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1 Limited Liability Company "Study-Style", Moscow, Dubininskaya st., 57, building 1, room I, room 7b, OKPO, OGRN, TIN KPP FINAL QUALIFICATION (DIploma) work on the topic: "PNEUMONIA" 2

2 CONTENTS INTRODUCTION ... 4 Chapter 1. GENERAL CHARACTERISTICS OF THE DISEASE The concept and essence of pneumonia Classification of pneumonia Epidemiology of pneumonia Chapter 2. ANALYSIS OF DIAGNOSIS AND TREATMENT METHODS OF PNEUMONIA OF VARIOUS SERIOUS X-ray diagnostics of pneumonia Varieties of treatment of pneumonia, differing in severity Prevention of pneumonia Chapter 3. ORGANIZATION AND METHODOLOGY (on the example of the SMP substation) Preclinical methods for diagnosing pneumonia Organization of the study Results and conclusions on the study CONCLUSION LIST OF LITERATURE SOURCES:

3 INTRODUCTION Relevance of the topic. Confirming and arguing such an aspect as the relevance of the topic of this WRC, initially, one should look at several key aspects related to the pneumonia disease, its features, severity and frequency of occurrence. The first of these is undoubtedly the fact that the end of the 20th century showed scorched rates of growth in the number of people exposed to the disease, as well as the rate of death from it. This situation has spread not only throughout the territory of the Russian Federation, but also throughout the world space, as a whole. like cancer and AIDS. Among infectious diseases - 1st place (causes every second death in the geriatric population and 90% of deaths from respiratory infections in people over 64 years old) 2. This is due to the fact that the pathogenesis of pneumonia affects only the respiratory system, which is key to work the whole organism. The second factor is, of course, that pneumonia entails severe complications, often of a chronic nature, which are derivatives of pathologies from active inflammatory and purulent processes in the lungs. One of the most severe and leading in the number of lethal outcomes of the disease is such a form of pneumonia as community-acquired. The incidence of community-acquired pneumonia averages 10-12%, varying depending on the age, gender, race and socioeconomic conditions of the population being examined. According to 1 Guchev, I.A., Sinopalnikov, A.I. Modern guidelines for the management of community-acquired pneumonia in adults: the path to a single standard. // Clinical microbiology and antimicrobial chemotherapy V.10, 4. - S Sinopalnikov, A.I., Kozlov, R.S. Community-acquired respiratory tract infections. Guide for doctors. - M.: Premier MT, Our City, p. four

According to UK experts, 5-11 adults out of 1000 suffer from CAP per year, which is 5-12% of all cases of lower respiratory tract infections 3. Annually in the USA 4 million cases of pneumonia are registered among adults, of which 1 million are hospitalized 4. The incidence of CAP in young and middle-aged people is 1-11.6%, increasing to 25-51% in the older age group. According to official statistics, in 2014 in Russia, among people over the age of 18, the incidence rate was 3.9%, and in 2015 in all age groups - 4.1%. However, according to calculations, the real incidence reaches 14-15%. Mortality in CAP averages less than 1% among outpatients and 5-14% among hospitalized patients 5. At the same time, according to individual authors, the incidence of adverse outcomes in patients over 60 years of age, in the presence of concomitant diseases and / or severe CAP reaches 15-50% and does not differ significantly from the indicators recorded in the pre-antibiotic era. Based on the foregoing, it is precisely this type of pneumonia diagnosis, such as preclinical and its methods, that are characterized by high rates of relevance. A detailed and thorough knowledge of the protocols and features of this diagnostic variety is useful both for patients and for medical workers at various levels. This is due to the fact that the earlier the diagnosis is made and confirmed, the faster the therapeutic and drug measures are taken, which improves the overall prognosis, facilitates the course of the disease and prevents the occurrence of complications of various kinds. 3 Pulmonology. / ed. N. Buna [and others]; per. from English. ed. S.I. Ovcharenko. - M.: Reed Elsiver LLC, p. 4 Mandell, L.A. Infectious Diseases Society of America / American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. // Clinical Infectious Diseases Vol P.s27-s72. 5 Woodhead, M. Guidelines for the management of adult lower respiratory tract infections. // European Respiratory Journal Vol P

5 As for researchers, over the past 10 years, many scientists have been improving, developing and facilitating preclinical methods for diagnosing pneumonia. But, despite this, nevertheless, the level of complexity of the study of aspects of this technique is not full-fledged and leaves much to be desired. The same circumstance, in fact, justifies the expediency of choosing a research topic in this graduate work. Object of study. Pneumonia disease, its features and diagnostic methods inherent in it. Subject of study. Study of the effectiveness of the preclinical method for diagnosing pneumonia on the example of employees of the SMP substation. Goals and objectives of the study: The key goal of this WRC is to prove the effectiveness, importance and expediency of such a diagnostic method for pneumonia as a preclinical one. In view of the goal set, in a similar way, a range of tasks was formed that also required solutions in this work: - characterize the disease pneumonia, give its classification and frequency of occurrence; - comprehensively study all possible methods of diagnosis, treatment and prevention of pneumonia; - prove that preclinical diagnostics is the most important and effective; - conduct a study on the example of the frequency and severity of pneumonia at the SMP substation; - to analyze the used diagnostic and therapeutic methods for patients of the EMS substation; - on the basis of the results obtained, practically confirm the rationality and importance of using the preclinical method for diagnosing pneumonia (confirm with conclusions). 6

6 Research hypothesis: Can high-quality preclinical diagnosis of pneumonia prevent its complications and reduce the chance of death, as well as improve the prognosis and effectiveness of treatment? The practical significance of the study. The practical value of this work lies in the fact that the compiled and studied theoretical and practical material is evidence of the importance and indispensability of using the preclinical diagnostic method in the process of identifying and surgically treating various pneumonias. Research methodology. The work combines general scientific and private scientific research methods. The interdisciplinary approach chosen by the author to solve the set goals and objectives made it possible to conduct a comprehensive analysis, which the author built on a combination of various research methods. The degree of study of the topic: The problems of pulmonology, as well as the improvement of the methods of preclinical diagnostics, as well as the problems of the incidence of pneumonia, in general, have been dealt with by a very wide range of physicians and researchers for many years. This work was based on textbooks, articles by the following authors: Mishin V.V., Kuzmin A.P., Ryabukhin A.E., Stepanov S.A., Guchev, I.A., Sinopalnikov, A.I. , Boone N., etc. 7

7 Chapter 1. GENERAL CHARACTERISTICS OF THE DISEASE 1.1 The concept and essence of pneumonia lung structures such as alveoli and interstitial tissue 6. It is also worth noting that exudation of a similar pathogenic nature is actively developing in this case 7. Etiology. This terminology implies a set of a wide range of diseases. At the same time, it is quite logical that each of them is characterized by an individual etiology and pathogenesis. Based on this, each pneumonia pathology is characterized by individual symptoms, a picture during the implementation of x-ray diagnostics, indicators and results of various laboratory and percussion, as well as anamnestic manipulations. There is also a type of pneumonia, which is characterized by a non-infectious nature of the pathogenesis and is called alveolitis. It differs in that it manifests itself mainly in the form of abstruction of the respiratory sections of the lung. This type of pneumonia often leads to the development and occurrence of more severe forms of pneumonia, such as: mycotic or pneumonia, the causative agents of which are fungi, bacterial, or viral-bacterial, caused by microorganisms similar to their names. Pathogenesis. Often, the path through which bacteria and viruses penetrate into the human body, and into lung tissue, in particular, is called bronchogenic. This trend is predisposed by several 6 Leach, Richard E. Acute and Critical Care Medicine at a Glance. 2. Wiley-Blackwell, McLuckie A. ISBN. Respiratory disease and its management. New York: Springer, P. 51. ISBN

8 related aspects, including: aspiration, the presence of microorganisms in the air we breathe, the displacement of infection localized in the nasopharynx to the lower respiratory tract, medical invasive procedures. In addition to all of the above methods of infection, there is also a hematogenous type of infection, that is, the spread of the pathogen through the circulation of blood masses in the body, but it is an order of magnitude less common than bronchogenic. It becomes possible in the case of intrauterine infection, drug addiction, purulent abscesses. The chance to get infected through the lymph is critically small even in comparison with hematogenous. Then, after the pathogen enters the body, regardless of the form and severity of pneumonia, there is a fixation and an increase in the number of infection agents or the virus. This happens at the morphological level of the bronchial epithelium, namely, bronchitis pathogenic activity and concomitant symptoms begin. Its severity varies, depending on the duration of the course of the disease, from catarrhal forms to necrotic varieties of bronchitis and bronchitis. At the moment when the inflammatory process spreads further, crossing the border of the respiratory bronchioles, infection begins directly in the tissues of the lungs, which is referred to as nothing more than pneumonia. Due to the fact that the patency in the bronchi is complicated, areas of tissue affected by atelectasis and emphysema begin to appear. Further, the body, according to the natural physiological reflex, manifested in the form of sneezing or coughing, activates a protective mechanism aimed at removing pathogenic pathogens from the body. But in the case of pneumonia, this trend does not improve, but quite the opposite, only aggravates the situation, contributing to the spread of infections in the lung tissues and respiratory structures. New pneumonia foci lead to increased respiratory failure, 9

