Viral pneumonia x-ray diagnostics. Features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome. X-ray of the lungs for focal, lobar and interstitial pneumonia

• Despite the fact that modern classifications of pneumonia show strikingly little interest in the radiological characteristics of the process, determining the predominant pathological picture and complications of pneumonia certainly remains the primary task of radiological examination

What are we dealing with?

• We are dealing with an amazingly delicate and well-functioning respiratory mechanism that ensures not only successful gas exchange, but also a number of complex hormonal functions

• When the immune system is weakened, the lung often becomes a battlefield on which “military actions” are played out.

Lungs are normal

Modern technologies

Anatomy of the alveoli

Pneumonia substrate

Required component

• Exudate in the lumen of the alveoli - an obligatory sign of pneumonia - is always displayed on a high-quality radiograph

• For all types of infiltration, it is necessary to undergo 4 pathological stages of the process

Possibility of establishing the etiology of pneumonia

• The X-ray method does not provide reliable signs for distinguishing between pneumonia caused by different pathogens

Process stages

• Hot flash – increased pulmonary pattern

• Red and gray liver are not distinguishable radiologically, but their substrate - effusion in the lumen of the alveoli - necessarily darkens against the background of healthy lung tissue

• Resolution stage - similar to the high tide stage, with a gradual normalization of the picture

Upper lobe pneumonia

Upper lobe pneumonia

Middle lobe pneumonia

• An example of middle lobe pneumonia

Middle lobe pneumonia

Middle lobe pneumonia

Middle lobe pneumonia

Lower lobe pneumonia

Segmental pneumonia

Segmental pneumonia

• Areas of drainage infiltration are visible in the axillary segment on the left and focal infiltration in the lingual segments

One-sidedness of the lesion

• Pneumonia in 95% of cases is a one-sided process

• Bilateral lesions are a sign of an atypical course, which should alert the attention of the radiologist and the attending physician

Upper lobe pneumonia (klibsiela), beginning to resolve

Resolution phase

Middle lobe pneumonia

Resolution phase of pneumonia

• After the resolution of pneumonia, residual pleural layers and local areas of increased pulmonary pattern may remain for several weeks or more.

Focal pneumonia

• The site of infiltration is visible behind the shadow of the heart

Focal pneumonia

Focal mycoplasma pneumonia

Focal aspiration pneumonia

• The lower parts of the right lung are affected.

• Postoperative period

Interstitial pneumonia

• Multiple pneumonic areas in the lung fields on both sides

Interstitial adenoviral pneumonia

Interstitial pneumonia

• Almost total lung damage with Pneumocystis carinii Pneumonie

Toxic pneumonia

• Almost total infiltration of lung tissue

• Develops after aspiration of toxic substances

Abscess pneumonia

• A crescent-shaped strip of gas appeared in the infiltration area on the right - a sign of abscess formation

Abscess pneumonia

Abscess pneumonia

• Bilateral pneumonia, left with abscess formation

Abscess pneumonia

Abscess pneumonia

• Large area of ​​destruction with the presence of rejected masses in the cavity - sequester

Abscess pneumonia

• The dynamics of pneumonia, in contrast to disintegrated peripheral cancer, is faster, the clinical picture of cancer is more “erased”

Abscess pneumonia

Abscess pneumonia

• CT is the most revealing research method for destructive pneumonia

Abscess pneumonia

Abscess pneumonia

Dynamics of an abscess

Abscess pneumonia

• Dynamics of the course of pneumonia (dates are visible in the pictures)

• The multiplicity and uniformity of lesions in pneumonia is evidence in favor of hematogenous dissemination of the process, which is usually a manifestation of sepsis

Septic “metastatic” pneumonia

Pulmonary embolism

Pneumonia is an inflammation of the lungs that occurs due to the presence of a large number of pathogens in the body. For example, the disease can be caused due to bacteria such as pneumococcus, streptococcus, staphylococcus and other diseases. In addition, the causes of the disease can be intracellular pathogens, viruses and fungi.

These toxins lead to the destruction of areas of tissue in the lungs. X-rays help to more effectively monitor the patient's condition. For example, when infected with bacteria, viruses or fungi, it is not advisable to treat the patient with antibiotics.

Unfortunately, some doctors have to treat pneumonia without x-rays. This happens due to a shortage of devices, especially in rural areas. Therefore, treatment without an x-ray may not be very effective.

X-rays should be done for symptoms that are reliably established. For example, if a patient is wheezing, a radiograph may be suggested. But with laboratory tests, the reliability of the method decreases. In this case, inflammation will not be detected.

Signs of pneumonia, in most cases, are weakness, headache, fatigue, muscle pain and loss of appetite. Although some signs may differ, since it all depends on the cause of the disease and the extent of the affected areas.

In addition to these symptoms, you can also notice a high temperature, reaching 40 degrees Celsius. A dry cough gives way to a wet cough with purulent sputum. Chest pain occurs when breathing or coughing. This indicates damage to the pleura.

If pneumonia is in an advanced state, the disease is accompanied by shortness of breath, the skin becomes pale, and the area near the nose and lips takes on a bluish tint. If most of these symptoms coincide, and when tests are taken, there is an increase in the number of leukocytes, an x-ray is indicated. To track changes in shadows during treatment for lobar or focal pneumonia, you need to take repeated x-rays.

Contraindications for referral for radiography should be minimal, with the exception of pregnant women. In their position, radiography is done, observing the following rules: lead aprons are used, a smaller amount is given for the procedure, and the number of studies is reduced. An x-ray is a negative that has shadows that show foci of inflammation; they are depicted in white.

The lesions are small-focal, reaching no more than 3 mm, while medium-sized lesions can be no more than 8 mm. As for large-focal ones, they are found in sizes from 8 to 12 mm, and focal ones are more than 12 mm. In addition, opacities are divided depending on their distribution in the lungs in one segment. If there is inflammation in only one segment, then it is widespread.

The spots are located on several segments, which means they are subtotal spots. If the intensity is greater, then the airiness of the lung tissue is less. The shading is unclear and uneven.

On an x-ray with lobar pneumonia, you can see a large darkening with medium intensity. The darkening may be on one or both lungs. Lobar pneumonia can be caused by Friendler's bacillus. This disease is severe and can lead to death.

Lobar pneumonia on x-rays

On an x-ray, lobar pneumonia can be recognized by changes in the physiological damage to the domes of the diaphragm; there are shadows on one or both sides; the mediastinum moves toward the site of the greatest damage. There is a complete deformation of the lung pattern.

Focal pneumonia on x-ray

As for focal pneumonia, small infiltrates appear with it, it is difficult to detect, especially in the initial stages. Infiltration is a compaction that forms in a tissue or organ. Its occurrence depends on the accumulation of elements of cells, lymph or blood. Although focal pneumonia is characterized by a not very large increase in the number of leukocytes, high temperature, and wheezing.

Symptoms such as noticeable deformation of the pulmonary pattern in a certain area, the presence of shadows in the image, the presence of pleurisy. In addition, due to infiltration, root enlargement occurs. Focal pneumonia is difficult to diagnose.

Dark spots can be observed due to the low airiness of the lung tissue. In the first days of the disease, infiltrates are almost invisible, but very soon the shadow turns into a pneumonic focus. Although focal pneumonia is quite difficult to diagnose, it can still show up on photographs.

What does pneumonia look like on x-rays in children?

Inflammation in children occurs faster and more complex. Even the smallest infiltrate can lead to lobar inflammation.

Therefore, it is very important to make a diagnosis immediately.

In addition to this main symptom, children have other indications of the disease. Partial darkening of areas of the lungs. If the inflammation is advanced, then you can see a high density of spots.

Infiltrates no more than 2 mm. Lymph nodes in the mediastinum are very poorly visible. If only the shadows disappear, then the deformation of the radiography remains for some time. Due to the high density of the damaged area, the structure of the root and the pattern of the lungs overlap. Most often, swelling of the lung tissue occurs. This leads to difficulties during diagnosis.

In addition, children have a small volume of lung tissue, but a large number of lung pattern elements per unit area.

Features of the X-ray image in this disease reflect foci of clearing and darkening, based on blockage of the bronchi. The disease occurs due to the entry of stomach contents into the bronchi.

Atelectasis occurs in places where the passage is disrupted. Looking at the picture, they can be seen in a triangular shape. The dome of the diaphragm will rise, and the mediastinum will shift to the affected side.

In case of inflammation due to staphylococcus, in the picture you can see a limited compaction that is one-sided in nature. Somewhere after the second day, or at least after the fifth, dry and airy bullae containing liquid and air appear during the disease. Bullae in the lungs are formations that look like air bubbles in the lung tissue. Sometimes you can find another name for this phenomenon, for example, bleb or cyst. Although they are still variants of bulls. The thickness of the lung tissue changes, so it is often difficult to identify the exact amount of infiltrates in the image.

In the case of interstitial pneumonia in an adult, changes are noticeable in the image. An enlarged root after radiography is basal infiltration, this is exactly what it looks like with this inflammation. Peribronchial compaction occurs. The bronchovascular bundle expands unevenly.

The causative agents of pneumonia were listed earlier. If the disease appears due to intracellular pathogens or viruses, then these inflammations are classified as another group, atypical. This is due to the fact that they have their own characteristics; in addition, they differ in diagnosis and treatment methods. When the disease occurs due to ingestion of fungi, in most cases, people with HIV infection are observed, since they have a weakened immune system. In addition to these facts, there are others that are worth adding, since disease prevention is always effective.

Such causes include chest injuries, diseases of internal organs, severe stress or immune deficiency, smoking and alcohol abuse. In addition, diseases of this type can be caused by cancer, swallowing disorders, or age exceeding 60 years.

Features of X-ray diagnostics of various types of pneumonia

Symptoms of pneumonia are partly similar to those of other diseases of the bronchopulmonary system. Therefore, doctors are not limited to identifying complaints and features of the development of the disease, and directly examining the patient. A number of additional instrumental and laboratory studies are being carried out.

Important! An X-ray of the lungs for pneumonia in order to confirm the disease is mandatory; without it, the diagnosis cannot be considered reliable.

Possibilities of using x-ray diagnostics

Radiography for pneumonia helps not only to establish a diagnosis and exclude other pathologies with similar symptoms, but also to monitor treatment, promptly identify possible complications, and establish the effectiveness of therapy. It is mandatory to conduct research in two projections.

Main objectives of the study:

• to confirm the diagnosis of pneumonia, type of disease, extent of damage;
• for diagnosing a protracted course, the effectiveness of therapy;
• to monitor recovery and complete restoration of the lung structure;
• to avoid the development of complications.

• pregnancy;
• extremely serious condition of the patient;
• the presence of concomitant ongoing bleeding.

These contraindications are relative. If the condition requires immediate diagnosis due to a direct threat to life, then the study is still carried out. At the same time, negative consequences are minimized. For pregnant women, additional protection of the abdomen and pelvis with shielding aprons is used.

The disease is characterized by the leakage of fluid into the alveoli, swelling of the tissues, and the presence of a large number of cells in them, primarily leukocytes and macrophages. This manifests itself clinically (in the form of an acute infectious inflammatory process) and radiologically.

Unambiguous signs of pneumonia on an x-ray are darkening of some part of the lung field.

Focal shadows or a widespread, confluent decrease in transparency are revealed. Characterized by fuzzy blurred contours.

Pneumonia is classified as:

• Focal (a small area of ​​lung tissue is affected);
• Segmental (one or more segments are involved in the process);
• Lobar (large, involving a share);
• Total (damage to the entire lung).

The degree of involvement of various lung structures and the prevalence of the pathological process affect the prognosis of the disease and determine treatment tactics.

Study results for various types of pneumonia

Radiographs of different types of pneumonia are fundamentally different: focal bronchopneumonia, lobar pneumonia and interstitial pneumonia.

It must be remembered that changes detected by radiography lag behind clinical manifestations.

Symptoms appear later and remain for a certain time after the symptoms disappear. The description of the image maximally reflects the height of the disease with inflammatory changes in the lung tissue and filling of the alveoli with fluid.

With a focal process, the following are revealed:

• shadows, violation of transparency in a limited area;
• enlarged root of the lung (corresponds to the affected side);
• deformed, enhanced bronchial and pulmonary vascular pattern in the damaged area.

Croupous inflammation goes through several stages.

If you do an X-ray at the very beginning (the stage of hot flashes), then in the presence of typical symptoms (high body temperature, chills, cough, feeling short of air, pain in the chest when taking a deep breath), the changes may be nonspecific.

• locally enhanced pulmonary vascular pattern;
• the transparency of the fields is unchanged or slightly reduced;
• The root on the affected side is slightly expanded.

These changes may be missed or attributed to symptoms of bronchitis. After several days of illness, upon transition to the hepatization stage, all the signs indicating inflammation of the lung tissue and effusion into the alveoli are already visible.

The pathology during this period is as follows:

• decreased transparency of the pulmonary field;
• local sharp decrease in airiness and intense darkening;
• root expansion on the side of inflammation;
• compaction of the pleural layers.

Lobar pneumonia always occurs with a pleural reaction. When an effusion forms, darkening is observed in the pleural fissure.

Interstitial pneumonia affects the connective tissue located around the alveolar structures and blood vessels of the lungs (interstitium). Inflammatory changes, primarily swelling of the tissue, lead to disruption of gas exchange. Key Features:

With adequate treatment of all variants of the disease, clinical manifestations are weakened and the inflammatory process in the lungs is reduced.

After the resolution stage, the dynamics of changes in pneumonia are observed in the image during the control study. Most typical:

Complete restoration of the structure of the affected lung occurs after clinical recovery. The X-ray picture looks altered for at least a month.

Features of changes in childhood

Pneumonia in a child is prone to spread and confluent damage. Focal can quickly turn into lobar.

The most characteristic signs of the disease in a child:

After clinical recovery, changes in the vascular pattern and root of the lung persist for the longest time.

It is necessary to monitor the child’s condition and direct therapeutic measures towards the complete restoration of not only the affected lung tissue, but also the accompanying local bronchitis, the signs of which persist on x-rays for a long time.

Features of X-ray diagnostics of atypical pneumonia

Atypical pneumonia is distinguished not only by the presence of atypical pathogens (Klebsiella, mycoplasma, chlamydia), but also by the characteristics of its manifestations. First of all, this is the predominance of signs of respiratory failure (feeling of lack of air) over the symptoms of inflammation (low temperature, slight cough).

The X-ray picture depends on the pathogen. Main features:

With timely diagnosis and adequate treatment, the effectiveness of therapy is high. However, X-ray changes may persist even after 4 weeks.

In some cases, limited compaction of the tissues of the pleura and lungs (the outcome of inflammation) remains irreversible.

Thus, the use of radiography for pneumonia helps to make a timely diagnosis and determine the form of the disease. This allows you to differentiate therapy, avoid the development of complications and prevent a threat not only to the health, but also to the life of the patient.

X-ray of the lungs for focal, lobar and interstitial pneumonia

X-ray of the lungs for pneumonia (pneumonia) is a diagnostic method that a modern medical clinic cannot do without. The shortage of X-rays is acutely felt by village outpatient clinics and first aid stations. The medical workers who work in them have to treat pneumonia “blindly.”

Pneumonia is caused not only by bacterial agents, but also by fungi and viruses. Against this background, it is not always rational to use antibiotics for pneumonia. Using X-rays, the patient's condition can be monitored dynamically during treatment.

How effective is a lung x-ray for pneumonia?

X-ray of the lungs for pneumonia is only as effective as X-ray diagnostics are prescribed in a timely manner. If X-ray examination is used to detect wheezing in a person, but normal laboratory tests, the statistical reliability of the method is reduced. In such a situation, the results of the x-ray do not reveal pneumonia. Wheezing is caused by bronchitis or a cold.

The possibilities of X-rays for pneumonia are extensive, but the study is necessary to identify clinical symptoms that with a high degree of certainty indicate pneumonia.

It is possible to do without chest x-rays, but this reduces the effectiveness of monitoring the timely detection and treatment of the disease.

