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Fibrous-cavernous pulmonary tuberculosis: how long do you live with it and how is it treated? Cavernous and fibrous-cavernous pulmonary tuberculosis.

Fibrous pulmonary tuberculosis is a type of complication of the disease that occurs against the background of illiterate and untimely treatment various forms tuberculosis (disseminated, focal, infiltrative and cavernous). This form of complication is chronic and can develop over years - gradually and imperceptibly for a person who has been poorly treated for tuberculosis. In addition, emphysema, vascular lesions, and bronchiectasis develop in the lungs, that is, there is a gradual destruction of the functionality of the lung tissue - its damage and death.

It manifests itself in the form of the formation of one or several cavities with the presence of a fibrous capsule. A cavity is a cavity in which several layers develop: one of them is called pyogenic. It is in this layer that pus is formed, covered with a layer of mucus - it contains concentrated large number tuberculosis bacteria, which gradually mix with sputum. This explains the rapid spread of the disease to unaffected areas of the lung.

The other layer of the cavity consists of granulation tissue - if appropriate therapeutic measures are not carried out, then this type of tissue begins to die and turn into another pyogenic layer.

The third layer of the cavity is called fibrous. There are cases when, with complicated fibrous tuberculosis, the formation of foci of perifocal inflammation may occur.

At the initial stage of the disease, the patient may feel better, mistakenly believing that he is already on the path to recovery. But this is far from true. This happens because the intoxication of the body decreases. Over time, the disease returns and manifests itself with even greater force. And such a wave-like changing clinical picture is characteristic of the course of fibrous tuberculosis: there is a periodic change in periods of exacerbation and subsidence of the disease.

Periods of exacerbation are characterized by several of the most pronounced symptoms:

  • elevated temperature,
  • fatigue and weakness throughout the body,
  • poor appetite and weight loss,
  • coughing attacks with a small amount of sputum (sometimes mixed with bloody clots),
  • as well as constant mood swings.

Upon external medical examination, signs clearly indicate fibrous form signs of the course of tuberculosis: atrophy of the pectoral muscles, asthenia of the physique, shortness of breath, lag of one half of the chest from the other with breathing movements, cyanosis, etc. Upon auscultation, bronchial breathing of the amphoric type is observed, wheezing of different volumes - dry and wet.

Sometimes creaking wheezing can be heard, which indicates the inflamed walls of the bronchi are coming apart.

Medicine set three types of fibrous pulmonary tuberculosis, due to the characteristic clinical picture for each type:

  • Limited;
  • Progressive;
  • Fibrous-cavernous.

Limited fibrous cavernous pulmonary tuberculosis characterized by the relative stability of the clinical picture, as well as the existing fibrous cavity and limited fibrosis within a lobe of the lung or a certain zone thereof. After a long course of chemotherapy, the pathological process stabilizes - inflammation in the layers of the cavity subsides, lesions of the bronchopulmonary tissue almost completely resolve. Periods of calm of the disease between exacerbations can stretch from several months to several years. During such periods, the release of bacteria is inconsistent and meager.

Fibrous-cavernous tuberculosis occurs with this clinical picture in patients who fully comply with all medical recommendations and those who follow the regime long-term treatment. This form of tuberculosis progresses, as a rule, in people who do not comply with the regimen and abuse bad habits.

Progressive fibrocavernous tuberculosis characterized for long periods exacerbations with short intervals and subsidence between them. During the period of exacerbation, a vivid clinical picture of intoxication of the body develops. There is a cough with sputum production, pain in the chest area, and after a while shortness of breath occurs. Some patients allow the disease to develop to extensive complications: large infiltrative-caseous lesions appear, which lead to caseous pneumonia with the formation of giant cavities and multi-chamber cavities.

With such a progressive stage, as a rule, there is a constant release of bacteria into the environment in large volumes, and mycobacteria have developed resistance to medicines which interferes with effective treatment. In most cases, fibrous-cavernous tuberculosis of this course is observed in patients who lead an asocial lifestyle with no correct mode day, diet and appropriate treatment. It can also develop in patients who do not tolerate chemotherapy well or have other severe, chronic illnesses.

Fibrous-cavernous pulmonary tuberculosis with complications has a progressive, wavy clinical picture. The most striking and severe symptoms of this form are pulmonary heart failure with the addition of amyloidosis of internal organs, as well as chronic renal failure. Repeated foci of pulmonary bleeding may also open, which can become protracted, and pneumothorax with the addition of purulent pleurisy.

In addition, a complication of fibrocavernous tuberculosis is a failure of the function endocrine system, which may appear as diabetes mellitus, pituitary cachexia and Itsenko-Cushing syndrome.

Often there are such pathological disorders such as arthralgia and nonspecific polyarthritis.

In the progressive complicated stage of the disease, the patient constantly releases Mycobacterium tuberculosis into the environment, and drug resistance of the bacteria often develops.

Principles and strategies for the treatment of fibrocavernous tuberculosis

The goals of treatment for this diagnosis are the destruction of mycobacteria, the removal of intoxication, the elimination of all developing complications and the prevention of the subsequent development of cavities.

To make an accurate diagnosis, in addition to a medical examination and questioning of the patient, a complex diagnostic procedures. The following laboratory tests are performed:

  • Sputum culture.
  • Smear microscopy.
  • General blood test.
  • General urine analysis.
  • X-ray tomography.
  • Bronchological examination.
  • Ultrasound of the abdominal cavity.
  • Coagulogram.

Treatment of this pathology involves a long process, using complex techniques, including chemotherapy, hormonal therapy, as well as immunomodulatory and metabolic therapy. Surgery is often prescribed to remove the affected organ tissue.

Drug therapy is selected for the patient based on the duration pathological process and stages of development. When the disease is initially detected, an active course of chemotherapy is first administered. This treatment is carried out with four anti-tuberculosis drugs: pyrazinamide, isoniazid, rifampicin, streptomycin or ethambutol . Depending on the resistance of the mycobacterium, treatment can last from 3 to 5 months.

