Pneumonia. Pneumonia in a child - symptoms, treatment, causes

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Pneumonia is a disease associated with the development of an inflammatory process in the lung tissue, intra-alveolar exudation under the influence of infectious and, less commonly, non-infectious agents. Depending on the type of pathogen, pneumonia can be viral, viral-bacterial, bacterial or fungal.

Typical acute pneumonia is one of the common diseases. The average statistical indicator is approximately 10-13% of patients who are in therapeutic hospitals. The incidence rate of typical pneumonia is 10 men and 8 women per 1000 people. The majority of patients (about 55%) are elderly people. Also, a large number of patients are children. early age(period up to three years).

Types of pneumonia

Modern medicine is faced with various forms of pneumonia: from mild subclinical to severe and life-threatening. This variation can be explained by the variety of pathogens that can provoke pneumonia, and the individual immune response of the body to a specific infectious agent.

Taking into account criteria such as infection conditions, pneumonia is classified into:

1. Community-acquired - occur at home, more often after a cold, against the background of ARVI. This type pneumonia is more common than others.
2. Intrahospital (hospital, nosocomial) - arise and develop when the patient is in the hospital. In this case, the criterion for nosocomial pneumonia is the appearance of symptoms of the disease in a patient hospitalized for another reason within 48 hours or more from the moment of admission to the hospital. The development of the disease before the end of the second day from the moment of admission is regarded as community-acquired pneumonia.
3. Aspiration - develops from the entry into the lungs of stomach contents, saliva containing microflora oral cavity. As a rule, this occurs with vomiting. At risk for aspiration pneumonia are bedridden patients, patients on mechanical ventilation, and patients with chronic alcoholism.
4. Pneumonia in people with immunodeficiency – oncology (against the background specific treatment), HIV, drug-related immunodeficiencies, and congenital conditions.

Based on clinical and morphological features, pneumonia is divided into parenchymal and interstitial. The first type, in turn, is divided into lobar (polysegmental), focal and segmental pneumonia.

According to the severity of clinical manifestations, three degrees of severity of pneumonia are determined:

1. Mild severity is characterized by weak signs intoxication with a body temperature of up to 38 degrees, with a respiratory rate (RR) of up to 25 movements, clear consciousness and normal blood pressure, leukocytosis.
2. The average degree is classified as moderate intoxication with a body temperature above 38 degrees, respiratory rate - 25-30, heart rate up to 100 beats per minute, sweating, a slight decrease in blood pressure, an increase in the number of leukocytes in the CBC with a shift of the formula to the left.
3. A severe degree is considered to be indicators of pronounced intoxication with a body temperature above 39 degrees, a respiratory rate of more than 30, a heart rate of more than 100 beats, clouding of consciousness with delirium, a strong decrease in blood pressure, respiratory failure, severe leukocytosis, morphological changes neutrophils (granularity), a decrease in the number of leukocytes is possible.

Currently, only two degrees of severity of the disease are most often distinguished: mild and severe. To identify a severe degree, scales for assessing the severity of the disease are used: PSI, ATS, CURB-65, etc.

The principle of these scales is to identify groups at risk of poor prognosis among patients with pneumonia. The figure below shows the ATS scale for identifying severe disease.

On the territory of the Russian Federation, taking into account the shortcomings of American and European scales, as well as taking into account Russian specifics, criteria of the Russian Respiratory Society have been developed for assessing the patient’s condition (figure below).

Pneumonia is considered severe if at least one criterion is present

It is worth mentioning separately a number of factors in which pneumonia is more severe

1. Pneumonia develops against the background of concomitant diseases. At the same time, the immune system is weakened, the disease occurs more often (on average compared to other categories), and recovery occurs later. This is especially true for patients with chronic respiratory diseases, of cardio-vascular system, alcoholism and diabetes.
2. Pathogen type. When affected by gram-negative flora, the likelihood of death is much higher.
3. The larger the volume lung tissue susceptible to the inflammatory process, the more serious the patient’s condition.
4. Late treatment and diagnosis contributes to the development of severe disease.
5. Severe pneumonia often occurs in people who are homeless or living in poor conditions, who are unemployed or have low incomes.
6. Severe pneumonia is more common in people over 60 years of age and newborns.

During acute typical lobar pneumonia there are also stages:

1. The flushing stage is the first stage of development of this disease. Lasts from several hours to three days. At this time, the pulmonary capillaries expand, and the blood in the lung tissue rushes in and begins to stagnate. The patient's body temperature rises sharply, a dry cough appears, shortness of breath is observed, and the patient feels pain when inhaling and coughing.
2. The second stage is the red liver stage. Lasts from one to three days, the alveoli are filled with sweating plasma, and the lung tissue thickens. At this time, the alveoli lose their airiness, and the lungs become red. The pain gets worse, the body temperature is steadily elevated, and “rusty” sputum appears.
3. The third stage of gray hepatization lasts from four to eight days. During the flow in the alveoli, red blood cells disintegrate and the hemoglobin contained in them becomes hemosiderin. During this process, the color of the lung turns brown. And the leukocytes entering the alveoli also make it gray. The cough becomes productive, the patient coughs up purulent or mucous sputum. The pain dulls, shortness of breath decreases. Body temperature decreases.
4. The fourth stage of resolution is accompanied by the process of recovery and resorption of sputum. Its duration is from 10 to 12 days. At this time, gradual dissolution and liquefaction of sputum occurs and the airiness of the lungs is restored. The resorption process is long, but painless. Symptoms subside, sputum is coughed up easily, pain is practically absent or mild, breathing process and body temperature are normalized.

The results of radiography allow us to determine the stage of development of the disease. At the height of the disease, a darkening of varying extent and size (focal, segmental, lobar) is observed on the radiograph. At the resolution stage, the darkening decreases in size, infiltration disappears, and an increase in the pulmonary pattern may persist as residual effects for up to a month. Sometimes after recovery, areas of fibrosis and sclerosis may remain. In this regard, it is recommended to keep the last photographs in hand after the disease has resolved.

In atypical pneumonia associated with a lack of immunity, the above stages are not inherent. It is characterized by smoother symptoms and changing periods of the disease. In addition, with atypical pneumonia, only interstitial changes without clear infiltration are often observed.

Correct and timely determination by the attending physician of the degree and stages of pneumonia allows one to avoid many complications in the further course of the disease. Therefore, it is very important to identify the source of infection and begin treatment on time.

Additional studies and patient management tactics

Patients with suspected pneumonia will be prescribed:

1. UAC, OAM;
2. X-ray of organs chest in two projections (if necessary, the number of projections increases, this is decided by the radiologist);
3. Blood chemistry;
4. Sputum tests: general, for BK, for microflora and its resistance-sensitivity spectrum;
5. Computed tomography and bronchoscopy may be additionally performed for special indications. This is done, as a rule, to exclude/clarify localization cancerous tumors in the lungs, abscesses, encysted pleurisy, decay cavities, bronchiectasis and so on.

Based on all the collected data, after determining the degrees and stages of development of pneumonia, the doctor can determine the optimal tactics for managing the patient and where it is best to treat him. Also, based on data reflecting the severity of the disease, make a forecast. This is all important for further patient management.

Depending on the symptomatology of which stage of pneumonia caused you to see a doctor, the medical background of the treatment is determined and the intensity of the course is prescribed. The disease requires complex therapy, the specifics of the intervention vary according to the clinical picture at each stage.

Depending on the intensity of the lesion, the following categories of inflammation are distinguished:

1. Mild pneumonia. Symptoms are mild, intoxication is practically not observed. Body temperature does not exceed 38°C, blood pressure remains at normal level, perhaps a slightly noticeable increase in breathing.
2. Moderate inflammation. It is characterized by an increase in heart rate, intermittent breathing, intoxication is felt, the temperature reaches 38°C, and blood pressure decreases.
3. Severe pneumonia. She is accompanied rapid breathing, body temperature above 39°C, severe intoxication, a sharp drop in pressure, cyanosis and tissue hypoxia.