X-ray for pneumonia - indications and contraindications

An X-ray for pneumonia is then shown; the symptoms of pneumonia are characterized by cough, chills, sputum production, and laboratory tests show an increase in the number of leukocytes.

If a person is diagnosed with lobar or focal pneumonia, repeat radiographs are ordered to monitor changes in the “bad” shadows during treatment.

A specific indication for an X-ray of the lungs is a serious suspicion of an inflammatory process in the lung tissue or other dangerous disease. To take a picture of a person, you need to take into account the harm and benefits of the examination. Only if the benefits of x-ray exposure outweigh the harm, x-rays can be taken.

There are no contraindications for the study. The only restriction is pregnancy. However, if pneumonia is suspected in pregnant women, an x-ray of the lungs is performed. At the same time, the X-ray room staff does everything possible to protect the woman’s organs from radiation (lead aprons, reducing the time and number of procedures).

X-ray symptoms of focal pneumonia

Focal pneumonia is laboratory characterized by a slight increase in white blood cells, wheezing and fever. It may not be detected on an x-ray, since in the initial stages the disease is characterized by the appearance of small infiltrates. However, a qualified radiologist can assume an inflammatory process in the lung tissue even in the absence of infiltrates based on indirect x-ray symptoms:

X-ray for pneumonia

Pneumonia, due to its prevalence and increasing incidence, can be considered one of the most important problems in global and domestic medicine. To a certain extent, this trend is explained by the spread of diseases that affect the human immune system (alcoholism, hepatitis, diabetes, HIV), as well as self-medication undertaken by patients, causing resistance to antibiotics in pneumonia pathogens.

Due to the fact that when diagnosing pneumonia one cannot rely on characteristic clinical signs, since all symptoms and complaints often indicate a whole range of pathological processes in the lungs, radiography can be considered the reference method of research. Difficulties in diagnosis can be caused by a wide variety of signs of the course of the disease, in which pneumonia on x-ray can become a determining factor when choosing treatment tactics.

Causes of pneumonia

Pneumonia is an inflammatory disease accompanied by damage to all structures of the lower respiratory tract (interstitial tissue of the lungs, alveoli, bronchioles) and a characteristic darkening on the x-ray. Pathological processes occurring in the pulmonary structures often do not allow one to draw a clear clinical picture of the course of the disease, since pneumonia is not always an “independent disease.”

In half of the cases, it develops as a complication of pathologies such as:

• immunodeficiency;
• congestive heart failure;
• Chronical bronchitis.

In fact, the development of pneumonia is caused by the reaction of lung tissue to the negative impact of any external factor:

The morphological cause of the long course of the disease can be considered a violation of regenerative functions in the area of ​​inflammation, leading to the formation of foci of fibrosis and the release of intraalveolar exudate. In this case, there is a disturbance in the blood supply to the lung tissue, accompanied by the formation of blood clots, air microembolism and general intoxication of the body caused by the release of toxic substances by pathogenic microorganisms.

Radiological evaluation criteria

X-ray manifestations of pneumonia are extremely varied, however, as with any other pathologies of the lungs, they are based on 4 signs: changes in the pulmonary pattern and roots of the lungs, darkening or clearing that forms against the background of the pulmonary field. The causes of darkening are mainly the formation of exudate or purulent contents in the alveoli.

Clearing is a consequence of the formation of an air cavity. Deviations in the structure of the pulmonary pattern indicate damage to the interstitial tissue, accompanied by impaired blood flow. A change in the image of the roots of the lungs indicates damage to the bronchi, lymph nodes, and vascular system.

On an x-ray indicating the presence of pneumonia, the following signs can be observed:

• complete loss of transparency of the lung tissue (total darkening of the lung field);
• darkening of one or more lobes of the lung (subtotal darkening);
• darkening located within one segment of the lung (limited darkening).

However, all these evaluation criteria, with equal probability, may indicate a whole group of lung diseases (pulmonary infarction, malignant neoplasm, pleurisy, tuberculosis, atelectasis). In this regard, x-rays for pneumonia should be performed repeatedly for diagnostic purposes, and in accordance with the stages of the disease, which will allow monitoring dynamic changes in the condition of the lungs in accordance with the stages of the spread of pathology and assessing the body’s response to the therapy.

Stages of pneumonia in the picture

Pathological changes in the lungs during pneumonia correspond to 4 stages, characterizing the body's response to the presence of the pathogen and the degree of tissue damage.

Tide stage

The duration of this stage is 12-72 hours and is characterized by an intense rush of blood to the vascular system of the lungs, a decrease in their functional activity and the formation of alveolar exudate. On an x-ray, you can see an increase in the intensity and clarity of the pulmonary pattern, a slight darkening of the pulmonary fields in the area of ​​localization of pathological changes and an increase in the area of ​​the lung root with a simultaneous loss of its structure. A photo of the chest, at the first stage of the disease, due to increased blood supply, resembles a lattice (honeycomb lung).

Red liver stage

The duration can take from 24 to 72 hours. At this time, there is a thickening of the interstitial tissue, which begins to resemble the liver in structure. A certain amount of blood (erythrocytes) appears in the exudate. The X-ray picture has only minor differences from stage 1, expressed in a decrease in the severity of the pulmonary pattern with its simultaneous enlargement and increased darkening of the pulmonary fields (the “ground glass” effect). Determining the stage of the disease in the initial stages of development can only be done by comparing images taken at intervals of 1–2 days.

Gray hepatization stage

The duration of this stage can be from 2 to 6 days. This time period is characterized by the appearance of purulent contents in the exudate. When performing radiography, a significant darkening of the fields is noted, against which the bronchi not affected by the pathological process appear as stripes of clearing. Free fluid is clearly visualized when taking pictures with the patient lying on the affected side. In this case, the exudate is redistributed, forming a horizontal darkening in the form of a stripe.

Resolution stage

During this period, regeneration processes prevail over destruction processes, which leads to the restoration of damaged lung tissue. X-ray signs of recovery can be considered a decrease in the intensity or area of ​​darkening, a change in the pulmonary pattern at the site of the lesion (the disappearance of large elements and the formation of small ones).

The root of the lung remains expanded for several months. A characteristic radiological sign after pneumonia may be scar formations in the form of shadows stretched along the wall of the lung. There is also no horizontal shadowing, reflecting free fluid in the cavity. Classic radiological signs of pneumonia may have a less pronounced manifestation in different types of disease (lobar, focal or segmental pneumonia).

Atypical forms of pneumonia

In addition to generally recognized radiographic signs, pneumonia may also have uncharacteristic manifestations caused by atypical etiological factors that provoke the development of pathology.

Caseous pneumonia

Caseous pneumonia (CP) is a pathological condition that is either a complication of tuberculosis or an independent disease that develops against the background of immunodeficiency or malnutrition. The characteristic manifestations of KP are not the release of exudate as a reaction to the inflammatory process, but the formation of necrotic zones.

In this case, the process of necrosis is accompanied by the melting of lung tissue, the formation of curdled masses (caseinification) and the formation of cavities (one large or several small ones). KP can be determined on x-ray by the characteristic displacement of organs located in the chest (mediastinal organs) towards the affected lung. Also, due to insufficient ventilation of the lung, an upward displacement of the dome of the diaphragm and a decrease in the intercostal distance are observed.

Cavities, more than 3 cm in diameter, are defined on x-ray as round or semicircular formations in the wall of the lung with a darkened outline and clearing in the center. Small cavities form a picture of destructive damage to the lung tissue. As a rule, the lesion is observed in both lungs in the form of extensive and severe opacification of the upper parts of the lungs and cavernous focal lesions of the lower lobes.

Pneumocystis pneumonia

Pneumocystis pneumonia (PP) is a fungal disease transmitted similarly to a respiratory infection. In the vast majority of cases, the disease is characterized by a latent course, not accompanied by any manifestations of the disease. However, in people with immunodeficiency, PP occurs in a severe form, accompanied by severe respiratory failure. On a radiograph, PP appears as a bilateral, symmetrically located lung lesion, expressed in the loss of transparency of the hilar regions.

In this case, the opacities have a cloud-like shape and, due to their symmetry, are called “butterfly wings”. A lung affected by PP appears on an x-ray as a piece of cotton wool. In some cases, infiltrates characteristic of tuberculous lesions and located in the upper lobe of the lung are visible. Another common sign of PP on x-ray is areas of clearing that occur as a result of the development of pneumothorax. For a long time, PP served as an indicator to identify patients with AIDS.

Atypical pneumonia

The concept of “atypical pneumonia (AP)” includes several types of pneumonia caused by the following diseases:

An X-ray image of mycoplasma pneumonia (MP) in the initial stages of development has some similarities with the classical development of the disease. As a rule, there is an increase in the intensity of the pulmonary pattern and darkening in areas of parenchymal infiltration. Darkening can occupy one lobe of the lung, or its entire surface. In 20% of cases, darkening can be focal in nature and be multiple or single. However, the intensity of the darkening may be so insignificant that when performing an x-ray on old equipment, the image may not show any abnormalities.

Chlamydial pneumonia (CP) has extremely diverse radiological signs, expressed in the appearance of a “ground glass” effect on images, characterizing interstitial damage to lung tissue or darkening of one lobe, characterizing the formation of an infiltrate. Band-like shading, indicating the presence of pleural effusion, is usually slight or absent.

Legionella pneumonia (LP) is characterized by focal shadows, which, when repeated images are taken at intervals of several days, show progression and merge into one continuous shadow. The appearance of free fluid in the form of a strip of horizontal darkening is observed in only a third of patients. In places where infiltrates are close to the pleura, the darkening is so intense that it may resemble a pulmonary infarction.

When diagnosing AP, regardless of the result shown by the x-ray, it is advisable to resort to examination using computed tomography. This technique allows you to obtain photo and video images made in various modes and avoid the appearance of areas hidden for viewing.

As a rule, radiography for pneumonia can provide sufficient information to make a diagnosis. To a certain extent, this is due to the fact that at the time of visiting a doctor, the patient has a detailed picture of the pathological process. However, early diagnosis of pneumonia remains the main problem, the solution of which will significantly reduce the duration of the disease and reduce the percentage of deaths.

X-ray of the lungs for pneumonia: what signs of inflammation look like in the images

X-ray of the lungs for pneumonia is not only a method for identifying the disease, but also a way to monitor the dynamics of its course during therapy. There are several forms of inflammatory changes in the lungs, depending on the area of ​​distribution of the pathological process, the x-ray semiotics of which differ.

X-ray signs of lobar pneumonia

X-ray images of lobar pneumonia are characterized by the following syndromes:

1. Extensive (total) decrease in the transparency of the lung tissue.
2. Subtotal darkening - when inflammation is localized within one or two lobes of the lungs.
3. Limited darkening – infiltrative changes in the lung tissue that do not extend beyond the segment.

The above symptoms are observed not only with lobar pneumonia. They can also be observed in: atelectasis, lung cancer, pleurisy, tuberculous pneumonitis, pulmonary infarction.

X-ray of pneumonia should be based on additional signs of the stage-by-stage course of inflammatory changes in the lung tissue for a reliable diagnosis.

Photo of a radiograph for pneumonia: in the stage of gray hepatization (a), after resolution (b)

What do pictures of the lungs look like in the stage of congestion with lobar inflammation?

The flushing stage is the initial stage of the formation of lobar pneumonia. With it, the following radiological syndromes are observed in the images:

1. Enrichment and strengthening of the pulmonary pattern.
2. Reduced or normal transparency of the lung fields.
3. Expansion of the root of the lung on the affected side.

A change in the pulmonary pattern occurs due to an increase in blood supply against the background of a decrease in the functional capacity of the lung tissue. An image of the chest organs in such a situation looks like a grid. True, such changes are observed only at the site of localization of the inflammatory focus.

As airiness increases, the lung fields on the radiograph become transparent. Morphological sections of tissue at the flushing stage indicate that the alveoli become red due to bleeding, but this sign cannot be recorded x-ray.

The root of the lung becomes expanded, and its structure decreases, which is due to vascular hypertension.

X-ray of the lungs in the stage of gray hepatization

X-ray of the chest organs in the stage of gray hepatization can record the following X-ray signs of pneumonia:

1. Reduced transparency of the lung fields in the area of ​​inflammatory lesion.
2. The appearance of intense shadows corresponding to the size of the damaged tissue.
3. Against the background of massive darkening, stripes of clearing indicate visualization of the trachea and bronchi, which are not affected by inflammation.
4. Root expansion on the pathological side.
5. Consolidation of the pleural layers in the area of ​​inflammation.
6. Effusion in the pleural fissure due to pleurisy.

It is better to diagnose pleurisy when performing laterography (exposure with the patient positioned on the painful side). In this case, the free liquid will spread along the costal arch, forming a horizontal darkening stripe. Morphological photographs in the gray hepatization stage show the accumulation of fibrin in the alveolar cavity.

Photo: X-ray of left-sided hilar pneumonia. Arrows indicate deformation of the pulmonary pattern and absence of root structure (a). 2 months after pneumonia, fibrous cords formed against the background of inflammation - carnification (b)

Stage of resolution of pneumonia on x-ray

On a radiograph with pneumonia in the resolution stage, the following signs are observed:

1. Reduce darkening intensity.
2. Reducing the size of the shadow.
3. Root expansion.
4. Enrichment of the pulmonary pattern (many small elements per unit area) at the site of the existing focus of inflammation.

An enlarged root of the lung in the stage of resolution of pneumonia can be observed for several more months in a row until the anatomical structures are restored. After healing of pleurisy, linear shadows of fibrinous deposits or cicatricial adhesions may remain at the site of inflammatory foci, complicating the breathing process. These changes reflect morphological photographs of the lungs in the stage of resolution of pneumonia - there is no infiltration in the alveoli, but fibrous deposits may remain.

What complications of pneumonia look like in pictures

Complications of pneumonia - abscesses, exudative and fibrinous pleurisy, periscisuritis also have their own x-ray manifestations in lung images.

What does an abscess look like on an x-ray?

Skialological picture of an abscess on an x-ray:

• enlightenment cavity;
• fuzzy rounded contour with perifocal inflammatory foci;
• level of darkening in the projection of decay due to infiltration;
• disappearance of the horizontal level during drainage of the abscess.

With abscess pneumonia, several cavities of decay of lung tissue may be observed, which merge with each other.

Photo of a radiograph of an abscess of the right lung after lobar pneumonia. Left – reduction of the horizontal border after drainage of the abscess

Skialological symptoms of pleurisy in photographs

Exudative pleurisy in the photographs is manifested by the following signs:

• darkening of the lower pulmonary field due to infiltrative fluid;
• upper oblique Sokolov-Damoiso-Ellis boundary;
• shift of the mediastinum to the opposite side.

Inflammation of the interlobar pleura (periscisuritis) is determined by a radiologist by the following radiological syndromes:

• clarity of the contour of the interlobar fissure;
• the severity of the lumens of the subsegmental bronchi during lung infiltration;
• root expansion on the affected side.

The article discusses a classic example of x-ray diagnosis of pneumonia against the background of lobar inflammation. There are other forms of the disease (focal, segmental, lobar), in which the above X-ray syndromes are only partially expressed.

Bronchopneumonia: clinical and radiological pictures

Clinical picture. The onset of the disease often cannot be accurately determined, because it develops against the background of bronchitis or acute catarrh of the upper respiratory tract. However, in young people the disease can begin acutely and even with chills (M.Yu. Lyanda, M.F. Ryabov). Much less frequently, patients report pain in the chest or under the shoulder blade, general weakness, headache, and shortness of breath, which is more often observed in older people. Body temperature usually rises. In this case, a rise to 37–38° is often observed, more often to 39° and even 40°, rarely above 40°. Fever of remitting or intermittent type predominates. In cases where bronchopneumonia develops against the background of a disease accompanied by fever, the previous temperature curve undergoes some changes (height, character). In elderly and weakened patients, bronchopneumonia occurs at normal or subfebrile temperature.

During an objective examination of the patient, attention is drawn to some hyperemia or cyanosis (in old people) of the skin of the face, lips, and sometimes shortness of breath. The respiratory rate reaches 25–30 per minute.

