Algorithm for effective treatment of bronchopulmonary diseases. Diseases of the bronchopulmonary system Chronic nonspecific lung diseases Inflammatory processes in the bronchopulmonary system, as a rule
We are talking about patients with chronic inflammatory diseases of the lungs and bronchi. Diseases united by this term (chronic obstructive pulmonary disease, chronic bronchitis, bronchiectasis, pneumonia, etc.) proceed for a long time and require maximum attention, since they are unpleasant with recurring exacerbations and are fraught with a gradual aggravation of secondary changes in the lungs. We are talking about exacerbations. Exacerbations are always the starting point in the progression of the entire pathological process.
To some extent, it is not the doctor who is the first, but the patient himself, if he suffers from a chronic process for a long time, is called upon to determine the beginning of an exacerbation in himself, knowing the sensations from previous periods of deterioration. Usually, the signal is gradually appearing signs of intoxication (fatigue, weakness, loss of appetite, sweating), increased cough and shortness of breath (especially in obstructive conditions - with wheezing when breathing), a change in the nature of sputum (from pure mucous it turns into opaque with yellowish or greenish shade). Unfortunately, body temperature does not always rise. You need to study yourself in order to start therapy in the event of an exacerbation not in the morning or evening of the next day after the examination by a therapist or pulmonologist, but immediately.
The regime for exacerbations is not strict bed, that is, you can walk, do light household chores (if there is no excessive weakness), but it is advisable to stay close to the bed, go to bed periodically. Going to work or school is strictly prohibited.
Appetite is reduced, so nutrition should be as complete as possible, contain more proteins, easily digestible fats (sour cream, vegetable oils), vitamins. An extremely important recommendation is to drink a lot if there are no serious contraindications to this (a sharp increase in blood or eye pressure, severe heart or kidney failure). Intensive water exchange promotes the removal of bacterial toxins from the body and facilitates the separation of sputum.
One of the most important points in treatment is adequate sputum drainage. Sputum must be actively coughed up from different positions ("positional drainage"), especially those that provide the best drainage. In each new position, you need to stay for a while, and then try to clear your throat. First they lie on their back, then turn on their side, then on their stomach, on the other side, and so on, in a circle, each time making a quarter turn. Last position: lying on the edge of the bed, on the stomach with the shoulder lowered below the level of the bed (“as if reaching for a slipper”). This is done several times a day. What is coughed up should always be spit out.
Expectorants make sputum more liquid, but they cannot be used indiscriminately. All expectorants are endowed with nuances in the mechanism of action, so a doctor should prescribe them. Everyone knows expectorant herbs (coltsfoot, thyme, thermopsis, as well as herbal preparations - bronchicum, doctor mom cough syrup etc.) act reflexively, irritating the gastric mucosa, and have no practical significance in chronic processes in the bronchi - they should not be used, and they are contraindicated in case of peptic ulcer.
For obstructive bronchitis (bronchitis that occurs with narrowing of the bronchi - popularly known as "bronchitis with an asthmatic component"), doctors usually prescribe bronchodilators during exacerbations. These are aerosols that relieve suffocation. Important warning: There are older bronchodilators containing ephedrine(For example, broncholithin, solutan) - such drugs are categorically contraindicated in hypertension, heart disease.
Each patient with chronic bronchitis should have an electric compressor-type inhaler - a nebulizer (the compressor delivers a pulsating stream of air that forms an aerosol cloud from a medicinal solution). During exacerbations, such a device is indispensable. Inhalations are carried out in the morning and in the evening (inhalations should not be done by means not provided for this, for example, mineral waters, home-made decoctions of herbs; use plain boiled water to dilute solutions!). Inhalation should be followed by positional drainage, since the solutions used for inhalation effectively thin the sputum.
The problem of antibiotic therapy in chronic processes in the lungs is very complex. On the one hand, the decision to prescribe an antibiotic must be made by the doctor. On the other hand, a quick recovery can only lead to the fastest possible start of therapy with the appropriate drug. In the interests of the patient, one has to deviate from the rules and give the following recommendation: for a patient suffering from chronic bronchitis and knowing about his disease, it makes sense to have at home a package of a reliable antibacterial agent (which one - the doctor will tell you) with a good expiration date and start taking it as soon as there will be signs of exacerbation. Most likely, the sick person, having taken the first antibiotic pill, will do the right thing, since the onset of an exacerbation in itself indicates that the body has taken a step back in its resistance to microbes, and it needs help.
Indeed, the occurrence of an exacerbation is a breakdown of the body's immune defenses. The reasons can be very different, among them hypothermia, stressful situations, the beginning of flowering of plants to which there is an allergy, etc. A very common option is the aggravation of a chronic process in response to a respiratory viral infection. In this regard, reasonable preventive measures will not interfere, for example, warmer clothes in the cold season, avoiding long waits for transport in the cold, having an umbrella in case of rain, a huge cup of hot tea with honey after hypothermia, etc. Partially preventing a virus attack can be limited contact with other people (especially those already infected). During epidemics, all Japanese wear gauze masks even on the street - they reject complexes and do the right thing: prevention is expensive. Now masks are available, they can be bought at every pharmacy. Wear a mask at least at work, and answer puzzled questions and glances that you have a slight runny nose.
It is not necessary to “stimulate the immune system” with drugs. This is unattainable and can be harmful. It would be nice not to harm! Warmth can enhance protection against germs. An increase in body temperature, if it is not excessive (no more than 38.5-39 ° C), is a factor that ensures the most active interaction of the elements of immunity. Even if the patient does not feel well, but he does not have an excruciating headache, it is advisable to refrain from taking antipyretic, painkillers. A vicious practice - to take "3 times a day" medicines "for colds" - with a viral infection in a previously healthy person, it increases the recovery time and contributes to the development of complications, and in a patient with chronic bronchitis it inevitably leads to exacerbation. Moreover, with a sluggish infection and a very weak temperature reaction, repeated, for example, in the evenings, moderately hot baths or showers will contribute to recovery. Hot baths are contraindicated for the elderly; those who do not tolerate them at all or suffer from hypertension, heart disease, atherosclerosis of cerebral vessels. You can limit yourself to a warm water procedure. After it - tea with honey or jam.
All questions concerning further measures in the treatment of a particular patient, of course, are called upon to decide the doctor. After the exacerbation subsides, the problem of preventing a new one arises, and therefore it is necessary to pay more attention to your health. Hardening and regular adequate physical activity have a good effect. Prophylactic inhalations with the help of a home nebulizer are very useful. They are done from time to time (especially when there is a feeling of sputum retention); it is enough to use a physiological solution of sodium chloride and, after inhalation, cough well. For a person suffering from chronic bronchitis, it is very important to avoid influences that irritate the mucous membrane of the bronchial tree. If possible, it is necessary to reduce the impact of air pollutants (dust, exhaust gases, chemicals, including household chemicals). It is recommended to wear a respirator during repair work, refuse to do painting work on your own, avoid physical education near motorways, standing in traffic jams, etc. It is useful to use humidifiers at home and in the office, especially in winter and when the air conditioner is running.
We have to raise the issue of smoking. From the point of view of logic, a smoking patient suffering from chronic respiratory diseases is an unnatural phenomenon, but ... terribly common. Smoking, harmful to everyone, is triple dangerous for our patient, as it provokes exacerbations and accelerates the progression of secondary changes in the lungs, which inevitably lead to respiratory failure. At first, this is not obvious to a person, but when shortness of breath begins to torment even at rest, it will be too late. It must be pointed out that quitting smoking during an exacerbation is not worth it, as this can make it difficult for sputum to pass. However, as soon as there has been an improvement, stop smoking!
Types of diseases :
1) Hereditary:
· bronchial asthma;
2) Inflammatory:
· bronchitis;
· pneumonia;
Bronchial asthma is caused by an allergic factor and is a hereditary disease. It begins in childhood and persists throughout life with periodic exacerbations and blunting of symptoms. This disease is treated throughout life, an integrated approach is applied, hormonal drugs are often used in treatment. The disease - bronchial asthma, significantly worsens the patient's quality of life, makes him dependent on a large number of medications and reduces his ability to work.
Inflammatory diseases include bronchitis and pneumonia.
Inflammation of the lining of the bronchi is called bronchitis. With a viral and bacterial infection, it can proceed in an acute form, chronic bronchitis is more often associated with fine particles, for example, dust. Statistics show that every third person who applied with a cough or asthma attacks has bronchitis. About 10% of the population suffer from this disease - chronic bronchitis. One of the main reasons is smoking. Almost 40 percent of people addicted to this habit in Russia, most of them are men. The main danger of the disease is a change in the structure of the bronchus and its protective functions. This disease is also referred to as occupational diseases, it affects painters, miners, quarry workers. Bronchitis should not be left to chance, timely measures are required to prevent complications.