The pathology can be aggravated by the following conditions:

• concomitant chronic diseases of the respiratory system, diabetes, cardiovascular system disorders, alcoholism, weakened immunity;
• delayed diagnosis can lead to rapid damage to a large part of the lungs and resistance to drug effects;
• some types of viral pathogens multiply rapidly and exhibit resistance to antimicrobial therapy;
• newborns, children, and the elderly are more susceptible to pneumonia.

Severe inflammation is often diagnosed in people from vulnerable sections of the population, patients living in unfavorable conditions.

Initial stage of pneumonia

The first stage of pneumonia is also called the flushing stage; in adults, this stage can last up to three days. A common reason for delayed diagnosis of pathology is the similarity of this early process with respiratory diseases. The patient may notice a dry cough and shortness of breath, signs of fever, painful sensations in the sternum during inhalation and exhalation.

With the rapid development of a severe form of the disease, confusion may occur and hallucinations may occur. Movements of the chest are often asymmetrical, as swelling occurs in the affected lobe. Cyanosis of the lips and hyperemia of the cheeks are possible.

Clinical picture at the second stage

The red liver stage is accompanied by a rapid deterioration in health; usually the diagnosis is formulated at this stage. This stage of inflammation development can last up to three days, during which time the lung tissue thickens, turns red, and the alveoli are filled with plasma. Breathing delivers severe pain, the body temperature remains high. Severe fever appears, intoxication occurs, and reddish sputum is released.

The stage is characterized by a stable and serious condition of the patient. The patient suffers from hallucinations, panic attacks, and is afraid of death. The cause of these phenomena is oxygen hypoxia. During listening, wheezing clearly stands out.

Clinical manifestations of the third stage

Lobar pneumonia at the gray hepatic stage does not require constant medical supervision, unlike the previous stage. With lobar pneumonia, the patient is still in in serious condition, but intoxication gradually recedes, coughing helps clear the bronchi from mucus.

Within 4-8 days, the lungs change color to gray and brown, and active breakdown of red blood cells occurs in the alveoli. Acute painful sensations when breathing turn into dull pain, body temperature returns to normal. Pus may come out along with sputum.

Last stage

This stage is also called the resolution stage, since during it the patient gradually recovers. Treatment continues, the patient complies with the prescribed regimen. In 10-12 days, the structure of the lungs returns to a healthy phase, the sputum thins out and resolves. Body temperature is kept at a normal level. The cough still persists, but the sputum is released painlessly, it is clean, breathing and heart rate are normalized.

The stages of pneumonia in children occur rapidly; they are characterized by more pronounced symptoms at stages 2 and 3.

Types of pneumonia by type of course

Treatment is prescribed depending on the identified form of pathology:

1. Acute pneumonia is characterized by pronounced symptoms. This category of disease is accompanied by extremely severe inflammatory lesion. Typically, acute pathology occurs against the background of other complex diseases; in rare cases, it is the result of an isolated viral infection.
2. Protracted pathology has a more moderate course and smoothed signs, but it requires long-term treatment. Delayed diagnosis due to smooth manifestation of symptoms often leads to worsening of the disease. Patients complain of mild symptoms of fever, slight fever. Complications for this form of pathology may include cardiovascular problems and disruptions in hematopoiesis.
3. Chronic inflammation is a consequence of pulmonary pathology that is not cured in the initial stages. Such dynamics are initially provoked by mild pneumonia, because its sluggish symptoms prevent a correct diagnosis. Go to chronic form is fraught with deterioration of the condition.

Atypical pneumonia, which has smoothed out signs and a mild change of stages, is placed in a separate category. At the same time, patients do not produce mucus or sputum, and there is no cough. The disease manifests itself in the form of severe intoxication, severe malaise against the background of a sharp increase in temperature.

If you suspect any stage or form of pneumonia, you should immediately consult a doctor: if qualified medical care is provided at the first sign, the chances of recovery without complications associated with the disease increase significantly.

Pneumonia: a brief overview of the disease…………………………………………………….2

Symptoms………………………………………………………………………………………2

When is it necessary to urgently call a doctor?……………………………………………..3

Basic methods for diagnosing pneumonia………………………………………………………4

Modern methods of treatment………………………………………………………..4

List of references……………………………………………………….11

Pneumonia: A Brief Overview of the Disease

In Russia, 4 out of every thousand people suffer from community-acquired pneumonia (CAP) annually. Moreover, the vast majority of patients are successfully treated on an outpatient basis. But we must not forget that this disease is fraught with the development of serious complications that can lead to death. CAP is especially dangerous for elderly and senile people: the incidence of pneumonia in them is 3-6 times higher than in young people, and the mortality rate is 10 times higher than in other age groups.

Pneumonia is an infectious and inflammatory disease characterized by damage predominantly to the parenchymal (respiratory) part of the lungs. Pneumonia (P) is one of the most common infectious diseases lower respiratory tract. P is a heterogeneous group of diseases of the respiratory system. It is customary to distinguish between community-acquired, hospital-acquired P and P in patients with immunodeficiency. Nosocomial pneumonia is caused by hospital strains of microbes and is diagnosed in patients after 48 or more hours of hospital stay, regardless of the reason for hospitalization and provided that the patients did not have initial signs of an infectious disease of the lower respiratory tract upon admission to the hospital.

CAP develops in a person outside the hospital, and about 20% of patients with this form of the disease require hospitalization.

The incidence of P among adults is 5-8 cases per year per 1000 population and about 10 cases per 1000 children. In our country, more than 400,000 cases of P are registered annually, but there is reason to consider this figure to be significantly underestimated.

Symptoms

The “gold standard” in diagnosing P is based on 5 signs: acute onset with severe general intoxication syndrome, changes in percussion pulmonary sound, auscultation pattern, leukocytosis and new infiltrates in the lungs that were not previously identified. If the patient is concerned coughing with sputum (sometimes the cough is dry, in some cases there may be no cough at the beginning of the disease), prolonged (more than 72 hours) fever, heavy sweating at night, then the cause of such symptoms may be pneumonia. Sometimes patients say that they recently had the flu or were very cold.

In elderly patients, pneumonia often occurs with scanty symptoms, and this makes diagnosis difficult. 75-80% of elderly patients have fever, and in 20-25% pneumonia occurs with normal or even low (up to 35 ° C) temperature, which is an unfavorable prognostic sign.

Sometimes the only manifestation of pneumonia in the elderly and old age is shortness of breath. In debilitated patients (eg. suffered stroke) there may be no cough. The disease causes drowsiness, lethargy, impotence, and lack of appetite. Being a serious illness, pneumonia in older people is always accompanied by decompensation of the underlying disease. If the patient suffered from heart failure, its course worsens (shortness of breath, swelling increases, the medications that the patient took for its treatment cease to help); if you have diabetes, a ketoacidotic coma may develop; if liver cirrhosis, signs of liver failure may appear; if chronic pyelonephritis, there may be renal failure.

When is it necessary to urgently call a doctor?

For the majority of patients with mild P and other lower respiratory tract infections (about 80% of patients), treatment on an outpatient basis is sufficient. These patients do not require complex diagnostic studies, including radiography. However, for patients in whom initial treatment at home was ineffective, a chest x-ray is required to decide on the conditions for providing medical care.

There are a number of simple clinical criteria, the presence of which requires mandatory treatment in a hospital, since the mortality rate for severe P exceeds 10-15%.

Criteria for severe P:

Respiratory rate > 30 per 1 min;

impaired consciousness, disorientation;

inability to organize patient care at home and treatment of concomitant diseases of the cardiovascular system, liver and kidneys.