Physical examination reveals various changes in individual patients depending on the location (superficial, deep) and size of the inflammatory focus. Centrally or even superficially located, but small lesions do not cause changes in vocal tremor of percussion sound. Increased vocal tremors, dullness of percussion sound, as well as the manifestation of bronchial or vesicobronchial breathing are possible only with bronchopneumonia that spreads to large areas of the lung tissue. Along with this, there are areas where breathing is weakened or completely absent (areas of pulmonary atelectasis). If the process of bronchopneumonia takes on a confluent character, spreading to an entire lobe or a significant part of it, then physical research methods reveal changes similar to those of lobar pneumonia.

The most constant symptom of bronchopneumonia is moist rales, which are heard in a limited area, above the lesion and, most importantly, are sonorous. This makes it possible to differentiate bronchopneumonia in the case of inflammation localized in the lower parts of the lungs from congestion in the lungs. Along with sonorous moist rales over a considerable distance or in more or less limited areas, scattered, dry and moist rales can be heard, indicating concomitant bronchitis or bronchiolitis. Due to the relatively limited possibilities for identifying inflammatory foci in bronchopneumonia using physical methods, the role of x-ray examination is increasing. However, the absence of visible changes in the lungs during fluoroscopy (especially in one position) does not provide grounds for categorically denying the presence of bronchopneumonia. Changes in bronchopneumonia can be observed not only in the alveoli, but also in the interstitial tissue of the lungs, where they manifest themselves, in particular, in the form of infiltration along the vascular-bronchial bundles. Bronchopneumonia of this localization can only be recognized radiographically. X-ray examination (in sagittal positions) also reveals small-focal hilar and paravertebral pneumonia, the determination of which by physical research methods is completely inaccessible.

On the part of the cardiovascular system, disturbances similar to those with lobar pneumonia may be observed: tachycardia, expansion of the borders of the heart in diameter, muffling of the first sound at the apex, changes in cardiac output, peripheral vascular resistance, especially in cases similar to lobar pneumonia in clinical course (confluent forms extending to the lobe of the lung or a significant part of it, etc.). In the blood with bronchopneumonia, leukocytosis is usually observed, but less pronounced than with lobar pneumonia (10,000 - 15,000 in 1 mm3) , with some, sometimes vaguely expressed shift to the left. Often, bronchopneumonia occurs with a normal content of leukocytes in the peripheral blood (according to M.Yu. Lyanda, 44.8%). ROE is usually accelerated, but less than with lobar P. When examining urine in patients with bronchopneumonia, a small amount of protein is sometimes detected (up to 0.5°/01), which is regarded as “febrile albuminuria” (A.M. Damir). After the temperature normalizes, albuminuria usually disappears.

The duration of bronchopneumonia varies and depends on the condition of the body and the virulence of the microbes that caused the disease.

Complications of bronchopneumonia due to the use of antibiotics and sulfonamides have become significantly less common than during the antibiotic period. According to V.P. Dyachenko and A.A. Stupnitsky, in the period 1952–1957. complications with focal P. were observed in 25 out of 353 patients (pleurisy - in 25 patients, lung abscess - in 6). According to V.I. Struchkov (1958), suppurative processes in the lungs during bronchopneumonia were observed in 1.2% (relative to the number of patients studied), while in the period 1941–1945. they were observed in 4.75% (M.F. Ryabov). Complications such as lung gangrene and purulent pleurisy have disappeared; Exudative serous pleurisy is also observed much less frequently.

Diagnosis and differential diagnosis. Small lesions, especially deep ones, often cannot be recognized using physical examination methods. In patients with emphysema, even larger pneumonic foci are often not detected by percussion and auscultation. Bronchopneumonia is difficult to recognize in debilitated patients, in people with nutritional dystrophy, severe heart disease, which is due to the presence of frequent and shallow breathing, as well as in some cases, congestion in the lungs. Recognition of bronchopneumonia in patients with myocardial infarction is difficult, especially in the first period of the disease, when, due to the forced position, their examination is sharply complicated. In these cases, general clinical observation of the patient (cough, the nature of the temperature curve, blood changes, etc.), as well as x-ray examination, is of great help.

As a result of the widespread use of antibiotics and sulfonamides, the typical, cyclical course of lobar pneumonia with severe symptomatology has become rare, which makes the differential diagnosis between lobar pneumonia and bronchopneumonia difficult. An acute onset with chills, stabbing pain in the side, more severe intoxication, rusty coloration of sputum, lobar or partially lobar spread of the process, high leukocytosis - all this speaks in favor of lobar pneumonia. In addition, the course of the inflammatory process as a whole with lobar pneumonia is much more pronounced.

X-ray examination helps significantly in identifying bronchopneumonia in capillary bronchitis.

Protracted forms of bronchopneumonia are differentiated from pulmonary tuberculosis on the basis of multiple studies of sputum (culture), the results of infection of animals (for tuberculosis - a guinea pig), as well as repeated radiography data.

X-ray picture. X-ray examination for bronchopneumonia is sometimes crucial for diagnosis, especially when recognizing the so-called. atypical forms of pneumonia (viral, influenza, acute interstitial, staphylococcal, etc.), the clinical course and symptoms of which in the vast majority of cases are not sufficiently characteristic. At the same time, one should not overestimate in other cases very scanty or even negative radiological data in limited small-focal bronchopneumonia, in which clinical symptomatology may be more conclusive. Numerous bronchopneumonia, different in their etiology and pathogenesis, often give completely similar radiological semiotics. Only some of them, such as staphylococcal pneumonia, have known specific radiological features.

With severe bronchopneumonia, the x-ray picture is usually quite convincing. The focal nature of the lesion is clearly evident. In some cases, foci of inflammatory infiltration involve groups of pulmonary lobules (lobular pneumonia), in others they are limited to damage to several nearby acini (acinous pneumonia). On a radiograph, lesions of acinar pneumonia usually range in size from 1 to 3 mm in diameter, with lobular they reach 10–15 mm . In both cases, there are multiple foci of inflammation, although their number can vary significantly. Often the lesions merge into larger spotted shadows, which, in turn, can turn into a continuous lobar darkening (pseudolobar pneumonia). With a dense arrangement of inflammatory foci, their apparent merging into larger shadows can arise as a consequence of the projection summation of focal shadows located at different depths. Unlike tuberculous focal lesions, foci of bronchopneumonia are more often localized in the lower and middle parts of the pulmonary fields. Sometimes radiologically it is possible to identify the predominant perioronchial localization of focal shadows, which is an indication of the pathogenetic connection of pneumonia with damage to the bronchial tree.

In focal lobular pneumonia, the lesions rarely have any regular geometric shape, which is explained mainly by the true and projection fusion of individual lesions, which have vague outlines and a relatively low shadow density. Through the shadow of even a large lesion, a pulmonary pattern can be easily traced, noticeably enhanced and excessive both due to vascular hyperemia and due to peribronchial inflammatory infiltration and edema. In contrast to the inflammatory infiltrate, with lobar pneumonia or tuberculosis, light stripes of the lumens of the bronchi cannot be traced (A.E. Prozorov). The reaction from the interstitial tissue can be expressed to a greater or lesser extent, but is always an almost indispensable component of the X-ray picture of bronchopneumonia. The reaction from the roots of the lungs, depending on the volume of pulmonary lesions, the nature of the pathogen, and the general phenomena of intoxication, is expressed differently in individual cases.

Dynamic radiological observations show that bronchopneumonic foci can sometimes completely disappear after 3–5 days, leaving behind only an enhanced heavy pulmonary pattern. But sometimes the x-ray picture becomes very persistent. New focal shadows may appear, sometimes in another lung (vagus pneumonia). With long-term radiographic changes, the process, as a rule, turns into a chronic form of focal pneumosclerosis with the development of bronchiectasis. Repeated X-ray monitoring is also necessary for the early detection of complications of bronchopneumonia such as exudative pleurisy and abscess formation.

With small focal (acinous) bronchopneumonia, individual focal shadows do not differ in appearance from foci with hematogenous tuberculous dissemination. Small focal bronchopneumonia is supported by the known limited nature of the lesion, usually in the lower and middle parts of the lungs, while with tuberculosis a universal lesion is observed. A small number of delicate small pneumonic lesions can sometimes be difficult to distinguish even on radiographs and go unnoticed during transillumination. The only indication of the presence of P. in such cases may be the strengthening and redundancy of the bronchovascular pulmonary pattern and the expansion of the shadows of the roots. With a large number of small focal shadows, even with fluoroscopy, a noticeable decrease in the transparency of the pulmonary field in the affected area is observed. The radiograph reveals a fairly dense seeding of foci, behind which the pulmonary pattern may become invisible.

Bronchopneumonia, in addition to lobular and small focal ones, can also manifest itself in the form of segmental and even lobar lesions. The extensive continuous pathological shadows that arise in this case, according to most authors, never reach the intensity of the shadow that is characteristic of lobar pneumonia. The latter is also distinguished by the presence of light stripes of the bronchi that retain their airiness, as well as the almost constant limitation of the pneumonic process by extensive, but one pathological darkening. Multiple pneumonic foci and bilateral lung damage occur with bronchopneumonia immeasurably more often than with lobar pneumonia. (G.R. Rubinstein).

Small focal, lobular, segmental and lobar lesions of the lungs can be observed in the X-ray picture both in bacterial bronchopneumonia (pneumococcal, streptococcal and staphylococcal pneumonia, typhoid pneumonia, etc.), and in viral ones, as well as, for example, in pneumonia due to Q fever . Sometimes a patient, especially with dynamic X-ray observation, may experience combinations of individual specified X-ray morphological forms (for example, the simultaneous presence of lobular foci and segmental opacities), as well as the transition of one form to another (more often the fusion of lobular bronchopneumonic foci into segmental and lobar infiltration). The variety of X-ray morphological manifestations of the pneumonic process, their pronounced dynamism and the multiplicity of lesions are apparently explained by the hematogenous origin of some pneumonias. From this point of view, their classification into the group of bronchopneumonia is largely arbitrary.

The X-ray picture of primary influenza pneumonia (viral influenza pneumonia) can be extremely diverse. Hirsch points out that during a particular epidemic, a very specific localization of pneumonia may predominate; however, more often, in his opinion, they are localized in the lower parts of the lungs, above the diaphragm. According to V.A. Dyachenko, influenza pneumonia is characterized by the early appearance of pathological darkening, often on the second day from the onset of the disease, and most importantly, the almost natural location of the focus of inflammatory infiltration along the edge of the pulmonary lobe (marginal or periscissural pneumonia). The inflammatory process is often segmental in nature. All this allows the author to consider influenza pneumonia as typical, in contrast to a significant part of researchers who classify all viral pneumonia, including influenza pneumonia, into the group of so-called atypical pneumonia. According to A.E. Prozorov, with viral P. broncholobular focal forms, segmental, lobar and occasionally disseminated with a pronounced interstitial component in the form of mainly perivascular changes, can be observed. The latter type, according to the author, is associated with the hematogenous origin of pneumonic lesions. Most researchers emphasize the almost obligatory involvement of interstitial connective tissue in the inflammatory process during influenza pneumonia. It is in this regard that on radiographs, sometimes even with the rapid disappearance of the pathological focus of darkening, an enhanced stringy pattern or “mesh” pattern remains in its place for a relatively long time.

In case of viral, in particular influenza pneumonia, a moderate reaction from the pulmonary roots can be considered quite characteristic and should be taken into account in the x-ray picture. With influenza pneumonia, a vaguely defined “path” may also be observed connecting the expanded root with the area of ​​pneumonic darkening. According to A.E. Prozorov, influenza pneumonia is prone to abscess formation. Small pleurisy may often be observed.

With Q fever, lobular, segmental and lobar pneumonic foci are identified radiographically. The darkening can be very gentle, cloud-like, but can also reach medium intensity. More often, the lesions are located away from the root, the shadow of which is usually normal. Migration of pneumonic foci is rarely observed. Reversal usually occurs within 2–5 weeks.

Septic metastatic pneumonia usually gives a fairly bright radiological picture. The shadows of pneumonic foci are, as a rule, multiple and visible in both pulmonary fields, which is typical for their hematogenous occurrence. There is no preferred localization of lesions along the pulmonary lobes. Usually several pneumonic foci immediately appear, to which new ones can quickly join. With septic pneumonia, both small-focal disseminations and larger foci of darkening, up to segmental and lobar, occur. Multiple large foci of septic pneumonia in the X-ray picture may resemble metastases of malignant tumors. Individual pneumonic foci often give quite intense and well-defined round shadows. In another projection, such a shadow turns into an irregular or triangular one with the apex facing the root (segmental lesion). The most typical feature of these pneumonias is the tendency to abscess formation. The cavities of multiple abscesses are quickly cleared of necrotic masses, the walls of the cavities look thin, without the wide rim of perifocal inflammation characteristic of an ordinary pulmonary abscess. The amount of purulent content in abscesses is small, and fluid levels are located only in the lower parts of the cavities or are not visible at all. With the often favorable course of septic pneumonia, a rapid, within a few days, reverse development of cavities can occur with their transformation into foci of pneumosclerosis or thin-walled pulmonary cysts.

A peculiar x-ray picture can be observed with staphylococcal septic pneumonia, which, according to Hirsch, accounts for about 10% of all primary pneumonia and sometimes joins pneumonia of a different etiology. Staphylococcal pneumonia is observed both in adults and in early childhood. Characterized by a general severe course and rapid variability of the x-ray picture, expressed in the formation of multiple large foci of darkening, merging with each other and then forming multiple abscesses and purulent exudate in the pleural cavity. In children with a favorable course, the formation of thin-walled cystic cavities is subsequently observed.

A special form is represented by septic interstitial pneumonia (V.I. Yakovleva), in which focal compactions of the lung tissue itself are either completely absent or quantitatively negligible. X-ray changes in the lungs are expressed only in the appearance of excessive radial heaviness emanating from the roots and a pronounced mesh pattern in the peripheral parts. The X-ray picture is not very characteristic and can only be taken into account when comparing it with clinical data. Typhoid pneumonia is characterized by radiologically significant persistence of focal changes (according to T.V. Rosenthal, up to 2 months after the onset of typhoid fever). With these pneumonias, mainly small-focal and lobular disseminations are observed, which are not prone to abscess formation.

The prognosis for bronchopneumonia depends on the previous general condition of the patient, the state of his cardiovascular system and is closely related to the nature of the underlying disease. The dependence of the outcomes of bronchopneumonia on the age of the patients was noted. Thus, as age increases, the course of the disease lengthens, later the clinical and radiological pictures normalize, and recurrent diseases are more often observed.

The prognosis of bronchopneumonia is especially serious (even death) in the elderly, in people with diseases of the cardiovascular system with symptoms of circulatory failure, in patients with a pronounced violation of general nutrition (nutritional dystrophy, vitamin deficiencies), as well as in diseases accompanied by cachexia.

Lecture for doctors "Radiation diagnosis of pneumonia". The lecture for doctors is conducted by the Scientific Clinical Center of JSC Russian Railways.

Pneumonia (pneumonia) is a group of acute local infectious inflammatory diseases, different in etiology, pathogenesis and morphological characteristics, which are characterized by focal damage to the respiratory sections (alveoli, bronchioles) of the lungs with intra-alveolar exudation, confirmed by physical and x-ray examination, and are accompanied by varying degrees of severity of a febrile reaction and intoxication.

The definition emphasizes the acute nature of inflammation, so there is no need to use the term “acute pneumonia” (in the International Classification of Diseases adopted by the World Health Organization, the heading “acute pneumonia” is absent and is replaced by the term “pneumonia”).

Depending on the epidemiological situation, the incidence of pneumonia in Russia ranges from 3-5 to 10-14 cases per 1000 population, and in the elderly group it can reach 30-50 cases per 1000 population per year.

Classification

In our country, the classification of acute pneumonia (AP) proposed by E.V. has been used for a long time. Gembitskiy et al. (1983). This is a modification of the classification developed by N.S. Molchanov (1962) and approved by the XV All-Union Congress of Therapists. It contains the following sections.

Etiology:

Bacterial (indicating the pathogen);

Viral (indicating the pathogen);

Ornithosis;

Rickettsial;

Mycoplasma;

Fungal (indicating the species);

Mixed;

Allergic, infectious-allergic;

Unknown etiology.

