per day, prednisolone 2-5 mg per 1 kg of body weight, immunoglobulin.

Treatment. Penicillin remains the main antimicrobial drug for the treatment of generalized forms of meningococcal infection. Penicillin is prescribed in a daily dose of 200-300 thousand units per kg of body weight per day. The dose is usually divided into 6 doses and administered intramuscularly, although in severe and advanced cases, you can start with intravenous administration of drugs.

Ampicillin is prescribed in a daily dose of 200-300 mg per kg of body weight per day. It is introduced in 4-6 doses.

Ceftriaxone is prescribed for children, depending on age, at 50-80 mg / kg / day in 2 doses, for adults - 2 g 2 times a day.

Cefotaxime is administered at a daily dose of 200 mg/kg/day divided into 4 doses.

In case of intolerance to beta-lactam antibiotics, chloramphenicol at a dose of 80–100 mg/kg per day divided into 3 doses (no more than 4 g per day for adult patients) may be an alternative drug.

The reserve drug for the treatment of purulent meningitis is meropenem (for meningitis / meningoencephalitis, 40 mg / kg is prescribed every 8 hours. The maximum daily dose is 6 g, divided into 3 doses).

6. Viral hepatitis B. Classification. Features of the course in children of the first year of life. laboratory markers. Treatment. Prevention.

Features of the course in children of the first year of life. Hepatitis B in children of the first year of life is characterized by a predominance of moderate and severe forms of the disease, which together make up 50%. At the same time, HB forms of different severity occur both in perinatal and postnatal parenteral infection. Nevertheless, children of the 1st year of life (especially the first six months) still remain a high-risk group for the development of a malignant form of hepatitis B, accounting for 70-90% of patients with this form of hepatitis B. Mortality in the malignant form of hepatitis B remains very high and reaches 75%.

Hepatitis B in infancy resolves slowly and tends to be prolonged - up to 6-9 months. However, with typical icteric variants of hepatitis B, recovery occurs with elimination of the pathogen. At the same time, anicteric and subclinical forms can transform into chronic hepatitis.

In the ante- and perinatal route of infection with the hepatitis B virus, the formation of a primary chronic process in the liver is observed with great frequency, which takes a torpid course, manifesting clinical and biochemical activity for many years.

In young children, intoxication with chronic hepatitis B (CHB) is not pronounced. Children are capricious, have a reduced appetite, may lag behind in weight. The leading syndrome of CHB is hepatolienal. The liver is of dense consistency, protrudes from the hypochondrium by 3-5 cm, painless; the spleen is palpated 1-4 cm from under the edge of the costal arch. Jaundice in CHB, as a rule, does not occur if there is no layering of hepatitis D. In the biochemical blood test, there is a moderate increase in the activity of hepatocellular enzymes and dysproteinemia in the form of a slight decrease in the content of albumins and an increase in the fraction of gamma globulins.

The greatest clinical and biochemical activity of CHB occurs in the first 3-5 years, and then there is a gradual regression of chronic hepatitis, which is observed after the cessation of active (full) replication of the pathogen.

The degree of CHB activity in children varies from low to moderate, while pronounced activity is observed in a small number of patients. We did not observe trends towards the formation of liver cirrhosis in children with CHB at the age of 1 year. In general, the frequency of cirrhosis in the outcome of CHB in children ranges from 1.3 to 2%.

Laboratory markers: HBsAg, HBeAg, anti-HBcore, anti-HBe, anti-HBs.

Treatment. Bed rest. Diet number 5-5a. vitamins. When diagnosing mild and moderate forms of the disease, children receive symptomatic treatment, drinking 5% glucose solution, mineral water, they are prescribed a complex of vitamins (C, B1, B2, B6) and, if necessary, choleretic drugs (flamin, berberine, etc.).

In severe form, corticosteroid hormones are prescribed in a short course (prednisolone at the rate of 3-5 mg / kg for 3 days, followed by a decrease by 1/3 of the dose, which is given for 2-3 days, then reduced by another 1/3 of the initial dose and is given within 2-3 days with subsequent cancellation); intravenous drip infusions are carried out: reopoliglyukin (5-10 ml / kg), 10% glucose solution (50 ml / kg), albumin (5 ml / kg); liquid is administered at the rate of 50-100 ml/kg per day.

