Inflammation of the lungs( pneumonia) symptoms

Inflammation of the lungs is called a variety of diseases under the general name pneumonia .All respiratory system infections rank first among all human infectious diseases. Although usually inflammation of the lungs is caused by an infectious microorganism, it can also be associated with inhalation of irritating gases or particles. The lungs have a complex defense system: strong branching and constriction of the bronchial passages make it difficult to penetrate foreign bodies deep into the lungs;millions of tiny hairs, or cilia, in the walls of the bronchi constantly capture particles from the respiratory tract;when coughing, irritants are emitted from the lungs at high speed, and white blood cells, known as macrophages, capture and destroy many carriers of infection.

Despite this defenses, the pneumonia still occurs frequently. Inflammation can be limited to air sacs( alveoli) of the lungs( lobar pneumonia) or to develop foci in all lungs, arising in the respiratory tract and spreading to the alveoli( bronchopneumonia).The accumulation of fluid in the alveoli can disrupt the supply of oxygen to the blood.

There is no doubt that pneumonia is a poly-physiological disease. And it is the etiological factor that is the determining factor both in the clinical course of the disease and in the choice of antibiotic therapy. He also largely determines the severity of the course of pneumonia and its outcome. How to treat this ailment with folk remedies look here.

Pneumococci, streptococci and hemophilic rod belong to the main role in the onset of pneumonia, the total proportion of which can reach 80%.Pneumonia can also cause staphylococci, Klebsiella, Proteus, Pseudomonas aeruginosa, Escherichia coli, but their specific gravity is relatively small. However, during the epidemic of influenza, the frequency of staphylococcal pneumonia naturally increases. Weakened patients with impaired immunity are more likely to have pneumonia caused by Klebsiella, Proteus and Escherichia coli. In patients with chronic bronchitis, great importance belongs to staphylococcus, hemophilic rods, as well as gram-negative flora and pneumococcus. There are also atypical pneumonia, the etiology of which is associated with mycoplasma, legionella, chlamydia. Their frequency has recently increased noticeably.

The independent etiological role of the viral infection in pneumonia is very doubtful. However, it is undoubtedly an important factor contributing to the onset of pneumonia.

In modern conditions, in connection with the need to select an adequate option for etiotropic therapy, it is crucial to establish the etiology of pneumonia with the definition of a probable pathogen. This is also important because pneumonia of different etiology is characterized by different clinical course, different, including x-ray, symptomatology, have different prognosis and require a differentiated definition of the duration of treatment.

Meanwhile, the quality and capabilities of bacteriological diagnosis in pneumonia do not always allow to correctly resolve the issue of the etiology of pneumonia. In this regard, the role of assessing clinical manifestations and the epidemiological situation for the approximate establishment of the etiology of pneumonia increases.

This is also important because, as a rule, the situation requires immediate treatment before the bacteriological diagnosis is established, and the results of the bacteriological study can be obtained no earlier than 48 hours later.

Cells of the body can thus lack oxygen,and in serious cases this can result in a violation of breathing. Before the advent of antibiotics, pneumonia was the leading cause of death, and recently strains of the most common bacterial pneumonia( caused by Streptococcus pneumoniae) have become resistant to penicillin. Pneumonia is especially common in the elderly or those who are weakened by the underlying illness. Currently, it remains among the top 10 causes of death.

However, despite the serious health risks associated with the disease, the prospect for a full recovery is good, especially with early detection and treatment. For the elderly and those at high risk, there is a vaccine that provides protection against 23 different strains of S. pneumoniae( which account for 90 percent of streptococcal pneumonia).

According to the International Consensus and the Russian Therapeutic Protocol( Order of the Ministry of Health of the Russian Federation No. 300, 1998), additional characteristics were included in the classification of pneumonias, providing for their separation into:

• community-acquired pneumonia;

• Nosocomial( hospital, hospital-acquired) pneumonia;

• pneumonia in patients with immunodeficiency of different origin;

• Aspiration pneumonia.

In contrast to the "typical" pneumonia caused by pneumococcus, so-called atypical pneumonia is identified.

The term "atypical pneumonia" appeared in the 40s of the XX century.and under it understood the defeat of a lighter current than the typical lobar pneumococcal pneumonia. Initially, the causative agent of this "SARS" was unknown and it was assumed that it is the so-called agent of the

Eaton. Later it was deciphered as Mycoplasma pneumoniae, and then Chlamidia pneumoniae and Legionella pneumophila were also classified among the pathogens causing this variant of pneumonia.

А.И.Sinopalnikov and A.A.Zaytsev( 2010) proposed to distinguish:

a) protracted, or slowly resolved;

b) Progressive and

c) Persistent pneumonia.

Each of these variants of pneumonia is characterized by different duration of the course, the severity and nature of the complications and, finally, the choice of adequate therapy.

• Case history and physical examination.

• Chest X-ray.

• Sowing culture of blood and saliva.

• In difficult cases, a lung tissue biopsy can be performed.

• Viral or bacterial infections are the most common causes of pneumonia.

• Other microorganisms can also occasionally cause pneumonia;For example, fungal and parasitic pneumonia usually affects people with AIDS.

• Although bacteria are usually inhaled, they can spread to the lungs through the bloodstream from another place in the body.

• Inhalation of chemical irritants, such as poisonous gases, can lead to pneumonia.

• Vomiting in the lungs( which can occur when a person loses consciousness) can cause a disease known as aspiration pneumonia.

• Small or very large age, smoking, recent surgery, hospitalization and use of chemotherapeutic agents and immunosuppressants are risk factors for pneumonia.