Pathogenesis:

Primary;

Secondary.

Primary AP is an independent acute inflammatory process of predominantly infectious etiology. Secondary means pneumonia that occurs as a complication of other diseases (diseases of the cardiovascular system with circulatory disorders in the pulmonary circulation, chronic diseases of the kidneys, blood system, metabolism, infectious diseases, etc.) or developing against the background of chronic diseases of the respiratory system (tumor, bronchiectasis and etc.) etc.

Clinical and morphological characteristics:

Parenchymatous - lobar, focal;

Interstitial.

The division into focal and lobar AP is valid only for pneumococcal pneumonia. Establishing a diagnosis of interstitial pneumonia must be approached with great responsibility. This is due to the fact that interstitial processes in the lung accompany a large group of both pulmonary and extrapulmonary diseases, which can contribute to the overdiagnosis of interstitial pneumonia.

Localization and extent:

One-sided;

Bilateral (indicating the extent of both localizations). Gravity:

Extremely heavy;

Heavy;

Moderate;

Light and abortifacient. Flow:

Acute;

Lingering.

It was proposed to consider a protracted course of AP in which its complete resolution did not occur within a period of up to 4 weeks, which is not true, since the complete resolution of pneumonia caused by staphylococcus and a number of other pathogens requires a much longer period.

Currently, this classification is not used for a number of reasons described below.

The modern definition of pneumonia emphasizes the infectious nature of the inflammatory process and, thus, excludes from the group of pneumonia pulmonary inflammations of other origins (immune, toxic, allergic, eosinophilic, etc.), for which it is advisable to use the term “pneumonitis” in order to avoid terminological confusion.

Inflammatory processes in the lungs caused by obligate bacterial or viral pathogens (causative agents of plague, typhoid fever, measles, rubella, etc.) are considered within the framework of the corresponding nosological forms.

Due to the need for early etiotropic treatment of pneumonia and the impossibility in most cases of timely verification of its causative agent, the European Respiratory Society (1993) proposed a working classification of pneumonia based on the clinical and etiological principle, taking into account the epidemic situation and risk factors.

Community acquired pneumonia.

Hospital acquired (hospital or nosocomial) pneumonia.

Pneumonia in immunodeficiency states.

Aspiration pneumonia.

The presented grouping of clinical forms of pneumonia allows us to identify a certain spectrum of pathogens characteristic of each form of the disease. This makes it possible to make a more targeted empirical choice of antibacterial drugs at the initial stage of treatment of the disease.

The general group did not include atypical pneumonia as a disease caused by atypical pathogens and having an atypical clinical picture. With such pneumonia, there is no alveolar exudation, and therefore there is no main auscultatory sign - moist, ringing, fine-bubble rales. In Russia, the term “atypical pneumonia” was used several years ago to refer to severe acute respiratory syndrome (SARS), caused by a coronavirus and spreading in a certain epidemic situation. The causative agent of acute respiratory syndrome, labeled as SARS-CoV, belongs to the group Coronavirus. Its source is animals (cats, dogs); the disease is transmitted from person to person.

Community-acquired pneumonia is an acute infectious disease of predominantly bacterial etiology, occurring in out-of-hospital conditions, belonging to the most common forms of pneumonia and having the most characteristic clinical picture. As before, pneumonia that occurs in closed youth groups (schoolchildren, students, soldiers) and often has the character of an epidemic outbreak occurs with atypical symptoms.

Hospital-acquired (nosocomial) pneumonia includes those pneumonias that developed within 48-72 hours or more after the patient was admitted to the hospital for another disease. The main reasons leading to the development of nosocomial pneumonia are most often previous operations, artificial ventilation, various endoscopic procedures and previous treatment with broad-spectrum antibiotics.

Pneumonia that develops against the background of an altered immune status occurs in patients with AIDS, people receiving immunosuppressive treatment, patients with systemic diseases, etc. They are classified as pneumonia in immunodeficiency states.

Aspiration pneumonia most often develops in persons suffering from alcoholism and drug addiction, less often - after anesthesia, with depression of consciousness. The role of gastroesophageal reflux in the occurrence of aspiration pneumonia has increased.

Etiology

In community-acquired pneumonia in 80-90% of cases, the causative agents are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae And Moraxella catarrhalis. Among the most common pathogens of pneumonia, the main one remains Streptococcus pneumoniae(Pneumococcus). In addition, it can be caused Chlamydia psittaci and Klebsiella (Friedlander's bacillus).

Hospital-acquired (nosocomial) pneumonia is characterized by a wide variety of etiological agents, including gram-negative microflora (enterobacteria, Pseudomonas aeruginosa, Acinetobacter), Staphylococcus aureus and anaerobes.

Pneumonia in patients with an immunodeficiency state, in addition to pneumococci and gram-negative bacilli, is often caused by Pneumocystis jiroveci (Pneumocystis carinii), viruses (including cytomegalovirus - a marker of HIV infection), fungi, Nocardia spp. and mycobacteria. If neutropenia is detected in such patients during a blood test, then the pathogens most often are Staphylococcus aureus, Escherichia coli And Pseudomonas aeruginosa, often leading to a septic course of the disease.

Since the main cause of aspiration pneumonia is the penetration of microflora of the oropharynx or stomach into the respiratory tract, the main pathogens are anaerobic bacteria, gram-negative microflora and Staphylococcus aureus.

The main causative agents of atypical pneumonia are Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Legionella pneumophyla And Coxiella burnetti.

During an influenza epidemic, the role of viral-bacterial associations increases (staphylococci are most often found), as well as opportunistic microorganisms. In viral-bacterial pneumonia, respiratory viruses play an etiological role only in the initial period of the disease: the main etiological factor determining the clinical picture, severity and outcome of the disease remains the bacterial microflora.

Pathogenesis

In the pathogenesis of pneumonia, the main role belongs to the influence of an infectious pathogen entering the lungs from the outside. Most often, microflora penetrates into different parts of the lungs through the bronchi by aspiration (from the nasal or oropharynx) and inhalation routes (together with inhaled air). The bronchogenic route of infection is considered the main route for community-acquired pneumonia.

The pathogen enters the lungs through the hematogenous route in pneumonia that develops as a complication of sepsis and infectious diseases, as well as in pneumonia of thrombotic etiology. Lymphogenic spread

The resolution of infection with the development of the disease is noted only with chest wounds.

There is also an endogenous mechanism for the development of inflammation of the lung tissue, due to the activation of the lung microflora. Its role is especially great in nosocomial pneumonia.

The initial link in the development of pneumonia is the adhesion of microorganisms (Fig. 1-1) to the surface of the epithelial cells of the bronchial tree, which is largely facilitated by the previous dysfunction of the ciliated epithelium and impaired mucociliary clearance. After adhesion, the next stage in the development of inflammation is colonization of epithelial cells by the microorganism. Damage to their membrane promotes intensive production of biologically active substances - cytokines (IL-1, 8, 12, etc.).

Under the influence of cytokines, chemotaxis of macrophages, neutrophils and other effector cells taking part in the local inflammatory reaction occurs. In the development of subsequent stages of inflammation, invasion and intracellular persistence of microorganisms, as well as their production of endo- and exotoxins, play a significant role. These processes lead to inflammation of the alveoli and bronchioles and the development of clinical signs of the disease.

Risk factors play an important role in the development of pneumonia. These include age (elderly people and children), smoking, chronic diseases of the lungs, heart, kidneys and gastrointestinal tract, immunodeficiency conditions, contact with birds, rodents

Rice. 1-1. Pathogenesis of pneumonia

And other animals, travel (trains, stations, planes, hotels), hypothermia and staying in a closed group.

In addition to infectious ones, the development of pneumonia can be facilitated by unfavorable factors of the external and internal environment, under the influence of which there is a decrease in the general nonspecific resistance of the body (suppression of phagocytosis, production of bacteriolysins, etc.) and suppression of local protective mechanisms (impaired mucociliary clearance, decrease in the phagocytic activity of alveolar macrophages and neutrophils and etc.).

In the pathogenesis of nosocomial pneumonia, importance is often attached to the development of immune reactions. Saprophytes and pathogenic microorganisms, becoming antigens, contribute to the production of antibodies, which are fixed primarily on the cells of the mucous membrane of the respiratory tract. Here the antigen-antibody reaction occurs, which leads to tissue damage and the development of the inflammatory process.

When there are common antigenic determinants of microorganisms and lung tissue, or when the latter is damaged by viruses, microorganisms and toxins, leading to the manifestation of its antigenic properties, autoallergic processes develop. They contribute to a longer existence of pathological changes and a protracted course of the disease. In addition, the protracted course of pneumonia is often caused by associations of microorganisms (see Fig. 1-1).

Clinical painting

The clinical picture consists of a combination of the following main syndromes.

General intoxication syndrome: general weakness, fatigue, headaches and muscle pain, shortness of breath, palpitations, pallor and loss of appetite.

Syndrome of general inflammatory changes: feeling of heat, chills, increased body temperature, changes in acute-phase blood parameters (leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR, fibrinogen concentrations, a2-globulins and C-reactive protein).

Syndrome of inflammatory changes in the lung tissue (cough, sputum production, shortening of percussion sound), increased vocal tremors and bronchophony, changes in the frequency and nature of breathing, the appearance of moist rales and characteristic radiological changes.

Syndrome involving other organs and systems (cardiovascular system, gastrointestinal tract, kidneys, nervous system).

The severity of these disorders characterizes the severity of pneumonia (Table 1-1).

The clinical picture of pneumonia depends on a number of reasons and is largely determined by the characteristics of the pathogen and the state of the macroorganism. Thus, in the clinical picture of atypical pneumonia, signs of general intoxication predominate, while the symptoms of bronchopulmonary syndrome fade into the background. Aspiration pneumonia is characterized by the development of purulent

Table 1-1.

destructive processes in the lungs. At different stages of the disease, the clinical picture may change depending on the addition of certain complications.

Complications

All complications of pneumonia are divided into pulmonary and extrapulmonary. Major pulmonary complications:

Abscess formation; pleurisy (para- and metapneumonic), much less often - pleural empyema;

Attachment of the asthmatic component.

In severe cases of pneumonia (viral or massive confluent bacterial pneumonia), conditions are created for the formation of pulmonary edema, the development of acute respiratory failure and distress syndrome.

Extrapulmonary complications:

Infectious-toxic shock with symptoms of acute vascular, acute left ventricular and renal failure, ulceration of the gastrointestinal mucosa and bleeding, as well as the development of disseminated intravascular coagulation (DIC) of blood at the final stage;

Infectious-allergic myocarditis;

Infective endocarditis (IE);

Pericarditis;

Meningitis or meningoencephalitis;

Anemia;

Glomerulonephritis;

Hepatitis.

In addition, with severe lobar pneumonia, the development of intoxication psychoses is possible, and with confluent total pneumonia - acute pulmonary heart disease, disseminated intravascular coagulation syndrome and sepsis.

Required:

Determine the main complaints that suggest pneumonia;

Assess the severity of the patient’s condition;

Suggest the etiology of the disease, taking into account the onset and course of the process.

The main complaints presented by patients: cough, sputum production, chest pain, aggravated by breathing and coughing, shortness of breath, poor general health and increased body temperature.

The cough can be dry (in the initial period of lobar pneumonia, throughout the entire disease with interstitial pneumonia) or with sputum (mucous, mucopurulent, purulent mucous, bloody).

“Rusty” sputum is characteristic of lobar pneumonia, and bloody, viscous sputum is characteristic of pneumonia caused by Klebsiella (Friedlander’s bacillus). Purulent bloody sputum is one of the signs of pneumonia of streptococcal etiology. Viral pneumonia can occur with the release of bloody sputum. A persistent, sometimes paroxysmal cough with a small amount of mucopurulent sputum is noted with mycoplasma pneumonia. In addition, they are characterized by a feeling of “soreness” in the throat.

Hemoptysis is one of the characteristic features of pneumonia in pulmonary mycoses. It can also be a sign of pulmonary embolism; in this case, hemoptysis in combination with pain in the side is a sign of infarction pneumonia.

Pain in the side, aggravated by deep breathing and coughing, is characteristic of pneumonia involving the pleura in the pathological process (most often for lobar pneumococcal pneumonia). The development of parapneumonic pleurisy is recorded in half of patients with pneumonia caused by Pfeiffer bacillus, and in 30-80% of patients with diseases of streptococcal etiology. When pneumonia is localized in the lower parts of the lungs and the diaphragmatic pleura is involved in the process, the pain can radiate to the abdominal cavity, resembling the picture of an acute abdomen. If the upper or lower lingular segment of the left lung is involved in the process, then the pain is localized in the heart area.

In 25% of patients, shortness of breath is one of the main complaints. It is most pronounced in pneumonia that develops against the background of chronic respiratory diseases (chronic bronchitis, bronchiectasis) and heart failure. The severity of shortness of breath increases in parallel with the disturbance in general health (headache, lethargy, delirium, vomiting, etc.).

Symptoms of severe intoxication are most characteristic of psittacosis and mycoplasma pneumonia, often present in staphylococcal, influenza and pneumococcal (lobar) pneumonia, as well as in diseases caused by viral-bacterial associations.

The patient may experience chills and increased body temperature. An acute onset with chills is more typical for bacterial pneumonia, primarily for lobar (pneumococcal) pneumonia. The disease, as a rule, begins suddenly with the onset of stunning chills and fever.

body temperature to febrile. Against the general background of intoxication and febrile temperature, local symptoms are noted.

With viral pneumonia at the onset of the disease, the patient does not give the impression of being seriously ill (except for patients with influenza), since the clinical picture is not yet accompanied by symptoms of pneumonia.

To establish an etiological diagnosis, a correct assessment of the symptoms of the disease at its very beginning is important. Hoarseness or the inability to speak is characteristic of pneumonia caused by the parainfluenza virus (children may even develop false croup). Watery eyes, pain in the eyes (symptoms of conjunctivitis), sore throat when swallowing, copious nasal discharge (symptoms of nasopharyngitis) without changes in other parts of the respiratory tract are recorded in pneumonia caused by adenovirus. If patients, against the background of mild catarrhal symptoms in the upper respiratory tract, develop bronchitis (often with an asthmatic component) and pneumonia, then it is more likely that their causative agent is the respiratory syncytial virus. This disease is characterized by low body temperature and severe symptoms of intoxication.

When studying your medical history, you should pay attention to concomitant diseases of other organs and systems that may affect the symptoms and course of pneumonia. Thus, patients with various tumor diseases, hematological malignancies, receiving chemotherapy, immunosuppressants and (or) drug addiction are classified as a group in which the development of pneumonia occurs against the background of a sharp change in immune status.

In the occurrence of pneumonia occurring with atypical symptoms, importance is attached to the epidemiological history: contact with birds (domestic or ornamental) - sources Chlamydia psittaci, rodents; travel (for example, Legionella can be found in water in hotel air conditioning systems). Pay attention to group outbreaks of febrile diseases in closely interacting groups.

The atypical course of pneumonia is characterized by fever, headache and the appearance of a non-productive cough. Damage to the lower sections is preceded by symptoms of pathological changes in the upper respiratory tract: sore throat, loss of voice and cough, which is periodically paroxysmal in nature and disturbs sleep.

Aspiration pneumonia is characterized by a gradual onset, increased body temperature, cough with the discharge of purulent sputum, the most common lesion of the upper segment of the lower lobe (with aspiration in a semi-sitting position) or the posterior sections of the upper lobe (with aspiration in a lying position) of the right lung, a prolonged course with the development late purulent complications in the form of lung abscess or pleural empyema.

If you suspect the development of pneumonia in a patient who is in the hospital for another disease, you should remember the risk factors for the development of nosocomial pneumonia. These include the patient's stay in intensive care wards or resuscitation departments, artificial ventilation, tracheostomy, bronchoscopic examinations, the postoperative period, previous massive antibiotic therapy and septic conditions. This group of patients has concerns

Leaving is extremely difficult. Complications such as pleural empyema and atelectasis often develop.

