Book: “Diseases of the respiratory system VOLUME 2” (N.R. Paleev; 1989)

Chapter 2. Acute pneumonia.

Diagnosis of lung diseases remains an urgent task. Currently, even in specialized centers, the number of post-mortem discrepancies in diagnoses ranges from 4 to 7% [Pilipchuk N. S., 1983].

According to the differential diagnostic commission of the VNIIP from the USSR, the diagnosis of acute pneumonia established in clinics is not confirmed in half of the patients [Kokosov A. N. et al., 1986]. Yu. A. Panfilov et al. (1980) point to the following differential diagnostic tasks:

• 1) distinguishing pneumonia from extrapulmonary diseases;
• 2) differentiation of pneumonia from other respiratory diseases;
• 3) differentiation of pneumonia according to various criteria (etiology, primary or secondary, extent of damage, course, complications, etc.).

Acute pneumonia should be distinguished from diseases of the cardiovascular system associated with stagnation in the pulmonary circulation. A differential sign of congestive wheezing in the lungs is its variability with changes in body position. Certain diagnostic difficulties arise when distinguishing between hypostasis and hypostatic pneumonia.

Swelling of the interstitial tissue of the lung and accompanying atelectasis, with hypostasis, can cause a shortening of the percussion sound, especially in the presence of slight hydrothorax. Therefore, when recognizing hypostatic pneumonia, one should take into account the appearance in the posterior lower parts of the lungs of respiratory sounds with a bronchial tint or even bronchial breathing; increased bronchophony, sudden deterioration of the patient’s condition and increased body temperature.

Making a differential diagnosis between focal pneumonia and pulmonary embolism is of particular importance for everyday therapeutic practice. The threat of thromboembolic complications increases sharply with phlebothrombosis and thrombophlebitis of various localizations, in the acute period of myocardial infarction, in chronic heart diseases with the formation of heart failure and heart rhythm disturbances, after fractures of long tubular bones, in people forced to remain on strict bed rest for a long time, in postoperative period, etc.

Thromboembolism of small branches of the pulmonary artery, which occurs clinically as atypical pneumonia, is characterized by a sudden, often paroxysmal appearance of shortness of breath or dyspnea with sharp pain in the chest, often a delayed (3-5 days) increase in body temperature without preceding chills; absence of pronounced intoxication at the onset of the disease, even at high temperatures, hemoptysis with reddish mucous sputum.

The signs of overload of the right parts of the heart and the degree of hypoxemia detected in some cases do not correspond to the volume of infiltration in the lungs and are observed even in its absence.

Icterus due to thromboembolism of small branches of the pulmonary artery is not accompanied by intoxication and liver damage. Percussion and auscultation symptoms (shortening of percussion sound in a limited area, hard breathing and moist rales, pleural friction noise or signs of pleural effusion) are nonspecific and are not significant in the differential diagnosis.

An important role is played by x-ray examination, which reveals bulging of the pulmonary cone, sharp expansion and chopped off of the root of the lung, regional disappearance or weakening of the vascular pattern, disc-shaped atelectasis and high standing of the diaphragm on the affected side. After a few days, signs of a pulmonary infarction can be observed.

A typical darkening in the shape of a triangle with the apex directed towards the root of the lung is rare. Usually the darkening has the shape of a strip, “rocket” or “pear”, often involving the pleural membranes and the presence of both exudative and adhesive phenomena. The formation of new focal shadows against the background of ongoing antibacterial treatment is typical. Hemogram changes are nonspecific. Of the biochemical indicators, an increase in the level of lactate dehydrogenase and bilirubin is important, while the activity of glutamate dehydrogenase remains within physiological limits.

In patients with acute respiratory viral infection, it is necessary to exclude pneumonia by physical and necessarily x-ray examination if shortness of breath, chest pain, cough increases, an increase in the amount of sputum and especially a change in its character, an increase in malaise, and fever. One of the first symptoms of pneumonia at the end of a viral infection is a second wave of fever.

Diagnosis of viral, mycoplasma or rickettsial pneumonia always requires a chest x-ray.

Differentiation of acute pneumonia and bronchogenic cancer requires in-depth x-ray, bronchoscopic and multiple cytological examinations, especially in elderly men with recurrent acute pneumonia in the same area of ​​the lung.

It is important to take into account the presence on the lateral radiograph of a pronounced shadow overlapping the root of the lung, the discrepancy between the severity of shortness of breath and the volume of pulmonary infiltration, the development of a dry cough before the body temperature rises, and hemoptysis with “unmotivated” chest pain.

Differential diagnosis of acute pneumonia and infiltrative pulmonary tuberculosis sometimes presents significant difficulties, especially when pneumonia is localized in the upper lobes of the lungs and tuberculous lesions in the lower lobes.

It should be borne in mind that the acute onset of the disease occurs twice as often with pneumonia. This corresponds to symptoms of intoxication, rapid development of shortness of breath, cough with sputum, and chest pain. For infiltrative tuberculosis, the gradual or asymptomatic onset of the disease and the lack of effect of conventional antibacterial therapy are more indicative.

Leukocytosis with a shift of the leukocyte formula to the left and an increase in ESR are more likely to be characteristic of pneumonia, while lymphocytosis is characteristic of tuberculosis. The most important diagnostic value is the identification of Mycobacterium tuberculosis in sputum, while the results of the Mantoux test do not always help in the correct recognition of the pathological process.

Thus, according to our observations, a positive tuberculin test was recorded in 39.2% of patients with pneumonia, and a negative one - in 13.3% of patients with tuberculosis.

Sometimes tuberculous lobitis with an acute onset of the disease is mistakenly regarded as lobar lobar pneumonia. Anamnesis and the timing of the reverse development of the infiltrate during treatment are of differential diagnostic importance. Even more often, another form of tuberculosis is mistaken for lobar pneumonia - caseous pneumonia, which can begin acutely, with chills and manifest itself as a change in percussion sound, bronchial breathing, rusty sputum and a corresponding x-ray picture.

However, the sputum soon becomes greenish and purulent; Particularly loud wheezing is heard; hectic fever, night sweats, and signs of collapse of lung tissue are noted; Mycobacterium tuberculosis is sown.

In differential diagnosis, probable predisposing factors of tuberculosis should be taken into account [Kornilova Z. X., Yurchenko L. N., 1986]. The first group of factors includes frequent and prolonged colds, diabetes mellitus, alcoholism, smoking, silicosis, treatment with glucocorticoids, the second group includes contact with a patient with tuberculosis, previous tuberculosis, a positive tuberculin test, lack of effect from nonspecific antibacterial therapy, detection of Mycobacterium tuberculosis and etc.

Significant importance in distinguishing acute pneumonia and tuberculous infiltrate are radiological signs, systematized by A. I. Borokhov and P. G. Dukov (1977) and reflected in Table. 2.8. It is necessary to especially emphasize the importance of x-ray examination for lower lobe localization

tuberculosis. In this case, the lateral tomogram reveals a focal darkening structure with calcified inclusions and foci of dissemination around the main pathological focus [Vorohov A.I., Dukov P.G., 1977]. The differential diagnostic difficulties encountered justify the recommendations of R. Hegglin (1965), according to which each pulmonary process must be considered tuberculous until it is clearly determined that it belongs to another group of diseases.

Complications of acute pneumonia.

Viral-bacterial pneumonia is often accompanied by acute bronchitis, tracheitis, laryngitis, sinusitis, and otitis media. These pathological processes can be considered more likely to accompany acute pneumonia, rather than complicating its course.

The most common complications of acute pneumonia are certain disorders of the respiratory system. These include primarily serous-fibrinous or purulent pleurisy. Pleural effusion is observed on average in 40% of patients with bacterial pneumonia.

It has been established: the longer the patient does not seek medical help after the onset of symptoms of the disease, the greater the likelihood of the formation of pleural effusion. In 10-15% of patients with acute pneumonia, a slight pleural effusion is observed, which is quickly absorbed with adequate therapy. Every patient with lobar pneumonia develops dry pleurisy.

E. M. Gelshtein and V. F. Zelenin (1949) did not consider such forms of pleurisy as a complication of lobar pneumonia. A complication, in their opinion, is the addition of significant serous-fibrous effusion to pneumonia at the height of pneumonia (parapneumonic pleurisy) or after a crisis (metapneumonic pleurisy). They observed empyema in approximately 2% of patients.

Suppurative processes in the lung tissue occur on average in 2.5-4% of patients with acute pneumonia [Fedorov B.P., Vol-Epstein G.L., 1976; Gogin E. E., Tikhomirov E. S., 1979]. The clinical picture of these complications is reflected in the chapter “Abscess and gangrene of the lung.” Complications of destructive processes in the lungs become, in turn, spontaneous pneumothorax and pyopneumothorax.

In severe cases of pneumonia in patients with chronic obstructive bronchitis (especially in elderly and senile people), with a massive, confluent nature of the inflammatory process and destruction of lung tissue, acute respiratory failure may develop, associated with a drop in oxygen tension in the arterial blood (Po2) or an increase in tension carbon dioxide in it (Pco2), or both shifts together.

Based on this, hypoxemic and hypercapnic forms of acute respiratory failure are distinguished, although both types of disorders can be simultaneously observed in the same patient, but one of them usually dominates.

Hypercapnic form of acute respiratory failure with a rise in Pco2 levels above 40 mm Hg. Art. develops mainly with severe respiratory disorders, respiratory depression and previous chronic obstructive pulmonary diseases.

The first signs of acute respiratory failure are confusion and impaired consciousness, sometimes psychotic disorders (especially in people who have abused alcohol), an increase in sinus tachycardia and the appearance of new arrhythmias, arterial hypertension or, conversely, hypotension, distal tremor, increased cyanosis and sweating. If there is a threat of this complication and especially its development, regular monitoring of arterial blood gas parameters is necessary.

Arterial hypoxemia, hypercapnia and metabolic acidosis in combination with severe intoxication and alveolar hypoventilation create conditions for the formation of pulmonary edema in viral or massive confluent pneumonia.

Usually this complication occurs suddenly, but sometimes a prodromal period is observed in the form of a feeling of pressure behind the sternum, anxiety, dry cough, and a feeling of lack of air. The patient assumes the orthopneic position; breathing is difficult, requires physical effort, severe shortness of breath; tachycardia; bubbling breathing with (discharge of white, yellowish or pink frothy sputum; percussion sound over the lungs with a tympanic tinge; many moist rales of various sizes are heard.

Radiographs reveal inhomogeneous darkening initially in the lower parts with gradual filling of all pulmonary fields.

Acute cor pulmonale is observed in confluent total pneumonia. The risk of developing acute cor pulmonale, as well as acute respiratory failure, increases when pneumonia develops against the background of chronic obstructive bronchitis, pulmonary emphysema, and bronchial asthma.

Characterized by increased shortness of breath, cyanosis and tachycardia, acute enlargement of the liver, swelling of the neck veins, and electrocardiographic signs of overload of the right side of the heart.

In severe cases of lobar pneumonia (especially against the background of cerebral atherosclerosis or chronic alcoholism), the development of intoxication psychoses during a critical drop in body temperature is possible; in patients with confluent pneumonia, acute vascular insufficiency sometimes occurs with arterial hypotension, blackouts, gray cyanosis, coldness of the extremities, frequent and small pulse.

Septic complications of acute pneumonia, especially infectious-toxic (septic) shock, are extremely difficult. Lobar pneumonia (especially left-sided) can be complicated by purulent pericarditis and mediastinitis. Staphylococcal, less commonly streptococcal and pneumococcal pneumonia can sometimes cause septic endocarditis.

The septic process with bacterial pneumonia can result in the development of secondary purulent meningitis. With mycoplasma pneumonia, meningoencephalitis occasionally occurs, with influenza pneumonia - encephalitis. There are also infectious-toxic lesions of the liver, kidneys and urinary tract, joints, and salivary glands.

Infectious-allergic myocarditis can occur with all types of pneumonia; in case of septic complications, this is accompanied by infectious-toxic damage to the myocardium. In the clinical picture of the general infectious process, the symptoms of myocarditis in most cases are secondary. However, in some cases, myocarditis can be severe, complicated by progressive heart failure and lead to death [Sumarokov A.V., Moiseev V.S., 1978].

Treatment of pneumonia It must be early, rational, individual and complex. Components of the treatment complex: fight against infection and intoxication; activation of the body's defenses; normalization of impaired functions of organs and systems; acceleration of regenerative processes.

K. G. Nikulin (1977) proposes to subdivide the complex of therapeutic measures depending on the stage of the pneumonic process:

• 1) bacterial aggression;
• 2) clinical stabilization;
• 3) morphological
• 4) functional recovery.

At the stage of bacterial aggression and stabilization of the process, antibacterial therapy should be the main one.

Patients with acute pneumonia must be treated in a hospital, although bed rest for uncomplicated cases is prescribed only for the period of fever.

Treatment at home is possible if the disease is mild and treatment is carried out in full. After normalization of body temperature, the patient is allowed to walk and care for himself.

At the same time, proper patient care has not lost its importance to this day (spacious room, good lighting and ventilation). The bed should have a fairly firm mattress, which is comfortable for the patient and facilitates his examination. Cool air is maintained in the ward, which improves sleep, deepens breathing and stimulates mucociliary function of the bronchial tree.

Oral care and abundant (up to 2.5-3 liters per day) drinking (fruit drinks, liquid fruit, berry, vegetable juices) are necessary, with a diuresis of at least 1.5 liters per day. The diet of a patient with pneumonia during a febrile period consists of a variety of easily digestible foods containing sufficient amounts of proteins, fats, carbohydrates, microelements, and vitamins.

Antibacterial therapy

Antibacterial therapy should be:

• 1) early and course, taking into account the nature of the pathological process and the patient’s condition;
• 2) directed against an identified or suspected pathogen;
• 3) adequate in terms of the choice of drug (pharmacokinetics and pharmacodynamics), permissible doses (single and daily) and method of administration;
• 4) corrected during treatment depending on the clinical effect, sensitivity of the pathogen and possible side effects of the drug.

The severity of the patient’s condition determines the choice of an antibacterial drug of a bactericidal type and the possibility of its intravenous administration. Early etiotropic therapy, predominantly with one (according to the etiology) drug, gives the same immediate and long-term results as long-term treatment with combinations of antibacterial drugs without taking into account the etiology of the disease.

When establishing an early etiological diagnosis, combinations of antibacterial agents are required only for pneumonia caused by gram-negative bacteria (Klebsiella, Pseudomonas aeruginosa, Proteus, etc.), with association of pathogens and the absence of one antibiotic that affects all pathogenic agents, resistance of the pathogen to several antibiotics, as well as with in order to overcome the emerging resistance of microorganisms when long-term treatment with antibiotics is necessary.

It should be borne in mind that acquired resistance in microorganisms depends on the duration of use and the breadth of action of the antibiotic, on the type of microorganism and the type of antibiotic. Naturally, bacteriological examination of sputum with quantitative calculation of the content of microorganisms in 1 ml increases the accuracy of the etiological diagnosis of pneumonia, and the determination of an antibiogram contributes to the choice of therapeutic drug.

Therapy with a drug selected based on epidemiological and clinical-radiological data without bacterioscopic, bacteriological, or immunological confirmation of the etiology remains largely empirical.

Adequate etiotropic therapy ensures a decrease in body temperature after 2-3 days, after which treatment is continued in an effective dose for 3-4 days of a fever-free state with possible discontinuation of the drug when the leukogram is normalized or, as most authors believe, after 6 days of normal body temperature. The presence of residual infiltration of lung tissue after 5-6 days of normal temperature is not an obstacle to discontinuation of the antibacterial drug.

Taking into account whether an antibiotic belongs to a specific chemical group eliminates the use of drugs of the same type and allows for a rational transition from one group to another if toxic or allergic reactions occur.

For example, if a patient is allergic to penicillins, a patient can be treated with macrolides due to the different chemical structure of the core of these medications. It should be emphasized that when resistance to an antibiotic from a certain chemical group develops, resistance to other drugs in this group also occurs.

Cross-resistance also occurs between antibiotics of different chemical groups, for example, between erythromycin and chloramphenicol, semi-synthetic penicillins (methicillin, cloxacillin) and cephaloridine.

The type of action of the antibiotic is essential - bacteriostatic or bactericidal. The acute course of the inflammatory process, the serious condition of the patient, and signs of suppression of natural immunity dictate the need to use bactericidal drugs. The type of action is also taken into account in combination therapy with antibiotics. It is irrational to combine a drug with bactericidal and bacteriostatic action.

The spectrum of action of the antibiotic determines the choice of drug depending on the etiology of the disease, i.e., the nature of the microorganism. It is natural, for example, for pneumonia caused by pneumococcus (a gram-positive microorganism), to use a drug from the group of antibiotics with an average spectrum of action on gram-positive microorganisms.

At the same time, we should not forget about the possible resistance of microorganisms to antibiotics of each group. Therefore, an antibiotic is prescribed taking into account this very important factor that determines the success of treatment. Different colonies of microorganisms may differ in sensitivity to the antibiotic.

This must be taken into account when analyzing the results of therapy, when incomplete effectiveness can be overcome by increasing the concentration of the antibiotic in the blood. In principle, an antibiotic dose is considered adequately effective if it is possible to achieve a concentration in the blood that is 2-3 times higher than the minimum inhibitory concentration (MIC).

However, the use of broad-spectrum antibiotics (i.e., affecting gram-positive and gram-negative cocci) is not always justified. Thus, if a patient with staphylococcal pneumonia is resistant to benzylpenicillin, one can resort to methicillin or oxacillin - drugs that are not inactivated by staphylococcal penicillinase.

In order to solve practical issues of antibacterial tactics, one should keep in mind the degree of sensitivity of microorganisms to the agent chosen for treatment. Resistance is distinguished in biological and clinical terms.

Resistance in biological terms means that higher concentrations of antibiotics are required to suppress a given species or strain of microorganism than other species or strains of the same microorganism. In clinical terms, resistance is defined as the inability to create a therapeutic concentration of a drug at the site of infection due to the peculiarities of its pharmacokinetics or toxicity.

So, if pneumonia is complicated by pleural empyema and the sensitivity of the pathogen to penicillin is confirmed by a study, intramuscular and intravenous administration of this drug will be ineffective, since its concentration in the pleural cavity will be only 20-30% of its content in the blood. When abscess formation occurs, the antibiotic content in the lesion decreases due to the pyogenic membrane.

This barrier is overcome by the influence of the antibiotic on the site of infection through a catheter inserted into the drainable bronchus. Thus, the method of administration of an antibiotic or other agent is a matter of therapeutic tactics and is justified by the need to create an effective concentration in the pneumonic focus.

In pulmonology, the following methods of drug administration are used: oral, intramuscular, intravenous, intratracheal, transtracheal, intrabronchial and transthoracic. The indication for intravenous administration of antibiotics is the need to quickly create a high concentration of the drug in the blood. If multiple infusions and prolonged administration of antibiotics are necessary, a permanent catheter is installed in the jugular or subclavian vein.

The transthoracic method of using drugs is indicated in the presence of large abscess cavities located superficially. It is possible to simultaneously use several methods of administration, for example, intravenous, intramuscular and intrabronchial during sanitation bronchoscopy in patients with severe staphylococcal pneumonia [Gembitsky E.V. et al., 1982].

A measure of the sensitivity of microorganisms to antibiotics in laboratory conditions is the minimum concentration of antibiotic calculated per 1 ml of nutrient medium, which retards the growth of the pathogen under stationary experimental conditions.

In clinical conditions, the division of microorganisms into more sensitive and resistant ones should be made on the basis of the correspondence of the minimum inhibitory concentration of the antibiotic, determined in laboratory conditions, to the concentration of the drug created in the blood, urine, bile, and organ tissues when non-toxic doses are administered.

For practical purposes, it is recommended to divide microorganisms according to the degree of sensitivity to antibiotics into 4 groups. The first group includes sensitive microorganisms; Regardless of the severity of the disease they cause, the doses of antibiotic usually used are sufficient to achieve a therapeutic effect.

The second group includes moderately sensitive microorganisms; To achieve a therapeutic effect for the disease caused by them, increased doses of the antibiotic are necessary. The third group includes weakly sensitive microorganisms; the therapeutic effect in these cases can be achieved with a high concentration of the antibiotic at the site of infection, in particular by administering the drug directly to the site of inflammation.

The fourth group includes resistant microorganisms; in this situation, a therapeutic effect cannot be achieved with this antibiotic.

The minimum inhibitory concentrations of antibiotics according to the sensitivity groups of microorganisms are presented in Table. 2.9.

There are natural, primary and acquired resistance of a microorganism to an antibacterial agent. The natural resistance of bacteria to a particular antibacterial agent is specific

a feature of a microorganism, its biological essence. As a result, the microorganism only responds to certain antibiotics and does not respond to others (for example, E. coli is naturally resistant to penicillin).

Acquired resistance of microorganisms occurs during treatment with antibiotics. The mechanism of this resistance and the rate of its occurrence are different. In clinical practice, the problem of resistance of staphylococci, as well as a number of gram-negative microorganisms (Klebsiella, Proteus, Salmonella, etc.) is currently particularly relevant.

At the same time, the rate of emergence of acquired resistance should be taken into account. Resistance to streptomycin, erythromycin, kanamycin develops rapidly; slowly - to chloramphenicol, penicillin, tetracycline, gentamicin, lincomycin.

Therefore, a categorical recommendation to change antibiotics during long-term treatment every 7-10 days cannot always be accepted [Fedoseev G. B., Skipsky I. M., 1983]. It must be emphasized that the emergence of rapid resistance can be prevented by the simultaneous use of 2-3 drugs.

If it is necessary to replace a drug, it is necessary to take into account the possibility of cross-resistance not only within one group of antibiotics, but also between groups.

Cross-resistance is observed in the following groups:

• 1) tetracyclines (among each other);
• 2) tetracycline and chloramphenicol (for gram-negative flora);
• 3) aminoglycosides (kanamycin, neomycin, gentamicin) and streptomycin (but not vice versa);
• 4) erythromycin, oleandomycin, lincomycin;
• 5) erythromycin, chloramphenicol;
• 6) methicillin and cephaloridine;
• 7) penicillin and erythromycin (partial resistance).

A combination of antibiotics is used to increase the effectiveness of therapy. But this should not be a simple pile of drugs.

The combined use of antibiotics has its own strict indications:

• 1) unknown bacteriological nature of the infection;
• 2) the presence of mixed flora;
• 3) severe diseases that are not susceptible to the influence of a specific antibiotic;
• 4) persistent infections.

According to S. M. Navashin and I. P. Fomina (1982), combination antibiotic therapy should be based on knowledge of the mechanism of action and spectrum of antibiotics, the characteristics of the pathogen, the nature of the pathological process and the patient’s condition.

To prevent polypharmacy, the use of combination antibacterial therapy should be justified each time (Table 2.10). Using the synergistic action of various drugs, it is sometimes possible to prevent or reduce a side effect by reducing the dose of each antibiotic.