If relapses occur, despite treatment, therapy consists of increasing the doses of the above drugs and prescribing a complex of five medications, that is, both streptomycin and ethambutol are prescribed. The course of treatment in this way lasts from four to six months. The effectiveness of treatment is determined by examining a sputum smear. In parallel with chemotherapy, antioxidant, vitamin, hepatropic, detoxification, as well as symptomatic therapy are carried out.

Surgical intervention is performed in cases where the closure of the cavernous lesion occurs very slowly and threatens the patient’s life. If, for clinical reasons, the doctor is not satisfied with the effectiveness of the chemotherapy, surgical treatment may also be prescribed. In case of unilateral organ damage, a lung resection may be prescribed to the extent necessary for recovery.

Doctors give different prognoses after treatment: from cautious to unfavorable. With a complication such as caseous pneumonia extremely unfavorable prognoses are given.

Competent and timely care and monitoring plays a very important role on the path to recovery. This is done by the middle level of medical personnel - nurses, who are the link between the doctor and the patient. On the shoulders nursing staff There are four primary and important tasks for competent treatment:

  • Carrying out differential diagnosis.
  • Recording of symptoms and round-the-clock (if the patient is being treated in a hospital) monitoring of his condition.
  • Comprehensive patient care, both in hospital and at home.
  • Providing emergency assistance in the event of complications.

Measures to prevent fibrocavernous tuberculosis

For the purpose of prevention, various measures are carried out, among which a special place is occupied by vaccination of the population, timely identification of infected patients who are bacteria carriers, as well as propaganda of information about the disease. Also, the complex of preventive measures includes anti-epidemic and preventive measures and the mandatory organization of planned research, especially among people involved in animal husbandry and working in conditions heavy pollution air.

These preventive measures are carried out by medical institutions that specialize in tuberculosis (TB dispensaries). And in order to independently protect yourself not only from fibrous-cavernous, but also from other forms of tuberculosis, you must follow the following preventive recommendations:

  • Do fluorography of the lungs twice a year;
  • Avoid any contact with patients suffering from open forms of tuberculosis;
  • Give up bad habits;
  • Twice a year, during the period of decreased immunity (spring-autumn), take multivitamins;
  • Adhere to a healthy lifestyle - proper nutrition, sports, hardening, etc.

Cavernous tuberculosis is included in the group dangerous diseases with serious complications. And if for some reason the patient refuses to undergo the prescribed treatment, then such a permissive attitude towards health can lead to death.

Caverns from fibrosis (with a focus of broncho-genic dropout) form in the lung after progression certain type tuberculosis infection. The surrounding bronchial tissue changes around the lesion, and a chronic process called fibrocavernous pulmonary tuberculosis begins to develop.

Concept, development, process

Fibrous-cavernous pulmonary tuberculosis is a long-term, chronic wave-like process, with periods of inflammatory subsidence. It always forms after the progression of infiltrative, disseminated, cavernous tuberculosis, and is a consequence of their transition to fibrous tuberculosis.

The disease can be unilateral or bilateral. There are one or several caverns. Around them, sclerosis of the surrounding tissue and fibrous layers develop, affecting the pleura. This type of disease almost always takes complicated forms and can be fatal.

The cavity is represented by several layers creating a cartilaginous density (capsule), which characterize the processes of caseosis, granulation and predominant fibrosis with perifocal inflammation around.

The process develops over 1.5-3 years, with connective tissue growing around the cavity (due to its inability to scar). The cavity communicates with the main bronchus by draining bronchioles, and therefore is prone to contamination.

Fibrous growths stretch next to the bronchi and blood vessels. The long-term possibility of necrosis of the caseous layer and arrosion of blood vessels often results in pulmonary hemorrhage, which can only be stopped surgical method or leads to morphological changes: emphysema, bronchiectasis, pneumosclerosis and changes in the position of mediastinal organs.

Fibrous-cavernous tuberculosis occurs in waves, always progresses with the formation of new cavities, passes with symptoms of respiratory failure, and is accompanied by the constant release of mycobacteria. According to the ICD, this disease has code A15, confirmed by bacteriological, histological methods or bacterioscopy.

The causes of the pathological process are considered to be:

  • previous tuberculosis infection;
  • close contact with an active bacteria carrier;
  • changes in lung tissue that remain after TVS;
  • stress and unfavorable environment;
  • physical stress;
  • long-term hormonal treatment or immunosuppressant therapy.

Risk factors in the development of the disease are social problems:

  • poverty (malnutrition, lack of sanitation, vitamin deficiency, poor living conditions);
  • antisocial lifestyle (homelessness, drug addiction, alcoholism, free lifestyle);
  • stay in places of deprivation of liberty;
  • overpopulation;
  • diabetes mellitus, autoimmune diseases, low immunity, HIV infection;
  • inadequate previous chemotherapy.

Patients with fibrous tuberculosis due to the complex course, the presence of symptoms of intoxication, complications, active process and bacterial excretion are recommended to be treated in a hospital for a course of 120 days.

Signs of illness

Classify such clinical options development of fibrous-cavernous tuberculosis:

  1. Damage limitation and stability. It occurs with rare outbreaks, with no exacerbation for several years.
  2. Progression. Exacerbations are replaced by remissions, the periods between them are different.
  3. Transition to a complicated form. Spitting up blood, pleural empyema, bleeding from the lungs may develop. spontaneous pneumothorax, renal amyloidosis, cardiopulmonary failure etc.

The question constantly arises: is fibrocavernous pulmonary tuberculosis contagious or not? Before the start of adequate therapy, patients constantly secrete a large number of mycobacteria, and therefore are open, epidemiologically dangerous carriers of drug-resistant mycobacteria.

Symptoms of the disease depend on the stage of the process. Patients note: increasing general weakness, wet cough with difficult to separate viscous sputum mixed with blood, shortness of breath, low-grade fever. The patient loses weight (even to the point of cachexia), heavy sweats and acrocyanosis of the skin appear.