9 and then lack of oxygen, when pneumonia is characterized by a severe form, HF can also occur. As for the localization of pneumonia within the lobes of the lung and its segments, in most cases this disease affects: on the left - II, VI, X and VI, VIII, IX, X on the right. A common occurrence is also the spread of infection and pathogenicity to nodes related to the lymphatic system. At risk are such nodes as bronchopulmonary, paratracheal, as well as bifurcation. Continuation of the section in the full version of the work 1.2 Classification of pneumonia The collective experience of recent years has made it possible not only to clarify the nature and symptoms of pneumonia, but also to identify previously unknown varieties of these processes. The widespread use of sulfonamides, antibiotics and other modern drugs contributed to a marked change in the course and outcomes of various types of pneumonia. Clinical diagnosis of erased forms of pneumonia has become much more difficult. The difficulties of differential diagnosis also increased, especially since a large number of acute inflammatory processes of the lungs were added to the previously known and well-studied nosological forms, the presence of which previous generations of doctors did not even suspect. X-ray examination played a big role in a detailed study of various types of pneumonia. If earlier the typical clinical picture of croupous and focal pneumonia made it possible for an experienced clinician to do without X-ray examination, today, due to the predominance of erased clinical forms, it has become 10

10 is necessary at all stages of the course, including when evaluating the results of treatment and determining the outcomes of the disease 8. Not all currently known pneumonias are manifested by characteristic and even more pathognomonic pictures. On the contrary, many of them have similar symptoms. Only solid knowledge concerning all aspects of these processes - epidemiological, etiopathogenetic, morphological, clinical, radiological - can contribute to the success of diagnosis. In the study of patients with acute inflammatory processes, the radiologist, as a rule, is limited to the use of classical methods - transillumination of images in various projections, including layered, some functional tests. Such valuable additional methods as bronchography, angiography, bronchoscopy, lung puncture, are used in these processes only in exceptional cases, which naturally complicates the task of the researcher. Meanwhile, the diagnosis in an acute process should be made quickly and reliably, since the appointment of treatment and the further course of the disease depend on this. Currently, there is no generally accepted classification of acute pneumonia. The proposed groupings suffer from a common drawback - the lack of a single principle. Indeed, in these groups, one can simultaneously find processes distinguished according to the principle of morphological (for example, parenchymal, interstitial pneumonia), etiological (viral, Friedländer pneumonia), pathogenetic (septic, metastatic, allergic pneumonia), etc. It is most correct to group acute pneumonic processes according to etiological principles. This makes it possible to compare 8 Ivanovsky B. V. Differential diagnosis of tuberculosis and sarcoidosis of the lungs (literature review). Probl. tub., 2004, 8, p.

12 3. Embolism and pulmonary infarction. Infarction pneumonia. II. With changes in the bronchi. III. Ascidatory pneumonia. IV. Pneumonia in various diseases of the body. 1. Septic metastatic pneumonia. 2. Pneumonia in infectious diseases. 3. Pneumonia with allergies. This classification is not without some shortcomings. Not everywhere the uniform principle of grouping of nosological forms is sustained, not all allocated processes can be completely carried to acute pneumonia. Although cumbersome, the classification is not comprehensive, it does not cover all possible cases of pneumonia. Continuation of the section in the full version of the work 1.3 Epidemiology of pneumonia The global prevalence and incidence of pneumonia is extremely high. During the year, out of the total population of the planet, pneumonia is carried by approximately 450 million people. The worst thing about this figure is that 7 million of them do not survive to recover 10. The epidemiology of pneumonia at the present stage is characterized by a trend that has emerged since the late 80s towards an increase in the incidence, number of complications and deaths worldwide. This is confirmed by the data obtained as a result of a retrospective analysis of 8 children's clinics in the United States. The ratio of hospitalized patients increased over the study period from 22.6% (2004) to 53% (2009). From Sergey Netesov. Middle East pneumonia has also become Korean, but this is not a pandemic. b-Science (). 13

In 13 hospitalized children, complicated pneumonia was observed in 42% of cases (in the group of children older than 61 months of life - 53%) 11. The economic losses that such a high incidence of CAP entails are also significant. The annual costs associated with the treatment of this disease in the United States are 8.4-10 billion US dollars, of which 92% are hospitalized patients. Treatment of one patient in a hospital costs US dollars, and at home US dollars. The cost of treating all children with pneumonia worldwide is about US$600 million 12. A number of studies of childhood pneumonia conducted in Europe and North America note the significant role of viruses as causative agents of pneumonia in preschool children (respiratory syncytial virus, adenovirus, rhinovirus, influenza viruses A and B, parainfluenza), in schoolchildren - M. pneumoniae and C. pneumoniae, in newborns - C. trachomatis 13. According to data obtained in New Zealand, community-acquired pneumonia of viral etiology, as well as mixed (viral - bacterial) etiology occur in adult patients relatively often, and the latter tend to be more severe and be accompanied by severe clinical symptoms. The viral etiology of the process was confirmed in 29%, with the main pathogens being rhinoviruses and influenza virus serotype A, two or more pathogens were detected in 16% working age. Lethality also depends on the causative agent of CAP (Table 1). 11 Tan, T. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. // Pediatrics Vol.110, 1. - P Pneumonia. / WHO fact sheet p. 13 Somer, A. Chlamydia pneumoniae in children with community-acquired pneumonia in Istanbul, Turkey. // Journal of tropical pediatrics Vol.52, 3. - P Ribeiro, D. D. Pneumonia and risk of venous thrombosis: results from the MEGA study / D. D. Ribeiro, W. M. Lijfering, A. Van Hylckama, F. R. Rosendaal, S. C. Cannegieter // J. Tromb. Haemost Vol. 10. P

14 Table 1. Mortality in community-acquired pneumonia depending on the pathogen Pathogen Mortality, % S. pneumoniae 12.3 H. influenzae 7.4 M. pneumoniae 1.4 Legionella spp. 14.7 S. aureus 31.8 K. pneumoniae 35.7 C. pneumoniae 9.8 According to Russian authors, the predominant pathogens of lethal CAP were K. Pneumonia, S. aureus, S. pneumoniae and H. Influenza in percentage terms 31 .4%, 28.6%, 12.9% and 11.4% respectively. Pneumonia leads to huge medical costs. According to some authors, they cause temporary disability for an average of 25.6 days (12.8-45). EaP-related spending reaches $24 billion annually in the US. The annual cost of antibiotics alone for patients with community-acquired pneumonia that does not require hospitalization is approximately $100 million in the United States. 15 The cost of inpatient care accounts for 87% of the total annual cost of treating patients with CAP. 15 Singh, N. Short-course Empiric Antibiotic Therapy for Patients with Pulmonary Infiltrates in the Intensive Care Unit A Proposed Solution for Indiscriminate Antibiotic Prescription / N. Singh, P. Rogers, C. W. Atwood et al. // Am. J. Respir. Crit. Care Med Vol P

15 Chapter 2. ANALYSIS OF DIAGNOSIS AND TREATMENT METHODS FOR PNEUMONIA OF DIFFERENT GRAVITY roots of lungs 16. Syndrome of extensive shading of the pulmonary field. The pathological process displayed by this syndrome is determined by the position of the mediastinum and the nature of the shading. The position of the mediastinum and the nature of shading in various diseases are shown in Table. 2. Table 2. Position of the mediastinum and the nature of shading in various diseases Position of the mediastinum Homogeneous shading Inhomogeneous shading Not displaced Inflammatory infiltration Pulmonary edema Shifts towards shading Atelectasis Pleural ligaments Absence of lung Cirrhosis of the lung Shifted to the opposite side Fluid in the pleural cavity Large neoplasms Large neoplasm Syndromic approach to X-ray diagnostics of diseases of the respiratory organs is quite fruitful. A detailed analysis of the features of the x-ray picture in many cases provides a correct determination of the nature of bronchopulmonary pathology. The data obtained during X-ray examination also serve as the basis for a rational further examination of patients using other radiation imaging methods: X-ray CT, MRI, ultrasound and radionuclide methods Zworykin IA Cysts and cyst-like formations of the lungs. L.: Medgiz, p. 17 Mirganiev Sh. M. Clinical and radiological diagnosis of pneumonia, Tashkent: Medicine, p. 16

16 Primary pneumonias, bacterial pneumonias, pneumococcal pneumonias The X-ray picture of lobar pneumonia with lobar spread is quite typical. Its evolution corresponds to the change of pathological stages. In the stage of the tide, there is an increase in the pulmonary pattern in the affected lobe due to the resulting hyperemia. The transparency of the lung field remains normal or slightly reduced. The root of the lung on the diseased side expands somewhat, its structure becomes less distinct. When the process is located in the lower lobe, the mobility of the corresponding dome of the diaphragm is limited. In the stage of hepatization, which occurs on the 2-3rd day from the onset of the disease, an intense darkening appears, corresponding to the localization of the affected lobe. Darkening in lobar pneumonia differs from lobar atelectasis in that it corresponds to the usual size of the lobe or even slightly larger, in addition, darkening in lobar pneumonia differs in two more features: firstly, the intensity of the shadow increases towards the periphery, while the uniformity of the shadow also rises; secondly, a careful study of the nature of the darkening shows that against its background in the medial sections, light stripes of the bronchi of large and medium Kashira are visible, the gaps of which, in croupous pneumonia, in most cases remain free. The adjacent pleura thickens, in some cases a lunge is found in the pleural cavity, which is better detected in the lateroposition on the side. There are no radiological differences between the stage of red and gray hepatization 18. The expansion stage is characterized by a gradual decrease in the intensity of the shadow, its fragmentation and a decrease in size. The shadow of the root remains extended and non-structural for a long time. The same 18 Vinner MG, Sokolov VA X-ray diagnostics and differential diagnostics of disseminated lung lesions. Vestn. rentgenol., 1975, 6, p.