Analyzing the general provisions of adequate combined antibacterial therapy for acute pneumonia, it should be noted that antibiotics in combination with sulfonamides are used for pneumonia caused by Klebsiella, Pseudomonas aeruginosa, various mixed infections, as well as actinomycosis, plague, listeriosis.

In all cases, the combination of sulfonamides (especially long-acting ones) with antibiotics does not lead to an increase in the therapeutic effect, but increases the risk of adverse reactions [Navashin S. M., Fomina I. P., 1982].

In acute pneumonia, early antibacterial therapy begins before the pathogen is isolated and its antibiogram is determined. The choice of the initial antibacterial agent is based on epidemiological data, clinical-pathogenetic and clinical-radiological features of the disease, taking into account the patient’s medical history before the development of acute pneumonia.

Until an etiological diagnosis is established, antibacterial therapy remains empirical in nature. With regard to bacterial pneumonia, this difficulty is overcome to some extent by examining a Gram-stained sputum smear. The main pathogens isolated in various clinical forms of pneumonia are given in Table. 2.11.

In our country, the most famous scheme for choosing an antibiotic for acute pneumonia of unknown etiology, proposed by S. M. Navashin and I. P. Fomina (1982). Antibiotics have been identified for each form of acute pneumonia

first and second stages (Table 2.12). Instead of cephalothin, you can use kefzol (cefazolin, cefamezine) or other drugs from the cephalosporin group.

For staphylococcal etiology of acute pneumonia, first-generation cephalosporins are preferable, since they are most resistant to staphylococcal penicillinase.

The causative agents of acute pneumonia that occurs in a previously healthy person are usually considered to be viruses, pneumococci, mycoplasma and legionella. In this regard, treatment of such patients most often begins with penicillin (at an average dose of up to 6,000,000 units/day intramuscularly).

The drug of choice is erythromycin (0.25-0.5 g orally every 4-6 hours or 0.4-0.6 g, sometimes up to 1 g/day intravenously), especially effective for mycoplasma or legionella pneumo-

NI. The development of destructive processes in the lung tissue makes it advisable to use cephalosporins: cephaloridine (ceporin) up to 6 g/day, cefazolin (kefzol) 3-4 g/day or cephaloxime (claforan) up to 6 g/day intramuscularly or intravenously. With intramuscular administration of 1 g of claforan, its content in sputum reaches 1.3 μg/ml, 20-130 times higher than the MG1K of possible pathogens.

Certain difficulties arise in the treatment of acute pneumonia in pregnant women, in elderly and senile people, as well as in the development of secondary pneumonia in people hospitalized for other diseases.

In the first case, natural and semi-synthetic penicillin, erythromycin, fusidine and lincomycin are considered the drugs of choice; in the second, semisynthetic penicillins (in particular, ampicillin 2-4 g/day intramuscularly); in the third case, two options for empirical antibacterial therapy are provided.

If a limited pulmonary infiltrate is detected, the most likely causative agents of pneumonia are aerobic gram-negative microorganisms (Klebsiella, Escherichia coli, Pseudomonas aeruginosa) or staphylococcus.

Such patients are prescribed a combination of antibiotics from the group of cephalosporins and aminoglycosides. If improvement is observed within 72 hours, then this therapy is continued for 2 weeks.

If there is no effect and it is impossible to invasively diagnose the etiology of pneumonia, the therapy is expanded to include drugs aimed at Legionella (erythromycin), Pneumocystis (Biseptol) and fungi (amphotericin B).

In the second option of empirical antibacterial therapy, used in patients with diffuse infiltrate in the lungs, bactrim is immediately added to the combination of cephalosporin and aminoglycoside antibiotics.

If the course of the disease is favorable, empirical antibacterial therapy should continue until the patient’s body temperature is stable. When using penicillin, cephalosporins or erythromycin, its duration is usually at least 10 days.

The severe course of the disease makes it necessary to carry out antibacterial therapy until the infiltrative changes in the lungs are completely resolved. At the same time, the persistence of radiological changes with complete normalization of the patient’s well-being cannot serve as an indication for continued antibacterial therapy. For Legionnaires' disease, treatment with erythromycin lasts 21 days.

It should be noted that the use of broad-spectrum antibiotics and the combination of antibacterial agents that affect both the pathogenic and non-pathogenic flora of the patient create a threat of the emergence of resistant species of microorganisms or the activation of saprophytes, which under normal conditions do not affect the lungs.

It is known that prescribing excessive doses of antibiotics can cause pulmonary superinfection with persistent fever. To avoid this, it is advisable to use antibacterial agents in the lowest effective doses; in this case, one should strive for monotherapy, which is preferred in modern pulmonology [Sergeyuk E. M., 1984].

Combined antibacterial therapy is considered justified in cases of severe disease that requires immediate initiation of treatment without an etiological diagnosis.

Rational antibacterial therapy, in contrast to empirical therapy, is determined by the etiological focus, taking into account the pharmacokinetics and pharmacodynamics of the prescribed drug (Table 2.13). Approximate doses of antibacterial drugs for the treatment of acute pneumonia are given in Table. 2.14.

Penicillins and cephalosporins are currently the main antibacterial drugs used in medical practice in general, including in the treatment of acute pneumonia. This is due to their high activity against

resistance to microorganisms and minimal toxicity compared to other antibiotics. These groups of antibiotics are generally characterized by a bactericidal type of action, high activity against gram-positive and gram-negative microorganisms, and good tolerability even with long-term use.

If to “old”, traditionally apply

antibiotics (benzylpenicillin, streptomycin, tetracycline, chloramphenicol) the frequency of isolation of resistant strains is 40-80%, while for semisynthetic penicillins and cephalosporins it varies within 10-30% [Navashin S. M., Fomina I. P., 1982] .

The class of penicillins includes penicillinase-resistant drugs (methicillin, oxacillin and dicloxacillin), resistant to the action of staphylococcal penicillinase, and broad-spectrum drugs - ampicillin, ampiox (a combined form of ampicillin with oxacillin), carbenicillin.

Cephalosporin drugs are distinguished by a wide spectrum of antibacterial action, resistance to staphylococcal penicillinase, and high activity against benzylpenicillin-resistant penicillinase-forming staphylococci; When using these drugs, incomplete cross-allergy with penicillins is possible.

When developing therapeutic tactics, it is necessary to take into account that oxacillin and dicloxacillin have pronounced lipophilic properties and acid stability, which is associated with their good absorption and effectiveness when taken orally.

Methicillin is destroyed by gastric acid, so it is effective only when administered parenterally. In relation to penicillinase-forming staphylococcus, the activity of oxacillin and dicloxacillin is 5-8 times higher than the activity of methicillin.

Dicloxacillin is 2-4 times more active than oxacillin and methicillin against benzylpenicillin-sensitive and resistant strains of staphylococci, therefore it is used in significantly lower doses (2 g, in severe cases no more than 4 g), while oxacillin it is necessary to prescribe 6-8 g or more.

All three penicillinase-stable penicillins are characterized by lower (compared to benzylpenicillin) activity against staphylococci that do not form penicillinase, as well as pneumococci and group A streptococci; Therefore, for pneumonia caused by these pathogens, benzylpenicillin remains the first choice antibiotic.

At the same time, none of the penicillinase-stable penicillins is effective against pneumonia caused by so-called methicillin-resistant multi-resistant staphylococci. The possibility of cross-allergy to these three drugs is of significant importance for therapeutic practice.

The group of broad-spectrum semisynthetic penicillins is represented by ampicillin, carbenicillin and ampiox. Ampicillin has established itself as a highly effective remedy in the treatment of pneumonia.

Most strains of Proteus, Escherichia coli and Haemophilus influenzae are sensitive to it. Ampicillin is highly active (at the level of benzylpenicillin) against pneumococci and group A streptococci.

Compared to other penicillins, it has the most pronounced activity against enterococci.

However, ampicillin, like benzylpenicillin, does not act on penicillinase-forming staphylococci. When isolating penicillinase-negative staphylococci, preference should be given to benzylpenicillin.

Ampicillin is also ineffective against diseases caused by 3-lactamase-producing strains of Escherichia coli, Proteus, Enterobacter and Klebsiella. The lack of effect of ampicillin in diseases caused by Pseudomonas aeruginosa is due to the natural resistance of these microorganisms to this antibiotic.

The antibacterial effect of ampicillin is enhanced when combined with aminoglycosides (kanamycin, gentamicin) and oxacillin.

Ampiox, a combination drug of ampicillin and oxacillin, is used as a means of rapid action in the form of injections and orally. The drug is active against penicillinase-forming staphylococci, streptococci, Escherichia coli and Haemophilus influenzae, Proteus and is especially indicated for microbial associations before obtaining the results of an antibiogram.

Carbenicillin has noticeable activity against Pseudomonas aeruginosa, all types of Proteus and some bacteroides. It acts on other gram-negative microorganisms in the same way as ampicillin. The drug is indicated primarily for the destruction of lung tissue caused by Pseudomonas aeruginosa, Proteus of all types and ampicillin-resistant strains of Escherichia coli.

Despite its wide spectrum of action, carbenicillin is inferior to other antibiotics in the treatment of pneumonia caused by gram-positive pathogens. The combination of carbenicillin with penicillinase-resistant penicillins, as well as with gentamicin, is considered one of the optimal methods for treating secondary pneumonia.

In cases of severe pneumonia, obviously mixed flora, or the impossibility of identifying it, cephalosporins are the drugs of choice. First generation cephalosporins (cephalothin, cephaloridine) are active against gram-positive and gram-negative cocci, most rod-shaped microorganisms.

The next generations of cephalosporins are distinguished by more pronounced activity and a wider spectrum of action. Cefuroxime is superior in activity to cephalothin and cephaloridine against Klebsiella, Proteus and other microorganisms; Cefotaxime has even higher activity. In severe cases of pneumonia with destruction of lung tissue, the drug of choice for monotherapy is cefuroxime.

Aminoglycosides occupy one of the leading places in the treatment of pneumonia caused by gram-negative bacilli (Ps. aeruginosa, Proteus) or their associations with gram-positive cocci. After a single intramuscular injection of gentamicin at a dose of 80 mg in 24 hours, 89.7% of the dose taken is released; in this case, most of the drug (80% of the administered dose) is excreted within 8 hours.

These data determine three times the daily dose of the drug. With a daily dose of 240-320 mg of gentamicin, a good effect is achieved in 71.4% of patients, satisfactory - in 28.6’% [Zamataev I.P. et al., 1980].

If it is necessary to expand the spectrum of action or enhance the bactericidal effect, aminoglycosides are used in combination with semisynthetic penicillins or cephalosporins. Such combinations are usually prescribed before establishing a bacteriological diagnosis and determining the antibiogram of the pathogen in hopes of expanding the spectrum of action to include the suspected pathogens. The drugs are used in medium rather than maximum doses, which helps reduce the frequency of side effects.

Due to the nephrotoxicity of cephaloridine and gentamicin and the danger of additive effects when combined, it is advisable to combine gentamicin with cefazolin.

Broad-spectrum antibiotics also include kanamycin, the second drug in the treatment of purulent-inflammatory pulmonary diseases caused predominantly by gram-negative microorganisms resistant to other antibiotics, or a combination of gram-positive and gram-negative microbes.

Of the tetracycline drugs used in the treatment of pneumonia, doxycycline (a semi-synthetic derivative of oxytetracycline) is of particular interest. The drug is active against most gram-positive and gram-negative microorganisms and has an exceptional duration of action.

The antibiotic is quickly absorbed from the gastrointestinal tract and remains in high concentration in biological fluids and tissues throughout the day.

With normal renal function, 1 hour after taking 0.1 g of doxycycline, the concentration of the drug in the blood serum reaches 1.84 mcg/ml, increases after 2-4 n and remains at a high level (2.8 mcg/ml) up to 12 hours [ Zamotaev I.P. et al., 1980]. On the first day, the drug is prescribed at a dose of 0.1 g every 12 hours; in subsequent days, 0.1 g/day. When using doxycycline in the treatment of acute pneumonia, cure is observed in 64.1% of patients, improvement in 28.1% [Slivovski D., 1982].

Lincomycin is indicated for the treatment of acute pneumonia caused by gram-positive microorganisms resistant to other antibiotics (staphylococci, streptococci, pneumococci), as well as allergies to drugs of the penicillin group.

The use of lincomycin may be accompanied by severe side effects. In this regard, the drug should not be prescribed when other less toxic antibiotics are effective. Lincomycin-resistant pneumococci, viridans and pyogenic streptococci are rarely isolated. At the same time, during treatment, staphylococci may develop resistance to the antibiotic.

After 6-10 days of therapy with lincomycin, 20% or more strains of staphylococci resistant to its action are sown, so long-term use of the antibiotic requires constant monitoring of the sensitivity of the pathogen.

Fusidine is an alternative drug against staphylococci, including those resistant to other antibiotics. Maximum concentrations of the drug in the blood are reached 2-3 hours after ingestion and remain at therapeutic levels for 24 hours.

For staphylococcal destruction of the lungs, especially those caused by methicillin-resistant strains, it is recommended to use a combination of fusidine with methicillin, erythromycin, novobiocin, and rifampicin.

Rifampicin is a broad-spectrum antibiotic with bactericidal activity against gram-positive microorganisms and mycobacterium tuberculosis.

For acute pneumonia, the drug is prescribed primarily in cases where the disease is caused by multidrug-resistant staphylococci [Pozdnyakova V.P. et al., 1981; Navashin S.M., Fomina I.P., 1982].

Treatment with rifampicin should be carried out under careful observation and antibiogram monitoring, since its use can cause the emergence of resistant strains of bacteria relatively quickly. The duration of treatment is determined individually depending on the severity of the disease.

Erythromycin is the main treatment for Legionella pneumonia and an alternative drug against pneumococci, streptococci, staphylococci, and rickettsia. Erythromycin has preferential activity against coccal forms of microorganisms, including strains of staphylococci resistant to penicillin, tetracycline, streptomycin and other antibiotics.

For most sensitive microorganisms, the MIC of the antibiotic ranges from 0.01-0.4 μg/ml. The sensitivity limit to erythromycin is determined by the average concentration of the antibiotic in the blood and is 3-5 mcg/ml.

After a single oral dose of 500 mg of antibiotic, its maximum concentration in the blood serum (0.8-4 μg/ml) is observed after 2-3 hours, and after 6-7 hours it decreases to 0.4-1.6 μg/ml. Erythromycin may be the drug of choice for the treatment of pneumonia in outpatient settings in people under 40 years of age if they cannot obtain sputum for bacterioscopic examination.

Levomycetin is used as the main remedy (along with tetracycline drugs) for Curicettsial pneumonia. In other cases, it is rarely prescribed as the first drug for the treatment of acute pneumonia due to possible side effects.

The drug is effective against a number of gram-positive and gram-negative microorganisms, including those resistant to penicillin and ampicillin. For mixed aerobic and anaerobic microflora, a combination of chloramphenicol with an aminoglycoside antibiotic is recommended. For anaerobic infection, metronidazole is also included in the drug complex.

Sulfonamide drugs have not lost their importance in the treatment of acute focal pneumonia of mild and moderate severity (especially pneumococcal etiology).

Their use has expanded with the introduction into clinical practice of long-acting drugs (sulfapyridazine, sulfamonomethoxine, sulfadimethoxine, etc.), as well as the combination of sulfamethoxazole with trimethoprim (Bactrim), which provides an antibacterial effect comparable to the effect of antibiotics.

When using sulfonamides, interruptions in treatment should not be allowed; taking the drugs must be continued for 3-5 days after the elimination of the main symptoms of the disease.

The duration of the course of treatment is on average 7-14 days. To prevent side effects during treatment with sulfonamides, prophylactic vitamin therapy is prescribed.

When sulfonamides are combined with erythromycin, lincomycin, novobiocin, fusidine and tetracycline, the antibacterial activity is mutually enhanced and the spectrum of action is expanded; when they are combined with rifampicin, streptomycin, monomycin, kanamycin, gentamicin, nitroxoline, the antibacterial effect of the drugs does not change.

It is not advisable to combine sulfonamides with nevigramon (antagonism is sometimes noted), as well as ristomycin, chloramphenicol and nitrofurans due to a decrease in the total effect [Pyatak O. A. et al., 1986].

The rationality of combining sulfonamides with penicillins is not shared by all authors [Gogin E. E. et al., 1986].

The most widely used in modern clinical practice is Bactrim (Biseptol), a combination drug containing 400 mg (800 mg) of sulfamethoxazole and 80 mg (160 mg) of trimethoprim in one tablet.

The drug is quickly absorbed; its maximum concentration in the blood is observed 1-3 hours after ingestion and persists for 7 hours. High concentrations are created in the lungs and kidneys. Within 24 hours, 40-50% of trimethoprim and about 60% of sulfamethoxazole are released.

In a number of patients, the use of nitroxoline, which has antibacterial activity against gram-positive and gram-negative microorganisms and is effective against some fungi of the genus Candida, is indicated.

When nitroxoline is co-administered with nystatin and levorin, a potentiation of the effect is observed. Nitroxoline cannot be combined with nitrofurans.

For the prevention and treatment of candidiasis with long-term use of antibiotics, as well as for the treatment of visceral aspergillosis, levorin is prescribed orally and in the form of inhalations. Amphotericin B has high activity against many pathogenic fungi.

A characteristic feature of amphotericin B compared to other drugs is its effectiveness in deep and systemic mycoses. The drug is administered intravenously or inhaled.

Thus, the basis for the success of antibacterial therapy is compliance with its principles: timely administration and etiotropy of chemotherapeutic effects, selection of the most effective and least toxic drug, taking into account the pharmacokinetic characteristics of the drug, dynamic monitoring of the sensitivity of microorganisms to the drugs used.

Timely withdrawal of antibacterial drugs is also of considerable importance for preventing toxic and allergic complications of antibacterial therapy and normalizing the body’s immunological reactivity.

Nonspecific therapy

In case of severe lobar or viral-bacterial pneumonia and its complication by acute destruction of lung tissue, active detoxification therapy is necessary.

For this purpose, intravenous drip transfusions of rheopolyglucin (400-800 ml/day), hemodez (200-400 ml/day), single-group hyperimmune (antistaphylococcal, antiprotean, antipseudomonas) plasma (at the rate of 4-5 ml/kg for 10- 12 days).

Severe dehydration and a tendency to develop acute vascular insufficiency serve as the basis for transfusion of protein, as well as a 5 or 10% albumin solution. For arterial hypotension with clear peripheral signs of collapse, 60-90 mg of prednisolone or 100-250 mg of hydrocortisone in 200-400 ml of isotonic sodium chloride solution is administered intravenously.

Along with this, 1-2 ml of cardamine or 10% sulfocamphocaine solution is administered parenterally. If necessary, cardiac glycosides are also used (0.5 ml of 0.06% solution of corglycone or 0.05% solution of strophanthin 1-2 times a day intravenously).

Progressive right ventricular failure in combination with hemoptysis, increasing thrombocytopenia and increased fibrinogen content in the blood plasma makes it necessary to use heparin (up to 40,000 - 60,000 units/day) in combination with antiplatelet agents (dipyridamole 0.025 g 3 times a day), xanthinol nicotinate 0.15 g 3 times a day, pentoxifylline 0.2 g 3 times a day or 0.1 g intravenously in an isotonic sodium chloride solution 2 times a day.

Nonsteroidal anti-inflammatory drugs (acetylsalicylic acid - 0.25-0.5 g/day, indomethacin - 0.025 g 3 times a day) also act as antiplatelet agents; These same drugs are used as antipyretics and analgesics for pain caused by damage to the pleura.

For hemoptysis, codeine preparations are indicated; for pulmonary hemorrhage, parenteral administration of 1 ml of a 1% morphine solution is indicated.

A dry, non-productive cough, which debilitates the patient and disrupts sleep, becomes an indication for the prescription of non-narcotic antitussive drugs (glaucine 0.05 g, libexin 0.1 g or tusuprex 0.02 g 3-4 times a day), which do not depress respiration, do not inhibit intestinal motility and do not cause drug dependence.

Attacks of dry, painful cough with scant discharge of very viscous sputum may be based on bronchospasms, inflammatory swelling of the bronchial mucosa and hypersecretion of the bronchial glands with the formation of bronchial obstruction syndrome.

It is assumed that the phenomena of bronchial obstruction are accompanied by activation of cholinergic mechanisms against the background of adrenergic imbalance [Yakovlev V.N. et al., 1984].

In these cases, drugs with a bronchodilator effect are indicated: aminophylline (5-10 ml of a 2.4% solution intravenously), atropine (inhalation of fine aerosols), as well as salbutamol, fenoterol (Berotec), Atrovent or Berodual, produced in aerosol packaging with a dosing valve for use as a personal inhaler.

In the resolution phase of pneumonia, solutan has a distinct bronchodilator and expectorant effect (10-30 drops orally 2-3 times a day after meals or 12-15 drops in 10-15 ml of isotonic sodium chloride solution in the form of inhalations).

Oxygen therapy is of eternal importance for bronchial obstruction syndrome. To calm and soften a dry cough in the first days of acute pneumonia, inhalations of sodium bicarbonate or sodium chloride (warm aerosols such as fogs), as well as eucalyptus, turpentine or thymol essential oils, which have a bronchodilator, expectorant and antiseptic effect, are used.

In case of difficulty in sputum discharge, expectoration-stimulating medicines of reflex action are prescribed (terpine hydrate, sodium benzoate, thermopsis preparations, marshmallow, licorice, elecampane, thyme, anise and other medicinal plants), and in case of increased viscosity of sputum, drugs of resorptive action (mainly 3% potassium iodide solution , which is taken 1 tablespoon 5-6 times a day after meals or with milk).

In addition, mucolytic agents that thin the sputum are used: acetylcysteine ​​(mucosolvin) in inhalation, bromhexine (bisolvone) orally (4-8 mg, i.e. 1-2 tablets 3-4 times a day), proteolytic enzymes (trypsin, chymotrypsin , chymopsin), ribonuclease or deoxyribonuclease in inhalation in the form of fine aerosols.

If the above medications are ineffective or insufficiently effective and the bronchi are obstructed by mucous or purulent secretions, therapeutic bronchoscopy with evacuation of the contents of the bronchial tree and rinsing of the bronchi with a 0.1% furagin solution is indicated; repeated therapeutic bronchoscopy is necessary for obstructive atelectasis and the development of acute lung abscess.

Among the nonspecific local protective factors in pneumonia, the function of neutrophilic granulocytes and alveolar macrophages is important. Their phagocytic activity increases under the influence of lysozyme and interferon.

It was found that interferon at a dilution of 1:8 or 1:16 enhances phagocytosis and metabolic activity of peripheral blood granulocytes, while low (1:32) or too high (1:2) dilution does not significantly affect these indicators [Chernushenko E V. et al., 1986].

