Pneumonia – sharp damage of lungs of infectious and inflammatory character in which all structural elements of pulmonary fabric are involved, mainly - alveoluses and interstitsialny tissue of lungs. The clinic of pneumonia is characterized by fever, weakness, perspiration, thorax pain, short wind, cough with a phlegm (mucous, purulent, "rusty"). Pneumonia is diagnosed on the basis of an auskultativny picture, the lungs given to a X-ray analysis. In the sharp period treatment includes antibiotic treatment, dezintoksikatsionny therapy, immunostimulation; reception of mucolytics, expectorant, antihistamines; after the termination of fever – physical therapy, LFK.
Pneumonia - the inflammation of the lower airways of various etiology proceeding with an intra alveolar ekssudation and which is followed by characteristic kliniko-radiological signs. The acute pneumonia occurs at 10-14 people from 1000, in age group 50 years – at 17 people from 1000 are more senior. Relevance of a problem of incidence of an acute pneumonia remains, despite introduction of new antimicrobic medicines, also as the high percent of complications and a lethality (to 9%) from pneumonia remains. Among the reasons of mortality of the population pneumonia costs on the 4th place after diseases of heart and vessels, malignant new growths, traumatism and poisonings. Pneumonia can develop at the weakened patients, joining the course of heart failure, oncological diseases, violations of brain blood circulation, and complicates an outcome of the last. At patients with AIDS pneumonia is the main immediate cause of death.
Reasons and mechanism of development of pneumonia
Among the reasons causing pneumonia the bacterial infection is on the first place. Most often causative agents of pneumonia are:
- grampolozhitelny microorganisms: pneumococci (from 40 to 60%), staphylococcus (from 2 to 5%), streptococci (2,5%);
- gramotritsatelny microorganisms: Friedlander's stick (from 3 to 8%), hemophilic stick (7%), enterobakteriya (6%), proteas, colibacillus, legionella, etc. (from 1,5 to 4,5%);
- mycoplasmas (6%);
- viral infections (viruses of herpes, flu and paraflu, adenoviruses etc.);
- fungal infections.
Also pneumonia can develop owing to influence of noninfectious factors: injuries of a thorax, ionizing radiation, toxic substances, allergic agents.
Patients with stagnant heart failure, chronic bronchitis, a chronic nasopharyngeal infection, congenital malformations of lungs, with heavy immunodeficiency, the weakened and exhausted patients, patients treat risk group on development of pneumonia, it is long being on a bed rest, and also persons of advanced and senile age.
The people smoking and abusing alcohol are especially subject to development of pneumonia. Nicotine and vapors of alcohol injure a mucous membrane of bronchial tubes and protective factors of bronkhopulmonalny system oppress, creating a favorable environment for introduction and reproduction of an infection.
Infectious causative agents of pneumonia get into lungs bronkhogenny, hematogenic or limfogenny in the ways. At the available decrease in a protective bronkhopulmonalny barrier in alveoluses the infectious inflammation which through permeable interalveolar partitions extends to other departments of pulmonary fabric develops. In alveoluses there is a formation of the exudate interfering gas exchange of oxygen between pulmonary fabric and blood vessels. Develop oxygen and respiratory insufficiency, and at the complicated course of pneumonia - heart failure.
In development of pneumonia 4 stages are allocated:
- the inflow stage (from 12 hours to 3 days) – is characterized by a sharp krovenapolneniye of vessels of lungs and a fibrinozny ekssudation in alveoluses;
- the stage of a red opecheneniye (from 1 to 3 days) – occurs the lung tissue consolidation, on structure reminding a liver. In alveolar exudate erythrocytes in a large number are found;
- the stage of a gray opecheneniye – (from 2 to 6 days) - is characterized by disintegration of erythrocytes and a massive exit of leukocytes in alveoluses;
- the permission stage – is restored normal structure of tissue of lung.
Classification of pneumonia
1. On the basis of epidemiological data distinguish pneumonia:
- extra sick-lists (extra hospital)
- intrahospital (hospital)
- caused by immunodeficiency
- atypical current.
2. On an etiologichesky factor, with specification of the activator, pneumonia happens:
3. On the mechanism of development allocate pneumonia:
- primary, developing as independent pathology
- secondary, developing as a complication of associated diseases (for example, stagnant pneumonia)
- aspiration, developing at hit of foreign matters in bronchial tubes (food particles, emetic masses, etc.)