17 should also be said about the pulmonary pattern at the site of the former hepatization: it remains intensified for another 2-3 weeks. after clinical recovery, and the pleura, bordering the affected lobe, is compacted even longer. In some cases, changes in the lungs can be bilateral; however, as a rule, they do not develop synchronously, but sequentially 19. The experience of recent years indicates that in most cases lobar pneumonia does not proceed according to the lobar type, but begins with a segmental lesion. If active treatment begins in the first 1-2 days of illness, which is now common, the shared process may not occur. Bronchopneumonia (lobular, catarrhal, focal pneumonia) X-ray manifestations of bronchopneumonia differ significantly from the picture of croupous pneumonia. Bilateral (rarely unilateral) focal shadows up to 1-1.5 cm in size are characteristic, corresponding to the size of the lung lobules. In the downward direction, the number of foci usually increases. The outlines of the shadows of the foci are fuzzy, their intensity is low. The tops are usually not affected. Pulmonary pattern is enhanced throughout the lung fields due to hyperemia. The shadows of the roots of the lungs are expanded, their structure becomes homogeneous. As a rule, the reaction of the pleura is detected, exudative pleurisy is often detected. The mobility of the diaphragm in most cases is limited. Bronchopneumonia is characterized by rapid dynamics of the x-ray picture: within 4-6 days it changes significantly, and after 8-10 days the foci usually resolve. Along with bronchopneumonia, in which the size of the foci does not exceed 1-1.5 cm, sometimes there are processes accompanied by the fusion of foci, and much larger foci are formed. Honey. magazine Uzbekistan, 1975, 12, p.

18 sizes. Confluent foci often form in debilitated or insufficiently vigorously treated patients. Another variant of the X-ray picture of bronchopneumonia is characterized by smaller sizes of foci. In some cases, miliary bronchopneumonia is detected, characterized by a large number of small foci with a diameter of 1.5-2 mm, overlapping the pulmonary pattern. As a result, the shadows of the roots of the lungs appear as if chopped off. Distinguishing miliary bronchopneumonia from other pulmonary disseminations, in particular tuberculosis and cancer, is sometimes extremely difficult, and even impossible with a single study. Rapid dynamics, negative tuberculin tests, absence of damage to other organs are some of the signs that speak in favor of bronchopneumonia. Large-focus confluent pneumonia may resemble, in its x-ray picture, multiple metastases of malignant tumors in the lungs. The main distinguishing feature that speaks in favor of bronchopneumonia is the rapid reverse development of the process. Staphylococcal and streptococcal pneumonias The X-ray picture of strepto- and staphylococcal pneumonias is characterized by the presence of multiple bilateral inflammatory foci of medium and large sizes. The outlines of the foci are fuzzy, the intensity of the shadows depends on their size; there is a pronounced tendency towards their merger and subsequent disintegration. In these cases, against the background of the shadows of inflammatory foci, enlightenments appear, delimited from below by the horizontal level of the liquid. Relatively fast change of a radiological picture is characteristic. Within 1-2 weeks. (sometimes longer) one can observe the appearance of infiltrates, their disintegration, the transformation of decay cavities into thin-walled cysts with their subsequent decrease. On one radiograph, all stages of the development of pneumonic infiltrates can be detected, which gives the radiological picture a peculiar look. Often joins exudative pleurisy, often 19

19 purulent. Schinz (1968) considers a triad of symptoms characteristic of these pneumonias: infiltrates, rounded decay cavities, pleural exudate 20. Friedlander's pneumonia X-ray manifestations of Friedlander's pneumonia in some cases are quite characteristic. The appeared inflammatory infiltrates quickly merge into an extensive lobar lesion, resembling hepatization in croupous pneumonia; sometimes the affected proportion increases markedly. With frequent localization in the right upper lobe on the radiograph, the displacement of the small interlobar fissure downwards by the whole intercostal space is determined; the trachea and the upper part of the median shadow may be displaced in the opposite direction. Already in the first days of the disease, against the background of blackouts, enlightenments can be detected due to the melting of the lung tissue. They are often multiple; their outlines can be quite clear due to the rapid drainage of the contents of the cavities through the bronchi. Another type of x-ray picture is lobar opacity with foci in other parts of the same lung or in the contralateral lung. Enlightenments also appear in these tricks, sometimes limited from below by the horizontal level of the liquid. Some of these cavities rapidly develop into thin-walled cystic masses without visible perifocal inflammation. The reaction of the roots and pleura is expressed in most cases. Tularemia pneumonia The radiological picture of tularemia pneumonia is characterized by hyperplasia of the lymph nodes of the roots, the contours of which become fuzzy. In the supradiaphragmatic parts of the lungs, infiltrates are found on one or both sides. Often, along with the infiltrate, a pleural effusion is also detected. The reverse development of infiltrates occurs within days, but sometimes the process is delayed for 5-6 weeks. 20 Rabinova A. Ya. Lateral chest radiograph. Moscow: Medgiz, p. twenty

20 In a significant proportion of cases in the pulmonary form of tularemia, enlarged axillary lymph nodes can be felt. Pleural effusion is observed for a long time; at a puncture, a yellow transparent or cloudy liquid is obtained, the relative density of which is always higher. Tularemic bronchitis accompanying pneumonia is manifested by a long-lasting increase in the pulmonary pattern. Lung abscesses, pleural empyema, and spontaneous pneumothorax are observed as late complications. Influenza pneumonia The most characteristic radiological sign of diseases is the strengthening and deformation of the lung pattern in a stranded or cellular type. More often these changes are limited to the middle or lower sections of one or both lungs. With bilateral lesions, the picture is usually asymmetric. 21

22 10. Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prevention: A guide for doctors / Edited by A. G. Chuchalin. - M., p. 11. Vovk, E. I. Community-acquired pneumonia at the beginning of the 21st century: payment for life in a big city / E. I. Vovk, A. L. Vertkin // Attending physician S Gerasimov, V. B. Pharmacoeconomics and pharmacoepidemiology, practice of acceptable solutions / V. B. Gerasimov, A. L. Khokhlov, O. I. Karpov. Moscow: Medicine, p. 13. Guchev, I.A., Sinopalnikov, A.I. Modern guidelines for the management of community-acquired pneumonia in adults: the path to a single standard. // Clinical microbiology and antimicrobial chemotherapy V.10, 4. - S Davydovsky IV Pathological anatomy and pathogenesis of human diseases. Moscow: Medgiz, p. 15. Dvizhkov P. P. Pneumoconiosis. Moscow: Medicine, p. 16. Esipova Ya. K. Lung in pathology. Novosibirsk: Science, p. 17. Zhestkov, A. V. Clinical and immunological features of occupational bronchitis / A. V. Zhestkov, V. V. Kosarev, S. A. Babanov et al. // Pulmonology S. Zworykin I. A. Cysts and cyst-like formations of the lungs. L.: Medgiz, p. 19. Ivanovsky B. V. Differential diagnosis of tuberculosis and sarcoidosis of the lungs (literature review). Probl. tube., 2004, 8, p Kazakov A.F. Modern possibilities of differential diagnosis of rounded lesions in the lungs. Probl. tub., 2003, 12, with Karzilov A.I. Biomechanical homeostasis of the external respiration apparatus and mechanisms for its provision under normal conditions and at 23

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27 Indiscriminate Antibiotic Prescription / N. Singh, P. Rogers, C. W. Atwood et al. // Am. J. Respir. Crit. Care Med Vol P Somer, A. Chlamydia pneumoniae in children with community acquired pneumonia in Istanbul, Turkey. // Journal of tropical pediatrics Vol.52, 3. - P Tan, T. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. // Pediatrics Vol.110, 1. - P Thornsberry, C. Regional trends in antimicrobial resistance among clinical isolates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States: results from the TRUST Surveillance Program, / C. Thornsberry, D. F. Sahm, L. J. Kelly et al. // clinic. Infect. Dis Vol. 34 (Suppl. 1). - P Woodhead, M. Guidelines for the management of adult lower respiratory tract infections. // European Respiratory Journal Vol P To get the full version of the work, please contact us by phone or email us Your Study-Style! 28

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Lecture plan

• Definition, relevance of pneumonia

• The pathogenesis of pneumonia

• Classification of pneumonia

• Criteria for diagnosing pneumonia

• Principles of treatment: regime organization, aerotherapy, antibiotic therapy, immunotherapy and physiotherapy, prevention

• Pneumonia is a non-specific inflammation of the lung tissue, which is based on infectious toxicosis, respiratory failure, water-electrolyte and other metabolic disorders with pathological changes in all organs and systems of the child's body.

