Acute pneumonia, relevance of the topic. Relevance of the problem of pneumonia

5.1. Features of product quality management

Features of the product quality management process arise from the features of product quality as an object of management.

Let's look at these features.

1. Product quality management is one of the aspects of production management. However, the process of product quality management is not limited only to the manufacturing process, but is considered much more broadly. GOST 15467 defines product quality management

as “actions carried out during the creation and operation or consumption of products in order to establish, ensure and maintain the required level of its quality.”

From this definition follows the first feature of product quality management - quality management actions must be carried out at all stages of the product life cycle: product quality is established at the stages of scientific research and design, ensured during the manufacturing process and maintained at the stage of operation or consumption. In this case, the research and design stages are crucial, because It is at these stages that the main properties and parameters of future products are determined, as well as the nature of the production processes for their manufacture.

2. The second feature is that the duration of the entire cycle from the beginning of quality formation to its implementation can reach several years. In this regard, the quality management process can be significantly extended over time.

3. The third feature follows from the fact that the level of individual product quality indicators tends to decrease during the transition from one stage of the life cycle to another (i.e., it decreases as the product moves through the stages of the life cycle: research - development - manufacturing - operation). This objective circumstance must be taken into account when forming goals and criteria for quality management at each stage of the product life cycle.

4. The next feature is due to the dynamism of product quality as an object of management. It manifests itself in a constant change in the level of quality under the influence of various factors both during the production process and in operation. This feature makes quality unstable, which implies the need for continuous consideration and analysis of all factors affecting quality when making management decisions.

5. In its structure, product quality represents a hierarchical system of properties, in which the properties of each previous level are determined by the simpler properties of subsequent levels. Therefore, changing a certain property can be achieved by

influence on the corresponding properties located at lower levels of the hierarchy.

A large number of quality properties, the complexity of their interdependencies, the lack of a guarantee of completeness of coverage, and reliable methods for calculating them increase the difficulty of managing the process of forming product quality. This is the fifth feature of product quality management.

6. Product quality is a probabilistic system of properties in which the interaction of its component parts cannot be precisely predetermined, because changes in the impact of factors affecting individual properties and overall quality are difficult to predetermine. Therefore, the quality management process should be based on the use of methods of probability theory and mathematical statistics.

7. Another feature is the need for additional efforts and costs to maintain the level of quality of technical products in the field of operation.

These features are reflected in the nature of the product quality management process.

5.2. Factors and conditions affecting product quality assurance

Product quality is formed at the stages of its design and manufacturing and is maintained during the operation stage. At each stage, quality is influenced by certain factors and conditions.

Product quality management is a constant, systematic, purposeful process of influencing factors and conditions, ensuring the creation of products of optimal quality and its maintenance when using the products.

The factor ensuring product quality is understood as a specific force that changes the properties of raw materials, materials, structural elements or the product as a whole. This includes: objects and tools, equipment, tooling, tools, technology, as well as professional knowledge and skills of developers, workers, and production organizers.

The conditions for ensuring product quality are understood as production circumstances, conditions, and environments in which the factors for ensuring product quality operate.

Let's consider main factors, determining the quality of products at different stages of its life cycle.

At the design and development stage the main factors

ensuring the quality of products are:

− in-depth pre-design study of the product, taking into account domestic and foreign patents;

− technical and economic justification of the design and operational characteristics of the product;

− zero-defect design;

− widespread use of standard diagrams, maximum use of unified, standardized parts, assemblies, and assemblies;

− inclusion of built-in control systems in the product, including automatic;

− inclusion in the design of the product of duplicate systems that are vital for it;

− conducting laboratory tests under difficult conditions;

− verification and clarification of technical documentation based on the results of testing a pilot batch

And operation data.

On production stage factors affecting product quality,

can be divided into: technical, organizational, informational, social, economic.

Technical factors include:

− quality of objects of labor: raw materials, materials, purchased components, documentation, etc. Quality assurance here can be achieved by increasing the efficiency of incoming control of raw materials, materials, semi-finished products and components;

− quality of labor tools: equipment, equipment, technological equipment, tools, measuring instruments, labor automation equipment, etc. The main ways to implement this factor are technical re-equipment and reconstruction of production, comprehensive mechanization and automation of production processes, the use of high-precision equipment;

− quality of technological processes. Strengthening the effect of this factor can be achieved through the development of operational technologies, typification of technological processes, introduction of advanced technologies, and active quality control in the production process.

TO organizational factors include:

− organization of production: specialization, production structure, organization of operational production planning. Improving product quality due to this factor can be achieved by introducing effective forms of in-plant specialization: subject, detail; organization of continuous production (conveyor and production lines); development of cyclical and operational production schedules that ensure the rhythmic operation of the enterprise, etc.;

− labor organization: rational division and cooperation of labor, rational organization of workplaces and their maintenance, rational work and rest regime, dissemination of advanced techniques and methods of work

etc.;

− management organization: rational management structure, rationalization of document flow, rational technology for interaction between departments, automation of production management.

Information factors are:

− registration of quality data, their identification, storage;

− automation of collection and processing of quality information;

− providing operational information about the quality of managers and specialists, its use, etc.

A particularly important factor is to ensure timely information about the quality of manufactured products. Timely information is an indispensable condition for timely adoption of management decisions to ensure product quality. The required information efficiency is ensured by the creation and operation of automated product quality management systems based on the use of computer technology.

Social factors include:

− professional structure of personnel;

− advanced training of personnel;

− personnel certification;

− staff motivation;

− social and domestic employee service, etc.

Economic factors include:

− financing work to ensure and improve product quality;

− financial liability of employees for the production of substandard products;

− material incentives for personnel for the creation and production of high quality products;

− accounting, analysis and regulation of costs to ensure product quality, etc.

On operation stage The main factors influencing the maintenance of the quality and reliability of technical devices are:

− use of devices for their intended purpose in compliance with the modes provided for in the technical documentation;

− improving service and carrying out routine maintenance within the prescribed time frame;

− improving the quality of current scheduled preventative and major repairs.

Factors such as improving labor and technological discipline, developing personal initiative and a creative attitude to the work of each employee have a decisive impact on product quality at all three considered stages of the life cycle of technical devices; constant growth of the professional level of employees; application of an effective system of moral and material incentives.

Let's consider the conditions for ensuring product quality.

In relation to the place of ensuring product quality, conditions are divided into internal and external.

Internal conditions include:

− the nature of the production process, its intensity, rhythm, duration;

− level of equipment and maintenance of workplaces;

− environmental condition of production premises;

− interior and production design;

− state of labor safety;

− the state of labor and technological discipline;

− moral and psychological climate and relationships in the team, the nature of conflict resolution;

− the nature of material and moral incentives for quality.

External conditions include:

- scientific and technical development of the country;

- ecological state of the environment;

- current economic mechanism;

- organization of management at the enterprise;

- economic condition of the enterprise;

- pricing principles;

- legislative and legal environment;

- general social and material condition of workers.

The conditions for ensuring product quality in some cases have a decisive impact on those forces that directly change the properties of the product. They can facilitate the full manifestation of the capabilities of factors or restrain them to varying degrees, inhibit the manifestation of their capabilities (for example, changing the priority of bonuses - for qualitative or quantitative indicators, etc.).

Ensuring the most harmonious combination of factors and conditions is one of the most important and complex tasks of quality assurance and product quality management.

The considered factors and conditions allow us to formulate the main

directions for improving product quality:

− creation of technologically advanced device designs;

− improvement of manufacturing processes;

− increasing the level of product unification;

− increasing the technical level of production, comprehensive mechanization and automation of production processes (main and auxiliary);

− rhythmic work of all departments of the enterprise;

− development and application of progressive methods for monitoring and analyzing product quality;

− unconditional adherence to technological, production and performance discipline;

− compliance with the requirements of standards;

− introduction of progressive labor organization and improvement of production standards;

− development and stimulation of creative activity of employees, their interest in improving product quality, etc.

5.3. Quality management systems

As the problem of ensuring product quality became more acute, methods for solving it were developed and improved, the development of which led to the creation of quality management techniques and the development of new ways to improve it. The main achievement in the field of quality improvement is an integrated, systematic approach to quality management and, on its basis, the creation of quality management systems at different levels of management. The essence of the systems approach lies in the consistent and interconnected implementation of a set of technical, organizational, economic, ideological measures that affect quality at all stages of the product life cycle.

The need for a systematic approach to product quality management arises from the diversity and interconnectedness of external and internal factors and conditions affecting quality, from the continuity of its formation and provision throughout the life cycle, and the participation in this process of all elements of the sphere of production and operation or consumption. Integrated quality management is a modern form of management - an enterprise management system focused on achieving commercial success through the production of products of the required level of quality.

A systematically integrated approach to quality management began to be implemented in the 50s of the 20th century. in the creation and widespread implementation at enterprises of developed countries product quality management systems(V

foreign companies - quality management systems, quality systems). The first major step in this direction in our country was

creation and implementation in 1955 of the Saratov system of defect-free manufacturing of products and their delivery to the technical control department and the customer from the first presentation (BIP system). In subsequent years, systemic methods of quality management developed and underwent practical testing at enterprises in many cities of the country (systems: KANARSPI - quality, reliability, resource from the first products; NORM - scientific organization of work to increase motor resource; SBT - defect-free labor system; NOTPU - scientific organization labor, production and management, etc.).

The generalization of experience and the development of systemic methods of quality management led to the development in the early 70s of the main provisions of a comprehensive

product quality management systems (KS UKP). This system combined everything that was best and progressive in that period, which was characteristic of previous systems.

IN The KS UKP was based on general organizational principles and a unified methodology for organizing quality management work, which did not depend on production specifics and were acceptable for most enterprises. The organizational and methodological basis of the KS UKP were enterprise standards, and the basic provisions, principles of development and operation of the KS UKP were developed GOSTs. Unlike previous domestic systems, the CS UKP covered all the main stages and phases of the product life cycle and all participants in the production process. It was organically part of the production management system and was its functional subsystem.

Despite the undoubted advantages of the CS, the UKP had significant drawbacks, the main of which were the lack of connection between the quality of products and the economic results of the enterprise; focus primarily on quality control rather than on its prevention; placing concerns about quality mainly on specialized services, rather than involving all participants in the production process in solving problems, etc. This resulted in the disinterest of managers and performers in improving product quality and, as a consequence, a formal approach to the implementation of systems and ensuring their functioning. Moreover, KS UCP were not adapted to effective functioning in market conditions, since they were focused on ensuring standard quality indicators, and not on rapidly changing consumer requirements.

Further development of quality management systems took place as part of higher-level management systems: sectoral and territorial, up to the state level, based on the development of “Quality” programs and their inclusion in national economic plans. In 1978, Gosstandart developed the basic principles of the Unified System of State Management of Product Quality (USGUKP).

IN other industrialized countries (USA, Germany, England, Japan, etc.) also carried out work to create quality management systems, which were reflected in the relevant national standards. The experience of the largest companies in many developed countries in quality management, characterized by a wide variety of concepts and methods for developing quality management systems, was summarized in a set of international standards (IS) ISO 9000 series. Today, ISO 9000 series standards have been adopted as national standards in almost all developed countries world, including in Russia. The characteristics of these standards are discussed in the next paragraph.

Work on the further development of the principles and methods of quality management led to the creation of the concept general government

quality (TQM - Total Quality Management). Total Quality Management is defined as a quality-focused approach to enterprise management that is participatory and aimed at achieving long-term success by satisfying customer requirements and benefiting members and society.