Patients with a malignant form of hepatitis are transferred to the intensive care unit. Prednisolone is prescribed at a dose of 10-15 mg / kg intravenously in equal doses after 4 hours without a night break. Intravenous drip: albumin (5 ml / kg), polydez (10-15 ml / kg), reopoliglyukin (10-15 ml / kg), 10% glucose solution (30-50 ml / kg) - no more than 100 ml / kg kg of all infusion solutions per day under the control of diuresis. Lasix at a dose of 1-2 mg/kg and mannitol at a dose of 1.5 mg/kg are administered by stream slowly. Inhibitors of proteolysis (gordox, contrykal) are connected in an age dosage.

Prevention. In the complex of preventive measures, measures aimed at preventing infections with viral hepatitis B during blood transfusions and conducting therapeutic and diagnostic parenteral manipulations are of paramount importance. All donors are subjected to a comprehensive clinical and laboratory examination for the presence of hepatitis B antigens. Persons who have had viral hepatitis B, regardless of the statute of limitations, as well as those who have been in contact with patients over the past 6 months, are excluded from donation.

TASK. Child, 4 years old

1. Survey plan.

2. Interpretation of laboratory studies. OAC is normal.

3. Differential diagnosis. Particular difficulties are caused by the differential diagnosis of OOB of infectious and allergic genesis. In favor of the allergic etiology of broncho-obstructive syndrome, the child's pedigree burdened by allergic diseases, anamnestic, clinical and laboratory data indicating allergic lesions of a different localization may testify. And yet, the allergic nature of the obstruction often begins to be thought about in the recurrent course of the obstructive syndrome.

When a foreign body is aspirated, cough, auscultatory changes in the lungs appear suddenly, against the background of the complete health of the child. Parents can often indicate the exact time of onset of respiratory distress, cough. The severity of symptoms may change with a change in body position, there are no signs of a viral infection.

If pneumonia is suspected (persistent febrile fever for more than 3 days, severe toxicosis, local shortening of the percussion tone and wheezing in the lungs), an X-ray examination of the chest is performed.

4. Clinical diagnosis. Acute obstructive bronchitis.

5. Treatment. Bed rest. Dairy-vegetarian diet. Oxygen therapy. Salbutamol 2 mg taken via spacer. Eufillin 12-16 mg/kg/day. Vibration massage.

Diphtheria pharynx- a form of diphtheria, in which the entrance gate of infection is the mucous membrane of the pharynx.

. Localized (mild) form - diphtheroid inflammation, not extending beyond the palatine tonsils. Initially, the affected mucosa is covered with gray loose islands of fibrinous exudate, which are easily removed and do not leave behind a defect. Then a continuous layer of a gray thin film is formed, which is also easily removed. With further progression, the film becomes dense, leathery, bluish-white or light gray. If the film is saturated with blood, it becomes almost black. The film consists of a necrotic epithelial layer, fibrinous exudate, corynebacteria and phagocyte cells (neutrophilic granulocytes and macrophages). The film is surrounded by a hyperemic mucous membrane, is firmly connected with the underlying tissues and does not spontaneously separate, which contributes to the absorption of exotoxin. When the film is removed, a bleeding surface (erosion) remains in its place. Deep defects (ulcers), as a rule, are not formed, however, infection of mucosal defects with secondary microflora, primarily pyogenic cocci, can occur. Films are usually stored no more than 3-7 days. A characteristic feature of diphtheria is the development of regional lymphadenitis. Without treatment, the localized form of diphtheria of the pharynx lasts 6-7 days, with the introduction of antidiphtheria serum, the effect occurs within a day. In the absence of therapy, the process can progress. Films similar to diphtheria can form in the pharynx and in other diseases: acute candidiasis, fusotreponematosis, streptococcal pharyngitis, infectious mononucleosis.