Relevance:

• The incidence of pneumonia ranges from 4 to 20 cases per 1000 children aged 1 month to 15 years.

• In Ukraine, there has been an increase in the prevalence of pneumonia among children in the last three years (from 8.66 to 10.34).

• Mortality from pneumonia among children of the first year of life is from 1.5 to 6 cases per 10,000 children, which is 3-5% in the overall structure of mortality in children under 1 year of age.

• Every year about 5 million children die from pneumonia in the world.

Etiology

• Intrahospital (nosocomial) pneumoniae in most cases are caused by Ps. aeruginosa, less often - Cl. pneumoniae, St. aureus, Proteus spp. and others. These pathogens are resistant to antibiotics, which leads to a severe course of the disease and mortality.

• community-acquired pneumonia(home, non-hospital). The spectrum of pathogens depends on the age of the patients.

• newborns: depends on the spectrum of urogenital infections in women.

• Postnatal pneumonia more often caused by group B streptococci, less often by E. coli, Klebsiella pneumoniae, St. aureus, St. epidermalis.

• Antenatal- streptococci of groups G, D, Ch. frachomatis, ureaplasma urealiticum, Listeria monocytogenes, Treponeta pallidum.

• Children of the first half of the year: staphylococci, gram-negative intestinal flora, rarely - Moraxella catarrhalis, Str. pneumoniae, H. influenzae, Ch. trachomatis.

From 6 months to 5 years in the first place are Str. Pneumoniae (70-88% of all pneumonias) and H. influenzae type b (Hib infection) - up to 10%. In these children, respiratory syncytial virus, influenza, parainfluenza, rhino and adenoviruses are also often isolated, but most authors consider them to be factors that contribute to infection of the lower respiratory tract by bacterial flora.

• In children 6-15 years old: bacterial pneumonias account for 35-40% of all pneumonias and are caused by pneumococci Str. pyogenes; M. pneumoniae (23-44%), Ch. Pneumoniae (15-30%). The role of Hib infection is decreasing.

• With insufficiency of the humoral link of immunity, pneumococcal, staphylococcal, cytomegalovirus pneumonias are observed.

• With primary cellular immunodeficiencies, with long-term glucocorticoid therapy - P. carinii, M. avium, fungi of the genus Candida, Aspergilus. Often viral-bacterial and bacterial-fungal associations (65-80%).

Pathogenesis

• In the pathogenesis of the development of acute pneumonia, V.G. Maidannik distinguishes six phases.

• The first is contamination by microorganisms and edematous-inflammatory destruction of the upper respiratory tract, impaired function of the ciliated epithelium, spread of the pathogen along the tracheobronchial tree.

• The second is the primary alteration of the lung tissue, the activation of LPO processes, the development of inflammation.

• Third: damage by prooxidants not only to the structures of the pathogen, but also to the macroorganism (surfactant) destabilization of cell membranes → the phase of secondary toxic autoaggression. The area of ​​damage to the lung tissue increases.

• Fourth: violation of tissue respiration, central regulation of respiration, ventilation, gas exchange and perfusion of the lungs.

• Fifth: the development of DN and impaired non-respiratory function of the lungs (clearing, immune, excretory, metabolic, etc.).

• Sixth: metabolic and functional disorders of other organs and systems of the body. The most severe metabolic disorders are observed in newborns and young children.

• There are 4 ways of contamination of the lungs with pathogenic flora:

• aspiration of the contents of the oropharynx (sleep microaspiration) is the main route;

• airborne;

• hematogenous spread of the pathogen from the extrapulmonary focus of infection;

• Spread of infection from adjacent tissues of neighboring organs.

Classification

• Pneumonia

• primary (uncomplicated)

• secondary (complicated)

• Forms:

• focal

• segmental

• croupous

• interstitial

Localization

• unilateral

• bilateral

• lung segment

• lung lobe

• lung

Flow

• acute (up to 6 weeks)

• protracted (from 6 weeks to 6 months)

• recurrent

Respiratory failure

• 0 st.

• I st.

• II Art.

• III Art.

Pneumonia complicated:

• General violations

• toxic-septic condition

• infectious-toxic shock

• cardiovascular syndrome

• DVZ syndrome

• changes in the central nervous system - neurotoxicosis, hypoxic encephalopathy

• Pulmonary-purulent process

• destruction

• abscess

• pleurisy

• pneumothorax

• Inflammation of various organs

• sinusitis

• pyelonephritis

• meningitis

• osteomyelitis

Pneumonia code according to MKH-10:

• J11-J18 - pneumonia

• P23 - congenital pneumonia

Clinical criteria for pneumonia in a newborn child

• aggravated ante- and intranatal history;

• pallor, perioral and acrocyanosis;

• groaning breath;

• tension and swelling of the wings of the nose; retraction of pliable places of the chest;

• respiratory arrhythmia;

• rapid increase in pulmonary heart failure and toxicosis;

• muscle hypotension, inhibition of reflexes of the newborn;

• hepatolienal syndrome;

• weight loss;

• coughing; less cough;

• increase in body temperature; may be normal in immature newborns;

• radiograph: lung tissue infiltrates, often on both sides; strengthening of the pulmonary pattern in the perifocal areas.

Clinical criteria for the diagnosis of pneumonia in young children:

• wet or unproductive cough;

• shortness of breath, breathing with the participation of auxiliary muscles;

• remote wheezing in broncho-obstructive syndrome;

• general weakness, refusal to eat, delayed weight gain;

• pale skin, perioral cyanosis, aggravated by exercise;

• violation of thermoregulation (hyper- or hypothermia, toxicosis);

• hard bronchial or weakened breathing, moist rales join after 3-5 days;

• shortening of percussion sound in the projection of the infiltrate;

• hemogram: neutrophilic leukocytosis, formula shift to the left;

• radiograph: lung tissue infiltrates, increased lung pattern in the perifocal areas.

Criteria for the degree of DN

Treatment of pneumonia

• Children with acute pneumonia can be treated at home and in a hospital. Indications for hospitalization are as follows:

• 1) vital indications - intensive therapy, resuscitation measures are necessary;

• 2) a decrease in the reactivity of the child's body, the threat of complications;

• 3) unfavorable living conditions of the family, there is no possibility to organize a “hospital at home”.

• In the hospital, the child should be in a separate room (box) to prevent cross-infection. Until the age of 6, the mother must be with the child.

• Wet cleaning, quartzing, airing (4-6 times a day) should be carried out in the ward.

• The head of the bed should be raised.

Food

• Depends on the age of the child. In a serious condition of a patient of the 1st year of life, the number of feedings can be increased by 1-2, while excluding complementary foods for several days. The main food is breast milk or adapted milk formula. With the necessary oral rehydration, rehydron, gastrolith, ORS 200, herbal tea, fractionally are prescribed.

Treatment of respiratory failure

• Ensure free airway patency.

• The microclimate of the ward: fresh enough humid air, tº in the ward should be 18-19ºС.

• With respiratory failure of the II degree, oxygen therapy is added: through a nasal probe - 20-30% of oxygen utilization; through a mask - 20-50%, in an incubator - 20-50%, in an oxygen tent - 30-70%.

• With DN III degree - artificial ventilation of the lungs.

Antibacterial therapy

• Basic principles of rational antibiotic therapy in children.

• Start of treatment - after diagnosis. It is desirable to carry out crops on the flora with the determination of sensitivity to antibiotics. The results will be in 3-5 days. We select the starting therapy empirically, taking into account the age of the patient, home or hospital pneumonia, and regional characteristics.

• First course - prescribe broad-spectrum antibiotics (mainly β-lactams).

• Main course – (replacement of empirically selected antibiotic) depends on the result of culture or on the clinical picture.

• Dose selection - depends on the severity, age, body weight.

• Choice of route of administration: in severe cases, it is mainly administered parenterally.

• Choice of injection frequency: it is necessary to create a constant concentration of the antibiotic in the body.

• Choosing a rational combination: synergism is required, only bactericidal or only bacteriostatic. Drugs should not enhance the toxic effect of each other.

• Conditions for stopping treatment: not earlier than 3 days of normal temperature, the general condition of the child.

• The accuracy of empiric therapy can be 80-90%.

In the winter season, with the onset of cold weather, the risk of diseases of the upper and lower respiratory tract increases: pneumonia, tonsillitis, tracheitis.

Pneumonia is now one of the most common diseases. Despite advances in drug therapy, pneumonia is still considered a dangerous and sometimes even fatal disease. Patients with pneumonia make up a significant percentage of those who seek medical help in polyclinics, therapeutic and pulmonological departments of hospitals, which is associated with a high incidence, especially during an influenza epidemic and outbreaks of acute respiratory diseases.

This is an acute infectious disease, predominantly of bacterial (viral) etiology, characterized by focal lesions of the respiratory sections of the lungs, the presence of intra-alveolar exudation, detected during physical and instrumental examination, feverish reaction and intoxication expressed to varying degrees.

Inflammatory lung disease can be suspected if the following signs are present:

• Fever (temperature rise above 38 degrees);
• Intoxication, general malaise, loss of appetite;
• Pain during breathing on the side of the affected lung, aggravated by coughing (with the involvement of the pleura in the inflammation process);
• Cough dry or with phlegm;
• Dyspnea.