• Other diseases increase the risk of developing pneumonia and can cause complications. These diseases include asthma, chronic bronchitis, poorly controlled diabetes mellitus, AIDS, alcoholism, Hodgkin's disease, leukemia, multiple myeloma and chronic kidney disease.

• Symptoms vary greatly depending on the type of pneumonia. Older and very sick people usually have less obvious symptoms and less heat, even though pneumonia is more dangerous for these patients.

• Temperature( above 38 ° C, possibly up to 40.5 ° C) and chills.

• Cough, possibly with bloody yellow or green sputum.(Cough can last up to six to eight weeks after the infection subsides, especially if it is a viral infection.)

• Pain in the chest when inhaled.

• Shortness of breath.

• Headache, sore throat and muscle pain.

• General poor health.

• Weakness and fatigue.

• Abundant sweating.

• Loss of appetite.

• In severe cases: difficulty breathing, cyanotic skin tone, confusion.

The notion that pneumococcus, haemophilus rod, streptococcus, gram-negative flora, and also mycoplasma have a leading role in the emergence of community-acquired pneumonia.

The data obtained by SM.Navashin et al.(1999), have made it possible to establish a marked decrease in the role of Streptococcus pneumoniae in the development of domestic pneumonia to a level of 30% and somewhat higher. Haemophilus influenzae are responsible, according to their data, for the development of pneumonia in 5-10% of adults, more often in smokers and patients with chronic obstructive bronchitis. Moraxella( Branchamella) catarrhalis - gram-negative coccobacilli - caused pneumonia in 1-2% of patients, usually suffering from chronic bronchitis. Mycoplasma pneumoniae - devoid of an external membrane, which causes its natural resistance to( i-lactam antibiotics - causes community-acquired pneumonia in 20-30% of individuals younger than 35 years, the etiological "contribution" of this pathogen in older age groups is more modest( 1 to 9%Chlamidia pneumoniae - microorganisms, which are exclusively intracellular parasites close in structure to gram-negative bacteria, cause pneumonia in 2-3% of cases, usually of a mild course. Escherichia coli, Klebsiella pneumoniae, belonging to the family of enterobacteria, arepneumonia in less than 5% of patients, usually with concomitant diseases such as diabetes, congestive heart failure, kidney failure, liver failure Staphilococcus aureus causes pneumonia in less than 5% of patients with certain risk factors - the elderly,drug addicts, with chronic hemodialysis, influenza. The pathogens of community-acquired pneumonia, listed above, also include microorganisms of the genus Legionella - gram-negative rods, which are obligate pathogens. This is primarily Legionella pneumophila - an infrequent pathogen of pneumonia - from 2% to 10%.

However, legionellosis pneumonia takes the second place( after pneumococcal) according to the frequency of lethal outcomes of the disease.

Community-acquired pneumonia is one of the most important health problems, due to the high incidence and mortality, as well as the significant direct and indirect costs associated with this disease.

Incidence in Europe ranges from 2 to 15 cases per 1000 population, and in Russia, up to 10-15 cases per 1000 people per year.

These indicators are significantly higher in elderly patients, ranging from 25 to 44 cases per 1000 people per year in patients older than 70 years and from 68 to 114 in patients in homes with disabilities and nursing homes.

Pneumonia caused by various pathogens has clinical and radiological features that allow a doctor with a high probability to determine its etiology and thereby not only formulate a nosological diagnosis, but also determine therapeutic tactics.

Etiology of community-acquired pneumonia, as well as pathogen distribution mechanisms are very diverse. Often they are associated with microflora, usually colonizing the upper respiratory tract.

The main mechanism is the microaspiration of bacteria that make up the normal microflora of the oropharynx. In this case, the massiveness of the dose of microorganisms or their increased virulence are important against the background of damage to the protective mechanisms of the tracheobronchial tree. Particular importance in this case can play a viral respiratory infection, which is associated with a dysfunction of the ciliary epithelium and a decrease in the phagocytic activity of alveolar macrophages.

Less frequent way in case of pneumonia occurrence is the inhalation of microbial aerosol, which can occur in case of infection with obligate pathogens( eg Legionella spp., Etc.).

Even less important is the hematogenous pathway for the spread of microorganisms from the extrapulmonary focus of infection, which is usually observed with sepsis.

Finally, it is possible to directly spread the infection from a focus associated with liver disease, mediastinum, or as a result of a penetrating chest injury. The pathogenesis of pneumonia largely determines its etiological structure.

Such factors as absence of sputum, impossibility of receiving bronchial secretions by invasive methods due to the patient's severe condition or insufficient qualification of medical staff, contamination of the bronchial contents of the oropharynx microflora, a high level of carrier of a number of pathogens( from 5 to 60% indifferent age groups), the use of antibiotics in the prehospital stage.

The diagnostic value of a study of free-coughing sputum by microscopy or culture is very limited in view of the reasons outlined above. Sputum is considered to be satisfactory in quality if more than 25 neutrophils and less than 10 epithelial cells are detected with a Gram Skin microscopy with an increase of 100.The significance of sputum culture is, in particular, in the identification of resistant strains of a probable pathogen of pneumonia.

Patients with community-acquired pneumonia, who are treated on an outpatient basis, are shown to have bacteriological examination of the sputum, which should be performed prior to the initiation of antibiotic therapy. Serologic examination may be necessary for suspected legionellosis or mycoplasmal pneumonia.

However, more often the latter is useful for retrospective diagnosis of legionella pneumonia in the period of its epidemic outbreak.