3.Common (moderate) form - a form of diphtheria of the pharynx, in which the films cover not only the palatine tonsils, but also neighboring areas of the mucous membrane of the pharynx and oral cavity. At the same time, swelling of the oropharyngeal mucosa is moderate. Tonsillar l. y. slightly enlarged and slightly painful on palpation. There is no swelling of the subcutaneous tissue of the neck

True croup is a diphtheria lesion of the larynx and lower airways. Depending on the spread of the process: localized croup (diphtheria of the larynx), common (diphtheria of the larynx and trachea) and descending (larynx, trachea, bronchi). The diphtheria process in the larynx goes through three stages:

catarrhal stage,

stenotic stage,

asphyxic stage.

In adults, due to the anatomical features, diphtheria of the larynx is difficult to diagnose, typical symptoms appear late. Sometimes a sign of damage to the larynx is hoarseness, even with a descending croup. Paleness of the skin, tachycardia, shortness of breath, forced position, participation in breathing of the wings of the nose, anxiety of the patient, agitation may indicate respiratory failure. Diphtheria croup is recognized most often with stenosis of the larynx in the asphyxial period.

True and false croup. Differential diagnosis.

True and false croup occur against the background of the underlying disease on the 2-3rd day from the rise in temperature and the appearance of general symptoms. A similar beginning is replaced by a noticeable difference in the further course of the disease. So, the true croup is characterized by a gradual increase in the degree of obstruction of the larynx and the corresponding gradual development of respiratory disorders. In its course, a dysphonic stage is distinguished, which proceeds without signs of obstruction, stenotic and asphyxic stages. With false croup, there is no staging of the course, the degree of narrowing of the larynx changes during the day, severe obstruction develops suddenly in the form of an attack (more often at night).

The swelling of the vocal cords that accompanies true croup leads to a gradual aggravation of voice disorders (dysphonia) up to complete aphonia. Characterized by the absence of amplification of the voice during coughing, screaming or crying. At the onset of aphonia, there is a silent cough and crying. False croup is usually accompanied by hoarseness, but never leads to aphonia. The amplification of the voice during screaming and coughing persists.

During laryngoscopy in patients with true croup, catarrhal changes in the mucous membrane of the larynx (edema and hyperemia), narrowing of its lumen and characteristic diphtheria raids are detected. Often, diphtheria raids are also detected when examining the throat. They are poorly removed and often expose small ulcerative defects underneath. With false croup, laryngoscopy determines catarrhal inflammation, stenosis of the larynx and the accumulation of a large amount of thick mucus in it. Easily removable plaque may be present.

Finally, bacteriological examination of throat swabs helps to differentiate true and false croup. The detection of diphtheria bacillus 100% confirms the diagnosis of true croup.

difference between hemolytic jaundice from the physiological in that with hemolytic jaundice there is a conflict between the Rh factor and the erythrocytes stick together and after a few weeks it disappears. and with physiological, there is a replacement of hemoglobin types

Question Hemolytic disease of the newborn. Etiology, pathogenesis, clinical forms. The difference between hemolytic jaundice and physiological.

Hemolytic disease of the newborn.

It is based on the hemolysis of erythrocytes of the fetus, then the child, caused by the incompatibility of the blood of the mother and fetus for erythrocyte antigens, group antigens, and the Rh factor.

Causes:

Rh factor incompatibility. Mother -, child +

· By group. Mother 1, child 2 or 3

Of great importance are:

previous sensitization of a woman. (allergies)

previous pregnancies

· Blood transfusion.

Clinic:

Form 1 - edematous - the most severe.

Either the fetus or the child dies after childbirth. The skin is pale with a waxy or cyanotic tint. The presence of free fluid in the cavities.

2 form - icteric.

Symptoms:

Early jaundice

Enlargement of the liver and spleen

Urine is intensely colored

The color of the stool is not changed

There is a lot of bilirubin - the condition is worsened.

The child is lethargic, physiological reflexes are worsened. If bilirubin reaches critical numbers - nuclear jaundice (CNS damage) - convulsions, stiff neck, setting sun syndrome, cerebral crying, tension of the large fontanel.

The norm of bilirubin is 80 mol / l. Nuclear jaundice - 450-500 mol / l.

3 form - anemic.

