Acute pneumonia
Contents:
Description:
Pneumonia (pneumonia from Greek pneumon - lungs) - the zayobolevaniye combining group various on an etiology, a payotogenez and the morphological characteristic inflammatory is more often infectious, processes in lungs with преимущественньш defeat of their respiratory departments.
Symptoms of the Acute pneumonia:
It is well known that the clinical picture of an acute pnevmoyoniya differs in various degree of manifestation of the general proyoyavleniye of a disease and symptoms of damage of lungs and bronchial tubes. These distinctions considerably are defined by character of the activator.
Pneumococcal pneumonia. Long since clinically bright tyayozhely form of an acute pneumonia of the pneumococcal nature of a nayozyvala lung fever (pleuropneumonia). In sovreyomenny conditions" as well as earlier, this form of pneumonia nachinayotsya suddenly, often by a fever, sometimes tremendous, goyolovny pain, the stitch amplifying at gluyoboky breath and cough, short wind, dry cough, a weakness chuvyostvo, temperature increase to 39-40 °C. Thorax pain can be so strong that the patient holds the breath, suppresses cough. At localization in lower parts and when involving in process of a diaphragmal pleura pain can irradiate in an abdominal cavity, симулируя a picture of an acute abdomen. The patient is excited, sometimes заторможен, raves, sometimes there is a picture of acute psychosis, especially at the persons having alcoholism.
Face of the patient pale, a feverish flush on the party of defeat, inflating of wings of a nose at breath. At persons with diseases of serdechnoyososudisty system, chronic bronchitis and at elderly vyyorazhenny cyanosis. Breath is speeded up till 30-40 in 1 min.
Physical signs at a lung fever depend on a phase and prevalence of process. In the course of accumulation of exudate in alveoluses, reduction of lightness of affected areas and their consolidation the tympanic shade of percussion tone gradually is replaced by obtusion. Respiratory noise at the very beginning of a disease remains vesicular, but is a little weakened because of a shchazheniye at breath in connection with silyyony pain. Lag at a dyyokhaniye of the "sick" side of a thorax is noted. On the 2-3rd days of a boyolezna at height of a breath crepitation is listened. Because of frequent and shallow breathing crepitation is quite often not udayotsya to be heard.
Sometimes over a zone of defeat it is possible to define existence of small-bubbling wet and dry rattles, especially at patients with chronic bronchitis. Further at most of patients in the field of obtusion of a percussion zvuyok strengthening of voice trembling is noted, bronchial breath, a bronchophony are listened, crepitation disappears, the pleural rub vyyoyavlyatsya. The lung fever soprovozhyodatsya by a dry plastic pleuritis (pleuropneumonia), is more rare - exudative.
From the beginning of fluidifying of exudate and recovery of an aerayotion of alveoluses obtusion of percussion tone decreases, oslayobevat bronchial breath and again crepitation appears. In the course of an exudate rassasyvaniye bronchial breath smeyonyaetsya-rigid, and then vesicular, disappear the shortened percussion tone, the strengthened voice trembling and a bronkhofoyoniya. Sometimes in a permission stage over a zone of pneumonic infiltrate ringing, small-bubbling rattles appear.
Emphysematous expansion of a healthy lung is found in a number of patients.
From the very beginning of a disease tachycardia develops (100-120 in 1 min.), long increase of pulse characterizes a heavy current of a lung fever which is followed by a lowering of arterial pressure. Sometimes the extent of relative cordial dullness to the right at the expense of a prayovy auricle and a right ventricle increases and the emphasis of the II tone on a pulmonary artery appears.
Also functional changes of digestive organs are observed. At the beginning of a disease the toshnoyota, vomiting, anorexia, a chair delay can disturb. Language dry and oblozhenyony, a stomach is blown up because of a meteorism. At a heavy current the ikterichnost of scleras and skin poyoyavlyatsya, the liver increases in sizes, becomes painful.