It is necessary for all patients with suspected lower respiratory tract infections to call a local (family) doctor or go to the clinic at their place of residence. The doctor will not only listen to the lungs, but will also prescribe additional tests.

Basic methods for diagnosing pneumonia

The main methods for diagnosing pneumonia are a chest x-ray and a complete blood count. Radiography allows you to confirm the diagnosis of pneumonia, diagnosing it is complicated (abscess, etc.). However, sometimes it is not possible to detect signs characteristic of this disease on an x-ray. Such X-ray negative pneumonia usually occurs if it is caused by viruses or mycoplasmas.

A general blood test most often reveals increased ESR and leukocytosis with a neutrophil shift to the left (increased number of young neutrophils with an unsegmented nucleus), which indicates activation immune system. But in every third patient (most often in weakened patients or with viral pneumonia) leukocytosis is absent.

Sputum examination in patients with pneumonia is not always carried out, since at the onset of the disease there is often no productive cough. Even if it is possible to collect sputum before starting antibiotics, in less than 50% of patients the causative agent of the disease can be identified. In this regard, antimicrobial therapy is most often selected empirically.

Modern treatments

If a patient is diagnosed with pneumonia (according to a physical and x-ray examination, the doctor must prescribe antibacterial drugs. If the x-ray does not reveal signs of infiltration, but there are signs of an acute bacterial infection (fever, purulent sputum), then antibacterial treatment is prescribed to patients who are in risk group (persons with chronic obstructive pulmonary diseases, bronchial asthma, smokers, people suffering from immunodeficiency, elderly and senile people).

The choice of antibacterial drugs is often made based on existing risk factors and assumptions about which pathogens are most likely to cause the disease. Preference is given to oral antibiotics. The effectiveness of antibiotic therapy is assessed 48-72 hours from the start of treatment. In the absence of positive dynamics (decrease in body temperature, improvement in the general condition of the patient, etc.), a replacement or increase in the dose of the drug or the addition of an antimicrobial agent of another chemical group is required. The duration of antibiotic therapy for uncomplicated pneumonia is 5-10 days, Tue. h. 3-4 days after standing normalization of body temperature. If there are clinical and/or epidemiological data on mycoplasma, chlamydial or legionella pneumonia, antibacterial therapy should be longer (2-3 weeks) due to the risk of recurrent infection. The doctor prescribes a course of antibiotics for complicated CAP to each patient individually.

Treatment P must meet its main goal, that is, be of high quality and effective. This purpose is served by:

timely initiation of treatment (optimally, immediately after the onset of full-blown symptoms of the disease);

selection of the most effective and safe medicines;

constant monitoring of the effectiveness of treatment and, if ineffective, replacement of antibacterial (AB) drugs no later than 48 hours from the start of their use (rule: mandatory clinical examination 48 hours after the start of treatment);

compliance with the optimal duration of treatment - usually at least 7 days (when using azithromycin - 3-5 days);

rehabilitation treatment (physical therapy, physiotherapy, therapeutic nutrition, correction of anemia, etc.) and monitoring of patients throughout the entire recovery period, i.e. from 3 to 6 months after the end of the disease.

Etiology of P. Each of the above types of P corresponds to the most typical pathogens (Table 1), which should be taken into account when choosing AB therapy. Thus, with community-acquired P, the most common S. pneumoniae and atypical microorganisms (chlamydia, mycoplasma). P in smokers and patients with chronic obstructive bronchitis is often caused by N.influenzae. Gram-negative enterobacteria and S. aureus often occur in elderly patients, as well as in patients with diabetes. The causative agents of P in persons suffering from alcoholism may be E. coli, K. pneumoniae, and in patients with P against the background of bronchiectasis, P. aeruginosa. In addition, there are clear clinical criteria corresponding to an increased risk of infection with resistant microorganisms (Table 2).

Selection of AB drugs for the treatment of P; types of AB therapy. The choice of AB drugs for the treatment of P depends on the type of pathogen and its sensitivity to AB drugs. AB therapy P is divided into:

Table 2. Risk factors for infections caused by resistant pathogens

Empirical therapy- use of antibacterial agents until the pathogen is identified. Empirically selected treatment must also be limited to those cases where the pathogen cannot be identified. When choosing a drug for empirical therapy, you should rely on data on the most common pathogens (see Table 1), take into account clinical features diseases (see below) and risk factors for microbial resistance (see Table 2).

Therapy after pathogen isolation. In this case, the choice of drug depends on the type of microorganism and/or the results of antibiotic sensitivity testing in vitro.

Prescribing AB drugs to patients as early as possible is the most important factor reducing mortality in P.

Selection of drugs for empirical treatment of community-acquired P at home. For therapy at home conditions (non-severe course of community-acquired P), preference is given to antibiotics for oral administration. The first-line drug for empirical therapy at home is amoxicillin. P series drugs:

erythromycin or azithromycin (in particular, used if you are allergic to penicillins);

sparfloxacin, levofloxacin or moxifloxacin (used in patients at high risk of having antibiotic-resistant microorganisms).

In patients with concomitant COPD, amoxicillin/clavulanate should be used as first-line drugs (the first-line drugs in this case are levofloxacin or moxifloxacin).

Efficacy and safety assessment. If after 48 hours there is no normalization of body temperature, the initially used drug should be replaced with a second-line drug or the issue of hospitalization of the patient in a hospital should be decided. Duration of treatment (if clinically effective) 7 days. Assessing the safety of treatment consists of taking into account the risk factors of using individual AB drugs and monitoring possible adverse reactions to them.

Selection of drugs for empirical treatment of community-acquired P in hospital settings. When empirically treating P in a hospital setting (usually in patients with severe course community-acquired P) all drugs are prescribed intravenously. Drugs of choice in the treatment of hospitalized patients without concomitant diseases and factors risk are:

First line drugs - a combination of ceftriaxone with erythromycin;

P series drugs - amoxicillin/clavulanate, clarithromycin.

In the elderly and those suffering from chronic alcoholism, treatment should begin with a combination of ceftriaxone: doxycycline or levofloxacin.

When treating patients with concomitant bronchiectasis and COPD, preference is given to:

for first-line drugs - a combination of cefepime (or ceftriaxone) with ciprofloxacin;

second line drugs - ceftriaxone + levofloxacin + amikacin (gentamicin).

If aspiration P is suspected, use:

First line drugs – ceftriaxone in combination with clindamycin;

II line drugs – levofloxacin + metronidazole or levofloxacin + clindamycin.

In patients with severe P requiring treatment in the ICU, therapy should be started with the combination: ceftriaxone + levofloxacin + amikacin (gentamicin). If an infection caused by Pseudomonas aeruginosa is suspected, use ciprofloxacin + amikacin (gentamicin).

Additional therapy. In addition to AB drugs, the following are used in the treatment of severe P:

infusion therapy (for severe fever, decreased blood pressure or diuresis, or other symptoms of hypohydration);

NSAIDs for pleural pain;

oxygen (with signs of hypoxia).

In addition to antibacterial therapy Prescribe drugs that dilute sputum and improve its elimination; sometimes adaptogens are recommended - drugs that increase the body’s nonspecific resistance (Eleutherococcus extract, tinctures: ginseng, aralia, Rhodiola rosea).

Breathing exercises:

1. Inflate a balloon.

Starting position (i.p.): lying on your back, one hand on your stomach, the other on your chest. Inhale slowly and stick out your stomach. Exhale - pull in your stomach (an exercise for training diaphragmatic breathing).

I. p.: lying on your back, arms along the body. Bend your elbows - inhale, straighten - exhale.

I. p.: lying on your side, one hand under your head, the other lying on your hip. Raise your free hand up and pull it towards your head - inhale, lower your hand - exhale. Do the same while lying on the other side.