Historically, the beginning of clinical studies of lobar pneumonia was initiated by Corvisart and his pupil Laennec. They also introduced auscultation into clinical practice, and Laennec invented a stethoscope and described such physical phenomena as crepitation, dry and wet rales, bronchophonia, and egoophony. The term "croupous pneumonia" was introduced by S.P.Botkin to designate an especially severe course of the disease, as evidenced by the appearance of signs of croup. The term "croupous pneumonia" is used only in Russian literature. It is now recognized that typical croupous pneumonia is always pneumococcal. However, the term "croupous pneumonia" is still used in clinical practice, although it is not always lobar, and maybe, in particular, segmental, and sometimes - multi-annual. It should be stressed that up to 60% of focal pneumonias are also pneumococcal.

It is described up to 75 kinds of pneumococci, of which no more than two or three can be causative agents of the so-called croupous pneumonia.

Infection penetrates the body by aerogenic means. The rapid, almost simultaneous damage to the lung lobe and the sudden onset of the disease gave reason to believe that the basis for its occurrence is the presence of a hyperergic reaction. Predisposing factors are cooling, fatigue, dystrophy, severe cardiovascular diseases, and the like. In these conditions, the infection spreads very quickly, hitting a whole lot, and sometimes all the lungs.

The pathological and anatomical picture with typical pneumococcal pneumonia( lobar) undergoes evolution with a successive change in the four stages of development.

The stage of tidal or hyperemia. At this stage, the capillaries are dilated and filled with blood, serous fluid, a small amount of erythrocytes, leukocytes and cells of the alveolar epithelial cells begin to accumulate in the alveoli. Due to the increase in the number of red blood cells by diapedesis and the loss of fibrin, this stage on the 2-3 day of the disease passes into the next.

The stage of red curing. The cavities of the alveoli in this stage are filled with fibrin with a significant admixture of erythrocytes, a small number of leukocytes and cells of the alveolar epithelium. The affected share is increased in volume, dense, airless. Its color on the cut is reddish-brown. On the pleura, enveloping the affected part, there are fibrinous overlays;they are also visible inside the vessels and lymphatic fissures. Subsequently, red blood cells undergo hemolysis and decay. This stage lasts 2-3 days, after which it passes to the next.

The stage of gray custody. The affected share remains dense. Its color on the cut is grayish-yellowish. The alveoli contain fibrin with an admixture of leukocytes. Erythrocytes are absent. At the end of the gray surgery phase, a crisis occurs in the development of the disease and the next stage begins.

Permission Stage. Releasing proteolytic enzymes cause fibrin liquefaction, leukocytes and alveolar epithelial cells undergo lipid transformation and decay. Liquefying exudate is excreted in the bronchi and is absorbed through the lymphatic ways.

In typical cases, the disease begins suddenly - with a chill, often stunning, a rapid increase in temperature to 40 ° C, stitching pain in the chest, intensifying with inspiration, which is due to the pleural response to inflammation, headache, often vomiting. Less often the disease is preceded by a premorbid condition for several days: weakness, weakness, aches in the body, etc.

Already on the 1-2 day of the disease there is a cough, initially painful, as a small amount of mucous sputum is difficult to remove and every coughing impulse aggravates pleural pain. The sputum gradually acquires a mucus-purulent character, and in some patients it is stained with blood and acquires a "rusty" shade, pathognomonic for pneumococcal lobar pneumonia. Croupous pneumonia usually develops in one lung, more often right, but there may be a bilateral lesion. Often the process is localized in the lower lobe, but may be involved in the inflammatory process and upper lobes. Sometimes the emerging pain syndrome simulates acute appendicitis or cholecystitis. The defeat of the pleura can lead to the appearance of pain in the heart, resembling ischemic disease.

Characterized by hyperemia of the face, a blush on the cheeks. At the height of intoxication, visible mucous membranes can acquire a cyanotic hue, sclera is often sub-bacterial. On the lips and wings of the nose there are herpetic eruptions. Body temperature persists for several days on high figures with slight fluctuations. Respiration is rapid, superficial - up to 40 per minute and more. The pulse is increased to 100-120 beats per minute.

Physical symptoms depend on the volume of lung damage, the prevalence and phase of the inflammatory process. In the first days of the disease, stupidity arises and rapidly grows with percussion, corresponding to the affected area of ​​the lung. At the beginning of the phase of custody, gentle crepitation - crepitatio indux - can be heard. At this time, bronchial breathing can be heard. In the resolution phase, percussion dullness is replaced by a pulmonary sound, breathing loses bronchial hue, becomes hard, and then vesicular. The final crepitation - crepitatio redux - is heard.

An intensive homogenous obscuration with bulging outer contours is determined by X-ray examination. The development of destructive changes is uncharacteristic. Often there is a pleural effusion, which gives reason to denote the pathological process as pleuropneumonia.

The temperature decreases gradually, for 2-4 days( lytic), or suddenly, throughout the day( critically).The crisis is accompanied by profuse sweating. The beginning of the crisis usually occurs on the 3rd, 5th, 7th, 11th day.

Recently, the clinical picture of typical pneumococcal pneumonia is noticeably smoothed out as a result of antibiotic therapy.

The state of the cardiovascular system in elderly and senile patients determines the prognosis of the disease, which justifies the aphorism of the French clinician Corvisart( 1807): "La maladie est au poumon, le danger au coeur"( lungs are a pain in the heart).

During the crisis, there may come a sharp drop in blood pressure with a small, frequent pulse and increased cyanosis - the phenomena of collapse, pulmonary edema may develop.