The TQM concept is based on the fact that in modern conditions the solution to the quality problem is increasingly determined by the human factor, that is, the attitude of people to business and the attitude of managers towards staff. The main task of management is to initiate the creative potential of employees in a certain direction. At the same time, the TQM concept is based on such concepts as corporate (corporate) culture, leadership style, and democratization of management. The concept places quality at the center of all production activities, which predetermines the satisfaction of consumer requirements and, as a result, improvement of the economic and social situation of the enterprise.

Basic principles TQM concepts are:

1. Giving the quality policy a priority role among other areas and aspects of the company's policy. Quality is the basis of effective management.

2. Product quality management is ensured at all stages of product creation and use.

3. Involving in activities to ensure and improve the quality of all company personnel, down to each worker, as well as all related companies. Motto: “Quality is everyone’s concern.”

4. Activation of the “human factor” by creating an atmosphere of satisfaction, interested participation, well-being among all employees of the company and related companies.

5. The main rule of work is to constantly meet consumer requirements by improving our activities. This also applies

To organization of intra-production relationships, when the principle is implemented: “the performer of the subsequent technological operation is your consumer.”

6. Quality must be inherent in the product, and not proven by control.

7. Self-monitoring of the quality of results at each workplace.

8. Continuous training and improvement of all employees in the field of quality.

9. Constant analysis and improvement of the quality assurance system.

TQM goes far beyond ensuring product quality; it permeates the very essence of management. This gave rise to calling the TQM approach “fourth generation management.” It is important to note that the ISO 9000 series of standards is not an alternative to TQM. Moreover, in the words of A. Feigenbaum, the founder of integrated quality management, “these two types of movement are, as it were, partners in achieving a common goal, but at different stages

movement of the enterprise towards quality. In this case, the basis is ISO standards, and the evolutionary development is TQM.”

IN in accordance with MSQuality Management System is a management system for directing and managing an organization in relation to quality.

IN the basis for building a quality management system is laidprocess approach, in which the quality management system is considered as a set of interconnected processes that transform inputs into outputs using resources.

Process model quality management system (Fig. 5.1) includes the following activities:

Activities involving management responsibility; - resource management; - management of product life cycle processes;

Measurement, analysis and improvement.

These activities form a closed cycle and are united by activities for continuous improvement of the quality management system. In this case, the inputs are the requirements of consumers (and other interested parties) for products, and the outputs are their satisfaction. Communication between these activities and with external stakeholders is ensured by appropriate information.

The continuous implementation of the listed activities constitutes the content of quality management.

The quality management system should cover the following stages of the product life cycle:

determination and analysis of product requirements;

design and development;

procurement (materials and technical support);

production;

service.

Stakeholders in quality management are:

- consumers and end users;

- employees of the organization;

- owners/investors (such as shareholders, individuals or groups, including the public sector, with a specific interest in the organization);

- suppliers and partners;

- society in the form of various associations and government structures on which the organization or its products have an impact.

Let's consider the types of activities included in the quality management system model.

Activities involving management responsibility.

For the quality management system to operate successfully and meet the needs and expectations of interested parties, top management must ensure:

a) bringing to the attention of the organization consumer requirements, as well as legislative and mandatory requirements;

b) development of a quality policy.

Quality Policy – The overall intentions and direction of an organization's quality activities, as formally articulated by senior management. The quality policy should be consistent with the overall policy of the organization and provide the basis for setting quality objectives;

c) product quality planning, including developing quality objectives and identifying the processes and resources required to achieve those objectives. Quality objectives should be established for appropriate functions and levels of the organization;

d) planning the creation and development of a quality management system; e) assigning responsibility and authority to employees of the organization

in achieving quality goals, their involvement and motivation; f) development and creation of appropriate exchange processes

information; g) conducting an analysis by management of the management system

quality to ensure its continued suitability and effectiveness and to assess opportunities for improvement;

h) provision of necessary resources.

Top management must appoint management representative and empower it to manage, continuously monitor, evaluate and coordinate the quality management system, both during its creation and during its operation and improvement. The representative reports to senior management and liaises with customers and other interested parties on issues related to the quality management system.

Resource management.

The resources necessary for the functioning of the quality management system include: employees, infrastructure, production environment, information, suppliers and partners, natural resources, financial resources.

Resource management includes:

- determining the need for resources and requirements for them;

- identification of resource sources;

- planning, organizing and managing the provision of resources;

- control of resources, including their quality;

- involvement, motivation, training of personnel in relation to ensuring product quality;

- monitoring the ability of suppliers to supply appropriate products and encouraging them to continuously improve performance;

- ensuring an efficient and favorable state of the infrastructure and production environment.

Infrastructure required for product life cycle processes includes production facilities, workspace, tools and equipment, support services, information

And communication technologies, vehicles.

Management must determine the infrastructure and ensure its operational condition, including its safety for the environment.

Work environment– a combination of human and physical factors – includes:

− methods and technology of effective work and opportunities for the fullest involvement and realization of the potential of the organization’s employees;

− safety precautions;

− ergonomics;

− placement of workplaces;

− social interaction;

− personnel services facilities in the organization;

− environmental and sanitary conditions in working areas. The work environment should have a positive impact on

motivation, satisfaction and performance of staff.

Process management at product life cycle stages

includes:

planning, organizing processes and managing their implementation;

control and analysis during the execution of processes;

ensuring identification and traceability of products during

its manufacture;

optimization of process elements (for example, optimization of suppliers when purchasing products - their assessment and selection);

management of devices for monitoring and measuring products and processes (defining procedures and devices for monitoring and measurements necessary to control the compliance of products and processes with established requirements; ensuring the accuracy of measuring equipment, its timely verification, calibration, adjustment). This activity must be carried out in accordance with the requirements of the Law of the Russian Federation “On Ensuring the Uniformity of Measurements” and other regulatory documents.

Measurement, analysis and improvement includes actions:

Assessing the satisfaction of consumers and other stakeholders;

Internal audits (inspections) of the quality management system (self-assessment);

Monitoring and measurement of processes and products.

Monitoring and inspection programs should be developed;

Management of non-conforming products (identification, actions to eliminate non-conformity or to use non-conforming products);

Data analysis (on customer satisfaction, compliance with product requirements, characteristics and trends of processes and products, suppliers);

Continuous improvement and increase in the effectiveness of the quality management system and the activities of the organization as a whole;

Corrective and preventive actions to eliminate the causes of existing or potential nonconformities.

One of the fundamental requirements MS to quality management systems - the need for their thoroughdocumentation.

System documentation should include: a) statements of quality policy and objectives; b) quality manual;

c) documented procedures, work instructions and drawings; d) documents necessary for the organization to ensure effective

planning, implementation of processes and their management (quality plans, technical requirements, methodological documents);

e) records (documents containing objective evidence of actions performed or results achieved).

Creating or improving a quality management system should begin with defining the company's policy and goals in the field of quality, which should reflect the main directions of its activities, goals and objectives in terms of quality. The policy is formulated by the management of the enterprise. Quality goals are established for the relevant levels and divisions of the organization. They must be measurable and consistent with the quality policy.

The quality manual is the fundamental document of the quality management system and contains its general description, the basic provisions and principles of the construction and operation of the system, a description of its elements, a list of quality assurance procedures and their performers. A quality manual serves various purposes. In contractual situations, the Guide can be used as a demonstration document for customers. During the operation of the system, the Manual serves as a model that must be followed, as well as a reference for employees of the enterprise.

The documentation of the quality management system also contains a detailed description of the functions, tasks and procedures for quality assurance; methods and technology for their solution and implementation; content and type of information received and issued; forms of documents containing this information; specific units or individuals performing procedures and using information.

Documentation can be in any form or medium, based on the needs of the organization. The standards also specify requirements for document management.

Organizationally, the quality management system is part of the organization's management system. It organically permeates the general management system, involving all personnel of the organization in solving problems of ensuring and improving product quality.

At the enterprise level, quality management is organized in one of two ways. The first is a clear distribution of functions and tasks of product quality management between existing departments and employees, periodic review of both the functions and tasks themselves, and their distribution in order to improve performance. In this case, a specialized body is not created - a quality management department.

The second involves, in addition to the first option, the allocation of coordination functions and organizational and methodological support, and the creation of a special body - a quality management department (service). This department is responsible for many special product quality management functions.

Each of these two options has its advantages and disadvantages.

So the advantage of the first option is that all participants in the production process are responsible for quality. There is no feeling that someone is responsible for them and must resolve all issues related to quality. The disadvantage is that no one performs a number of coordinating functions, no one solves organizational and methodological issues of a general nature.

The second option does not have this drawback, but employees of the enterprise often have the feeling that there are specially designated people at the enterprise who are responsible for quality, therefore, they must solve all problems related to quality, i.e. The responsibility of each employee for quality is reduced.

In any case, the overall management of the quality management system should be headed by the head of the enterprise, who is responsible for all the activities of the enterprise and for economic results, which in a market economy cannot be high if the quality of the products is poor.

Practical management of the creation and operation of the quality management system is provided by management representative– either quality director or deputy. General Director for Quality, or one of the deputy first managers entrusted with this work.

5.4. International standards for quality management systems

IN 1987 The International Organization for Standardization ISO (TC 176) developed a series of international standards ISO 9000 - ISO 9004, which establishes requirements for quality management systems in enterprises. In 1994, this series of standards was revised and expanded, and also supplemented with standards of the 10000 series. The next edition of these standards has been released under the name ISO 9000 Family of Standards “Quality Management Systems”. Improvement of these standards continues.

IN These standards have found a concentrated expression of the best world achievements in the field of product quality management. These standards are recognized and adopted as national standards in many countries,

V including in our country. We have adopted these standards as GOSTs.

The ISO 9000 family of standards are increasingly used in contracts between firms to evaluate the supplier's product quality management system. At the same time, compliance of such a system with the requirements of ISO standards is considered as a certain guarantee that the supplier is able to fulfill the requirements of the contract and ensure stable product quality. Therefore, contracts include a requirement for such compliance, which complements the requirements for the product or service reflected in product standards, technical specifications or other regulatory documents.

The ISO 9000 family of standards includes the following standards:

- ISO 9000 – 2000 (GOST R ISO 9000 – 2001) “Quality management systems. Fundamentals and vocabulary";

- ISO 9001 – 2000 (GOST R ISO 9001 – 2001) “Quality management systems. Requirements";

- ISO 9004 – 2000 (GOST R ISO 9004 – 2001) “Quality management systems. Recommendations for improving activities";

- ISO 19011 – 2002 (GOST R ISO 19011 – 2003) “Guidelines for auditing quality management systems and/or environmental management systems.”

These standards are complemented by the 10000 series standards, which provide guidance on the development of quality programs, quality assurance of measurement equipment, measurement process management, continuing education and training, economic aspects of quality, etc.

Together they form a coherent set of standards for quality management systems. The numbers of Russian GOSTs, which are authentic texts of the relevant international standards, are indicated in brackets.

The ISO 9000 standard describes the main provisions of quality management systems and establishes the corresponding terminology. This standard can be used both by an organization that has or is creating a quality management system, and by other interested parties (consumers, auditors, certification bodies, etc.).

The ISO 9001 standard contains requirements for quality management systems that are common to organizations in any sector of industry or economy, regardless of product category (of which four are defined: services; software; hardware; processed materials). This standard can be used both for internal use by organizations (including self-assessment) and for the purposes of certification, contracting, audits of quality management systems by consumers or third parties.