I. p.: lying on your healthy side with slightly bent legs (inhale). Pull the leg lying on top to your stomach, while moving your free arm back (exhale). Return to i. p. (inhale).

I. p.: lying on your back, legs bent. Raise your pelvis - exhale. Return to i. p. - inhale.

I. p.: lying on your back. Arms to the sides - inhale, pull your bent legs to your chest - exhale.

I. p.: sitting on a chair, arms down. Hands to the sides - inhale, clasp your chest with crossed arms - exhale.

I. p.: sitting on a chair, hands on knees. Move your right hand to the side - inhale, put it on the opposite shoulder, bend to the left - exhale. Repeat with the other hand.

I. p.: sitting on a chair, hands on your waist. Bend to the left, lowering your left hand down, pull your right hand along your body - inhale. Return to i. p. - exhale. Do the same in the other direction.

I. p.: sitting on a chair, hands on knees. Raise your hands up - inhale, lower your hands to your knees, slightly leaning forward - exhale.

I. p.: sitting on a chair, hands behind your head. Keep your elbows apart - inhale, bend forward, bring your elbows together - exhale.

I. p.: sitting on a chair, holding its back with your hands. Bend over, bring your shoulder blades together - inhale, relax your back muscles - exhale.

I. p.: standing, arms down. Spread your arms to the sides - inhale, lean forward, hug your chest, squeezing it slightly - exhale.

I. p.: standing, feet shoulder-width apart, straightened, extended forward (inhale). Turn your torso to the side - exhale, return to i. p. - inhale.

I. p.: standing, hands on the belt - inhale. Bend forward - exhale, return to i. p. - inhale.

Each exercise should be repeated 6-8 times at a slow pace. If the doctor does not allow you to stand up, you should only do exercises that are performed lying down .

The effectiveness of treatment is assessed:

clinically (monitoring the dynamics of P symptoms and body temperature);

radiographically - every 7 days until the condition normalizes (with the exception of patients with suspected abscess formation, pleurisy, etc. - radiography in these patients is carried out more often);

microbiologically (during hospitalization and again if treatment is ineffective).

Duration of treatment:

if ineffective (persistence of symptoms and fever, deterioration of the X-ray picture), the AB drug is changed after 24 hours;

If AB therapy is effective, it is also carried out 2-3 days after normalization of body temperature, but not all less 7 days (exceptions: abscessing P, sepsis, P caused L. pneumoniae u S. aureus, - the duration of treatment in these cases is at least 21 days).

Bibliography

Federal Guide to the Use of Medicines (formulary system) Issue IV. – M.: “Echo”, 2003. – 928 p.

New Pharmacy, No. 17, 2009. Article: Community-acquired pneumonia: modern knowledge, pp. 17-20.

Pneumonia

Version: MedElement Disease Directory

Pneumonia without specified pathogen (J18)

Pulmonology

general information

Short description

Pneumonia(pneumonia) - the name of a group of acute local infectious diseases of the lungs, different in etiology, pathogenesis and morphological characteristics, with predominant damage to the respiratory sections (alveoli The alveolus is a bubble-like formation in the lungs, entwined with a network of capillaries. Gas exchange occurs through the walls of the alveoli (there are over 700 million of them in the human lungs)
, bronchioles Bronchioles are the terminal branches of the bronchial tree that do not contain cartilage and pass into the alveolar ducts of the lungs
) and intraalveolar exudation.

Note. Excluded from this section and all subsections (J18 -):

Other interstitial lung diseases with mention of fibrosis (J84.1);
- Interstitial pulmonary disease, unspecified (J84.9);
- Lung abscess with pneumonia (J85.1);
- Lung diseases caused by external agents (J60-J70) including:
- Pneumonitis caused by solids and liquids (J69 -);
- Acute interstitial pulmonary disorders caused by drugs (J70.2);
- Chronic interstitial pulmonary disorders caused by drugs (J70.3);
- Pulmonary interstitial disorders caused by drugs, unspecified (J70.4);

Pulmonary complications of anesthesia during pregnancy (O29.0);
- Aspiration pneumonitis, due to anesthesia during labor and delivery (O74.0);
- Pulmonary complications due to the use of anesthesia in the postpartum period (O89.0);
- Congenital pneumonia, unspecified (P23.9);
- Neonatal aspiration syndrome, unspecified (P24.9).

Classification

Pneumatics are divided into the following types:
- lobar (pleuropneumonia, with damage to the lobe of the lung);
- focal (bronchopneumonia, with damage to the alveoli adjacent to the bronchi);
- interstitial;
- sharp;
- chronic.

Note. It should be borne in mind that lobar pneumonia is only one of the forms of pneumococcal pneumonia and does not occur in pneumonia of a different nature, and interstitial inflammation of the lung tissue modern classification classified as alveolites.

The division of pneumonia into acute and chronic is not used in all sources, since it is believed that in the case of so-called chronic pneumonia, we are usually talking about repeated acute infectious processes in the lungs of the same location.

Depending on the pathogen:
- pneumococcal;
- streptococcal;
- staphylococcal;
- chlamydia;
- mycoplasma;
- Friedlander's.

In clinical practice, it is not always possible to identify the pathogen, so it is customary to distinguish:

1. Community-acquired pneumonia(other names - household, home outpatient) - acquired outside a hospital setting.

2. Phospital-acquired pneumonia(nosocomial, nosocomial) - develop after 2 or more days of the patient’s stay in the hospital in the absence of clinical and radiological signs of lung damage upon admission.

3. Pneumonia in persons with immunodeficiency states.

4. Atypical pneumonia.

According to the development mechanism:
- primary;
- secondary - developed in connection with another pathological process(aspiration, congestive, post-traumatic, immunodeficiency, infarction, atelectatic).

Etiology and pathogenesis

The occurrence of pneumonia in the vast majority of cases is associated with aspiration Aspiration (lat. apiratio) - the “sucking” effect that occurs due to the creation low blood pressure
microbes (usually saprophytes) from the oropharynx; less often, infection occurs through the hemato- and lymphogenous route or from neighboring foci of infection.

As a pathogen inflammation of the lungs are pneumo-, staphylo- and strep-to-coccus, Pfeiffer's pa-loch-ka, sometimes coli-coli, kleb-si-el-la pneu-mo-nii , pro-tey, hemophilic and blue-noy pa-loch-ki, legi-o-nell-la, pa-loch-ka plague, voz-bu-di-tel Ku-li-ho- rad-ki - rick-ket-sia Ber-not-ta, some vi-ru-sy, vi-rus-no-bak-te-ri-al-nye as-sociations, tank -te-ro-i-dy, mi-coplasma, fungi, pneumocys-sta, bran-hamel-la, aci-no-bacteria, aspergillus and aero-mo-us.

Hi-mi-che-skie and fi-zi-che-skie agents: impact on the lungs of chemical substances, thermal factors (burn or cooling), radio-active lu-che-niya. Chemical and physical agents, as etiological factors, usually coexist with infectious ones.

Pneumonia can occur as a result of allergic reactions in the lungs or be a manifestation of a s-with-the-s-illness ( inter-ter-stiti-al pneu-mo-nii for the protection of so-e-di-tel-noy tissue).

They enter the lung tissue through the bronchogene, hematogene and lymphogeneic routes from the upper respiratory tract. paths, as a rule, in the presence of acute or chronic foci of infection, and from infectious foci in the bronchi (chronic bronchitis , bron-ho-ak-ta-zy). Viral infection contributes to the activation of bacterial infection and the emergence of bacterial focal or pre-left pneumonic mo-niy.

Chronic pneu-mo-nia may be a consequence of unresolved acute pneumonia when resorption is delayed and stopped Resorption - resorption of necrotic masses, exudate by absorption of substances into the blood vessels or lymphatic vessels
exudate Exudate is a protein-rich liquid that comes out of small veins and capillaries into surrounding tissues and body cavities during inflammation.
in the alve-o-la and the formation of pneumosclerosis, inflammatory cellular changes in the inter-stitial tissue not infrequently immunological character (lymphocytic and plasma-cell infiltration).