Aspiration pneumonia occurs in severe alcoholism, epilepsy, in patients in a comatose state, in acute cerebrovascular accident and other neurological diseases, as well as in swallowing disorders, vomiting, etc.

Knowledge of these variants of the clinical course of pneumonia, taking into account the specific gravity of various pathogens in each of them, will allow, with a certain degree of probability, to carry out the etiological diagnosis of the disease already at this stage of the diagnostic search.

On first stage of diagnostic search pneumonia can be assumed, but a definitive diagnosis cannot be made, since the main symptom of the disease - the syndrome of inflammatory changes in the lung tissue - can be detected at the second stage, and in some cases - only at the third stage of the diagnostic search. Along with this, in elderly patients or with severe concomitant illness, extrapulmonary symptoms (confusion, disorientation) may come to the fore, which should prompt the doctor to suspect the development of pneumonia at the first stage of the diagnostic search.

The most significant for the diagnosis is the existence of a syndrome of inflammatory changes in the lung tissue, consisting of the following symptoms:

Lagging of the affected side of the chest when breathing;

Shortening of percussion sound in the area of ​​projection of the lesion over a greater or lesser extent;

Changes in the nature of breathing (hard, bronchial, weakened, etc.);

The occurrence of pathological respiratory sounds (moist, ringing, fine-bubble rales and crepitus).

The breathing pattern can change in different ways. In the initial stage of lobar pneumonia, it may be weakened, with prolonged exhalation; in the hepatization phase, along with an increase in dullness of the percussion sound, bronchial breathing is listened to; when the pneumonic focus resolves with a decrease in percussion dullness, breathing becomes harsh. With focal pneumonia there is no such clear dynamics of physical data. The most persistent symptoms of focal pneumonia are hard breathing and moist, ringing, fine-bubble rales. In some cases (for example, with central hilar pneumonia), physical data are presented very poorly, and recognition of the disease is possible only after an X-ray examination.

Mycoplasma pneumonia is characterized by a paucity of physical data. Severe intoxication in combination with a very small number of wheezes (extensive exudation “clogs” the bronchioles and alveoli) is noted in pneumonia caused by Klebsiella pneumonia. For interstitial pneumonia of any etiology, percussion and auscultation data are very scarce.

In a number of cases (with pneumonia that developed against the background of chronic bronchitis, diseases caused by the Pfeiffer bacillus, as well as in the case of

connections to pneumonia of an allergic/asthmatic component) upon auscultation, a lot of bass and treble dry rales, which are not characteristic of inflammatory infiltration syndrome, come to the fore. The most pronounced sensitizing effect is exerted by mold fungi (urticaria, allergic rhinitis, eosinophilic infiltrate, Quincke's edema).

Physical examination helps to detect other pulmonary complications of pneumonia: pleurisy (pleural friction noise or percussion dullness without respiratory sounds) and lung abscess (dullness and sharp weakening of breathing in the first phase, dull tympanitis, amphoric breathing and moist medium-bubble rales in the second phase).

It is possible to determine the concomitant involvement of organs and systems in the pathological process or complications caused by damage to other organs. In severe cases of pneumonia, a decrease in blood pressure is often noted (a sign of vascular and heart failure).

Other symptoms can help establish an etiological diagnosis:

The detection of a small-spotted (as with rubella) rash in combination with lymphadenopathy is characteristic of an adenoviral infection;

Local enlargement of the lymph nodes (especially axillary and supraclavicular) allows one to suspect a lung tumor and perifocal pneumonia;

Fungal pneumonia is combined with damage to the mucous membranes, skin and nails;

Hepatolienal syndrome and slight jaundice are characteristic of ornithosis and Cu-rickettsial pneumonia;

For typical lobar (pneumococcal) pneumonia, the characteristic appearance of the patient is noted (pale face with a feverish blush on the affected side, herpetic rashes, swelling of the wings of the nose when breathing).

The most important is the detection of signs that confirm or reject the existence of pneumonia; clarifying the nature and specificity of the pathogen; indicating the severity of the inflammatory process; clarifying the state of the body’s immunological reactivity; clarifying the degree of involvement of other organs and systems in the process and the development of complications.

The most important method to clarify the existence of pneumonia and the degree of involvement of lung tissue in the process is an X-ray examination of the chest organs. Large-frame fluorography and radiography in two projections, carried out in dynamics, help (taking into account the clinical picture) to diagnose pneumonia.

Sometimes, by the nature of x-ray changes, one can judge with a certain degree of probability about the pathogen that caused the disease. Staphylococcal pneumonia is distinguished by a clear segmentation of lung damage involving several segments (in 60% of cases - bilateral damage). Their characteristic radiological sign is the formation on the 5-7th day from the onset of the disease of multiple cavities in the lungs, such as pneumocele, and subsequently - necrotic cavities containing fluid.

Unlike true abscesses, the configuration and number of cavities change rapidly.

Lobar lesions most often serve as a sign of lobar pneumococcal pneumonia. Homogeneous darkening of the entire lobe or most of it, usually not corresponding to the segmental division of the lung, is also recorded in pneumonia caused by Klebsiella. Most often, lesions are found in the upper lobe of the right lung.

X-ray examination can detect effusion in the pleural cavity, sometimes not determined by physical methods. It is often formed during streptococcal pneumonia, as well as during a disease caused by Pfeiffer's bacillus, localized in the lower lobe, and in two thirds of patients involving more than one lobe.

Focal pneumonia is often characterized by a discrepancy between clinical and radiological data.

X-ray examination data are especially important when detecting a disease with mild auscultatory changes, which is typical for interstitial and hilar pneumonia. In such cases, computed tomography (CT) is recommended to clarify the diagnosis. It is also carried out to diagnose pneumonia that occurs with pronounced clinical signs, but without clear radiological changes. CT scan of the lungs in this situation can detect infiltration of the lung tissue.

If it is necessary to carry out a differential diagnosis of pneumonia with tuberculosis and lung cancer, bronchoscopy is performed.

Bronchography makes it possible to detect decay cavities in the lung tissue, as well as bronchiectasis, around which infiltrative changes occur during exacerbation (the so-called perifocal pneumonia).

Sputum examination helps clarify the etiology of the disease. A large number of eosinophils indicates allergic processes, the presence of atypical cells indicates lung cancer and perifocal pneumonia. Mycobacterium tuberculosis is found in tuberculosis; elastic fibers serve as evidence of the breakdown of lung tissue (cancer, tuberculosis, abscess). In case of mycotic pneumonia, along with the detection of fungi, the absence of pyogenic microflora is noted due to the inhibitory effect of the waste products of the former.

According to bacterioscopy (microscopy of sputum smears stained with Gram), it is possible to determine gram-negative or gram-positive microorganisms living in the bronchi already on the first day of the patient’s hospital stay (this is important to consider when choosing antibiotics).

Bacteriological examination of sputum (bronchial washings) before prescribing antibacterial drugs helps to detect the pathogen and determine its sensitivity to antibiotics. The study of bronchial lavage is especially important in the diagnosis of pneumonia of Pneumocystis etiology.

In the diagnosis of viral and viral-bacterial pneumonia, virological and serological studies are important.

In recent years, particular importance has been attached to the determination of antigens in urine. Antigen detection Streptococcus pneumoniae And Legionella pneumophila provo-

using the urease test. It can be positive even if the patient received antibiotics the day before. When examining patients who are not amenable to conventional treatment, in the case of an atypical course of the disease or the development of severe complications, all complex immunological, virological and serological methods must be used.

The severity of the inflammatory process can be judged by the severity of acute-phase blood parameters and the dynamics of their changes (leukocytosis with a shift in the leukocyte formula, an increase in ESR, an increased content of α 2 -globulins, fibrinogen, CRP, sialic acids). For bacterial pneumonia, neutrophilic leukocytosis with a shift in the leukocyte formula to the left is more typical. ESR is increased, and the degree of its increase is determined by the prevalence and severity of the process. Viral pneumonia is distinguished by leukopenia. With ornithosis pneumonia, a significant increase in ESR is noted. For parainfluenza and adenoviral pneumonia, as a rule, a tendency to leukopenia is characteristic, but the ESR in these cases is not changed.

In severe cases of pneumonia, repeat sputum cultures are performed, the results of which can help determine the etiology of the disease.

Laboratory and instrumental research methods are of additional importance in clarifying the degree of involvement of other organs and systems in the process and the development of complications:

An ECG allows you to assess the condition of the myocardium;

Echocardiography (EchoCG) for complications of IE helps to detect pericardial effusion or bacterial colonies on the heart valves;

Indicators of external respiration function allow us to assess the state of bronchial patency.

Diagnostics

Diagnosis of pneumonia is based on determining the main and additional diagnostic criteria. The main criterion is the syndrome of local inflammatory infiltration of lung tissue (clinical and radiological data). Additional criteria include:

Syndrome of general inflammatory changes;

Intoxication syndrome;

Syndrome of involvement of other organs and systems;

Existence of risk factors.

A major role in establishing an etiological diagnosis belongs to a correct assessment of the epidemiological situation in combination with the clinical picture of the disease and X-ray data. Help in this case is provided by the results of bacterioscopy, which should be performed on the first day of the disease and interpreted taking into account clinical data.

The etiology of pneumonia, in which the properties of the pathogen are not fully expressed and there is no characteristic clinical and radiological picture, is established according to bacteriological, virological and serological studies during treatment. Even using a wide range of microbiological studies, it is possible to determine the etiology of the disease in hardly half of the cases.

Conditions of occurrence (clinical and etiological classification);

Etiology (if established);

Localization and prevalence;

The severity of the current;

Presence of complications;

The flow phase (height, resolution, convalescence). Treatment

The principles of treating a patient with pneumonia are presented in Table. 1-2. Table 1-2. Principles of treating a patient with pneumonia

The treatment measures carried out are listed below.

Therapeutic regimen and rational nutrition.

Drug treatment:

Etiotropic;

Pathogenetic;

Symptomatic.

Physiotherapeutic effects.

Dispensary observation.

Therapeutic regimen and balanced nutrition

Patients with pneumonia must be hospitalized. Indications for it include the patient’s age over 65 years with any degree of severity of the disease, the existence of serious concomitant diseases and (or) signs of impairment of the vital functions of the body, as well as the lack of adequate care at home. In other cases, you can organize a hospital at home. Bed rest is mandatory during the entire period of fever and intoxication. At the same time, the patient needs plenty of fluids, a diet rich in vitamins and proteins.

Drug treatment

It is carried out with the help of medications that affect the pathogen (etiotropic therapy), various links in pathogenesis, individual signs of the disease (hypoxia, fever, cough, etc.) and developed complications.

opinions. The main method of treating pneumonia is antibacterial therapy, which is prescribed empirically until the results of a bacteriological study are obtained. Its results become known 2-3 days after collecting the material and in most cases do not have a significant impact on treatment tactics (Table 1-3).

Table 1-3.

End of table. 1-3

* On the first day, a double dose of 0.5 g is prescribed.

Etiotropic treatment of pneumonia. Antibacterial drugs are used, when prescribing which three basic conditions must be met:

Start treatment as early as possible, without waiting for the isolation and identification of the pathogen, focusing in the choice of dosage regimen on the features of the clinical picture and radiographic data;

Prescribing drugs in sufficient doses and at such intervals that a therapeutic concentration of the drug is created and maintained in the blood and lung tissue;

Monitoring the effectiveness of treatment using clinical observation and, if possible, bacteriological examination.

Of all antibacterial agents, the most effective are antibiotics, which are chosen taking into account the characteristics of the possible pathogen and the patient’s tolerability of the drug. For gram-positive microflora, it is preferable to prescribe semisynthetic penicillins and cephalosporins; for gram-negative microflora, fluoroquinolones, aminoglycosides and imipenem (imipenem + cilastatin) are preferable. Patients with viral-bacterial association should be prescribed broad-spectrum antibiotics in combination with semisynthetic and protected penicillins.

A subjective response to antibiotics is usually noted within 3-4 days from the start of treatment. Objective response includes assessment of fever, symptoms, laboratory values, and radiographic changes. The average dynamics of these parameters is presented in table. 1-4.

The effectiveness of antibiotics is assessed after 2-3 days. If there is no clinical effect from using the drug for three days, it should be replaced with another, focusing, if possible, on the sensitivity of the isolated microflora. Despite the high efficiency, with

Table 1-4.

long-term antibacterial therapy, the antibacterial agent is replaced with another after 10-12 days.

Treatment of community-acquired pneumonia

Patients can be treated both in outpatient and inpatient settings. When conducting antibacterial therapy on an outpatient basis, two groups of patients are distinguished:

Group I - age less than 60 years, no concomitant diseases;

Group II - age over 60 years and (or) concomitant diseases.

As a rule, the duration of antibacterial therapy is 7-10 days.

Conducting antibacterial therapy in patients of group I

The drugs of choice are amoxicillin (0.5-1.0 g orally 3 times a day) or amoxicillin + clavulanic acid (0.625 g orally 3 times a day). Alternative drugs - macrolides: clarithromycin (orally 0.5 g 2 times a day), roxithromycin (orally 0.15 g 2 times a day), azithromycin (orally 0.5 g 1 time a day), spiramycin (orally 1.5 million IU 3 times a day). If an atypical pathogen is suspected, macrolides are considered the drugs of choice, and respiratory fluoroquinolones (oral levofloxacin at a dose of 0.5 g once a day or moxifloxacin at a dose of 0.4 g once a day) can be alternative drugs.

Conducting antibacterial therapy in patients of group II

The drugs of choice are amoxicillin + clavulanic acid (0.625 g orally 3 times a day or 1.0 g 2 times a day), cefuroxime (0.5 g orally 2 times a day). Alternative drugs: levofloxacin (0.5 g orally once a day), moxifloxacin (0.4 g orally once a day) or ceftriaxone (intramuscular 1.0-2.0 g once a day).

Macrolides should be preferred in case of intolerance to β-lactam antibiotics and pneumonia, presumably caused by Mycoplasma pneumoniae And Chlamydia pneumoniae. The indication for parenteral administration of drugs is the impossibility of taking them orally.

Antibacterial therapy in hospital settings

Drug treatment in hospital depends on the severity of pneumonia.

Treatment of mild to moderate pneumonia. Drugs of choice: amoxicillin + clavulanic acid (intravenous 1.2 g 3 times a day), ampicillin (intravenous or intramuscular 1.0-2.0 g 4 times a day), benzylpenicillin (intravenous 2 million units 4-6 once a day), cefotaxime (intravenously or intramuscularly 1.0-2.0 g 2-3 times a day), ceftriaxone (intravenously or intramuscularly 1.0-2.0 g 1 time a day), cefuroxime (intravenously or intramuscularly 0.75 g 3 times a day). Alternative drugs: levofloxacin (intravenously at a dose of 0.5 g once a day) or moxifloxacin (intravenously at a dose of 0.4 g once a day).

After 3-4 days of treatment, when a clinical effect is achieved (normalization of body temperature, reduction in the severity of intoxication and other symptoms of the disease), one should switch from parenteral administration of drugs to oral administration. The total duration of treatment is 7-10 days.

Treatment of severe pneumonia. Drugs of choice: a combination of clarithromycin (0.5 g intravenously 2 times a day), or spiramycin (1.5 million IU intravenously 3 times a day), or erythromycin (orally 0.5-1.0 g 4 times a day). day) with amoxicillin + clavulanic acid (intravenous 1.0-2.0 g 3 times a day) or cefepime (intravenous 1.0-2.0 g 2 times a day), or cefotaxime (intravenous 1.0 -2.0 g 2-3 times a day), or ceftriaxone (intravenously at a dose of 1.0-2.0 g 1 time a day). Alternative medicines: a combination of levofloxacin (intravenously at a dose of 0.5 g 1-2 times a day), or moxifloxacin (intravenously at a dose of 0.4 g once a day), or ofloxacin (intravenously at a dose of 0.4 g 2 times a day ), or ciprofloxacin (intravenously at 0.2-0.4 g 2 times a day) with cefotaxime (intravenously at 1.0-2.0 g 2-3 times a day) or ceftriaxone (intravenously at a dose of 1.0- 2.0 g 1 time per day).