The use of 3 ampoules of interferon per inhalation (a course of 10-12 inhalations) ensures a more rapid increase in the interferon response of leukocytes and an improvement in clinical, laboratory and radiological parameters.

For a nonspecific effect on the immunobiological properties of the body and to increase the patient's reactivity, aloe, FiBS, and autohemotherapy are used.

We more often use FiBS 1 ml once a day subcutaneously (for a course of 30-35 injections). To speed up regeneration, methyluracil is prescribed 1 g 3-4 times a day for 10-14 days. In case of purulent intoxication and slow reparation in debilitated patients, it is possible to use anabolic agents (sublingual nerobol 5 mg 2 times a day for 4-8 weeks; retabolil 1 ml once every 7-10 days, 4-6 injections).

In case of prolonged pneumonia, glucocorticoids are indicated along with treatment with antibacterial agents. B. E. Votchal (1965) in these cases recommended prescribing prednisolone in a daily dose of 30-40 mg for a period of 5-7, less often 10 days with rapid discontinuation of the drug.

Physical methods of treatment can accelerate the resorption of inflammatory infiltrates, reduce intoxication, normalize ventilation of the lungs and blood circulation in them, mobilize protective processes, and achieve analgesic and desensitizing effects.

Physiotherapy should not be prescribed during periods of severe intoxication, in severe condition of the patient, body temperature above 38 ° C, congestive heart failure, hemoptysis.

During the period of active inflammation, simultaneously with early antibacterial pharmacotherapy, an ultra-high frequency (UHF) electric field is applied to the lesion area in the lung. At the same time, exudation in tissues decreases, capillary blood circulation is actively restored, and swelling of inflamed tissues decreases.

Under the influence of the UHF electric field, the vital activity of bacteria decreases, local phagocytosis increases, the creation of a leukocyte bank and the delimitation of the source of inflammation from healthy tissues are accelerated.

The power of the UHF electric field for treating adults is 70-80 - 100 W. Procedures lasting 10-15 minutes are carried out daily. The course of treatment is 8-10-12 procedures.

During the period of resorption of pronounced infiltrative phenomena, preference is given to microwave therapy - exposure to ultra-high frequency (microwave) electromagnetic radiation fields.

Microwaves have an anti-inflammatory effect, changing blood circulation in tissues, stimulating regenerative processes, increasing the synthesis of glucocorticoids in the adrenal cortex, causing slowing and deepening of breathing, reducing ventilation-perfusion disorders and tissue hypoxia.

The use of microwaves in acute pneumonia leads to accelerated resolution of infiltrative changes in the lungs, restoration of external respiration function and tissue metabolism, positive immunological changes, and a reduction in the number of complications.

During treatment, a cylindrical emitter with a diameter of 14 cm is installed above the source of inflammation with a gap of 5-7 cm, usually at the back or side of the chest.

For bilateral pneumonia, a rectangular emitter is used and placed over the right and left half of the chest (emitter power - 30, .40, 50 W; exposure duration - 15 minutes).

Procedures are prescribed daily for treatment in a hospital and every other day for treatment in a clinic. The course of treatment consists of 10-12 procedures.

Electromagnetic waves of the decimeter range (UHF) have a beneficial effect on the course of prolonged pneumonia. To enhance the therapeutic effect when carrying out DMV therapy, it is advisable to include the projection of the roots of the lungs and adrenal glands in the area of ​​influence, and not just the area of ​​inflammation.

During treatment, a rectangular emitter is placed with a gap of 3-5 cm transverse to the spine from the back at the level of the IV-VIII thoracic vertebrae (I field), and then at the level of the IX thoracic-III lumbar vertebrae (II field).

An output power of 35-40 W is used, acting for 10 minutes on each field, daily or 2 days in a row, followed by a one-day break per week, for a course of 10-15 procedures.

Impact on one field is indicated for prolonged pneumonia with low-grade fever, increased bronchopulmonary pattern, according to radiographs, but the absence of pronounced disturbances in the function of external respiration.

If body temperature normalizes or mild subfebrile condition persists, 3-5 sessions of erythemal ultraviolet irradiation are prescribed. Then, if necessary, 6-8 sessions of inductothermy are carried out.

An integral flux of ultraviolet rays with a wavelength of 180-400 nm is used. This therapeutic method is based on an active hyposensitizing effect, an effect on vitamin D synthesis, and an increase in erythropoiesis.

Ultraviolet radiation has an anti-inflammatory effect as a nonspecific irritant due to the release of biologically active substances in the skin and stimulation of metabolic processes in tissues.

Inductothermy differs from UHF in that when exposed to a magnetic field, changes occur primarily in conductive tissues (blood, lymph, parenchymal organs, muscles).

The observed significant thermal effect in these tissues is due to the appearance of Foucault eddy currents. Inductothermy leads to a generalized increase in blood and lymph circulation, significant relaxation of smooth and striated muscles, increased metabolism, increased synthesis of glucocorticoids in the adrenal glands and decreased binding of transcortin.

When treated with inductothermy in patients with pneumonia, the separation of sputum significantly improves and the viscosity of sputum decreases, bronchospasm decreases, and the ventilation and drainage function of the bronchi is restored. However, the active influence of the magnetic field on the hemodynamics of the pulmonary circulation sometimes leads to pain in the heart area. This negative reaction is quickly eliminated when the procedures are cancelled.

Inductothermy is prescribed during the period of resolution of acute pneumonia. The impact is carried out with an inductor - a cable or disk with a diameter of 20 cm. The inductor is placed on the back of the chest, capturing the left or right half of it, or on the subscapular areas on both sides.

The strength of the anode current is 160-180-200 mA, the duration of the procedure is 10-15-20 minutes. Treatment is carried out daily in a hospital or every other day in a clinic; There are 10-12 procedures per course.

Amplipulse therapy is used to improve the drainage function of the bronchi in patients with prolonged pneumonia with copious but poorly discharged sputum (often against the background of obstructive bronchitis).

The impact is carried out paravertebrally at the level of the IV-VI thoracic vertebrae, using a variable mode. The course requires 10-12 procedures.

Thermal therapeutic agents (paraffin, ozokerite, mud) should be prescribed to eliminate the residual effects of acute or prolonged pneumonia. Application is made to the interscapular area or the right half of the chest in front every other day. The temperature of mud is 38-42 °C, paraffin - 52-54 °C, ozokerite - 48-50 °C. The duration of the procedures is 15-20 minutes. The course of treatment consists of 10-12 procedures.

Electrophoresis of medicinal substances is used at the stage of resorption of inflammatory changes in the lung tissue or to eliminate individual symptoms (relieve pain from pleural adhesions, improve sputum separation, reduce bronchospasm).

For this purpose, medicinal ions of calcium, magnesium, aloe extract, iodine, heparin, aminophylline, lidase, etc. are used. For electrophoresis, either ready-made solutions are taken, or a single dose of the drug is dissolved in distilled water or in a buffer solution.

A pad with a medicinal substance is placed on the projection of the pathological process or in the interscapular region, the second pad is placed on the front or lateral surface of the chest. The size of the gaskets is 100-200 cm2; current density 0.03-0.05 mA/cm2, exposure duration 15-30 minutes. Procedures are prescribed every other day or daily in courses of 10-15 procedures.

Aeroion therapy is used during the recovery period or during the period of incomplete remission [Kokosov A. N., 1985]. The method of exposure to air ions is remote. The number of air ions per procedure is 150-300 billion, the duration of the procedure is 5-10-15 minutes. Procedures are prescribed daily or every other day. A course of treatment requires 10-15 procedures.

Therapeutic physical training with a set of breathing exercises is a means of rehabilitation therapy.

The importance of early inclusion of breathing exercises in the complex of therapeutic measures should be especially emphasized.

Therapeutic exercises should begin on the 2-3rd day after body temperature normalizes or decreases to low-grade levels.

Moderate tachycardia and shortness of breath are not contraindications for therapeutic exercises, since the dosage of physical activity, the nature and number of exercises in classes are chosen taking these factors into account. The classes use exercises that help increase the respiratory mobility of the chest and stretch the pleural adhesions, strengthening the respiratory muscles and the muscles of the abdominal process.

The localization of the process in the lungs is also taken into account. During the period of bed rest, simple low-intensity gymnastic exercises are prescribed for the arms and legs; exercises for the torso are performed with a small range of motion.

Breathing exercises are carried out without deepening your breathing. During the treatment and training period, schemes of therapeutic gymnastics procedures and an approximate set of physical exercises are built taking into account the regime established for the patient (semi-bed, ward, general hospital).

Timely prescription and full implementation of a complex of therapeutic exercises ensures a more complete restoration of the functional state of the respiratory and cardiovascular systems. The use of therapeutic physical culture in elderly patients is especially important.

Our observations have shown that through careful, gradual training it is possible to restore the function of external respiration during a hospital stay, to teach these patients the correct act of breathing, the ability to more fully use the capabilities of their breathing apparatus. After discharge from the hospital, it is recommended to continue physical therapy exercises.

Sanatorium-resort treatment of persons who have suffered acute pneumonia is often carried out in local suburban medical institutions.

Sanatorium-resort treatment in low mountains, forest areas, and on the southern coast of Crimea gives a good effect. Yu. N. Shteyngard et al. (1985) developed a two-stage treatment of patients with acute pneumonia with early rehabilitation in a sanatorium-resort institution and the use of peat applications on the area of ​​​​the approximate projection of the lesion (temperature 40-42 ° C, exposure 15-30 minutes, 10-12 procedures per course, prescribed every other day).

By referring patients for rehabilitation on the 3rd-4th day of persistent normalization of temperature, the authors reduced the length of their hospital stay by 2-4 times.

REHABILITATION, DISPANSERIZATION AND OCCUPATIONAL EXAMINATION

Treatment and preventive measures to restore the health of persons who have suffered acute pneumonia include 3 types of rehabilitation:

• 1) medical (rehabilitation treatment);
• 2) professional (labor rehabilitation);
• 3) social (retraining, employment, use of residual working capacity, etc.).

Medical rehabilitation consists of 3 stages:

• 1) clinical (hospital or clinic, outpatient clinic);
• 2) sanatorium-resort (sanatorium; sanatorium-preventorium; country rehabilitation center; resort-type research institution);
• 3) outpatient-dispensary observation.

Despite the harmony of the system, many specific issues of rehabilitation have not yet been finally resolved. The criteria for selecting patients, the rationale for complexes of rehabilitation treatment, the method of monitoring the effectiveness of therapy, the terms of rehabilitation, the criteria for the transition of acute pneumonia into protracted and chronic forms need to be clarified.

Medical rehabilitation, in full or in part, is necessary for all patients with a protracted course of acute pneumonia, complications and the threat of transition to a chronic course.

The leading tasks of the clinical stage of rehabilitation are the achievement of medical and, if possible, professional rehabilitation.

The criteria for successful completion of the clinical stage of rehabilitation can be considered:

• 1) absence of clinical symptoms of the inflammatory process and normalization of the patient’s well-being;
• 2) radiological signs of elimination of infiltrative changes;
• 3) restoration of bronchial patency and blood gas composition;
• 4) normalization of hemogram parameters (except for ESR).

Second stage of rehabilitation - sanatorium, in country boarding houses or outpatient clinic (if sanatorium-resort treatment or after-care in a country hospital is not possible). The objectives of this stage of rehabilitation are:

• 1) complete functional restoration of the respiratory system;
• 2) increasing the body’s nonspecific resistance;
• 3) complete morphological restoration of organs;
• 4) elimination of chronic foci of infection in the body.

The leading means of rehabilitation at this stage are therapeutic motor regimen, therapeutic exercise and massage, physiotherapy, diet therapy, vitamin and enzyme therapy, and only if necessary, other medications.

A significant role during this period is given to the fight against chronic foci of infection. According to V.I. Tyshetsky et al. (1982), the need for a rehabilitation bed (country aftercare hospital, sanatorium, resort) per 10,000 population over 14 years of age with an average length of stay in a pulmonary rehabilitation bed of 24.5 days is 1.6 beds.

Third stage of rehabilitation - polyclinic dispensary observation. Health measures are aimed at increasing nonspecific resistance, maintaining mucociliary function of the bronchi, and sanitizing focal infections.

Polyclinic follow-up should continue for 3 months for persons with clinical and radiological recovery after acute pneumonia and for 1 year for prolonged and recurrent forms of pneumonia.

Purposeful planned differentiated implementation of measures for primary and secondary prevention of pneumonia corresponds to the allocation of 4 groups of dispensary observation:

• 1) persons at risk of developing nonspecific lung diseases;
• 2) persons in the pre-illness period;
• 3) patients with acute nonspecific lung diseases and convalescents;
• 4) patients with chronic nonspecific lung diseases [Chuchalin A. G., Kopylev I. D., 1985].

The set of primary prevention measures in the 1st dispensary group consists of improving working conditions, eliminating discomfort in the workplace and at home, and maintaining a healthy lifestyle. Particular attention should be paid to the following activities:

• 1) fight against smoking,
• 2) combating alcohol abuse;
• 3) promotion of hardening and physical culture,
• 4) prevention and timely treatment of respiratory viral infections,
• 5) vocational guidance for teenagers and appropriate employment for workers;
• 6) social and hygienic prevention,
• 7) personal hygiene skills.

Dispensary observation is carried out until risk factors for the development of nonspecific lung diseases are eliminated at least once a year. A minimum of studies includes an X-ray examination of the chest organs, a clinical blood test, and an assessment of external respiratory function [Chuchalin A. G., Kopylev I. D., 1985].

One of the generally available ways to prevent acute pneumonia is to improve the health of people in the second dispensary group. Particular attention is paid to persons with impaired nasal breathing and chronic foci of infection (rhinitis, deviated nasal septum, tonsillitis, sinusitis, etc.), persons with a history of allergic diseases, as well as those who have had acute viral infections within a year.

This group should also include persons with pulmonary metatuberculous changes, but already deregistered for this disease, pleural adhesions, metapneumonic or post-traumatic pneumosclerosis, congenital and acquired pathology of the bronchopulmonary and thoracodiaphragmatic apparatus.

Health improvement is carried out according to an individualized comprehensive plan with the consultation or participation of an otorhinolaryngologist, pulmonologist, immunologist, allergist, dentist, phthisiatrician, sometimes a dermatologist, thoracic surgeon, and physiotherapist.

Clinical examination in this group is carried out at least once a year, after which the subject is observed for another year as part of the first group.

Convalescents after acute pneumonia, which make up the 3rd group of dispensary observation, are recommended to be divided into persons with a favorable cyclic course of the inflammatory process (subgroup A) and persons with a protracted and complicated course of the disease (subgroup B).

Dispensary observation of patients in subgroup A is carried out for 3 months with frequency of visits at 2 weeks, 1.5 and 3 months after discharge from the hospital or return to work.

The examination program is minimal and includes a clinical blood test, a general urine test, a study of external respiratory function, fluorography or radiography in 2-3 projections (pulmonary fluoroscopy), consultation with an otolaryngologist and dentist.

When making a conclusion about recovery, the patient should be observed for another year in the first group.

Subgroup B should be monitored for a year and examined after 1.5; 3, 6, 12 months from the start of observation. At the first visit, the same tests are indicated as for an uncomplicated course of the disease. Additional studies are prescribed after consultation with a phthisiatrician or thoracic surgeon.

At subsequent visits, the examination program may include a morphofunctional assessment of the bronchial tree (bronchoscopy, lung tomography), assessment of the severity of the inflammatory process, immunological status, bacteriological and virological examination.

Upon recovery, these patients are transferred to the second dispensary group. If the implementation of the treatment and health plan for 12 months did not ensure stabilization of the process, it is necessary to make a conclusion about the transformation of the disease into a chronic form and transfer the patient to the fourth group of dispensary observation.

In acute pneumonia, all patients are temporarily disabled. The duration of temporary disability depends on a number of factors: the period of treatment, the timeliness of diagnosis and hospitalization, the age of the patient, the nature and severity of pneumonia, the presence of concomitant diseases, the etiology of the process, etc.

Thus, the results of our observations showed that the duration of temporary disability in patients hospitalized on the 10th day and later was 45.2 + 1.25 days compared to 23.5 ± 0.95 days among people hospitalized during the first 3 days of illness.

According to Yu. D. Arbatskaya et al. (1977), the period of temporary disability for persons over 50 years of age was 31 days, and for persons under 30 years of age - only 23 days. In the studies of Yu. A. Panfilov et al. (1980) these figures were almost identical (32.5 days in patients over 50 years old and 24.6 days in patients 20-30 years old).

The duration of temporary disability in acute pneumonia increases with concomitant diseases (especially chronic obstructive bronchitis, pulmonary emphysema) and severe inflammatory process.

When discharging patients who have suffered acute pneumonia to work, one should be guided by the criteria of recovery and restoration of working capacity. Currently, it is recognized that it is necessary to distinguish 2 groups of convalescents after acute pneumonia.

The first group includes persons who were in the hospital until complete recovery and were discharged to work when the clinical and radiological picture, laboratory and biochemical data normalized. Convalescents in this group are under clinical observation for 3 months and are examined 3 times during this period: 2 weeks, 1 and 2 months after discharge.

Under unfavorable working conditions, convalescents of this group should be employed under the VKK for various periods of time (1-2 months). Such an expert decision should be made in relation to patients working as foundries, molders, steelworkers, furnaces, drivers, construction workers, agricultural workers, etc.

The 2nd group includes persons discharged with residual symptoms of acute pneumonia and in need of rehabilitation using suburban after-care hospitals, sanatoriums and subsequent dispensary observation.

Forecast. With timely and accurate diagnosis and rational treatment, acute pneumonia usually ends with recovery by the end of the 3-4th week from the onset of the disease. The reverse development of clinical symptoms of pneumonia, with a favorable course, occurs by 7-14 days. X-ray signs of inflammation disappear in 2-3 weeks. At the same time, in 25-30% of patients, acute pneumonia acquires a protracted course [Silvestrov V.P., Fedotov P.I., 1986].

In some patients, clinical and radiological signs of an ongoing inflammatory process may persist for up to 6 months. With long-term (up to 3-4 years) observation of convalescents, it was found that acute pneumonia ends in complete recovery in 91.9% of patients, contributes to the progression of previous chronic bronchitis in 2.7%, causes the development of chronic bronchitis in 4.9% and takes chronic course in 1.2% [Polushkina A.F., Gubernskova A.N., 1977].

Before the introduction of antibiotics into clinical practice, mortality in acute pneumonia reached 9-38% [Tushinsky M.D. et al., 1960]. Currently, it is about 1% [Molchanov N.S., Stavskaya V.V., 1971]. Mortality is especially high with viral-bacterial and staphylococcal pneumonia in elderly, weakened people.

Prevention of acute pneumonia is inextricably linked with the development and improvement of broad national health measures, including improving the environment, labor protection, improving technology and industrial sanitation, and increasing the material well-being of the population.

At the same time, the prevention of acute pneumonia means strengthening among the population the skills of collective and personal hygiene, physical education and sports, hardening the body, eradicating bad habits, preventing and timely adequate treatment of influenza and other viral respiratory infections.

Pulmonary tuberculosis

Regardless of the clinical variant of pneumonia and the form of pulmonary tuberculosis, when carrying out differential diagnosis between these diseases, it is necessary, first of all, to use well-known methods for diagnosing pulmonary tuberculosis as a nosological unit.

Analysis of anamnesis data

The following anamnestic data suggest the presence of tuberculosis in a patient:

• presence of tuberculosis in the patient’s family;
• the patient has previously had tuberculosis of any localization;
• determining the course of the disease. An acute onset and severe course are observed in acute miliary pulmonary tuberculosis and caseous pneumonia; in other forms of tuberculosis, the onset of the disease is usually gradual, often completely imperceptible. Acute lobar pneumonia has an acute onset, focal pneumonia begins gradually, but the duration of the initial period, of course, is much less than with pulmonary tuberculosis;
• information about previous diseases. Diseases such as exudative pleurisy, frequently recurring fibrinous (dry) pleurisy, prolonged low-grade fever of unknown origin and unexplained malaise, sweating, weight loss, prolonged cough (especially if the patient does not smoke) with hemoptysis can be manifestations of pulmonary tuberculosis.

Analysis of data from external examination of patients

Previous tuberculosis can be indicated by retracted irregular scars in the area of ​​previously affected cervical lymph nodes, and tuberculosis of the spine that once took place can be indicated by kyphosis.

Rapidly developing severe intoxication and the patient's serious condition are more characteristic of lobar or total pneumonia and are not characteristic of tuberculosis, with the exception of acute miliary tuberculosis and caseous pneumonia.

Analysis of physical data obtained during examination of the lungs

Unfortunately, there are no physical symptoms that are absolutely pathognomonic for pulmonary tuberculosis. Data such as changes in vocal tremors, bronchophony, bronchial breathing, crepitus, wet and dry rales, pleural friction noise can be observed both in pulmonary tuberculosis and in nonspecific lung diseases, including pneumonia.

However, the following features of physical data characteristic of pulmonary tuberculosis may have a certain diagnostic value:

• localization of pathological percussion and auscultation phenomena mainly in the upper parts of the lungs (of course, this is not an absolute rule);
• the paucity of physical data in comparison with the data of X-ray examination (the aphorism of old doctors “little is heard, but much is seen in pulmonary tuberculosis and much is heard, but little is seen in non-tuberculous pneumonia”). Of course, this pattern does not apply to all forms of tuberculosis, but can be observed in focal, miliary tuberculosis, and tuberculoma.

Setting up tuberculin tests

Tuberculin tests (tuberculin diagnostics) are based on the determination of tuberculin allergy - increased sensitivity of the body to tuberculin resulting from infection with virulent mycobacterium tuberculosis or BCG vaccination.

The most commonly used intradermal Mantoux test is where 0.1 ml of tuberculin is injected into the skin of the inner surface of the middle third of the forearm. The test results are assessed after 72 hours by measuring the diameter of the papule using a transparent millimeter ruler. The transverse (relative to the axis of the arm) diameter of the papule is recorded; the reaction is considered negative when the diameter of the papule is from 0 to 1 mm, doubtful - with a diameter of 2-4 mm, positive - with a diameter of 5 mm or more, hyperergic - with a diameter of 17 mm or more in children and adolescents and 21 mm or more in adults . Hyperergic reactions also include vesicular-necrotic reactions, regardless of the size of the infiltrate.

A positive and especially hyperergic tuberculin test may indicate the presence of pulmonary tuberculosis. However, the final diagnosis of pulmonary tuberculosis is made only on the basis of a comprehensive clinical, laboratory and x-ray examination of the patient, and, of course, the results of tuberculin tests are also taken into account.

Microbiological diagnosis of tuberculosis

Determination of Mycobacterium tuberculosis in sputum, bronchial washings, and pleural exudate is the most important method for diagnosing tuberculosis. Classic microbiological methods are used: bacterioscopy, cultural examination or seeding, biological test on laboratory animals susceptible to tuberculosis infection.