The diagnosis is made by a doctor. It is important to seek medical help on the first day of the disease. A chest x-ray, computed tomography, and auscultatory data help the doctor make a diagnosis. The selection of drug therapy is strictly individual, depending on the alleged causative agent of the disease. Pneumonia is treated on an outpatient or inpatient basis, depending on the severity of the disease. Indications for hospitalization are determined by the doctor.

The relevance of the problem of pneumonia

The problem of diagnosis and treatment of pneumonia is one of the most urgent in modern therapeutic practice. Only in the last 5 years in Belarus, the increase in the incidence amounted to 61%. Mortality from pneumonia, according to different authors, ranges from 1 to 50%. In our republic, mortality increased by 52% over 5 years. Despite the impressive success of pharmacotherapy, the development of new generations of antibacterial drugs, the proportion of pneumonia in the structure of morbidity is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, excluding SARS, the number of patients with pneumonia exceeds 60%.

In modern conditions of the "economical" approach to financing health care, the most appropriate spending of the allocated budget funds is a priority, which predetermines the development of clear criteria and indications for the hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good end result at a lower cost. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for the hospitalization of patients with pneumonia into everyday practice, which would make it possible to facilitate the work of the district physician, save budgetary funds, and predict possible outcomes of the disease in a timely manner.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Healthcare organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics show an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. In the United States, this pathology ranks sixth in the structure of mortality and is the most common cause of death from infectious diseases. More than 60,000 deaths from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and severe illness. Tuberculosis and lung cancer are often hidden under its mask. A study of autopsy protocols for those who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made in less than a third of patients during the first day after admission to the hospital, and in 40% during the first week. On the first day of hospital stay, 27% of patients died. The coincidence of clinical and pathoanatomical diagnoses was noted in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change at the present stage of the “gold standard” for diagnosing pneumonia, which includes an acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, less often leukopenia with a neutrophilic shift in the blood, and radiographically detectable infiltrate in the lung tissue , which was not previously defined. Many researchers also note the formal, superficial attitude of doctors to the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

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On the problem of diagnosis and treatment of pneumonia

Community-acquired pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

Relevance. Respiratory diseases occupy one of the leading places in the structure of morbidity and mortality in children. Pneumonia plays an important role among them. This is due both to the high incidence of respiratory tract lesions in children and to the severe prognosis of many late diagnosed and untreated pneumonias. In the Russian Federation, the incidence of pneumonia in children is in the range of 6.3-11.9%. One of the main reasons for the increase in the number of pneumonias is the high level of diagnostic errors and late diagnosis. Significantly increased the proportion of pneumonia, in which the clinical picture does not match the x-ray data, increased the number of asymptomatic forms of the disease. There are also difficulties in the etiological diagnosis of pneumonia, since over time the list of pathogens is expanded and modified. More recently, community-acquired pneumonia has been associated mainly with Streptococcus pneumoniae. At present, the etiology of the disease has expanded significantly, and in addition to bacteria, it can also be represented by atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae), fungi, and viruses (influenza, parainfluenza, metapneumoviruses, etc.), the role of the latter is especially large in children under 5 years 4. All this leads to untimely correction of treatment, aggravation of the patient's condition, the appointment of additional drugs, which ultimately affects the prognosis of the disease. Thus, despite a fairly detailed study of the problem of childhood pneumonia, there is a need to clarify the modern clinical features of pneumonia, to study the significance of various pathogens, including pneumotropic viruses, in this disease.

Purpose of the study: identification of modern clinical, laboratory and etiological features of the course of pneumonia in children. Materials and methods. A comprehensive examination of 166 children with community-acquired pneumonia aged 1 to 15 years who were treated in the pulmonology department of the children's hospital of the Children's City Clinical Hospital, Orenburg, was carried out. Among the examined children there were 85 boys (51.2%) and 81 girls (48.8%). All patients were divided into 2 groups according to the morphological forms of pneumonia (patients with focal pneumonia and segmental pneumonia) and into 4 groups according to age - young children (1-2 years old), preschoolers (3-6 years old), younger schoolchildren (7-2 years old). 10 years old) and older students (11-15 years old). All patients underwent the following examination: a clinical blood test, a general urinalysis, a biochemical blood test with the determination of the level of C-reactive protein (CRP), chest x-ray, microscopic and bacteriological examination of sputum for flora and sensitivity to antibiotics. To detect respiratory viruses and S. pneumoniae, 40 patients underwent a study of tracheobronchial aspirates by real-time polymerase chain reaction (PCR) in order to detect ribonucleic acid (RNA) of respiratory syncytial virus, rhinovirus, metapneumovirus, parainfluenza virus 1, 2, 3, 4 types, deoxyribonucleic acid (DNA) adenovirus and pneumococcus. The data obtained during the study were processed using the STATISTICA 6.1 software product. In the course of the analysis, the calculation of elementary statistics was performed, the construction and visual analysis of the correlation fields of the connection between the analyzed parameters, the comparison of the frequency characteristics was carried out using non-parametric methods chi-square, chi-square with Yates correction, Fisher's exact method. Comparison of quantitative indicators in the studied groups was carried out using the Student's t-test with a normal distribution of the sample and the Wilcoxon-Mann-Whitney U test with not normal distribution. The relationship between individual quantitative traits was determined by the Spearman rank correlation method. Differences in mean values, correlation coefficients were recognized as statistically significant at a significance level of p 9 /l, segmental - 10.4±8.2 x10 9 /l.

In the group of segmental pneumonias, the ESR value was higher than in focal pneumonias - 19.11±17.36 mm/h versus 12.67±13.1 mm/h, respectively (p 9 /l to 7.65±2.1x 10 9 /l (p

List of sources used:

1. Community-acquired pneumonia in children: prevalence, diagnosis, treatment and prevention. - M.: Original layout, 2012. - 64 p.

2. Sinopalnikov A.I., Kozlov R.S. Community-acquired respiratory tract infections. A guide for doctors - M .: Premier MT, Our city, 2007. - 352 p.

hospital pneumonia

Main tabs

INTRODUCTION

Pneumonia is currently a very urgent problem, because despite the constantly growing number of new antibacterial drugs, high mortality from this disease remains. Currently, for practical purposes, pneumonia is divided into community-acquired and nosocomial. In these two large groups, there are also aspiration and atypical pneumonias (caused by intracellular agents - mycoplasma, chlamydia, legionella), as well as pneumonia in patients with neutropenia and / or against the background of various immunodeficiencies.

The international statistical classification of diseases provides for the definition of pneumonia solely on an etiological basis. More than 90% of HP cases are of bacterial origin. Viruses, fungi and protozoa are characterized by a minimal "contribution" to the etiology of the disease. Over the past two decades, there have been significant changes in the epidemiology of HP. This is characterized by the increased etiological significance of pathogens such as mycoplasma, legionella, chlamydia, mycobacteria, pneumocystis and a significant increase in the resistance of staphylococci, pneumococci, streptococci and Haemophilus influenzae to the most widely used antibiotics. The acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta-lactamases that destroy the structure of beta-lactam antibiotics. Nosocomial bacterial strains are usually distinguished by high resistance. In part, these changes are due to the selective pressure on microorganisms of the ubiquitous new broad-spectrum antibiotics. Other factors are the growth in the number of multidrug-resistant strains and the increase in the number of invasive diagnostic and therapeutic manipulations in a modern hospital. In the early antibiotic era, when only penicillin was available to the doctor, about 65% of all nosocomial infections, including HP, were due to staphylococci. The introduction of penicillinase-resistant beta-lactams into clinical practice reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%) increased, which replaced gram-positive pathogens (30%) and anaerobes (3%). Since that time, multi-resistant gram-negative microorganisms (intestinal aerobes and Pseudomonas aeruginosa) have been put forward among the most relevant nosocomial pathogens. Currently, there is a resurgence of gram-positive microorganisms as topical nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

On average, the incidence of nosocomial pneumonia (HP) is 5-10 cases per 1000 hospitalized patients, but in patients on mechanical ventilation, this figure increases by 20 times or more. Mortality in GP, ​​despite the objective achievements in antimicrobial chemotherapy, today is 33-71%. In general, nosocomial pneumonia (NP) accounts for about 20% of all nosocomial infections and ranks third after wound infections and urinary tract infections. The frequency of NP increases in patients who are in the hospital for a long time; when using immunosuppressive drugs; in persons suffering from serious illnesses; in elderly patients.

ETIOLOGY AND PATHOGENESIS of nosocomial pneumonia

Hospital (nosocomial, nosocomial) pneumonia (interpreted as the appearance after 48 hours or more from the moment of hospitalization of a new pulmonary infiltrate in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sputum, leukocytosis, etc.) and with the exclusion of infections, who were in the incubation period when the patient was admitted to the hospital) is the second most common and leading cause of death in the structure of nosocomial infections.

Studies conducted in Moscow have shown that the most common (up to 60%) bacterial pathogens of community-acquired pneumonia are pneumococci, streptococci and Haemophilus influenzae. Less often - staphylococcus aureus, Klebsiella, enterobacter, legionella. In young people, pneumonia is more often caused by a monoculture of the pathogen (usually pneumococcus), and in the elderly - by an association of bacteria. It is important to note that these associations are represented by a combination of gram-positive and gram-negative microorganisms. The frequency of mycoplasmal and chlamydial pneumonia varies depending on the epidemiological situation. Young people are more likely to be affected by this infection.