Inflammation of the lungs is pneumonia. It is often the leading cause of death in young children. A fairly common and frequently occurring disease, on average, about three million people a year suffer from it, while every fourth disease acquires severe forms and consequences, up to a threat to human life. Reduced immunity, infection in the lungs, risk factors, lung pathology - these reasons give rise to the disease - pneumonia. Complications can be pleurisy, abscess or gangrene of the lung, endocarditis and others. Treatment of pneumonia should begin at the earliest stages, under the supervision of a doctor in a hospital. It should be complex with the subsequent rehabilitation of the patient.
Diagnostics
Diagnosis of many diseases of the bronchopulmonary system is based on radiography, X-ray computed tomography (RCT), ultrasound (ultrasound), magnetic resonance imaging (MRI) of the chest. Methods of medical imaging (radiation diagnostics), despite the different ways of obtaining an image, reflect the macrostructure and anatomical and topographic features of the respiratory system.
Visual diagnosis of respiratory distress syndrome.
One of the few methods of objectification and quantitative assessment of the level of intoxication is the determination of the concentration of medium molecular blood oligopeptides (the level of medium molecules). The simplest and most accessible, in fact, express method, is the method proposed by N. P. Gabrielyan, which gives an integral characteristic of this indicator. Normally, the level of medium molecules is kept within 220-250 units. With moderate intoxication, this figure increases to 350-400 units, with severe intoxication - up to 500-600 units. with a maximum increase of up to 900-1200 units, which already reflects an almost incurable state. More fully reveals the nature of endotoxicosis by the method of determining medium molecules, proposed by M.Ya. Malakhova (1995). One of the more accurate criteria for diagnosing respiratory distress syndrome are various methods for determining the volume of extravascular lung fluid (EAF). In vivo, including in dynamics, various colorful, isotope methods and thermal dilution can be used. Noteworthy are the results of such studies, which show that even after mild surgical interventions outside the chest cavity, there are signs of an increase in the volume of the VSL. At the same time, it is noted that even a two-fold increase in the volume of VZHP may still not be accompanied by any clinical, radiological, or laboratory (blood gases) manifestations. When the first signs of RDS are observed, it means that a pathological process has already gone far enough. Given these data, one can doubt the true frequency of this complication. It can be assumed that the phenomenon of respiratory distress syndrome is an almost constant companion of many pathological conditions and diseases. We should talk not so much about the frequency of RDS, but about the frequency of one or another degree of severity of RDS.
Chest X-ray.
Chest X-ray is a research method that allows you to get an image of the chest organs on x-ray film. X-rays are produced (generated) in the x-ray machine, which are directed towards the chest of the subject to the x-ray film, causing a photochemical reaction in it. Radioactive, X-rays, passing through the human body, are completely retained by some tissues, partially by others, and not at all by others. As a result, an image is formed on x-ray film.
Research objectives.
X-ray method of examination of the chest is used to recognize, first of all, lung diseases - pneumonia, tuberculosis, tumors, occupational injuries, as well as for the diagnosis of heart defects, diseases of the heart muscle, diseases of the pericardium. The method helps in recognizing changes in the spine, lymph nodes. The X-ray method is widely used for preventive examinations, especially when detecting early signs of tuberculosis, tumors, occupational diseases, when other symptoms of these diseases are still absent.
How research is done.
X-ray examination of the chest is performed in the X-ray room. The patient undresses to the waist, stands in front of a special shield, which contains a cassette with x-ray film. An x-ray machine with a tube that generates x-rays is placed about 2 m from the patient. Pictures are usually taken in two standard positions of the patient - straight (face shot) and side. The research time is a few seconds. The patient does not experience any discomfort during the study.
The main signs of disease, detected by x-ray of the lungs. When describing x-rays, there are not so many signs of disease (see Figure 1).
Rice. 1.
CT scan.
Computed tomography (CT) is one of the methods of X-ray examination. Any X-ray imaging is based on the different densities of the organs and tissues through which the X-rays pass. In conventional radiography, the picture is a reflection of the organ or part of it being examined. At the same time, small pathological formations may be poorly visible or not visualized at all due to the superposition of tissues (superposition of one layer on another).
To eliminate these interferences, the technique of linear tomography was introduced into practice. It made it possible to obtain a layered longitudinal image. The selection of the layer is achieved due to the simultaneous movement in opposite directions of the table on which the patient lies, and the film cassette.
The next step was computed tomography, for which its creators Cormac and Hounsfield were awarded the Nobel Prize.
The method makes it possible to obtain an isolated image of the transverse tissue layer. This is achieved by rotating a narrow beam x-ray tube around the patient and then reconstructing the image using special computer programs. The transverse plane image, which is not available in conventional X-ray diagnostics, is often optimal for diagnosis, as it gives a clear idea of the relationship of organs.
For the successful and effective use of CT, it is necessary to take into account indications and contraindications, the effectiveness of the method in each specific case, and follow the algorithm based on the principle "from simple to complex". Computed tomography should be prescribed by a doctor, taking into account clinical data and all previous studies of the patient (in some cases, preliminary radiography or ultrasound is necessary). This approach allows you to determine the area of interest, make the study focused, avoid studies without indications, and reduce the dose of radiation exposure.
Proper use of modern diagnostic capabilities makes it possible to identify various pathologies at different stages.
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Chapter 2. Nursing care for bronchopulmonary diseases
Before nursing interventions, it is necessary to ask the patient and his relatives, conduct an objective study - this will allow the nurse to assess the patient's physical and mental condition, as well as identify his problems and suspect diseases. When interviewing a patient and his relatives, it is necessary to ask questions about past diseases, the presence of bad habits, the possibility of having hereditary diseases. Analysis of the obtained data helps to identify the patient's problems.
Leading complaints of patients with violations of the functions of the respiratory system:
cough is a complex protective reflex act aimed at excretion from the bronchi and into. d.p. sputum or foreign body; The nature of the cough matters, duration, time of appearance, volume, timbre - dry and wet; "morning", "evening", "night"; loud, "barking", quiet and short/cough; paroxysmal, strong or silent.
pain in the chest (m. b. associated with breathing, with movement, with body position) - a symptom of an emergency, a protective reaction of the body, indicating the presence of a damaging factor or pathological process; The origin, localization, character, intensity, duration and irradiation of pain, connection with breathing, coughing and body position matters.
shortness of breath (at rest, during physical exertion) - a subjective feeling of difficulty breathing, accompanied by a feeling of lack of air and anxiety (objectively: a violation of the frequency, depth, rhythm of breathing); Can be inspiratory (inhale) and expiratory (exhale).
asthma attack - a symptom of an emergency, severe shortness of breath with deep inhalation and exhalation, increased breathing, a painful feeling of lack of air, a feeling of tightness in the chest;
hemoptysis - coughing up blood in the form of streaks or clots less than 50 ml per day; May be "rusty" color, "raspberry jelly" color.
symptoms of general malaise (fever, general weakness, loss of appetite, headache, etc.);
The nursing process in pulmonology includes all the necessary stages of its organization: examination, nursing diagnosis, planning, implementation (implementation) of the plan and evaluation of the results.
Nursing diagnosis may be: fever, chills, headache, weakness, poor sleep, chest pain, dry or wet cough with mucopurulent, purulent or rusty sputum, shortness of breath with prolonged exhalation, tachycardia, cyanosis.
Examination, treatment, care and observation plan:
1) preparation of the patient for X-ray, laboratory, for consultation of specialists;
2) fulfillment of medical prescriptions for the treatment of the patient (timely distribution of medicines, production of injections and infusions
3) organization of other research methods (physiotherapy, exercise therapy, massage, oxygen therapy);
4) provision of pre-medical emergency care;
5) organization of care and monitoring of the patient.
Implementation of the plan:
a) timely and targeted fulfillment of prescriptions (antibiotics of various spectrums of action, sulfonamides, nitrofurans, nystatin or levorin, mucolytics);
b) timely collection of biological material (blood, sputum, urine) for laboratory testing;
c) preparation for pleural puncture (in the presence of fluid in the pleural cavity), X-ray and endoscopic examination;
d) if necessary, organizing a consultation with a physiotherapist for prescribing physiotherapeutic methods, an exercise therapy doctor for prescribing exercise therapy and massage, a phthisiatrician and an oncologist;
e) carrying out oxygen therapy, organizing timely ventilation of the ward, wet cleaning with disinfectant. means, washing and disinfection of the spittoon
f) timely change of bed and underwear, prevention of bedsores, regular turning of the patient to create drainage and sputum discharge - 4-5 times a day for 20-30 minutes, feeding seriously ill patients, hygienic care of the sick;
g) monitoring the activity of the cardiovascular system (heart rate, blood pressure) of the bronchopulmonary system (respiratory rate, sputum amount), physiological functions.
h) teaching the patient how to properly use the inhaler.
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Respiratory allergies are common allergic diseases with predominant damage to the respiratory system.
Etiology
Allergosis develops as a result of sensitization by endogenous and exogenous allergens.