The laboratory parameters are characterized by a significant neutrophilic leukocytosis 20-30 x 109 / l and higher. Shift of the leukocyte formula to the left before the young forms of neutrophils;can be detected toxic granularity of neutrophils. At the height of the disease is characterized by aneosinophilia. With the recovery, the number of leukocytes decreases, the ESR simultaneously increases to 40 mm per hour and higher( the "cross symptom").In the blood there are eosinophils( "eosinophilic recovery"), the number of neutrophils decreases and, conversely, the number of lymphocytes increases.

When bacterial culture is sown in 20-40% of cases, bacteremia is found.

Almost always, the pleural reaction is determined, but significant pleural effusion occurs in only 10-15% of patients.

According to the summary data, there is a decrease in the incidence of lobar pneumococcal pneumonia and simultaneously there is an increase in focal pneumonia of pneumococcal nature.

May be community-acquired, complicating viral infections, or hospital, developing in the elderly, with diabetes, brain injury, after mechanical ventilation. Long stay in the hospital increases the risk of staphylococcal infections. The risk of developing staphylococcal pneumonia may also be chronic obstructive bronchitis.

In recent years, staphylococcal pneumonia occurs quite often, and in the structure of pneumonia they are 5-10%.According to the peculiarities of pathogenesis, primary and secondary( septic) forms of staphylococcal pneumonia should be distinguished.

Primary staphylococcal pneumonia develops usually acute amongst overall health. However, it is often associated with influenza. Such a staphylococcal pneumonia is severe and characterized by a tendency to rapid festering.

Acute onset of the disease is accompanied by a significant fever and chills. Expressed dyspnea, pain in the chest, cough with the release of purulent or mucopurulent sputum, often containing an admixture of blood.

There is also marked general weakness, sweating, tachycardia. Dullness of percussion sound is also revealed, with auscultation - weakened breathing, often with a bronchial hue, finely bubbly wet wheezing. Typically, rapid development of destructive changes in the lungs, usually multiple. In the pathological process, extensive areas of lung tissue can be involved, more often in both lungs. However, the severity of the patient's condition does not always correspond to the changes found in the lungs. Yu. M.Muromsky et al.(1982) found that destructive changes in lung tissue cause staphylococcus strains producing lecithinase, phosphatase, as well as a-and β-hemolysins.

In some cases, initial clinical manifestations are more blurred. The temperature is subfebrile, and the general condition of the patient is relatively satisfactory.

Radiological picture differs in variety and significant variability. Numerous large-focus and focal shadows of polysegmental localization are revealed. Against the background of widespread infiltrative changes, cavities of various sizes are visible, some of which can contain a horizontal liquid level. The described changes are located partly in the depth of the lung tissue, but some of them have subpleural localization. Possible their breakthrough into the pleural cavity with the development of the picture of pyopneumothorax, which significantly worsens the patient's condition and the prognosis of the disease. In such cases, rapid drainage of the pleural cavity and transfer of the patient to the intensive care unit are necessary.

Both variants of staphylococcal pneumonia described above are inherent in primary staphylococcal pneumonia, which is determined by IP.Zamotayev( 1993) as a bronchogenic.

Along with the primary staphylococcal pneumonia, I.P.Zamotayev identifies a hematogenous variant of staphylococcal pneumonia, which is characterized by a clinical picture of the septic process: tremendous chills, high fever, severe intoxication, severe respiratory complaints with the appearance of pain in the chest, cough with bleeding, dyspnea and increasing respiratory insufficiency. The percussion picture is mosaic: areas of blunting alternate with tympanic. At auscultation, the areas of weakened breathing alternate with amphoric breathing, sonorous wheezing sounds are heard. In the analysis of blood - pronounced leukocytosis, left-handed stab-shift, lymphopenia, a significant increase in ESR.Often there is a tendency to anemia.

Radiological picture is characterized by the presence of multiple inflammatory foci, more often in both the lungs, medium and large sizes. These foci tend to merge and subsequently disintegrate. More often they have a regular rounded shape and can contain a horizontal level of liquid. In the process of dynamic observation, they can decrease in size and transform into a thin-walled cyst.

Often, in this version, there is a picture of pyopnecho-motorax.

Diagnosis of staphylococcal pneumonia should be based on the following data:

1) presence in the body of foci of staphylococcal infection;

2) severe clinical course of the disease;

3) features of the X-ray picture with frequent presence of multiple destructive cavities;

4) revealing of golden pathogenic staphylococcus in sputum;

5) the lack of a positive effect when using unprotected β-lactam antibiotics. The diagnosis becomes even more justified when a picture of pyopneumotorax is detected.

Staphylococcal pneumonia, as mentioned above, may be community-acquired, but often they are hospital( nosocomial).In such cases, they tend to acquire septic currents.

This type of pneumonia is relatively rare. It is believed that in the structure of pneumonia its specific gravity varies within the range of 0.5-4.0%.However, among patients with the most severe forms of pneumonia, it increases to 8-9.8%.More often, the defeat is shared, often referring to the upper lobe. This localization of the process with Klebsiella pneumonia is more common than with pneumococcal pneumonia. Consideration of this circumstance has a certain value, first, when conducting differential diagnosis with tuberculosis, and secondly, with an indicative choice of the etiology of pneumonia. Men get sick 5-7 times more often than women, elderly people are more likely to be young.

Predisposing factors are alcoholism, eating disorders, diabetes mellitus, chronic obstructive bronchitis.