The transformation of acute pneumonia into a chronic form or their prolonged development is facilitated by the immune system -Ru-she-nii, equipped with the re-spir-ra-tor-virus infection, chronic Czech infection of the upper-ni-h-dy-ha-tel-nyh ways (chro-ni-che-ton-zil-li-you, si-nu-si-you and others) and bron -khov, me-ta-bo-li-che-ski-mi na-ru-she-ni-yami with sa-har-nom dia-be-te, chron-ni-che-sk al-ko-lism and other things

Community-acquired pneumonia develop, as a rule, against the background of a violation defense mechanisms bronchopulmonary system (often after influenza). Their typical pathogens are pneumococci, streptococci, hemophilus influenzae and others.

In occurrence hospital-acquired pneumonia suppression of the cough reflex and damage to the tracheo-bronchial tree during surgery are important artificial ventilation lungs, tracheostomy, bronchoscopy; humoral disorder Humoral - relating to the liquid internal environments of the body.
and tissue immunity due to severe illness internal organs, as well as the very fact that patients are in the hospital. In this case, the causative agent is usually gram-negative flora ( coli, Proteus, Klebsiella, Pseudomonas aeruginosa), staphylococci and others.

Hospital-acquired pneumonia is often more severe than community-acquired pneumonia and is more likely to develop complications and has a higher mortality rate. In people with immunodeficiency conditions (with cancer, due to chemotherapy, with HIV infection), the causative agents of pneumonia can be gram-negative microorganisms such as staphylococcus, fungi, pneumocystis, cytomegaloviruses and others.

Atypical pneumonia occur more often in young people, as well as in travelers, often have an epidemic nature, possible pathogens are chlamydia, legionella, mycoplasma.

Epidemiology

Pneumonia is one of the most common acute infectious diseases. The incidence of community-acquired pneumonia in adults ranges from 1 to 11.6‰ - young and middle age, 25-44‰ - older age group.

Risk factors and groups

Risk factors for prolonged pneumonia:
- age over 55 years;
- alcoholism;
- smoking;
- presence of concomitant disabling diseases of internal organs (congestive heart failure, COPD Chronic obstructive pulmonary disease (COPD) is an independent disease characterized by partially irreversible restriction of air flow in the respiratory tract
, diabetes mellitus and others);

Virulent pathogens (L.pneumophila, S.aureus, gram-negative enterobacteria);
- multilobar infiltration;
- severe course of community-acquired pneumonia;
- clinical ineffectiveness of the treatment (leukocytosis and fever persist);
- secondary bacteremia Bacteremia - the presence of bacteria in the circulating blood; often occurs when infectious diseases as a result of the penetration of pathogens into the blood through the natural barriers of the macroorganism
.

Clinical picture

Clinical diagnostic criteria

Fever for more than 4 days, tachypnea, shortness of breath, physical signs of pneumonia.

Symptoms, course

The symptoms and course of pneumonia depend on the etiology, nature and phase of the course, the morphological substrate of the disease and its prevalence in the lungs, as well as the presence of complications (pleurisy Pleurisy - inflammation of the pleura (the serous membrane that covers the lungs and lines the walls chest cavity)
, pulmonary suppuration and others).

Lobar pneumonia
As a rule, it has an acute onset, which is often preceded by cooling.
The patient experiences a chill; body temperature rises to 39-40 o C, less often to 38 o C or 41 o C; pain when breathing on the side of the affected lung gets worse when coughing. The cough is initially dry, then with a purulent or “rusty” sticky moist mixture mixed with blood. An analogous or less violent onset of illness is possible as a result of an acute respiratory disease or against the backdrop of a chro-no-che-bron-hi-ta.

The patient's condition is usually severe. Skin-blood-faces are hyper-remi-ro-va-ny and qi-a-no-tich-ny. From the very beginning of the illness, rapid, shallow breathing is observed, with the wings of the nose spreading. Herpes infection is often noted.
As a result of the influence of anti-bak-te-ri-al-nyh drugs, a gradual (li-ti-che-che-s) decrease in temperature is observed .

The chest is in the act of breathing on the side of the affected lung. Depending on the morphological stage of the disease, percussion of the affected lung reveals dull tympanitis (stage of va), shortening (dullness) of the pulmonary sound (stage of red and gray guarding) and pulmonary sound ( solution stage).

At auscultation Auscultation is a method of physical diagnosis in medicine, which consists of listening to sounds produced during the functioning of organs.
depending on the stage of morpho-logical changes, an enhanced ve-zi-cul-lar breathing and crepitatio indux Crepitatio indux or Laeneck noise - crunching or crackling wheezing in the initial stage of lobar pneumonia.
, bron-chi-al-noe breathing and ve-zi-ku-lyar-noe or weakened ve-zi-ku-lyar-noe breathing, against the background of co- then I will listen to the crepitatio redus.
In the guarding phase there is increased voice tremors and bronchial phonation. Due to the unequal dimensions of development, morpho-logical changes in the lungs of percussion and auscultation car- you can be colorful.
Due to damage to the pleura (pa-rap-nev-mo-ni-che-skmy se-ros-no-fib-ri-nos-pleu-ritis), a noise can be heard friction of the pleura.
At the height of the disease, the pulse is rapid, soft, and corresponds to a decreased blood pressure. Often with suppression of the first tone and emphasis of the second tone on the pulmonary artery. The ESR is higher.
With an X-ray study, the homogeneity of the entire affected lobe is determined or its parts, especially on side X-rays. X-rays may not be very accurate in the first hours of illness. Persons suffering from alcoholism more often have an atypical course of the disease.

Pneumococcal lobar pneumonia
It is characterized by an acute onset with a sharp rise in temperature to 39-40˚ C, accompanied by chills and sweating. Also appear headache, significant weakness, lethargy. With severe hyperthermia and intoxication, cerebral symptoms such as severe headache, vomiting, stunnedness of the patient or confusion, and even meningeal symptoms may be observed.

Pain occurs early in the chest on the side of inflammation. Often with pneumonia, the pleural reaction is very pronounced, so chest pain is the main complaint and requires emergency care. A distinctive feature of pleural pain in pneumonia is its connection with breathing and coughing: there is a sharp increase in pain when inhaling and coughing. In the first days, a cough may appear with the release of sputum rusty from the admixture of red blood cells, and sometimes mild hemoptysis.

Upon examination The forced position of the patient often attracts attention: often he lies precisely on the side of inflammation. The face is usually hyperemic, sometimes the feverish blush is more pronounced on the cheek corresponding to the side of the lesion. Characteristic shortness of breath (up to 30-40 breaths per minute) is combined with cyanosis of the lips and swelling of the wings of the nose.
In the early stages of the disease, blistering rashes on the lips (herpes labialis) often occur.
When examining the chest, a lag on the affected side during breathing is usually revealed - the patient seems to feel sorry for the side of inflammation due to severe pleural pain.
Above the inflammation zone with percussion lungs, the acceleration of percussion sound is determined, breathing acquires a bronchial hue, and fine-bubbly moist crepitating rales appear early. Characterized by tachycardia - up to 10 beats per minute - and a slight decrease blood pressure. Muffling of the first tone and emphasis of the second tone on the pulmonary artery are not uncommon. A pronounced pleural reaction is sometimes combined with reflex pain in the corresponding half of the abdomen, pain on palpation in its upper parts.
Ictericity Icterus, otherwise known as icterus
mucous membranes and skin may appear due to the destruction of red blood cells in the affected lobe of the lung and, possibly, the formation of focal necrosis in the liver.
Neutrophilic leukocytosis is characteristic; its absence (especially leukopenia Leukopenia - low level of leukocytes in peripheral blood
) may be a prognostically unfavorable sign. ESR increases. An X-ray examination reveals a homogeneous darkening of the entire affected lobe and part of it, especially noticeable on lateral radiographs. In the first hours of illness, fluoroscopy may not be informative.