The general condition is slightly disturbed. By the 7th-10th day, pallor appears, the liver and spleen are enlarged. Bilirubin in the blood is less than 60 mol / l. Hemoglobin is reduced - 140 and less.

Sepsis of the newborn. Etiology, clinic.

Sepsis.

Sepsis- a severe general infectious disease caused by the spread of bac.flora from a local focus.

The infection from the local focus got into the blood, lymph nodes and all organs. Sepsis is a generalized form of purulent-septic disease.

Causes:

Staphylococcus 50-60%

Prematurity 30-40%

Contributing factors:

maternal infections

Prematurity

Immaturity

Classification:

By time of occurrence

Intrauterine

Postnatal

・At the entrance gate

umbilical

Pulmonary

Intestinal

· Cryptogenic

· Catheterization.

· With the flow

Lightning fast (1-7 days)

septic shock

Acute (1-2 months)

Protracted (more than 8 weeks)

Clinic:

Septicemia - Only in the blood.

Pronounced toxicosis without abscesses. Decreased motor, reflex, sucking activity; flatulence, pale skin with a microcyanotic shade, acrocionosis, muffled heart sounds, arrhythmia, expansion of the boundaries of the heart, enlarged liver and spleen, vascular network on the abdomen, hemorrhagic syndrome.

Septicopyemia is organ damage.

Pronounced toxicosis without abscesses. Decreased motor, reflex, sucking activity; flatulence, pale skin with a microcyanotic shade, acrocionosis, muffled heart sounds, arrhythmia, expansion of the boundaries of the heart, enlarged liver and spleen, vascular network on the abdomen, hemorrhagic syndrome. Symptoms of the affected organ - lungs - pneumonia, intestines - diarrhea, brain - meningitis, convulsions.

Croup is a common respiratory disease characterized by inflammation of the upper respiratory tract. This pathology causes swelling of the trachea and larynx, as a result of which the patient has difficulty and rapid breathing, a characteristic whistle is heard on inspiration and a characteristic croupy (barking) cough occurs. Often, croup, the symptoms of which are more common in preschool children, is diagnosed as laryngitis in adult patients.

Mostly croups are found in children under the age of 4-6 years. This is caused, first of all, by the anatomical features of the structure of the upper respiratory tract. In older children, the airways are wider, the cartilage in the walls is less elastic, with inflammation, the effect of swelling of the mucous membrane is not so critical, significant. Parents who first notice symptoms of croup in their child often panic. Do not be afraid - you should immediately go to a pediatrician or general practitioner. Timely diagnosis is the key to successful treatment.

Croup: pathogenesis

Croup occurs with various inflammatory diseases of the respiratory system, changes in the vocal cords and subglottic space. When interviewed, patients often complain of a barking cough, and the patient's voice is hoarse and hoarse. Changes in the tissues of the respiratory tract, swelling of the mucous membrane of the larynx, lead to a narrowing and deterioration of the lumen, while the air flow accelerates, which causes rapid breathing, drying of the mucous membrane and the formation of a crust, which further reduces the lumen of the larynx. It becomes difficult for the child to breathe and then the auxiliary muscles of the chest are turned on, which, upon visual inspection, looks like its protrusion. Due to this, an elongated breath occurs through a narrowed inflamed larynx, the pause between inhalation and exhalation increases, breathing is accompanied by a characteristic noise (stenotic breathing). Thus, the lack of oxygen is partially compensated, the necessary gas exchange in the lungs is maintained. But, despite this, the minute volume of oxygen in the lungs still decreases, even with an increase in the degree of stenosis of the larynx, part of the blood in the lung sac is not oxygenated and is thrown off into the arterial circulatory system of the systemic circulation. This condition eventually leads to arterial hypoxia, and then to hypoxemia. The latter should be regarded as the beginning of lung function decompensation. It is important to understand that the greater the narrowing of the larynx, the more pronounced the hypoxia will be, which adversely affects all organs and systems. Hypoxemia causes tissue hypoxia, later - severe disorders of cellular metabolism with pronounced changes in the cardiovascular, central nervous, neuroendocrine, and other vital systems of the human body.