Exogenous allergens of a non-infectious nature include: household - washing powders, household chemicals; epidermal - wool, skin scales of domestic animals; pollen - pollen of various plants; food - food; herbal, medicinal. Allergens of an infectious nature include bacterial, fungal, viral, etc.
Classification
The classification is as follows.
1. Allergic rhinitis or rhinosinusitis.
2. Allergic laryngitis, pharyngitis.
3. Allergic tracheitis.
4. Allergic bronchitis.
5. Eosinophilic pulmonary infiltrate.
6. Bronchial asthma.
Symptoms and diagnosis
Allergic rhinitis and rhinosinusitis. History - the presence of allergic diseases in parents and close relatives of the child, the relationship of diseases with allergens.
Symptoms are acute onset: sudden onset of severe itching, burning in the nose, bouts of sneezing, profuse liquid, often foamy discharge from the nose.
On examination, swelling of the mucous membrane of the nasal septum, lower and middle turbinates is revealed. The mucous membrane has a pale gray color with a bluish tint, the surface is shiny with a marble pattern.
An x-ray examination of the skull shows thickening of the mucous membrane of the maxillary and frontal sinuses, the ethmoid labyrinth.
Positive skin tests with infectious and non-infectious allergens are characteristic.
In laboratory diagnosis - an increase in the level of immunoglobulin E in the nasal secretion.
Allergic laryngitis and pharyngitis can occur in the form of laryngotracheitis.
It is characterized by an acute onset, dryness of the mucous membrane, a feeling of itching, soreness in the throat, bouts of dry cough, which later becomes “barking”, rough, hoarseness of voice appears, up to aphonia.
With the development of stenosis, inspiratory dyspnea appears, the participation of auxiliary muscles in the act of breathing, retraction of the pliable places of the chest, swelling of the wings of the nose, abdominal breathing becomes more intense and amplitude.
Bronchial obstruction develops due to edema, spasm and exudate and, as a result, obstructive ventilation failure.
The use of antibacterial agents does not have a positive effect, it may even worsen the condition.
Laboratory data - positive skin tests, increased levels of immunoglobulin E in the blood serum.
Allergic bronchitis occurs in the form of asthmatic bronchitis.
In the anamnesis there are data on the allergization of the body. In contrast to true bronchial asthma, asthmatic bronchitis develops a spasm of large and medium-sized bronchi, so asthma attacks do not occur.
Eosinophilic pulmonary infiltrate develops with sensitization of the body.
The most common cause of occurrence is ascariasis. In the general blood test, high eosinophilia (more than 10%) appears against the background of leukocytosis. Foci of infiltration appear in the lungs, homogeneous, without clear boundaries, which disappear without a trace after 1–3 weeks. Sometimes an infiltrate, having disappeared in one place, may occur in another.
2. Bronchial asthma
Bronchial asthma- an infectious-allergic or allergic disease of a chronic course with periodically recurring attacks of suffocation caused by a violation of bronchial patency as a result of bronchospasm, swelling of the bronchial mucosa and accumulation of viscous sputum.
Bronchial asthma is a serious health problem worldwide. It affects from 5 to 7% of the population of Russia. There is an increase in morbidity and an increase in mortality.
Classification (A. D. Ado and P. K. Bulatova, 1969)
1) atopic;
2) infectious-allergic;
3) mixed. Type:
1) asthmatic bronchitis;
2) bronchial asthma. Severity:
1) mild degree:
a) intermittent: attacks of bronchial asthma less than twice a week, exacerbations are short, from several hours to several days. At night, seizures occur rarely - twice or less a month;
b) persistent: seizures do not occur every day, no more than two per week.
At night, asthma symptoms occur more than twice a month;
2) the average degree - manifests itself every day, requires daily use of bronchodilators. Night attacks occur more than once a week;
3) severe degree - bronchial obstruction, expressed to varying degrees constantly, physical activity is limited.
The main link in the pathogenesis of bronchial asthma is the development of sensitization of the body to a particular allergen with the occurrence of allergic inflammation in the mucous membrane of the bronchial tree.
When collecting an anamnesis from a patient, it is necessary to establish the nature of the first attack, the place and season, the duration and frequency of attacks, the effectiveness of the therapy, the patient's condition during the non-attack period.
Pathogenesis
The main link in the pathogenesis of bronchial asthma is the development of sensitization of the body to a particular allergen and the occurrence of allergic inflammation.
Clinic
The main symptom is the presence of asthma attacks of the expiratory type with remote wheezing, paroxysmal cough. The forced position of the patient during an attack: the legs are lowered down, the patient sits on the bed, the body is tilted forward, hands rest on the bed on the sides of the body.
Symptoms of respiratory failure appear (participation of auxiliary muscles in the act of breathing, retraction of the intercostal spaces, cyanosis of the nasolabial triangle, shortness of breath). The chest is emphysematously swollen, barrel-shaped.
Percussion-box sound, the borders of the lungs are shifted down. Auscultatory - weakened breathing (short inhalation, long exhalation), an abundance of dry whistling rales, wet rales of various calibers. From the side of the cardiovascular system - narrowing the boundaries of absolute cardiac dullness, tachycardia, increased blood pressure.
On the part of the nervous system, there is increased nervous excitability or lethargy, a change in autonomic reactions (sweating, paresthesia).
Laboratory diagnostics
In the general history of blood - lymphocytosis, eosinophilia. In the general analysis of sputum - eosinophilia, epithelial cells, macrophages, or Charcot-Leiden crystals, and Kurshman spirals.
Instrumental research methods. On x-ray - emphysema of the lungs (increased transparency, the borders of the lungs are shifted down). Spirography: a decrease in the rate of exhalation (pneumotachometry), a decrease in VC, hyperventilation at rest.
Allergological examination. Carrying out skin tests with bacterial and non-bacterial allergens gives a positive result. Provocative tests with allergens are also positive.
Immunological indicators. With atopic bronchial asthma, the level of immunoglobulins A decreases and the content of immunoglobulins E increases, with mixed and infectious asthma, the level of immunoglobulins G and A increases.
In the atopic form, the number of T-lymphocytes decreases, in the infectious-allergic form it increases.
In the atopic form, the number of suppressors is reduced and the content of T-helpers is increased. With sensitization by fungal agents, the level of CEC increases.
Patient examination
Questioning (collection of anamnesis, complaints). Inspection (palpation, percussion, auscultation). General blood analysis. Microscopy and culture of sputum.
X-ray of the chest organs. Study of indicators of external respiration. Allergological, immunological examination.
Differential Diagnosis
The differential diagnosis of bronchial asthma is carried out with diseases manifested by a bronchospastic syndrome of a non-allergic nature, which are called "syndromic asthma"; chronic obstructive bronchitis, diseases of the cardiovascular system with left ventricular failure (cardiac asthma), hysteroid respiratory disorders (hysteroid asthma), mechanical blockage of the upper respiratory tract (obstructive asthma).
Differentiate with diseases of an allergic nature: polyposis, allergic bronchopulmonary aspergillosis with obstructive respiratory disorders.
It is necessary to take into account the presence of a combination of two or more diseases in a patient.
In contrast to bronchial asthma in chronic obstructive bronchitis, the obstructive syndrome persists steadily and does not reverse development even when treated with hormonal drugs, and there is no eosinophilia in the sputum during the analysis.
With left ventricular failure, the development of cardiac asthma is possible, which is manifested by an attack of shortness of breath at night; a feeling of lack of air and tightness in the chest develops into suffocation.
It is combined with arrhythmia and tachycardia (with bronchial asthma, bradycardia is more common). Unlike bronchial asthma, both phases of breathing are difficult. An attack of cardiac asthma can be prolonged (until the use of diuretics or neuroglycerin).
Hysteroid asthma has three forms. The first form is similar to a respiratory cramp. The breath of the "driven dog" - inhalation and exhalation are strengthened. There are no pathological signs on physical examination.
The second form of suffocation is observed in hysterical people and is caused by a violation of the contraction of the diaphragm. During an attack, breathing is difficult or impossible, in the area of the solar plexus - a feeling of pain.
To stop the attack, the patient is offered to inhale hot water vapor or give anesthesia.
Obstructive asthma is a symptom complex of suffocation, which is based on a violation of the patency of the upper respiratory tract.
The cause of obturation may be tumors, foreign body, stenosis, aortic aneurysm. The greatest value in the diagnosis belongs to the tomographic examination of the chest and bronchoscopy.
The combination of symptoms of shortness of breath and suffocation also occurs in other conditions (anemic, uremic, cerebral asthma, periarthritis nodosa, carcinoid syndrome).
Pollinosis, or hay fever, is an independent allergic disease in which the body is sensitized to plant pollen.
These diseases are characterized by: bronchospasm, rhinorrhea and conjunctivitis. The disease is characterized by seasonality. It starts with the flowering period of plants and decreases when it ends.