At focal pneumococcal pneumonia symptoms are usually less severe. There is a rise in temperature to 38-38.5˚C, a cough is dry or with the separation of mucopurulent sputum, pain is likely to appear when coughing and deep breathing, signs of inflammation of the lung tissue are objectively detected, expressed to varying degrees depending on the extent and location (superficial or deep) of the inflammation; most often the focus of crepitant wheezing is detected.

Staphylococcal pneumonia
A pneumo-cock-co-howl may occur in a similar way. However, more often it has a more severe course, accompanied by the de-structuring of the lungs with the formation of thin-to-skin shadowy air-po-lo-s-s, abscesses of the lungs. With the manifestations of pronounced in-tox-si-cation pro-te-ka-et stafi-lo-kok-ko-vaya (usually many-o-chago-vaya) pneu-mo- a disease that aggravates a viral infection of the bronchopulmonary system (viral pneumonia). During influenza epidemics, the virus often increases significantly.
For this type of pneumonia, pronounced in-tok-si-katsi-on-ny syn-drome which manifests itself as hyperthermia, chills, hyperemia Hyperemia is increased blood supply to any part of the peripheral vascular system.
skin bleeds and mucus membranes, headache, dizzy, ta-hi-kar-di-ey , pronounced shortness of breath, nausea, vomiting, bleeding.
In case of severe infection, toxic shock, the development of so-su-di-flock inaccuracy (BP 90-80 ; 60-50 mm Hg, pale skin, cold extremities, appearance of sticky sweat).
As the in-tok-si-kaci-on-syn-dro-ma progresses, cerebral disorders appear, on-ras -the heart's in-accuracy, the disruption of the heart's rhythm, the development of an abnormal lung, hepatitis -re-nal-syn-dro-ma, DIC-syndrome Consumptive coagulopathy (DIC syndrome) - impaired blood clotting due to massive release of thromboplastic substances from tissues
, tok-si-che-sky en-te-ro-ko-li-ta. Such pneu-mos can lead to a quick lethal outcome.

Streptococcal pneumonia develops acutely, in some cases due to a previous sore throat or sepsis. The disease is accompanied by fever, cough, chest pain, and shortness of breath. Significant pleural effusion is often found; with thoracentesis, serous, serous-hemorrhagic or purulent fluid is obtained.

Pneumonia caused by Klebsiella pneumoniae (Friedlander's bacillus)
It occurs relatively rarely (more often with alcoholism, in weakened patients, against the background of decreased immunity). A severe course is observed; mortality reaches 50%.
Occurs with pronounced symptoms of intoxication, rapid development respiratory failure. The sputum is often jelly-like, viscous, with an unpleasant smell of burnt meat, but may be purulent or rusty in color.
Scanty auscultatory symptoms, characterized by polylobular distribution with more frequent, compared to pneumococcal pneumonia, involvement upper lobes. Formation of abscesses and complications of empyema are typical Empyema is a significant accumulation of pus in a body cavity or hollow organ
.

Legionella pneumonia
It develops more often in people living in air-conditioned rooms, as well as those engaged in excavation work. Characteristically acute onset with high temperature, shortness of breath, bradycardia. The disease is severe and is often accompanied by complications such as intestinal damage (pain and diarrhea). The analyzes reveal significant increase in ESR, leukocytosis, neutrophilia.

Mycoplasma pneumonia
The disease is more common among young people in closely interacting groups, and is more common in the autumn-winter period. Has a gradual onset, with catarrhal symptoms. Characteristic is the discrepancy between severe intoxication (fever, severe malaise, headache and muscle pain) and the absence or mild severity of symptoms of respiratory damage (local dry wheezing, hard breathing). Often observed skin rashes, hemolytic anemia. The X-ray often reveals interstitial changes and increased pulmonary pattern. Mycoplasma pneumonia, as a rule, is not accompanied by leukocytosis; a moderate increase in ESR is observed.

Viral pneumonia
With viral pneumonia, low-grade fever, chills, nasopharyngitis, hoarseness, and signs of myocarditis may be observed. Myocarditis - inflammation of the myocardium (the middle layer of the heart wall, formed by contractile muscle fibers and atypical fibers that make up the conduction system of the heart.); manifested by signs of impairment of its contractility, excitability and conductivity
, conjunctivitis. In the case of severe influenza pneumonia, severe toxicity, toxic pulmonary edema, and hemoptysis appear. During the examination, leukopenia is often detected with normal or increased ESR. An X-ray examination reveals the deformation and meshness of the pulmonary pattern. The question of availability is purely viral pneumonia is controversial and is not accepted by all authors.

Diagnostics

Pneumonia is usually recognized on the basis of the characteristic clinical picture of the disease - the totality of its pulmonary and extrapulmonary manifestations, as well as the x-ray picture.

The diagnosis is made based on the following clinical signs:
1. Pulmonary- cough, shortness of breath, sputum production (can be mucous, mucopurulent, etc.), pain when breathing, the presence of local clinical signs (bronchial breathing, dullness of percussion sound, crepitating rales, pleural friction noise);
2. INnon-pulmonary- acute fever, clinical and laboratory signs intoxication.

X-ray examination chest organs in two projections is performed to clarify the diagnosis. Detects infiltration in the lungs. In case of pneumonia, increased ve-zi-cul-lar breathing is noted, sometimes with foci of bronchitis, crepitation, small- and medium-sized non-bubbling rales, focal ones that are not visible on X-rays.

Fiberoptic bronchoscopy or other invasive diagnostic methods are performed if pulmonary tuberculosis is suspected in the absence of a productive cough; for “obstructive pneumonia” due to bronchogenic carcinoma, aspirated bronchial foreign body, etc.

A viral or ricket-si-oz etiology for the disease can be assumed by the inconsistency between the islands of WHO -no-repentant infections-he-but-to-si-che-ski-mi phenomena and minimal changes in the respiratory organs with direct research (x-ray examination reveals focal or interstitial shadows in lungs).
It should be taken into account that pneumonia can occur atypically in elderly patients suffering from severe somatic diseases or severe immunodeficiency. Such patients may be asymptomatic and have predominantly extrapulmonary symptoms(disorders of the central nervous system, etc.), as well as weak or absent physical signs of pulmonary inflammation, it is difficult to determine the causative agent of pneumonia.
Suspicion of pneumonia in elderly and debilitated patients should appear when the patient’s activity decreases significantly for no apparent reason. The patient becomes increasingly weak, he lies down all the time and stops moving, becomes indifferent and drowsy, and refuses to eat. A careful examination always reveals significant shortness of breath and tachycardia, sometimes a one-sided flush of the cheek and a dry tongue are observed. Auscultation of the lungs usually reveals a focus of sonorous moist rales.

Laboratory diagnostics

1. Clinical analysis blood. The analysis data does not allow us to draw a conclusion about the potential causative agent of pneumonia. Leukocytosis more than 10-12x10 9 /l indicates a high probability of bacterial infection, and leukopenia below 3x10 9 /l or leukocytosis above 25x10 9 /l are unfavorable prognostic signs.

2. Biochemical tests blood do not provide specific information, but can indicate damage to a number of organs (systems) using detectable abnormalities.

3. Determination of the gas composition of arterial blood necessary for patients with symptoms of respiratory failure.

4. Microbiological studies are carried out e-ed to begin treatment to establish an etiological diagnosis. A study of smears or smears from the pharynx, throat, bronchi is carried out for bacteria, including vi-ru-sy, mi-ko-bak-te -rii tu-ber-ku-le-za, mi-coplasma pneu-mo-nii and rick-ket-sii; also used immunological methods. Recommended bacterioscopy with Gram stain and culture of sputum obtained by deep coughing.