Sputum analysis is one of the main and most common methods. To increase the sensitivity of the method, the flotation method is used, in which mycobacteria are extracted from an aqueous suspension of sputum using liquids with a relative density lower than that of water (xylene, toluene, gasoline, benzene). At the same time, the detection rate of mycobacteria increases by no less than 10% compared to conventional microscopy.

Smears are prepared from native sputum. Staining is done using the Ziehl-Nielson method. Mycobacteria are found in the preparation in the form of thin straight or slightly curved bright red rods.

In recent years, the method of fluorescent microscopy has begun to be used. The method is based on the ability of mycobacterial lipids to perceive luminescent dyes and then glow when irradiated with ultraviolet rays. Mycobacterium tuberculosis under fluorescent microscopy gives a bright red or fluorescent yellow glow on a green background (depending on the type of dye). Luminescence microscopy significantly increases the efficiency of the bacterioscopic method for detecting Mycobacterium tuberculosis.

The culture method (cultural method for detecting Mycobacterium tuberculosis) is more sensitive compared to the bacterioscopic method. It detects Mycobacterium tuberculosis in sputum when there are several dozen viable individuals in 1 liter. Various nutrient media are used for the cultivation of Mycobacterium tuberculosis. As a standard medium for the primary isolation of the pathogen, WHO experts recommend Lowenstein-Jensen medium (solid egg medium), on which good growth of Mycobacterium tuberculosis is obtained 15-25 days after inoculation of bacterioscopically positive material.

When bacterioscopically negative material (sputum) is sown on solid nutrient media, the average duration of mycobacterial growth is 20-46 days, however, individual strains can grow up to 60-90 days. This is why sputum cultures should be kept in a thermostat for at least 3 months. Then microscopy of a smear from the grown colonies, stained by Ziehl-Neelsen, is performed. Mycobacterium tuberculosis is found in the form of bright red or dark red rods.

A biological test is the most sensitive method for detecting Mycobacterium tuberculosis. It is used when the results of bacterioscopy and sputum culture are negative, but there is still suspicion of tuberculosis. The test consists of injecting the guinea pig with specially treated sputum from the patient. Then the pig is slaughtered after 3 months and if the biological test is positive, morphological signs of tuberculosis are found in the organs and tissues. During the autopsy, fingerprint smears are taken from the organs for bacterioscopic examination. In the absence of macroscopic signs of tuberculosis in the organs, cultures are taken from the lymph nodes, spleen, liver, lungs and specially treated material onto solid nutrient media.

The biological method, due to its labor intensity, is used relatively rarely.

In the diagnosis of pulmonary tuberculosis, the leading role belongs to x-ray research methods. L.I. Dmitrieva (1996) suggests using them as follows:

• mandatory radiographic diagnostic minimum (large-frame fluorography, plain radiography);
• in-depth x-ray examination (radiography in two mutually perpendicular projections; fluoroscopy; standard tomography);
• additional X-ray examination (various methods of radiography and tomography, including computed tomography and magnetic resonance imaging).

Characteristic radiological manifestations of individual forms of pulmonary tuberculosis are presented below.

Focal pulmonary tuberculosis

Focal pulmonary tuberculosis is a clinical form characterized by a limited inflammatory process (the size of the lesions is about 10 mm) and an asymptomatic clinical course. The main clinical features of focal pulmonary tuberculosis are as follows:

• long-term chronic wave-like course with alternating phases of exacerbation and subsidence. This course is not typical for acute pneumonia;
• absence of clear clinical manifestations even in the acute phase, and even more so in the compaction phase; with pneumonia, as a rule, the symptom of intoxication is significantly expressed, especially with lobar pneumonia;
• characterized by prolonged coughing without or with the release of a small amount of sputum (even if the patient is not a smoker);
• listening to fine wheezing in a limited area of ​​the lung and, as a rule, after coughing;
• characteristic x-ray picture.

Radiological manifestations of focal pulmonary tuberculosis can be divided into three main groups):

• fresh forms are distinguished by blurred foci of various shapes and sizes, sometimes merging against the background of pronounced lymphangitis;
• subacute forms are characterized by more sharply defined foci due to pronounced productive changes;
• fibrous-indurative changes with a predominance of linear strands over focal shadows.

With an exacerbation of focal tuberculosis, a zone of perifocal inflammation appears around old lesions and the development of new lesions is possible against the background of dense old lesions.

Infiltrative pulmonary tuberculosis

Infiltrative pulmonary tuberculosis is a clinical form characterized by a predominantly exudative type of inflammatory process with a tendency to the rapid formation of caseous necrosis and destruction.

In size, tuberculosis infiltrates are small (diameter from 1.5 to 3 cm), medium (from 3 to 5 cm) and large (more than 5 cm).

Clinical symptoms of infiltrative pulmonary tuberculosis are determined by the size of the lesion and the phase of the process.

The following clinical and radiological variants of infiltrative pulmonary tuberculosis are distinguished:

• cloud-shaped variant - characterized by a gentle, non-intense homogeneous shadow with fuzzy contours. In this case, rapid formation of decay and a fresh cavity is possible;
• round variant - manifests itself as a round, homogeneous, low-intensity shadow with clear contours, the diameter of the shadow is more than 10 mm;
• lobitis - the infiltrative process affects the entire lobe, the shadow is inhomogeneous with the presence of decay cavities;
• periscissuritis - an extensive infiltrate, localized at interlobar fissures and often causing the development of interlobar pleurisy, while the shadow on one side has a clear outline, on the other, its outlines are blurred;
• lobular variant - characterized by an inhomogeneous shadow formed as a result of the merging of large and small foci.

It is very difficult to differentiate infiltrative pulmonary tuberculosis and acute pneumonia based on clinical signs, since there is a great similarity in the clinical manifestations of both of these diseases. As a rule, infiltrative tuberculosis, like acute pneumonia, occurs with high body temperature, severe symptoms of intoxication, and physical findings are also similar. However, unlike pneumonia, hemoptysis is much more often observed with infiltrative tuberculosis. Very rarely, tuberculosis infiltrate is asymptomatic or low-symptomatic. In making the diagnosis of infiltrative pulmonary tuberculosis, the leading role is played by x-ray examination of the lungs, a sharply positive tuberculin test, determination of mycobacteria in sputum, and a clear positive effect of antituberculosis therapy.

In addition, it should be taken into account that all clinical and radiological variants of infiltrative tuberculosis are characterized not only by the presence of an infiltrative shadow, but also by bronchogenic contamination in the form of fresh foci both in the lung in which there is an infiltrate and in the second lung. Quite often, with tuberculous infiltrate, there is a “path” running from the infiltrate to the root of the lung, caused by inflammatory peribronchial and perivascular changes (this is clearly visible on radiographs). Finally, it should be taken into account that, despite the fact that tuberculous infiltrate can be located in any part of the lung, it is still most often localized in the region of the second bronchopulmonary segment and on an anterior radiograph is most often detected in the lateral zone of the subclavian region.

Caseous pneumonia

Caseous pneumonia is a clinical form of pulmonary tuberculosis, characterized by pronounced exudative inflammation of the entire lobe of the lung or most of it, which is quickly replaced by caseous-necrotic changes (“curdled” decay) with subsequent formation of cavities. The course of caseous pneumonia is severe.

Miliary pulmonary tuberculosis

Miliary pulmonary tuberculosis is the dissemination of the tuberculous process with the formation of small foci (1-2 mm) with a predominantly productive reaction, although caseous-necrotic changes are also possible. The disease begins acutely, body temperature rises to 39-40°C, intoxication syndrome is pronounced, patients are bothered by severe weakness, sweating (debilitating night sweats are possible), anorexia, weight loss, shortness of breath, persistent dry cough. During percussion of the lungs, there are no significant changes in the percussion sound; during auscultation of the lungs, a small amount of dry rales may be heard due to the development of bronchiolitis. Thus, there is a certain similarity in the clinical manifestations of severe pneumonia and miliary pulmonary tuberculosis.

Disseminated pulmonary tuberculosis

Disseminated pulmonary tuberculosis is a clinical form characterized by the formation of many tuberculous foci. According to the course, acute, subacute and chronic forms of disseminated pulmonary tuberculosis are distinguished. Acute and subacute forms are characterized by a severe course; patients have high body temperature, chills, night sweats, a very pronounced intoxication syndrome, and a disturbing cough, usually dry, less often with sputum production. Severe shortness of breath may develop. When auscultating the lungs, you can hear fine bubbling rales and crepitus in the upper and middle sections. The main diagnostic method is x-ray.

In acute disseminated tuberculosis, focal shadows are detected in the lungs, evenly distributed from the apexes to the diaphragm - a picture of dense dissemination of small and medium-sized soft foci.

Subacute disseminated tuberculosis is characterized by the appearance of larger soft foci merging with each other. The lesions have a tendency to decay and rapid formation of cavities.

Chronic disseminated pulmonary tuberculosis usually develops unnoticed, its clinical course is long, periodic dissemination of the process in the lungs may not give a clear clinical picture or occur under the guise of pneumonia, exacerbation of chronic bronchitis. Fibrinous or exudative pleurisy often develops. Physical data in chronic disseminated pulmonary tuberculosis are scarce: a shortening of the percussion sound can be detected, mainly in the upper parts of the lungs; under areas of dullness, hard vesicular breathing can be heard, sometimes fine bubbles or single dry rales (due to damage to the bronchi). Chronic disseminated pulmonary tuberculosis, both acute and subacute, can be complicated by decay and cavity formation. In this case, a tetrad of symptoms is characteristic: cough with sputum, hemoptysis, moist rales, Mycobacterium tuberculosis in the sputum.

The progression of the process in chronic disseminated pulmonary tuberculosis leads to increased development of fibrosis and cirrhosis of the lungs.

Thus, disseminated pulmonary tuberculosis is quite difficult to distinguish from pneumonia. The decisive role in diagnosis belongs to the X-ray method of examination.

The main radiological signs of disseminated pulmonary tuberculosis are (M. N. Lomako, 1978):

• bilateral lesions;
• polymorphism of focal shadows;
• alternation of clearly defined lesions with fresh, poorly contoured lesions;
• localization of lesions in the upper posterosternal regions (segments 1-2);
• different sizes of lesions in different parts of the lungs: in the upper sections the lesions are larger, with clear contours and even the presence of calcareous inclusions; in the lower sections the lesions are smaller in size with more vague contours;
• symmetrical location of lesions in both lungs in acute, asymmetrical in chronic disseminated pulmonary tuberculosis;
• the appearance of decay cavities as the process progresses;
• progressive development of fibrosis and cirrhosis.

Differential diagnosis of pneumonia, pulmonary tuberculoma, cavernous and fibrous-cavernous pulmonary tuberculosis is not difficult due to the fact that these forms of tuberculosis have clear radiological manifestations.

Tuberculoma is an isolated and encapsulated by connective tissue cheesy-necrotic lesion of a round shape more than 1 cm in diameter.

In X-ray imaging, tuberculoma appears as a clearly defined formation of a homogeneous or heterogeneous structure against the background of an intact lung. It is localized mainly in segments 1-2.6. Its shape is round, the edges are smooth. For the most part, tuberculoma has a homogeneous structure. However, in some cases, its structure is heterogeneous, which is due to calcifications, foci of clearing, and fibrous changes.

The most important differential diagnostic feature, not typical for pneumonia, is the presence of a double path in tuberculoma, which goes from tuberculoma to the root of the lung. This track is caused by dense peribronchial and perivascular infiltration. Often a capsule is detected around the tuberculoma. Focal shadows may be found in the lung tissue around the tuberculoma. During the period of exacerbation of the tuberculosis process, the X-ray image of tuberculoma is less clear than in the remission phase; even a focus of decay may appear. With the progressive course of tuberculoma, with the development of communication between it and the draining bronchus, Mycobacterium tuberculosis may appear in the sputum.

Tuberculoma is sometimes difficult to distinguish from peripheral lung cancer. The most reliable method for diagnosing tuberculoma is bronchoscopy with biopsy followed by cytological and bacteriological examination.

Exudative pleurisy

The need for differential diagnosis of pneumonia with exudative pleurisy is due to a certain similarity in the symptoms of both diseases - the presence of shortness of breath, symptoms of intoxication, increased body temperature, and a dull percussion sound on the affected side. The main distinguishing features are the following:

• a significantly more pronounced lag in breathing of the corresponding half of the chest with exudative pleurisy than with pneumonia;
• greater intensity of dull sound during percussion with exudative pleurisy than with lobar pneumonia. The dullness of the percussion sound in case of exudative pleurisy is considered absolute (“femoral”), it increases significantly downward, and during percussion the pessimeter finger seems to feel resistance. With pneumonia, the intensity of percussion sound is less;
• absence of auscultatory phenomena over the zone of dullness (no vesicular and bronchial breathing, vocal tremor, bronchophony);
• intense dense homogeneous darkening with a superior oblique border during an X-ray examination of the lungs, mediastinal shift to the healthy side;
• detection of fluid in the pleural cavity using ultrasound and pleural puncture.

Pulmonary infarction

Pulmonary infarction occurs due to pulmonary embolism. The main signs that distinguish it from pneumonia are:

• the appearance at the beginning of the disease of intense chest pain and shortness of breath, then an increase in body temperature; with lobar pneumonia, the relationship between pain and increased body temperature is the opposite: as a rule, a sudden increase in body temperature and chills are observed; after this, chest pain appears, sometimes with pneumonia, a simultaneous increase in body temperature and chest pain is possible;
• absence of severe intoxication at the onset of pulmonary embolism;
• hemoptysis is a common sign of pulmonary infarction, however, this can also be observed with pneumonia, but with a pulmonary infarction, almost pure scarlet blood is released, and with pneumonia, mucopurulent sputum mixed with blood is coughed up (or “rusty sputum”);
• smaller area of ​​lung damage (as a rule, less than the size of the lobe) in contrast, for example, to lobar damage in pneumococcal pneumonia;
• a sharp decrease in the accumulation of the isotope in the infarction zone (due to a sharp disruption of capillary blood flow) during radioisotope scanning of the lungs;
• characteristic ECG changes that suddenly appear - deviation of the electrical axis of the heart to the right, overload of the right atrium (high pointed wave Pvo II and III standard leads, in lead aVF), rotation of the heart around the longitudinal axis clockwise with the right ventricle forward (appearance of deep wave 5 in all chest leads). These ECG changes can also be observed in acute lobar pneumonia, but they are much less pronounced and observed less frequently;
• the presence of thrombophlebitis of the veins of the lower extremities;
• characteristic radiological changes are bulging of the cone a.pulmonalis, the focus of darkening has the shape of a strip, less often - a triangle with the apex directed to the root of the lung.

Lungs' cancer

Lung cancer is a common disease. From 1985 to 2000, the number of patients with lung cancer will increase by 44%, and mortality - by 34.4%. The following methods are used to diagnose lung cancer.

Analysis of anamnesis data

Lung cancer affects men more often, especially those over 50 years of age. As a rule, they abuse smoking for a long time. Many patients have occupational hazards that contribute to the development of lung cancer: working with carcinogenic chemicals, nickel, cobalt, chromium compounds, iron oxides, sulfur compounds, radioactive substances, asbestos, radon, etc. The appearance of such symptoms is of great importance in the diagnosis of lung cancer such as a persistent cough, change in voice timbre, the appearance of blood in the sputum, increased body temperature, lack of appetite, weight loss, chest pain. The significance of these anamnestic data increases even more if they are combined with deformation or blurring of the root of the lungs, first identified during an x-ray examination.

Peripheral lung cancer develops from the epithelium of small bronchi or from the epithelium of the alveoli and can be located in any part (segment) of the lung. However, it is most often localized in the anterior segments of the upper lobes of the lungs.

Radiological manifestations of peripheral cancer largely depend on the size of the tumor. Radiological signs of peripheral lung cancer can be characterized as follows:

• a small tumor (up to 1-2 cm in diameter), as a rule, manifests itself as a darkening center of irregular round, polygonal shape; medium and large sized cancers have a more regular spherical shape;
• The intensity of the shadow of a cancerous tumor depends on its size. With a node diameter of up to 2 cm, the shadow has a low intensity; with a larger tumor diameter, its intensity increases significantly;
• very often the tumor shadow has an inhomogeneous character, which is due to the uneven growth of the tumor and the presence of several tumor nodules in it. This is especially noticeable with large tumors;
• the contours of tumor darkening depend on the phase of tumor development. The tumor is up to 2 cm in size and has an irregular polygonal shape and unclear contours. When the tumor size is up to 2.5-3 cm, the darkening has a spherical shape, the contours become radiant. With dimensions of 3-3.5 cm in diameter, the contours of the tumor become clearer, however, with further growth of peripheral cancer, the clarity of the contours disappears, the tuberosity of the tumor is clearly visible, and sometimes decay cavities are identified in it;
• characteristic is Rigler's symptom - the presence of a notch along the contour of the tumor, which is due to uneven growth of cancer;
• Quite often, with peripheral lung cancer, a “path” to the root of the lung is visible, caused by lymphangitis, peribronchial and perivascular tumor growth;
• X-ray examination over time reveals progressive tumor growth. According to V. A. Normantovich (1998), in 37% of patients tumor doubling occurs within 17-80 days; in 43% of patients - 81-160 days, in 20% of cases - 161-256 days;
• in advanced cases, the tumor compresses the corresponding bronchus, and atelectasis of the lung lobe develops.

More detailed X-ray signs of cancer and bronchial compression are detected using X-ray tomography and computed tomography of the lung.

When differentially diagnosing acute pneumonia and peripheral lung cancer, the following circumstances must be taken into account:

• in acute pneumonia, under the influence of rational antibacterial therapy, positive dynamics appear quite quickly - a decrease in the severity and then the complete disappearance of the darkening focus; with cancer, such dynamics are not observed;
• Acute pneumonia is characterized by a positive Fleischner's symptom - good visibility of small bronchi against a background of darkening; this sign is not observed in lung cancer;

Central cancer of the upper lobe and middle lobe bronchi is manifested by darkening of the entire lobe or segment with a decrease in the volume of the lung lobe. X-ray tomography reveals the symptom of the stump of the lobar bronchus. Cancer of the main bronchus is characterized by varying degrees of stenosis, up to complete stenosis with the development of atelectasis of the entire lobe of the lung. Stenosis of large bronchi is clearly detected by X-ray tomography and computed tomography.

An important diagnostic method is bronchographic examination, which reveals a break (“amputation”) of the bronchus when the tumor covers its lumen.

Bronchoscopy

Bronchoscopy with multiple biopsies of the bronchial mucosa is of great importance in the diagnosis of lung cancer. During bronchoscopy, direct signs of lung cancer can be identified: endobronchial, endophytic or exophytic tumor growth, infiltrative changes in the bronchial wall. A tumor growing peribronchially is manifested by indirect signs: protrusion, rigidity of the bronchial wall, looseness of the mucous membrane, unclear pattern of the cartilaginous rings of the lobar and segmental bronchi. Along with a biopsy of the bronchial mucosa, a bronchial wash is performed, followed by a cytological examination of the wash.

In 1982, Kinsley et al. described the method of fibrobronchoscopy with simultaneous ultraviolet irradiation of the bronchial mucosa. The method is based on the fact that bronchogenic cancer cells have the ability to selectively accumulate a hematoporphyrin derivative compared to healthy tissues and then fluoresce in ultraviolet rays. When using this technique, the fiberoptic bronchoscope is equipped with a special ultraviolet irradiation source, a light guide, a filter and a focused image intensifier.

In some cases, during bronchoscopy, a transbronchial puncture biopsy of a lymph node suspicious for metastasis is performed.

Cytological examination of sputum

It is necessary to test sputum for cancer cells at least 5 times. Cancer cells can be detected in the sputum of 50-85% of patients with central and 30-60% of patients with peripheral lung cancer.

Cytological examination of pleural exudate

The appearance of exudative pleurisy in lung cancer indicates an advanced tumor process. In this case, the pleural fluid is often hemorrhagic in nature; cytological examination reveals tumor cells.

Needle biopsy of palpable peripheral lymph nodes

Palpable peripheral lymph nodes (cervical, axillary, etc.) indicate metastasis of lung cancer. A puncture biopsy of these lymph nodes provides verification of cancer metastasis in 60-70% of patients.

Immunological diagnostic methods

Immunological methods for diagnosing cancer have not yet received widespread clinical use. However, according to literature data, in the complex diagnosis of lung cancer, the detection of tumor markers in the blood: carcinoembryonic antigen, tissue polypeptide antigen, lipid-bound sialic acids may have a certain diagnostic value. It is necessary to take into account the non-specificity of these tumor markers; they can be detected in the blood in cancer of other organs (liver, stomach, etc.).

Transthoracic puncture

Transthoracic puncture is performed under X-ray television control and is the main method for verifying the diagnosis of peripheral cancer, confirming the diagnosis in 65-70% of cases.

Acute appendicitis

The need for differential diagnosis of acute appendicitis and pneumonia arises when it is localized in the lower lobe of the right lung. This is most often observed in children. Right lower lobe pneumonia is often accompanied by pain and muscle tension in the right half of the abdomen, including in the right iliac region.

The main differential diagnostic differences between right-sided lower lobe pneumonia and acute appendicitis are as follows:

• with pneumonia, pain in the right iliac region does not increase when moving the hand deeper during palpation of the abdomen; in acute appendicitis, the pain increases sharply, and at the same time the tension in the abdominal muscles increases;
• with pneumonia, pain intensifies with breathing; with acute appendicitis, this relationship is not typical or is poorly expressed; however, when coughing, abdominal pain increases in both pneumonia and acute appendicitis;
• in acute appendicitis, the temperature in the rectum is significantly higher than the temperature in the axillary region (the difference exceeds GS), in acute pneumonia there is no such pattern;
• thorough percussion and auscultation, x-ray examination of the lungs reveal symptoms of acute pneumonia in the lower lobe of the right lung, which serves as the main criterion for differential diagnosis.