- heart attack pneumonia, developing owing to a thrombembolia of small vascular branches of a pulmonary artery.
4. On degree of interest of pulmonary fabric pneumonia meets:
- unilateral (with damage of the right or left lung)
- total, share, segmentary, subdolkovy, radical (central).
5. On character of a course of pneumonia can be:
- sharp long
6. Taking into account development of functional violations of pneumonia proceed:
- with existence of functional violations (with the indication of their characteristics and expressivenesses)
- with lack of functional violations.
7. Taking into account development of complications of pneumonia happen:
- uncomplicated current
- the complicated current (pleurisy, abscess, bacterial toxic shock, myocarditis, endocarditis etc.).
8. On the basis of kliniko-morphological features distinguish pneumonia:
- parenchymatous (krupozny or share)
- focal (bronchial pneumonia, dolkovy pneumonia)
- interstitsialny (is more often at mikoplazmenny defeat).
9. Depending on weight of a course of pneumonia divide on:
- easy degree – it is characterized by poorly expressed intoxication (clear consciousness, body temperature to 38 °C, HELL is normal, tachycardia no more than 90 . in min.), short wind at rest is absent, the small center of an inflammation radiological is defined.
- average degree – symptoms of moderately expressed intoxication (clear consciousness, perspiration, the expressed weakness, body temperature to 39 °C, HELL is moderately reduced, tachycardia about 100 . in min.), breath frequency – to 30 in min. at rest, radiological is defined the expressed infiltration.
- heavy degree – it is characterized by the expressed intoxication (fever of 39-40 °C, creation turbidity, an adinamiya, nonsense, tachycardia over 100 . in min., a collapse), short wind to 40 in min. at rest, cyanosis, radiological is defined extensive infiltration, development of complications of pneumonia.
The sharp beginning from fever over 39 °C, a fever, thorax pains, short wind, weakness is characteristic. Cough disturbs: at first dry, unproductive, further, for 3-4 day – with a "rusty" phlegm. Body temperature is constantly high. At krupozny pneumonia fever, cough and otkhozhdeny phlegms keep up to 10 days.
At heavy degree of a course of krupozny pneumonia hyperaemia of integuments and cyanosis of a nasolabial triangle is defined. On lips, cheeks, a chin, wings of a nose herpetic rashes are visible. Condition of the patient heavy. Breath is superficial, speeded up, with inflating of wings of a nose. Auskultativno listens a krepitation and damp melkopuzyrchaty rattles. Pulse, frequent, quite often arrhythmic, HELL it is lowered, warm deafs of tone.
It is characterized by the gradual, hardly noticeable beginning, is more often after the postponed SARS or a sharp trakheobronkhit. Body temperature febrilny (38-38,5 °C) with daily fluctuations, cough is followed by an otkhozhdeniye of a mucopurulent phlegm, perspiration, weakness are noted, at breath – thorax pain on a breath and at cough, . At focal drain pneumonia the condition of the patient worsens: there are expressed short wind, cyanosis.
At an auskultation rigid breath is listened, the exhalation is extended, dry small - and srednepuzyrchaty rattles, a krepitation over the inflammation center.
Features of a course of pneumonia are caused by severity, properties of the activator and existence of complications.
Complicated is considered the course of pneumonia which is followed by development in bronchopulmonary system and other bodies of the inflammatory and jet processes caused directly by pneumonia. The current and an outcome of pneumonia in many respects depends on existence of complications. Complications of pneumonia can be pulmonary and extra pulmonary.
Among extra pulmonary complications of pneumonia sharp warm and pulmonary insufficiency, an endocarditis, myocarditis, meningitis and an encephalomeningitis often develop, glomerulonefrit, infectious and toxic shock, anemia, psychoses etc.
Diagnosis of pneumonia
At diagnosis of pneumonia several problems are solved at once: differential diagnostics of an inflammation with other pulmonary processes, clarification of an etiology and severity (complications) of pneumonia. Pneumonia at the patient should be suspected on the basis of symptomatic signs: bystry development of fever and intoxication, cough.
At a fizikalny research consolidation of pulmonary fabric (on the basis of perkutorny obtusion of a pulmonary sound and strengthening of a bronkhofoniya), a characteristic auskultativny picture - focal, damp, melkopuzyrchaty, sonorous rattles or a krepitation is defined. At an echocardiography and ultrasonography of a pleural cavity the pleural exudate sometimes is defined.