The stage of exacerbation is characterized by a persistent runny nose, pain in the eyes and tearing, coughing up to the development of an asthma attack.
Possible fever, arthralgia. In the general blood test - eosinophilia (up to 20%). During the remission period, it does not manifest itself clinically.
Allergic bronchopulmonary aspergillosis- a disease caused by sensitization of the body to asperginella fungi. With this disease, damage to the alveoli, vessels of the lungs, bronchi, and other organs is possible.
The clinical sign is the symptom complex of bronchial asthma (obstructive syndrome, eosinophilia, increased immunoglobulin E).
Confirmation of the diagnosis is carried out by detecting skin sensitization to aspergillus allergens.
Diagnosis example. Bronchial asthma, atopic form, with frequent relapses, remission period, uncomplicated.
Treatment
The goal of treatment is to prevent the occurrence of attacks of suffocation, shortness of breath during physical exertion, coughing, and nocturnal respiratory failure. Elimination of bronchial obstruction. Maintain normal lung function.
The objectives of the therapy:
1) stop exposure to the body of the allergen - the cause of the disease. With pollen allergy, the patient is offered to move to another area during the flowering period of plants. With occupational allergies - change the place and working conditions. With food - strict adherence to an elementary diet;
2) carry out specific desensitization followed by the production of blocking antibodies (immunoglobulins G);
3) stabilize the walls of mast cells and prevent the secretion of biologically active substances;
4) limit the impact of irritants on the respiratory tract - cold air, strong odors, tobacco smoke;
5) rehabilitation of chronic foci of infection (teeth with inflammation, sinusitis, rhinitis);
6) to limit the developing allergic inflammation by prescribing glucocorticoids in inhaled form;
7) prevent the use of non-steroidal anti-inflammatory drugs.
Principles of treatment.
1. Elimination of the allergen (exclusion, elimination).
2. Bronchospasm therapy:
1) selective?-agonists (berotec, salbutalone, ventosin, terbutamol, fenotirol, guoetarin);
2) non-selective adrenomimetics (adrenaline, ephedrine, asthmapent, fulprenaline, isadrin, euspiran, novodrin);
3) phosphodiesterase antagonists, xanthines (theobramins, theophylline, eufilkin);
4) anticholinergics (atropine, ipratropine).
3. Histamine H 2 receptor blockers (tavegil, fencarol, suprastin, atosinil, pipolfen, displeron).
4. Drugs that reduce bronchial reactivity (glucocorticoids, intal, betotifen).
5. Expectorants:
1) increasing the liquid phase of sputum (thermopsis, licorice root, marshmallow, potassium iodide, alkionium chloride);
2) mucolytic drugs (acetylcysteine (ACC)), ribonuclease, deoxyribonuclease);
3) drugs that combine a mucoliptic effect with an increase in the level of surfactant (bromgesin, ambrocagn, lazolvan).
6. Antibiotics.
7. Vibration massage with postural drainage.
8. Physiotherapeutic procedures, reflexology (acupuncture, oxygen therapy).
9. Bronchoscopy, intranasal tracheobronchial sanitation.
10. Rehabilitation in the gnotobiological department.
11. Sauna therapy.
3. Acute bronchitis
Bronchitis is a disease of the bronchi, accompanied by a gradually developing inflammation of the mucous membrane with subsequent involvement of the deep layers of the walls of the bronchi.
Etiology
More often it develops during activation, reproduction of the opportunistic flora of the organism itself with a violation of mucociliary clearance due to SARS.
A predisposing factor is cooling or sudden heating, polluted air, smoking.
Pathogens - viruses, bacteria, mixed, allergens.
Classification:
1) acute bronchitis (simple);
2) acute obstructive bronchitis (with symptoms of bronchospasm);
3) acute bronchiolitis (with respiratory failure);
4) recurrent bronchitis.
Pathogenesis
Viruses, bacteria, mixed or allergens multiply, damaging the epithelium of the bronchi, reduce the barrier properties and cause inflammation, impaired nerve conduction and trophism.
The narrowing of the bronchial passages occurs as a result of mucosal edema, excess mucus in the bronchi and spasm of the smooth muscles of the bronchi.
Clinic
The flow is undulating. By the end of the first week of illness, the cough becomes wet, the temperature returns to normal.
The main clinical symptom is cough with mucous or purulent sputum; subfebrile temperature, no symptoms of intoxication. Auscultatory - dry and wet, wheezing wheezes of medium caliber on exhalation, hard breathing are heard.
Wheezing is scattered, practically disappears after coughing. In the general analysis of blood - moderately pronounced hematological changes: increased ESR, monocytosis.
On radiography - strengthening of the broncho-vascular pattern, expansion of the roots, symmetrical changes.
Acute obstructive bronchitis is characterized by shortness of breath on exertion; agonizing cough with scanty expectoration.
Auscultatory - lengthening of exhalation. With forced breathing - wheezing wheezing on exhalation. In the general blood test, hematological changes are more often leukopenia.
On the radiograph - emphysema, increased transparency of the lung tissue, expansion of the roots of the lungs.
Acute bronchiolitis (capillary bronchitis) is characterized by a generalized obstructive lesion of the bronchioles and small bronchi.
The pathogenesis is associated with the development of edema of the mucous wall of bronchioles, papillary growth of their epithelium.
Clinically manifested by severe shortness of breath (up to 70–90 breaths per minute) against the background of persistent febrile temperature; increased nervous excitability associated with respiratory failure within a month after normalization of temperature; perioral cyanosis; auscultatory heard small bubbling, cracking asymmetric rales. Cough dry, high-pitched. The chest is swollen.
In the general blood test - hematological changes: increased ESR, neutrophilic shift, moderate leukocytosis.
On the radiograph - the alternation of areas with increased density with areas of normal pneumatization; low standing of the diaphragm, sometimes total darkening of the lung field, atelectasis.
Recurrent bronchitis is diagnosed when there are three or more diseases during the year with a prolonged cough and auscultatory changes in bronchitis without an asthmatic component, but with a tendency to a protracted course. This disease does not cause irreversible changes and sclerosis. The pathogenesis is due to a decrease in the barrier function of the bronchial mucosa to resist infections.
Predisposing factors: immunity defects, heredity, predisposition, polluted air, damage to the bronchial mucosa by exogenous factors, bronchial hyperreactivity. Recurrent bronchitis develops against the background of clinical signs of SARS.
moderate fever. The cough is initially dry, then wet, with mucous or mucopurulent sputum. Percussion-pulmonary sound with a box shade. Auscultatory - hard breathing, dry, moist rales of medium and small caliber, scattered on both sides.
In the general blood test, hematological changes - leukocytosis or leukopenia, monocytosis.
On the radiograph - increased lung pattern, expansion of the roots, atelectasis, hypoventilation. Bronchological examination - signs of bronchospasm, delayed filling of the bronchi with contrast, narrowing of the bronchi.
Survey plan
The plan of examination of the patient is as follows.
1. Collection of anamnesis (earlier ARVI, premorbid background, concomitant diseases, frequency of ARVI, hereditary predisposition, allergy to something, assessment of the effect of the treatment).
2. Examination of the patient (assessment of cough, breathing, chest shape).
3. Palpation (the presence of emphysema, atelectasis).
4. Percussion - the mobility of the lungs during breathing, air filling.
5. Auscultation (vesicular breathing, hard, diffuse wheezing).
6. Blood test - increase in ESR, shift of the leukocyte formula.
7. General analysis of urine.
8. Analysis of sputum from the nasopharyngeal mucosa with the determination of sensitivity to antibiotics.
10. The study of the ventilation function of the lungs.
11. Radiography - the study of the vascular and pulmonary pattern, the structure of the roots of the lungs.
12. Bronchoscopy and mucosal examination.
13. Tomography of the lungs.
14. Immunological study.
Differential Diagnosis
Differential diagnosis is carried out with:
1) bronchopneumonia, which is characterized by local damage to the lungs, intoxication, persistent fever; X-ray changes characteristic of a focal lesion;
2) bronchial asthma, which is accompanied by asthma attacks, hereditary predisposition, contact with an infectious allergen;
3) with congenital or acquired heart disease, which are characterized by congestion in the lungs. Diagnosis example. Acute infectious-allergic obstructive bronchitis DN 2 .
Treatment
Principles of treatment:
1) antibacterial therapy: antibiotics: ampicillin, tetracycline and others, sulfa drugs: sulfapyridazine, sulfomonolithaxin;
2) mucolytic drugs: acetlcysteine, bromhexine, trypsin, chymotrypsin;
3) expectorants: breast collection (coltsfoot, wild rosemary, marshmallow, elecampane), broncholithin;
4) bronchitis: amupect, berotene;
5) endobroncholitin: eufillin in aerosol;
6) vitamins of groups B, A, C (cocarboxylase, biplex);
7) immunostimulants (immunal, thymolin);
8) physiotherapy, massage, breathing exercises.