The ISO 9004 standard is an extension of the ISO 9001 standard. It provides guidance on ensuring the effectiveness and efficiency of quality management systems and improving the performance of an organization in

in general. This standard is not intended for certification or contracting purposes.

The ISO 19011 standard contains guidelines for the audit (verification) of quality management systems and environmental management systems.

This set of standards declares a systematic approach to quality management and indicates that the quality management system is part of the organization's management system and, in accordance with quality objectives, is aimed at meeting the needs, expectations and requirements of consumers and other interested parties. According to this quality management should be based on the following eight principles:

a) Customer Focus Organizations depend on their customers and therefore need to understand

their current and future needs, meet their requirements and strive to exceed their expectations.

b) Leadership of the manager Leaders ensure unity of purpose and direction of activity

organizations. They should create and maintain an internal environment in which employees can be fully involved in solving the organization's problems.

c) Employee Involvement Employees at all levels form the backbone of the organization, and their full

involvement enables the organization to benefit from their capabilities.

d) Process approach The desired result is achieved more effectively when activities and

relevant resources are managed as a process. e) Systematic approach to management

Identifying, understanding and managing interrelated processes as a system contributes to the effectiveness and efficiency of the organization in achieving its goals.

f) Continuous improvement Continuous improvement of the organization's activities as a whole should be

be considered as its permanent goal.

g) Fact-Based Decision Making Effective decisions are based on the analysis of data and information. h) Mutually beneficial relationships with suppliers

The organization and its suppliers are interdependent, and relationships of mutual benefit enhance the ability of both parties to create value.

These eight quality management principles form the basis for the quality management system standards in the ISO family.

Test questions for Chapter 5

1. What are the features of product quality management?

2. What are the “factors” and “conditions” for ensuring product quality?

3. What factors determine product quality at different stages of its life cycle?

4. What conditions influence product quality assurance?

5. What are the main directions for improving product quality?

6. What is the retrospective of the development of methods for solving the problem of ensuring and improving product quality?

7. Describe the concept of “total quality management”. What are its basic principles?

8. What approach is used in international standards as the basis for building a quality management system?

9. What stages of the product life cycle should a quality management system cover?

10. Who are the stakeholders in quality management?

11. Name the types of activities that make up the process model of the quality management system and characterize them.

12. What is the composition of the quality management system documentation? What's it like

its content?

13. How is product quality management organized at an enterprise?

14. List the international standards of the ISO 9000 family “Quality management systems” and describe them.

15. What principles should quality management be based on in accordance with international standards?

Transcript

1 Limited Liability Company "Study-Style", Moscow, Dubininskaya str., 57, building 1, room. I, room 7b, OKPO, OGRN, INN KPP GRADUATE QUALIFICATION (DIPLOMA) THESIS on the topic: “PNEUMONIA” 2

2 CONTENTS INTRODUCTION... 4 Chapter 1. GENERAL CHARACTERISTICS OF THE DISEASE Concept and essence of pneumonia Classification of pneumonia Epidemiology of pneumonia Chapter 2. ANALYSIS OF METHODS OF DIAGNOSIS AND TREATMENT OF PNEUMONIA OF DIFFERENT SEVERITY X-ray diagnosis of pneumonia Types of treatment of pneumonia differing in severity Prevention of pneumonia Chapter 3. ORGANIZATION ME AND RESEARCH METHODOLOGY (using the example of an emergency medical service substation) Preclinical methods for diagnosing pneumonia Organization of the study Results and conclusions of the study CONCLUSION LIST OF LITERATURE SOURCES:

3 INTRODUCTION Relevance of the topic. Confirming and arguing such an aspect as the relevance of the topic of this WRC, initially, one should look at several key aspects associated with the disease pneumonia, its characteristics, severity and frequency of occurrence. The first of these, undoubtedly, is the fact that the end of the 20th century showed scorched growth rates in the number of people exposed to this disease, as well as the frequency of deaths. This situation has spread not only throughout the territory of the Russian Federation, but also throughout the world as a whole. 1. Pneumonia, according to the rating of the severity of pathologies that can cause death, today occupies 5th place, yielding leadership to such terrible, incurable ailments like cancer and AIDS. Among infectious diseases - 1st place (causes every second death in the geriatric population and 90% of deaths from respiratory infections in people over 64 years of age) 2. This is due to the fact that the pathogenesis of pneumonia affects exclusively the respiratory system, which is key for work the whole body. The second factor is, undoubtedly, that pneumonia entails severe complications, often of a chronic nature, which are derived pathologies from active inflammatory and purulent processes in the lungs. One of the most severe and leading in terms of mortality outcomes of the disease is a form of pneumonia known as community-acquired pneumonia. The incidence of community-acquired pneumonia averages 10-12%, varying depending on the age, gender, race and socio-economic conditions of the population being studied. According to 1 Guchev, I.A., Sinopalnikov, A.I. Modern guidelines for the management of community-acquired pneumonia in adults: the path to a unified standard. // Clinical microbiology and antimicrobial chemotherapy T.10, 4. - S Sinopalnikov, A.I., Kozlov, R.S. Community-acquired respiratory tract infections. Guide for doctors. - M.: Premier MT, Our City, p. 4

4 According to UK specialists, 5-11 adults out of 1000 suffer from CAP per year, which is 5-12% of all cases of lower respiratory tract infections 3. Every year in the USA, 4 million cases of pneumonia are registered among adults, of which 1 million are subject to hospitalization 4. The incidence of CAP in young and middle-aged people is 1-11.6%, increasing to 25-51% in the older age group. According to official statistics, in 2014 in Russia among people over 18 years of age the incidence rate was 3.9%, and in 2015 in all age groups - 4.1%. However, according to calculations, the actual incidence reaches 14-15%. Mortality in CAP is on average less than 1% among outpatients and 5-14% among hospitalized patients 5. At the same time, according to some authors, the incidence of adverse outcomes in patients over 60 years of age, with concomitant diseases and/or severe CAP reaches 15-50% and does not differ significantly from the indicators recorded in the pre-antibiotic era. Based on all of the above, it is precisely this type of diagnosis of pneumonia, such as preclinical and its methods, that are characterized by high rates of relevance. Detailed and thorough knowledge of the protocols and features of this diagnostic type is useful both for patients and for medical workers at various levels. This is due to the fact that the earlier the diagnosis is made and confirmed, the more quickly therapeutic and medicinal measures are taken, which improves the overall prognosis, alleviates the course of the disease and prevents the occurrence of complications of various kinds. 3 Pulmonology. / ed. N. Buna [etc.]; lane from English edited by S.I. Ovcharenko. - M.: Reed Elsiver LLC, p. 4 Mandell, L.A. Infectious Diseases Society of America / American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. // Clinical Infectious Diseases Vol P.s27-s72. 5 Woodhead, M. Guidelines for the management of adult lower respiratory tract infections. // European Respiratory Journal Vol P

5 As for researchers, over the last 10 years many scientists have been working on improving, developing and facilitating preclinical methods for diagnosing pneumonia. But, despite this, the level of complexity of studying the aspects of this technique is not complete and leaves much to be desired. This same circumstance, in fact, justifies the expediency of choosing a research topic in this graduate work. Object of study. The disease pneumonia, its characteristics and its inherent diagnostic techniques. Subject of study. Study of the effectiveness of a preclinical method for diagnosing pneumonia using the example of emergency medical service substation workers. Goals and objectives of the study: The key goal of this research study is to prove the effectiveness, importance and feasibility of such a diagnostic method for pneumonia as a preclinical one. In view of the set goal, in a similar way, a range of tasks was formed that also require solutions in this work: - characterize the disease pneumonia, give its classification and frequency of occurrence; - comprehensively study all possible methods of diagnosis, treatment and prevention of pneumonia; - prove that preclinical diagnostics is the most important and effective; - conduct a study on the frequency and severity of pneumonia at an EMS substation; - analyze the diagnostic and therapeutic methods used for patients at the EMS substation; - based on the results obtained, practically confirm the rationality and importance of using a preclinical method for diagnosing pneumonia (confirm with conclusions). 6

6 Research hypothesis: Is high-quality preclinical diagnosis of pneumonia capable of preventing its complications and reducing the chance of death, as well as improving the prognosis and effectiveness of treatment? Practical significance of the study. The practical value of this work lies in the fact that the compiled and studied theoretical and practical material provides evidence of the importance and indispensability of using a preclinical diagnostic method in the process of identifying and surgical treatment of various pneumonias. Research methodology. The work combines general scientific and specific scientific research methods. The interdisciplinary approach chosen by the author to solve the set goals and objectives allowed for a comprehensive analysis, which the author built on a combination of various research methods. Degree of knowledge of the topic: The problems of pulmonology, as well as the improvement of preclinical diagnostic techniques, as well as the problems of the incidence of pneumonia, in general, have been studied by a very wide range of doctors and researchers for many years. This work was based on textbooks and articles by the following authors: Mishin V.V., Kuzmin A.P., Ryabukhin A.E., Stepanov S.A., Guchev, I.A., Sinopalnikov, A.I. , Boone N., etc. 7

7 Chapter 1. GENERAL CHARACTERISTICS OF THE DISEASE 1.1 The concept and essence of pneumonia Pneumonia (ancient Greek πνευµονία from πνεύµων), or pneumonia, is pathological processes occurring in the tissues of the lung, often characterized by an inflammatory nature, and also mainly affecting such pulmonary structures as alveoli and interstitial tissue 6. It is also worth noting that in this case exudation of a similar pathogenic nature actively develops 7. Etiology. This terminology implies a combination of a wide range of diseases. At the same time, it is quite logical that each of them has an individual etiology and pathogenesis. Based on this, each pneumonia pathology is characterized by individual symptoms, a picture during X-ray diagnostics, indicators and results of various laboratory and percussion, as well as anamnestic manipulations. There is also a type of pneumonia, which is characterized by a non-infectious nature of the pathogenesis and is called alveolitis. It differs in that it manifests itself mainly in the form of obstruction of the respiratory areas of the lung. This type of pneumonia often leads to the development and occurrence of more severe forms of pneumonia, such as: mycotic or pneumonia, the causative agents of which are fungi, bacterial, or viral-bacterial, caused by microorganisms similar to their names. Pathogenesis. Often, the route through which bacteria and viruses enter the human body, and lung tissue in particular, is called bronchogenic. Several factors contribute to this trend 6 Leach, Richard E. Acute and Critical Care Medicine at a Glance. 2. Wiley-Blackwell, ISBN McLuckie A. Respiratory disease and its management. New York: Springer, P. 51. ISBN

8 related aspects, which include: aspiration, the presence of microorganisms in the air we breathe, displacement of infection localized in the nasopharynx to the lower respiratory tract, medical invasive procedures. In addition to all of the above methods of infection, there is also a hematogenous type of infection, that is, the spread of pathogens through the circulation of blood masses in the body, but it is an order of magnitude less common than bronchogenic. It becomes possible in the case of intrauterine infection, drug addiction, purulent abscesses. The chance of infection through lymph is critically small even in comparison with hematogenous infection. Then, after the pathogen enters the body, regardless of the form and severity of pneumonia, the number of infectious agents or the virus becomes established and increases. This happens at the morphological level of the bronchial epithelium, namely, bronchitis pathogenic activity and accompanying symptoms begin. Its severity varies, depending on the duration of the disease, from the catarrhal form to the necrotic varieties of bronchitis and broncholitis. At the moment when the inflammatory process spreads further, crossing the border of the respiratory bronchioles, infection of the lung tissue itself begins, which is called nothing less than pneumonia. Due to the fact that the patency in the bronchi is complicated, areas of tissue affected by atelectasis and emphysema begin to appear. Further, the body, according to a natural physiological reflex, manifested in the form of sneezing or coughing, activates a defense mechanism aimed at removing pathogenic agents from the body. But in the case of pneumonia, this trend does not improve, but on the contrary, only aggravates the situation, promoting the spread of infections in the lung tissues and respiratory structures. New pneumonia foci lead to increased respiratory failure, 9