Cardiogenic pulmonary edema

The need for differential diagnosis of pneumonia and cardiogenic pulmonary edema (“congestive lung”) is explained by the presence of similar symptoms: cough with sputum (sometimes mixed with blood), shortness of breath, crepitus and fine rales in the lower parts of the lungs. The following circumstances serve as differential diagnostic differences:

• the presence in patients with “congestive lungs” of symptoms of decompensated cardiac diseases (heart defects, post-infarction cardiosclerosis, severe arterial hypertension, diffuse myocarditis, exudative pericarditis, etc.);
• with “congestive lungs”, as a rule, an increase in the size of the heart is detected, atrial fibrillation is more often detected, episodes of cardiac asthma and pulmonary edema are observed (the clinic of these conditions is described in the chapter “Acute circulatory failure”);
• Pulmonary edema almost always occurs as a bilateral process; upon auscultation of the lungs, crepitus and fine rales are heard in the lower parts of both lungs;
• X-ray changes in the lungs during congestion depend on the severity of the congestive process. At the stage of interstitial edema, intensification and deformation of the pulmonary pattern are revealed, thanks to the shadows of longitudinal projections of overcrowded small vessels. With further progression of congestion and filling of the alveoli with transudate, bilateral darkening (often round in shape) without clear boundaries appears, mainly in the medial areas of the middle and lower fields. With significantly pronounced stagnation, an increase in the roots of the lungs is determined - they take on the shape of a butterfly;
• congestion in the lungs develops, as a rule, against the background of other clinical manifestations of circulatory failure (severe peripheral edema, ascites, enlarged painful liver);
• in the absence of concomitant pneumonia, congestion in the lungs is not accompanied by pronounced laboratory signs of inflammation;
• X-ray changes of a congestive nature are significantly reduced and may even disappear completely after successful treatment of heart failure;
• Sometimes in the sputum of patients with congestion in the lungs, alveolar epithelial cells are found, the protoplasm of which contains in excess phagocytosed grains of the hemoglobin derivative - hemosiderin.

The above signs make it possible to distinguish pneumonia from congestion in the lungs. However, it should be taken into account that pneumonia can develop against the background of congestion in the lungs. In this case, an asymmetric darkening is detected by X-ray, most often in the lower lobe of the right lung, and laboratory signs of an inflammatory process appear.

Pneumonitis in systemic vasculitis and diffuse connective tissue diseases

With systemic vasculitis and diffuse connective tissue diseases, focal darkening in the lower parts of the lungs or peribronchial, perivascular infiltration, and increased pulmonary pattern may be observed. In the differential diagnosis of pneumonia, attention should be paid to the characteristic clinical manifestations of systemic vasculitis and systemic connective tissue diseases (systematic lesions, articular syndrome, usually the involvement of the kidneys in the pathological process, erythematous skin rashes, hemorrhagic rashes, etc.), corresponding laboratory manifestations, ineffectiveness antibacterial therapy and the positive effect of treatment with glucocorticosteroids.

Etiological diagnosis

Currently, the problem of timely and successful etiological diagnosis has become extremely urgent. An accurate etiological diagnosis is the key to correct and successful treatment of pneumonia.

The main methods for establishing the etiological diagnosis of pneumonia are:

• A thorough analysis of the clinical, radiological and laboratory features of pneumonia depending on its etiology.
• Microbiological examination of sputum, sometimes bronchial lavage, pleural effusion with quantitative assessment of microflora content. Sputum should be collected in a sterile container after preliminary rinsing of the mouth. To increase the effectiveness of the study, it is advisable to first process the sputum using the Mulder method. To do this, take a purulent piece of sputum and thoroughly wash it in a sterile isotonic sodium chloride solution successively in three Petri dishes for 1 minute in each. This helps remove mucus containing microflora of the upper respiratory tract and oral cavity from the surface of the lump of mucus. It is advisable to take at least three lumps from different parts of the sputum. After this, the sputum is cultured on selective biological media. The number of microbial bodies in 1 ml of sputum is also counted.

The causative agents of pneumonia in a given patient are considered to be those microorganisms that are sown from sputum in the amount of 1,000,000 or more microbial bodies per 1 ml.

Simultaneously with sputum inoculation on selective biological media, sputum smears are made, followed by bacterioscopy. One smear is stained using the Romanovsky-Giemsa method for cytological analysis (the type and number of leukocytes, the presence of bronchial and alveolar epithelium, erythrocytes, atypical cells, etc. are determined). The second smear is stained with Gram and the abundance of microflora, the presence of gram-positive and gram-negative microorganisms, and their intra- or extracellular localization are assessed. But first it is necessary to establish that the drugs belong to sputum and not to the oral mucosa. The criteria for Gram-stained preparations to be classified as sputum are:

• the number of epithelial cells, the main source of which is the oropharynx, is less than 10 per total number of cells counted;
• predominance of neutrophilic leukocytes over epithelial cells;
• predominance of microorganisms of one morphological type. Bacterioscopy of sputum smears stained by Gram allows us to tentatively suggest the causative agent of pneumonia. Thus, when gram-positive diplococci are detected, one should think about pneumococcus; chains of gram-positive cocci are characteristic of streptococcus, clusters of gram-positive cocci are characteristic of staphylococcus; short gram-negative rods - for Haemophilus influenzae; In addition, gram-negative microorganisms include Moraxella, Neisseria, Klebsiella, and Escherichia coli.

Immunological studies. Immunological methods that allow verification of the causative agent of pneumonia include the identification of bacterial agents using immune sera in a counter immunoelectrophoresis reaction; determination of titers of specific antibodies (using enzyme immunoassay, indirect hemagglutination reaction, complement fixation reaction). The role of determining specific antibodies in blood serum especially increases when using the method of paired sera (a significant increase in antibody titer when repeated testing after 10-14 days compared to the titers obtained at the onset of the disease).

How is differential diagnosis of pneumonia carried out?

How is differential diagnosis of pneumonia carried out? This question interests many patients. Very often this disease is called pneumonia (pneumonia). As a rule, we are accustomed to the fact that pneumonia is severe. The main symptoms are fever, cough and weakness. But it turns out that there are several types of this disease. In order to recognize this disease and distinguish it from other lung diseases, a differential diagnosis of pneumonia is carried out.

What is characteristic of pneumonia?

The most common cause of pneumonia is an infection that is accompanied by damage to the lung tissue. Doctors distinguish pneumonia from bronchitis by the degree of localization of the inflammatory process in the lungs. If the inflammatory process occurs in the alveoli, then it is considered to be pneumonia. If there is inflammation of the bronchi, then we are talking about bronchitis.

But sometimes inflammation in the alveoli is not associated with infectious causes, in which case doctors diagnose pulmonitis. In addition, damage to the lung tissue can occur as a result of exposure to chemicals, radiation exposure, or may be a consequence of injury.

Is there a difference between pneumonia and bronchitis?

Differences between diseases:

1. During the inflammatory process, fluid accumulates in the alveoli, and gas exchange may occur.
2. If the development of pneumonia is expected, then in the areas of the lungs that are affected by the inflammatory process, there is no gas exchange. Fluid accumulates in the globules of the lungs.
3. With bronchitis, the inflammatory process occurs in the bronchi, which are responsible for the air conductivity of the lung tissue. Based on this, bronchitis and pneumonia affect different parts of the lung tissue.
4. A person who suffers from a cough and high temperature will not be able to independently distinguish the symptoms of pneumonia from bronchitis. Only a doctor can find differences in the clinical picture of these diseases.
5. Both diseases are accompanied by cough and high fever. Mucopurulent or purulent sputum is released. Patients often complain of lack of air. The patient is worried about nausea, which is the cause of intoxication.

How is the differential diagnosis made?

In order to distinguish between bronchitis and pneumonia, the doctor prescribes examinations:

• fluorography;
• X-ray.

Pneumonia is characterized by the appearance of foci of infiltration, which are absent in bronchitis.

The doctor also conducts a survey of the patient. When the lungs are affected, the cough can be either dry or with sputum; often the sputum contains pus mixed with mucus.

There is one more symptom that you need to notify your doctor about. Sometimes streaks of blood appear in the sputum. In this case, differential diagnosis of pneumonia and tuberculosis is required. In this case, it is extremely necessary to take an x-ray of the lungs.

Some patients may attribute this to nosebleeds or bleeding gums. However, bloody sputum can be a sign of tuberculosis or even cancer. It is very important not to waste time.

Signs of pneumonia are increased body temperature, as well as localization of chest pain on the left or right in the scapular region.

Pneumonia is characterized by pain when coughing or breathing. Substernal pain is more characteristic of bronchitis.

Sometimes patients complain of lack of air, but it is difficult to separate bronchitis and pneumonia based on this criterion. A similar symptom is common to both diseases.

What types of pneumonia are there?

Differential diagnosis of pneumonia is carried out depending on the type of disease. According to the modern classification, the cause of the disease is divided into the following factors:

1. If infection with the disease occurred at home or in the office, a diagnosis of community-acquired pneumonia is made.
2. Sometimes patients become ill in the hospital or after being discharged from it, and a diagnosis of hospital-acquired or nosocomial pneumonia is made.
3. If the disease develops as a result of lung injury, then aspiration pneumonia is diagnosed.
4. Pneumonia often develops as a result of radiation exposure.
5. Sometimes the disease occurs in people with severe immunodeficiency.

Almost anyone can get pneumonia. It often occurs in children. However, children and the elderly are at risk for this disease. Therefore, you should get vaccinated regularly.

It is very important to choose the right doctor. You should trust the treatment of the disease only to a specialist who has extensive experience.

Treatment of the disease requires the use of antibiotics. Flu medications, which are widely advertised today, can only blur the clinical picture.

Do not forget that in the distant past, pneumonia was considered a fatal disease. Without using antibiotics you can die. Depending on the severity of the disease, the doctor may recommend treatment at home or in a hospital.

A table that your doctor will familiarize you with can provide more detailed information about the differentiation of pneumonia.

How can you quickly cure pneumonia?

The doctor makes a forecast of the rate of cure of the disease after a thorough examination of the patient. Much depends on the patient's condition. Many people believe that antibiotics can cure illness. Yes, modern medicine has a wide range of antibiotics. But the fact is that antibiotics provide a favorable prognosis in the treatment of the disease.

However, antibiotics cannot speed up recovery. On average, the duration of treatment for the disease is about 21 days. If a person has good immunity, then he can recover in 10 days. In patients who suffer from HIV, the illness can last from 2 to 3 months. But the course of antibiotic treatment does not continue all this time.

Prevention of the disease is of great importance. It consists of hardening. After suffering from pneumonia, you should avoid contact with people who suffer from colds.

Pneumonia often develops after an acute respiratory infection. That is why acute respiratory infections need to be treated with all seriousness. It is very important to maintain bed rest during a cold. If you cannot cope with a cold, and the symptoms only increase, you need to consult a doctor.

There are a number of diseases that can complicate the course of the disease when the patient suffers from cancer, tuberculosis, diabetes or HIV.

Pneumonia must be treated under the strict supervision of a doctor.

Diagnosis of pneumonia in children

Laboratory diagnosis of pneumonia

A peripheral blood test should be performed in all patients with suspected pneumonia. Leukocytosis more than 10-12x109/l and band shift more than 10% indicate a high probability of bacterial pneumonia. When pneumonia is diagnosed, leukopenia less than 3x109/l or leukocytosis more than 25x109/l are considered unfavorable prognostic signs.

A biochemical blood test and a study of the acid-base state of the blood are standard methods for examining children and adolescents with severe pneumonia. those in need of hospitalization. The activity of liver enzymes, the level of creatinine and urea, and electrolytes are determined.

The etiological diagnosis is established mainly for severe pneumonia. Blood cultures are performed, which are positive in 10-40% of cases. Microbiological examination of sputum in pediatrics is not widely used due to technical difficulties in collecting sputum in the first 7-10 years of life. But in cases of bronchoscopy, microbiological examination is used; the material for it is aspirates from the nasopharynx, tracheostomy and endotracheal tube. In addition, to identify the pathogen, puncture of the pleural cavity and culture of punctate pleural contents are performed.

Serological research methods are also used to determine the etiology of the disease. Increase in titers of specific antibodies in paired sera taken during the acute period and the period of convalescence. may indicate mycoplasma or chlamydial etiology of pneumonia. Reliable methods are also considered to be the detection of antigens using latex agglutination, counter immunoelectrophoresis, and ELISA. PCR, etc. All these methods, however, take time, do not affect the choice of treatment tactics and have only epidemiological significance.

Instrumental methods for diagnosing pneumonia

The “gold standard” for diagnosing pneumonia in children is an X-ray examination of the chest organs, which is considered a highly informative and specific diagnostic method (the specificity of the method is 92%). When analyzing radiographs, the following indicators are assessed:

• size of lung infiltration and its prevalence;
• presence or absence of pleural effusion;
• the presence or absence of destruction of the pulmonary parenchyma.

All this data helps determine the severity of the disease and choose the right antibiotic therapy. Subsequently, with clear positive dynamics in the clinical manifestations of community-acquired pneumonia, there is no need for control radiography (upon discharge from the hospital or when the child is being treated at home). It is more advisable to carry out control radiography no earlier than 4-5 weeks from the onset of the disease.

X-ray examination of dynamics during the acute period of the disease is carried out only if there is progression of symptoms of lung damage or if signs of destruction and/or involvement of the pleura in the inflammatory process appear. In cases of complicated pneumonia, mandatory X-ray monitoring is carried out before the patient is discharged from the hospital.

For hospital-acquired pneumonia, it must be remembered that if pneumonia develops 48 hours before death, then an X-ray examination may give a negative result. Such X-ray negative pneumonia (when radiography performed 5-48 hours before the patient’s death did not reveal pneumonic infiltration in the lungs) is observed in 15-30% of cases. The diagnosis is established only clinically on the basis of severe respiratory failure, weakened breathing; There may often be a short-term rise in temperature.

A radiographic study of the dynamics of hospital-acquired pneumonia in the acute period of the disease is carried out when the symptoms of lung damage progress or when signs of destruction and/or involvement of the pleura in the inflammatory process appear. If there is a clear positive trend in the clinical manifestations of pneumonia, a control x-ray is performed upon discharge from the hospital.

When assessing the condition of children previously hospitalized for any pathology and children with severe community-acquired pneumonia, special attention should be paid to the condition and effectiveness of respiratory function, in particular pulse oximetry readings. In severe pneumonia and hospital-acquired pneumonia, especially VAP, it is also necessary to monitor indicators such as respiratory rate, pulse rate, blood pressure, acid-base status, diuresis, and in children in the first six months of life - body weight.

Computed tomography (CT) is used if necessary when carrying out differential diagnosis, since CT has 2 times higher sensitivity compared to plain radiography in identifying foci of infiltration in the lower and upper lobes of the lungs.

Fiberoptic bronchoscopy and other invasive techniques are used to obtain material for microbiological research in patients with severe immune disorders and for differential diagnosis.

Differential diagnosis of pneumonia in a child

When carrying out differential diagnosis, it is necessary to take into account the age of the child, since at different age periods pathological processes in the lungs have their own characteristics.

In infancy, the clinical picture of respiratory failure can be caused by conditions such as aspiration, foreign body in the bronchi, previously undiagnosed tracheoesophageal fistula, gastroesophageal reflux, malformations of the lungs (lobar emphysema), heart and large vessels, cystic fibrosis and α-antitrypsin deficiency. In children of the second or third years of life and at an older age (up to 6-7 years), Kartagener syndrome should be excluded; pulmonary hemosiderosis; nonspecific alveolitis; selective IgA deficiency.

Differential diagnosis at this age should be based on the use (in addition to lung radiography and peripheral blood analysis) of endoscopic examination of the trachea and bronchi, lung scintigraphy, angiography, sweat and other tests for cystic fibrosis, determination of the concentration of a-antitrypsin, study of blood immunogram and others research.

At any age it is necessary to exclude pulmonary tuberculosis. In the absence of positive dynamics of the process within 3-5 days (maximum - 7 days) of therapy, the protracted course of community-acquired pneumonia, its resistance to the therapy, it is necessary to expand the examination plan both to identify atypical pathogens (S. psittaci, Ps. aerugenozae, Leptospira, Coxiella burneti). and for the diagnosis of other lung diseases.

In patients with severe immune defects, when shortness of breath and focal infiltrative changes appear on a chest x-ray, it is necessary to exclude the involvement of the lungs in the main pathological process (for example, in systemic connective tissue diseases), as well as lung damage as a consequence of the therapy (drug-induced lung injury, radiation pneumonitis .d.).

What is pulmonary tuberculosis: differential diagnosis and clinical picture

Often in medical practice pulmonary tuberculosis is detected, differential diagnosis of which should be carried out with various diseases (pneumonia, atelectasis, sarcoidosis). Currently, pulmonary tuberculosis is one of the biggest problems. The thing is that about 2 billion people are infected with Mycobacterium tuberculosis. This disease has enormous social significance due to the difficulty of treatment, the possibility of an aerosol transmission mechanism, as well as a high mortality rate. What are the etiology, clinical picture, differential diagnosis and treatment of pulmonary tuberculosis infection?

Characteristics of pulmonary tuberculosis

Tuberculosis is a chronic disease caused by mycobacteria, which can affect various organs, including the lungs. Pulmonary tuberculosis most often occurs in adults. The causative agent of this infection is very resistant to the environment. Due to their structure, mycobacteria have become highly resistant to many modern anti-tuberculosis drugs. The infectious agent is transmitted by the following mechanisms:

• aerosol;
• fecal-oral;
• contact;
• vertical.

The transmission of mycobacteria through the air through coughing is of greatest importance. The airborne route is relevant only in the presence of an active form of the disease, when bacteria are found in sputum and can be released into the environment. The vertical mechanism is rare. The risk group among infected people includes people aged 20 to 40 years. Risk factors are:

• overcrowding of teams;
• close contact with a sick person;
• sharing utensils with the patient;
• decreased immunity;
• presence of HIV infection;
• drug use;
• presence of chronic alcoholism;
• the presence of chronic lung pathology;
• general exhaustion of the body;
• malnutrition (lack of vitamins);
• a history of diabetes mellitus;
• unfavorable living conditions;
• stay in places of deprivation of liberty.

Clinical symptoms

The clinical manifestations of pulmonary tuberculosis are quite varied. They are determined by the form of the disease. The most common symptoms are:

• increased body temperature;
• increased sweating at night;
• decreased appetite;
• weight loss;
• weakness;
• decreased performance;
• dyspnea;
• chest pain;
• cough;
• hemoptysis;
• enlarged lymph nodes.

Knowing these signs is necessary for a correct diagnosis. Differential diagnosis is often based on the symptoms of the disease, and not just the results of laboratory and instrumental studies. The most common complaint of patients in this situation is cough. With pulmonary tuberculosis, it is first dry, then with sputum. The patient may cough for several minutes without stopping. Often when you cough, purulent sputum is released. The cough is often accompanied by shortness of breath and chest pain. In addition to coughing, hemoptysis may occur.

Diagnostic measures

Today, the diagnosis of pulmonary tuberculosis involves:

• conducting a tuberculin test;
• Diaskin test;
• microbiological examination of sputum or biopsy;
• performing chest x-rays;
• general blood and urine tests.

The Mantoux test allows you to assess the state of immunity and determine infection. The test result can be negative, positive or doubtful. A negative result indicates the absence of disease. An important place is occupied by differential diagnosis. To clarify the diagnosis, differential diagnosis is carried out with the following diseases: lobar pneumonia, eosinophilic pulmonary infiltrate, actinomycosis, atelectasis, lung cancer, infarction.

Differential diagnosis

Each form of tuberculosis has its own characteristics. The following types of pulmonary tuberculosis are distinguished: primary, miliary, disseminated, infiltrative, tuberculoma. Clinical forms also include caseous pneumonia. Infiltrative pulmonary tuberculosis is very often detected. At the same time, areas of compaction form in the lung tissues. The infiltrate can occupy an area of ​​several segments or lobes of the organ. It can be very difficult to distinguish from nonspecific pneumonia. The first difference is that with pneumonia the severity of inflammatory processes is much less, while upon physical examination (listening to the lungs) severe symptoms are noted. With infiltrative tuberculosis, on the contrary, changes in tissues prevail over the results of physical examination.

Secondly, with tuberculosis and nonspecific pneumonia, different segments of the lung are affected. With tuberculosis, segments 1, 2 and 6 most often suffer, with pneumonia – 3, 4, 5, 7, 9, 10. Thirdly, anamnesis data are important. With pneumonia, there are often indications of hypothermia or pathology of the upper respiratory tract. Infiltrative tuberculosis can also be recognized clinically. It does not occur as acutely as pneumonia. Cough with tuberculosis is not as frequent, but longer lasting. Intoxication is more pronounced with pneumonia. The temperature rises slightly. With pneumonia it can reach 40 degrees. Fourthly, there are differences in the x-ray picture.

With infiltrative tuberculosis, a heterogeneous shadow, cavities with decay, calcifications, a Gohn's lesion and petrification in the area of ​​the roots of the lungs are found. The Mantoux test for pneumonia is often false positive. Histological examination is of great value. In pneumonia, neutrophils and macrophages are detected, while in tuberculosis, epithelial cells, lymphocytes, and Pirogov-Langhans cells are detected.

The most valuable distinguishing feature of tuberculosis is the presence of Mycobacterium tuberculosis in the sputum.

Tuberculosis and other diseases

In some cases, tuberculosis infection can be mistaken for an eosinophilic infiltrate. This condition is associated with exposure to an allergen. Unlike pulmonary tuberculosis, it is characterized by:

• an increase in eosinophils in the blood;
• rapid regression;
• the presence of darkening with unclear contours, which can be localized in any part of the lung.

A course similar to tuberculosis is observed with actinomycosis, the main symptom of which is chest pain. In the sputum of this disease, structural elements (drusen) of actinomycetes are detected. With actinomycosis, subcutaneous infiltrates or fistulas often form. Differential diagnosis can be made with atelectasis. The latter is characterized by collapse of the lung tissue. Unlike tuberculosis, with atelectasis the main symptoms are shortness of breath, difficulty breathing, and cyanosis. An x-ray shows a decrease in the volume of the affected segment of the lung or an entire lobe. The shadow is uniform and has clear contours. In addition, there is a displacement of healthy tissue towards the lesion.

Difference between caseous and lobar pneumonia

Caseous pneumonia is one of the clinical forms of tuberculosis. It is characterized by cheesy inflammation of the lung tissue. It is often a complication of fibrous-cavernous tuberculosis. It is necessary to be able to distinguish it from focal (lobar) pneumonia. Firstly, sputum in lobar pneumonia is rusty in color, while in caseous pneumonia it is mucopurulent. Secondly, with lobar pneumonia, auscultatory signs are more pronounced. Thirdly, during laboratory testing, lobar pneumonia is indicated by the detection of pneumococci. Urobilin, casts, and protein are found in the urine. In case of caseous pneumonia, mycobacteria are persistently detected.

Fourthly, during X-ray examination, lobar pneumonia most often affects 1 lung. In this case, the lower lobe is affected, whereas with caseous pneumonia, the upper lobe of the lung is involved in the process. After the correct diagnosis is made, treatment is carried out. For this purpose, anti-tuberculosis drugs are used. The first row includes Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Streptomycin. Thus, tuberculosis has a number of distinctive features that make it possible to exclude other lung diseases.

DIFFERENTIAL DIAGNOSIS FOR PNEUMONIA

Pneumonia– an acute local infectious-inflammatory disease of the lungs involving the respiratory sections (alveoli, bronchioles) in the pathological process, occurring with infiltration by inflammatory cells and intra-alveolar exudation.

Classification

By etiology:

ü bacterial (indicating the specific pathogen),

ü viral,

ü fungal

ü without specifying the pathogen.