4. Respiratory failure
Respiratory insufficiency is a pathological condition of the body, characterized by insufficient provision of the gas composition of the blood, or it can be achieved with the help of compensatory mechanisms of external respiration.
Etiology
There are five types of factors leading to a violation of external respiration:
1) damage to the bronchi and respiratory structures of the lungs:
a) violation of the structure and function of the bronchial tree: an increase in the tone of the smooth muscles of the bronchi (bronchospasm), edematous and inflammatory changes in the bronchial tree, damage to the supporting structures of the small bronchi, a decrease in the tone of the large bronchi (hypotonic hypokinesia);
b) damage to the respiratory elements of the lung tissue (infiltration of the lung tissue, destruction of the lung tissue, dystrophy of the lung tissue, pneumosclerosis);
c) decrease in functioning lung tissue (underdeveloped lung, compression and atelectasis of the lung, absence of part of the lung tissue after surgery);
2) violation of the musculoskeletal framework of the chest and pleura (impaired mobility of the ribs and diaphragm, pleural adhesions);
3) violation of the respiratory muscles (central and peripheral paralysis of the respiratory muscles, degenerative-dystrophic changes in the respiratory muscles);
4) circulatory disorders in the pulmonary circulation (damage to the vascular bed of the lungs, spasm of the pulmonary arterioles, stagnation of blood in the pulmonary circulation);
5) violation of the control of the act of breathing (depression of the respiratory center, respiratory neurosis, changes in local regulatory mechanisms).
Classification
1) ventilation;
2) alveolorespiratory.
Type of ventilation failure:
1) obstructive;
2) restrictive;
3) combined.
Severity: DN I degree, DN II degree, DN III degree.
Obstructive ventilation failure is caused by a violation of the gas flow through the airways of the lungs as a result of a decrease in the lumen of the bronchial tree.
Restrictive ventilation failure is the result of processes that limit the extensibility of lung tissue and a decrease in lung volumes. For example: pneumosclerosis, adhesions after pneumonia, lung resection, etc.
Combined ventilation failure occurs as a result of a combination of restrictive and obstructive changes.
Alveolorespiratory insufficiency develops as a result of a violation of pulmonary gas exchange due to a decrease in the diffusion capacity of the lungs, an uneven distribution of ventilation and ventilation-perfusion deposits of the lungs.
The main stages of diagnosis
Respiratory failure I degree. Manifested by the development of shortness of breath without the participation of auxiliary muscles, absent at rest.
Cyanosis of the nasolabial triangle is unstable, increases with physical exertion, anxiety, disappears when breathing 40-50% oxygen. The face is pale, puffy. Patients are restless, irritable. Blood pressure is normal or slightly elevated.
Indicators of external respiration: minute volume of respiration (MOD) is increased, vital capacity (VC) is lowered, respiratory reserve (RD) is lowered, respiratory volume (OD) is slightly reduced, respiratory equivalent (DE) is increased, oxygen utilization factor (KIO 2) is reduced . The gas composition of the blood at rest is unchanged, it is possible to saturate the blood with oxygen. The tension of carbon dioxide in the blood is within the normal range (30–40 mm Hg). Violations of the KOS is not determined.
Respiratory insufficiency II degree. It is characterized by shortness of breath at rest, retraction of compliant places of the chest (intercostal spaces, supraclavicular fossae), possibly with a predominance of inhalation or exhalation; ratio P / D 2 - 1.5: 1, tachycardia.
Cyanosis of the nasolabial triangle, face, hands does not disappear when 40–50% oxygen is inhaled. Diffuse pallor of the skin, hyperhidrosis, pallor of the nail beds. Arterial pressure rises.
Periods of anxiety alternate with periods of weakness and lethargy, VC is reduced by more than 25-30%. OD and RD reduced to 50%. DE is increased, which is due to a decrease in oxygen utilization in the lungs. Blood gas composition, CBS: blood oxygen saturation corresponds to 70–85%, i.e., decreases to 60 mm Hg. Art. Normocapnia or hypercapnia above 45 mm Hg. Art. Respiratory or metabolic acidosis: pH 7.34 - 7.25 (at a norm of 7.35 - 7.45), base deficiency (BE) increased.
Respiratory insufficiency III degree. It is clinically manifested by severe shortness of breath, the respiratory rate exceeds 150% of the norm, aperiodic breathing, bradypnea periodically occurs, breathing is asynchronous, paradoxical.
There is a decrease or absence of respiratory sounds on inspiration.
The ratio of P / D changes: cyanosis becomes diffuse, generalized pallor is possible, marbling of the skin and mucous membranes, sticky sweat, blood pressure is reduced. Consciousness and reaction to pain are sharply reduced, skeletal muscle tone is reduced. Seizures.
Precoma and coma. Indicators of external respiration: MOD is reduced, VC and OD are reduced by more than 50%, RD is 0. Blood gas composition of COS: blood oxygen saturation is less than 70% (45 mm Hg).
Decompensated mixed acidosis develops: pH less than 7.2; BE greater than 6–8, hypercapnia greater than 79 mm Hg. Art., the level of bicarbonates and buffer bases is reduced.
The survey plan includes:
1) questioning and examination;
2) objective examination (palpation, percussion, auscultation);
3) determination of CBS, partial pressure of O 2 and CO 2 in the blood;
4) study of indicators of external respiration.
Differential Diagnosis
Differential diagnosis of respiratory failure is based on a comparison of clinical symptoms and indicators of external respiration and tissue respiration. With the development of respiratory failure no more than II degree, it is necessary to find the cause of its development.
For example, in violation of alveolar patency, signs of depression of the central nervous system, a violation of the neuromuscular regulation of respiration and destructive processes are differentiated.
With the development of symptoms of obstruction, it is necessary to distinguish between diseases and conditions that cause high obstruction (acute stenosing laryngitis, tracheitis, allergic laryngeal edema, foreign body) and low obstruction (bronchitis, bronchiolitis, asthma attack and status asthmaticus). circulation).
Diagnosis example. Bronchopneumonia complicated by cardio-respiratory syndrome, acute course of II degree respiratory failure, obstructive ventilatory form.
Principle of treatment:
1) creation of a microclimate (ventilation of premises, humidification, aeronization);
2) maintenance of free airway patency (mucus suction, bronchodilators, expectorants, breathing exercises, vibration massage with postural drainage);
3) oxygen therapy (through a mask, nasopharyngeal catheter, oxygen tent, mechanical ventilation, hyperbaric oxygenation);
4) spontaneous breathing under constant positive pressure (CPAP);
5) normalization of pulmonary blood flow (eufillin, pentamine, benzohexonium);
6) CBS correction;
7) to improve the utilization of oxygen by tissues - a glucose-vitamin-energy complex (glucose 10-20; ascorbic acid, cocarboxylase, riboflavin, zeichrome C, calcium pantothenate, unition);
8) treatment of the underlying disease and concomitant pathological conditions.
5. Acute pneumonia
Pneumonia is an infectious lesion of the alveoli, accompanied by infiltration of inflammatory cells and exudation of the parenchyma in response to the invasion and proliferation of microorganisms in the usually sterile parts of the respiratory tract. One of the most common respiratory diseases; 3-5 cases per 1,000 people.
Etiology
The etiology of pneumonia may be due to:
1) bacterial flora (pneumococcus, streptococcus, staphylococcus, Escherichia coli, Proteus, etc.);
2) mycoplasma;
4) fungi.
1) bacterial flora (pneumococcus, streptococcus, staphylococcus, Haemophilus influenzae, Friednender's bacillus, enterobacteria, Escherichia coli, Proteus);
2) mycoplasma;
3) influenza, parainfluenza, herpes, respiratory sensitial, adenoviruses, etc.;
4) fungi.
Classification
1) focal bronchopneumonia;
2) segmental pneumonia;
3) interstitial pneumonia;
4) croupous pneumonia.
1) acute;
2) protracted.
The severity is determined by the severity of clinical manifestations or complications:
1) uncomplicated;
2) complicated (cardiorespiratory, circulatory, extrapulmonary complications).
Diagnostic criteria. Anamnestic:
1) the presence of respiratory diseases in the family (tuberculosis, bronchial asthma);
2) ARVI transferred the day before, adenovirus infection;
3) hypothermia.
Clinic
Complaints of cough, fever, weakness, sweating.
Signs of respiratory failure: breathing is groaning, rapid, the number of breaths is up to 60-80 breaths per minute, swelling of the wings of the nose, retraction of the pliable parts of the chest, violation of the rhythm of breathing, inhalation is longer than exhalation, cyanosis of the skin, nasolabial triangle is strongly pronounced, especially after exercise ; gray complexion, pallor of the skin of the face as a result of hypoxemia and hypercapnia, due to the exclusion of a more or less significant part of the alveoli from participating in normal respiratory gas exchange.
It is characterized by intoxication syndrome: fever, weakness, adynamia or agitation, sometimes accompanied by convulsions, sleep disturbance, loss of appetite.