Changes of a nervous system are noted at all patients and depend on weight of a current of a lung fever. At an easy current, they are shown by a headache, sleeplessness, and at a heavy current, especially the persons having alcoholism have an excitement, nonsense, symptoms of acute psychosis. Sometimes from the very beginning of a disease at patients meningeal symptoms develop: stiff neck, simyopty Ksrniga, skin hyperesthesia, stupefaction, silyyony headache and so forth.
Duration of the feverish period, duration and vyrayozhennost of subjective and objective signs very much of a variyoabelna also depend on a condition of reactivity of sick and proyovodimy treatment. Body temperature, having reached in several hours of high figures, there can be high several days, then critically decrease (during 12-24 h) or lytically (for 2-3 days). At the same time with decrease in a temperatuyora symptoms of intoxication disappear and physical signs of a lung fever decrease.
In peripheral blood the leukocytosis, more often moderate, mainly at the expense of neutrophils (80-90%) is noted. The maintenance of band neutrophils increases to 6-30%, the shift to the left to young and even myelocytes is sometimes noted. The toxic zerniyostost of neutrophils is characteristic. The inclusions which are painted in blue color - Business little bodies appear in more hard cases in protoplasm. The maintenance of eosinophils and basophiles in blood decreases, and extent of their decrease is most expressed at patients with a heavy current, and eosinophils can disappear a polyonost from peripheral blood. The lymphopenia and some increase in maintenance of monocytes, and a takyozha thrombocytopenia which is combined with increase in level of fibrinogen are noted. Changes of these indicators at patients with the heavy current expressed by a hemorrhagic syndrome are most expressed. Hemocoagulation amplifies and fibrinolitic activity of blood is oppressed, the maintenance of a fibriyonogen increases, at some patients it is combined with thrombocytopenia. SOE is considerably increased. Long preservation of a leukocytosis, deviation to the left, aneosinophilia and thrombocytopenia are characteristic of a heavy current of a zayobolevaniye and its various complications (абсцедированис, etc.). S-reactive protein, protein fractions of blood, sialic acids, гаптоглобин are sharply raised. In a phlegm, especially prior to antibacterial therapy, the pneumococcus is found. At an urine research the proteinuria, sometimes a cylindruria and the microhematuria caused by toxic defeat of a parenchyma of kidneys quite often come to light.
Acute inflammatory process in lungs is followed by increase in a glucocorticoid and mineralokortikoidny akyotivnost of bark of adrenal glands. Level free 17-oksikor-tikosteroidov in a blood plasma and Aldosteronum in urine is znachiyotelno increased in an acute phase of pneumonia with a gradual sniyozheniye in process of process subsiding.
Patients with a lung fever have considerable dysfunctions of external respiration: ZhEL, MVL are lowered, raised FASHION and OOL/OEL relation. At 2/z patients of a snizheyona distensibility of lungs and the maximum volume inspiratory rate and an exhalation. According to various authors, disturbances of bronchial passability come to light at 38-72% of patients.
ECG changes depends on age of the patient and a condition of a myocardium to a disease. At elderly people at a disease of a lung fever are sometimes noted decrease in a voltage, the negative tooth of T in II and III assignments, shift is lower than the isoelectric level of an interval of S - T. V hard cases can arise disturbances of a rhythm because of disturbance of a provodiyomost, premature ventricular contraction and even a ciliary arrhythmia.
Despite early purpose of effective antibakteriyoalny therapy, the lung fever in most cases keeps a number of symptoms, typical for this disease: considerable weight of a current, massive polysegmented defeat, frequent involvement in inflammatory process of a plevyora, a high leukocytosis with a neutrocytosis and shift of a leykotsiyotarny formula to the left. At the same time at the patients who do not have serious associated diseases at timely adequate treatment the lung fever proceeds in - nastoyayoshchy time much easier, than before use of antibiotics.
Complications in the acute period of a lung fever are most often connected with the changes of a cardiovascular .sistema caused by infectious and toxic shock, infektsion-but-allergic myocarditis.