Parenterally, the drugs are administered for 7-10 days. The total duration of treatment is 14-21 days.

Treatment of nosocomial pneumonia

When treating, it should be taken into account that often the causative agents of the disease are multidrug-resistant gram-negative bacteria (including Pseudomonas aeruginosa), staphylococci, and anaerobes. Treatment of nosocomial pneumonia with antibacterial agents depends on the presence or absence of associated risk factors. The duration of use of antibacterial drugs is determined individually. In the treatment of nosocomial (nosocomial) pneumonia, taking into account the most common pathogens (Pseudomonas aeruginosa, Staphylococcus aureus), the first place is taken by cephalosporins of the III-IV generation, resistant to the action of p-lactamases, fluoroquinolones and imipenem.

Antibacterial treatment of nosocomial pneumonia occurring in patients without associated risk factors

Drugs of choice: amoxicillin + clavulanic acid (intravenous 1.2 g 3 times a day), cefotaxime (intravenous or intramuscular 1.0-2.0 g 2-3 times a day), ceftriaxone (intravenous or intramuscular in

dose 1.0-2.0 g 1 time per day), cefuroxime (intravenously or intramuscularly 0.75 g 3 times per day). Alternative medicines: levofloxacin (intravenously at a dose of 0.5 g once a day), moxifloxacin (intravenously at a dose of 0.4 g once a day), a combination of cefepime (intravenously 1.0-2.0 g twice a day). day) with amikacin (intravenously at a dose of 15-20 mg/kg once a day) or gentamicin (intravenously at a dose of 3-5 mg/kg once a day).

Antibacterial treatment of nosocomial pneumonia occurring in patients with concomitant risk factors

Drugs of choice: imipenem (0.5 g intravenously 3-4 times a day), or ceftazidime (1-2 g intravenously 2-3 times a day), or cefepime (1.0-2.0 g

2 times a day), or meropenem (0.5 g intravenously 3-4 times a day) in combination with amikacin (intravenously at a dose of 15-20 mg/kg 1 time per day) or vancomycin (1.0 g intravenously 2 times a day). Alternative therapeutic agents: aztreonam (intravenously or intramuscularly at 0.5-2.0 g 2-3 times a day), or levofloxacin (intravenously at a dose of 0.5 g once a day), or moxifloxacin (intravenously at a dose of 0. 4 g 1 time per day), or a combination of amikacin (intravenously at a dose of 15-20 mg/kg 1 time per day) with piperacillin + tazobactam (intravenous 4.5 g 3 times per day) or with ticarcillin + clavulanic acid (intravenous 3.2 g 3 times a day). Instead of amikacin, gentamicin can be used (intravenous 3-5 mg/kg body weight once a day).

Treatment of aspiration pneumonia

Aspiration pneumonia is almost always caused by anaerobic and (or) gram-negative microflora, which requires the administration of aminoglycosides, protected penicillins in combination with metronidazole and carbapenems. Drugs of choice: amoxicillin + clavulanic acid (1.2 g intravenously

3 times a day, or benzylpenicillin (2 million units intravenously 4-6 times a day) in combination with metronidazole (0.5 g intravenously 3 times a day). Alternative medicines: imipenem (0.5 g intravenously 3-4 times a day) or meropenem (0.5 g intravenously 3-4 times a day). Intravenous administration of clindamycin (0.3-0.9 g 3 times a day) has a good effect. The duration of antibacterial therapy for aspiration pneumonia is determined individually.

Treatment of pneumonia in immunodeficiency states

Treatment of pneumonia in combination with severe immune defects should be carried out only in a hospital setting. In patients with immunodeficiency conditions, the choice of antibacterial therapy largely depends on the origin of the pathogen. The most common regimen is the administration of aminoglycosides in combination with modern cephalosporins. In AIDS patients with the development of pneumonia caused by Pneumocystis carinii, The accepted treatment regimen is parenteral administration of pentamidine, cotrimoxazole and septrim. Treatment of Pneumocystis pneumonia is carried out with cotrimoxazole (intravenously at a dose of 20 mg/kg per day in 3-4 doses). Duration of treatment - 21 days.

If antibiotics are poorly tolerated and the isolated microflora is highly sensitive to nitrofurans, furaltadone is prescribed (0.1 g orally

4 times a day), furazidin (intravenous drip of 300-500 ml of 0.1% solution per day; 3-5 infusions per course). If antibiotics are ineffective, you can

Successful use of quinoxaline derivatives (hydroxymethylquinoxaline dioxide).

To prevent candidiasis (especially with massive and long-term antibacterial therapy), the use of nystatin and levorin (orally 500 thousand units 4 times a day) is recommended.

For pneumonia of fungal etiology, antifungal agents are prescribed: amphotericin B, itraconazole, ketoconazole, fluconazole, etc.

Pathogenetic treatment of pneumonia. To restore nonspecific resistance in severe and prolonged pneumonia, immunomodulatory agents (interferon preparations, azoximer bromide, thymus extract) are used.

For staphylococcal pneumonia, passive immunization with staphylococcal toxoid is carried out.

To restore bronchial patency, bronchodilators and agents that dilute bronchial secretions are used (ingestion of acetylcysteine, ambroxol, bromhexine, hot alkaline drink). Bronchodilators are preferably administered by inhalation: adrenomimetic (fenoterol, salbutamol) and anticholinergic drugs (ipratropium bromide, orally - theophylline).

In cases of prolonged pneumonia, the restoration of bronchial drainage using bronchoscopic sanitation sometimes plays a decisive role.

To restore the body's nonspecific resistance, vitamins A, C, E, group B, biogenic stimulants and adaptogenic agents (aloe, tincture of ginseng and schisandra, liquid extract of Eleutherococcus) are prescribed.

For patients who may have a viral etiology, administration of human immunoglobulin anti-influenza and antiviral drugs (riboverine, ganciclovir, etc.) is recommended. On an outpatient basis, inhalations of phytoncides are used (garlic and/or onion juice, prepared ex temporae, in isotonic sodium chloride solution).

Symptomatic treatment of pneumonia. For a non-productive dry cough, antitussives are prescribed (codeine, prenoxdiazine, glaucine, butamirate + guaifenesin, butamirate, etc.); for difficult sputum discharge - expectorants (thermopsis herb infusion, marshmallow root, etc.) and mucolytic drugs (marshmallow herb extract, ambroxol, acetylcysteine). In case of poor tolerance to high body temperature, antipyretics (metamizole sodium, acetylsalicylic acid) are indicated. Patients with concomitant pathological changes in the cardiovascular system (especially the elderly), as well as in severe cases of the disease, are prescribed injections of camphor, procaine + sulfocamphoric acid.

The presence of shortness of breath and cyanosis is an indication for oxygen therapy. In case of severe intoxication and destruction of the pulmonary infiltrate, detoxification treatment is carried out (intravenous administration of dextran [average molecular weight 30,000-40,000], hemodez* and other solutions).

Intravenous administration of glucocorticoids is recommended for patients with severe pneumonia, severe intoxication and infectious-toxic shock.

Physiotherapeutic impact

When treating patients with pneumonia, distracting procedures are used (cupping, mustard plasters, mustard wraps), which are carried out from the first days of illness at low body temperatures. After a decrease in body temperature, diathermy, inductothermy, microwave, UHF, etc. are prescribed to eliminate inflammatory changes. Resorption of the source of pneumonia is facilitated by chest massage and physical therapy (physical therapy).

Aerosol therapy using bronchodilator mixtures alone or in combination with various antibacterial drugs is used in the resolution stage.

Dispensary observation

Recovery criteria:

Good health and general condition of the patient;

Persistent normalization of body temperature;

Elimination of clinical, laboratory and radiological signs of pneumonia.

Forecast

Pneumonia is one of those diseases that, as a rule, ends in complete recovery. The outcome of pneumonia largely depends on the prevalence of the inflammatory process, the existence or absence of complications, the start date and usefulness of antibiotic therapy, the condition of the body and other reasons.

All patients with a widespread inflammatory process, a prolonged course of pneumonia, impaired functions of external respiration and the immune system, as well as complicated pneumonia should be sent to rehabilitation departments for follow-up treatment and restoration of morphological and functional parameters.

The period of medical examination for patients who have had pneumonia without complications can be 6 months, in all other cases - at least a year.

Prevention

Preventive measures are aimed at carrying out general sanitary and hygienic measures (working hours, combating dust, gas pollution, overheating and hypothermia, ventilation of premises, isolation of sick people, etc.). Personal prevention includes hardening the body, physical education and tourism, good nutrition and sanitation of foci of infection. Timely and correct treatment of acute respiratory diseases and other anti-epidemic measures are of great importance.

Prevention of pneumonia is especially important in patients suffering from chronic pulmonary diseases. They consider it mandatory to carry out influenza vaccination, and, if possible, to immunize with a vaccine to prevent pneumococcal infections.

Strict adherence to the regimen and other doctor’s instructions is necessary for diseases that may be complicated by pneumonia (myocardial infarction, stroke, condition after surgery, etc.).

In 3% of cases, chronicity of the inflammatory process is noted. Chronic pneumonia or chronic pneumonia(CP) is a chronic lesion of the parenchyma and interstitial tissue of the lung, developing at the site of unresolved pneumonia, limited to a segment(s) or lobe(s) and clinically manifested by repeated outbreaks of the inflammatory process in the affected part of the lung. The morphological substrate of CP is pneumosclerosis and (or) carnification of the lung tissue, as well as irreversible changes in the bronchial tree such as local bronchitis, often with deformation and the development of bronchiectasis in the future. Due to the widespread and successful use of antibacterial drugs for the treatment of infectious processes of the lower respiratory tract, CP is currently rarely recorded.

The existence of CP is not recognized by all researchers, but it is identified by pathologists and a number of clinical doctors (Putov N.V., Silvestrov V.P.).

Classification. Currently, there is no classification of CP that would satisfy all the requirements. The classification of CP officially adopted in 1972 led to overdiagnosis of this disease and practically replaced all other forms of so-called chronic respiratory diseases of the lungs, in particular chronic bronchitis, bronchiectasis and chronic obstructive pulmonary disease.

Currently, the main criterion for the transition of protracted pneumonia to chronic pneumonia - the duration of the disease is 8 weeks - has been rejected (Silvestrov V.P., 1974). Only the absence of positive x-ray dynamics, despite long-term and intensive treatment, and most importantly, the existence of repeated outbreaks of the inflammatory process in the same area of ​​the lung, allows us to talk about the transition of prolonged pneumonia into a chronic form.

Etiology. CP is an inflammatory disease of infectious origin, so its etiology corresponds to that of pneumonia. Although there is no microorganism that causes the chronic course of pneumonia, varying degrees of importance of various pathogens in the transition of an acute inflammatory process to a chronic one have been proven.

Most often, the causative agents of the inflammatory process in CP are associations of nonbacterial (viruses, mycoplasmas) and bacterial (mainly pneumococci and Haemophilus influenzae) agents.

The role of viral infection is especially great in the transition of an acute inflammatory process to a chronic one.

Pneumonia, in the occurrence of which viruses play a leading role, leading to destructive processes, ends with the formation of fibrotic changes in the lungs.

The influenza virus damages the bronchial wall with the development of drainage and ventilation disorders, causes inflammatory changes in the interstitial tissue, which are relatively persistent and prone to slow reverse development.

The influenza virus is a conductor of autoinfection, creating a favorable background for the manifestation of the pathogenic properties of diverse opportunistic and saprophytic microflora.

A possible reason for the chronicity of the process is a defect in the development of lung tissue in the zone of acute inflammation, which contributes to the relapse of the inflammatory process, and colonization of the pathogen.

Pathogenesis. The immediate causes that determine the transition of an acute inflammatory process to a chronic one have not been sufficiently studied. The following facts are considered undoubted.

In the occurrence of repeated outbreaks of infection in a previously affected area of ​​the lung, remaining changes play a role, causing local disruption of the drainage function of the bronchi. In some cases, the determining factor in the pathogenesis of CP is concomitant chronic bronchitis, which greatly complicates the drainage and aeration function of the bronchi in the zone of acute inflammation.

A focal infection present in the patient’s body can serve as a constant source of autoinfection and sensitization of the body, expressed in the increased sensitivity of the bronchopulmonary system to various microorganisms, viruses and their metabolic products.

The prerequisites for the formation of CP are all conditions (intoxication, including viral intoxication, alcohol, smoking, hypothermia, fatigue, old age, etc.) that suppress general reactivity and contribute to changes in the immune status of the body and local immunity of the bronchopulmonary system. These changes are expressed in a decrease in the activity of alveolar macrophages and leukocytes, weakening of phagocytosis, deficiency of secretory IgA and a decrease in the concentration of bacteriolysins.

In CP, the development of autoimmune processes has been noted. Antipulmonary antibodies have pulmonary cytotoxic properties, which results in inflammation of the interstitial tissue.

As a result of the influence of all these factors, the inflammatory process in pneumonia (Fig. 1-2) is not completely eliminated. Areas of carnification remain, which subsequently serve as a site for recurrence of the inflammatory process.

The process is not limited to the lung parenchyma, but moves to the interstitial tissue, bronchi and blood vessels. In connection with this, the morphological substrate of CP is considered to be an inflammatory sclerotic process (pneumosclerosis), leading to a decrease in the volume of the affected part of the lung and its cicatricial wrinkling. In areas of the bronchial tree corresponding to the affected area, the phenomena of local bronchitis develop, which in the future can acquire a deforming character with the subsequent development of bronchiectasis.

The process never becomes diffuse, therefore the severity of functional disorders of the respiratory and circulatory system in the pulmonary circulation is insignificant. In this regard, the development of respiratory (pulmonary) failure and cor pulmonale, even with extensive foci of CP, is rarely recorded.

Rice. 1-2.

Clinical picture. The following main syndromes are characteristic of CP:

Inflammatory infiltration;

Local pneumosclerosis.

Broncho-obstructive syndrome and respiratory failure syndrome are optional signs that can occur at different stages of the disease.

There are three degrees of activity of the inflammatory process:

I degree - minimal signs;

II degree - moderate signs of exacerbation;

III degree - clinical, radiological and laboratory indicators of exacerbation are clearly expressed.

Depending on the predominance of a particular syndrome, CP occurs in two main forms - interstitial and bronchiectasis.

The interstitial form of CP is characterized by a predominance of changes in the form of focal pneumosclerosis (N.V. Putov, 1984). This is the most common form of CP. In the bronchiectasis form, along with focal pneumosclerosis, there are also bronchiectasis (CP with bronchiectasis). This form is not recognized by all doctors (N.R. Paleev, 1985).

N.V. Putov, in addition to the interstitial one, also identifies a carnifying form of CP (with a predominance of carnification of the alveoli). With this form of CP, patients, as a rule, do not complain, and radiographically there may be intense, fairly clearly defined shadows, which must be differentiated from signs of a peripheral tumor.

Interstitial form of chronic pneumonia. At the first stage of the diagnostic search The following complaints can be found:

Cough, in the vast majority of cases - with the release of a small amount of sputum, sometimes - hemoptysis;

Chest pain on the affected side;

Shortness of breath on exertion;

Increased body temperature;

Phenomena of asthenia (weakness, headache, sweating, loss of appetite and body weight).

Complaints are most vivid and numerous with severe exacerbation. The amount of sputum increases, it becomes purulent. After the addition of broncho-obstructive syndrome, along with the productive one, a persistent paroxysmal cough with difficult sputum production occurs.

In CP without bronchiectasis, the occurrence of hemoptysis always indicates the activity of the process and, as a rule, is slightly expressed. Hemoptysis is usually noted in the bronchiectasis form of CP, since it is one of the generally recognized symptoms of bronchiectasis.

In case of exacerbation of the process, chest pain often occurs or intensifies on the side of the inflammatory process: a constant feeling of heaviness (most often at the angle of the scapula) is disturbing. A nagging stabbing pain may intensify with breathing (involvement of the pleura in the process). Body temperature is often subfebrile, rarely febrile. An exacerbation is accompanied by sudden sweating, severe weakness and loss of appetite.