Respiratory tract infections occur when at least one of three conditions is present: a violation of the body's defenses, the entry of pathogenic microorganisms into the lower respiratory tract of a patient in an amount exceeding the body's defenses, the presence of a highly virulent microorganism.
Penetration of microorganisms into the lungs can occur in various ways, including through microaspiration of oropharyngeal secretions colonized by pathogenic bacteria, aspiration of esophageal/gastric contents, inhalation of an infected aerosol, penetration from a distant infected site by hematogenous route, exogenous penetration from an infected site (for example, the pleural cavity) , direct infection of the respiratory tract in intubated patients from intensive care staff or, which remains doubtful, through transfer from the gastrointestinal tract.
Not all of these routes are equally dangerous in terms of pathogen penetration. Of the possible routes of penetration of pathogenic microorganisms into the lower respiratory tract, the most common is microaspiration of small volumes of oropharyngeal secretion, previously infected with pathogenic bacteria. Since microaspiration occurs quite often (for example, microaspiration during sleep occurs in at least 45% of healthy volunteers), it is the presence of pathogenic bacteria that can overcome the defense mechanisms in the lower respiratory tract that plays an important role in the development of pneumonia. In one study, contamination of the oropharynx with enteric gram-negative bacteria (CGOB) was noted relatively rarely (

The study of factors contributing to the development of community-acquired pneumonia and the analysis of effective treatment

Description: In recent years, the number of patients with severe and complicated course of community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is the underestimation of the severity of the condition upon admission to the hospital due to the poor clinical, laboratory and radiological picture in the initial period of the disease. In Russia, medical personnel actively participate in conferences on the prevention of pneumonia.

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Chapter 1. What is community-acquired pneumonia?

1.6. Differential Diagnosis

1.8. Antibacterial therapy

1.9. Comprehensive treatment of community-acquired pneumonia

1.10. Socio-economic aspects

1.11. Preventive measures

CHAPTER 2. Analysis of statistical data on pneumonia in the city of Salavat

Results of the work performed

Respiratory diseases are one of the main causes of morbidity and mortality worldwide. At the present stage, the clinical course is changing and the severity of these diseases is aggravated, which leads to an increase in various complications, disability and increasing mortality. Community-acquired pneumonia still remains one of the leading pathologies in the group of respiratory diseases. The incidence of community-acquired pneumonia in most countries is 10-12%, varying depending on age, gender, socio-economic conditions.

In recent years, the number of patients with severe and complicated course of community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is the underestimation of the severity of the condition upon admission to the hospital, due to the poor clinical, laboratory and radiological picture in the initial period of the development of the disease. However, in a number of works there is an underestimation of the data of clinical and laboratory studies, complex prognosis methods are proposed, and an integrated approach to examining patients is often ignored. In this regard, the relevance of the problem of a comprehensive quantitative assessment of the severity of the condition of a patient with community-acquired pneumonia and predicting the course of the disease in the early stages of hospitalization is increasing.

In Russia, medical personnel actively participate in conferences on the prevention of pneumonia. In medical institutions, examinations are carried out annually. But, unfortunately, despite such work, the number of people with pneumonia remains one of the main problems in our country.

The urgency of the problem. This work focuses on the severity of the disease due to the large number of cases of severe consequences. The situation is constantly monitored, the incidence statistics, in particular, pneumonia, are being studied.

Considering this situation with pneumonia, I decided to tackle this problem.

Purpose of the study. The study of factors contributing to the development of community-acquired pneumonia and the analysis of effective treatment.

Object of study. Patients with community-acquired pneumonia in a hospital setting.

Subject of study. The role of the paramedic in the timely detection of community-acquired pneumonia and adequate therapy.

1) Identify and study the causes that contribute to the disease of community-acquired pneumonia.

2) Determine the risk factors for the incidence of community-acquired pneumonia.

3) To evaluate the comparative clinical, bacteriological efficacy and safety of various antibiotic therapy regimens in the treatment of hospitalized patients with community-acquired pneumonia.

4) Familiarization with the role of the paramedic in the prevention and treatment of community-acquired pneumonia.

Hypothesis. Community-acquired pneumonia is defined as a medical and social problem.

The practical significance of my work lies in the fact that the population is well versed in the symptoms of pneumonia, understands the risk factors for the onset of the disease, prevention, and the importance of timely and effective treatment of this disease.

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

Community-acquired pneumonia is an infectious disease of the lower respiratory tract. Community-acquired pneumonia in children and adults develops in most cases as a complication of a viral infection. The name of pneumonia characterizes the conditions of its occurrence. A person gets sick at home, without any contact with a medical institution.

What is pneumonia? This disease is conditionally divided into three types:

Mild pneumonia is the largest group. She is treated on an outpatient basis at home.

Moderate disease. Such pneumonia is treated in a hospital.

Severe form of pneumonia. She is treated only in the hospital, in the intensive care unit.

What is Community Acquired Pneumonia?

Community-acquired pneumonia is an acute infectious inflammatory disease of predominantly bacterial etiology that occurred in a community setting (outside the hospital or later than 4 weeks after discharge from it, or diagnosed in the first 48 hours from the moment of hospitalization, or developed in a patient who was not in nursing homes / departments long-term medical observation for more than 14 days), with damage to the respiratory sections of the lungs (alveoli, small-caliber bronchi and bronchioles), frequent presence of characteristic symptoms (acute fever, dry cough with subsequent sputum production, chest pain, shortness of breath) and previously absent clinical -radiological signs of a local lesion, not associated with other known causes.

Community-acquired pneumonia is one of the most common respiratory diseases. Its incidence is 8-15 per 1000 population. Its frequency increases significantly among the elderly and senile age. The list of main risk factors for the development of the disease and death includes:

smoking habit,

chronic obstructive pulmonary disease,

congestive heart failure,

Immunodeficiency states, overcrowding, etc.

More than a hundred microorganisms (bacteria, viruses, fungi, protozoa) have been described, which under certain conditions can be the causative agents of community-acquired pneumonia. However, most cases of the disease are associated with a relatively small range of pathogens.

In some categories of patients - recent intake of systemic antimicrobials, long-term therapy with systemic glucocorticosteroids in pharmacodynamic doses, cystic fibrosis, secondary bronchiectasis - in the etiology of community-acquired pneumonia, the relevance of Pseudomonas aeruginosa increases significantly.

The significance of anaerobes colonizing the oral cavity and upper respiratory tract in the etiology of community-acquired pneumonia has not yet been definitively determined, which is primarily due to the limitations of traditional culture methods for the study of respiratory samples. The likelihood of anaerobic infection may increase in individuals with proven or suspected aspiration due to episodes of impaired consciousness during convulsions, certain neurological diseases (eg, stroke), dysphagia, diseases accompanied by esophageal dysmotility.

The frequency of occurrence of other bacterial pathogens - Chlamydophila psittaci, Streptococcus pyogenes, Bordetella pertussis, etc. usually does not exceed 2-3%, and lung lesions caused by endemic micromycetes (Histoplasma capsulatum, Coccidioides immitis, etc.) are extremely rare.

Community-acquired pneumonia can be caused by respiratory viruses, most commonly influenza viruses, coronaviruses, rhinosyncytial virus, human metapneumovirus, and human bocavirus. In most cases, infections caused by a group of respiratory viruses are characterized by a mild course and are self-limited, however, in elderly and senile people, in the presence of concomitant bronchopulmonary, cardiovascular diseases or secondary immunodeficiency, they may be associated with the development of severe, life-threatening complications.

The growing relevance of viral pneumonia in recent years is due to the emergence and spread in the population of the pandemic influenza virus A / H1N1pdm2009, which can cause primary damage to the lung tissue and the development of rapidly progressive respiratory failure.

There are primary viral pneumonia (develops as a result of direct viral damage to the lungs, characterized by a rapidly progressive course with the development of severe respiratory failure) and secondary bacterial pneumonia, which can be combined with primary viral damage to the lungs or be an independent late complication of influenza. The most common causative agents of secondary bacterial pneumonia in patients with influenza are Staphylococcus aureus and Streptococcus pneumoniae. The frequency of detection of respiratory viruses in patients with community-acquired pneumonia is of a pronounced seasonal nature and increases in the cold season.

In community-acquired pneumonia, co-infection with two or more pathogens can be detected, it can be caused both by the association of various bacterial pathogens, and by their combination with respiratory viruses. The incidence of community-acquired pneumonia caused by the association of pathogens varies from 3 to 40%. According to a number of studies, community-acquired pneumonia caused by the association of pathogens tends to be more severe and have a worse prognosis.

The most common way for microorganisms to enter the lung tissue is:

1) Bronchogenic - and this is facilitated by:

Inhalation of microbes from the environment,

Relocation of pathogenic flora from the upper parts of the respiratory system (nose, pharynx) to the lower,

Medical manipulations (bronchoscopy, tracheal intubation, artificial lung ventilation, inhalation of medicinal substances from contaminated inhalers), etc.

2) The hematogenous route of infection (with blood flow) is less common - with intrauterine infection, septic processes and drug addiction with intravenous drug administration.

