Pneumonia (J18). Classification of pneumonia, causes, treatment Differential diagnosis of pneumonia

Community-acquired pneumonia: diagnosis and differential diagnosis

A.I. Sinopalnikov

The collective term "pneumonia" is usually used to designate a group of acute infectious (mainly bacterial nature) focal lesions of the respiratory parts of the lungs with different degrees of etiology, pathogenesis, morphological characteristics of focal lesions of the respiratory parts of the lungs with the presence of intraalveolar exudation, manifested in varying degrees of febrile reaction, intoxication and detected during physical and radiological studies.

The most widespread classification is taking into account the conditions in which the disease developed, the features of infection of the lung tissue, as well as the immunological reactivity of the organism. Correct consideration of these factors allows predicting the etiology of the disease with a significant degree of probability and, ultimately, choosing an adequate direction for empirical antimicrobial chemotherapy. In accordance with this classification, the following types of pneumonia are distinguished:

a) community-acquired (acquired outside a medical institution) pneumonia (synonyms: home, outpatient);

b) nosocomial (acquired in a medical institution) pneumonia (synonyms: hospital, nosocomial);

Alexander Igorevich Sinopalnikov - Professor, Head of the Department of Pulmonology with a course of phthisiology at the State Institute for Advanced Training of Doctors of the Ministry of Defense of the Russian Federation.

c) aspiration pneumonia;

d) pneumonia in persons with severe immunosuppression (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

The most practically significant is the division of pneumonia into community-acquired and nosocomial. It must be emphasized that such a subdivision has nothing to do with the severity of the course of the disease, and the main and only criterion for differentiation is the environment in which pneumonia developed.

The term “community-acquired pneumonia” describes cases of acute illness occurring in community-acquired

conditions, accompanied by symptoms of lower respiratory tract infection (fever, cough with sputum, possibly purulent, chest pain, shortness of breath) and radiographic evidence of “fresh” focal-in-infiltrative changes in the lungs in the absence of an obvious diagnostic alternative.

Diagnostics

The diagnosis of pneumonia is complicated by the fact that there is no specific clinical sign or combination of signs that can be reliably relied on if this diagnosis is suspected. Rather, the absence of any of the nonspecific symptoms or the absence of local stetho-acoustic

These changes in the lungs make the diagnosis of pneumonia less likely.

In general, the key clinical and radiological signs of community-acquired pneumonia (CAP) can be formulated as follows:

Analysis of clinical features and X-ray data allows in some cases to make an assumption about a particular pathogen, but this information is of relative value;

Sudden onset, febrile fever, tremendous chills, pleural pain in the chest, lobar infiltration are characteristic of Streptococcus pneumoniae (it is often possible to isolate pneumococcus from the blood), partly for Legionella spp., Less often for other pathogens. On the contrary, this picture is absolutely not typical for Mycoplasma pneumoniae and Chlamy-dophila (Chlamydia) pneumoniae;

“Classic” signs of pneumonia (acute febrile onset, chest pains, etc.) may be absent, especially in weak or elderly patients;

Approximately 25% of CAP patients over the age of 65 years have no fever, and leukocytosis is recorded only in 50-70%. In this case, symptoms can be represented by weakness, nausea, anorexia, abdominal pain, intellectual and mental disorders;

Late diagnosis and delay in starting antibiotic therapy lead to a worse prognosis: mortality among patients over 65 reaches 10-25%;

The most common X-ray signs of pneumonia are

Pneumonia should always be suspected if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and / or chest pain.

aklftsA, [іishmtyupya about «ischplssh 3 * 2003 7

mm. bbavr "FD-pduu

focal blackouts appear in the projection of one or more segments;

In cases of lobar infiltration, the phenomenon of "air bronchogram" is visualized in 33% of patients;

Pleural effusion complicates the course of CAP in 10-25% of cases and is not particularly important in predicting the etiology of the disease;

The formation of cavities of destruction in the lungs is not typical for pneumococcal, mycoplasma and chlamydial pneumonia, but rather testifies in favor of staphylococcal infection, aerobic gram-negative pathogens of the intestinal group and anaerobes;

Reticulo-nodular infiltration in the basal parts of the lungs is characteristic of mycoplasma pneumonia (however, in 20% of cases it may be accompanied by focal-confluent infiltration in the projection of several segments or even a lobe).

Pneumonia should always be suspected if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and / or chest pain. Patients with pneumonia often complain of unmotivated weakness, fatigue, and heavy sweating at night.

The information obtained from physical examination of patients with CAP depends on many factors, including the severity of the disease, the prevalence of pneumonic infiltration, age, and the presence of comorbidities. The classical objective signs of pneumonia are the shortening (dullness) of the percussion tone over the affected area of the lung, locally audible bronchial breathing, the focus of sonorous small bubbling rales or inspiratory crepitus, increased bronchophonia and vocal tremor. However, in some patients, the objective signs of pneumonia may differ from typical ones or be absent altogether (in about 20% of patients).

Chest x-ray

This is the most important diagnostic test. Almost always, the diagnosis of CAP requires the detection of focal infiltrative changes in the lungs in combination with the corresponding symptoms. And although there is an opinion that steto-acoustic signs of focal infiltration usually coincide with radiographic data, numerous studies have shown their low sensitivity and specificity in the diagnosis of pneumonia.

There are several reasons for false negative x-ray results in patients with pneumonia. These include dehydration (however, there is not enough data for this theory), deep neutro-

the development of a localized acute inflammatory reaction in the lung tissue, early stages of the disease (it is believed that pneumonia can be recognized by auscultation one day before the appearance of infiltration on the radiograph) and, finally, cases of pneumonia caused by Pneumocystis carinii in HIV-infected patients (in 10-20% of patients there are no radiological changes).