On external examination: the chest is in the form of a barrel, its lag in the act of breathing, on the affected side, depressions are visible above the collarbones and in the subclavian cavities. The patient has flaccid, very pale skin that gathers in wrinkled folds; there may be atrophy of the intercostal, shoulder muscles and backs. The liver is enlarged. Amyloid nephrosis may develop and edema may be present. Immunity is greatly reduced.

On auscultation one can always hear weakened, amphoric, harsh or bronchial breathing, with moist rales of various sizes. When percussing over the cavities, a shortened sound with a boxy tint is noted. There are silent cavities that cannot be heard on auscultation and cannot be detected by percussion. Advanced tuberculosis of this form becomes cirrhotic, becomes complicated and leads to death.

Diagnosis and prognosis

The diagnostic examination of the patient begins with a history, examination, differentiation with pulmonary diseases and examinations. Appointed general analysis blood, which shows: leukocytosis, lymphopenia, neutrophilia, high ESR. Hemoglobin and red blood cells are reduced, especially during bleeding.

Bacterial culture of sputum is prescribed to isolate the pathogen. A test for sensitivity to antibacterial agents. Fiberoptic bronchoscopy shows changes in the bronchi and impaired respiratory function.

X-ray shows cavities, lesions around them, wrinkling and fibrosis lung tissue, pleural layers. Deformation of the bronchial root is noted. The upper lobes of the lungs are reduced in volume and opaque due to hypoventilation. In the lower sections, high transparency is visible due to emphysema.

In addition to the above studies, the patient is also asked to do:

  • general urinalysis (there is a slight proteinuria or protein in renal amyloidosis, a few leukocytes and red blood cells);
  • other examinations of the bloodstream (determination of group, bilirubin, HIV);
  • lung tomography;
  • Ultrasound of internal organs;
  • tuberculin sensitivity: normergic or weakly positive.

The disease is differentiated from: abscesses, bronchiectasis, fungal processes.

Conservative treatment

Fibrous-cavernous pulmonary tuberculosis, treatment? Therapy at a tuberculosis clinic is recommended. Prescribe antibiotics to which you are sensitive given organism. Treatment for 18 months with 4 chemotherapy regimens with a reserve combination of drugs (Kanamycin, Cycloserine Prothionamide, PAS) and fluoroquinolones, in combination with hygiene, motor recovery and diet No. 11 or DOTS category 1 and 2 regimen (standard drugs), until cessation bacterial excretion. They also carry out: metabolite, immunomodulatory, vitamin, detoxification, hormonal and symptomatic therapy.

In recovery, the following are important: adherence to the regimen, time of taking medications, and elimination of bad habits.

If necessary, conservative treatment supplemented with surgical treatment (lung resection). Collapse therapy (artificial pneumothorax) is performed if:

  • after 3 months of chemotherapy treatment, the cavities do not close, the general condition does not improve;
  • pulmonary hemorrhage began.

After the first course of treatment and passing all necessary tests, determine the dynamics of the patient’s recovery and determine the activity of mycobacteria secretion. If the effect does not occur, then stronger antibacterial drugs are prescribed and treated for a long time until complete absence secreted Koch bacilli and improved well-being.

Dietary nutrition should include:

  • high-calorie quality products ( lard, butter, milk, porridge, meat products, natural honey, in combination with vegetables and fruits, juices and jelly);
  • frequent split meals (up to 5 times a day, with small snacks);
  • It is recommended to add a little salt to your food.

Traditional medicine for tuberculosis uses the following remedies:

  1. Plantain. One tbsp. l. dry leaves are brewed with 1 cup of boiling water for 2 hours. Then filter everything and drink 4 times before meals. per day 1 tbsp. spoon.
  2. Natural honey and juice fresh cucumber. An arbitrary portion of juice is mixed with honey and consumed 2 times a day, 3 tablespoons each.
  3. Lungwort. The herb (4 tsp) is brewed with two glasses of boiling water, wrapped and left for 2 hours. Then it is recommended to strain and drink 30 minutes before meals.
  4. Aloe and honey. The two components are mixed and given to the patient before meals.
  5. Oats with milk and lard. Pour oats into a saucepan (2/3) and pour milk, leaving 2 fingers from the top edge. Add melted pork lard to the thickness of 1 finger, close the lid tightly and place in the oven. Milk will need to be added to the saucepan until the oats are well cooked. It is recommended to drink the cooled mixture three times a day, 50 g each, at any convenient time.
  6. Before going to bed, it is recommended to wipe the patient with water at room temperature, with the addition of a few spoons of alcohol and apple cider vinegar.

The patient needs the support and help of loved ones. More timely carrying out BCG newborn children, early detection of patients, medical examination, X-ray of the lungs, sanitary education work are necessary for the prevention of tuberculosis.

Be healthy!

V.Yu. Mishin

Fibrous-cavernous pulmonary tuberculosis is a chronic form characterized by the presence of a fibrous cavity and the development of fibrous changes in the pulmonary tissue surrounding the cavity. It is characterized by foci of bronchogenic dropout of varying duration. Occurs in 5-10% of cases.

Pathogenesis and pathomorphology. Fibrous-cavernous tuberculosis occurs as a result of the progression of any other form of pulmonary tuberculosis. If the cavity is not prone to scarring, it begins to grow around it connective tissue, which leads to cavity deformation. This is how the aging of the cavity occurs and the development of fibrous-cavernous tuberculosis. This period is usually 1.5-3 years.

Fibrous-cavernous tuberculosis is characterized by the presence in one or both lungs of one or several cavities located among fibrously changed lung tissue.

The wall of a chronic cavity consists of three layers: caseous, granulation and fibrous, however distinctive feature This form is characterized by a sharp predominance of the fibrous layer. As a result, the walls of such a cavity have a cartilaginous density.