Due to the severe course and the possibility of an unfavorable outcome, early etiologic diagnosis, timely hospitalization and adequate therapy are very relevant.

The disease usually begins acutely, often against a background of complete clinical well-being. At the same time, body temperature rarely reaches 39 ° C, but cases when it does not reach 38 ° C are not uncommon. Cough is nasal, painful, unproductive. Sputum is usually viscous, jelly-like, can contain veins of blood, has the smell of burnt meat. Almost always there are pains in the chest of pleural origin. Possible development of exudative pleurisy. In this exudate is turbid, has a hemorrhagic hue, contains a large number of microorganisms of the Klebsiella genus. Usually expressed cyanosis of visible mucous membranes. Characteristic is the discrepancy between the relatively low body temperature, the low degree of physical data and the general severe state. Destructive cavities can quickly form, resulting in significant amounts of bloody sputum. Usually abscessing occurs in the first 4 days of the disease. With percussion there is a distinct blunting, and with auscultation - weakened bronchial breathing and a small number of wheezing. The latter is due to the filling of mucus lumens of alveoli and small bronchi. Dyspeptic disorders, icteric sclera and mucous membranes are often detected. In the blood test, leukopenia with monocytosis and a shift of the leukocyte formula to the left is detected. Leukocytosis is more common in purulent complications. At X-ray examination, a darkening area is found, initially homogeneous. The affected proportion appears to be increased in volume. In the future, sites of destruction, pleural effusion are formed.

In the pre-antibacterial era, the prognosis was often unfavorable. However, even now, the mortality rate is 8%.

Pneumonia caused by H. influenzae( Pfeffer's wand), is relatively rare, although in recent years it has shown a tendency to become more frequent. Often occurs in children. In adults, pneumonia caused by a hemophilic rod usually develops in areas of atelectasis caused by obturation of small bronchi in patients with chronic obstructive bronchitis. The defeat of the lungs is often widespread focal. In this case, focal changes can merge with the formation of focal shadows. Since the disease occurs against the background of purulent bronchitis, the mosaic nature of the physical data is characteristic. Hemophilic rods may cause secondary pneumonia in influenza.

The clinical picture of pneumonia that developed against a background of exacerbation of chronic obstructive bronchitis or influenza is characterized by the emergence of a second wave of fever, the appearance of blunting areas with percussion and localized wet wheezes in auscultation. In the blood test, leukocytosis of a neutrophilic nature is simultaneously recorded. In a number of cases, pneumonia can be complicated by meningitis, pericarditis, pleurisy, arthritis and a detailed picture of sepsis. For culture, blood agar is used. In other media, the hemophilic rod usually does not grow.

Mycoplasma is a highly virulent pathogen, transmitted by airborne droplets. Often there are epidemic rises of the disease, which last for several months and are repeated every 4 years, mainly in the autumn-winter period. Hospital pneumonia is quite rare.

The onset of the disease is gradual, with the appearance of catarrhal phenomena and malaise. A high or low febrile temperature can be observed. Chills and shortness of breath are not typical. Pleural pain is absent. Cough is often unproductive or with the separation of scanty mucous sputum.

At auscultation dry or local wet rales are heard. Pleural effusion develops extremely rarely.

Extrapulmonary and general symptoms are typical - myalgia, more often in the region of the back and thighs;profuse sweating, conjunctivitis, myocardial damage, pronounced general weakness.

In the study of blood, a small leukocytosis or leukopenia is noted, the leukocyte formula is not changed, anemia is often detected.

Radiographic examination reveals focal-spotted character shadows located mainly in the lower parts of the lungs.

Mycoplasmal pneumonia is characterized by dissociation of signs - a normal leukocyte formula and discharge of mucous sputum at high temperature;heavy sweats and severe weakness with low subfebrility or normal temperature.

The disease begins with a dry cough, sore throat( pharyngitis, laryngitis), malaise. There are chills, high fever. The cough is initially dry, but quickly becomes productive with the separation of small amounts of purulent sputum.

At auscultation, first crepitus is heard, then - local wet rales. Both shared and focal pneumonias can occur in the volume of one or more lobes. Chlamydial pneumonia can be complicated by pleural effusion, which is manifested by characteristic pains in the chest.

The leukocyte formula is usually unchanged, although neutrophilic leukocytosis may occur.

When X-ray examination reveals local or fairly common large-focal shadows, sometimes with the formation of small foci.

Legionella was first identified in 1976 during the outbreak of the disease among participants in the Congress of American Legionnaires.

In the subsequent it was found that clinically legionellosis can manifest itself in the form of two main forms: Legionnaires' disease - pneumonia caused by legionella, and Pontiac fever.

Pneumonia was severe and lethal with it reached 16-30% in the absence of treatment or the use of ineffective antibiotics.

Epidemic outbreaks usually occur in the fall. The causative agent is well preserved in the water, so living in the vicinity of open water can be considered a risk factor. The source of infection can also serve as air conditioners.

The disease can occur as community-acquired and hospital-acquired pneumonia.

Hospital nosocomial legionellosis pneumonia often develops in persons receiving glkozhoktikoidnye hormones and cytostatic agents. The lethality in this case can reach 50%.

The incubation period is 2-10 days. The disease begins with weakness, drowsiness, fever, cough with scant sputum, which may contain an admixture of blood. Sputum is often purulent. Dyspeptic disorders can be detected.

In physical examination, shortening of percussion sound, crepitation, local wet rales are determined. Often observed bradycardia, hypotension. A third of patients have pleural effusions.