It should also be taken into account that in addition to the mechanical factor in the pathogenesis of croup in acute respiratory diseases, the main role is played by reflex spasm of the muscles of the larynx, which is characterized by an increase in stenotic breathing, up to asphyxia. With croup, the child's psychosomatic state is also disturbed - anxiety arises, the baby is very capricious and he has a feeling of fear. For this reason, the use of sedatives in the complex therapy of croup is considered effective; in this case, there is an improvement in the child's breathing.

Separately, it should be noted that the accumulation of thick bacterial mucus in the vocal cavity, the formation of crusts and necrotic and fibrinous overlays leads to the occurrence of purulent laryngotracheobronchitis and laryngitis. The analysis often reveals streptococcus, staphylococcus, and other gram-negative flora.

Predisposing factors include past paratrophy, childhood eczema, drug allergies, birth injuries, frequent acute respiratory diseases of the respiratory tract.

Grain classification

In otolaryngology, there are concepts of true and false croup. The latter has a bacterial or viral etiology. Croup false is classified according to the degree of pathology of the respiratory system, changes in the mucous membrane of the larynx:

• I degree - with compensated stenosis;
• II degree - with subcompensated stenosis;
• III degree - with decompensated stenosis;
• IV degree - in the terminal stage of stenosis.

True croup successively passes from one stage to another. Based on this, it is possible to distinguish: catarrhal (dystrophic) stage of the disease, asphyxic and stenotic stages of croup.

Causes of croup

Croup occurs with swelling of the mucosa, swelling of the trachea and larynx. This pathology of the respiratory system is often caused by other common respiratory diseases (SARS or influenza). Also, often the symptoms of croup are manifested in allergic reactions to various irritants, seasonal natural phenomena. Less commonly, croup is a complication of diphtheria.

Often, croup develops as a result of an infectious lesion of the cartilage (epiglottis), which blocks the entrance to the larynx when saliva is swallowed. The child has general changes in the somatic condition: weakness, fever, painful swallowing, dry mouth, etc.

Croup symptoms

The child has a characteristic barking cough and whistling sounds when breathing in and out. When coughing, the face acquires a reddish tint from the tension that the patient experiences when coughing, expectorating the accumulated bacterial mucus. It is worth paying attention to the complexion, if the color is paler than usual, and the lips have a bluish tint, it means that the child is not only hard to breathe, but the body does not receive the necessary amount of oxygen. With such indicators, immediate hospitalization of the child in a specialized hospital is recommended. A high temperature may indicate a severe infectious croup, such as diphtheria or epiglotitis. How quickly a child gets into the hands of doctors will depend on his health, and sometimes life.

Various pathologies of the upper respiratory tract and, as a result, narrowing of the walls of the lumen of the larynx lead to breathing problems. The flow of air becomes more frequent, the so-called shortness of breath appears, which is accompanied by retraction of the jugular fossa and intercostal spaces. The pectoral muscles are not properly involved in the respiratory process: when inhaling, the chest decreases, while exhaling it expands. Too active breathing leads to drying of the mucosa and the formation of a crust. Thus, an even greater narrowing of the lumen of the larynx appears, breathing is extremely difficult, a characteristic whistle is heard. With an abundant accumulation of mucus in the lumen of the larynx, the vocal cords wheeze, the voice is hoarse. The variability of breath sounds indicates the dominance of the spastic components of the obstruction. A decrease in the intensity of breathing noise may signal an aggravation of stenosis.

Croup diagnosis

The symptoms of croup resemble any respiratory infection of the upper respiratory tract. Croup is diagnosed by the three symptoms identified: difficulty breathing, a sagging voice, and a coarse, barking cough. Taking into account the general picture of the disease, the diagnosis is not difficult for the doctor. There is a whole group of diseases of the respiratory system that the doctor needs to exclude, but often one disease pulls all the symptoms of croup. A pediatrician or an otolaryngologist can diagnose the disease. Depending on the course and stage of inflammation of the mucous membrane of the larynx, laryngoscopy may be necessary. A pulse oximeter is used to determine the level of oxygen in the blood. In case of broncho-pulmonary infectious complications, an examination by a pulmonologist will be required. If there is syphilis, then croup is diagnosed together with a venereologist. Tuberculosis patients will need to consult a phthisiatrician.