Around the cavity, fibrous growths along the bronchi and vessels are also visible, which cause deformation of the lung tissue. Cavities usually have a round, slit-like or irregular shape, but there are cavities consisting of a system of cavities. As a rule, the bronchi draining the cavity are affected.

It should be noted that the caseous layer of the cavity in this form of tuberculosis almost never disappears, i.e. the cavity is not cleaned. The long-term existence of conditions for necrosis of the cavity wall leads to vascular erosion, which is a constant threat of the development of pulmonary hemorrhage.

Bleeding that occurs can rarely be stopped conservatively, since the arrozonated vessels in the cavity wall gape and do not collapse due to massive fibrous growths around it.

Fibrous-cavernous tuberculosis is the result of a long-term process. As a result, around the cavity, as a rule, multiple foci of dissemination are visible in the form of small foci of caseosis, millet-like rashes (epithelioid cell granulomas) and small infiltrates without clear boundaries. The presence of these foci against the background of fibrotic changes in the lung tissue leads to a sharp reduction in the lung surface and the development of respiratory failure.

Clinical picture. Patients with fibrocavernous tuberculosis complain of weakness, cough with sputum, and shortness of breath. Their condition is often satisfactory; with widespread lung damage, it is of moderate severity. The body temperature before treatment is usually low-grade.

The progressive course of the disease is accompanied by severe weakness, weight loss, and increased humidity skin, acrocyanosis is observed. A long progressive course leads to the development of cachexia (habitusphtysicus). Rib cage has a barrel shape; on the affected side, there is retraction of the supraclavicular and subclavian cavities and lag of the affected side of the chest during breathing.

Percussion always notes a shortening of the sound over the affected areas and a boxy sound over the less affected lobes. Breathing is harsh or bronchial, a moderate amount of moist rales of various sizes is heard.

In the blood there is moderate leukocytosis and a shift of the formula to the left, lymphopenia, and an increase in ESR. At long term disease, the content of hemoglobin and red blood cells decreases.

Before treatment, patients with fibrous-cavernous tuberculosis always secrete MBT in their sputum. Bronchoscopy often reveals specific changes in the bronchi; dysfunction is also observed external respiration predominantly of the restrictive type and hypoxemia.

As the disease progresses, it takes on a wave-like course with the appearance of new cavities and foci and almost constant bacterial excretion.

The patient's condition becomes more serious, numerous complications develop (respiratory failure, chronic pulmonary hypertension, hemoptysis, etc.), often in combination with the development drug resistance MBT.

Nevertheless, in some cases it is possible to stabilize the tuberculosis process and achieve a positive therapeutic effect in the form of reducing the clinical manifestations of the disease, improving the somatic condition of the patient, and even achieving abacillation of sputum and sanitization of the cavity. In such cases, the process most often transforms into cirrhotic tuberculosis.

X-ray picture. With fibrous-cavernous tuberculosis, cavities, fibrous changes in the lung tissue and focal formations around the caverns and in other parts of the lungs are determined.

Cavities, as a rule, are irregular in shape, the outlines of the inner contour are sharper, the outer border is usually unclear and is lost in the adjacent fibrous zone.

Fibrous changes in lung tissue are characterized primarily by changes in the skeleton of the chest, which is caused by wrinkling of the lung tissue and pleura. The shadows of the ribs are located asymmetrically, more obliquely on the side of the predominant lesion.

The intercostal spaces become narrower in the upper sections, where the “older” pulmonary changes are more often located and, as a rule, older.

Fibrosis and wrinkling lead to changes in the position of the mediastinal organs. The shadow of the heart, trachea and bronchi shifts towards fibrous-cavernous changes.

The root of the lung is deformed and pulled up towards fibrosis. The less affected side usually has limited or widespread fibrous patchy changes; there may be fresh foci of bronchogenic contamination.

Due to the fact that with this form there is a tendency to periodic exacerbations, previous and newly appeared foci of bronchogenic contamination “merge” into infiltrates. Fresh decay cavities can be either round or irregular in shape; surrounded by a zone inflammatory tissue, adjacent to the cavity.

Diagnostics is carried out on the basis of a long history of the disease and the characteristic clinical and radiological picture of the disease, characteristic of chronic course specific lung damage.

Patients with fibrous-cavernous pulmonary tuberculosis, as a rule, are constant bacteria excretors, which allows them to be classified as a group of patients with open and epidemiologically dangerous tuberculosis.

Differential diagnosis carried out mainly with other chronic inflammatory destructive diseases of the lungs - chronic abscess, bronchiectasis, fungal infections.

Treatment carried out in the hospital of an anti-tuberculosis institution against the background of a hygienic and dietary regime. Therapeutic and motor regimens are determined by the patient’s condition. Therapeutic nutrition corresponds to diet No. 11.

Fibrous-cavernous pulmonary tuberculosis is classified as chronic form disease, which includes patients treated for a long time and ineffectively with anti-tuberculosis drugs.

Chemotherapy such patients are prescribed strictly individually in accordance with the drug sensitivity data of MBT.

As a rule, in the presence of resistance to the main anti-tuberculosis drugs, treatment is carried out in accordance with the IV chemotherapy regimen with a combination of reserve drugs, including kanamycin (capreomycin), prothionamide, cycloserine, PAS and fluoroquinolone. In this case, the main course of chemotherapy is carried out for at least 15-18 months.

Patients with fibrous-cavernous pulmonary tuberculosis require full pathogenetic therapy aimed at correcting various functions organisms impaired under the influence of chronic tuberculosis intoxication. Patients are prescribed metabolite, immunomodulatory and hormonal therapy. In some cases, surgical treatment is performed according to indications.

The proportion of fibrous-cavernous tuberculosis in newly diagnosed patients is 5.2-7.0%.