In the remission stage, complaints are few. The most common symptom is a cough with scanty mucopurulent sputum.

On first stage of diagnostic search It is considered important to establish a correct diagnosis to detect a connection between these complaints and previously suffered pneumonia (often a protracted course), untimely initiation and insufficiently complete treatment. In the absence of clear indications of the previous disease, it is necessary to establish whether there have been previously frequently recurring acute respiratory diseases. Repeated inflammation of the same area of ​​lung tissue can be noted.

In the anamnesis of patients with CP there are no indications of pneumoconiosis, tuberculosis, sarcoidosis and other diseases accompanied by similar clinical signs (their existence in the anamnesis requires a revision of the diagnostic concept).

On the second stage of the diagnostic search it is necessary to determine the syndromes of local pneumosclerosis and inflammatory infiltration, which can be characterized by the following clinical symptoms:

Delay in breathing and (or) retraction of the affected side of the chest (pronounced with significant involvement of lung tissue in the process);

Dullness or shortening of percussion sound;

Moist, ringing, fine-bubble rales over the lesion, caused by local focal pneumosclerosis.

If the pleura is involved in the process, then a pleural friction noise is heard. With broncho-obstructive syndrome, prolongation of exhalation and dry wheezing are noted. The latter also occur when an asthmatic (allergic) component is added to CP, the development of which is one of the main and serious complications of the disease at present. The development of respiratory failure is accompanied by shortness of breath at rest, cyanosis and tachycardia. Outside of exacerbation of CP, clinical signs are scarce: moist, silent, fine-bubble rales are heard in a limited area.

On third stage of diagnostic search perform instrumental and laboratory studies that allow:

Make a final diagnosis of CP based on radiological signs of local (segmental or lobar) pneumosclerosis, endoscopic signs of local bronchitis, and exclusion of diseases with a similar clinical picture;

Determine the degree of activity of the inflammatory process;

Determine and (or) clarify the severity of complications.

X-ray examination is of decisive importance in the diagnosis of CP and its exacerbations. With a pronounced exacerbation of the process, inflammation of the infiltrative and (or) peribronchial type is noted. The infiltrative type is characterized by focal darkening against the background of variously expressed interstitial changes (pneumosclerosis) and adhesive pleurisy (interlobar, paramediastinal adhesions, fusion of the costophrenic sinuses). The peribronchial type is characterized by changes around the segmental bronchi in the form of concentric couplings or cords parallel to the bronchus in combination with signs of focal pneumosclerosis (heaviness and deformation of the pulmonary pattern, a decrease in the volume of the affected area of ​​the lung). There is no characteristic localization of the inflammatory process in CP.

Since the clinical picture is similar to CP in the chronic focal form of pulmonary tuberculosis, chronic abscess and bronchogenic tumors, radiological methods become crucial for differential diagnosis. X-ray examination in combination with data from the first and second stages of the diagnostic search also makes it possible to exclude thoracic sarcoidosis and Hamman-Rich syndrome. The results are of decisive importance in carrying out differential diagnosis

MSCT.

Bronchography is performed before surgery to clarify the nature and extent of bronchial damage.

Bronchoscopic examination data significantly helps:

In establishing the final diagnosis of CP, since local purulent or catarrhal endobronchitis is a bronchoscopic marker of the disease;

In the exclusion (detection) of bronchogenic cancer, manifesting a clinical picture similar to CP;

In assessing the degree of activity of the inflammatory process (by the severity of hyperemia and swelling of the mucous membrane, the nature and amount of secretion in the bronchi).

All patients with CP undergo a study of external respiratory function (spirometry). Its results help to detect and assess the severity of broncho-obstructive syndrome and respiratory failure. In uncomplicated CP, restrictive disorders are usually identified.

The detection of a large number of neutrophils during sputum microscopy indicates the activity of the inflammatory process: the detection of eosinophils is characteristic of the development of an allergic (asthmatic) component, complicating the course of CP; determination of Mycobacterium tuberculosis and elastic fibers forces us to reconsider the previously assumed diagnosis of CP.

Bacteriological examination of sputum helps determine the type of microflora. A high concentration of microorganisms (more than 10 6 in 1 μl) reliably indicates its pathogenicity. When sputum is cultured, the sensitivity of microflora to antibiotics is also determined.

The role of clinical and biochemical blood tests in assessing the activity of the inflammatory process is insignificant. The results obtained do not sufficiently reflect the degree of inflammation. Changes in acute-phase indicators (increased ESR, leukocytosis with a shift in the leukocyte formula to the left, increased fibrinogen content, β-2-globulins, CRP) are noted only with severe inflammation. If the process is less active, all of these indicators may be normal. Exacerbation of the pathological process in these cases is diagnosed based on a combination of clinical picture data, the results of X-ray examination and bronchoscopy, as well as sputum analysis.

Bronchiectasis form of chronic pneumonia. This form is distinguished based on a number of features of the clinical picture.

On first stage of diagnostic search A number of diagnostic clinical signs are noted.

The originality of complaints and the degree of their severity:

A large amount of sputum secreted (up to 200 ml per day), coming out “full of mouth” and sometimes acquiring a putrefactive character (hemoptysis is often noted);

When sputum production is delayed, the body temperature becomes febrile;

Patients are concerned about severe weight loss (carcinophobia often develops), lack of appetite and significant severity of symptoms of intoxication.

The active inflammatory process occurs continuously or with frequent exacerbations. This is explained by a more dramatic severity of morphological changes in the focus of chronic inflammation with a significant disruption of the drainage function of the regional bronchi, as well as more pronounced disturbances in general and immunological reactivity.

Less effective conservative therapy.

On the second stage of the diagnostic search a typical clinical picture is observed.

Distinct severity of clinical symptoms: loss of body weight, change in the shape of nails (they take on the appearance of watch glasses) and deformation of fingers like drumsticks. Physical changes detected during examination of the respiratory organs are also more pronounced and persistent. You can listen to not only small but also medium bubble rales. During percussion, it is possible to determine local shortening of the percussion sound.

Complications are detected: pulmonary hemorrhage, spontaneous pneumothorax, signs of cor pulmonale.

On third stage of diagnostic search The most important information for diagnosis is provided by x-ray examination of patients.

Plain radiographs show gross focal deformation of the pulmonary pattern and cystic clearings. A volumetric decrease in a lobe or segment of the lung is possible with a shift of the mediastinum towards the lesion.

CT scan can identify areas of carnification, thin-walled cavities and cylindrical expansion of the draining bronchus.

Bronchograms reveal pathological changes in the regional bronchi, specify the segmental localization of the process and the type of bronchiectasis (cylindrical, fusiform, saccular).

Complications of HP:

Broncho-obstructive syndrome;

Respiratory failure;

Chronic cor pulmonale;

Formation of an allergic (asthmatic) component;

Pulmonary hemorrhage;

Spontaneous pneumothorax.

Diagnostics. When establishing a diagnosis of CP, the following are taken into account:

A clear connection between the onset of the disease and previous pneumonia (less often with acute respiratory infection, including influenza);

Repeated inflammation of the same area of ​​lung tissue within one segment or lobe of the lung (focal nature of the pulmonary process), physical signs of focal inflammation and pneumosclerosis (depending on the phase of the process) and nonspecific signs of inflammation (according to laboratory research methods);

X-ray (including CT) signs of focal pneumosclerosis, the existence of deforming bronchitis, pleural adhesions and local bronchiectasis;

Bronchoscopic picture of local purulent or catarrhal bronchitis;

The absence of other chronic respiratory diseases of the lungs, as well as tuberculosis, pneumoconiosis, sarcoidosis, Hamman-Rich syndrome, which determine the long-term existence of pulmonary tissue compaction syndrome, as well as the development of bronchiectasis.

When formulating a diagnosis of “chronic pneumonia”, you should reflect:

Clinical and morphological form of pneumonia (interstitial CP or CP with bronchiectasis);

Localization of the process (shares and segments);

The phase of the process (exacerbation, remission), while during exacerbation the degree of activity of the process is indicated;

Complications.

Treatment. In the acute phase, treatment includes:

Measures aimed at eliminating the exacerbation of the inflammatory process (antibacterial therapy);

Pathogenetic therapy (restoration of bronchial patency; prescription of drugs that increase the body's resistance);

Treatment of complications.

In principle, the treatment corresponds to that for AP, but has some peculiarities.

When carrying out antibacterial therapy, the characteristics of the pathogen should be taken into account. The course of antibiotic treatment for CP is lengthened, and preference is given to the parenteral route of administration.

With the development of bronchiectasis, it is advisable to administer antibiotics locally through a bronchoscope after sanitizing the bronchi and washing them with hydroxymethylquinoxaline dioxide. If necessary (pronounced general signs of inflammation, high degree of activity of purulent endobronchitis), the same drugs are additionally administered parenterally.

The use of this method of drug delivery through a nebulizer opens up the possibility of inhalation therapy using a combination of the antibiotic thiamphenicol glycinate acetylcysteinate at a dose of 250 mg with the mucolytic ambroxol.

In case of severe relapse caused by staphylococcus, Pseudomonas aeruginosa and other pathogens, passive specific immunotherapy with hyperimmune plasma and γ-globulin should be performed.

During exacerbation of the disease and during the recovery stage, the use of immunomodulatory drugs is recommended: thymus extract, azoximer bromide, glucosaminyl muramyl dipeptide. Oral and parenteral administration of vitamin preparations and a complete diet rich in proteins and vitamins are necessary. In cases of weight loss and prolonged intoxication, anabolic steroids are prescribed (intramuscular administration of nandronol 2 ml once a week).

An important part of treatment is carrying out measures aimed at restoring or improving bronchial patency.

To improve the drainage function of the bronchi, expectorants and mucolytics are prescribed, sanitary bronchoscopy is performed, postural drainage and special exercises are used in a complex of breathing exercises.

In order to eliminate bronchospasm, long-acting theophylline preparations and inhaled bronchodilators (β2-agonists and m-anticholinergics or their combination - berodual) are prescribed. If the effect of therapeutic measures is insufficient, complex treatment includes intra-

tracheal administration of hydrocortisone at a dose of 25 mg and other glucocorticoids. For the asthmatic component, treatment is supplemented with the prescription of inhaled glucocorticoid drugs in the form of metered-dose inhalers.

In the phase of subsiding exacerbation It is recommended to take anti-inflammatory drugs (meloxicam, fenspiride) and biogenic stimulants (aloe, Chinese lemongrass, etc.). The use of antibiotics for active endobronchitis is limited to local administration (through a bronchoscope, inhalation). During this period, breathing exercises, chest massage and physiotherapeutic procedures (UHF therapy, diathermy, inductothermy, electrophoresis of calcium chloride, potassium iodide, etc.) become important.

Treatment of CP in remission involves a set of measures aimed at preventing exacerbation, i.e. secondary prevention measures. The patient should stop smoking and constantly practice breathing exercises. He needs rational employment, sanatorium treatment and observation in the pulmonology office of the clinic. A course of treatment with weakened vaccines is recommended: bronchomunal, ribomunil and bronchovaxone.

Forecast. In most cases, the prognosis is favorable for life, but patients require long-term follow-up and periodic treatment.

Prevention. The main preventive measures are prevention, early diagnosis, timely and rational treatment of pneumonia.

BRONCHIECTATIS DISEASE AND BRONCHIECTASIS

Bronchiectasis is an acquired (in some cases congenital) disease characterized by a chronic purulent process in irreversibly changed (dilated, deformed) and functionally defective bronchi, mainly in the lower parts of the lungs.

The main morphological substrate of the pathological process is primary bronchiectasis, which causes the appearance of a characteristic symptom complex. Essentially, they cannot be considered primary, since they usually develop as a result of infectious diseases of the bronchopulmonary system suffered in childhood, mainly of viral etiology, but their formation most likely requires the existence of a congenital defect of the bronchial wall.

At the same time, with primary bronchiectasis there are usually signs that make it possible to distinguish an independent nosological form - bronchiectasis. With it, there is no significant involvement of the lung tissue in the pathological process, and exacerbations of the disease occur mainly as an exacerbation of purulent bronchitis without infiltration of the lung parenchyma.

There are also secondary bronchiectasis that occurs as a complication or symptom of another disease, including chronic pneumonia and chronic deforming bronchitis. In secondary bronchiectasis, pronounced changes in the respiratory system are detected.

la, corresponding to the localization of bronchiectasis, which qualitatively distinguishes them from primary bronchiectasis (Putov N.V., 1978; Paleev N.R., 1985). In addition to the above diseases, there are many more reasons that contribute to the development of bronchiectasis (bronchiectasis) in adults. The reasons for the formation of secondary bronchiectasis are listed below (Shoikhet Ya.N., 2007).

Post-infectious (abscess pneumonia, tuberculosis, adenovirus infection and other infectious diseases of the respiratory tract).

Obstructive (foreign bodies, tumors, external compression of the airways).

Inhalation injury (inhalation of toxins, irritating gases, vapors and smoke, including thermal injury).

Aspiration (gastroesophageal reflux, aspiration pneumonia, medical procedures).

Genetically determined bronchiectasis (cystic fibrosis, ciliary dyskinesia syndrome, Ewing syndrome).

Congenital anomalies - dysplasia (agenesis, hypoplasia, sequestration, shunts, etc.).

Deficiency or abnormality of α 1 -antitrypsin.

Primary immune disorders (humoral defects, cellular or mixed disorders, neutrophil dysfunction).

Chronic diffuse lung diseases of known or unclear etiology (idiopathic pulmonary fibrosis, sarcoidosis, etc.).

Idiopathic inflammatory disorders (ankylosing spondylitis, inflammatory bowel disease, relapsing polychondritis).

Other causes (allergic bronchopulmonary aspergillosis or mycosis, HIV infection, AIDS, yellow nail syndrome, radiation injuries).

According to the mechanisms of occurrence, secondary bronchiectasis is divided into obstructive, destructive, traction, and also iatrogenic (after radiation treatment and aggressive antibiotic therapy).

Secondary bronchiectasis is not classified as bronchiectasis; it is a symptom of other underlying diseases.

The independence of bronchiectasis as a separate nosological form has been disputed to this day (Uglov F.G., 1977). This discussion is of practical importance: establishing a diagnosis of “chronic pneumonia” in patients with bronchiectasis often reassures both the doctor and the patient, as a result of which a surgeon’s consultation and bronchological examination are not carried out in a timely manner and the optimal timing for the operation is missed.

Since the 1970s, a decrease in the incidence of bronchiectasis has been noted. This can be explained by a pronounced decrease in the number of childhood infectious diseases (whooping cough, measles) and childhood tuberculosis, as well as by the success of drug treatment. At the same time, the prevalence of secondary bronchiectasis did not decrease.

Etiology

The causes of bronchiectasis cannot be considered sufficiently clear to date. Probably, the decisive role is played by the combination of the influence of the pathogen and the genetic inferiority of the bronchial tree.

A significant role in the formation of bronchiectasis is played by genetically determined inferiority of the bronchial tree, leading to disruption of the mechanical properties of the bronchial walls when they become infected (especially in early childhood).

Microorganisms that cause acute respiratory diseases (pneumonia, measles, whooping cough, etc.) in children can only conditionally be considered an etiological factor, since in the vast majority of patients they are completely cured.

There is a connection between the development of bronchiectasis and diseases of the upper respiratory tract:

Perhaps the insufficiency of the same protective mechanisms of the respiratory tract is important in their pathogenesis;

There is constant mutual infection of the upper and lower respiratory tract.

Infectious pathogens that cause a purulent process in already changed bronchi (pneumococcus, staphylococcus, Haemophilus influenzae, etc.) can be considered as a cause of exacerbations, but not the development of bronchiectasis.

The occurrence of bronchiectasis can be caused by weakness of the bronchial wall with congenital tracheobronchomegaly (Mounier-Kuhn syndrome), the absence of cartilaginous rings (Williams-Campbell syndrome) and relapsing polychondritis.

Pathogenesis

The most important role in the pathogenesis of bronchiectasis belongs to bronchiectasis and its suppuration.