9 and then a lack of oxygen, when pneumonia is characterized by a severe form, heart failure may also occur. As for the localization of pneumonia within the lobes of the lung and its segments, in most cases this disease affects: on the left - II, VI, X and VI, VIII, IX, X on the right. A frequent occurrence is also the spread of infection and pathogenicity to nodes related to the lymphatic system. Nodes at risk include bronchopulmonary, paratracheal, and bifurcation nodes. Continued section in the full version of the work 1.2 Classification of pneumonia The collective experience of recent years has made it possible not only to clarify the nature and symptoms of pneumonia, but also to identify previously unknown varieties of these processes. The widespread use of sulfonamides, antibiotics and other modern medications has contributed to a noticeable change in the course and outcomes of various types of pneumonia. Clinical diagnosis of erased forms of pneumonia has become much more difficult. The difficulties of differential diagnosis have also increased, especially since previously known and well-studied nosological forms have been supplemented by a large number of acute inflammatory processes of the lungs, the presence of which previous generations of doctors had not even suspected. X-ray examination played a major role in the detailed study of various types of pneumonia. If earlier the typical clinical picture of lobar and focal pneumonia made it possible for an experienced clinician to do without X-ray examination, today, due to the predominance of erased clinical forms, it has become 10

10 necessary at all stages of the course, including when assessing the results of treatment and determining the outcome of the disease 8. Not all currently known pneumonias manifest themselves in characteristic, let alone pathognomonic, patterns. On the contrary, many of them have similar symptoms. Only solid knowledge concerning all aspects of these processes - epidemiological, etiopathogenetic, morphological, clinical, radiological - can contribute to the success of diagnosis. When examining patients with acute inflammatory processes, the radiologist, as a rule, limits himself to the use of classical methods - transillumination of images in various projections, including layer-by-layer, and some functional tests. Such valuable additional methods as bronchography, angiography, bronchoscopy, and lung puncture are used in these processes only in exceptional cases, which naturally complicates the researcher’s task. Meanwhile, the diagnosis in an acute process must be made quickly and reliably, since the prescription of treatment and the further course of the disease depend on this. Currently, there is no generally accepted classification of acute pneumonia. The proposed groupings suffer from a common drawback - the absence of a single principle. Indeed, in these groupings one can simultaneously find processes distinguished according to the principle of morphological (for example, parenchymal, interstitial pneumonia), etiological (viral, Friedlander pneumonia), pathogenetic (septic, metastatic, allergic pneumonia), etc. It is most correct to group acute pneumonic processes by etiological principle. This makes it possible to compare 8 Ivanovsky B.V. Differential diagnosis of tuberculosis and pulmonary sarcoidosis (literature review). Problem Tub., 2004, 8, p.

12 3. Embolism and pulmonary infarction. Infarction pneumonia. II. With changes in the bronchi. III. Aspirated pneumonia. IV. Pneumonia in various diseases of the body. 1. Septic metastatic pneumonia. 2. Pneumonia in infectious diseases. 3. Pneumonia due to allergies. The above classification is not without some drawbacks. The single principle of grouping nosological forms is not followed everywhere; not all identified processes can be completely attributed to acute pneumonia. Although cumbersome, the classification is not comprehensive; it does not cover all possible cases of pneumonia. Continued section in the full version of the work 1.3 Epidemiology of pneumonia The worldwide prevalence and incidence of pneumonia is extremely high. Over the course of a year, approximately 450 million people out of the total population of the planet suffer from pneumonia. The worst thing about this figure is that 7 million of them do not survive to recover 10. The epidemiology of pneumonia at the present stage is characterized by a trend towards an increase in morbidity, complications and deaths around the world that has emerged since the late 80s. This is confirmed by data obtained from a retrospective analysis of 8 children's clinics in the United States. The ratio of hospitalized patients increased during the study period from 22.6% (2004) to 53% (2009). From Sergei Netesov. Middle Eastern pneumonia has also become Korean, but it is not a pandemic. Kommersant-Science (). 13

Of the 13 hospitalized children, complicated pneumonia was observed in 42% of cases (in the group of children over 61 months of age - 53%) 11. The economic losses that such a high incidence of CAP entails are also significant. Annual costs associated with the treatment of this disease in the United States amount to 8.4-10 billion US dollars, of which 92% are attributable to hospitalized patients. Treatment of one patient in a hospital costs US dollars, and at home, US dollars. The cost of treating all children suffering from pneumonia worldwide is about 600 million US dollars 12. A number of studies of childhood pneumonia conducted in Europe and North America note the significant role of viruses as causative agents of pneumonia in preschool children (respiratory syncytial virus, adenovirus, rhinovirus, influenza viruses A and B, parainfluenza), in schoolchildren - M. pneumoniae and C. pneumoniae, in newborns - C. trachomatis 13. According to data obtained in New Zealand, community-acquired pneumonia of viral etiology, as well as mixed (viral - bacterial) etiology occur relatively often in adult patients, and the latter tend to be more severe and accompanied by severe clinical symptoms. The viral etiology of the process was confirmed in 29%, with the main pathogens being rhinoviruses and influenza virus serotype A, two or more pathogens were identified in 16% 14. Analysis of the results for individual regions in the Russian Federation shows that the highest mortality from CAP is observed in men in working age. Mortality also depends on the causative agent of CAP (Table 1). 11 Tan, T. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. // Pediatrics Vol.110, 1. - P Pneumonia. / WHO Newsletter p. 13 Somer, A. Chlamydia pneumoniae in children with community-acquired pneumonia in Istanbul, Turkey. // Journal of tropical pediatrics Vol.52, 3. - P Ribeiro, D. D. Pneumonia and risk of venous thrombosis: results from the MEGA study / D. D. Ribeiro, W. M. Lijfering, A. Van Hylckama, F. R. Rosendaal, S. C. Cannegieter // J. Thromb. Haemost Vol. 10.P

14 Table 1. Mortality in community-acquired pneumonia depending on the pathogen Pathogen Mortality, % S. pneumoniae 12.3 H. influenzae 7.4 M. pneumoniae 1.4 Legionella spp. 14.7 S. aureus 31.8 K. pneumoniae 35.7 C. pneumoniae 9.8 According to Russian authors, the predominant pathogens of lethal CAP were K. Pneumonia, S. aureus, S. pneumoniae and H. Influenza in percentage 31 .4%, 28.6%, 12.9% and 11.4%, respectively. Pneumonia results in enormous medical costs. According to some authors, they cause temporary disability for an average of 25.6 days (12.8-45). EaP-related costs reach $24 billion annually in the United States. The annual cost of antibacterial drugs alone for patients with community-acquired pneumonia not requiring hospitalization is approximately $100 million in the United States. 15 The cost of inpatient treatment accounts for 87% of the total annual cost of treating patients with CAP. Continued section in the full version of the work 15 Singh, N. Short-course Empiric Antibiotic Therapy for Patients with Pulmonary Infiltrates in the Intensive Care Unit A Proposed Solution for Indiscriminate Antibiotic Prescription / N. Singh, P. Rogers, C. W. Atwood et al. //Am. J. Respira. Crit. Care Med Vol P

15 Chapter 2. ANALYSIS OF METHODS FOR DIAGNOSIS AND TREATMENT OF PNEUMONIA OF VARYING SEVERITY 2.1 X-ray diagnosis of pneumonia X-ray manifestations of pathological processes in the lungs are very different, but their key components are only four aspects, such as: shading of the pulmonary fields, clearing of the pulmonary fields, change in the pulmonary pattern, change roots of the lungs 16. Syndrome of extensive shading of the pulmonary field. The pathological process reflected by this syndrome is determined by the position of the mediastinum and the nature of the shading. The position of the mediastinum and the nature of shading in various diseases are shown in Table. 2. Table 2. Position of the mediastinum and the nature of shading in various diseases Position of the mediastinum Homogeneous shading Heterogeneous shading Not displaced Inflammatory infiltration Pulmonary edema Shifts towards the shading Atelectasis Pleural moorings Absence of the lung Cirrhosis of the lung Shifted to the opposite side Fluid in the pleural cavity Large neoplasms to the side Large neoplasms Syndromic approach to the X-ray diagnosis of respiratory diseases is quite fruitful. A detailed analysis of the features of the x-ray picture in many cases provides a correct determination of the nature of bronchopulmonary pathology. The data obtained from X-ray examination also serves as the basis for rational further examination of patients using other radiation imaging methods: X-ray CT, MRI, ultrasound and radionuclide methods Zvorykin I. A. Cysts and cyst-like formations of the lungs. L.: Medgiz, p. 17 Mirganiev Sh. M. Clinical and radiological diagnosis of pneumonia, Tashkent: Medicine, p. 16

16 Primary pneumonia, bacterial pneumonia, pneumococcal pneumonia The X-ray picture of lobar pneumonia with lobar spread is quite characteristic. Its evolution corresponds to the change in pathological stages. During the hot flash stage, there is an increase in the pulmonary pattern in the affected lobe due to the resulting hyperemia. The transparency of the pulmonary field remains normal or slightly decreases. The root of the lung on the affected side expands somewhat, its structure becomes less distinct. When the process is located in the lower lobe, the mobility of the corresponding dome of the diaphragm is limited. In the stage of hepatization, which occurs on the 2-3rd day from the onset of the disease, intense darkening appears, corresponding in localization to the affected lobe. Darkening with lobar pneumonia differs from lobar atelectasis in that it corresponds to the usual size of the lobe or even slightly larger; in addition, darkening with lobar pneumonia differs in two more features: firstly, the intensity of the shadow towards the periphery increases, while the uniformity of the shadow also rises; secondly, a careful study of the nature of the darkening shows that against its background in the medial sections, light stripes of the large and medium Kashira bronchi are visible, lumens of which in lobar pneumonia in most cases remain free. The adjacent pleura becomes denser; in some cases, a protrusion is found in the pleural cavity, which is better identified in the lateroposition on the side. There are no radiographic differences between the red and gray hepatic stages 18. The expansion stage is characterized by a gradual decrease in the intensity of the shadow, its fragmentation and reduction in size. The root shadow remains expanded and unstructured for a long time. The same 18 Winner M. G., Sokolov V. A. X-ray diagnostics and differential diagnosis of disseminated lung lesions. Vestn. Rentgenol., 1975, 6, p.