The formation of destruction in the lung is a very important and often critical stage in the clinical picture, course and outcome of the disease. With its appearance there arises real danger bronchogenic spread of Mycobacterium tuberculosis, introduction of infection into the upper respiratory tract and intestines and development series serious complications, especially hemoptysis or pulmonary hemorrhage with a fatal outcome.

Fibrous-cavernous tuberculosis and its complications are the main cause of death in patients with pulmonary tuberculosis (75-80%).

The disintegration of a focus of specific inflammation in the lungs and the formation of a cavity can be observed during the progression of any form of tuberculosis, if predisposing conditions arise for this in the form of a change in the reactivity of the body, an increase in its sensitization, massive superinfection, the addition of other diseases and exposure to various harmful factors that reduce overall resistance.

Under the influence of these factors, permeability increases vascular walls in the zone of tuberculous changes, where the proliferation of mycobacteria increases. The granulation tissue and caseous masses contained here are infiltrated by lymphoid elements and polynuclear cells, which secrete proteolytic enzymes, and a zone of perifocal inflammation appears around.

Subsequently, as a result of necrobiosis and purulent melting of the curdled masses, destruction is formed. For some time it remains closed and only after its contents are emptied through the draining bronchus and atmospheric air penetrates into the freed space, a destructive cavity is formed.

The wall of the newly formed decay cavity first consists of two layers: the inner - pyogenic-necrotic and the outer - granulation shaft. Then, in the outer part of the granulation layer, collagen fibers are gradually formed, which form a thin, sometimes interrupted fibrous layer.

Over time, a three-layer wall, characteristic of a cavity, forms around the decay cavity. The size of the cavity varies widely - from a few millimeters to 10-20 cm or more. Medium cavities (from 2 to 4 cm) are more common, and large (4-6 cm) and giant (more than 6 cm) cavities are less common. The size of the caverns depends not only on the volume of destroyed lung tissue and the elasticity of the surrounding parenchyma, but also on the condition of the draining bronchi, which are often involved in the pathological process.

As the process progresses, the walls of the bronchi are infiltrated by lymphoid and epithelioid cells, the mucous membrane is replaced by specific granulations, scars appear, which lead to the formation varying degrees stenosis. As a result, the normal patency of the bronchi is disrupted. When a valve mechanism is formed, the cavity stretches or swells; in such cases, its dimensions often significantly exceed the actual volume of destroyed lung tissue, and a zone of atelectasis or distelectasis is formed around the cavity.

Cavernous tuberculosis

The destructive cavity, as a unique manifestation of tuberculous inflammation, is dynamic. At effective treatment and much less often spontaneous resorption of the zone of perifocal inflammation and fresh bronchogenic foci occurs.

The cavity is clearly demarcated from the surrounding lung tissue, but its walls do not yet have a pronounced fibrous-sclerotic character (elastic cavity). The process is limited. In such cases, the cavernous form of pulmonary tuberculosis is diagnosed, the pathomorphological picture of which was described by A.I. Strukov in 1948

The clinical picture of cavernous tuberculosis is determined by the initial form of tuberculosis and the time of cavity formation. With recent decay, symptoms characteristic of the original form of the disease dominate.

The course of cavernous tuberculosis has the following features: with long-term cavernous tuberculosis, the process is characterized by a wave-like course with periodic outbreaks. Signs of exacerbation of the process are increased ESR, shift leukocyte formula to the left, lymphopenia.

With the formation of a cavity, bronchogenic spread of infection and persistent bacterial excretion begin to dominate. Intracanal spread of infection with damage to other organs (larynx, intestines) is possible. There is a tendency to hemoptysis and bleeding, which sometimes lead to asphyxia or aspiration pneumonia with subsequent bronchogenic contamination. The cavity can cause spontaneous pneumothorax and empyema.

If the cavity is small in size and does not communicate with the bronchus, when physical research it is difficult to define. When the cavities are healed and blocked, Mycobacterium tuberculosis is usually not found in the sputum. They can sometimes be detected after puncture and washing of the cavity with saline solution. In such cases, the hemogram, ESR, protein content and others are within normal limits. biochemical parameters. Bronchoscopy reveals deformation and varying degrees of bronchial stenosis.

Outcomes of cavernous tuberculosis

Relatively rarely, the cavity heals by forming a thin connective tissue scar, in which there is no specific granulation tissue and caseous necrosis. This outcome occurs only with fresh (elastic) and small cavities. An important condition This is due to the absence of pleural adhesions, which fix the affected part of the lungs to the chest and prevent the cavity from collapsing.

In other cases, after rejection of the pyogenic membrane, the cavity is filled with growing granulation tissue, which subsequently undergoes connective tissue transformation. At the same time, the capsule shrinks and the draining bronchus becomes obliterated. In place of such a cavity, a focus is formed.

It is possible to close the cavity by filling it with caseous masses, lymph and tissue fluid with the formation of a homogeneous focus resembling tuberculoma. This healing option is far from perfect. Often, under the influence of unfavorable factors, the process becomes aggravated and then a cavity is again discovered in this place.

It is possible to improve the cavity through the open route. In such cases, while maintaining the drainage function of the bronchi, most of the internal caseous-necrotic layer is rejected, and in the granulation layer there are many macrophages, polyblasts, epithelioid and giant cells with basal granulation and a large number of nuclei. Small ones are also intensively developing here. blood vessels And lymphoid follicles. Gradually inner surface The cavity becomes smooth and, to a greater or lesser extent, is lined with squamous epithelium. A capsule of concentrically located argyrophilic collagen fibers is formed around it. As a result, the cavity takes on the character of an air cyst.

However, only some patients experience complete connective tissue transformation and epithelization of the cavern walls. In most others, despite complete clinical well-being and a long-term absence of bacilli secretion, encapsulated tuberculosis foci, elements of specific granulation tissue.

Active tuberculous changes sometimes remain in areas of the lung tissue adjacent to the cavity, and in the bronchi - tuberculous tubercles and epithelioid cells.