Use of antibiotics led to reduction in 2-3 rayoz of number of purulent complications of an acute pneumonia. However at late begun treatment and at the persons of advanced, senile age having associated diseases at alcoholics the lung fever proceeds hard, is followed by seryyoezny complications (abscessing, purulent pleurisy, peyorikardit, etc.).
At timely and rational treatment the lung fever by the end of the 3-4th week comes to an end with a full vyzdoyorovleniye. At persons with the heavy, complicated current a zabolevayoniya the outcome in carnification or in a chronic pnevyomoniya is possible. The lethality at a lung fever makes 2,7-3%.
Along with a typical classical form of pneumococcal pneumonia what is croupous (pleuropneumonia) suyoshchestvut the pneumonia caused, apparently, by other strains of a pneumococcus. This pneumonia soprovozhdayotsya quite often by the smaller extent of defeat of pulmonary fabric. The Poyosledny circumstance defined the existing name of focal pneumonia (bronchial pneumonia). Quite often defeat of pulmonary fabric has drain character and extends to 1-2 and more segments. The disease often has secondary character, complicating a current of various infectious zaboleyovaniye (is more often than virus), chronic diseases of bronchopulmonary and cardiovascular systems, diseases of blood and exchange. In this regard clinical displays of pneumonia differ in a variety. Three groups of patients can be conditionally allocated. In one cases (30-35%) the clear clinic of an acute pneumonia is noted: fever to 38-39 °C, a zalozhenyonost in breasts, cough with a phlegm, the expressed signs of an inyotoksikation and clear physical changes, and степень expressivenesses of physical changes depends on a rasproyostranennost and localization of inflammatory process. In druyogy cases in clinic of a disease symptoms acute or exacerbations of chronic bronchitis prevail. The last obyostoyatelstvo defines so widespread diagnosis - bronchial pneumonia when, along with temperature increase and the phenomena of intoxication, symptoms of bronchitis and bronchial obstruction are noted. S] / з patients zatrudyonenny breath, persistent unproductive cough are observed. These bolyyony present the greatest difficulty at a razgranicheyoniya of an acute pneumonia from an exacerbation of chronic bronchitis. The correct diagnosis is promoted by detection of local asymmetry of physical data (change of percussion tone, strengthening of voice trembling, more expressed aus-kultativny symptomatology). Solving in these situations the radiographic research in 2-3 projections, testimonial of existence of pneumonic infiltration yavyolyatsya. The most part of patients of this group is made by persons 40 years having chronic bronchitis, piyevmosklerozy, emphysema of lungs, cardiovascular diseases are more senior. Pnevyomoniya at these patients flows with the expressed changes of cardiovascular system - persistent tachycardia, poyavleyoniy at a number of sick symptoms of heart failure on right ventricular type.
The third group of patients has a clinic of a disease erased and was shown only by persistent cough and signs of an intoksikayotion (the subfebrile condition interrupted by higher rises in temperature, astenisation). Shortening of a percussion sound, wet rattles come to light at single patients, are available rigid breath with a bronchial shade for a bolshinyostvo and the suyokhy rattles on the limited site differing in a postoyanyostvo.
The moderate leukocytosis is noted only at a half bolyyony. Are more characteristic neutrophylic shift to the left, increase in SOE. In hard cases - reduction of eosinophils. At the vyyorazhenny phenomena of intoxication the proteinuria, a microhematuria, a cylindruria are observed.
Staphylococcal pneumonia meets seldom, more often in период flu epidemics, and the bronchogenic secondary harakyoter carries.
The heavy fulminant current is observed at children, pozhiyoly people weakened by various infections or hroniyochesky diseases. The disease develops sharply: high fever, the confused consciousness, cough, a stethalgia, an asthma. Against the background of a dullness and the weakened dyyokhaniye over a zone of defeat sonorous wet rattles begin to be listened. Radiological extensive poyolisegmentarny infiltration of pulmonary fabric, quite often soputyostvuyushchy pleurisy comes to light. Further bulls and nekyorotichesky cavities decide on liquid level. The configuration and a koliyochestvo of cavities in a lung quickly change. Defeat often unilateral, tends to restriction, quite often byyovat break in a pleura with formation of a pyopneumothorax.