17 it should also be said about the pulmonary pattern at the site of the former hepatization: it remains enhanced for another 2-3 weeks. after clinical recovery, and the pleura bordering the affected lobe is compacted even longer. In some cases, changes in the lungs may be bilateral; Moreover, they, as a rule, do not develop synchronously, but sequentially 19. Experience of recent years indicates that in most cases, lobar pneumonia does not proceed according to the lobar type, but begins with a segmental lesion. If active treatment begins in the first 1-2 days of illness, which is now common, the lobar process may not occur. Bronchopneumonia (lobular, catarrhal, focal pneumonia) X-ray manifestations of bronchopneumonia differ significantly from the picture of lobar pneumonia. Characteristic are bilateral (less often unilateral) focal shadows up to 1-1.5 cm in size, corresponding to the size of the pulmonary lobules. The number of lesions usually increases towards the bottom. The outlines of the shadows of the lesions are unclear, their intensity is low. The apices are usually not affected. The pulmonary pattern intensifies throughout the pulmonary fields due to hyperemia. The shadows of the roots of the lungs are expanded, their structure becomes homogeneous. As a rule, a pleural reaction is detected, and exudative pleurisy is often detected. The mobility of the diaphragm is limited in most cases. Bronchopneumonia is characterized by rapid dynamics of the X-ray picture: within 4-6 days it changes significantly, and after 8-10 days the lesions usually resolve. Along with bronchopneumonia, in which the size of the foci does not exceed 1-1.5 cm, sometimes there are processes accompanied by the fusion of foci, and foci of much larger ones are formed. Honey. magazine Uzbekistan, 1975, 12, p.

18 sizes. Drain foci often form in weakened or insufficiently treated patients. Another version of the X-ray picture of bronchopneumonia is characterized by smaller lesions. In some cases, miliary bronchopneumonia is detected, characterized by a large number of small foci with a diameter of 1.5-2 mm, overlapping the pulmonary pattern. As a result, the shadows of the roots of the lungs appear as if chopped off. It is sometimes extremely difficult to distinguish miliary bronchopneumonia from other pulmonary disseminations, in particular tuberculosis and cancer, and even impossible with a single study. Rapid dynamics, negative tuberculin tests, absence of damage to other organs are some signs that speak in favor of bronchopneumonia. Large-focus confluent pneumonia can resemble in its x-ray picture multiple metastases of malignant tumors in the lungs. The main distinguishing feature that speaks in favor of bronchopneumonia is the rapid reverse development of the process. Staphylococcal and streptococcal pneumonia The X-ray picture of streptococcal and staphylococcal pneumonia is characterized by the presence of multiple bilateral inflammatory foci of medium and large size. The outlines of the foci are unclear, the intensity of the shadows depends on their size; there is a pronounced tendency towards their merger and subsequent disintegration. In these cases, against the background of shadows of inflammatory foci, clearings appear, delimited below by a horizontal fluid level. Characterized by a relatively rapid change in the x-ray picture. Within 1-2 weeks. (sometimes longer) one can observe the appearance of infiltrates, their disintegration, the transformation of decay cavities into thin-walled cysts with their subsequent decrease. On one radiograph one can detect all stages of the development of pneumonic infiltrates, which gives the X-ray picture a unique appearance. Exudative pleurisy is often associated, often 19

19 purulent. Schinz (1968) considers a triad of symptoms characteristic of these pneumonias: infiltrates, rounded cavities of decay, pleural exudate 20. Friedlander's pneumonia X-ray manifestations of Friedlander's pneumonia are quite characteristic in some cases. The emerging inflammatory infiltrates quickly merge into an extensive lobar lesion, reminiscent of hepatization in lobar pneumonia; sometimes the affected portion increases noticeably. With frequent localization in the right upper lobe, the x-ray shows a downward displacement of the small interlobar fissure by the entire intercostal space; the trachea and the upper part of the median shadow may be displaced in the opposite direction. Already in the first days of the disease, against the background of darkening, clearing may be detected due to the melting of the lung tissue. They are often multiple; their outlines can be quite clear due to the rapid drainage of the contents of the cavities through the bronchi. Another type of x-ray picture is a lobar darkening with foci in other parts of the same lung or in the contralateral lung. Clearances also appear in these foci, sometimes limited from below by the horizontal level of the liquid. Some of these cavities quickly develop into thin-walled cyst-like formations without visible perifocal inflammation. The reaction of the roots and pleura is pronounced in most cases. Tularemic pneumonia The X-ray picture of tularemic pneumonia is characterized by hyperplasia of the lymph nodes of the roots, the contours of which become unclear. Infiltrates are found in the supradiaphragmatic parts of the lungs on one or both sides. Often, pleural effusion is detected simultaneously with the infiltrate. The reverse development of infiltrates occurs within days, but sometimes the process is delayed for 5-6 weeks. 20 Rabinova A. Ya. Lateral chest radiograph. M.: Medgiz, p. 20

20 In a significant proportion of cases with pulmonary tularemia, enlarged axillary lymph nodes can be palpated. Pleural effusion occurs for a long time; upon puncture, a yellow, transparent or cloudy liquid is obtained, the relative density of which is always higher. Tularemic bronchitis that accompanies pneumonia is manifested by a long-lasting increase in the pulmonary pattern. Late complications include lung abscesses, pleural empyema, and spontaneous pneumothorax. Influenza pneumonia The most characteristic radiological sign of the disease is the intensification and deformation of the pulmonary pattern of a stringy or cellular type. More often, these changes are limited to the middle or lower parts of one or both lungs. With bilateral lesions, the picture is usually asymmetrical. 21

22 10. Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prevention: A manual for doctors / Edited by A. G. Chuchalin. - M., p. 11. Vovk, E. I. Community-acquired pneumonia at the beginning of the 21st century: the cost of living in a big city / E. I. Vovk, A. L. Vertkin // Attending physician S. Gerasimov, V. B. Pharmacoeconomics and pharmacoepidemiology, practice of acceptable solutions / V. B. Gerasimov, A. L. Khokhlov, O. I. Karpov. M.: Medicine, p. 13. Guchev, I.A., Sinopalnikov, A.I. Modern guidelines for the management of community-acquired pneumonia in adults: the path to a unified standard. // Clinical microbiology and antimicrobial chemotherapy Vol. 10, 4. - S Davydovsky I. V. Pathological anatomy and pathogenesis of human diseases. M.: Medgiz, p. 15. Dvizhkov P. P. Pneumoconiosis. M.: Medicine, p. 16. Esipova Y. K. Lung in pathology. Novosibirsk: Nauka, p. 17. Zhestkov, A. V. Clinical and immunological features of occupational bronchitis / A. V. Zhestkov, V. V. Kosarev, S. A. Babanov, etc. // Pulmonology S. Zvorykin I. A. Cysts and cyst-like formations of the lungs. L.: Medgiz, p. 19. Ivanovsky B.V. Differential diagnosis of tuberculosis and pulmonary sarcoidosis (literature review). Problem tub., 2004, 8, p. Kazakov A.F. Modern possibilities of differential diagnosis of round formations in the lungs. Problem Tub., 2003, 12, with Karzilov A.I. Biomechanical homeostasis of the external respiration apparatus and mechanisms for its provision under normal conditions and at 23

23 obstructive pulmonary diseases // Bulletin. Sib. Medicine T. 6, 1. S Kornilaev I.K. Features of the dynamics of acute focal pneumonia according to X-ray data. Health Turkmenistan, 1980, 5, p. Mazaev P. Ya., Voropaev M. M., Kopeiko I. P. Angiopulmonography in the clinic of surgical lung diseases. M.: Medicine, p. 24. Mirganiev Sh. M. Clinical and radiological diagnosis of pneumonia, Tashkent: Medicine, p. 25. Netesov S. Middle Eastern pneumonia has also become Korean, but it is not a pandemic. Kommersant-Science (). 26. Pneumonia. / WHO Newsletter p. 27. Pulmonology. / ed. N. Buna [etc.]; lane from English edited by S.I. Ovcharenko. - M.: Reed Elsiver LLC, p. 28. Puzik V.P., Uvarova O.A., Averbakh M.M. Pathomorphology of modern forms of pulmonary tuberculosis. M.: Medicine, p. 29. Rabinova A. Ya. Lateral chest radiograph. M.: Medgiz, p. 30. Rabukhin A. E. On some aspects of pneumology. Klin, med., 1976, 12, pp. Rational antimicrobial pharmacotherapy: Hand. for medical practitioners / Ed. ed. V. P. Yakovleva, S. V. Yakovleva. M.: Litterra, p. 32. Reinberg S. A. Pulmonary disseminations and their clinical and radiological characteristics. Klin, med., 1962, 4, p. Simbirtsev, A. S. Cytokines are a new system for regulating the body’s defense reactions / A. S. Simbirtsev // Cytokines and inflammation T S

24 34. Sinopalnikov, A.I., Kozlov, R.S. Community-acquired respiratory tract infections. Guide for doctors. - M.: Premier MT, Our City, p. 35. Suleymanov S.Sh., O.V.Molchanova, N.V.Kirpichnikova Biomedicine 3, 2010, S Tetenev F.F. Why is it necessary to study the mechanics of cardiac diastole, pulse wave and expansion of internal organs that do not have a skeleton? // Sib. honey. Journal T. 28, 1. S Tetenev F.F. Rationale for a new understanding of the physiology of mechanical movements of internal organs // Bulletin. Sib. Medicine T. 11, 4. S Tetenev F.F. New theories in the 21st century: 2nd ed., revised. and additional Tomsk: Publishing house Tom. university, p. 39. Upiter M. Z., Ananyeva V. F., Vardya E., Iigus X. O. On the issue of diagnosing “spherical” lung formations (analysis of 2750 observations). Vestn. rentgenol., 1974, 1, with Usenko, D. V. Prevention of respiratory infections: the place and role of probiotic products / D. V. Usenko // Directory of a polyclinic doctor T S Khamitov, R. F. Antimicrobial therapy of community-acquired pneumonia in outpatient clinics practice / R. F. Khamitov, K. R. Sulbaeva, T. N. Sulbaeva // Practical medicine (40). S Khidirbeyli X. A. X-ray diagnosis of pulmonary edema. Toolkit. M.: I Moscow. honey. Institute, p. 43. Khomyakov Yu.S. On the issue of active contractility of the lung // Sov. medicine S. Tselipanova, E. E. Clinical and laboratory assessment of the use of the biological drug Acipol in children with respiratory pathology: abstract. diss....cand. honey. Sciences: / Tselipanova Elena Evgenevna. M., p. 25

25 45. Chuchalin, G. A. Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prevention / G. A. Chuchalin, A. I. Sinopalnikov, L. S. Strachunsky, etc. // Klin. microbiol. antimicrobial chemotherapy T. S. Chuchalin, G. A. Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prevention / G. A. Chuchalin, A. I. Sinopalnikov, L. S. Strachunsky, etc. // Klin. microbiol. antimicrobial Chemoter T S Baudrexl A. Erfahrungen mit der offenen Lungenbiopsie bei der Diagnostik disseininierter vol. 92, p Beijers, R. Maternal prenatal anxiety and stress predict infant illnesses and health complaints. // Pediatrics Vol.126, 2. - P. e401- e Christ-Crain, M. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial / M. Christ-Crain, D. Stolz, R. Bingisser et al. //Am. J. Respira. Crit. Care Med Vol P De Vrese, M. Effect of Lactobaccilus gasseri PA 16/8, Bifidobacterium longum SP 07/3, B. bifidum MF 20/5 on common cold episodes:a double blind, randomized, controlled trial / M. De Vrese , P. Winkler, P. Rautenberg et al. // Clin. Nutr Vol P Guidelines for the management of adult lower respiratory tract infections. European Respiratory Journal Vol P Fernandez, E. Predictors of health decline in older adults with pneumonia: findings from the Community-Acquired Pneumonia Impact Study. // BMC Geriatrics Vol.10, 1. - P Jacobs, M. R. The Alexander Project: susceptibility of pathogens isolated from community acquired respiratory tract infection to commonly used antimicrobial agents / M. R. Jacobs, D. Felmingham, P. C. 26