Thus, cavernous tuberculosis is a process that is not homogeneous in its origin, pathomorphological substrate and final outcome. With ineffective treatment or its absence, the process progresses, repeated episodes of bronchogenic seeding, infiltrative outbreaks occur with the subsequent development of fibrosis in the wall of the cavern and around it, resulting in the formation of fibrous-cavernous pulmonary tuberculosis.

Fibrous-cavernous pulmonary tuberculosis

Fibrous-cavernous tuberculosis is the final stage in the progressive course of the destructive tuberculosis process. For all such patients, despite the variety of clinical and pathomorphological manifestations of the disease, common features are the presence of a fibrous cavity or caverns, the development of fibrotic changes in the lung tissue surrounding the cavity and polymorphic foci of bronchogenic dissemination, often in both lungs.

The walls of the cavern in such cases have a three-layer structure with a predominance of a coarse fibrous layer, which turns into fibrosis of the interlobular, interalveolar septa and pleura.

Progressive fibrous-cavernous tuberculosis is characterized by specific damage to peribronchial tissue, smooth muscles and cartilaginous plates large bronchi, as well as the presence of tubercular and infiltrative-ulcerative changes in the submucosal layer and bronchial mucosa. Small bronchi and bronchioles are especially often affected, the walls of which are exposed to caseous necrosis. As a result, narrowing, amputation, and obliteration of the bronchi are formed, and cylindrical and small saccular bronchiectasis occurs.

As fibrocavernous tuberculosis progresses, a giant cavity can form, often occupying an entire lung lobe or even almost everything light. Such a cavity can be multi-chambered with the presence of blood vessels in the beams crossing its lumen. Near such a cavity, in addition, large, often aneurysmically dilated blood vessels are identified, if the integrity of which is violated, massive pulmonary hemorrhage occurs.

Complete scarring of a fibrous cavity occurs relatively rarely, since massive fibrosis in its walls and in the surrounding lung tissue prevents the collapse of such a cavity and its scarring.

With fibrous-cavernous pulmonary tuberculosis, the process often involves first the visceral and then the parietal pleura. Areas of perifocal inflammation, tuberculous foci, limited or extensive, appear in it. planar fusions. For this reason, not only the mobility of the lung is limited, but also the stretching increases and the healing of cavities is hampered, especially if they are located in the apex or in the cortical layers.

An open cavity is a permanent source (reservoir) for the spread of Mycobacterium tuberculosis. It is estimated that this reservoir contains 10x10-10x12 mycobacteria - this is a huge bacterial population that is in an unstable state, multiplies and constantly maintains the inflammatory process with the presence of necrosis in the cavity wall.

During the outbreak, a rather pronounced perifocal inflammatory reaction develops around the cavity, and foci of bronchogenic dissemination arise. With each new exacerbation, new foci of dissemination appear, and the process becomes even more widespread. Individual foci of dissemination can merge into larger conglomerates; these conglomerates can also be subject to destruction and destruction. This is how new caverns, or “daughter caverns,” appear.

Thus, with fibrous-cavernous tuberculosis there is a threat of not only perifocal inflammation, not only bronchogenic dissemination, but also the appearance of new caverns both in the same and in the opposite lung. In the terminal phase of the process, areas of caseous pneumonia are formed.

This is the polymorphic pathomorphological picture of destructive tuberculosis, which also determines its unique clinical picture.

The clinical picture of fibrous-cavernous tuberculosis is very diverse, due to numerous morphological and functional changes. There are three clinical forms.

Limited and relatively stable fibro-cavernous process(this form is rare). This is fibrous-cavernous tuberculosis with limited damage and a stable course of the disease, rare outbreaks; in such patients there is often no isolation of mycobacteria or it occurs occasionally during rare exacerbations. The interval between exacerbations stretches for several months, and sometimes even for several years.

Such persons, in general, do not suffer much and do not really feel their illness. There is even a feeling of an ongoing recovery. Patients say that the cavities they have do not bother them much.

However, such a state, such stability of the tuberculosis process is observed mainly in patients who strictly adhere to the regime and adapt their life activities to new conditions - to the presence of a tuberculosis process. If they do not follow these rules, especially if they lead a chaotic lifestyle, abuse alcohol, are exposed to hyperinsolation and other unfavorable external influences, exacerbation and progression of the tuberculosis process occurs.

This variant of the course of the disease is possible only in patients who take chemotherapy drugs regularly and for a long time. With the “chaotic” use of therapeutic agents, it is not possible to achieve stabilization of the fibro-cavernous process. Due to the fact that patients are treated with chemotherapy for a long time, adequate chemotherapy is often hampered by two factors - drug resistance of mycobacteria and poor tolerability of chemotherapeutic agents. These two points do not always allow for adequate therapy, which also leads to the progression of the fibrocavernous process.

Progressive fibrocavernous tuberculosis. The progressive course of fibrocavernous tuberculosis (fast or slow) can develop from the very beginning of the disease without a previous period of stability. It (especially rapidly progressing) is characterized by undulation, i.e. frequent change flashes and intervals.

During the outbreak period, intoxication is pronounced, which may persist during the interval period. Patients are bothered by cough, sputum production, hemoptysis, chest pain, and eventually shortness of breath. These clinical manifestations during the exacerbation period correspond to the development of perifocal inflammation around the cavity, bronchogenic dissemination, and concomitant endobronchitis.

Sometimes the pleura may be damaged and pleurisy develops. If the cavity breaks into the pleural cavity, spontaneous pneumothorax and purulent pleurisy occur. Some patients develop meningitis, but this is currently uncommon.

At objective examination pallor, adynamia, body weight deficiency, and tachycardia are determined. The chest on the affected side is flattened and lags behind the healthy one in the act of breathing. During percussion, a shortening of the percussion sound is detected, and with large and rigid cavities, a boxy sound is detected. During auscultation, weakened or bronchial breathing, local wet and dry wheezing “cavern squeak”, “cart creaking” are heard. Over large and giant caverns, bronchial or amphoric breathing is determined. In such patients, low blood pressure, tachycardia, and accentuation of the second tone over the pulmonary artery are noted.