The development of bronchiectasis is caused by obstructive atelectasis that occurs when bronchial obstruction occurs. Its occurrence may be facilitated by a decrease in surfactant activity (congenital or acquired, caused by local inflammatory processes). In children, the causes of obstruction of the patency of large bronchi (and, thus, the formation of atelectasis) may be:

Compression of pliable and possibly congenitally defective bronchi by hyperplastic hilar lymph nodes (their hyperplasia is found in hilar pneumonia and tuberculous bronchoadenitis);

Long-term blockage of the bronchi with a dense mucus plug in acute respiratory infections.

Decreased (congenital or acquired) resistance of the bronchial walls to the action of bronchodilating forces (increased intrabronchial pressure when coughing, stretching of the bronchi with accumulating secretions, increased

negative intrapleural pressure due to a decrease in the volume of the atelectatic part of the lung) contributes to a persistent expansion of the lumen of the bronchi.

Dilatation of the bronchi and retention of bronchial secretions lead to the development of inflammation. As it progresses, irreversible changes occur in the walls of the bronchi (restructuring of the mucous membrane with complete or partial death of the ciliated epithelium and disruption of the cleansing function of the bronchi, degeneration of cartilaginous plates and smooth muscle tissue with their replacement by fibrous tissue, decreased stability and ability to perform basic functions) and develop bronchiectasis.

Bronchiectasis causes disruption of the coughing mechanism, stagnation and infection of secretions in the dilated bronchi, as well as the development of a chronically ongoing, periodically aggravated purulent process, which serves as the second most important factor in the pathogenesis of bronchiectasis. The essence of bronchiectasis is suppuration of formed bronchiectasis.

The altered secretion usually accumulates in the lower sections of the bronchial tree (freely flows from the upper sections under the influence of gravity). This explains the predominantly lower lobe localization of the pathological process.

Classification

Depending on the nature of the expansion of the bronchi, cylindrical, saccular, fusiform and mixed bronchiectasis are distinguished.

Based on the prevalence of the process, it is advisable to distinguish between unilateral and bilateral bronchiectasis (indicating the exact localization by segment).

According to the clinical course of V.F. Zelenin and E.M. Gelshtein (1952) distinguishes three stages of bronchiectasis: bronchitis (I), severe clinical symptoms (II) and the stage of complications (III).

Clinical painting

The symptoms of bronchiectasis are extremely similar to those of the bronchiectasis form of CP and secondary bronchiectasis of other etiologies. It is necessary to highlight only a number of features of bronchiectasis at each stage of the examination.

On first stage of diagnostic search pay attention to the occurrence of cough with sputum after childhood pneumonia, measles, whooping cough or severe influenza and frequent recurrent pneumonia throughout the subsequent period of life.

On the second stage of the diagnostic search Almost always (even during the period of remission), auscultation of the lungs reveals persistent foci of moist, ringing, fine-bubble rales.

Complications of bronchiectasis are often recorded:

Hemoptysis;

Asthmatic component;

Focal (perifocal) pneumonia;

Lung abscess;

Pleurisy (pleural empyema);

Amyloidosis of the kidneys, less often - of the spleen and liver (given the effective treatment of the underlying disease, amyloidosis currently develops extremely rarely and in the later stages of the disease);

Secondary chronic bronchitis.

Secondary chronic bronchitis is usually the most common and progressive complication. It leads to the development of respiratory and pulmonary-cardiac failure and is often the direct cause of death in patients. The latter can also be pulmonary hemorrhage or chronic renal failure resulting from secondary renal amyloidosis.

When analyzing radiographic data on third stage of diagnostic search it is necessary to take into account that most often the basal segments of the left lung and the middle lobe of the right lung are affected.

In addition to the previously described (see “Bronchiectasis form of chronic pneumonia”) methods of laboratory and instrumental diagnostics, in some cases additional research is required.

Serial angiopulmonography helps to determine anatomical changes in the vessels of the lungs and detect hemodynamic disturbances in the pulmonary circulation in various forms of bronchiectasis.

Bronchial arteriography makes it possible to detect blood shunting through pathologically dilated bronchial-pulmonary anastomoses.

Lung scanning helps to identify severe capillary blood flow disturbances in bronchiectasis.

All these research methods are carried out according to indications in the preoperative period, as they help to accurately determine the scope of the operation.

Diagnostics

The diagnosis of bronchiectasis is made when certain signs are detected:

Clear indications of the onset of cough with sputum in childhood after an acute respiratory illness;

Frequent outbreaks of pneumonia of the same localization;

Detection of persistently persistent foci of moist rales during physical examination during the period of remission of the disease;

X-ray signs of gross deformation of the pulmonary pattern, usually in the area of ​​the lower segments or middle lobe of the right lung, CT and bronchographic signs of bronchiectasis.

The formulation of a detailed clinical diagnosis includes:

Name of the disease (bronchiectasis);

Localization of the process (indicating the affected segments);

Process stage;

Phase of the course (exacerbation or remission);

Complications.

With secondary bronchiectasis, the formulation of the diagnosis begins with an indication of the underlying disease that led to its development.

Treatment

Conservative and surgical treatment is possible. Conservative treatment is recommended for patients:

With minor or clinically mild changes in the bronchi;

With a widespread and insufficiently clearly localized process (when surgical treatment is impossible);

In preparation for bronchography and radical surgery.

The main link of conservative treatment is sanitation of the bronchial tree, carried out through:

Impact on pyogenic microflora (through a bronchoscope, inhalation method of administering antibacterial drugs);

Elimination of purulent bronchial contents and sputum (breathing exercises, chest massage, postural and bronchoscopic drainage, use of mucolytic agents).

For more information about drug treatment, see the Pneumonia section. It is necessary to sanitize the upper respiratory tract, carry out general strengthening measures and provide adequate nutrition.

Surgical treatment is best performed at a young age. Persons over the age of 45 with bronchiectasis are operated on less frequently, since by this period of life they already have complications that prevent the operation. Resection of a lung lobe or individual segments is performed for unilateral bronchiectasis. For bilateral bronchiectasis, the most affected part of the lung (on one side) is removed.

Forecast

The outcome of the disease depends on the extent of the process and the existence of complications. Moderate damage, subject to systematic treatment, provides a long period of compensation and preservation of working capacity.

Prevention

Primary prevention of the disease consists of proper treatment of pneumonia (especially in childhood), which often develops against the background of infectious diseases (measles, whooping cough, influenza). Secondary prevention consists of maintaining a healthy lifestyle, treating intercurrent infectious diseases and combating focal infections of the upper respiratory tract.

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Pneumonia, due to its prevalence and increasing incidence, can be considered one of the most important problems in global and domestic medicine. To a certain extent, this trend is explained by the spread of diseases that affect the human immune system (alcoholism, hepatitis, diabetes, HIV), as well as self-medication undertaken by patients, causing resistance to antibiotics in pneumonia pathogens.

Due to the fact that when diagnosing pneumonia one cannot rely on characteristic clinical signs, since all symptoms and complaints often indicate a whole range of pathological processes in the lungs, radiography can be considered the reference method of research. Difficulties in diagnosis can be caused by a wide variety of signs of the course of the disease, in which pneumonia on x-ray can become a determining factor when choosing treatment tactics.

Causes of pneumonia

Pneumonia is an inflammatory disease accompanied by damage to all structures of the lower respiratory tract (interstitial tissue of the lungs, alveoli, bronchioles) and a characteristic darkening on the x-ray. Pathological processes occurring in the pulmonary structures often do not allow one to draw a clear clinical picture of the course of the disease, since pneumonia is not always an “independent disease.”

In half of the cases, it develops as a complication of pathologies such as:

• immunodeficiency;
• congestive heart failure;
• Chronical bronchitis.

The morphological cause of the long course of the disease can be considered a violation of regenerative functions in the area of ​​inflammation, leading to the formation of foci of fibrosis and the release of intraalveolar exudate. In this case, there is a disturbance in the blood supply to the lung tissue, accompanied by the formation of blood clots, air microembolism and general intoxication of the body caused by the release of toxic substances by pathogenic microorganisms.

Important! The anatomical features of the structure of the respiratory organs in children (narrow larynx and trachea, undeveloped bronchi) and constant stay in a horizontal position (in newborns) contribute to the difficulty of removing sputum, which can lead to the development of destructive pneumonia (purulent) and respiratory failure.

The anatomical structure of the lung explains the difference in the localization of the inflammatory process

Radiological evaluation criteria

X-ray manifestations of pneumonia are extremely varied, however, as with any other pathologies of the lungs, they are based on 4 signs: changes in the pulmonary pattern and roots of the lungs, darkening or clearing that forms against the background of the pulmonary field. The causes of darkening are mainly the formation of exudate or purulent contents in the alveoli.

Clearing is a consequence of the formation of an air cavity. Deviations in the structure of the pulmonary pattern indicate damage to the interstitial tissue, accompanied by impaired blood flow. A change in the image of the roots of the lungs indicates damage to the bronchi, lymph nodes, and vascular system.

On an x-ray indicating the presence of pneumonia, the following signs can be observed:

• complete loss of transparency of the lung tissue (total darkening of the lung field);
• darkening of one or more lobes of the lung (subtotal darkening);
• darkening located within one segment of the lung (limited darkening).

However, all these evaluation criteria, with equal probability, may indicate a whole group of lung diseases (pulmonary infarction, malignant neoplasm, pleurisy, tuberculosis, atelectasis). In this regard, x-rays for pneumonia should be performed repeatedly for diagnostic purposes, and in accordance with the stages of the disease, which will allow monitoring dynamic changes in the condition of the lungs in accordance with the stages of the spread of pathology and assessing the body’s response to the therapy.

Important! Although x-ray is the leading diagnostic method used to detect pneumonia, many specific processes can only be detected using computed tomography.

Stages of pneumonia in the picture

Pathological changes in the lungs during pneumonia correspond to 4 stages, characterizing the body's response to the presence of the pathogen and the degree of tissue damage.

Tide stage

The duration of this stage is 12-72 hours and is characterized by an intense rush of blood to the vascular system of the lungs, a decrease in their functional activity and the formation of alveolar exudate. On an x-ray, you can see an increase in the intensity and clarity of the pulmonary pattern, a slight darkening of the pulmonary fields in the area of ​​localization of pathological changes and an increase in the area of ​​the lung root with a simultaneous loss of its structure. A photo of the chest, at the first stage of the disease, due to increased blood supply, resembles a lattice (honeycomb lung).

Red liver stage

The duration can take from 24 to 72 hours. At this time, there is a thickening of the interstitial tissue, which begins to resemble the liver in structure. A certain amount of blood (erythrocytes) appears in the exudate. The X-ray picture has only minor differences from stage 1, expressed in a decrease in the severity of the pulmonary pattern with its simultaneous enlargement and increased darkening of the pulmonary fields (the “ground glass” effect). Determining the stage of the disease in the initial stages of development can only be done by comparing images taken at intervals of 1–2 days.

Pneumonia in the red hepatic stage with a pronounced “honeycomb lung” effect

Gray hepatization stage

The duration of this stage can be from 2 to 6 days. This time period is characterized by the appearance of purulent contents in the exudate. When performing radiography, a significant darkening of the fields is noted, against which the bronchi not affected by the pathological process appear as stripes of clearing. Free fluid is clearly visualized when taking pictures with the patient lying on the affected side. In this case, the exudate is redistributed, forming a horizontal darkening in the form of a stripe.

Resolution stage

During this period, regeneration processes prevail over destruction processes, which leads to the restoration of damaged lung tissue. X-ray signs of recovery can be considered a decrease in the intensity or area of ​​darkening, a change in the pulmonary pattern at the site of the lesion (the disappearance of large elements and the formation of small ones).

The root of the lung remains expanded for several months. A characteristic radiological sign after pneumonia may be scar formations in the form of shadows stretched along the wall of the lung. There is also no horizontal shadowing, reflecting free fluid in the cavity. Classic radiological signs of pneumonia may have a less pronounced manifestation in different types of disease (lobar, focal or segmental pneumonia).

Atypical forms of pneumonia

In addition to generally recognized radiographic signs, pneumonia may also have uncharacteristic manifestations caused by atypical etiological factors that provoke the development of pathology.

Caseous pneumonia

Caseous pneumonia (CP) is a pathological condition that is either a complication of tuberculosis or an independent disease that develops against the background of immunodeficiency or malnutrition. The characteristic manifestations of KP are not the release of exudate as a reaction to the inflammatory process, but the formation of necrotic zones.

In this case, the process of necrosis is accompanied by the melting of lung tissue, the formation of curdled masses (caseinification) and the formation of cavities (one large or several small ones). KP can be determined on x-ray by the characteristic displacement of organs located in the chest (mediastinal organs) towards the affected lung. Also, due to insufficient ventilation of the lung, an upward displacement of the dome of the diaphragm and a decrease in the intercostal distance are observed.

Cavities, more than 3 cm in diameter, are defined on x-ray as round or semicircular formations in the wall of the lung with a darkened outline and clearing in the center. Small cavities form a picture of destructive damage to the lung tissue. As a rule, the lesion is observed in both lungs in the form of extensive and severe opacification of the upper parts of the lungs and cavernous focal lesions of the lower lobes.

Important! Recovery from CP with drug therapy is almost impossible. Cure can only be achieved after surgery performed to remove necrotic areas.

A large cavity in the upper lobe of the lung, which is a sign of an atypical form of the inflammatory process

Pneumocystis pneumonia

Pneumocystis pneumonia (PP) is a fungal disease transmitted similarly to a respiratory infection. In the vast majority of cases, the disease is characterized by a latent course, not accompanied by any manifestations of the disease. However, in people with immunodeficiency, PP occurs in a severe form, accompanied by severe respiratory failure. On a radiograph, PP appears as a bilateral, symmetrically located lung lesion, expressed in the loss of transparency of the hilar regions.

In this case, the opacities have a cloud-like shape and, due to their symmetry, are called “butterfly wings”. A lung affected by PP appears on an x-ray as a piece of cotton wool. In some cases, infiltrates characteristic of tuberculous lesions and located in the upper lobe of the lung are visible. Another common sign of PP on x-ray is areas of clearing that occur as a result of the development of pneumothorax. For a long time, PP served as an indicator to identify patients with AIDS.

Atypical pneumonia

The concept of “atypical pneumonia (AP)” includes several types of pneumonia caused by the following diseases:

• mycoplasmosis
• chlamydia;
• legionellosis.

An X-ray image of mycoplasma pneumonia (MP) in the initial stages of development has some similarities with the classical development of the disease. As a rule, there is an increase in the intensity of the pulmonary pattern and darkening in areas of parenchymal infiltration. Darkening can occupy one lobe of the lung, or its entire surface. In 20% of cases, darkening can be focal in nature and be multiple or single. However, the intensity of the darkening may be so insignificant that when performing an x-ray on old equipment, the image may not show any abnormalities.

Increased pulmonary pattern and darkening of the lower lobe of the lung in MP

Chlamydial pneumonia (CP) has extremely diverse radiological signs, expressed in the appearance of a “ground glass” effect on images, characterizing interstitial damage to lung tissue or darkening of one lobe, characterizing the formation of an infiltrate. Band-like shading, indicating the presence of pleural effusion, is usually slight or absent.

Legionella pneumonia (LP) is characterized by focal shadows, which, when repeated images are taken at intervals of several days, show progression and merge into one continuous shadow. The appearance of free fluid in the form of a strip of horizontal darkening is observed in only a third of patients. In places where infiltrates are close to the pleura, the darkening is so intense that it may resemble a pulmonary infarction.

Important! A distinctive feature of AP is the lack of therapeutic effect from the use of penicillin antibiotics and cephalosporins.

When diagnosing AP, regardless of the result shown by the x-ray, it is advisable to resort to examination using computed tomography. This technique allows you to obtain photo and video images made in various modes and avoid the appearance of areas hidden for viewing.

As a rule, radiography for pneumonia can provide sufficient information to make a diagnosis. To a certain extent, this is due to the fact that at the time of visiting a doctor, the patient has a detailed picture of the pathological process. However, early diagnosis of pneumonia remains the main problem, the solution of which will significantly reduce the duration of the disease and reduce the percentage of deaths.