Disorders from the cardiovascular system: muffled heart tones, tachycardia, expansion of the boundaries of the heart, pulse filling is reduced, blood pressure is sometimes increased, the emphasis of the second tone on the aorta. Slowing of cardiac function in severe pneumonia is a formidable symptom.
Changes in the gastrointestinal tract develop due to a decrease in secretory and enzymatic activity: nausea, vomiting, flatulence due to impaired peristalsis, abdominal pain due to irritation of the lower intercostal nerves innervating the diaphragm, abdominal muscles and abdominal skin.
Objective changes in the lungs: functional data are expressed in segmental (polysegmental) and confluent pneumonia, less pronounced in focal pneumonia and bronchopneumonia.
Minimal changes in interstitial pneumonia. Examination and palpation of the chest reveal swelling, more in the anterior sections, tension, which is a characteristic sign of lung enphysema.
During percussion, the percussion sound is variegated (dullness during percussion alternates with areas of tympanic sound); dullness of percussion sound in the lower back sections of the lungs is characteristic of confluent pneumonia.
It is possible with percussion that there are no changes due to the small size of the inflammatory focus.
During auscultation, respiratory failure is heard: hard, puerile, weakened, wet wheezing, small, medium and large caliber, depending on the involvement of the bronchi in the inflammatory process; wheezing can be dry, of a varied nature (whistling, musical). With a deep location of inflammatory foci in the lungs, there may be no percussion and auscultatory changes.
Research methods
X-ray examination: in the pictures, emphysematous changes are combined with foci of infiltration of the lung tissue. It is possible to damage the entire segment of the lung, including the root on the side of the lesion.
In the general blood test, hematological changes: in the peripheral blood, neutrophilic leukocytosis with a shift to the left, an increase in ESR. With a decrease in the reactivity of the body, the indicators may be within the normal range.
Examination plan:
1) general analysis of blood and urine;
2) biochemical study of blood serum (protein fractions, sialic acids, seromucoid, fibrin, LDH);
3) radiography of the chest in two projections;
5) blood test for immunoglobulins, T- and B-lymphocytes;
6) bacteriological examination of mucus from the nasopharynx, sputum with the determination of the sensitivity of the isolated flora to antibacterial drugs;
7) assessment of the main indicators of external respiration;
8) study of pH and gas composition of blood;
9) radiography of the paranasal sinuses according to indications (complaints of pain when tilting the head, palpation in the projection of the sinuses, discharge from the nose).
Differential Diagnosis
Differential diagnosis is carried out with bronchitis, bronchiolitis, acute respiratory viral infection, acute dissimilated pulmonary tuberculosis.
Diagnosis example. Focal bronchopneumonia uncomplicated, acute course.
Treatment
Principle of treatment:
1) the patient is prescribed bed rest, aerotherapy, a diet corresponding to the severity of the condition;
2) antibacterial drugs antibiotics (semi-synthetic penicillins, aminoglycosides, cephalosporins), sulfanilamide drugs (sulfadimezin, sulfoalopanetaxin, biseptol), nitrofuran drugs (furagin, furadonin, furazolidone);
3) treatment of respiratory failure, elimination of obstructive syndrome (removal of mucus from the upper respiratory tract, expectorants and mucolytics, bronchodilators);
4) antihistamines (diphenhydramine, fenkarol, kis-tin, telfast);
5) increase in the patient's immunological activity (immunoglobulin, dibazol, pentoxin, methyluracil, immunomodulators - immunal);
6) vitamin therapy.
6. Pleurisy
Pleurisy is an inflammation of the pleura, accompanied by a tension in the function and structure of the pleural sheets and changing the activity of the external respiratory system.
Etiology
The development of pleurisy may be associated with an infectious agent (staphylococcus, pneumococcus, tuberculosis pathogen, viruses, fungi); non-infectious effects - a complication of the underlying disease (rheumatism, systemic lupus erythematosus, pancreatitis).
Pleurisy may be of unknown etiology (idiopathic pleurisy).
Classification
The classification is as follows:
1) dry pleurisy (fibrous);
2) effusion pleurisy: serous, serous-fibrinous, purulent, hemorrhagic (depending on the nature of the exudate).
Diagnostic criteria
History of previously transferred infectious diseases, pneumonia, inflammation of the paranasal sinuses; frequent hypothermia of the body; the presence in the family or close relatives of tuberculosis or other respiratory diseases.
Clinical signs of pleurisy are manifested by a painful wet cough with a small amount of mucous sputum; the patient complains of pain in the chest (one half), which is aggravated by breathing.
There is a syndrome of respiratory failure: shortness of breath, pallor of the skin, perioral cyanosis, aggravated by physical exertion; acrocyanosis. It is characterized by intoxication syndrome: fatigue, poor appetite, lethargy, weakness.
An objective examination reveals asymmetry of signs: the forced position of the child on the affected side with fixation of the diseased half of the chest.
The side with the focus of inflammation looks smaller, lags behind in the act of breathing, the shoulder is lowered.
With the accumulation of exudate in the pleural cavity during percussion, there is a shortening of the percussion sound with an upper border that goes from the spine upwards outward and to the inner edge of the scapula (Damuazo line).
This line and the spine limit the region of clear lung sound (Garland's triangle). On the healthy side of the chest there is a triangular area of percussion sound shortening (the Grocco-Rauhfus triangle).
Auscultatory: with exudative pleurisy, a sharp weakening of breathing is heard or there is no opportunity to listen to it, with dry pleurisy - pleural friction noise.
Additional research methods
On the radiograph there is an oblique darkening of the diseased lung (fluid level), mediastinal shift to the healthy side, infiltrates in the lung tissue.
The blood test has changes in the form of an increase in ESR, neutrophilic leukocytosis.
When examining the exudate of the pleural cavity, its nature is determined (serous, purulent, hemorrhagic), the specific gravity, the nature and number of formed elements, and the protein level are determined.
Inflammatory exudate is characterized by: the density is more than 1018, the amount of protein is more than 3%, a positive Rivalt test. In the cytological examination of the sediment at the beginning of the development of inflammation, neutrophils predominate.
With development, the number of neutrophils increases, and they can be destroyed. If eosinophils predominate in the sediment, then the patient has allergic pleurisy. The transudate is characterized by a sediment with a small amount of desquamated epithelium. With serous and hemorrhagic pleurisy, cultures on simple media do not give a result.
Tuberculous pleurisy can be established by inoculation on a special medium or infection of guinea pigs. Studies are supplemented with biopsy and morphological studies of altered areas of the pleura during thorocoscopy. In the presence of exudate in the pleural cavity, bronchoscopy is indicated.
Examination plan:
1) biochemical, general blood and urine tests;
2) examination of blood serum (protein, seromucoid, sialic acids, fibrinogen);
3) bacteriological studies of mucus from the pharynx and nose, sputum, fluid from the pleural cavity with the determination of the sensitivity of the isolated flora to antibiotics;
4) study of the immunological status with the determination of T- and B-lymphocytes;
5) X-ray of the chest in two projections in a vertical position;
6) pleural puncture;
7) tuberculin diagnostics.
Differential Diagnosis
Differential diagnosis is carried out between pleurisy of various etiologies (rheumatic pleurisy, with systemic lupus erythematosus, leukemia, lymphogranulomatosis, hemophilia, kidney disease, liver cirrhosis, liver amoebiasis, tumors, brucellosis, syphilis, mycosis), between effusion pleurisy and lower lobe atelectasis, lobar pneumonia .
Diagnosis example:
1) exudative pleurisy, purulent (pleural empyema, interlobar, pneumococcal);
2) dry pleurisy (fibrinous), effusion (purulent) pleurisy.
Treatment
Principle of treatment:
1) elimination of pain syndrome;
2) influence on the cause that caused pleurisy (antibiotics, anti-inflammatory therapy);
3) therapeutic pleural punctures;
4) symptomatic therapy;
5) physiotherapy, exercise therapy.
7. Chronic nonspecific lung diseases
Chronic nonspecific lung diseases are a group of diseases with different etiology and pathogenesis, characterized by damage to the lung tissue.
The classification is as follows:
1) chronic pneumonia;
2) malformations of the bronchopulmonary system;
3) hereditary lung diseases;
4) lung lesions in hereditary pathology;
5) bronchial asthma.
Chronic pneumonia is a chronic non-specific bronchopulmonary process, which is based on irreversible structural changes in the form of bronchial deformation, pneumosclerosis in one or more segments and is accompanied by inflammation in the lung or bronchi.
Etiology
Most often, chronic pneumonia develops as a result of recurrent or prolonged pneumonia of a staphylococcal nature, with destruction of the lungs.
Chronic secondary pneumonia is based on immunodeficiency states, aspiration of a foreign body, and malformations of the pulmonary system.