In a laboratory study, leukocytosis is detected with a shift of the formula to the left, relative lymphopenia, an increase in ESR, thrombocytopenia. In the analysis of urine - hematuria, proteinuria. There is also a positive polymerase chain reaction.

When X-ray examination - krupnoochagovye and focal shadows with a tendency to merge. With favorable dynamics, the normalization of the radiographic picture takes place within a month.

From extrapulmonary manifestations that are rare, it is necessary to mention endocarditis, pericarditis, myocarditis, pancreatitis, pyelonephritis.

The most effective treatment with macrolides, its duration - at least 2-3 weeks. The use of β-lactam antibiotics is ineffective.

It is very common that at least 20-25% of patients with SARS have only radiologic interstitial changes in their lungs. However, as V.E.Noniq( 2001), in such cases, computed tomography can detect pneumonic infiltration of the lung tissue. Moreover, even linear tomography contributes to the same effect.

Rapid indicative definition of the etiology of pneumonia can be facilitated by data obtained by sputum smear microscopy, as shown below( Russian consensus on pneumonia):

To determine the tactics of managing patients with community-acquired pneumonia, the recommendations of S.N.Avdeeva( 2002), which divides them into the following groups:

• pneumonia that does not require hospitalization;this group is the most numerous, its share is up to 80% of all patients with pneumonia;these patients suffer from mild pneumonia and can be treated on an outpatient basis;lethality does not exceed 1-5%;

• pneumonia requiring hospitalization of patients in a hospital;this group constitutes about 20% of all pneumonias;patients have background chronic diseases and severe clinical symptoms;the risk of mortality of hospitalized patients reaches 12%;

• pneumonia requiring hospitalization of patients in intensive care units;such patients are defined as suffering from severe community-acquired pneumonia;the lethality of this group is about 40%.

An evaluation of the severity of pneumonia is important in this regard. M.D. Niederman et al.(1993):

1. The frequency of respiratory movements is more than 30 in 1 min upon admission.

2. Severe respiratory failure.

3. The need for ventilation.

4. When performing lung radiography, the detection of bilateral lesions or lesions of several lobes;increase the size of the dimming by 50% or more within 48 hours after receipt.

5. Shock state( systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than 60 mm Hg).

6. The need for vasopressors for more than 4 hours

7. Diuresis less than 20 ml per hour( if there is no other explanation) or the need for hemodialysis.

Pneumonia in elderly and elderly people is a serious problem due to significant difficulties in diagnosis and treatment, as well as high mortality.

So, according to V.E.Nonikova( 1995), the National Center for Medical Statistics of the USA( 1993,2001), and M. Wood-head et al.(2005), the incidence of community-acquired pneumonia in the elderly is twice as high as in young people. The frequency of hospitalization with this disease increases with age more than 10 times.

According to N. Kolbe et al.(2008), with pneumonia in older persons, the resistance of the pathogen to antibiotics is much higher, which significantly worsens the prognosis of the disease.

Opinion I.V.Davydovsky( 1969) on the exceptional importance of pneumonia in the tanatogenesis of the gerontological population has not lost its relevance. Mortality among patients with pneumonia over 60 years is 10 times higher than in other age groups, and reaches 10-15% for pneumococcal pneumonia and 30-50% for pneumonia caused by gram-negative flora or complicated by bacteremia.

Evaluation of the two-year survival rate for the elderly has shown that after the pneumonia carried, the lethality from decompensation of background diseases is significantly increased.

Often, pneumonia develops in the terminal period of severe illnesses, often being the direct cause of death in old age. In elderly and senile age, the role of the Klebsiella pneumonia, as well as the Pseudomonas aeruginosa and Escherichia coli, is particularly important. In the majority of elderly people, pneumonia is caused by a mixed infection involving both gram-negative and gram-positive flora. In the etiology of modern pneumonia in the elderly, along with the bacterial flora, an important role is played by fungi, rickettsia and viruses.

Multimorbidity is a characteristic feature of the elderly.

Pneumonia in people over 60 years old is never the only disease. They always develop against the background of previous diseases, some of which play the role of predisposing, and others - pathogenetically or etiologically important.

The high frequency of errors in the diagnosis of pneumonia in the elderly indicates that their recognition at this age is associated with difficulties both in the prehospital and hospital settings. According to the frequency of diagnostic errors, pneumonia is left behind many diseases and can only be compared with tumors whose detection difficulties are well known.

Predominates the overdiagnosis of pneumonia. It is especially high among people over 60 years of age and twice the frequency of diagnostic errors in young people. The most common causes of clinical overdiagnosis are the incorrect treatment of febrile syndrome and erroneous interpretation of auscultation data. Hyperdiagnostics is also facilitated by the absence of a radiographic examination and misinterpretation of its data.

On the contrary, severe pain syndrome often leads away from the diagnosis of pneumonia, inciting the doctor to erroneous dysgnosis of myocardial infarction, renal colic, cholecystitis or intestinal obstruction.

According to V.E.Nonikova( 2001), a situation where pneumonia is not diagnosed( that is, a hypodiagnosis) is even more dangerous, since in these cases the beginning of adequate therapy is unreasonably delayed or the patient may be at risk of unnecessary surgery.

Based on the materials of V.E.Nonikov, the most frequent clinical symptoms of pneumonia in elderly people are fever, cough, and sputum. Approximately in 2 / 3bolnyh this age the disease begins gradually. Chills occur in 1/3 of the patients( as in younger patients).