5. Pleural fluid examination. Performed in the presence of pleural effusion Effusion is an accumulation of fluid (exudate or transudate) in the serous cavity.
and conditions safe conduct punctures (visualization on a laterogram of freely displaced fluid with a layer thickness of more than 1 cm).

Differential diagnosis

Differential diagnosis must be carried out with the following diseases and pathological conditions:

1. Pulmonary tuberculosis.

2. Neoplasms: primary lung cancer(especially the so-called pneumonic form of bronchioloalveolar cancer), endobronchial metastases, bronchial adenoma, lymphoma.

3. Pulmonary embolism and pulmonary infarction.

4. Immunopathological diseases: systemic vasculitis, lupus pneumonitis, allergic bronchopulmonary aspergillosis, bronchiolitis obliterans with organizing pneumonia, idiopathic pulmonary fibrosis, eosinophilic pneumonia, bronchocentric granulomatosis.

5. Other diseases and pathological conditions: congestive heart failure, drug-induced (toxic) pneumopathy, foreign body aspiration, sarcoidosis, pulmonary alveolar proteinosis, lipoid pneumonia, rounded atelectasis.

In the differential diagnosis of pneumonia highest value attached to a carefully collected anamnesis.

For acute bronchitis and exacerbation of chronic bronchitis In comparison with pneumonia, in-toxication is less pronounced. An X-ray examination does not reveal foci of obstruction.

Tuberculosis exudative pleurisy can begin as acutely as pneumonia: shortening of the percussion sound and bronchial breathing over the area of ​​the count bi-ro-van-nogo to the root of the lung-whom they can-ti-ro-vat to the-left pneu-mo-tion. Errors will be avoided by careful percussion, which reveals the dull sound and weakened breathing (with empi-em - weakened b-ron-hi-al-noe breathing). A pleural puncture followed by ex-su-da-ta examination and a radiograph in a lateral projection (intensity is revealed) help to carry out differentiation. dark shadow in the submuscular region).

Unlike neutrophilic leukocytes with pre-left (less often focal) pneumonia, the hemogram with ex-su-da-tiv ple-ri of tuberculous etiology, as a rule, is not treason-not-on.

Depending on the left and segmental pneumatic ri tu-ber-ku-lez-nom infiltration or focal-vom tu-ber-ku-le-ze Usually there is a less acute onset of the disease. Pneumonia resolves in the next 1.5 weeks under the influence of non-specific therapy, while The healing process is not subject to such rapid influence even with tuberculous therapy.

For mi-li-ar-nogo tu-ber-ku-le-za ha-rak-ter-on heavy in-talk-si-cation with high-ho-ho-rad-coy with weakly expressed physical symptoms, therefore, its differentiation from the small-scale race of the country's pneumatic system is required.

Acute pneumonia and obstructive pneu-monitis in bron-cho-gene cancer islands may appear against the backdrop of apparent prosperity; often, after cooling, they are noted to be warm, cold, nob, pain in the chest. However, with ob-structive pneu-mo-ni-the cough is often dry, paroxysmal, subsequently with a small amount of che-st-va mo-k-ro-you and blood-har-ka-nyem. In unclear cases, only bronchoscopy can clarify the diagnosis.

When the pleura is involved in the inflammatory process, irritation occurs at the endings of the right phrenic and lower intercostal nerves, which are also involved in the innervation of the upper parts of the anterior abdominal wall and abdominal organs. This causes pain to spread to the upper abdomen.
When they are palpated, pain is felt, especially in the area of ​​the right upper quadrant of the abdomen; when tapping along the right costal arch, the pain intensifies. Patients with pneumonia are often referred to surgical departments With diagnosis of appendicitis, acute cholecystitis, perforated ulcer stomach. In these situations, diagnosis is helped by the absence of symptoms of peritoneal irritation and tension in most patients. abdominal muscles. It should, however, be taken into account that this attribute is not absolute.

Complications

Possible complications pneumonia:
1. Pulmonary: exudative pleurisy, pyopneumothorax Pyopneumothorax - accumulation of pus and gas (air) in the pleural cavity; occurs in the presence of pneumothorax (presence of air or gas in the pleural cavity) or putrefactive pleurisy (inflammation of the pleura caused by putrefactive microflora with the formation of foul-smelling exudate)
, abscess formation, pulmonary edema;
2. Extrapulmonary: infectious-toxic shock, pericarditis, myocarditis, psychosis, sepsis and others.

Exudative pleurisy manifested by severe dullness and weakening of breathing on the affected side, lag of the lower part of the chest on the affected side when breathing.

Abscessation characterized by increasing intoxication, abundant night sweats, the temperature becomes hectic in nature with daily variations of up to 2 o C or more. The diagnosis of a lung abscess becomes obvious as a result of the abscess breaking into the bronchus and the discharge of a large amount of purulent foul-smelling sputum. The breakthrough of an abscess into the pleural cavity and the complication of pneumonia by the development of pyopneumothorax may indicate sharp deterioration conditions, increasing pain in the side when breathing, significant increase in shortness of breath and tachycardia, drop in blood pressure.

In appearance pulmonary edema In pneumonia, toxic damage to the pulmonary capillaries with increased vascular permeability plays an important role. The appearance of dry and especially wet wheezing over healthy lungs against the background of increased shortness of breath and deterioration of the patient’s condition, indicates a threat of developing pulmonary edema.

Sign of occurrence infectious-toxic shock the appearance of persistent tachycardia, especially over 120 beats per minute, should be considered. The development of shock is characterized by a strong deterioration in the condition, the appearance of severe weakness, and in some cases, a decrease in temperature. The patient's facial features become sharper, the skin acquires a gray tint, cyanosis increases, shortness of breath increases significantly, the pulse becomes frequent and small, blood pressure drops below 90/60 mmHg, and urination stops.

People who abuse alcohol are more likely to psychosis against the background of pneumonia. It is accompanied by visual and auditory hallucinations, motor and mental agitation, disorientation in time and space.

Pericarditis, endocarditis, meningitis are currently rare complications.

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Treatment

With an unknown pathogen treatment is determined:
1. Conditions for the occurrence of pneumonia (community-acquired/nosocomial/aspiration/congestive).
2. The age of the patient (more/less than 65 years), for children (up to one year/after one year).
3. The severity of the disease.
4. Place of treatment (outpatient clinic/department general profile/ intensive care unit).
5. Morphology (bronchopneumonia/focal pneumonia).
For more details, see the subsection " Bacterial pneumonia unspecified" (J15.9).

Pneumonia in COPD, bronchial asthma, bronchiectasis etc. are discussed in other subsections and require a separate approach.

At the height of the illness, patients are given a special regimen, a gentle (me-ha-ni-che-ski and he-mi-che-ski) di-e-ta, including ogre -no-one-var-no-so-li and up to-a-hundred-accurate amount of vitamins, especially A and C. Gradually with With the disappearance or significant reduction of intoxication phenomena, the regimen is expanded; in the absence of contraindications (heart disease, digestive organs), the patient is transferred to diet No. 15, which provides for an increase in the diet of sources of vitamins and calcium, fermented milk drinks (especially when treated with antibiotics), the exclusion of fatty and indigestible foods and dishes.

Drug therapy
For bacterial research, taking samples, smears, and swabs is taken. After this, etiotropic therapy begins, which is carried out under the supervision of clinical effectiveness, taking into account the sown microflora and its sensitivity to antibiotics.

In case of mild pneumonia in outpatients, preference is given to antibiotics for oral administration; in severe cases, antibiotics are administered intramuscularly or intravenously (it is possible to switch to the oral route of administration if the condition improves).