Staphylococcal pneumonia of hematogenous genesis quite often complicates the course of sepsis. The clinical picture is usually opreyodelyat the main center, by the phenomena of the general intoxication. At gemayotogenny staphylococcal pneumonia the infiltrative phase of pneumonia proceeds imperceptibly, without the expressed clinical symptomatology. Only several days later the state sharply worsens: there are tremendous oznoba, a high likhoyoradka, an asthma, a stethalgia, dry cough, the increasing dykhayotelny insufficiency. A motley picture at auscultation: sites of the weakened breath alternate with amphoric, sonorous wet rattles vyyoslushivatsya. Often arises пневмоторакс, it is frequent - pulmonary bleeding. The lethality remains high.
At elderly people, especially with chronic bronchitis, strayodayushchy alcoholism, the acute pneumonia quite often is caused by a gram-negative stick of Klebsiella pneumoniae - fridlen-derovsky pneumonia. This form of pneumonia is characterized by weight of a current, the extensive and progressing defeat of pulmonary fabric, bent to purulent complications (abscessing, a pleura empyema). Despite massive antibakyoterialny therapy, percent of lethal outcomes remains vyyosoky.
Streptococcal pneumonia meets seldom in recent years and in most cases is a complication of measles, whooping cough, flu and other acute respiratory or hronicheyosky pulmonary diseases. Bronchogenic spread of an infection leads to emergence of the small centers of pneumonia in preyodela of one segment with bystry spread of an infection on all lung with formation of the drain centers in the beginning. Mainly the lower shares of lungs are surprised. The streptococcal pnevyomoniya begins sharply with repeated oznob, fever, vyrayozhenny intoxication, stitches and cough with department of a liquid phlegm with streaks of the blood containing a big koyolichestvo of streptococci. The disease in 50-70% of cases oslozhyonyatsya by exudative pleurisy. Symptoms of pleurisy poyavlyayotsya on the 2-3rd days of a disease. Liquid serous or serous and hemorrhagic exudate contains a large number of streptococci. The high leukocytosis with the expressed shift of a neutrophylic formula is characteristic to the left. In 10-15% of cases bacteremia is found.
Reasons of the Acute pneumonia:
The etiological diagnosis of an acute pneumonia opens realyyony perspectives for individual therapy of patients, однако in practical conditions meets great difficulties. It is known that allocation from a phlegm of the patient of certain bakteyoriya does not mean yet that this microbe is prichiyony pneumonia.
Besides, quite often at a bacteriological research of a phlegm of patients with pneumonia associations of mikroyoorganizm are allocated.
If to exclude the pneumonia arising at samostoyayotelny infectious diseases (an ornithosis, a psittacosis, etc.), and also the pneumonia caused by noninfectious factors (medicinal, beam, etc.), then idea of pneumonia as about the process connected generally with the bacterial and viral infection which is characterized by the expressed pnevmotropnost is created. In an etiology of pneumonia, vyyozvanny gram-positive bacteria, the veduyoshchy role (80-95%) belongs to St of pneumoniae that is confirmed not only at bacteriological issledovayoniya, but also results of serological tests [Vishnyakoyova L. A., 1982; Pokhodzey I. V., 1982. - In book: Etiol. and патог. иифекц. process at it is acute, and хрон. восп. забол. lungs]. V. N. Pushkarev (in the same place, 1982) revealed a pneumococcus at kruyopozny pneumonia in 88%, and at focal - in 73%. Especially often the pneumococcus is allocated in the first days of a disease, before purpose of antibacterial therapy. It is proved that acute pneumonias cause pneumococci I, II, III, IV, VII, VIII, IX, XII, XIV, XIX and XXIII serotypes, and in the certain countries narrower group of serotypes prevails.