Shortening of percussion sound is typical, as a rule, with lobar pneumonia and parapneumonic pleurisy. Auscultatory data are presented in the lungs in the form of wet rales( 77%), dry wheezing( 44%), weakened breathing( 34%), crepitus( 18%) and bronchial respiration( 6%).

It is noticeable more often in cases of pneumonia in people over 60 years of age noted shortness of breath, heart rhythm disturbances, peripheral edema, confusion.

Data from routine laboratory studies do not have significant features in pneumonia in the elderly. Prognostically unfavorable for massive pneumonia in these individuals is leukopenia with neutrophilic shift and lymphopenia.

Clinical features of pneumonia in the elderly are:

• low physical symptoms, often lack of local clinical and radiologic signs of pulmonary inflammation, especially in dehydrated patients, which leads to disruption of exudation processes;

• an ambiguous treatment of detected wheezing, which can be heard in the lower parts of the elderly and without pneumonia, as a manifestation of the phenomenon of airway obstruction. The areas of blunting can be a manifestation of not only pneumonia, but also atelectasis;

• frequent absence of acute onset and pain syndrome;

• frequent violations from the side of the central nervous system( confusion, inhibition, disorientation), advancing acutely and not correlating with the degree of hypoxia;these disorders may be the first clinical manifestations of pneumonia, but are often regarded as acute disorders of cerebral circulation;

• shortness of breath as the main symptom of the disease, not explainable by other causes, such as heart failure, anemia, etc.;

• isolated fever, without signs of pulmonary inflammation;in 75% of patients the temperature is above 37.5 ° C;

• worsening of general condition, decreased physical activity, expressed and not always explainable loss of ability to self-service;

• unexplained falls, often preceding the onset of signs of pneumonia;it is not always clear whether the fall is one of the manifestations of pneumonia or pneumonia develops after a fall;

• exacerbation or decompensation of concomitant diseases - strengthening or appearance of signs of heart failure, heart rhythm disturbances, decompensation of diabetes mellitus, signs of respiratory failure. Often, this symptomatology appears in the clinical picture at the forefront;

• long-term resolution of pulmonary infiltration( up to several months).

This type of pneumonia ranked first among the causes of death from nosocomial infections.

Mortality from hospital pneumonia reaches 70%, but the direct cause of death of patients it is in 30-50%, when the infection is the main cause of death.

It is assumed that hospital pneumonia occurs in 5-10 cases per 1000 hospitalized.

When diagnosing nosocomial pneumonia, infections that were in the incubation period at the time of admission to the hospital should be excluded.

Etiology of hospital pneumonia is characterized by a significant uniqueness, which makes it difficult to plan etiotropic therapy.

Depending on the period of development of nosocomial pneumonia, it is customary to allocate:

• "early nosocomial pneumonia" that occurs within the first 5 days of hospitalization, which is characterized by pathogens that are sensitive to traditionally used antibiotics;

• "Late Nosocomial Pneumonia", which develops not earlier than the 5th day after admission, which is characterized by a high risk of having multidrug-resistant bacteria and a less favorable prognosis.

The risk of nosocomial pneumonia is especially high in patients with COPD.

Therefore, early hospital-acquired pneumonia in patients who did not receive antibiotic therapy is most likely due to normal microflora of the upper respiratory tract with a natural level of antibiotic resistance. However, the practice of using antibiotics for prophylactic purposes is widespread in Russian intensive care units and intensive care units. In these conditions, the etiological structure and the phenotype of resistance of the bacterium-causative agents of "early nosocomial pneumonia" approach "late nosocomial pneumonia".With nosocomial pneumonia, developed against or after treatment with antibiotics, a leading role can play primarily representatives of the enterobacteria family:

• Klebsiella and Enterobacter spp.

• Pseudomonas aeruginosa;

• Staphylococcus spp.

In a significant part of the cases, these agents of hospital pneumonia are characterized by the presence of resistance to antibiotics of different classes.

The following factors are the risk factors for detection of nosocomial pneumonias of multiple drug resistance:

• use of antibiotics in the previous 90 days;

• Nosocomial pneumonia, developed 5 days later or later from hospitalization;

• high prevalence of resistance of the main pathogens in the hospital;

• acute respiratory distress syndrome;

• chronic hemodialysis;

• presence of a family member with a disease caused by a multidrug-resistant pathogen.

Among the nosocomial pneumonia, a special place is occupied by the fan-associated pneumonia( VAP), that is, the pulmonary inflammation that develops in persons who are on artificial ventilation( IVL).The most important factors for predicting the likely etiology of VAP are the previous antibiotic therapy and the duration of the ventilator. Thus, in patients with early VAP( ie, pneumonia, developed with IVL duration of 5-7 days), not receiving antibiotics, the leading etiological agents are:

• S. pneumoniae;

• Enterobacteriaceae spp.(including Klebsiella pneumoniae),

• H. influenzae;

• S. aureus.

The leading role in the etiology of "late" VAP is played by:

• Pseudomonas aeruginosa,

• Enterobacteriaceae;

• Acinetobacter spp: ,

• Staphylococcus aureus.

Almost all agents of "late" VAP have a pronounced drug resistance to antibiotics, because such pneumonia usually occurs against the backdrop of prolonged therapy or prophylaxis with antibiotics.

A total of up to 30-100 pneumonia occurs per 1000 patients in the process of mechanical ventilation. Every day of the patient's stay in the intensive care unit or intensive care unit while carrying out a ventilation aid increases the risk of developing pneumonia by 1-3%.