26 Appelbaum et al. // J. Antimicrob. Chemother Vol P Kaplan, V. Pneumonia: still the old man's friend? / V. Kaplan, G. Clermont, M. F. Griffin et al. // Arch.Intern. Med Vol P Leach, Richard E. Acute and Critical Care Medicine at a Glance. 2. Wiley-Blackwell, ISBN Lee, G.E. National hospitalization trends for pediatric pneumonia and associated complications. // Pediatrics Vol.126, 2. - P Mandell, L.A. Infectious Diseases Society of America / American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. // Clinical Infectious Diseases Vol P.s27-s Martinez, J. A. Addition of macrolide to a beta lactam base empirical antibiotic regimen is associated with lower inhospitality mortality for patients with bacteremic pneumococcal pneumonia / J. A. Martinez , J. P. Horcajada, M. Almela et al. // Clin. Infect. Dis Vol P McLuckie A. Respiratory disease and its management. New York: Springer, P. 51. ISBN Menendez, R. Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome / R. Menendez, A. Torres, R. Zalacain et al. // Thorax Vol. 59. P Mortensen, E. M. Assessment of mortality after long-term follow-up of patients with community-acquired pneumonia / E. M. Mortensen // Clin. Infect. Dis Vol. 37. P Ribeiro, D. D. Pneumonia and risk of venous thrombosis: results from the MEGA study / D. D. Ribeiro, W. M. Lijfering, A. Van Hylckama, F. R. Rosendaal, S. C. Cannegieter // J. Tromb. Haemost Vol. 10. P Singh, N. Short-course Empiric Antibiotic Therapy for Patients with Pulmonary Infiltrates in the Intensive Care Unit A Proposed Solution for 27

27 Indiscriminate Antibiotic Prescription / N. Singh, P. Rogers, C. W. Atwood et al. //Am. J. Respira. Crit. Care Med Vol P Somer, A. Chlamydia pneumoniae in children with communityacquired pneumonia in Istanbul, Turkey. // Journal of tropical pediatrics Vol.52, 3. - P Tan, T. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. // Pediatrics Vol.110, 1. - P Thornsberry, C. Regional trends in antimicrobial resistance among clinical isolates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States: results from the TRUST Surveillance Program, / C. Thornsberry, D. F. Sahm, L. J. Kelly et al. // Clin. Infect. Dis Vol. 34 (Suppl. 1). - P Woodhead, M. Guidelines for the management of adult lower respiratory tract infections. // European Respiratory Journal Vol P To receive the full version of the work, contact us by phone or email us Your Study-Style! 28

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In the winter season, with the onset of cold weather, the risk of diseases of the upper and lower respiratory tract increases: pneumonia, sore throat, tracheitis.

Pneumonia is now one of the most common diseases. Despite the successes of drug therapy, pneumonia is still considered a dangerous and sometimes even fatal disease. Patients with pneumonia make up a significant percentage of those seeking medical care in clinics, therapeutic and pulmonology departments of hospitals, which is associated with high morbidity, especially during influenza epidemics and outbreaks of acute respiratory diseases.

This is an acute infectious disease, predominantly of bacterial (viral) etiology, characterized by focal damage to the respiratory parts of the lungs, the presence of intra-alveolar exudation, detected during physical and instrumental examination, expressed in varying degrees by a febrile reaction and intoxication.

Inflammatory lung disease can be suspected if the following signs are present:

• Fever (temperature above 38 degrees);
• Intoxication, general malaise, loss of appetite;
• Pain when breathing on the side of the affected lung, aggravated by coughing (when the pleura is involved in the process of inflammation);
• Cough is dry or with phlegm;
• Dyspnea.

The diagnosis is made by a doctor. It is important to seek medical help on the first day of illness. A chest x-ray, computed tomogram, and auscultatory data help the doctor make a diagnosis. The selection of drug therapy is strictly individual, depending on the suspected causative agent of the disease. Treatment of pneumonia is carried out on an outpatient or inpatient basis, depending on the severity of the disease. Indications for hospitalization are determined by the doctor.

Relevance of the problem of pneumonia

The problem of diagnosis and treatment of pneumonia is one of the most pressing in modern therapeutic practice. Over the past 5 years alone, the incidence rate in Belarus has increased by 61%. The mortality rate from pneumonia, according to various authors, ranges from 1 to 50%. In our republic, the mortality rate has increased by 52% over 5 years. Despite the impressive successes of pharmacotherapy and the development of new generations of antibacterial drugs, the share of pneumonia in the morbidity structure is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, not counting ARVI, the number of patients with pneumonia exceeds 60%.

In modern conditions of a “economical” approach to healthcare financing, the priority is the most appropriate expenditure of allocated budget funds, which predetermines the development of clear criteria and indications for hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good final result at lower costs. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for hospitalization of patients with pneumonia into everyday practice, which would facilitate the work of the local therapist, save budget funds, and timely predict possible outcomes of the disease.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Health care organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics indicate an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. In the United States, this pathology ranks sixth in the structure of mortality and is the most common cause of death from infectious diseases. More than 60,000 fatal outcomes from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and serious illness. Tuberculosis and lung cancer are often hidden under its mask. A study of autopsy reports of people who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made within the first day after admission to the hospital in less than a third of patients, and within the first week - in 40%. 27% of patients died on the first day of hospital stay. The coincidence of clinical and pathoanatomical diagnoses was observed in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change at the present stage in the “gold standard” for diagnosing pneumonia, which includes acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, and less often leukopenia with a neutrophilic shift in the blood, radiologically detectable infiltrate in the lung tissue , which was not previously defined. Many researchers also note the formal, superficial attitude of doctors towards the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

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On the problem of diagnosis and treatment of pneumonia

Community-acquired pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

Relevance. Respiratory diseases occupy one of the leading places in the structure of morbidity and mortality in children. Pneumonia plays an important role among them. This is due both to the high incidence of respiratory tract lesions in children and to the serious prognosis of many late-diagnosed and untreated pneumonias. In the Russian Federation, the incidence of pneumonia in children is in the range of 6.3-11.9%. One of the main reasons for the increase in the number of pneumonia is the high level of diagnostic errors and late diagnosis. The proportion of pneumonia in which the clinical picture does not correspond to radiological data has increased significantly, and the number of asymptomatic forms of the disease has increased. There are also difficulties in the etiological diagnosis of pneumonia, since over time the list of pathogens expands and modifies. Until relatively recently, community-acquired pneumonia was associated mainly with Streptococcus pneumoniae. Currently, the etiology of the disease has expanded significantly, and in addition to bacteria, it can also be represented by atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae), fungi, as well as viruses (influenza, parainfluenza, metapneumoviruses, etc.), the role of the latter is especially great in children under 5 4 years old. All this leads to untimely correction of treatment, worsening of the patient’s condition, and the prescription of additional medications, which ultimately affects the prognosis of the disease. Thus, despite a fairly detailed study of the problem of childhood pneumonia, there is a need to clarify the modern clinical features of pneumonia, to study the significance of various pathogens, including pneumotropic viruses, in this disease.

Purpose of the study: identification of modern clinical, laboratory and etiological features of the course of pneumonia in children. Materials and methods. A comprehensive examination was conducted of 166 children with community-acquired pneumonia aged from 1 to 15 years who were treated in the pulmonology department of the children's hospital of the Children's City Clinical Hospital of Orenburg. Among the examined children there were 85 boys (51.2%) and 81 girls (48.8%). All patients were divided into 2 groups according to the morphological forms of pneumonia (patients with focal pneumonia and segmental pneumonia) and into 4 groups according to age - young children (1 - 2 years), preschoolers (3 - 6 years), primary schoolchildren (7 - 10 years old) and older schoolchildren (11 – 15 years old). All patients underwent the following examination: clinical blood test, general urine test, biochemical blood test to determine the level of C-reactive protein (CRP), chest x-ray, microscopic and bacteriological examination of sputum for flora and sensitivity to antibiotics. To identify respiratory viruses and S. pneumoniae, 40 patients underwent a study of tracheobronchial aspirates using real-time polymerase chain reaction (PCR) to detect ribonucleic acid (RNA) of respiratory syncytial virus, rhinovirus, metapneumovirus, parainfluenza virus 1, 2, 3, 4 types, deoxyribonucleic acid (DNA) adenovirus and pneumococcus. The data obtained during the study was processed using the STATISTICA 6.1 software product. During the analysis, the calculation of elementary statistics, construction and visual analysis of correlation fields of connection between the analyzed parameters were carried out, comparison of frequency characteristics was carried out using non-parametric methods chi-square, chi-square with Yates' correction, and Fisher's exact method. Comparison of quantitative indicators in the study groups was performed using the Student's t-test for normal sample distribution and the Wilcoxon-Mann-Whitney U test for non-normal distribution. The relationship between individual quantitative characteristics was determined by the Spearman rank correlation method. Differences in average values ​​and correlation coefficients were considered statistically significant at the significance level of p 9 /l, segmental - 10.4±8.2 x10 9 /l.

In the group of segmental pneumonia, the ESR value was higher than in focal pneumonia - 19.11±17.36 mm/h versus 12.67±13.1 mm/h, respectively (p 9/l to 7.65±2.1x 10 9 /l (p

List of sources used:

1. Community-acquired pneumonia in children: prevalence, diagnosis, treatment and prevention. – M.: Original layout, 2012. – 64 p.

2. Sinopalnikov A.I., Kozlov R.S. Community-acquired respiratory tract infections. Guide for doctors - M.: Premier MT, Our City, 2007. - 352 p.

Hospital pneumonia

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INTRODUCTION

Pneumonia is currently a very pressing problem, since despite the constantly growing number of new antibacterial drugs, the mortality rate from this disease remains high. Currently, for practical purposes, pneumonia is divided into community-acquired and nosocomial. In these two large groups, there are also aspiration and atypical pneumonias (caused by intracellular agents - mycoplasma, chlamydia, legionella), as well as pneumonia in patients with neutropenia and/or against the background of various immunodeficiencies.

The International Statistical Classification of Diseases provides for the definition of pneumonia solely on the basis of etiology. In more than 90% of cases, HP is of bacterial origin. Viruses, fungi and protozoa are characterized by a minimal “contribution” to the etiology of the disease. Over the past two decades, significant changes have occurred in the epidemiology of HP. This is characterized by the increased etiological significance of pathogens such as mycoplasma, legionella, chlamydia, mycobacteria, pneumocystis and a significant increase in the resistance of staphylococci, pneumococci, streptococci and Haemophilus influenzae to the most widely used antibiotics. Acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta-lactamases, which destroy the structure of beta-lactam antibiotics. Nosocomial strains of bacteria are usually highly resistant. These changes are partly due to the selective pressure on microorganisms from the widespread use of new broad-spectrum antibiotics. Other factors are the increase in the number of multi-resistant strains and the increase in the number of invasive diagnostic and therapeutic procedures in a modern hospital. In the early antibiotic era, when only penicillin was available to the doctor, about 65% of all nosocomial infections, including GP, were due to staphylococci. The introduction of penicillinase-resistant betalactams into clinical practice reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%) increased, which replaced gram-positive pathogens (30%) and anaerobes (3%). Since this time, multidrug-resistant gram-negative microorganisms (coliform aerobes and Pseudomonas aeruginosa) have become one of the most important nosocomial pathogens. Currently, there is a revival of gram-positive microorganisms as actual nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

On average, the incidence of hospital-acquired pneumonia (HAP) is 5-10 cases per 1000 hospitalized patients, but in patients on mechanical ventilation this figure increases 20 times or more. Mortality in HP, despite objective advances in antimicrobial chemotherapy, today is 33-71%. In general, nosocomial pneumonia (NP) accounts for about 20% of all hospital-acquired infections and ranks third after wound infections and urinary tract infections. The frequency of NP increases in patients staying in hospital for a long time; when using immunosuppressive drugs; in persons suffering from serious illnesses; in elderly patients.