3) The lymphogenous route of penetration is very rare.

Further, with pneumonia of any etiology, the infectious agent is fixed and multiplied in the epithelium of the respiratory bronchioles - acute bronchitis or bronchiolitis of various types develops - from mild catarrhal to necrotic. The spread of microorganisms outside the respiratory bronchioles causes inflammation of the lung tissue - pneumonia. Due to the violation of bronchial patency, there are foci of atelectasis and emphysema. Reflexively, with the help of coughing and sneezing, the body tries to restore the patency of the bronchi, but as a result, the infection spreads to healthy tissues, and new foci of pneumonia form. Oxygen deficiency, respiratory failure, and in severe cases, heart failure develops. Most of all II, VI, X segments of the right lung and VI, VIII, IX, X segments of the left lung are affected.

Aspiration pneumonias are common in the mentally ill; in persons with diseases of the central nervous system; in persons suffering from alcoholism.

Pneumonia in immunodeficiency states is typical for cancer patients receiving immunosuppressive therapy, as well as drug addicts and HIV-infected people.

Great importance is attached to the classification of pneumonia to the diagnosis of the severity of pneumonia, the localization and extent of lung damage, the diagnosis of complications of pneumonia, which makes it possible to more objectively evaluate the prognosis of the disease, choose a rational program of complex treatment and identify a group of patients in need of intensive care. There is no doubt that all these headings, along with empirical or objectively confirmed information about the most likely causative agent of the disease, should be presented in the modern classification of pneumonia.

The most complete diagnosis of pneumonia should include the following headings:

The form of pneumonia (community-acquired, nosocomial, pneumonia against the background of immunodeficiency states, etc.);

The presence of additional clinical and epidemiological conditions for the occurrence of pneumonia;

Etiology of pneumonia (verified or suspected infectious agent);

Localization and extent;

Clinical and morphological variant of the course of pneumonia;

Severity of pneumonia;

The degree of respiratory failure;

The presence of complications.

Table 1. Comorbidities/risk factors associated with certain causative agents of community-acquired pneumonia.

The problem of diagnosis and treatment of pneumonia is one of the most urgent in modern therapeutic practice. Only in the last 5 years in Belarus, the increase in the incidence amounted to 61%. Mortality from pneumonia, according to different authors, ranges from 1 to 50%. In our republic, mortality increased by 52% over 5 years. Despite the impressive success of pharmacotherapy, the development of new generations of antibacterial drugs, the proportion of pneumonia in the structure of morbidity is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, excluding SARS, the number of patients with pneumonia exceeds 60%.

In modern conditions of the "economical" approach to financing health care, the most appropriate spending of the allocated budget funds is a priority, which predetermines the development of clear criteria and indications for the hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good end result at a lower cost. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for the hospitalization of patients with pneumonia into everyday practice, which would make it possible to facilitate the work of the district physician, save budgetary funds, and predict possible outcomes of the disease in a timely manner.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Healthcare organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics show an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. In the United States, this pathology ranks sixth in the structure of mortality and is the most common cause of death from infectious diseases. More than 60,000 deaths from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and severe illness. Tuberculosis and lung cancer are often hidden under its mask. A study of autopsy protocols for those who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made in less than a third of patients during the first day after admission to the hospital, and in 40% during the first week. On the first day of hospital stay, 27% of patients died. The coincidence of clinical and pathoanatomical diagnoses was noted in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change at the present stage of the “gold standard” for diagnosing pneumonia, which includes an acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, less often leukopenia with a neutrophilic shift in the blood, and radiographically detectable infiltrate in the lung tissue , which was not previously defined. Many researchers also note the formal, superficial attitude of doctors to the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

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On the problem of diagnosis and treatment of pneumonia

Community-acquired pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

Relevance. Respiratory diseases occupy one of the leading places in the structure of morbidity and mortality in children. Pneumonia plays an important role among them. This is due both to the high incidence of respiratory tract lesions in children and to the severe prognosis of many late diagnosed and untreated pneumonias. In the Russian Federation, the incidence of pneumonia in children is in the range of 6.3-11.9%. One of the main reasons for the increase in the number of pneumonias is the high level of diagnostic errors and late diagnosis. Significantly increased the proportion of pneumonia, in which the clinical picture does not match the x-ray data, increased the number of asymptomatic forms of the disease. There are also difficulties in the etiological diagnosis of pneumonia, since over time the list of pathogens is expanded and modified. More recently, community-acquired pneumonia has been associated mainly with Streptococcus pneumoniae. At present, the etiology of the disease has expanded significantly, and in addition to bacteria, it can also be represented by atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae), fungi, and viruses (influenza, parainfluenza, metapneumoviruses, etc.), the role of the latter is especially large in children under 5 years 4. All this leads to untimely correction of treatment, aggravation of the patient's condition, the appointment of additional drugs, which ultimately affects the prognosis of the disease. Thus, despite a fairly detailed study of the problem of childhood pneumonia, there is a need to clarify the modern clinical features of pneumonia, to study the significance of various pathogens, including pneumotropic viruses, in this disease.

Purpose of the study: identification of modern clinical, laboratory and etiological features of the course of pneumonia in children. Materials and methods. A comprehensive examination of 166 children with community-acquired pneumonia aged 1 to 15 years who were treated in the pulmonology department of the children's hospital of the Children's City Clinical Hospital, Orenburg, was carried out. Among the examined children there were 85 boys (51.2%) and 81 girls (48.8%). All patients were divided into 2 groups according to the morphological forms of pneumonia (patients with focal pneumonia and segmental pneumonia) and into 4 groups according to age - young children (1-2 years old), preschoolers (3-6 years old), younger schoolchildren (7-2 years old). 10 years old) and older students (11-15 years old). All patients underwent the following examination: a clinical blood test, a general urinalysis, a biochemical blood test with the determination of the level of C-reactive protein (CRP), chest x-ray, microscopic and bacteriological examination of sputum for flora and sensitivity to antibiotics. To detect respiratory viruses and S. pneumoniae, 40 patients underwent a study of tracheobronchial aspirates by real-time polymerase chain reaction (PCR) in order to detect ribonucleic acid (RNA) of respiratory syncytial virus, rhinovirus, metapneumovirus, parainfluenza virus 1, 2, 3, 4 types, deoxyribonucleic acid (DNA) adenovirus and pneumococcus. The data obtained during the study were processed using the STATISTICA 6.1 software product. In the course of the analysis, the calculation of elementary statistics was performed, the construction and visual analysis of the correlation fields of the connection between the analyzed parameters, the comparison of the frequency characteristics was carried out using non-parametric methods chi-square, chi-square with Yates correction, Fisher's exact method. Comparison of quantitative indicators in the studied groups was carried out using the Student's t-test with a normal distribution of the sample and the Wilcoxon-Mann-Whitney U test with not normal distribution. The relationship between individual quantitative traits was determined by the Spearman rank correlation method. Differences in mean values, correlation coefficients were recognized as statistically significant at a significance level of p 9 /l, segmental - 10.4±8.2 x10 9 /l.

In the group of segmental pneumonias, the ESR value was higher than in focal pneumonias - 19.11±17.36 mm/h versus 12.67±13.1 mm/h, respectively (p 9 /l to 7.65±2.1x 10 9 /l (p

List of sources used:

1. Community-acquired pneumonia in children: prevalence, diagnosis, treatment and prevention. - M.: Original layout, 2012. - 64 p.

2. Sinopalnikov A.I., Kozlov R.S. Community-acquired respiratory tract infections. A guide for doctors - M .: Premier MT, Our city, 2007. - 352 p.

hospital pneumonia

Main tabs

INTRODUCTION

Pneumonia is currently a very urgent problem, because despite the constantly growing number of new antibacterial drugs, high mortality from this disease remains. Currently, for practical purposes, pneumonia is divided into community-acquired and nosocomial. In these two large groups, there are also aspiration and atypical pneumonias (caused by intracellular agents - mycoplasma, chlamydia, legionella), as well as pneumonia in patients with neutropenia and / or against the background of various immunodeficiencies.

The international statistical classification of diseases provides for the definition of pneumonia solely on an etiological basis. More than 90% of HP cases are of bacterial origin. Viruses, fungi and protozoa are characterized by a minimal "contribution" to the etiology of the disease. Over the past two decades, there have been significant changes in the epidemiology of HP. This is characterized by the increased etiological significance of pathogens such as mycoplasma, legionella, chlamydia, mycobacteria, pneumocystis and a significant increase in the resistance of staphylococci, pneumococci, streptococci and Haemophilus influenzae to the most widely used antibiotics. The acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta-lactamases that destroy the structure of beta-lactam antibiotics. Nosocomial bacterial strains are usually distinguished by high resistance. In part, these changes are due to the selective pressure on microorganisms of the ubiquitous new broad-spectrum antibiotics. Other factors are the growth in the number of multidrug-resistant strains and the increase in the number of invasive diagnostic and therapeutic manipulations in a modern hospital. In the early antibiotic era, when only penicillin was available to the doctor, about 65% of all nosocomial infections, including HP, were due to staphylococci. The introduction of penicillinase-resistant beta-lactams into clinical practice reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%) increased, which replaced gram-positive pathogens (30%) and anaerobes (3%). Since that time, multi-resistant gram-negative microorganisms (intestinal aerobes and Pseudomonas aeruginosa) have been put forward among the most relevant nosocomial pathogens. Currently, there is a resurgence of gram-positive microorganisms as topical nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

On average, the incidence of nosocomial pneumonia (HP) is 5-10 cases per 1000 hospitalized patients, but in patients on mechanical ventilation, this figure increases by 20 times or more. Mortality in GP, ​​despite the objective achievements in antimicrobial chemotherapy, today is 33-71%. In general, nosocomial pneumonia (NP) accounts for about 20% of all nosocomial infections and ranks third after wound infections and urinary tract infections. The frequency of NP increases in patients who are in the hospital for a long time; when using immunosuppressive drugs; in persons suffering from serious illnesses; in elderly patients.