Epidemiological:

ü out-of-hospital,

ü hospital,

ü aspiration,

against the background of immunodeficiency.

By severity:

ü not heavy,

ü heavy.

By localization: indicating a segment or several segments.

According to the nature of the flow:

ü prolonged (duration of the disease more than 1 month).

Complications:

ü pulmonary

§ parapneumonic pleurisy,

§ pleural empyema,

§ abscess and gangrene of the lungs,

§ destruction of the lungs,

§ bronchial obstruction,

§ acute respiratory failure (distress syndrome).

ü extrapulmonary

§ infectious-toxic shock,

§ acute cor pulmonale,

§ DIC syndrome,

§ sepsis,

§ myocarditis,

§ endocarditis,

§ pericarditis,

§ meningitis,

§ encephalitis,

§ acute psychosis.

An example of a diagnosis:

1. Community-acquired pneumonia localized in S 8-9 of the right lung, non-severe course. DN I.

2. Community-acquired lower lobe left-sided pneumonia, severe, complicated by exudative pleurisy. DN II.

Community-acquired pneumonia (CAP)– an acute disease that arose in a community setting (outside a hospital, or diagnosed in the first 48 hours from hospitalization.

Etiology

The etiology of CAP is directly related to the normal microflora that colonizes the upper respiratory tract. The most common pathogens:

ü Streptococcus pneumoniae (30-50% of cases),

ü Haemophilus influenzae (before 10%) .

Atypical microorganisms (which cannot be identified by bacterioscopy or culture on conventional nutrient media) play a significant role in the etiology of CAP; 8-30% of cases of the disease:

ü Chlamydophila pneumoniae, Mycoplasma pneumonia(total up to 25%),

ü Legionella pneumophila.

Rare (3-5%) pathogens of CAP include:

ü Staphylococcus aureus,

ü Klebsiella pneumoniae

ü enterobacteria.

In very rare cases, CAP can cause Pseudomonas aeruginosa(in patients with cystic fibrosis, in the presence of bronchiectasis).

From a practical point of view, it is advisable to distinguish groups of patients with CAP, taking into account age, concomitant pathology and severity of the disease (Table 1).

Table 1

Groups of patients with CAP and probable pathogens

Nosocomial (hospital, nosocomial) pneumonia (NP) – a disease that develops 48 hours or more after hospitalization, excluding infections that were present in the incubation period at the time the patient was admitted to the hospital.

Risk factors:

ü length of hospital stay,

ü previous antibacterial therapy,

ü presence of underlying chronic diseases,

ü specificity of the medical institution.

Highlight early hospitalization pneumonia that occurs during the period from 2 to 5 days of hospitalization, which is characterized by pathogens that are mostly sensitive to traditionally used antimicrobial drugs ( S. Pneumoniae, Enterobacteriaceae, H. Influenzae) and has a favorable prognosis.

Late hospital stay pneumonia develops after the 5th day of hospitalization and is characterized by a high risk of multidrug-resistant pathogens (P. aeruginosa, Escherichia coli, Klebsiella pneumoniae and Acinetobacter spp.) and a less favorable prognosis.

Also distinguished ventilator-associated pneumonia (VAP) – pneumonia in persons on mechanical ventilation.

Aspiration pneumonia (AP) can be either out-of-hospital or intra-hospital. APs complicate the patient's aspiration of food, vomit, blood, toxic and other agents into the lower respiratory tract, accompanied by the penetration of pathogenic flora along with the aspirate. Aspiration usually develops in persons with disorders of consciousness of varying depth due to:

ü heavy alcohol intoxication,

ü stroke,

ü anesthesia,

ü coma of various etiologies,

ü poisoning with sleeping pills,

ü convulsive conditions.

Aspiration can occur with cardiospasm or the presence of tracheoesophageal fistulas.

Anaerobes cause the development of AP:

ü Bacteroides melaninogenicus,

ü Fusobacterium nucleatum,

ü Peptosstreptococcusand etc.,

as well as some aerobes:

ü Escherichia coli

ü Staphylococcusaureus,

ü Pseudomonas aerugenosa.

Pneumonia in persons with immunodeficiency.

The main causes of immunodeficiency are:

ü HIV infection,

ü leukemia;

ü long-term (> 3 weeks) use of cytostatics or systemic glucocorticoids for the treatment of tumors, systemic diseases, in patients after organ transplantation.

In a general blood test, immunodeficiency is manifested by prolonged neutropenia (< 500 клеток в 1 мкл крови) в период диагностики или в предыдущие 60 дней.

The most likely etiology of pneumonia in immunocompromised individuals is:

ü S. aureus,

ü Pseudomonas aeruginosa,

ü S. pneumonia,

ü H. Influenza

ü E. coli.

A specific causative agent of pneumonia against the background of immunodeficiency is Pneumocystis carinii. More than 3/4 of Pneumocystis pneumonia are associated with HIV . The remaining cases occur in patients with primary or secondary immunodeficiency, including iatrogenic immunosuppression.

Diagnostic standard for examining a patient with pneumonia

Clinical criteria:

ü Acute febrile fever, intoxication,

ü Cough is dry or with sputum,

ü Chest pain associated with breathing,

ü Local dullness of percussion sound,

ü Locally audible bronchial breathing, an area of ​​sonorous fine rales and/or crepitus, pleural friction noise.

Objective criteria:

ü leukocytosis > 10 G/l with a band shift > 10%, increased ESR;

ü infiltrative darkening on a plain radiograph of the chest organs;

ü identification of microorganisms in sputum during bacterioscopy with Gram staining of a smear, as well as verification of the microorganism and determination of its sensitivity to antibiotics during bacteriological examination;

ü blood oxygen saturation< 90% по данным пульсоксиметрии (является критерием тяжелой пневмонии и показанием для проведения кислородотерапии).

Listed criteria sufficient for the diagnosis and treatment of pneumonia on an outpatient basis, as well as during an uncomplicated course of the disease in an inpatient setting.

Additional research methods:

ü CT scan(with damage to the upper lobes, lymph nodes of the mediastinum, a decrease in the volume of the lobe, suspected abscess formation, with the ineffectiveness of antibacterial therapy, with an obvious clinical picture of pneumonia, changes on the radiograph are absent or are indirect in nature, recurrent pneumonia with the same localization, prolonged pneumonia).

ü Serological study with an atypical course of pneumonia in the risk group in people who abuse alcohol, drugs, in the elderly and senile, with immunodeficiency.

ü Microbiological examination pleural fluid.

ü Biochemical blood test in severe cases of pneumonia with manifestations of renal and liver failure, in patients with chronic diseases, decompensation of diabetes mellitus.

ü Cyto- and histological examination at risk for lung cancer in smokers over 40 years of age, with chronic bronchitis and a family history of cancer.

ü Bronchological examination: diagnostic bronchoscopy in the absence of effect from adequate therapy for pneumonia, if lung cancer is suspected, a foreign body, biopsy. Therapeutic bronchoscopy for abscess formation to ensure drainage.

ü Ultrasonography heart and abdominal organs if sepsis or infective endocarditis is suspected.

ü Isotope scanning lungs (pulmonary angiography if indicated) if PE is suspected.

Causes and nature of the atypical course of pneumonia.

Availability severe somatic diseases, severe immunodeficiency, old age and other factors can modify the course of pneumonia. Possible:

ü absence or low severity of physical signs of pulmonary inflammation;

ü absence of fever;

ü predominance of extrapulmonary symptoms (disorders of the central nervous system, etc.);

ü absence of typical changes in peripheral blood;

ü absence of typical radiological changes, which may be due not only to the variant of pneumonia, but also to the location and timing of the study.

Features of the course of pneumonia depending on the etiology or variant.

For pneumococcal CAP is characterized by an acute onset, high fever (39-40°C), chest pain, severe course, arterial hypotension, large infiltrate, good response to penicillins.

Staphylococcal pneumonia often occurs after a viral infection and is characterized by an acute onset, severe course, small size of the infiltrate (focus, focus), a tendency to abscess formation, bullous changes in the lungs, and resistance to penicillins.

Haemophilus influenzae causes pneumonia in people suffering from chronic bronchitis, alcoholism and other chronic diseases, the sputum is viscous, viscous, often streaked with blood, characterized by a severe clinical course, large (polysegmental, lobar) infiltrates, and a tendency to abscess formation.

Mycoplasma Pneumonia usually occurs in people under 35 years of age, is very contagious, and therefore can occur in the form of epidemic outbreaks in groups. Characterized by an acute onset, high fever with chills, symptoms of upper respiratory tract infection (pharyngitis, laryngotracheitis), muscle pain and headaches, increasing cough with a small amount of sputum, the course is usually not severe.

For legionella Pneumonia is also characterized by epidemic outbreaks among persons who work or visit damp, air-conditioned premises, severe clinical course, diarrhea, neurological symptoms, and impaired liver function.

The emergence aspiration pneumonia is usually preceded by a picture of a painful reflex cough, often accompanied by profuse salivation. Inflammatory foci are often multiple, of varying sizes, and often tend to merge. Infiltration, as a rule, is localized in the right lower lobe, which is due to the nature of the branching of the main bronchi, but it can also be bilateral. Aspiration pneumonia is characterized by:

ü documented aspiration or the presence of factors predisposing to the development of aspiration;

ü sputum with a putrid odor;

ü pneumonia in the lower lobe of the right lung;

ü necrotizing pneumonia or abscess formation, pleural empyema;

ü no growth of microorganisms under aerobic conditions.

Pneumonia in immunocompromised patients characterized by an acute onset, severe course, chills with high intoxication, a tendency to a septic state, abscess formation of the lungs and other internal organs. Radiologically, lobar and segmental infiltrates with pleural effusion are typical.

For Pneumocystis pneumonia is characterized by a clinical picture of interstitial inflammation of the lung tissue: a nonproductive cough for several weeks, severe shortness of breath (in 100% of patients) and symptoms of increasing respiratory failure, as well as a paucity of physical manifestations and features of radiological changes. X-ray manifestations at the onset of the disease may be absent, then a hilar decrease in pneumatization of the lung tissue and an increase in the interstitial pattern are revealed. In more than half of the cases, bilateral cloud-like infiltrates are detected (the “butterfly” symptom), and at the height of the disease, abundant focal shadows (“cotton-colored” lung) are detected, requiring differential diagnosis with disseminated tuberculosis. Up to 20% of Pneumocystis pneumonia can occur without a clear X-ray picture. A discrepancy between severe respiratory failure and moderate radiological changes is typical.

Fungal pneumonia is caused by fungi (micromycetes), often opportunistic: Aspergillus spp., Criptococcus neoformans, Candida spp. etc. Clinical manifestations of fungal pneumonia are nonspecific; it is impossible to make a diagnosis based only on clinical signs. The most common symptoms are fever refractory to broad-spectrum antibiotics (t > 38°C), lasting more than 96 hours, nonproductive cough, chest pain, hemoptysis, and respiratory failure. Fungal pneumonia develops very quickly and is accompanied by high mortality. Mandatory diagnostic methods, along with radiographs, are: high-resolution CT, microscopic examination of respiratory substrates (sputum, BAL fluid, etc.) with mandatory culture on nutrient media. It should be taken into account that the detection of fungi in normally non-sterile biosubstrates (including sputum) is due to colonization, which does not require specific treatment.

Principles of pneumonia therapy

ü Adequate antibacterial therapy.

ü Detoxification.

ü Anti-inflammatory therapy.

ü Improvement of bronchial drainage.

ü Correction of microcirculatory disorders.

ü Symptomatic treatment.

Indications for hospitalization:

1. Severe pneumonia*.

ü BH ³ 30 / min.

ü Body temperature< 35,0 0 С или ³ 40,0 0 С.

ü blood pressure< 90/60 мм рт.ст.

ü Heart rate > 125/min.

ü Impaired consciousness.

ü Leukocytosis > 20.0 G/l or leukopenia< 4,0 Г/л

ü Hemoglobin< 90 г/л

ü Hematocrit< 30%

ü Creatinine > 176.7 µmol/l

ü SaO 2< 90% (по данным пульсоксиметрии)

ü PaO 2< 60 мм рт.ст. и/или PaCO 2 >50 mmHg when breathing room air

ü Pneumonic infiltration is localized in more than one lobe

ü Presence of complications: decay cavity(s), pleural effusion, ITS.

* If at least one criterion is present, community-acquired pneumonia is regarded as severe

2. Ineffectiveness of initial antibiotic therapy in an outpatient setting for 48-72 hours.

3. Social indications (inability to organize adequate treatment of pneumonia at home).

Relative indications for hospitalization:

ü age over 60 years,

ü severe concomitant diseases (COPD, malignant neoplasms, diabetes mellitus, chronic renal failure, heart failure, alcoholism, drug addiction, exhaustion),

ü preferences of the patient and/or his family members.

To quickly navigate the management tactics of a particular patient, you can use the English CRB-65 scale.

Treatment of pneumonia

Mode: for the period of fever and intoxication - bed or semi-bed, with subsequent expansion.

Diet: complete, enriched with vitamins, including easily digestible foods, with thermal sparing and increasing the volume of fluid consumed.

Antibacterial therapy

Establishing a diagnosis of pneumonia is an absolute indication for prescribing antibacterial therapy. The first dose of antibiotic should be given within the first 4 hours of diagnosis!

A distinction is made between empirical therapy for pneumonia (with unknown etiology) and therapy for pneumonia of established etiology.

Antibacterial therapy for pneumonia of known etiology

S. pneumonia. The drugs of choice for treating pneumonia are aminopenicillins(amoxicillin - orally, ampicillin - parenterally), incl. inhibitor-protected (amoxicillin/clavulanate) and cephalosporins III generation (cefotaxime, ceftriaxone). Macrolide Antibiotics are an alternative for b-lactam allergies. They have high activity respiratory fluoroquinolones(levofloxacin, moxifloxacin), vancomycin And linezolid.

H. influenzae. The selection tools are aminopenicillins(amoxicillin - orally, ampicillin - parenterally), incl. inhibitor protected (amoxicillin/clavulanate), cephalosporins III generation (cefotaxime, ceftriaxone) fluoroquinolones

M. pneumonia, C. pneumonia. They have the greatest activity against “atypical” pathogens macrolides, tetracyclines(doxycycline), respiratory fluoroquinolones.

S. aureus. The drug of choice for pneumonia caused by MSSA is oxacillin, an alternative may be protected aminopenicillins, cephalosporinsI- IIgenerations, lincosamides. If MRSA is detected, glycopeptide antibiotics (vancomycin) or linezolid, and the latter should be preferred due to its pharmacokinetic characteristics.

Legionellaspp. In the treatment of Legionnaires' pneumonia, macrolides. Highly effective also fluoroquinolones(ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin).

Enterobacteriaceae. III generation cephalosporins have the widest spectrum of action. Treatment of hospital-acquired pneumonia requires preliminary determination of sensitivity to antibiotics.

P. aeruginosa. The combination of ceftazidime and tobramycin is considered one of the most common treatment regimens for pseudomonas pneumonia. The high frequency of acquired resistance of this pathogen to antibiotics requires a preliminary assessment of sensitivity in each specific case.

Empirical treatment planning is based on the likely etiology of the disease (Table 2).

Table 2.

Empirical antibacterial therapy for community-acquired pneumonia in outpatient patients

	Most Frequent pathogens	Drugs of choice
Non-severe CAP in patients without concomitant diseases who have not taken AMPs for ≥2 days in the last 3 months	S. pneumoniae M. pneumoniae C. pneumoniae H. influenzae	Amoxicillin orally or macrolide orally 1
Non-severe CAP in patients with concomitant diseases and/or who have taken antimicrobial medications for ≥2 days in the last 3 months	S. pneumoniae H. influenzae C. pneumoniae S. aureus Enterobacteriaceae	Amoxicillin/clavulanate, amoxicillin/sulbactam orally ± macrolide orally Respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin) by mouth

Note: 1 Macrolides are the drugs of choice if an “atypical” etiology of CAP is suspected ( C. pneumoniae, M. pneumoniae). Preference should be given to the most studied macrolides for CAP with improved pharmacokinetic properties (azithromycin, clarithromycin) or a favorable safety profile and minimal frequency of drug interactions (josamycin, spiramycin).

Table 3.

Empirical antibacterial therapy for community-acquired pneumonia

at hospitalized patients

	Most common pathogens
Pneumonia not severe currents 1	S. pneumoniae H. influenzae C. pneumoniae S. aureus Enterobacteriaceae	Benzylpenicillin IV, IM ± macrolide orally 2 Ampicillin IV, IM ± macrolide orally 2 Amoxicillin/clavulanate IV ± macrolide orally 2 Amoxicillin/sulbactam IV, IM ± macrolide 2 Cefotaxime IV, IM ± macrolide orally 2 Ceftriaxone IV, IM ± macrolide orally 2 Ertapenem IV, IM ± macrolide orally 2 Respiratory fluoroquinolone (levofloxacin, moxifloxacin) IV
Pneumonia severe course 3	S. pneumoniae Legionella spp. S. aureus Enterobacteriaceae	Amoxicillin/clavulanate IV + macrolide IV Cefotaxime IV + macrolide IV Ceftriaxone IV + macrolide IV Ertapenem IV + macrolide IV Respiratory fluoroquinolone (levofloxacin, moxifloxacin) IV + cefotaxime, ceftriaxone IV

Note:

1 Stepped therapy is preferred. If the patient’s condition is stable, oral administration of drugs is allowed immediately.

2 Preference should be given to the most studied macrolides for CAP with improved pharmacokinetic properties (azithromycin, clarithromycin) and/or a favorable safety profile and minimal frequency of drug interactions (josamycin, spiramycin).

3 If there are risk factors P. aeruginosa– infections (bronchiectasis , taking systemic glucocorticoids, broad-spectrum antibiotic therapy for more than 7 days during the last month, exhaustion) drugs of choice are ceftazidime, cefepime, cefoperazone/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, carbapenems (meropenem, imipenem), ciprofloxacin. All of the above drugs can be used in monotherapy or combination with aminoglycosides of the II-III generation. If aspiration is suspected, it is advisable to use amoxicillin/clavulanate, cefoperazone/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, carbapenems (meropenem, imipenem).

Initial effectiveness assessment therapy should be carried out in the first 48-72 hours. The main efficiency criteria are:

ü normalization of body temperature or its decrease< 37,5°С,

ü reduction of symptoms of intoxication,

ü reduction of shortness of breath and other manifestations of respiratory failure.

If the initially selected antibiotic is ineffective, it is first necessary to collect biomaterial for bacteriological examination (sputum, lavage fluid), if this was not done initially, and then change the antibacterial drug (Table 4). Outpatient patients must be hospitalized.

Table 4.

outpatient patients

Drugs at stage 1 of treatment	Drugs at stage 2 of treatment	Comments
Amoxicillin	Macrolides	pneumoniae, M. pneumoniae)
Amoxicillin/clavulanate	Macrolides Respiratory fluoroquinolones	(WITH.pneumoniae, M. pneumoniae)
Macrolides	Amoxicillin Amoxicillin/clavulanate Respiratory fluoroquinolones	A possible reason for the ineffectiveness of macrolides is resistant pneumococci or gram(-) bacteria

Table 5.

The choice of antibacterial drugs when the initial treatment regimen is ineffective in hospitalized patients

Drugs at stage 1 of treatment	Drugs for Stage 2 of treatment	Comments
Amoxicillin orally Ampicillin IM	Macrolides (replace or add) III generation cephalosporins Amoxicillin/clavulanate Macrolide	Possible “atypical” microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.), Gram(-) enterobacteria, S. aureus
Amoxicillin/clavulanate Amoxicillin/sulbactam	Macrolides (add). Respiratory fluoroquinolones	Possible “atypical” microorganisms (WITH.pneumoniae, M. pneumoniae, Legionella spp.)
Cephalosporins III generation	Macrolide (add) Respiratory fluoroquinolones	Possible “atypical” microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.)
Macrolides	Amoxicillin/clavulanate. Respiratory fluoroquinolones	A possible reason for the ineffectiveness of macrolides is resistant pneumococci or Gram(-) bacteria

Stepped antibacterial therapy for pneumonia

Stepped antibacterial therapy involves the two-stage use of antibacterial drugs with a transition from parenteral to non-parenteral (usually oral) route of administration in the shortest possible time, taking into account the clinical condition of the patient. The main idea of ​​step therapy is to reduce the duration of parenteral administration of the antibiotic, which provides a significant reduction in the cost of treatment and a reduction in hospital stay while maintaining high clinical effectiveness of therapy. The optimal option for stepwise therapy is the sequential use of two dosage forms of the same antibiotic, which ensures continuity of treatment. It is possible to sequentially use antibacterial drugs that are similar in their microbiological properties.

Criteria for transition to oral administration as part of stepwise antibacterial therapy for CAP

ü normal (or close to normal) body temperature (less than 37.5°C) with two measurements with an interval of 8 hours,

ü reduction of shortness of breath,

ü no impairment of consciousness,

ü positive dynamics of other symptoms of the disease,

ü absence of absorption disorders in the gastrointestinal tract,

ü consent (inclination) of patients to oral treatment.

Injectable drug	Oral drug	Dose, g	Frequency of reception
PENICILLINS and CEPHALOSPORINS
Benzylpenicillin 2 million units IV (IM) 4 times a day or Ampicillin 1-2 g IV (IM) 4 times a day	Amoxicillin
Amoxicillin/clavulanate, IV 1.2 g 3-4 times a day	Amoxicillin/clavulanate
Cefotaxime IV (IM) 1.0-2.0 g 2-3 times a day or Ceftriaxone IV (IM) 1.0-2.0 g 1 time per day	Amoxicillin/clavulanate
MACROLIDES
Clarithromycin IV 0.5 g 2 times a day	Clarithromycin Clarithromycin extended release
Azithromycin IV 0.5 g once a day	Azithromycin
RESPIRATORY FLUOROQUINOLONES
Levofloxacin IV 0.5 g once a day	Levofloxacin
Moxifloxacin IV 0.4 g once a day	Moxifloxacin

Empirical therapy for hospital-acquired pneumonia

Since hospital-acquired pneumonia is characterized by a significant variety of etiology, which makes it difficult to plan empirical therapy, after establishing a clinical diagnosis, the earliest possible microbiological diagnosis should be carried out:

ü microbiological examination of sputum (obtaining material during bronchoscopy may be indicated),

ü blood cultures for blood culture.

At pneumonia that developed in patients in general wards without risk factors, the means of choice for empirical therapy before establishing an etiological diagnosis may be parenteral cephalosporinsIIIgenerations in maximum doses. Alternatives are being considered fluoroquinolones. If there is evidence in favor pseudomonas etiology of pneumonia, it is advisable to prescribe a combination of antipseudomonas cephalosporinsIII- IVgenerations (ceftazidime, cefepime) with aminoglycosides (tobramycin, amikacin).