As a rule, the diagnosis of pneumonia after carrying out a X-ray analysis of lungs is confirmed. At any kinds of pneumonia more often process takes the lower shares of a lung. On roentgenograms at pneumonia the following changes can come to light:
- parenchymatous (focal or diffusion blackouts of various localization and extent);
- interstitsialny (the pulmonary drawing is strengthened due to perivaskulyarny and peribronkhialny infiltration).
Roentgenograms at pneumonia usually do at the beginning of a disease and 3-4 weeks later for control of permission of an inflammation and an exception of other pathology (is more often than bronkhogenny lung cancer). Changes in the general blood test at pneumonia are characterized leykotsitozy from 15 to 30 • 109/l, stab shift of a leykotsitarny formula from 6 to 30%, increase in SOE to 30-50 mm/h. In the general analysis of urine the proteinuria can be defined, the mikrogematuriya is more rare. Bakanaliz allows to reveal phlegms at pneumonia the activator and to define its sensitivity to antibiotics.
Treatment of pneumonia
Patients with pneumonia, as a rule, are hospitalized in all-therapeutic office or office of pulmonology. For fever and intoxication the bed rest, plentiful warm drink, high-calorific, vitamin-rich food is appointed. At the dressed-up phenomena of respiratory insufficiency sick with pneumonia appoint oxygen inhalations.
The basic in treatment of pneumonia is antibacterial therapy. It is necessary to appoint antibiotics as it is possible earlier, without waiting for definition of the activator. Selection of an antibiotic is carried out by the doctor, any self-treatment is inadmissible! At extra hospital pneumonia more often appoint penicillin (amoxicillin from klavulanovy to - that, ampicillin etc.), macroleads (, ), tsefalosporina (cefazolin, etc.). The choice of a way of introduction of an antibiotic is defined by weight of a course of pneumonia. For treatment of intrahospital pneumonia use penicillin, tsefalosporina, ftorkhinolona (ciprofloxacin, etc.), karbapenema (imipeny), aminoglycosides (gentamycin). At the unknown activator appoint the combined antibiotic treatment from 2-3 medicines. The course of treatment can proceed from 7-10 to 14 days, change of an antibiotic is possible.
At pneumonia performing dezintoksikatsionny therapy, immunostimulation, appointment febrifugal, expectorant and mukolitichesky, antihistamines is shown. After the termination of fever and intoxication the mode is expanded and appoint carrying out physical therapy (an electrophoresis with calcium chloride, potassium iodide, gialuronidazy, UVCh, massage, inhalations) and LFK for stimulation of permission of the inflammatory center.
Treatment of pneumonia is carried out to an absolute recovery of the patient which is defined by normalization of a state and health, fizikalny, radiological and laboratory indicators. At frequent repeated pneumonia of the same localization the issue of surgical intervention is resolved.
The forecast at pneumonia
At pneumonia the forecast is defined by a number of factors: virulence of the activator, age of the patient, background diseases, immune responsiveness, adequacy of treatment. The complicated options of a course of pneumonia, iimunodefitsitny states, resistance of activators to antibiotic treatment are adverse concerning the forecast. The pneumonia at children till 1 year caused by staphylococcus, a sinegnoyny stick, klebsiyelly is especially dangerous: the lethality at them makes from 10 to 30%.
At timely and adequate medical actions pneumonia comes to an end with recovery. By options of changes in pulmonary fabric the following outcomes of pneumonia can be observed:
- complete recovery of structure of pulmonary fabric - 70%;
- formation of the site of a local pneumosclerosis - 20%;
- formation of the site of a local karnifikation – 7%;
- reduction of a segment or share in the sizes – 2%;
- wrinkling of a segment or share – 1%.
Prevention of pneumonia
Measures of the prevention of development of pneumonia consist in an organism hardening, immunity maintenance, an exception of a factor of overcooling, sanitation of the chronic infectious centers of a nasopharynx, fight against dust content, the termination of smoking and abuse of alcohol. At the weakened lying patients for the purpose of prevention of pneumonia carrying out respiratory and remedial gymnastics, massage, purpose of antiagregant is expedient (a pentoksifillina, heparin).