ETIOLOGY AND PATHOGENESIS of nosocomial pneumonia

Hospital (nosocomial, nosocomial) pneumonia (interpreted as the appearance after 48 hours or more from the moment of hospitalization of a new pulmonary infiltrate in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sputum, leukocytosis, etc.) and with the exclusion of infections, who were in the incubation period when the patient was admitted to the hospital) is the second most common and leading cause of death in the structure of nosocomial infections.

Studies conducted in Moscow have shown that the most common (up to 60%) bacterial pathogens of community-acquired pneumonia are pneumococci, streptococci and Haemophilus influenzae. Less often - staphylococcus aureus, Klebsiella, enterobacter, legionella. In young people, pneumonia is more often caused by a monoculture of the pathogen (usually pneumococcus), and in the elderly - by an association of bacteria. It is important to note that these associations are represented by a combination of gram-positive and gram-negative microorganisms. The frequency of mycoplasmal and chlamydial pneumonia varies depending on the epidemiological situation. Young people are more likely to be affected by this infection.

Respiratory tract infections occur when at least one of three conditions is present: a violation of the body's defenses, the entry of pathogenic microorganisms into the lower respiratory tract of a patient in an amount exceeding the body's defenses, the presence of a highly virulent microorganism.
Penetration of microorganisms into the lungs can occur in various ways, including through microaspiration of oropharyngeal secretions colonized by pathogenic bacteria, aspiration of esophageal/gastric contents, inhalation of an infected aerosol, penetration from a distant infected site by hematogenous route, exogenous penetration from an infected site (for example, the pleural cavity) , direct infection of the respiratory tract in intubated patients from intensive care staff or, which remains doubtful, through transfer from the gastrointestinal tract.
Not all of these routes are equally dangerous in terms of pathogen penetration. Of the possible routes of penetration of pathogenic microorganisms into the lower respiratory tract, the most common is microaspiration of small volumes of oropharyngeal secretion, previously infected with pathogenic bacteria. Since microaspiration occurs quite often (for example, microaspiration during sleep occurs in at least 45% of healthy volunteers), it is the presence of pathogenic bacteria that can overcome the defense mechanisms in the lower respiratory tract that plays an important role in the development of pneumonia. In one study, contamination of the oropharynx with enteric gram-negative bacteria (CGOB) was noted relatively rarely (

Z.K. Zeinulina

GKP on REM City Polyclinic No. 4, pediatrician

The widespread occurrence of acute pneumonia poses a great danger to children. Timely correct diagnosis of acute pneumonia in children, assessment of the severity of the course of the disease, taking into account concomitant diseases, the correct choice of antibiotic therapy allows children to fully recover from pneumonia, reduce complications and mortality from pneumonia.

Bibliography: 5.

Keywords: children, pneumonia, etiology, antibiotics.

Pneumonia is a group of acute infectious diseases (infectious processes) of different etiology, pathogenesis and morphology, characterized by damage to the respiratory sections of the lungs with the obligatory presence of intraalveolar exudation.

Every year in Russia, 1.5 million people fall ill with pneumonia, and the correct diagnosis is made in 1/3 of patients (3).

Acute pneumonia (AP) is an acute respiratory disease with local manifestations in the lungs, confirmed by x-ray.

Current trends in acute pneumonia (5):

Increased frequency of intracellular microorganisms;

Hyper- (56%) and underdiagnosis (33%);

Preference for taking oral antibacterial drugs;

Shorter courses of antibiotic therapy;

Refusal of intravenous fluids and gamma globulin;

Inappropriate physiotherapy.

Classification of pneumonia to date (2):

In form - focal, focal-confluent, croupous, segmental, interstitial;

According to the place of origin and etiology - community-acquired, nosocomial, perinatal, with immunodeficiency, atypical, against the background of influenza, aspiration;

Downstream - acute up to 6 weeks, protracted in the absence of resolution in terms of 6 weeks to 8 months;

According to the presence of complications - uncomplicated, complicated.

Criteria for diagnosing pneumonia: violation of the general condition, fever, cough, shortness of breath of varying severity, characteristic physical changes in the lungs. X-ray confirmation is based on the detection of infiltrative changes on the radiograph. In the pathogenesis of the development of pneumonia, the following factors are of great importance:

microaspiration of the secretion of the nasopharynx occurs in 70% of healthy individuals (violation of self-purification);

inhalation of an aerosol with microorganisms: 60% of preschool children and 30% of school children and adults are carriers of pneumococcus;

20-40% of preschool children are carriers of Haemophilus influenzae;

there may be hematogenous spread of infection and direct spread of infection from neighboring organs.

Gold standard for clinical diagnosis (4):

Increase in body temperature;

Shortness of breath (up to 2 months - 60; 2 - 12 months - 50; 1 - 5 years - 40);

Local auscultatory and percussion symptoms;

Leukocytosis in the analysis of peripheral blood;

X-ray changes;

Toxicosis.

Once the diagnosis is made, the choice of the initial antibiotic is important (1).

The choice of the initial antibiotic depends on the clinical situation, the antimicrobial spectrum of action of the selected antibiotic, the results of sputum smear microscopy, the pharmacokinetics of the antimicrobial drug, the severity of the course of pneumonia, the safety and cost of the drug, the spectrum of antibacterial action, including potential pathogens, proven clinical and microbiological efficacy, ease of use, accumulation in the focus of inflammation, good tolerance and safety, affordable price.

Age 1-6 months. Definitely hospitalization!

"Typical" pneumonia: amoxicillin, amoxicillin/clavulanate, ampicillin/sulbactam, 3rd generation cephalosporins.
"Atypical" pneumonia - macrolides.

Mild course of pneumonia in children 6 months - 6 years

drugs of choice: amoxicillin, macrolides, alternative drugs amoxicillin / clavulanate, cefuroxime maxetil. Older than 7 years amoxicillin, macrolides.

Switching to oral antibiotics is possible with

persistent normalization of temperature, reduction of shortness of breath and cough, reduction of leukocytosis and blood neutrophilia (5-10 days of therapy).

With a clear clinical positive dynamics, a control radiograph at discharge is not required, but an outpatient radiographic control is necessary at 4-5 weeks.

Indications for continuing antibiotic therapy are not: subfebrile condition, dry cough, persistence of wheezing in the lungs,

accelerated ESR, guarded weakness, sweating, persistence of residual changes on the radiograph (infiltration, pattern enhancement)

Therapy is considered ineffective if there is no improvement within 24-48 hours: there is an increase in signs of respiratory failure; a drop in systolic pressure, which indicates the development of an infectious shock; an increase in the size of pneumonic infiltration by more than 50% compared with the original data; the appearance of other manifestations of organ failure. In these cases, it is necessary to switch to alternative ABs and strengthen the functional support of organs and systems.

Errors in antibiotic therapy: the appointment of gentamicin, co-trimoxazole, ampicillin orally and antibiotics in combination with nystatin, frequent changes in antibiotics during treatment,

continuation of antibiotic therapy until the complete disappearance of all clinical and laboratory parameters (2,3).

Hospitalization requirements (3):

The child is less than 2 months old. regardless of the severity and prevalence of the process

Age up to 3 years with the lobar nature of lung damage

Age up to 5 years with damage to more than one lobe of the lung

Leukopenia< 6 тыс., лейкоцитоз >20 thousand

Atelectasis

Unfavorable localization (С4-5)

Children with severe encephalopathy of any origin

Children of the first year of life with intrauterine infections

Children with congenital malformations, especially of the heart

Children with concomitant bronchial asthma, diabetes mellitus, diseases of the cardiovascular system, kidneys, oncohematology

Children from poor social conditions

Lack of guaranteed implementation of therapeutic measures at home

A direct indication for hospitalization is the toxic course of pneumonia: shortness of breath over 60 per minute for children of the first year of life and more than 50 per minute for children older than a year; retraction of the intercostal spaces and especially the jugular fossa during breathing; groaning breathing, violation of the rhythm of breathing; signs of acute heart failure; intractable hyperthermia; impaired consciousness, convulsions.

Complicated course of pneumonia: pneumonic toxicosis of varying severity; pleurisy; lung destruction, lung abscess; pneumothorax; pyopneumothorax.

Conclusions: Over the past 3 years, pediatricians have carried out early detection of acute pneumonia and timely hospitalization in hospitals in pediatric areas. After discharge from the hospital, rehabilitation measures and medical examinations are carried out. There was not a single lethal outcome. they were diagnosed early and prescribed adequate therapy.