If pneumonia occurs in young patients without chronic diseases, treatment can be started with penicillin (6-12 million units per day). In patients with chronic obstructive pulmonary diseases, it is preferable to use aminopenicillins (ampicillin 0.5 g 4 times a day orally, 0.5-1 g 4 times a day parenterally, amoxicillin 0.25-0.5 g 3 times a day). For intolerance to penicillins in mild cases, macrolides are used - erythromycin (0.5 g orally 4 times a day), azithromycin (sumamed - 5 g per day), roxithromycin (Rulid - 150 mg 2 times a day), etc. In case of development pneumonia in patients with chronic alcoholism and severe somatic diseases, as well as in elderly patients, are treated with cephalosporins II - III generation, a combination of penicillins with betalactamase inhibitors.

For bilobar pneumonia, as well as pneumonia accompanied by a severe course with severe symptoms of intoxication, and with an unknown pathogen, a combination of antibiotics is used (ampiox or cephalosporins of the second-third generation in combination with aminoglycosides - for example, gentamicin or netromycin), fluoroquinolones, carbapenems are used.

For nosocomial pneumonia, third generation cephalosporins (cefotaxime, cefuroxime, ceftriaxone), fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin), aminoglycosides (gentamicin, netromycin), vancomycin, carbapenems, and also, when determining the pathogen, antifungal agents are used. In persons with immunodeficiency states, when conducting empirical therapy for pneumonia, the choice of drugs is determined by the pathogen. For atypical pneumonia (mycoplasma, legionella, chlamydia), macrolides and tetracyclines are used (tetracycline 0.3-0.5 g 4 times a day, doxycycline 0.2 g per day in 1-2 doses).

The effectiveness of treatment with antibiotics for pneumonia is mainly revealed by the end of the first day, but no later than three days thereof at-me-not. After this period, if there is no therapeutic effect, the prescribed drug should be replaced with another. Indicators of the effectiveness of therapy are considered to be normalization of body temperature, disappearance or reduction of signs of intoxication. In case of uncomplicated community-acquired pneumonia, antibiotic therapy is carried out until the body temperature is stable normalized (usually about 10 days); in case of complicated course of the disease and nosocomial pneumonia, the duration of antibiotic therapy is determined individually.

In case of severe viral infections, after the introduction of a special nor-sky pro-ti-influenza gamma-glo-bu-li-na 3-6 ml, if necessary, repeated administration is carried out every 4-6 hours, in the first 2 days I was sick.

In addition to antibiotic therapy, symptomatic and pathogenetic treatment pneumonia. In case of respiratory failure, oxygen therapy is used. For high, difficult to tolerate fever, as well as for severe pleural pain, non-steroidal anti-inflammatory drugs (paracetamol, voltaren, etc.) are indicated; Heparin is used to correct microcirculatory disorders (up to 20,000 units per day).

Patients are placed in intensive therapy wards for severe acute and exacerbation of chronic pneumonia , caused by false acute or chronic breathing with inaccuracy. Bron-ho-scopic drainage may be carried out, with art-te-ri-al hyper-drip - an auxiliary artificial vein ti-lation of the lungs. In the event of the development of pulmonary edema, infectious shock and other severe complications, treatment of patients pnev-mo-ni-it is carried out together with re-a-nima-to-log.

Patients who have had pneumonia and are discharged from the hospital during a period of clinical recovery or remission should be taken under dispensary observation. For rehabilitation, they can be sent to sanatoriums.

Forecast

In the majority of cases of community-acquired pneumonia in immunocompetent young and middle-aged patients, normalization of body temperature is observed on the 2-4th day of treatment, and radiological “recovery” occurs within up to 4 weeks.

The prognosis for pneumonia became more favorable towards the end of the 20th century, however, it remains serious for pneumonia caused by staphylococcus and Klebsiella pneumonia (Friedlander's bacillus), with frequent recurrent chro-no-che-pneu-mo-s, caused by a false ob-structive process, breathing-ha-tel- not-to-one-hundred-accuracy, and also with the development of pneumonia in persons with severe heart disease -so-su-di-stop and other si-s-those. In these cases, the mortality rate from pneumonia remains high.

PORT scale

In all patients with community-acquired pneumonia, without exception, it is recommended to initially determine whether there is increased risk complications and death in the patient (class II-V) or not (class I).

Step 1. Stratification of patients into risk class I and risk classes II-V

Note. If there is at least one “Yes”, you should proceed to the next step. If all answers are “No”, the patient can be classified as risk class I.

Step 2. Score degree of risk

Note. In the column " Malignant neoplasms“cases of tumor diseases manifesting an active course or diagnosed within the last year are taken into account, excluding basal cell and squamous cell skin cancer.

The column “Liver diseases” takes into account cases of clinically and/or histologically diagnosed liver cirrhosis and active chronic hepatitis.

The column "Chronic heart failure" takes into account cases of heart failure due to systolic or diastolic dysfunction of the left ventricle, confirmed by anamnesis, physical examination, chest radiography, echocardiography, myocardial scintigraphy or ventriculography.

The column "Cerebrovascular diseases" takes into account cases of recent stroke, transient ischemic attack and residual effects after the transferred acute disorder cerebral circulation, confirmed by CT or MRI of the brain.

The column “Kidney diseases” takes into account cases of anamnestic confirmed chronic kidney disease and increased concentrations of creatinine/urea nitrogen in the blood serum.

Step 3. Risk assessment and choice of treatment site for patients

Hospitalization

Indications for hospitalization:
1. Age over 70 years, severe infectious-toxic syndrome (respiratory rate is more than 30 per 1 minute, blood pressure is below 90/60 mm Hg, body temperature is above 38.5 o C).
2. The presence of severe concomitant diseases (chronic obstructive pulmonary diseases, diabetes mellitus, congestive heart failure, severe liver and kidney diseases, chronic alcoholism, substance abuse and others).
3. Suspicion of secondary pneumonia (congestive heart failure, possible pulmonary embolism, aspiration, etc.).
4. Development of complications such as pleurisy, infectious-toxic shock, abscess formation, disturbances of consciousness.
5. Social indications (there is no opportunity to organize the necessary care and treatment at home).
6. Ineffectiveness of outpatient therapy for 3 days.

With a mild course and favorable living conditions, treatment of pneumonia can be carried out at home, but the majority of patients with pneumonia need inpatient treatment.
Patients with pre-left and other pneumonia and severe infectious syndrome should be treated ex-training hospital li-zi-rovat. The choice of treatment site and (partially) prognosis can be made according to CURB-65/CRB-65 state assessment scales.

CURB-65 and CRB-65 scales for community-acquired pneumonia

Prevention

To prevent community-acquired pneumonia, pneumococcal and influenza vaccines are used.
Pneumococcal vaccine should be given when there is a high risk of developing pneumococcal infections (as recommended by the Committee of Advisors on Immunization Practices):
- persons over 65 years of age;
- persons aged 2 to 64 years with diseases of internal organs (chronic diseases of the cardiovascular system, chronic bronchopulmonary diseases, diabetes mellitus, alcoholism, chronic liver diseases);
- persons aged 2 to 64 years with functional or organic asplenia Asplenia - developmental anomaly: absence of the spleen
(with sickle cell anemia, after splenectomy);
- persons over 2 years of age with immunodeficiency conditions.
The influenza vaccine is effective in preventing the development of influenza and its complications (including pneumonia) in healthy people under 65 years of age. In people aged 65 years and older, vaccination is moderately effective.

Information

Sources and literature

1. Complete reference book for a practicing physician /edited by Vorobyov A.I., 10th edition, 2010
   1. pp. 183-187
2. Russian therapeutic reference book / edited by Academician of the Russian Academy of Medical Sciences Chuchalin A.G., 2007
   1. pp. 96-100
3. www.monomed.ru
   1. Electronic medical directory

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