The majority of strains of a pneumococcus are sensitive to penicillin. Staphylococcus frequency among etiological factors of pneumonia at adults is small and makes 0,4-5%. It is confirmed also by serological methods of a research. The streptococcus and a hemophilic stick (N. of influenzae) are also rare causative agents of an acute pneumonia [Pokhodzey I. V. — In ки.: Etiol. and патог. инфекц. process at it is acute, and хрон. восп. забол. lungs..., 1982]. ,
In an etiology of the secondary pneumonia developing often at patients with chronic diseases of various bodies and siyosty the leading role is played by gram-negative bakyoteriya. According to W. E. Stamm [in book Fishman A., 1980], at patients with chronic bronchopulmonary diseases of a pnevyomoniya Klebsiella pneumoniae, Ps are caused more often. aeruginosa, E. coli, Staph, aureus, Enterobacteriae; at urological bolyyony E. coli, Proteus, Ps. aeruginosa; at surgical - Staph, aureus, E. coli, Proteus, Pr. aeruginosa; at blood diseases - E. coli, Klebsiella, Ps. aeruginosa, Staph, aureus, at skin diseases - Staph, aureus, Ps. aeruginosa, E. coli, Proteus. These activators are important especially at a so-called hospital infection.
The role which increased in recent years conditional патогенных microorganisms in development of acute pneumonias is result of the broad and prolonged use of anyotibakterialny drugs (antibiotics) leading to dysbacteriosis and superinfection and also use of immu-nodepressantpy means.
The etiology of aspiration pneumonia is connected, as a rule, with a mephitic gangrene. It is Bact. melaninogenicus, V. of fragilis, Fusobacterium, Peptostreptococcus, etc. Less often at aspiration pneumonia aerobic vozbuyoditel come to light (Staph, aureus, Str. pneumoniae, Enterobacteriae, Pseudomonas).
According to literature, at 3,2-8,8% of patients the acute pnevyomoniya is caused by viruses, more often it is influenza viruses And, In, adenoviruses, are more rare a parainfluenza virus, a rhinovirus. Bolshinstyovo of researchers consider a respiratory viral infection as one of the major contributing factors to developing of pneumonia which development is connected further with endo-, more rare an exogenous bacterial infection.
Etiological communication of acute pneumonias with a mycoplasma pneumonia, according to literature, is established by from 6 to 51%. Apparently, independent pneumoyoniae value M. in development of pneumonia in adults is limited, and in a bolyyoshinstvo of cases these microorganisms take part in an asyosotsiation with viruses and bacteria. According to V. N. Pushka-rev (Saturday. Etiol. and патог. инф. process at it is acute, and хрон. восп. забол. lungs, 1982), the acute pneumonia at 44,2% of patients was virus and bacterial, M. is revealed by pneumoniae at 6,1% bolyyony, in the majority in association.
Quite often acute pneumonias can accompany and осложнять infectious diseases, such as an ornithosis, whooping cough, measles, chicken pox, a tularemia, a brucellosis, a hay fever, a sibiryosky ulcer, plague, a salmonellosis, a typhoid at which the vosyopaleniye of lungs can be caused by a specific vozbudiyotel of this infectious disease or (thicket) присоединившейся a bacterial infection.
Experience of the Great Patriotic War showed a significant role of an injury in developing of pneumonia. Znachiyotelny frequency of pneumonia at breast wounds (18%) was noted, a stomach (35,8%), skulls (17,5%). After a cranial mozgoyovoy of an injury of pneumonia developed in the first days on the protiyovopolozhny party that gave the grounds to attach sushchestyovenny significance to neurohumoral mechanisms in their vozniknoyoveniya [Molchanov N. With, Stavskaya V. V., 1971].
Treatment of the Acute pneumonia:
Treatment of pneumonia is performed by means of antibiotics which are selected taking into account a contagium. If the contagium is not revealed, apply a combination of penicillin and antibiotics of a broad spectrum of activity. Also drugs for fluidifying of a phlegm and a bronchiectasia – both for internal, and for external use, in the form of inhalations are used.