ETIOLOGY AND PATHOGENESIS of hospital-acquired pneumonia

Hospital (nosocomial, nosocomial) pneumonia (interpreted as the appearance 48 hours or more after hospitalization of a new pulmonary infiltrate in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sputum, leukocytosis, etc.) and with the exclusion of infections, which were in the incubation period when the patient was admitted to the hospital) is the second most common and leading cause of death in the structure of nosocomial infections.

Studies conducted in Moscow showed that the most common (up to 60%) bacterial pathogens of community-acquired pneumonia are pneumococci, streptococci and Haemophilus influenzae. Less commonly - staphylococcus, klebsiella, enterobacter, legionella. In young people, pneumonia is more often caused by a monoculture of the pathogen (usually pneumococcus), and in older people - by an association of bacteria. It is important to note that these associations are represented by a combination of gram-positive and gram-negative microorganisms. The frequency of mycoplasma and chlamydial pneumonia varies depending on the epidemiological situation. Young people are more often susceptible to this infection.

Respiratory tract infections occur in the presence of at least one of three conditions: a violation of the body’s defenses, the entry of pathogenic microorganisms into the lower respiratory tract of a patient in quantities exceeding the body’s defenses, and the presence of a highly virulent microorganism.
Penetration of microorganisms into the lungs can occur in various ways, including through microaspiration of oropharyngeal secretions colonized by pathogenic bacteria, aspiration of esophageal/stomach contents, inhalation of an infected aerosol, penetration from a distant infected site by hematogenous route, exogenous penetration from an infected site (for example, the pleural cavity) , direct infection of the respiratory tract in intubated patients from intensive care unit staff or, which remains doubtful, through transfer from the gastrointestinal tract.
Not all of these routes are equally dangerous in terms of pathogen penetration. Of the possible routes of penetration of pathogenic microorganisms into the lower respiratory tract, the most common is microaspiration of small volumes of oropharyngeal secretions previously contaminated with pathogenic bacteria. Since microaspiration occurs quite often (for example, microaspiration during sleep is observed in at least 45% of healthy volunteers), it is the presence of pathogenic bacteria that can overcome the protective mechanisms in the lower respiratory tract that plays an important role in the development of pneumonia. In one study, oropharyngeal contamination with enteric gram-negative bacteria (EGN) was relatively rare (

Study of factors contributing to the development of community-acquired pneumonia and analysis of effective treatment

Description: In recent years, the number of patients with severe and complicated community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is the underestimation of the severity of the condition upon admission to the hospital due to the poor clinical, laboratory and radiological picture in the initial period of development of the disease. In Russia, medical personnel actively participate in conferences on the prevention of pneumonia.

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Chapter 1. What is community-acquired pneumonia?

1.6. Differential diagnosis

1.8. Antibacterial therapy

1.9. Comprehensive treatment of community-acquired pneumonia

1.10. Socio-economic aspects

1.11. Preventive measures

CHAPTER 2. Analysis of statistical data on pneumonia in the city of Salavat

Results of the work performed

Respiratory diseases are one of the leading causes of morbidity and mortality worldwide. At the present stage, the clinical course is changing and the severity of these diseases is aggravating, which leads to an increase in various complications, disability and increasing mortality. Community-acquired pneumonia still remains one of the leading pathologies in the group of respiratory diseases. The incidence of community-acquired pneumonia in most countries is 10-12%, varying depending on age, gender, and socio-economic conditions.

In recent years, the number of patients with severe and complicated community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is the underestimation of the severity of the condition upon admission to the hospital, due to the poor clinical, laboratory and radiological picture in the initial period of development of the disease. However, a number of works show an underestimation of data from clinical and laboratory studies, propose complex prognosis methods, and often ignore an integrated approach to examining patients. In this regard, the relevance of the problem of comprehensive quantitative assessment of the severity of the condition of a patient with community-acquired pneumonia and predicting the course of the disease in the early stages of hospitalization is increasing.

In Russia, medical personnel actively participate in conferences on the prevention of pneumonia. Examinations are carried out annually in medical institutions. But, unfortunately, despite such work, the number of cases of pneumonia remains one of the main problems in our country.

Relevance of the problem. This work focuses on the severity of the disease due to the large number of cases of severe consequences. The situation is being constantly monitored and morbidity statistics, in particular pneumonia, are being studied.

Considering this situation regarding pneumonia, I decided to tackle this problem.

Purpose of the study. Study of factors contributing to the development of community-acquired pneumonia and analysis of effective treatment.

Object of study. Patients with community-acquired pneumonia in a hospital setting.

Subject of study. The role of the paramedic in the timely detection of community-acquired pneumonia and adequate treatment.

1) Identify and study the causes contributing to the disease of community-acquired pneumonia.

2) Determine risk factors for the incidence of community-acquired pneumonia.

3) Assess the comparative clinical, bacteriological effectiveness and safety of various antibacterial therapy regimens in the treatment of hospitalized patients with community-acquired pneumonia.

4) Familiarization with the role of the paramedic in the prevention and treatment of community-acquired pneumonia.

Hypothesis. Community-acquired pneumonia is defined as a medical and social problem.

The practical significance of my work will be to ensure that the population is well versed in the symptoms of pneumonia, understands the risk factors for the disease, prevention, and the importance of timely and effective treatment of this disease.

Community-acquired pneumonia is one of the most common infectious diseases of the respiratory tract. Most often, this disease is the cause of death from various infections. This occurs as a result of a decrease in people’s immunity and the rapid adaptation of pathogens to antibiotics.

Community-acquired pneumonia is an infectious disease of the lower respiratory tract. Community-acquired pneumonia in children and adults develops in most cases as a complication of a viral infection. The name of pneumonia characterizes the conditions under which it occurs. A person falls ill at home, without any contact with a medical facility.

What is pneumonia like? This disease is conventionally divided into three types:

Mild pneumonia is the largest group. She is treated on an outpatient basis, at home.

The disease is of moderate severity. Such pneumonia is treated in a hospital.

Severe form of pneumonia. She is being treated only in a hospital, in the intensive care unit.

What is community-acquired pneumonia?

Community-acquired pneumonia acute infectious inflammatory disease of predominantly bacterial etiology that arose in a community setting (outside the hospital or later than 4 weeks after discharge from it, or diagnosed in the first 48 hours from hospitalization, or developed in a patient who was not in nursing homes/departments long-term medical observation over 14 days), with damage to the respiratory parts of the lungs (alveoli, small-caliber bronchi and bronchioles), frequent presence of characteristic symptoms (acute fever, dry cough followed by sputum production, chest pain, shortness of breath) and previously absent clinical symptoms -radiological signs of local damage not associated with other known causes.

Community-acquired pneumonia is one of the most common respiratory diseases. Its incidence is 8-15 per 1000 population. Its frequency increases significantly among elderly and senile people. The list of main risk factors for the development of the disease and death includes:

Smoking habit

Chronic obstructive pulmonary diseases,

Congestive heart failure,

Immunodeficiency conditions, overcrowding, etc.

More than a hundred microorganisms (bacteria, viruses, fungi, protozoa) have been described, which under certain conditions can be the causative agents of community-acquired pneumonia. However, most cases of the disease are associated with a relatively small range of pathogens.

In some categories of patients - recent use of systemic antimicrobial drugs, long-term therapy with systemic glucocorticosteroids in pharmacodynamic doses, cystic fibrosis, secondary bronchiectasis - the relevance of Pseudomonas aeruginosa in the etiology of community-acquired pneumonia increases significantly.

The significance of anaerobes colonizing the oral cavity and upper respiratory tract in the etiology of community-acquired pneumonia has not yet been fully determined, which is primarily due to the limitations of traditional cultural methods for studying respiratory samples. The likelihood of infection with anaerobes may increase in persons with proven or suspected aspiration due to episodes of impaired consciousness due to seizures, certain neurological diseases (for example, stroke), dysphagia, diseases accompanied by impaired motility of the esophagus.

The frequency of occurrence of other bacterial pathogens - Chlamydophila psittaci, Streptococcus pyogenes, Bordetella pertussis, etc. usually does not exceed 2-3%, and lung lesions caused by endemic micromycetes (Histoplasma capsulatum, Coccidioides immitis, etc.) are extremely rare.

Community-acquired pneumonia can be caused by respiratory viruses, most often influenza viruses, coronaviruses, rhinosyncytial virus, human metapneumovirus, human bocavirus. In most cases, infections caused by a group of respiratory viruses are characterized by a mild course and are self-limiting, however, in elderly and senile people, in the presence of concomitant bronchopulmonary, cardiovascular diseases or secondary immunodeficiency, they can be associated with the development of severe, life-threatening complications.

The growing relevance of viral pneumonia in recent years is due to the emergence and spread of the pandemic influenza virus A/H1N1pdm2009 in the population, which can cause primary damage to lung tissue and the development of rapidly progressing respiratory failure.

There are primary viral pneumonia (develops as a result of direct viral damage to the lungs, characterized by a rapidly progressive course with the development of severe respiratory failure) and secondary bacterial pneumonia, which can be combined with primary viral damage to the lungs or be an independent late complication of influenza. The most common causes of secondary bacterial pneumonia in patients with influenza are Staphylococcus aureus and Streptococcus pneumoniae. The frequency of detection of respiratory viruses in patients with community-acquired pneumonia is strongly seasonal and increases in the cold season.

In case of community-acquired pneumonia, co-infection with two or more pathogens can be detected; it can be caused either by the association of various bacterial pathogens or by their combination with respiratory viruses. The incidence of community-acquired pneumonia caused by association of pathogens varies from 3 to 40%. According to a number of studies, community-acquired pneumonia caused by an association of pathogens tends to be more severe and have a worse prognosis.

The most common route for microorganisms to enter lung tissue is:

1) Bronchogenic and this is facilitated by:

Inhalation of microbes from the environment,

Relocation of pathogenic flora from the upper parts of the respiratory system (nose, pharynx) to the lower ones,

Medical procedures (bronchoscopy, tracheal intubation, artificial ventilation, inhalation of drugs from contaminated inhalers), etc.

2) The hematogenous route of spread of infection (through the bloodstream) is less common with intrauterine infection, septic processes and drug addiction with intravenous drug administration.

3) The lymphogenous route of penetration is very rare.

Further, with pneumonia of any etiology, the infectious agent fixes and multiplies in the epithelium of the respiratory bronchioles; acute bronchitis or bronchiolitis of various types develops, from mild catarrhal to necrotic. The spread of microorganisms beyond the respiratory bronchioles causes inflammation of the lung tissue - pneumonia. Due to disruption of bronchial obstruction, foci of atelectasis and emphysema occur. Reflexively, with the help of coughing and sneezing, the body tries to restore the patency of the bronchi, but as a result, the infection spreads to healthy tissues, and new foci of pneumonia are formed. Oxygen deficiency, respiratory failure, and in severe cases, heart failure develop. Segments II, VI, X of the right lung and segments VI, VIII, IX, X of the left lung are most affected.