The complexity of the problem is reflected in the classification of pneumonia, when one of the leading pathogenetic mechanisms - aspiration, considered both in hospital and in community-acquired pneumonia, is published in the title of a separate heading "aspiration pneumonia."A special place in this case is the most difficult version of this pneumonia - Mendelssohn's syndrome.

The etiology of aspiration pneumonia( both community-acquired and hospital) is characterized by the participation of anaerobes in a "pure form" or in combination with an aerobic gram-negative flora. These microorganisms often cause severe and early-onset destruction of the lung tissue in the form of abscessed pneumonia or gangrene of the lungs.

Aspiration pneumonia( AP) is commonly referred to only as pneumonia in patients after a documented episode of massive aspiration or in patients who have risk factors for aspiration.

Two conditions are necessary for the development of AP:

• violation of local respiratory protection factors in the form of pharyngeal closure, cough reflex, active mucociliary clearance, etc.;

• pathological nature of the aspiration material - high acidity, a large number of microorganisms, a large volume of material, etc.

The main risk factors for the development of aspiration pneumonia by NA.Cassire and MS Niederman( 1998):

Risk factors associated with the patient

- Mental disorders

- Severe background diseases

- Stroke

- Epilepsy

- Alcoholism

- Dysphagia

- Gastroesophageal reflux

- Condition after gastrectomy

- Probe for enteral

- Diseases of the teeth and gums

Risk factors associated with the properties of the aspirated material

- pH of the material below 2.5

- Large particles in the aspirate

- Large volume of aspirate( more than 25 ml)

- Hypertonicth character aspirate

- High bacterial contamination

AP may develop as community-acquired pneumonia, but, apparently, most often it occurs as a hospital pneumonia.

AP takes a rather large proportion among all forms of pneumonia - about 25% of severe pneumonia in intensive care units accounted for its share.

AP is caused by microorganisms normally colonizing the upper respiratory tract, i.e., malovirulent bacteria, in most cases anaerobes, and can be considered as a pleuropulmonary infection that passes through the following stages of development: pneumonitis, necrotizing pneumonia, lung abscess, pleural empyema.

Distribution of aspirated material, therefore, the localization of infectious foci in the lungs depends on the position of the patient's body at the time of aspiration. Most AP develops in the posterior segments of the upper lobes and the upper segments of the lower lobes, if aspiration occurred at the time when the patient was in a horizontal position, and in the lower lobes( more often on the right), if the patient was in a vertical position.

The disease develops gradually without a clearly delineated acute onset. In many patients, an abscess or empyema develops 8 to 14 days after aspiration.

With the appearance of foci of destruction, approximately half of the patients have sputum production with a fetid putrefactive odor, possibly hemoptysis.

At the same time, the absence of putrefactive odor in the formation of an abscess does not exclude the role of anaerobic microorganisms in the onset of AP, since many anaerobes do not lead to the formation of metabolic products with a putrefactive odor.

Other symptoms, quite typical for pneumonia, are cough, shortness of breath, pleural pain, leukocytosis.

However, in many patients their development is preceded by several days, and sometimes weeks of less pronounced clinical signs: weakness, low-grade fever, cough, in a number of patients - weight loss and anemia.

With AP caused by anaerobes, patients almost never experience chills.

So the typical clinical features are:

• gradual onset;

• documented aspiration or factors predisposing to the development of aspiration;

• fetid smell of phlegm, pleural fluid;

• localization of pneumonia in dependent segments;

• necrotizing pneumonia, abscess, empyema;

• presence of gas above the exudate in the pleural cavity( pyopneumothorax);

• no growth of microorganisms under aerobic conditions.

• Do not smoke.

• People at high risk for developing pneumonia should be vaccinated against pneumococcal pneumonia. The risk group includes people aged 65 years, with heart disease, lung or kidney disease, with diabetes mellitus or a weak immune system and alcoholics. A vaccine is required only once;it provides long-term protection and is 60-80 percent more effective for those whose immune system functions in the usual way.

• Annual flu vaccination( especially for people aged 65 years) may be recommended, as pneumonia is a common complication of severe influenza.

• To treat a bacterial infection, prescribe antibiotics;they must be accepted for the entire prescribed period. Interruption of treatment can cause a relapse of the disease.

• Antifungal agents, for example amphotericin B, are prescribed to treat a fungal infection.

• Antiviral drugs, such as neuraminidase inhibitors, ribavirin, acyclovir and ganciclovir sodium, may be effective against certain types of viral infection.

• Your doctor may recommend analgesics to reduce fever and pain. Talk to your doctor before taking over-the-counter painkillers.

• Take nonprescription cough medicines containing dextromethorphan if you have a persistent dry cough. However, if you cough with phlegm, suppressing the cough completely can cause the accumulation of mucus in the lungs and lead to serious complications.

• Your doctor can instruct you how to remove mucus from the lungs by taking different postures when the head is below the trunk.

• Patients who do not have cardiac or renal failure should drink at least eight glasses of water per day to reduce pulmonary discharge and that they are easier to remove.

• Bed rest until the fever recedes.

• Hospitalization may be recommended, especially in the early stages of infection and / or for elderly patients, as pneumonia may suddenly become violent within a few hours.

• Oxygen can be supplied through a mask to facilitate breathing. In serious cases, a respirator may be required.

• Surplus fluid in the space around the lung can be removed with a syringe and a needle inserted through the chest wall.

• Consult your doctor if you experience symptoms of pneumonia, especially above 38 ° C, dyspnea in a lying position, or bloody sputum when coughing.

• Warning! Call an "ambulance" if you have difficulty breathing or a blue tint on the lips, nose, or nails.