Progressive forms of fibrous-cavernous tuberculosis are characterized by constant and massive bacterial excretion and the presence of drug-resistant Mycobacterium tuberculosis. Tuberculin sensitivity decreases.

In the peripheral blood, leukocytosis with a pronounced shift to the left, a significant increase in ESR, and there may be signs of anemia are detected. There is a pronounced imbalance of protein fractions of blood serum, an increase in fibrinogen content, C-reactive protein etc.

With bronchoscopy, it is relatively often possible to detect specific changes in large, and especially in small bronchi. As the disease progresses, respiratory and circulatory function worsens, pulmonary hypertension progresses, the intensity of oxidative processes decreases, all types of metabolism are disrupted, blood oxygenation decreases, hypoxemia increases, gastric juice secretion and acidity decrease, and dystrophic changes and dysfunction various departments nervous and endocrine systems.

The general condition of the patient is adversely affected by specific (tuberculosis of the larynx or intestines) or nonspecific (amyloidosis of parenchymal organs, pulmonary heart failure, etc.) complications. The latter are most pronounced in long-term fibrous-cavernous tuberculosis, especially in old age and in the presence of concomitant diseases cardiovascular system, kidneys, digestive organs.

In some patients, the progressive course of fibrous-cavernous tuberculosis ends with the development of infiltrative-caseous or caseous pneumonia. Such a patient does not recover from the outbreak state, intoxication is extremely pronounced. Sometimes new caverns appear, sometimes they are gigantic. Drug resistance of mycobacteria often develops, which prevents the stabilization of the tuberculosis process.

Fibrous-cavernous tuberculosis with complications. This variant of tuberculosis is characterized by complications and an undulating course. Pulmonary heart failure develops more often, cor pulmonale(especially with a long course of the disease).

And if in the first stages the pulmonary heart is characterized by compensation, then subcompensation and decompensation occur, i.e. Pulmonary heart failure occurs with the presence of shortness of breath, subsequent circulatory disorders, with the development of muscular dystrophy and arrhythmias, with hypertension in the pulmonary circulation. It is these symptoms of pulmonary heart failure that occupy a leading place in the picture of the disease, all other signs fade into the background.

The next complication is amyloidosis of internal organs, including the kidneys, the development of renal failure, chronic uremia. Previously, amyloidosis was observed in 4-10% of such patients; in recent years, its frequency has increased slightly.

Given this clinical form Fibrous-cavernous tuberculosis, the leading symptom may be pulmonary hemorrhage, which is repeated many times (hemophthisis - “blood consumption”). Pulmonary bleeding and hemoptysis occur in 30-50% of cases, including profuse bleeding in 8-12% of cases.

This variant of fibrocavernous tuberculosis is very dangerous for the patient’s life, since with extensive pulmonary hemorrhage it can occur instant death from suffocation. But even if this does not happen, bleeding and hemoptysis lead to aspiration pneumonia, aggravation of the tuberculosis process. Frequent complications are pneumothorax, pleural empyema, and pleural tuberculosis.

Among other complications, a patient with fibrocavernous tuberculosis may experience arthropathy, arthralgia (and even polyarthritis, such as universal hyperplastic periostitis), endocrinopathies such as Cushing's syndrome or pituitary cachexia, adyssonism, and dysfunction of the thyroid gland.

X-ray diagnosis of cavernous and fibrous-cavernous pulmonary tuberculosis

A destructive cavity in the lung is detected X-ray only if, after rejection of the molten contents, air enters it through the draining bronchus. Therefore, one of its radiological signs is the display of clearing against a background of darkening. The latter, in turn, depends on many factors - the initial form of the process, the structure of the cavity wall, and the condition of the lung tissue.

The main radiological symptom of a destructive cavity is the presence around the clearing of a ring-shaped or wider border shadow with a continuous closed loop, which is preserved in at least two mutually perpendicular projections. There are no elements of the pulmonary pattern in the clearing window.

Along with the main radiological sign A destructive tuberculous cavity in the lung may reveal additional radiological symptoms:

  • the presence of a horizontal or meniscus-shaped fluid level within the lung tissue;
  • signs of a draining bronchus, which becomes visible as a result of infiltration or sclerosis of its walls and, like a pointer, targets the location of the cavity in the lung;
  • in some cases, in the absence of an obvious x-ray image of the cavity, foci of bronchogenic dissemination are detected, which indirectly indicate its presence.

They are usually large, irregular in shape, without clear contours, confluent in places, numerous and have typical localization in the lungs. Such foci are located below the source of their formation and in more in the anterior (3, 4, 5th) and lower (7, 8, 9, 10th) segments, which are better ventilated during breathing.

In the X-ray picture of pulmonary tuberculosis in the decay phase, the initial form of the process dominates. So, with disseminated tuberculosis X-ray picture the decay phase is characterized by the presence of foci of dissemination and one or more thin-walled, round, as if stamped cavities without perifocal inflammation.

With focal tuberculosis in the decay phase, a small, relatively round and thin ring-shaped shadow with individual foci within it or adjacent to its outer contour is usually determined against the background of limited polymorphic foci (symptom of the “necklace” - alterative cavity).

The disintegration phase of infiltrative tuberculosis is characterized by the display of the infiltrate and the cavity in it with a land map-shaped closed contour. At the first stages, such a cavity may contain sequesters and small quantity fluid, and its shape is elongated towards the draining bronchus. Then the contours of the cavity are somewhat smoothed out. It becomes oval or round, but with the presence of a more or less pronounced zone of perifocal inflammation (pneumoniogenic cavity).

When pulmonary tuberculoma disintegrates, a crescent-shaped, crescent-shaped, sometimes irregular bay-shaped cavity is determined in its thickness, usually located eccentrically at the pole to which the draining bronchus approaches. As long as the cavity in the tuberculoma retains this appearance and occupies only part of it, the process should be defined as tuberculoma in the decay phase. Only after complete emptying and uniform thinning of the wall can it be considered as a cavity formed from tuberculoma.