Classification
1) with deformation of the bronchi (without their expansion);
2) with bronchiectasis. Disease period:
1) exacerbation;
2) remission.
The severity of the disease depends on the volume and nature of the lesion, the frequency and duration of exacerbations, and the presence of complications.
Clinic
Chronic pneumonia: a history of repeated pneumonia with a protracted course and destruction of the lungs. It is clinically manifested by a constant wet cough, aggravated during an exacerbation.
Mucopurulent sputum, more often in the morning. The symptoms of intoxication are pronounced: pallor of the skin, cyanosis of the nasolabial triangle, decreased appetite. Syndrome of chronic heart and lung failure; cyanosis, shortness of breath, tachycardia, nail phalanges in the form of "watch glasses" and "drumsticks".
The chest is deformed - flattening, asymmetry in the act of breathing; percussion - shortening of the sound above the affected area. Auscultatory - bronchial amphoric, weakened breathing. Wheezing varied, wet and dry.
Polycystic lung disease is characterized by a wet cough with purulent sputum, shortness of breath, swelling and retraction of individual parts of the chest. Percussion - shortening of the sound over the foci of inflammation. Auscultatory - amphoric breathing, moist rales.
Lung damage in primary immunodeficiency states. Characteristic frequent SARS, sinusitis, otitis media, hepatolienal syndrome. Decrease in immunoglobulins of a certain class. In the general blood test, lymphopenia; decrease in T- and B-lymphocytes.
Primary pulmonary hypertension. Clinical manifestations: cough may be absent, patients are sharply emaciated, ECG shows right ventricular hypertrophy; on the radiograph - the expansion of the roots of the lungs, the expansion of the branches of the pulmonary artery.
Kartagener syndrome is characterized by a triad of symptoms:
1) reverse arrangement of internal organs;
2) bronchiectasis;
3) sinusitis.
Percussion - shortening of the sound above the lesion; auscultatory - moist rales. On the radiograph, the lung lesion is diffuse in nature with localization to a greater extent in the basal segments.
Idiopathic hemosiderosis of the lungs is characterized by damage to the lungs and the deposition of iron in them and anemia.
In sputum - macrophages with gynosiderin. In the blood, the content of indirect bilirubin is increased. On the radiograph - small cloud-like (1-2 cm) focal shadows, often symmetrical.
Trachea and main bronchi
At the border of the VII cervical vertebrae, the larynx passes into the trachea, trachea; in men this level is lower, in women it is higher. In the trachea, the cervical part, pars cervicalis and the thoracic part, pars thoracica are distinguished. The trachea occupies a position in front of the esophagus and in the chest cavity - behind the large vessels. Trachea length 9-15 cm, width 1.5-2.7 cm.
At level IV of the thoracic vertebra, the trachea is divided into the main right and left bronchi, bronchi principales dexter et sinister. The bifurcation of the trachea into two bronchi is called the bifurcation of the trachea, bifurcatio tracheae. On the inside, the place of separation is a lunate protrusion protruding into the cavity of the trachea - the keel of the trachea, carina tracheae.
The main bronchi diverge asymmetrically to the sides: the right one, shorter (3 cm), but wider, departs from the trachea at an obtuse angle (an unpaired vein lies above it); the left bronchus is longer (4-5 cm), narrower and departs from the trachea almost at a right angle (the aortic arch passes over it).
The skeleton of the trachea and main bronchi are arcuate (more than 2/3 of the circumference) cartilages of the trachea, cartilagines tracheales. Their posterior ends are connected by a soft membranous wall adjacent to the esophagus and forming the posterior wall of the trachea and main bronchi, the so-called membranous wall, paries membranaceus. The number of cartilages of the trachea 16-20; right bronchus - 6-S and left - 9-12. The cartilages are interconnected by annular ligaments (tracheal), ligg. anularia (trachealia), which posteriorly pass into the membranous wall of the trachea and bronchi. In the composition of the membranous wall of the trachea and bronchi, in addition, there are smooth muscle fibers of the longitudinal and transverse directions, forming the muscle of the trachea, m. trachealis.
The outer surface of the trachea and bronchi is covered with a connective tissue sheath, tunica adventitia.
The inner surface of the trachea and bronchi is lined with a mucous membrane, tunica mucosa, which, with the help of a submucosa, tela submucosa, is rather loosely connected to cartilage.
The mucous membrane of the trachea is devoid of folds, covered, as in the larynx, with multi-row prismatic ciliated epithelium and contains many mucous glands of the trachea, glandulae tracheales; in the mucous membrane of the bronchi, these are the bronchial glands, glandulae bronchiales.
Both those and others lie predominantly in the submucosa in the region of the intercartilaginous spaces and the membranous wall of the trachea and bronchi, and also in a smaller amount behind the cartilage.
Innervation: rr. tracheales from n. laryngeus recurrens (a branch of n. vagus) and truncus sympathicus, rr. bronchiales anteriores et posteriores (n. vagus).
Blood supply: rr. tracheales (from a. thyroidea inferior), rr. bronchiales (from aorta thoracica and a. thoracica interna).
Venous blood flows into the venous plexuses surrounding the trachea, and then into v. thyroidea inferior, a no w. bronchiales in v. azygos and v. hemiazygos. Lymphatic vessels drain lymph into nodi lymphatici cervicales profundi anterior (pretracheales, paratracheales) et laterales (jugulares) and into mediastinales anteriores (tracheobronchiales, paratracheales).
The external structure of the lungs
The lung, pulmo, is a paired organ located in the chest cavity. In children, the lung is pale pink, later becoming slate-blue with stripes and spots. Normal lung tissue is elastic and finely porous in section.
Each lung (right and left) has the shape of a truncated cone: the apex of the lung, apex pulmonis, is directed upwards into the region of the supraclavicular fossa; the base of the lung, basis pulmonis, rests on the diaphragm. The right lung is wider than the left, but somewhat shorter.
In the lower part of the anterior edge of the left lung, there is a cardiac notch of the left lung, incisura cardiaca pulmonis sinistri, - the place where the heart fits.
In the lungs, the following surfaces are distinguished:
costal surface, facies costalis, in which the vertebral part is isolated, pars vertebralis;
diaphragmatic surface, facies diaphragmatica; interlobar surfaces, facies interlobares;
mediastinal surface, facies mediastinalis, and cardiac depression, impressio cardiaca.
The costal surface of the lungs is convex and often bears the imprints of the ribs.
On the concave mediastinal surface there is a bay-shaped depression - the gate of the lung, hilum pulmonis, - the place of entry into the lung of the pulmonary and bronchial arteries, the main bronchus and nerves, the exit point of the pulmonary and bronchial veins and lymphatic vessels. The relationship of these formations in the gates of both lungs is not the same. At the gates of the right lung, the anterior-upper position is occupied by the bronchus, the posterior-lower position by the veins, and the middle position by the artery. At the gates of the left lung, the anterior-upper position is occupied by the artery, the posterior-lower position by the veins, and the middle position by the bronchus. The totality of all these formations (vessels, lymph nodes, nerves and bronchi) that perform the gates of the lungs constitutes the root of the lung, radix pulmonis.
The places where the surfaces of the lungs pass one into another are called edges. The lung has two edges: the lower edge, margo inferior, and the front edge, margo anterior.
The lung consists of lobes, lobi: the right - of three, the left - of two. In accordance with this, in the left lung there is one oblique fissure, fissura obiiqua, - a deep furrow dividing it into upper and lower lobes, lobus superior et lobus inferior. There are two interlobar sulci in the right lung, of which the upper one is called the horizontal fissure (right lung), fissura horizontal is (pulmonis dextri). These furrows divide it into three lobes: upper, middle and lower, lobus superior, lobus medius et lobus inferior. In the depth of the furrows, the interlobar surface, fades interlobaris, is determined.
The groove between the lobes of the left lung is projected onto the chest as a line connecting the spinous process of the III thoracic vertebra with the anterior end of the bone part of the VI rib. The furrows of the lobes of the right lung are projected onto the chest as follows.
The upper interlobar fissure, being the border between the upper and middle lobes, corresponds to the course of the IV rib from the middle axillary line, linea axillaris media, to the sternum. The lower fissure, being the boundary between the middle and lower lobes in front and the upper and lower posterior, runs along the line connecting the spinous process of the III thoracic vertebra with the cartilage of the VI rib along the mid-clavicular line, linea medioclavicularis.
The internal structure of the lungs
Each of the main bronchi, entering through the gates of the lungs into the corresponding lung, branches into the lobar bronchi.
The right bronchus gives three lobar bronchi, bronchia lobares, of which one follows above the artery, and the other two below the artery. The left bronchus gives rise to two lobar bronchi located under the artery.
Each of the branches brings air to the lobes of the lungs.
The lobar bronchi, in turn, are divided into segmental bronchi, bronchi segmentates. Each segmental bronchus, both in the right and in the left lung, dichotomously divides, while the branches of the bronchi decrease in diameter and become small bronchi; there are 9-10 orders of such branches. Small branches with a diameter of about 1 mm - bronchioles, bronchioli.