At pneumonia in patients in general wards with risk factors there is a high probability of the etiological role of pseudomonas and other “non-fermenting” microorganisms. Possible options for choosing antibiotics:

ü carbapinems (imipenem, meropenem),

ü antipseudomonal cephalosporins of III-IV generations in combination with aminoglycosides,

ü antipseudomonal penicillins (azlocillin, ticarcillin, piperacillin) in combination with aminoglycosides,

ü aztreonam in combination with aminoglycosides,

ü fluoroquinolones,

ü glycopeptides (vancomycin).

Empirical treatment of pneumonia that develops against the background of neutropenia.

Taking into account the specific etiology, empirical therapy includes glycopeptides, co-trimoxazole and antifungal drugs.

Aspiration pneumonia

The basis of empirical therapy for aspiration pneumonia is the need to use antibacterial drugs with pronounced antianaerobic activity (protected b-lactams, carbapenems, metronidazole).

Criteria for the sufficiency of antimicrobial therapy for CAP

ü Body temperature less than 37.5°C for at least three days in a row

ü No intoxication

ü Absence of respiratory failure (RR less than 20 per minute)

ü Absence of purulent sputum

ü The number of leukocytes in the blood is less than 10 G/l, neutrophils< 80%, юных форм < 6%

ü Absence of negative dynamics on the radiograph

Table 7.

Clinical signs and conditions not considered indications

to continue antibiotic therapy

Clinical signs	Explanations
Persistent low-grade fever (body temperature within 37.0-37.5ºС)	In the absence of other signs of bacterial infection, it may be a manifestation of non-infectious inflammation, post-infectious asthenia (autonomic dysfunction), drug fever
Persistence of residual changes on the radiograph (infiltration, increased pulmonary pattern)	Can be observed for 1-2 months after CAP
Dry cough	Can be observed for 1-2 months after CAP, especially in smokers and patients with COPD
Persistence of wheezing upon auscultation	Dry wheezing can be observed for 3-4 weeks or more after CAP and reflects the natural course of the disease (local pneumosclerosis at the site of the focus of inflammation)
Increase in ESR	Nonspecific indicator, not a sign of bacterial infection
Persistent weakness, sweating	Manifestations of post-infectious asthenia

Approximate timing of antibacterial therapy for known etiologies:

ü for pneumococcal pneumonia - at least 5 days,

ü for pneumonia caused by enterobacteria and Pseudomonas aeruginosa - 14 days,

ü for pneumonia caused by staphylococci - 10 days,

ü for pneumonia caused by pneumocystis - 14-21 days,

ü for pneumonia caused by Legionella - 21 days,

ü for pneumonia complicated by abscess formation – more than 30 days

In cases where, against the background of an improvement in the clinical picture, by the end of the 4th week from the onset of the disease it is not possible to achieve complete radiological resolution of focal infiltrative changes in the lungs, one should speak of prolonged CAP.

In such a clinical situation, it is necessary, first of all, to establish possible risk factors for a protracted course of the disease:

ü age over 55 years;

ü alcoholism;

ü the presence of concomitant disabling diseases of internal organs (COPD, congestive heart failure, renal failure, malignant neoplasms, diabetes mellitus, etc.);

ü severe pneumonia;

ü multilobar infiltration;

highly virulent pathogens ( L. pneumophila, S. aureus, gram-negative enterobacteria);

ü smoking;

ü clinical ineffectiveness of initial therapy (persistent leukocytosis and fever);

ü secondary bacteremia;

ü secondary resistance of pathogens to antibiotics (age > 65 years, β-lactam therapy within the previous 3 months, immunodeficiency diseases/conditions).

Algorithm of action for slowly resolving pneumonia

If clinical improvement is not observed and the patient does not have risk factors for slow resolution of CAP, then differential diagnosis with diseases such as:

ü local bronchial obstruction (tumor);

ü tuberculosis;

ü congestive heart failure;

ü drug fever, etc.

Detoxification therapy

ü saline solutions (physiological, Ringer's, etc.) 1000-3000 ml,

ü glucose 5% - 400-800 ml/day,

ü hemodez 400 ml/day.

Solutions are administered under the control of central venous pressure and diuresis.

Oxygen therapy- through a mask, catheters, mechanical ventilation, depending on the degree of respiratory failure.

Anti-inflammatory therapy

NSAIDs (aspirin, ibuprofen, diclofenac, etc.) orally or parenterally.

Improving bronchial drainage

ü Atrovent, Berodual through a nebulizer 4 times a day,

ü mucoregulators (ambroxol, acetylcysteine ​​orally or inhaled)

Correction of microcirculatory disorders

ü heparin 20,000 units/day,

ü rheopolyglucin 400 ml/day.

Immune replacement therapy

ü Gabriglobin (Gabreglobine) 1 dose – 2.5 g, course of treatment 2.5-10 g 1 time/day for 3-10 days

The general complex of therapeutic measures must include therapeutic exercises. Breathing exercises not only improve ventilation and blood circulation, but are also a means of preventing complications (hypostasis, atelectasis, pleural adhesions, etc.). For uncomplicated pneumonia, the rehabilitation treatment program can begin and end in a hospital setting. In severe cases of the disease, after hospital treatment, patients can be sent to specialized sanatoriums and rehabilitation departments. The use of complex restorative treatment leads in the vast majority of cases to the patient’s recovery and restoration of ability to work.

Physiotherapy atpneumonia is aimed at eliminating inflammation, achieving faster resorption of the inflammatory focus, improving the function of external respiration, lymph and blood circulation of the bronchopulmonary system, restoring impaired immune status, and providing a hyposensitizing effect.

Contraindications: severe intoxication, body temperature above 38°, stage II-III heart failure, pulmonary hemorrhage and hemoptysis, thromboembolism, infarction-pneumonia, pneumothorax, suspected neoplasm.

In the first days of the disease prescribe exposure to an electric field UHF on the chest in continuous (power 40-100 W) or pulsed (4.5-6 W) modes. The UHF electric field has anti-inflammatory, improves blood circulation, analgesic, improves nervous system function, and desensitizing effects. UHF should not be prescribed for destructive pneumonia. Also recommended inhalation phytoncides, bronchodilators, alkaline solutions, herbal decoctions with expectorant action, erythema ultraviolet irradiation chest (usually in separate fields) corresponding to the affected lobe of the lung, one field daily. A good effect at the infiltration stage is achieved by using galvanization chest against the background of antibiotic therapy for 20-40 minutes, which is carried out with intravenous drip after 1/2 - 2/3 of the solution volume has been consumed, and with intramuscular administration - 1-1.5 hours after injection. This increases the concentration of the drug in the inflammatory focus.

During the permission period inflammatory focus is prescribed Microwave therapy on the area of ​​the lesion or lower lobes of the lungs. Unlike UHF, the microwave electric field does not act on the entire body, but locally, on the inflammatory area. The same principle is used inductothermy(treatment with a high-frequency alternating magnetic field), using low-thermal and thermal doses. Inductothermy has a sedative, antispasmodic, analgesic effect, tissue muscle tone decreases, blood vessels dilate, inactive capillaries open, blood flow increases, the activity and intensity of phagocytosis and nonspecific immunity increases, and the function of the sympathoadrenal system improves.

During the same period, the disease is carried out magnetic therapy using a low-frequency (50 Hz) magnetic field in continuous or intermittent modes, which has a beneficial effect on the functions of the cardiovascular system, causing the advantage of this method in the treatment of patients with concomitant cardiovascular pathology. Contraindications for magnetic therapy are the general serious condition of the patient, body temperature above 38 o C, severe hypotension, stage III hypertension, bleeding or tendency to bleeding, systemic blood diseases, cachexia, recurrent thrombophlebitis, skin defects in the area of ​​treatment

To improve the resorption of the inflammatory focus and eliminate bronchospasm, pain, and difficult sputum discharge, use electrophoresis calcium, magnesium, heparin, aminophylline, aloe extract, ascorbic acid, lysozyme. In this case, one electrode (100-150 cm 2) is placed in the interscapular region, the second - taking into account the localization of the source of inflammation.

During the period of resolution of the inflammatory focus, use inhalation with expectorants, mucolytics, restorative drugs, as well as thermotherapy– applications of ozokerite, paraffin, silt and peat mud. In the 2-3rd week, you can prescribe climatotherapeutic procedures (daytime stay on the veranda, air baths).

All methods are combined with exercise therapy and massage. Physical therapy is indicated on the 2-3rd day from the moment body temperature normalizes. Use exercises that help increase the respiratory mobility of the chest wall, stretch the pleural adhesions, strengthen the respiratory muscles and abdominal muscles.

During treatment prolonged pneumonia Hardening methods (water rubdowns, douses, showers), climatotherapy (in a sanatorium or rehabilitation department), general UV irradiation, aerosol therapy with expectorants, mucolytic and restorative drugs are becoming more important.

Clinical examination.

Dispensary observation is carried out for 6 months with visits to the local therapist 1, 3 and 6 months after discharge. A general blood test, sputum test, fluorogram, spirogram are performed twice, after 1 and 6 months, a biochemical blood test - once after 6 months. If necessary, consultations with an ENT doctor, dentist and pulmonologist are carried out. Wellness activities: vitamin therapy, exercise therapy, sauna, sanitization of foci of infection, prevention of acute respiratory viral infections and influenza, smoking cessation, referral to specialized sanatoriums.

Test questions on the topic.

1. Definition of pneumonia.

2. Classification of pneumonia.

3. Clinical and instrumental signs of pneumonia.

4. The main pathogens of pneumonia.

5. Features of the course of pneumonia depending on the pathogen.

6. Principles of pneumonia therapy.

7. Empirical choice of antibiotic.

8. Step therapy.

9. Criteria for effectiveness and antibiotic withdrawal.

10. Complex therapy of pneumonia.

11. Prolonged course of pneumonia: causes and tactics.

12. Physiotherapy of pneumonia.

13. Clinical observation after pneumonia.

Diagnostic algorithm for community-acquired pneumonia

Diagnostic search algorithm for nosocomial pneumonia

Successful treatment of any pathology is impossible without a complete examination. A number of diseases require comparative analysis to more accurately clarify the picture. In this sense, differential diagnosis of pneumonia is necessary to exclude similar symptoms, and ultimately determine the only correct diagnosis and prescribe a therapeutic course. The technique allows you to avoid incorrect treatment and incorrect dosages of drugs, prevents complications and side effects associated with erroneous examination, which is especially important for diseases in children. Detailed information about pneumonia is available

Diagnostic methods

The process of differential testing of pathologies is carried out according to the elimination scheme, that is, at first the symptoms are grouped, then excluded in small groups until the real clinical picture is formed. Diagnostics is carried out in several stages:

• Primary data are summarized under the general syndrome, and on their basis a list of possible pathologies is formed
• A graph of symptoms, the general condition of the patient, changes in his well-being is studied in detail and a chart is drawn up, taking into account various factors
• A comparative analysis is carried out according to the list, including the clinical picture, accompanying signs and their features. Another graph of similar and different values ​​is drawn up
• The symptoms are compared and their belonging to the original disease is determined
• The specialist finds third-party signs that are not related to this pathology
• Diseases whose clinical picture does not fit into the overall picture are excluded
• Based on the final information, a diagnosis is established and treatment is prescribed.

As for the general examination methods, in this case they are identical to traditional analyzes and testing of the patient:

• Listening to the patient's complaints, collecting anamnesis, checking the medical record for past pathologies
• Auscultation and percussion
• General inspection
• Biochemical tests
• X-ray
• Electrocardiogram
• Ultrasonography
• Magnetic resonance and computed tomography
• Bronchoscopy
• Spirometry.

The collected and analyzed anamnesis allows us to obtain a reliable picture, including the causes of the disease in children and adults, and frequently recurring symptoms. The doctor also identifies other disorders in the body. The initial examination does not provide complete data, since the patient’s assessment of his own well-being is almost always subjective. Small children generally cannot tell where it hurts.

Differentiation of pneumonia

Pathologies of the respiratory system have the same clinical picture, especially in the first stages of development. Many analyzes and tests take time to carry out, and in the case of acute cases, every minute matters, especially for children. Patients often turn to doctors when processes become threatening.

Poorly treatable pneumonia may turn out to be tuberculosis or mask oncological pathologies. In addition, there is some similarity of symptoms with heart failure, thromboembolism, and vasculitis. First of all, differentiation is established between different types of pneumonia in children and adults. Visual data on symptoms and causes are shown in the table:

Type of pathogen that caused pneumonia	Etiological factor	Clinical picture	Temperature	Complications
Pneumococci	Chronic lung pathologies, community infections	Begins with an acute manifestation, cough with rusty sputum	38-40 0 C, fever	Pleurisy, abscess, empyema
Mycoplasmas	Preschool children, adults during seasonal influenza epidemics	Gradual development, runny nose, sore throat, cough, myocarditis, anemia	Low-grade fever	Lung tissue infiltrates, erythema, skin rash, meningitis, encephalitis
Influenza	Chronic obstruction, heart failure, smoking, old age, children under 6 years of age	Flank pain, persistent cough with purulent discharge, cyanosis	Absent or low-grade	Meningitis, arthritis, septicemia, epiglottitis
Legionella	Staying in the air conditioner area or near open water bodies, immunodeficiency syndrome	Acute onset and severe course, cough with sputum, headaches and joint pain, hemoptysis is rare	Fever, chills, maximum readings	Lesions of the digestive system, toxic shock
Chlamydia	Intrapartum infection in children under 6 months, transmission of infection by birds	Rhinitis, laryngitis, weakness, myalgia, dry cough, scanty sputum	38-39 0 C	Otitis, reactive arthritis, atherosclerosis, sarcoidosis
Staphylococcus	Children of the neonatal period, surgical interventions, drug addiction, alcoholism	Severe course, painful cough, shortness of breath, intoxication	39-40 0 C	Pneumosclerosis, sepsis, endocarditis
Bacteroides, actinomycetes	Invasive procedures, surgeries, open wounds, insect and animal bites	Intoxication, nausea, headache, tachycardia, hypotension, cyanosis. Purulent sputum in cough	Fever, chills, 38-39 0 C	Failure and dysfunction of all systems, sepsis, death
Klebsiella	Diabetes mellitus, hepatic cirrhosis	Acute onset, pain in the side, jaundice, dry cough and hemoptysis	39-40 0 C	Vascular thrombosis, fibrosis, infarction
Escherechia and Protea	Pyelonephritis, epicystoma, elderly people	Severe cough, severe course with abscesses, hypotension	High performance	Pleural empyema
Pseudomonas	Weakened children, adults with reduced immunity. Transmitted by aerosol, food and contact	Persistent, wet cough with purulent sputum, oxygen deficiency, cyanosis, shortness of breath	Low-grade fever	Meningitis, pyelonephritis, osteomyelitis
Fungi	Chemotherapy for cancer patients. Taking antibiotics, immunosuppressants	Weakness, myalgia, dry cough, pulmonary hemorrhage	Low-grade fever gives way to high levels	Thrombosis, hemorrhagic infarction, abscesses
Pneumocysts	Malignant tumors, immunodeficiency syndrome	Gradual development, cyanosis, frothy sputum, anorexia	Spasmodic	Pneumothorax, pleurisy, impaired gas exchange, death
Viruses	Young children, elderly and frail people	Pharyngitis, rhinitis, swollen lymph nodes, frequent cough with moist rales	Fluctuations during the day	Otitis, encephalitis, meningitis, empyema

Since most symptoms have a similar pattern, the main principle of diagnosis is bacterial culture. When collecting anamnesis, the doctor must reflect the following points:

• Etiological factors
• Presence of background pathologies
• Prevalence and characteristics of pneumonia foci
• Severity
• Stage of development
• Possible complications and risks of their occurrence.

In each specific case, the type of pathogen is indicated. If such data are not available or it takes time to obtain them, the reasons, available results of radiographs, bronchoscopy and spirometry are described. If there is a lack of information, an empirical treatment regimen should be prescribed, which is adjusted as the diagnosis is completed.

If there is an underlying disease, the pediatrician or therapist describes its symptoms, features of the course and impact on the patient’s condition. Therapy is based on the specific interaction and combination of different drugs and antibiotics. This fact is most important, since associated pneumonia can become protracted or lead to irreversible consequences.

Differentiation with other diseases

When examining a patient, the doctor faces two tasks. The first is to limit pulmonary inflammation from other diseases of the respiratory system. The second is the definition of extrapulmonary pathologies by symptoms from the respiratory system. Each of these principles has specific distinctive features:

With tuberculosis

The most common mistakes are made when comparing these two diseases. According to research, infection with mycobacteria is complicated by influenza or pneumonia. Exacerbation of tuberculosis is similar to the manifestations of pneumonia - a dry cough, pale skin, low-grade fever.

Sometimes the inflammatory process is accompanied by positive tuberculin tests, which further complicates the diagnosis. However, differentiation plays an important role, since most physiotherapy methods that are used for pneumonia are unacceptable for tuberculosis. The formation of infiltrates may be accompanied by nonspecific changes - hyperemia, hyperreaction, lymphostasis. This creates favorable conditions for viruses to attach to mycobacteria.

When analyzing the patient’s condition, the main question arises - how does developing catarrh affect the course of existing tuberculosis. Typically, the clinical picture of the formation of cavities and caseous formations is similar. In both cases, an acute onset is detected, a cough with pain, sputum with bloody discharge. An X-ray examination shows that the affected area is enlarged and there are characteristic changes.

The difference consists of a number of factors: with tuberculosis, the shadows are heterogeneous and compacted, areas of clearing coincide with the seeded foci. Therapeutic regimens effective for pneumonia do not produce results within more than three days. A massive proliferation of mycobacteria is found in the sputum. Also, the limitation allows you to determine the biochemical test. With tuberculosis, an increase in leukocyte elements is detected in the blood, which are reduced in pneumonia.

With bronchitis

Pathology most often begins to develop as a result of respiratory viral infections or simultaneously with them. The main symptom is coughing attacks, first dry, then with sputum production. Increases in temperature are short-term in nature, it rises within 2-3 days, then remains within the subfebrile range. The sound does not change during percussion; wheezing is observed during auscultation. The pulmonary pattern is enhanced, but there is no infiltration.

When differentiating pneumonia and bronchitis, there are two main mistakes: when the first disease is interpreted as an exacerbation of the second. In addition, patients with pneumonia who smoke may exhibit the characteristic pattern of chronic smoker's bronchitis. In most cases, pulmonary inflammation is more severe. It is predominantly bacteriological in nature, while bronchitis is pulmonary. The difficulty arises when the origin of both pathologies is the same, but in such cases confirmation will be based on additional examinations.

With the flu

Misdiagnosis when compared with respiratory pathologies is not uncommon. During a pandemic, it is especially difficult to limit pulmonary inflammation and influenza. First of all, the specifics of the clinical picture should be taken into account:

• Respiratory lesions begin acutely, the temperature is high, a runny nose is added, the cough is dry, the sputum is clear and non-viscous. Sore throat, red eyes, swollen face.
• With the flu, the patient complains of joint pain and aches, severe weakness, and fever with high temperatures. Catarrhal signs, which are absent at first, appear after 3-4 days.
• Pneumonia can develop either slowly or suddenly. The patient suffers from shortness of breath, loses appetite, and loses weight sharply. The cough is frequent, the discharge is viscous, purulent or bloody. There is pain in the chest area.

Often, pulmonary inflammation is a complication after influenza or respiratory infections. In this case, they can develop as a result of direct viral damage or due to the penetration of bacteria as a secondary factor. The examination reveals tissue compaction, foci of infiltration, and individual areas of destruction.

With pleurisy

Massive inflammatory damage to the respiratory system resembles pleural changes, especially when both processes occur in the lower lobe areas. Painful sensations in the chest are characteristic of both pathologies. Some patients complain of discomfort when coughing. But there are a number of symptoms that are fundamentally different. Exudative pleurisy is characterized by a special sign - the sound of pleura rubbing during breathing.

After the first stage of development with a specific clinical picture, the following series of symptoms occurs. This is a more acute pain than with pneumonia, which intensifies when bending and turning. The temperature is normal or slightly elevated, the cough is dry, and sputum is difficult to produce. An x-ray is considered the most reliable examination method, but if the effusion volume is less than 300 ml, confirmation by puncture is required, which helps not only to determine the amount of fluid, but also its composition. The same method is suitable for differentiation from pneumonia. In addition, the data of biochemical analysis are important.

With atelectasis

Damage to the lungs with tissue collapse and impaired gas exchange may also have similar symptoms to pneumonia. Respiratory failure, cyanosis, shortness of breath. Chest pain is associated with impaired gas exchange. The collapsed area creates a favorable environment for the development of infection. The etiological factors of atelectasis are blockages and compression associated with injuries, aspirations, destructive tissue changes, and surfactant deficiency. This is the main difference from pneumonia.

The initial clinical picture is identical: with atelectasis, cyanosis, shortness of breath, and cough are also observed. Typically dry. As the condition worsens and respiratory failure develops, the risk of death increases. The temperature is rising. If an infection develops against the background of a collapsed lung. This indicates the onset of pneumonia with abscess formation. In this case, intoxication and sputum are added, often with bloody spots due to damage to blood vessels and increased pressure in the pulmonary circulation.

With cancer

The initial manifestations of oncological formations do not differ from the inflammatory process in the lungs. Just a few years ago, the rate of misdiagnosis was 70%. If pneumonia is suspected, the doctor prescribes antibiotics. If the drugs do not bring results after two weeks of use, it is necessary to urgently examine the patient for the development of malignant neoplasms. Differentiation lies in early diagnosis, since with cancer the signs are initially scant, only in the later stages they become pronounced.

When metastasis begins and the tumor grows into the pleural tissue, the clinical picture becomes clear. The patient develops pain and coughs with sputum and blood clots. An X-ray image makes it especially clear to see the progression of the pathology. Later, characteristic joint pain appears, especially at night. With all open signs, the temperature rarely rises; it remains low-grade throughout the disease.

With other pathologies

It is often necessary to distinguish between pulmonary inflammation and dysfunction of the heart and blood vessels, which lead to stagnation in the respiratory system and proliferation of connective tissue. Like pneumonia, hepostasis is accompanied by shortness of breath, wheezing and percussion sounds. Since cardiac failure is characterized by hypothermia, the patient's condition gradually worsens.

With collagenosis and rheumatoid arthritis, a person also suffers from similar symptoms. At the same time, the data from auscultation and X-ray examination are identical - increased pulmonary shadows, the presence of infiltrates. The difference is that antibacterial therapy for collagenosis is ineffective, but when taking glucocorticosteroids, positive dynamics are noted. In addition, there is practically no sputum, no changes in the position of the diaphragm, and bilateral atelectasis.

During a heart attack, the lungs are affected due to thrombosis affecting the adjacent arteries. The pathology develops after phlebitis of the lower extremities and varicose veins. In addition, people with myocardial dysfunction, vasculitis, and ischemia are susceptible to the disease. The main symptom is pain, which intensifies when turning the torso, coughing, sneezing, or laughing. Many patients develop serous pleural lesions against the background of a heart attack.