After other pathologies are excluded and the final diagnosis of croup is established, treatment is prescribed in accordance with the overall clinical picture. At the last examination, coarse rales with a characteristic whistle are heard in the lungs. Wheezing signals an exacerbation of the disease. Since bacterial mucus is collected in the larynx, it will be necessary to take a smear for bacteriological culture in order to identify the verification of the pathogen. It will be necessary to conduct PCR tests, RIF and ELISA studies. Laryngoscopy data will help to find out the degree of narrowing of the walls of the larynx, the inflammatory process, to detect fibrinous films characteristic of diphtheria. Complications require additional investigations: otoscopy, lumbar puncture, pharyngoscopy, rhinoscopy, paranasal sinuses, and lung radiography.

True and false croup: differential diagnosis

If the patient has an established diagnosis of croup, symptoms and treatment depend on the clinical picture of the course of the disease. False croup is diagnosed only with diphtheria and is accompanied by inflammation in the vocal cords. With false croup, inflammation affects, in addition to the vocal cords, the mucous membrane of the larynx, trachea, up to the bronchi. False croup is diagnosed with all other respiratory diseases (ARI, parainfluenza, influenza, etc.), except for diphtheria.

The main symptoms of a true croup of diphtheria etiology are a barking cough, a hoarse voice, difficulty in inhaling and exhaling - stenotic breathing. Similar symptoms of croup develop on the rise, within 4-5 days. After that, the hoarse voice is replaced by aphonia, and the barking rough cough becomes silent. With appropriate treatment, a gradual elimination of symptoms is observed: the stenosis decreases and disappears completely, the cough disappears, the voice is completely restored.

The first manifestations of false croup appear suddenly and often also disappear suddenly. This form of pathology is characterized first by sudden stenosis during sleep during the day or at night. True croup ends with stenosis, and as a result, asphyxia. With isolated true croup, the general specific intoxication is not pronounced, the course of the disease depends on the nature of hypoxia.

With influenza, croup symptoms appear in the first 1-2 days of the disease, or already during the period of a second wave of the disease. Croup against the background of the flu is different: from mild to extremely severe.

At the first manifestations of croup, there is often an increase in temperature of about 39 °, runny nose, severe chest cough, symptoms of intoxication (lethargy, fatigue, headache, drowsiness, in case of complications - convulsions, impaired consciousness).

Croup treatment

In the case of diagnosing true diphtheria croup, patients are immediately hospitalized. Treatment is carried out in a complex with antispastic, antihistamine and sedative drugs. Drug treatment is prescribed in accordance with the indicators of diagnostic studies, bacteriological culture and other diagnostic measures. The effectiveness of treatment directly depends on the stage at which the development of the disease is. It is customary to prescribe intravenous or intramuscular administration of antidiphtheria serum. Detoxification therapy is practiced - drip administration of glucose and various sorbents, prednisolone is used according to the doctor's prescription.

Depending on the patient's cough, they use: antitussives (oxeladin, glaucine, codeine, etc.) - with a dry cough, mucolytics (acetylcysteine, carbocysteine, ambroxol) - with a wet, expectorant cough with copious sputum.

In severe laryngeal stenosis, the doctor may prescribe glucocorticosteroids. If croup is of an acute viral infectious nature, appropriate antiviral drugs are prescribed. Antibiotic treatment is necessary to prevent secondary bacterial infection of the patient. With symptoms of hypoxia, oxygen therapy is applicable, inhalation treatment is carried out.

Croup prevention

To prevent diphtheria croup, babies at the age of three months are vaccinated. False croup does not involve any preventive measures. The most important thing is to provide the baby with healthy immunity. It is to children with a weakened immune system that all conceivable and unimaginable diseases “stick” to them. Proper nutrition, which includes all the necessary nutrients, regular walks and sleep, wellness and tempering procedures - this is not a complete list of activities that help maintain the baby's immunity at the right level. Love your baby, seek medical help in a timely manner and all diseases will bypass you!