The entire bronchial system from the main to the bronchioles makes up the bronchial tree, arbor bronchialis, which serves to conduct the flow of air during breathing.
Further branching of the bronchioles is the alveolar tree, arbor alveolaris.
As the bronchi branch, the structure of their walls changes. If in the main bronchi the cartilaginous skeleton occupies an average of 2/3 of the circumference, then only small, cartilaginous plaques of various shapes are included in the walls of the smaller bronchial branches. As the cartilage tissue decreases in the wall of the bronchial branches, the mass of connective tissue increases.
The bronchioles are devoid of cartilage. In the wall of the bronchioles there are spiral smooth muscle fibers.
The inner surface of the branches of the bronchial tree is lined with a mucous membrane covered with a multi-row ciliated epithelium, gradually turning into a multi-row cubic, and, finally, in the terminal bronchioles, into a single-layer cubic ciliated, contains a significant amount of mucous bronchial glands, glandulae bronchiales. There are no glands in the bronchioles.
The bronchioles approach the secondary pulmonary lobules, which are separated from each other by connective tissue septa. Inside each lobule, the bronchioles suitable for them are divided into 18-20 bronchioles of the 2nd-3rd order, and the latter, in turn, are divided into respiratory bronchioles, bronchioli respiratorii.
Respiratory bronchioles bring air to areas of the lung called pulmonary acini, acini pulmonares (structural unit of the lung), the number of which in one lung reaches 15,000.
Within the acinus, the respiratory bronchioles branch into bronchioles of the 2nd-3rd order, and the last respiratory bronchioles give 2-9 alveolar passages, ductuli alveolares, the wall of which protrudes with vesicles - the alveoli of the lungs, alveoli pulmonis. Alveolar passages end in alveolar sacs, sacculi alveolares. The alveolar ducts and alveolar sacs, belonging to one respiratory alveolus of the last order, make up the primary lobule.
The total number of alveoli in each lung ranges from 300 to 350 million, and the total area of their respiratory surface is up to 80 m2.
The wall of the alveolar ducts is lined with a single-layer cubic ciliated epithelium and contains elastic fibers. The alveoli of the lung are lined with a single-layer flat (respiratory) epithelium, surrounded by a dense network of capillaries.
Thus, the lung parenchyma consists of a system of branching air tubes (bronchi, their branches, bronchioles, alveoli) and branching blood vessels (arteries and veins), lymphatic vessels and nerves. All these formations are interconnected by connective tissue.
Bronchopulmonary segments
The lungs are subdivided into bronchopulmonary segments, segmenta bronhopulmonalia (Fig. 4a, b; see Appendix).
The bronchopulmonary segment is a section of the lung lobe ventilated by one segmental bronchus and supplied by one artery.
The veins that drain blood from the segment pass through the intersegmental septa and are most often common to two adjacent segments.
The segments are separated from one another by connective tissue septa and have the shape of irregular cones and pyramids, with the apex facing the hilum and the base facing the surface of the lungs. According to the International Anatomical Nomenclature, both the right and left lungs are divided into 10 segments.
The bronchopulmonary segment is not only a morphological, but also a functional unit of the lung, since many pathological processes in the lungs begin within one segment.
In the right lung, ten bronchopulmonary segments, segmenta bronchopulmonalia, are distinguished.
The upper lobe of the right lung contains three segments, to which segmental bronchi are suitable, extending from the right upper lobar bronchus, bronchus lobaris superior dexter, which is divided into three segmental bronchi:
The apical segment (Cj), segmentum apicale (S,), occupies the upper medial portion of the lobe, filling the dome of the pleura;
The posterior segment (C2), segmentum posterius (S2), occupies the dorsal part of the upper lobe, adjacent to the dorsolateral surface of the chest at the level of the IV ribs;
The anterior segment (C3), segmentum anterius (S3), is part of the ventral surface of the upper lobe and is adjacent to the base of the anterior chest wall (between the cartilages of the I and IV ribs).
The middle lobe of the right lung consists of two segments, which are approached by segmental bronchi from the right middle lobe bronchus, bronchus lobaris medius dexter, originating from the anterior surface of the main bronchus; heading anteriorly, downwards and outwards, the bronchus is divided into two segmental bronchi:
The lateral segment (C4), segmentum laterale (S4), faces the anterolateral costal surface with its base (at the level of the II ribs), and the apex is upward, posterior and medial;
The medial segment (C5), segmentum mediale (S5), is part of the costal (at the level of the II ribs), medial and diaphragmatic surfaces of the middle lobe.
The lower lobe of the right lung consists of five segments and is ventilated by the right lower lobar bronchus, bronchus lobaris inferior dexter, which gives off one segmental bronchus on its way and, reaching the basal sections of the lower lobe, is divided into four segmental bronchi:
The apical (upper) segment (C6), segmentum apicale (superior) (S6), occupies the apex of the lower lobe and is adjacent to the base of the posterior chest wall (at the level of the II ribs) and to the spine;
The medial (cardiac) basal segment (C7), segmentum basale mediale (cardiacum) (S7), occupies the lower medial part of the lower lobe, reaching its medial and diaphragmatic surfaces;
The anterior basal segment (C8), segmentum basale anterius (S8), occupies the anterolateral part of the lower lobe, goes to its costal (at the level of VIII ribs) and diaphragmatic surfaces;
The lateral basal segment (C9), segmentum basale laterale (S9), occupies the mid-lateral part of the base of the lower lobe, partially participating in the formation of the diaphragmatic and costal (at the level of VII-IX ribs) of its surfaces;
The posterior basal segment (C | 0), segmentum basale posterius (S10), occupies part of the base of the lower lobe, has a costal (at the level of the VII ribs), diaphragmatic and medial surfaces.
In the left lung, nine bronchopulmonary segments, segmenta bronchopulmonalia, are distinguished.
The upper lobe of the left lung contains four segments ventilated by segmental bronchi from the left upper lobar bronchus, bronchus lobaris superior sinister, which is divided into two branches - apical and reed, due to which some authors divide the upper lobe into two parts corresponding to these bronchi:
The apical-posterior segment (C|+2), segmentum apico posterius (S1+2), no topography, approximately corresponds to the apical and posterior segments of the upper lobe of the right lung;
The anterior segment (C3), segmentum anterius (S3), is the largest segment of the left lung, it occupies the median part of the upper lobe;
The upper lingual segment (C4), segmentum lingulare superius (S4), occupies the upper part of the uvula of the lung and the middle sections of the upper lobe;
The lower reed segment (C5), segmentum lingulare inferius (S5), occupies the lower anterior part of the lower lobe.
The lower lobe of the left lung consists of five segments, which are approached by segmental bronchi from the left lower lobar bronchus, bronchus lobaris inferior sinister, which in its direction is actually a continuation of the left main bronchus:
The apical (upper) segment (C6), segmentum apicale (superius) (S6), occupies the top of the lower lobe;
The medial (cardiac) besal segment (C8), segmentum basale mediale (cardiacum) (S8), occupies the lower medial part of the lobe corresponding to the cardiac depression;
The anterior basal segment (C8), segmentum basale anterius (Sg), occupies the anterolateral portion of the base of the lower lobe, making up parts of the costal and diaphragmatic surfaces;
The lateral basal segment (C9), segmentum basales laterale (S9), occupies the mid-lateral part of the base of the lower lobe;
The posterior basal segment (C10), segmentum basale posterius (S10), occupies the posterior basal part of the base of the lower lobe, being one of the largest.
Lung borders
The apex of the lung will stand in the area of the supraclavicular fossa 2-3 cm above the level of the clavicle, located here medially from the scalene muscles.
The anterior borders of both lungs behind the sternum form an hourglass figure. Their edges are closest in the region of the IV ribs. Here, a narrow gap is formed between the lungs, elongated in the vertical direction, more often somewhat to the left of the midline.
Above the second rib, the borders of both lungs diverge, forming a wider gap occupied by the thymus gland in children, and in adults by its remnants. Below the IV rib, the borders of the lungs also diverge, mainly due to the anterior edge of the left lung (incisura cardiaca). In the region of this gap, a section of the anterior surface of the heart is adjacent to the anterior chest wall.
Posteriorly, the lung margins are spaced one from the other by the width of the vertebral bodies. The borders of the tops and the anterior edge of the lungs coincide with the borders of the pleura of these departments.
The lower border of the right lung is determined: along the linea medioclavicularis (mamillaris) - on the VI rib (lower edge); 1 inea axillaris media - on the VIII rib; along linea scapularis - on the X rib; along linea paravertebralis - at the level of the spinous process of the XI vertebra.
The lower border of the left lung in front, at the level of the IV rib, goes horizontally, and then along the linea medioclavicularis goes down to the VI rib, from where the borders of the lungs on both sides are approximately the same.