The X-ray picture of the cavernous form of pulmonary tuberculosis is characterized by the following features:

  • limited localization of the process, usually within one or two segments;
  • absence of typical signs of the initial form of the disease;
  • a formed cavity with well-emphasized external and internal contours of its walls, which can have different sizes, most often round or oval in shape, with relatively thin or medium-thick, but uneven walls and the presence of moderate fibrosis and a few compacted foci around it.

IN in rare cases with the cavernous form, several cavities are found, but they correspond to the above characteristics. The cavernous form of tuberculosis is not always stable and can have different phases of its course. As it progresses, the size of the cavity increases, perifocal infiltration appears around it, or bronchogenic contamination occurs.

The formation of fresh foci of bronchogenic dissemination is an indicator of the seeding phase, which, with vigorous treatment, can be eliminated with complete resorption of the foci, without the formation of fibrosis, but with preservation of the cavity itself. However, more often the progression of the cavernous form of tuberculosis leads to the development of fibrous-cavernous pulmonary tuberculosis.

The X-ray picture of the fibrous-cavernous form of the process is characterized not only and not so much by the formed cavity, but also by the presence of pronounced and varying degrees common fibrotic and specific changes in the lungs. The lesions are usually polymorphic in nature and predominantly bronchogenic in origin. Sometimes during an outbreak, along with compacted ones, fresh foci and areas of infiltration appear and the lung tissue disintegrates.

The unevenly distributed fibrosis that develops in this form alternates with emphysema. The roots of the lungs, as a result of sclerosis developing in them, especially on the side of the greatest damage, become deformed and thickened, as well as the adjacent parts of the pleura.

Bronchographic examination reveals deforming bronchitis or bronchiectasis of varying degrees of severity and prevalence. With a volumetric decrease in individual segments and lobes, the mediastinal organs shift towards the lesion.

Treatment

The main method of treating patients with destructive tuberculosis is combination chemotherapy using 4-5 tuberculostatic drugs, taking into account the sensitivity of Mycobacterium tuberculosis. Antibacterial therapy at the first stage, it is usually carried out for 4-6 months, and after achieving favorable results, it is carried out intermittently until the full clinical effect is achieved.

In addition, various types of pathogenetic treatment are carried out. Currently, it is mandatory to use alternative methods of drug administration - intrapulmonary intracavitary and pericavitary administration of drugs. For cavernous tuberculosis, the technique is widely used collapse therapy(artificial pneumothorax, pneumoperitoneum).

In recent years, thanks to the creation of an affordable and effective endobronchial valve, a new method of treating such patients has emerged - using local artificial lung collapse(A.V. Levin, 2008). The valve is made of a rubber mixture, indifferent to the human body, and is a hollow cylinder. The internal opening of the valve on one side has an even round shape, on the other it is made in the form of a falling petal valve, closed by excess external pressure due to the elastic properties of the material. Two-thirds of the outer surface of the valve consists of thin lamellar radial petals for fixing it in the bronchus. The valve is installed using both a rigid bronchoscope and a bronchofiberscope.

The size of the valve depends on the location of the tuberculous process, which is the source of bleeding, and the diameter of the draining bronchus where the valve is installed (main, lobar, segmental), and should exceed the diameter of the bronchus lumen by 2-2.5 times.

The valve allows air, sputum, and bronchial contents to escape when exhaling and coughing from the lesion. In this case, the return of air into the affected areas of the lung does not occur, thereby gradually achieving a state of therapeutic hypoventilation and lung atelectasis. The criteria for including the valve in the treatment complex are drug resistance of Mycobacterium tuberculosis, exhaustion of chemotherapy and traditional collapse therapy for closing cavities and cavities.

The use of an endobronchial valve allows you to achieve the following goals:

  • cavity reduction;
  • closing part of the cavities, which makes it possible to operate on the patient;
  • achieving abacillation in unresectable patients;
  • prevention of complications;
  • improving quality of life.

According to the Research Institute of Phthisiopulmonology of St. Petersburg (2010), closure of decay cavities using valve bronchoblocking is achieved in 73.9% of cases; in the conditions of the Nizhny Novgorod Regional Clinical Tuberculosis Dispensary (2011), this technique made it possible to achieve complete closure of decay cavities in 70% of patients.

The advantages of this method are:

  • the ability, in the absence of conditions for radical resection, to assess the patient’s functional reserves for the use of surgical treatment methods;
  • the ability to reduce cavities and achieve abacillation in unresectable patients.

In the absence of significant positive changes from treatment, surgical intervention should be used in a timely manner, mainly resection of affected parts of the lung. In the future, chemotherapy is continued. Its duration depends on the presence or absence of drug resistance and the phase of treatment in which the operation was performed.

The choice of one type of operation or another and its volume are determined by the extent of the process, the state of the bronchial system, functional reserves and the patient’s reactivity. Secondary caseous pneumonia, being a severe complication of fibrous-cavernous tuberculosis, requires short-term preparation and prompt surgical treatment due to its extremely high mortality rate.

According to the surgical department of the Central Research Institute of Tuberculosis of the Russian Academy of Medical Sciences (Moscow), surgical treatment can improve the health of 88-91% of patients, including lung resections and pneumonectomies - 89%, thoracoplastic operations - 86%. In the Nizhny Novgorod Regional Anti-TB Dispensary, surgical closure of decay cavities in newly diagnosed patients in 2010 was performed in 97.6% of cases.

However, the extent of the lesions, the high frequency of multidrug resistance of Mycobacterium tuberculosis, severe, sometimes fatal pleuropulmonary and systemic complications, especially in patients with fibrocavernous tuberculosis, pose significant difficulties for both conservative and surgical treatment of destructive forms of pulmonary tuberculosis.