Sudden attacks of shortness of breath, even suffocation, are characteristic of thromboembolism. Diagnosis and differentiation are based on a preliminary examination of thrombophlebitis, diseases associated with vascular damage. The blockage is not related to bacterial etiology; the pathogen may act as a subsequent factor, since in the area. Closed by a blood clot, microcirculation is disrupted, which creates conditions for the penetration and growth of pathogens. For such patients, isotope scanning of the respiratory organs and angiopulmonography of the system are performed.

To visually compare the principles of differentiation, you can use the table, which displays the characteristic signs and causes of the four main pathologies:

Symptoms	Pneumonia	Tuberculosis	Cancer	Flu. Respiratory diseases
Etiological factors	Hypothermia, weakened immunity, frequent colds	Chronic lung diseases, bad habits, low social level	Predisposition, bronchial obstruction, smoking, alcoholism, low immunity	Seasonal epidemics, weak body defense mechanism
Patient age	Any	Most often from 25 to 40 years	Mostly over 50 years of age	Any
First stage of development	Spicy	Asymptomatic, sometimes acute	Gradual	Spicy
Cough	Dry, hemoptysis is rare, sputum depends on the type of pathogen	Moderate, purulent sputum, hemoptysis in special forms	Constant, severe, hemoptysis progresses to bleeding	First dry, then wet. Sputum is clear
Painful sensations in the chest	Moderate	Rare	Growing	Short-term
Temperature	39-40 0 C	38 0 C	37.5 0 C	39-40 0 C
Dyspnea	Moderate, short-term	In advanced stages or absent	Increasing	Absent
Weight loss	Rarely	In some forms	Progressive	Not typical
Intoxication	Depending on the pathogen	Moderate	Strong, especially in the last stages and after chemotherapy	Can not be
Sputum test	Depending on the pathogen	Mycobacteria	Cancer cells	Viruses and bacteria are not detected
Auscultation	Wheezing is strong and moist	Wheezing in the upper areas. Weakly expressed	Intense wheezing	Weakly expressed
Percussion	Short sound	Short sound	Dullness	Clear lung sound
Tests for tuberculin	Moderately positive	Hyperergic	Negative	Not carried out

Differential diagnosis is a technique necessary to distinguish between several types of pathologies with the same symptoms. It plays an important role in determining therapeutic regimens, especially in cases where bacteria are capable of exhibiting resistance. Thanks to these methods of examination, it became possible for the early detection of not only pneumonia, but also tuberculosis, atelectasis, cancer, and empyema. The techniques are aimed at accelerating recovery, improving the condition of patients with irreversible disorders and preventing death for people at risk.

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

What is community-acquired pneumonia?

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

Pneumonia in an adult

Adults most often suffer from pneumonia as a result of bacteria entering the body, which are the causative agents of the disease. Community-acquired pneumonia in adults does not depend on geographical areas and socio-economic relations.

What is pneumonia like?

This disease is conventionally divided into three types:

1. Mild pneumonia is the largest group. She is treated on an outpatient basis, at home.
2. The disease is of moderate severity. Such pneumonia is treated in hospital. The peculiarity of this group is that most patients have chronic diseases.
3. Severe form of pneumonia. She is being treated only in the hospital, in the intensive care unit.

Community-acquired pneumonia occurs:

• Focal. A small area of ​​the lungs is inflamed.
• Segmental. Damage to one or several parts of the organ is typical.
• Share. Some part of the organ is damaged.
• Total. The entire lung is affected.

Community-acquired pneumonia can be unilateral and bilateral, right-sided and left-sided.

Symptoms

• Body temperature rises.
• Chills and weakness appear.
• Performance and appetite decrease.
• Sweating appears, especially at night.
• Head, joints and muscles hurt.
• Consciousness becomes confused and orientation is disturbed if the disease is severe.
• Pain in the chest area.
• Herpes may appear.

• Abdominal pain, diarrhea and vomiting.
• Shortness of breath that occurs during physical activity. This does not happen when a person is at rest.

Causes

Community-acquired pneumonia develops when microbes enter a weakened human body and cause inflammation. The causes of the disease are as follows:

• Hypothermia of the body.
• Viral infections.
• Concomitant diseases: diabetes, heart, lungs and others.
• Weakened immunity.
• Excessive consumption of alcoholic beverages.
• Prolonged stay on bed rest.
• Postponed surgeries.
• Elderly age.

Pathogens

• Pneumococci (most often the cause of the disease).
• Staphylococci.
• Atypical pathogens: mycoplasmas and chlamydia.
• Klebsiella.
• Viruses.
• Pneumocystis.
• Escherichia coli.
• Haemophilus influenzae.

Diagnostics

During the examination, it is very important to identify and evaluate the clinical symptoms of the disease, such as fever, chest pain, cough with sputum. Therefore, if a person has community-acquired pneumonia, a medical history must be created for each patient. In it, the doctor writes down all the patient’s complaints and prescriptions. To confirm the diagnosis, a radiation examination is performed: chest x-ray. Clinical manifestations of community-acquired pneumonia are:

• Cough with the release of mucopurulent sputum, which contains streaks of blood.
• Chest pain when breathing and coughing.
• Fever and shortness of breath.
• Trembling voice.
• Wheezing.

Sometimes the symptoms differ from those typical for a given disease, which makes it difficult to make a correct diagnosis and determine a treatment method.

Radiation examination

The patient is prescribed an x-ray if he has community-acquired pneumonia. Diagnosis using the radiation method involves examining the organs of the chest cavity in the anterior part. The picture is taken in frontal and lateral projection. The patient undergoes an X-ray examination as soon as he sees a doctor, and then half a month after treatment with antibacterial agents has begun. But this procedure can be performed earlier if complications arise during treatment or the clinical picture of the disease changes significantly.

The main sign of community-acquired pneumonia during an X-ray examination is compaction of the lung tissue; darkening is detected in the image. If there are no signs of compaction, then there is no pneumonia.

Lower lobe right-sided pneumonia

Many patients go to the hospital when they are bothered by symptoms such as shortness of breath, cough accompanied by mucous sputum, fever up to 39 degrees, pain with a tingling sensation on the right side under the rib. After listening to the patient’s complaints, the doctor examines him, listens and probes where necessary. If there is a suspicion that the patient has community-acquired right-sided pneumonia, which, as a rule, is much more common (which is why we pay special attention to it), he is prescribed a full examination:

• Laboratory tests: general, clinical and biochemical blood tests, urine and sputum tests.
• Instrumental studies, which include chest x-ray, fibrobronchoscopy and electrocardiogram. The shape of the darkening on the x-ray image allows you to clarify the diagnosis, and fiberoscopy helps to identify the involvement of the bronchi and trachea in the process of inflammation.

If the results of all tests confirm that the patient has right-sided community-acquired pneumonia, the medical history is supplemented. Before starting therapy, the results of studies for all indicators are recorded in the patient’s chart. This is necessary in order to make adjustments as necessary during treatment.

Laboratory and instrumental studies may show inflammation of the lower right lobe of the lung. This is a different story of the disease. Community-acquired lower lobe pneumonia - this will be the diagnosis. When it is accurately established, the doctor prescribes treatment individual for each patient.

How to treat community-acquired pneumonia?

Patients with this diagnosis can be treated both in a hospital and at home. If a patient has community-acquired pneumonia, a medical history is required, regardless of the place of treatment. Patients undergoing outpatient treatment are divided into two groups. The first category includes people under 60 years of age who do not have concomitant diseases. The second category includes people over 60 or people with concomitant diseases (of any age). When a person has community-acquired pneumonia, treatment is carried out with antibacterial drugs.

For patients of the first group the following are prescribed:

• "Amoxicillin" dosage of 0.5-1 g or "Amoxicillin/clavulanate" - 0.625 g at a time. Taken 3 times a day.
• An alternative to these drugs may be: Clarithromycin or Roxithromycin in dosages of 0.5 g and 0.15 g, respectively. Take twice a day. Azithromycin may be prescribed, which is taken once a day in an amount of 0.5 g.
• If there is a suspicion that the disease is caused by an atypical pathogen, the doctor may prescribe Levofloxacin or Moxifloxacin 0.5 g and 0.4 g, respectively. Both drugs are taken once a day.

If patients of the second group have community-acquired pneumonia, treatment is carried out using the following drugs:

• Amoxicillin/clavulanate is prescribed three times a day, 0.625 g or twice a day, 1 g; Cefuroxime should be taken in the amount of 0.5 g at a time, twice a day.
• Alternative drugs may be prescribed: Levofloxacin or Moxifloxacin, 0.5 g and 0.4 g, respectively, once a day orally. Ceftriaxone is prescribed 1-2 g intramuscularly, also once a day.

Treatment of the disease in children

Community-acquired pneumonia in children with an uncomplicated form of the disease, depending on age, is treated with the following drugs:

• Children under 6 months are prescribed: “Josamycin” twice a day for a week at the rate of 20 mg per kilogram of body weight. Maybe Azithromycin - the daily dose should not exceed 5 mg per kilogram of body weight, the duration of treatment is 5 days.
• Children under 5 years of age are prescribed Amoxicillin 25 mg/kg orally twice a day, treatment duration is 5 days. They may prescribe Amoxicillin/clavulanate at a dose of 40-50 mg per kilogram of body weight or Cefuroxin Axetil at a dosage of 20-40 mg/kg, respectively. Both drugs are taken twice a day, the duration of treatment is 5 days.
• Children over 5 years of age are prescribed Amoxicillin at a dosage of 25 mg/kg in the morning and evening. If there is a suspicion of atypical pneumonia, prescribe Josamycin orally, increasing the dosage to 40 mg/kg per day for a week or Azithromycin according to the scheme: 1 day - 10 mg/kg, then 5 mg/kg for 5 days. If there is no positive result in treatment, you can replace Amoxicillin at the rate of 50 mg/kg once a day.

Preventive measures to prevent the disease

Prevention of community-acquired pneumonia is carried out using pneumococcal and influenza vaccines. If necessary, they are administered simultaneously, only in different hands. A 23-valent unconjugate vaccine is used for this purpose. It is introduced:

• People who are over 50 years old.
• Persons living in nursing homes.
• Adults and children with chronic diseases of the lungs, heart and blood vessels or who are under constant medical supervision.
• Children and adolescents (from six months to adulthood) who have been taking aspirin for a long time.
• Pregnant women in the 2nd and 3rd trimesters.
• Doctors, nurses and other staff of hospitals and outpatient clinics.
• Employees of patient care departments.
• Family members of those people who are at risk.
• Medical workers caring for patients at home.

Prevention of community-acquired pneumonia is:

• A healthy lifestyle that includes physical exercise, regular long walks in the fresh air, and active recreation.
• A balanced healthy diet with a standardized content of proteins, vitamins and microelements.
• Annual vaccination of children and adults against influenza, which is done before the onset of the cold season. Very often the flu causes complications. A person gets sick with pneumonia, which has a complicated course.
• Life without hypothermia and drafts.
• Daily cleaning and ventilation of the premises.
• Frequent hand washing and rinsing of nasal passages.
• Limit contact with ARVI patients.
• During the period of massive spread of infection, take honey and garlic. They are excellent immunostimulating agents.
• If you or your child gets sick with the flu, do not self-medicate, but call a doctor.

Community-acquired pneumonia

About the article

For citation: Novikov Yu.K. Community-acquired pneumonia // Breast cancer. 1999. No. 17. P. 825

Department of Pulmonology, Federal Institute of Internal Medicine, Russian State Medical University

There are many options for defining pneumonia as a nosological form. Regardless of the authors' style, in most cases the definition contains the keywords: inflammation, infectious, alveoli, inflammatory cells and exudate. Thus, the definition of pneumonia can be presented as follows: pneumonia is an infectious lesion of the alveoli, accompanied by infiltration of the parenchyma by inflammatory cells and exudation in response to the introduction of microorganisms into the sterile (normal) parts of the respiratory tract. Pneumonia does not include lung damage due to infectious diseases (plague, typhoid fever, tularemia, etc.). These are other nosological forms.

Traditionally, classifications (N.V. Molchanov, 1964; E.V. Gembitsky and O.V. Korovina, 1968, V.P. Silvestrov, 1982) divided pneumonia according to etiology (in first place) due to the importance of the microbial factor in the genesis of the disease , morphology and course. Various versions of the classifications described in detail the location and complications. By focusing the doctor's attention on these aspects, the authors did not take into account the course of his clinical thinking: the doctor saw in front of him a child, an elderly or young person suffering from concomitant diseases or initially healthy, and the place where pneumonia developed - at home or in a hospital - was ignored. Therefore, even before the adoption of the modern classification of pneumonia, attempts were made to generalize clinical data for the possible identification of microorganisms that caused pneumonia (Fig. 1). Actually, this is the prototype of the classification, which primarily distinguishes hospital-acquired and community-acquired pneumonia. It is rational to isolate pneumonia in patients with immunodeficiency, but a separate consideration of atypical pneumonia is inappropriate, since in essence it is community-acquired pneumonia. The classification of aspiration pneumonia as a separate category also raises doubts, since aspiration is present in the genesis of both hospital-acquired and community-acquired pneumonia. Leaving aside the confusion of criteria given in one classification: on the one hand - anamnestic (community-acquired and hospital-acquired), on the other - pathogenetic (aspiration and in people with immunodeficiency), we can imagine classification in the following form:

community-acquired pneumonia (including atypical);

nosocomial (hospital, nosocomial) pneumonia;

pneumonia in persons with immunodeficiency (congenital or acquired).

The localization and extent of the process and the presence of complications are still indicated in the diagnosis.

An example of a diagnosis:

Community-acquired lobar (pneumococcal) pneumonia of the lower lobe of the right lung. Heavy current. Right-sided exudative pleurisy. Infectious-toxic kidney. Respiratory failure stage II.

In community-acquired pneumonia, the most common pathogens are:

Nosocomial pneumonia

Nosocomial pneumonia– a pulmonary infection that developed two or more days after the patient was admitted to the hospital, in the absence of signs of the disease at the time of hospitalization. Manifestations of nosocomial pneumonia are similar to those in other forms of pneumonia: fever, cough with sputum, tachypnea, leukocytosis, infiltrative changes in the lungs, etc., but may be mild and erased. Diagnosis is based on clinical, physical, radiological and laboratory criteria. Treatment of nosocomial pneumonia includes adequate antibiotic therapy, sanitation of the respiratory tract (lavage, inhalation, physiotherapy), and infusion therapy.

Nosocomial pneumonia

Hospital-acquired (nosocomial, nosocomial) pneumonia is a hospital-acquired lower respiratory tract infection, the symptoms of which develop no earlier than 48 hours after the patient’s admission to a hospital. Nosocomial pneumonia is one of the three most common nosocomial infections, second in prevalence only to wound infections and urinary tract infections. Nosocomial pneumonia develops in 0.5-1% of patients treated in hospitals, and in patients in intensive care units it occurs 5-10 times more often. The mortality rate for nosocomial pneumonia is extremely high - from 10-20% to 70-80% (depending on the type of pathogen and the severity of the patient’s background condition).

Classification of nosocomial pneumonia

According to the timing of occurrence, hospital infection is divided into early and late. Nosocomial pneumonia is considered early if it occurs within the first 5 days after admission to the hospital. As a rule, it is caused by pathogens that were present in the patient’s body even before hospitalization (St. аureus, St. pneumoniae, H. influenzae and other representatives of the microflora of the upper respiratory tract). Typically, these pathogens show sensitivity to traditional antibiotics, and pneumonia itself proceeds more favorably.

Late nosocomial pneumonia manifests itself after 5 or more days of hospital treatment. Its development is caused by hospital strains themselves (methicillin-resistant St. aureus, Acinetobacter spp., P. aeruginosa, Enterobacteriaceae, etc.), exhibiting highly virulent properties and multiresistance to antimicrobial drugs. The course and prognosis of late nosocomial pneumonia are very serious.

Taking into account the causative factors, 3 forms of nosocomial respiratory tract infection are distinguished: ventilator-associated, postoperative and aspiration pneumonia. At the same time, quite often different forms are layered on top of each other, further aggravating the course of hospital-acquired pneumonia and increasing the risk of death.

Causes of nosocomial pneumonia

The main role in the etiology of nosocomial pneumonia belongs to gram-negative flora (Pseudomonas aeruginosa, Klebsiella, Escherichia coli, Proteus, Serration, etc.) - these bacteria are found in the secretions of the respiratory tract in 50-70% of cases. In 15-30% of patients, the leading pathogen is methicillin-resistant Staphylococcus aureus. Due to various adaptive mechanisms, these bacteria develop resistance to most known antibacterial agents. Anaerobes (bacteriodes, fusobacteria, etc.) are the etiological agents of 10-30% of nosocomial pneumonias. Approximately 4% of patients develop Legionella pneumonia - as a rule, it occurs as a massive outbreak in hospitals, caused by Legionella contamination of air conditioning and water supply systems.

Nosocomial lower respiratory tract infections caused by viruses are diagnosed much less frequently than bacterial pneumonia. Among the causative agents of nosocomial viral pneumonia, the leading role belongs to influenza A and B viruses, the RS virus, and in patients with weakened immunity – cytomegalovirus.

Common risk factors for infectious complications of the respiratory tract are long-term hospitalization, hypokinesia, uncontrolled antibiotic therapy, and old and senile age. The severity of the patient’s condition, caused by concomitant COPD, the postoperative period, trauma, blood loss, shock, immunosuppression, coma, etc., is of significant importance. Medical manipulations can contribute to the colonization of the lower respiratory tract with microbial flora: endotracheal intubation and reintubation, tracheostomy, bronchoscopy, bronchography, etc. The main routes for pathogenic microflora to enter the respiratory tract are aspiration of secretions from the oropharynx or stomach contents, and hematogenous spread of infection from distant foci.

Ventilator-associated pneumonia occurs in patients on mechanical ventilation; Moreover, every day spent on mechanical breathing increases the risk of developing hospital-acquired pneumonia by 1%. Postoperative, or congestive pneumonia, develops in immobilized patients who have undergone severe surgical interventions, mainly in the thoracic and abdominal cavities. In this case, the background for the development of pulmonary infection is a violation of the drainage function of the bronchi and hypoventilation. The aspiration mechanism of nosocomial pneumonia is typical for patients with cerebrovascular disorders who have impaired cough and swallowing reflexes; in this case, the pathogenic effect is exerted not only by infectious agents, but also by the aggressive nature of the gastric aspirate.

Symptoms of hospital-acquired pneumonia

A feature of the course of nosocomial pneumonia is the blurring of symptoms, which makes recognition of a pulmonary infection difficult. First of all, this is explained by the general severity of the patients’ condition associated with the underlying disease, surgery, old age, coma, etc.

Differential diagnosis of pneumonia: table of main diagnostic criteria

Pneumonia is an inflammatory disease of the lungs that occurs as a result of damage to the organ by a bacteria, virus or fungal infection. To select adequate treatment, it is necessary to establish a correct and timely diagnosis. In some cases, the symptoms of pneumonia may overlap with other respiratory diseases, but their treatment methods will differ. In this case, the doctor needs to conduct a differential diagnosis to clarify the correct diagnosis. To obtain a high-quality diagnosis, it is recommended to undergo examination at the Yusupov Hospital.

Differential diagnosis of community-acquired pneumonia in the form of a table

Community-acquired pneumonia (that is, pneumonia that occurred outside of a hospital; synonym: outpatient, home) is a very serious disease and can be fatal, so it is important to start treatment as early as possible. The effectiveness of treatment will depend on a correctly established diagnosis. Differential diagnosis is aimed at comparing diseases according to certain criteria (symptoms, research results) and excluding inappropriate diseases to obtain the only correct diagnosis. In case of pneumonia, differential diagnosis will help to exclude the following diseases:

They have a similar clinical picture at the beginning of the disease.

Differential diagnosis of pneumonia and tuberculosis

The most common diagnostic errors are made when comparing pneumonia and tuberculosis. It is important to distinguish between these two diseases, since the therapeutic regimens for their treatment differ significantly. Those methods of therapy that give results for pneumonia will not be effective for tuberculosis. Also, most methods of physiotherapy for pneumonia cannot be used for tuberculosis (it can only aggravate the condition).

Differential diagnosis of pneumonia and obstructive bronchitis

Both pathologies most often begin with acute respiratory diseases. In obstructive bronchitis and pneumonia, the main symptom is a cough with sputum production. However, pneumonia is usually more severe: the patient has severe intoxication and high body temperature. In some cases, pneumonia in a smoking patient will have the same clinical picture as chronic bronchitis of a smoker. With obstructive bronchitis, the temperature may rise for two to three days and then does not exceed subfebrile levels. When carrying out a differential diagnosis, the nature of the origin of the disease is taken into account: in pneumonia it is predominantly bacterial, in obstructive bronchitis it is pulmonary.

Differential diagnosis of pneumonia and lung cancer

The initial manifestations of pneumonia and the development of the oncological process are no different. If pneumonia is suspected, the patient is prescribed a course of antibiotics. If they do not show results after a week, the patient is sent for examination to confirm or exclude a malignant neoplasm. Differential analysis is carried out at an early stage of cancer, since characteristic symptoms will appear in the future. When the tumor metastasizes and grows into the pleural tissue, the disease has a pronounced clinical picture. There is severe pain when coughing, and there is blood in the sputum. Joint pain occurs.

Diff. diagnosis of pneumonia: table of pathogens of pneumonia

Differential diagnosis of pneumonia allows you to accurately make a diagnosis to prescribe the necessary therapy. However, to use effective medications, it is important to consider the cause of pneumonia. Below is a table with the main causative agents of pneumonia and how they manifest themselves:

Treatment of pneumonia

Timely and accurate diagnosis is performed at the Yusupov Hospital. The clinic performs all the necessary diagnostic measures to detect pneumonia: examination by a therapist, laboratory tests, radiography. High-quality diagnostics allows you to determine the type of pneumonia, which is important when prescribing therapy.

Pneumonia is treated medically with antibiotic therapy. The choice of drug will depend on the causative agent of the disease. Additionally, medications are used to eliminate symptoms: antipyretics, painkillers, expectorants. After receiving the first positive results of treatment and stabilizing the normal temperature, special massages and breathing exercises are prescribed. A patient with pneumonia should remain in bed, eat well, take vitamins, and drink enough fluids.

The Yusupov Hospital offers its patients inpatient treatment with comfortable wards. The patient is provided with round-the-clock medical care by experienced therapists and qualified junior staff. The wards have all the necessary hygiene items; a special ventilation system ensures air purification in every room of the hospital. Patients are provided with a balanced diet, which is selected by a nutritionist, taking into account the patient’s wishes.

Yusupov Hospital is located near the center of Moscow and accepts patients around the clock. You can ask for help, make an appointment and get advice from specialists by phone.