Aspiration pneumonia is common in the mentally ill; in persons with diseases of the central nervous system; in persons suffering from alcoholism.

Pneumonia in immunodeficiency states is typical for cancer patients receiving immunosuppressive therapy, as well as drug addicts and HIV-infected people.

Great importance is attached to the classification of pneumonia in diagnosing the severity of pneumonia, the localization and extent of lung damage, diagnosing complications of pneumonia, which makes it possible to more objectively assess the prognosis of the disease, select a rational program of complex treatment and identify a group of patients in need of intensive care. There is no doubt that all these headings, along with empirical or objectively confirmed information about the most likely causative agent of the disease, should be presented in the modern classification of pneumonia.

The most complete diagnosis of pneumonia should include the following categories:

A form of pneumonia (community-acquired, nosocomial, pneumonia due to immunodeficiency conditions, etc.);

The presence of additional clinical and epidemiological conditions for the occurrence of pneumonia;

Etiology of pneumonia (verified or suspected causative agent);

Localization and extent;

Clinical and morphological variant of the course of pneumonia;

Severity of pneumonia;

Degree of respiratory failure;

Presence of complications.

Table 1. Comorbidities/risk factors associated with specific pathogens associated with community-acquired pneumonia.

It is one of the most relevant in modern therapeutic practice. Over the past 5 years alone, the incidence rate in Belarus has increased by 61%. The mortality rate from pneumonia, according to various authors, ranges from 1 to 50%. In our republic, the mortality rate has increased by 52% over 5 years. Despite the impressive successes of pharmacotherapy and the development of new generations of antibacterial drugs, the share of pneumonia in the morbidity structure is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, not counting ARVI, the number of patients with pneumonia exceeds 60%.

In modern conditions of a “economical” approach to healthcare financing, the priority is the most appropriate expenditure of allocated budget funds, which predetermines the development of clear criteria and indications for hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good final result at lower costs. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for hospitalization of patients with pneumonia into everyday practice, which would facilitate the work of the local therapist, save budget funds, and timely predict possible outcomes of the disease.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Health care organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics indicate an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. In the United States, this pathology ranks sixth in the structure of mortality and is the most common cause of death from infectious diseases. More than 60,000 fatal outcomes from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and serious illness. Tuberculosis and lung cancer are often hidden under its mask. A study of autopsy reports of people who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made within the first day after admission to the hospital in less than a third of patients, and within the first week - in 40%. 27% of patients died on the first day of hospital stay. The coincidence of clinical and pathoanatomical diagnoses was observed in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change at the present stage in the “gold standard” for diagnosing pneumonia, which includes acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, and less often leukopenia with a neutrophilic shift in the blood, radiologically detectable infiltrate in the lung tissue , which was not previously defined. Many researchers also note the formal, superficial attitude of doctors towards the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

Lecture outline

• Definition, relevance of pneumonia

• Pathogenesis of pneumonia

• Classification of pneumonia

• Criteria for diagnosing pneumonia

• Principles of treatment: organization of the regimen, aerotherapy, antibacterial therapy, immunotherapy and physiotherapeutic methods of treatment, prevention

• Pneumonia is a nonspecific inflammation of the lung tissue, which is based on infectious toxicosis, respiratory failure, water-electrolyte and other metabolic disorders with pathological changes in all organs and systems of the child’s body.

Relevance:

• The incidence of pneumonia ranges from 4 to 20 cases per 1000 children aged 1 month to 15 years.

• In Ukraine, there has been an increase in the prevalence of pneumonia among children in the last three years (from 8.66 to 10.34).

• Mortality from pneumonia among children in the first year of life is from 1.5 to 6 cases per 10,000 children, which is 3-5% in the overall structure of mortality in children under 1 year of age.

• Every year, about 5 million children die from pneumonia around the world.

Etiology

• In-hospital (nosocomial) Pneumonia in most cases is caused by Ps. aeruginosa, also – Kl. pneumonia, St. aureus, Proteus spp. etc. These pathogens are resistant to antibiotics, which leads to severe disease and mortality.

• Community-acquired pneumonia(home, non-hospital). The spectrum of pathogens depends on the age of the patients.

• Newborns: depends on the spectrum of urogenital infections in women.

• Postnatal pneumonia more often caused by group B streptococci, less often by E. coli, Klebsiella pneumoniae, St. aureus, St. epidermalis.

• Antenatal– streptococci of groups G, D, Ch. frachomatis, ureaplasma urealiticum, Listeria monocytogenes, Treponeta pallidum.

• Children of the first half of the year: staphylococci, gram-negative intestinal flora, rarely - Moraxella catarrhalis, Str. рneumoniae, H. influenzae, Ch. trachomatis.

From 6 months to 5 years Str. comes out on top. Pneumoniae (70-88% of all pneumonias) and H. influenzae type b (Hib infection) - up to 10%. These children also often isolate respiratory syncytial virus, influenza viruses, parainfluenza, rhino- and adenoviruses, but most authors consider them to be factors that contribute to infection of the lower respiratory tract by bacterial flora.

• For children 6-15 years old: bacterial pneumonias account for 35-40% of all pneumonias and are caused by pneumococci Str. pyogenes; M. pneumoniae (23-44%), Ch. Pneumoniae (15-30%). The role of Hib infection is reduced.

• In case of insufficiency of humoral immunity, pneumococcal, staphylococcal, and cytomegalovirus pneumonia are observed.

• In case of primary cellular immunodeficiencies, with long-term glucocorticoid therapy - P. carinii, M. avium, fungi of the genus Candida, Aspergilus. Often viral-bacterial and bacterial-fungal associations (65-80%).

Pathogenesis

• In the pathogenesis of the development of acute pneumonia, V.G. Maidannik distinguishes six phases.

• The first is contamination by microorganisms and edematous-inflammatory destruction of the upper respiratory tract, dysfunction of the ciliated epithelium, and spread of the pathogen along the tracheobronchial tree.

• The second is the primary alteration of lung tissue, activation of lipid peroxidation processes, and development of inflammation.

• Third: damage by prooxidants not only to the structures of the pathogen, but also to the macroorganism (surfactant), destabilization of cell membranes→phase of secondary toxic autoaggression. The area of ​​damage to lung tissue increases.

• Fourth: disruption of tissue respiration, central regulation of respiration, ventilation, gas exchange and perfusion of the lungs.

• Fifth: the development of DN and disruption of the non-respiratory function of the lungs (cleansing, immune, excretory, metabolic, etc.).

• Sixth: metabolic and functional disorders of other organs and systems of the body. The most severe metabolic disorders are observed in newborns and young children.

• There are 4 ways of contamination of the lungs with pathogenic flora:

• aspiration of oropharyngeal contents (microaspiration during sleep) is the main route;

• airborne;

• hematogenous spread of the pathogen from an extrapulmonary source of infection;

• Spread of infection from adjacent tissues of neighboring organs.

Classification

• Pneumonia

• primary (uncomplicated)

• secondary (complicated)

• Shapes:

• focal

• segmental

• lobar

• interstitial

Localization

• one-sided

• bilateral

• lung segment

• lung lobe

• lung

Flow

• acute (up to 6 weeks)

• prolonged (from 6 weeks to 6 months)

• recurrent

Respiratory failure

• 0 tbsp.

• I Art.

• II Art.

• III Art.

Complicated pneumonia:

• General violations

• toxic-septic condition

• infectious-toxic shock

• cardiovascular syndrome

• DVZ syndrome

• changes in the central nervous system - neurotoxicosis, hypoxic encephalopathy

• Pulmonary purulent process

• destruction

• abscess

• pleurisy

• pneumothorax

• Inflammation of various organs

• sinusitis

• pyelonephritis

• meningitis

• osteomyelitis

Pneumonia code according to MKH-10:

• J11-J18 – pneumonia

• P23 – congenital pneumonia

Clinical criteria for pneumonia in a newborn baby

• burdened ante- and intrapartum anamnesis;

• pallor, perioral and acrocyanosis;

• groaning breath;

• tension and swelling of the wings of the nose; retraction of the pliable areas of the chest;

• respiratory arrhythmia;

• rapid increase in pulmonary heart failure and toxicosis;

• muscle hypotonia, inhibition of newborn reflexes;

• hepatolienal syndrome;

• weight loss;

• coughing; less frequent cough;

• increased body temperature; may be normal in immature newborns;

• X-ray: pulmonary tissue infiltrates, usually on both sides; increased pulmonary pattern in perifocal areas.

Clinical criteria for the diagnosis of pneumonia in young children:

• wet or unproductive cough;

• shortness of breath, breathing with the participation of auxiliary muscles;

• distant wheezing in broncho-obstructive syndrome;

• general weakness, refusal to eat, delayed weight gain;

• pale skin, perioral cyanosis, worsens with exercise;

• violation of thermoregulation (hyper- or hypothermia, toxicosis);

• hard bronchial or weakened breathing, after 3-5 days moist rales appear;

• shortening of percussion sound in the projection of infiltrate;

• hemogram: neutrophilic leukocytosis, shift of the formula to the left;

• X-ray: infiltrates of lung tissue, increased pulmonary pattern in perifocal areas.

Criteria for the degree of DN

Treatment of pneumonia

• Children with acute pneumonia can be treated at home or in a hospital. Indications for hospitalization are as follows:

• 1) vital indications - intensive care and resuscitation measures are required;

• 2) decreased reactivity of the child’s body, the threat of complications;

• 3) unfavorable living conditions of the family, there is no possibility of organizing a “hospital at home.”

• In a hospital, the child should be in a separate room (box) to prevent cross-infection. Until the age of 6, the mother must be with the child.

• The room should be wet cleaned, quartzed, and ventilated (4-6 times a day).

• The head of the bed should be raised.

Nutrition

• Depends on the age of the child. In a serious condition of a patient in the 1st year of life, the number of feedings can be increased by 1-2, while complementary feeding can be excluded for several days. The main food is breast milk or adapted milk formula. If oral rehydration is necessary, rehydron, gastrolit, ORS 200, herbal tea, in fractions are prescribed.

Treatment of respiratory failure

• Ensure clear airways.

• Microclimate of the room: fresh, fairly humid air, the temperature in the room should be 18-19ºС.

• In case of stage 2 respiratory failure, oxygen therapy is added: through a nasal tube - 20-30% oxygen utilization; through a mask - 20-50%, in an incubator - 20-50%, in an oxygen tent - 30-70%.

• For grade III DN, artificial ventilation is required.

Antibacterial therapy

• Basic principles of rational antibacterial therapy in children.

• Treatment begins after diagnosis. It is advisable to conduct flora cultures to determine sensitivity to antibiotics. Results will be available in 3-5 days. We select initial therapy empirically, taking into account the patient’s age, home or hospital pneumonia, and regional characteristics.

• First course – broad-spectrum antibiotics are prescribed (mainly β-lactams).

• Main course – (replacement of empirically selected antibiotic) depends on culture result or clinical picture.

• Dose selection – depends on the severity, age, body weight.

• Choice of route of administration: in severe cases, it is preferably administered parenterally.

• Choice of frequency of administration: it is necessary to create a constant concentration of the antibiotic in the body.

• Choosing a rational combination: synergism is required, only bactericidal or only bacteriostatic. Drugs should not enhance each other's toxic effects.

• Conditions for stopping treatment: no earlier than 3 days of normal temperature and general condition of the child.

• The accuracy of empirical therapy can be 80-90%.