Sometimes there are diagnostic problems associated with false positive x-ray results (see below).

The value of chest x-ray is not only in verifying the diagnosis of pneumonia (as a rule, in the presence of appropriate clinical signs), assessing the dynamics of the process and the completeness of recovery. Changes on the radiograph (prevalence of infiltration, presence or absence of pleural effusion, destruction) correspond to the severity of the disease and serve as a kind of “guide” in the choice of antibiotic therapy.

Other studies

A clinical blood test is the standard diagnostic test. Obviously, neither the total number of leukocytes in the peripheral blood, nor the leukocyte formula make it possible to speak with certainty about the potential causative agent of pneumonia. However, leukocytosis of more than 10-12 x 109 / L indicates a high likelihood of bacterial infection, and leukopenia below 3 x 109 / L or leukocytosis above 25 x 109 / L are unfavorable prognostic signs.

Biochemical blood tests, including liver and kidney function tests, and electrolyte analysis are also standard methods of investigation in patients with CAP requiring hospitalization.

In hospitalized patients with CAP, microbiological studies are mandatory: blood cultures twice (before antibiotics are prescribed), in the presence of a productive cough, bacterioscopy of a Gram stained sputum smear and its culture (see below).

In patients with symptoms of respiratory failure due to widespread pneumonic infiltration, massive pleural effusion, the development of pneumonia against the background of chronic obstructive pulmonary disease, it is necessary to determine arterial blood gases. In this case, hypoxemia with a decrease in the pO_ level below 60 mm Hg. Art. prognostically unfavorable and indicates the need to place the patient in the intensive care unit.

In the presence of pleural effusion and conditions for safe pleural puncture (visualization on a laterogram of freely displaceable fluid with a layer thickness> 1.0 cm), examination of pleural fluid should include counting leukocytes with a leukocyte formula, determining pH, lactate dehydrogenase activity, protein content, staining strokes on Gram and on

The absence or inaccessibility of radiographic confirmation of focal infiltration in the lungs makes the diagnosis of pneumonia inaccurate / uncertain.

Probable causative agents of CAP, depending on the conditions of its occurrence

Conditions of occurrence Possible pathogens

Alcoholism Chronic bronchitis / tobacco smoking Decompensated diabetes mellitus Staying in nursing homes Non-sanitized oral cavity Influenza epidemic Massive aspiration Development of pneumonia on the background of bronchiectasis, cystic fibrosis Intravenous drug addiction Local bronchial obstruction (for example, lung cancer) Contact with air conditioners, humidifiers An outbreak of the disease in a team (schoolchildren, military personnel) S. pneumoniae, anaerobes, aerobic enterobacteria (Klebsiella pneumoniae, etc.) S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Legionella spp. S. pneumoniae, Staphylococcus aureus S. pneumoniae, Enterobacteriaceae, H. influenzae, S. aureus, Chlamydophila pneumoniae, anaerobes Anaerobes S. pneumoniae, S. aureus, Streptococcus pyogenes, H. influenzae Anaerobes Pseudomonas aeruginosa, a P. cepacia, S. S. aureus, anaerobes Anaerobes Legionella pneumophila S. pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae

no Bartlett J.G. Management of Respiratory Tract Infections. Philadelphia, 1999. Mandell L.A. et al. // Clin. Infect. Dis. 2000. V. 31. P 383.

acid-fast bacteria, sowing on aerobes, anaerobes and mycobacteria.

Diagnosing CAP

The diagnosis of CAP is definite if the patient has radiologically confirmed focal infiltration of lung tissue and at least two clinical signs from among the following:

a) acute fever at the onset of the disease (body temperature> 38.0 ° C);

b) cough with phlegm;

c) physical signs (focus of crepitus and / or fine bubbling rales, hard bronchial breathing, shortening of percussion sound);

d) leukocytosis> 10 x 109 / l and / or stab shift (> 10%).

If possible, you should strive for clinical and radiological confirmation of the diagnosis of CAP. In this case, it is necessary to take into account the likelihood of known syndromic diseases / pathological conditions.

The absence or inaccessibility of radiographic confirmation of focal infiltration in the lungs makes the diagnosis of CAP inaccurate / uncertain. In this case, the diagnosis of the disease is based on taking into account the data of the anamnesis, complaints and corresponding local symptoms.

If, when examining a patient with fever, complaints of cough, shortness of breath, sputum and / or chest pain, X-ray examination is unavailable and there are no local stetho-acoustic symptoms, then the assumption of PFS becomes unlikely.

Etiological diagnosis

Obviously, the establishment of the fact of PFS, based on the results of physical and X-ray studies, can only be equated to a syndromic diagnosis, but it becomes nosological after the pathogen is identified. Unconditional evidence of the causal role of the microorganism in the development of pneumonia is its isolation from the lung tissue, however, the clinician has to rely on the results of micro-

biological blood tests (positive in 6-10% of cases), pleural fluid, sputum (possible contamination of bronchial secretions when passing through the oropharynx) or immunoserological tests, as well as anamnestic data (table).

Standard test methods are Gram-stained bacterioscopy and deep-coughing sputum culture. Before starting a microbiological study, it is necessary to stain the smear according to Gram. If there are less than 25 leukocytes and more than 10 epithelial cells in the smear, further examination is impractical (most likely the material is the contents of the oral cavity). The detection in a smear of a significant number of gram-positive or gram-negative microorganisms with typical morphology (gram-positive lanceolate diplococci - S. pneumoniae; clusters of gram-positive cocci in the form of clusters - S. aureus, gram-negative coccobacilli - H. influenzae) can serve as a guide for

the appointment of antibiotic therapy. The diagnostic value of sputum test results can be assessed as high when a potential pathogen is isolated in a concentration of more than 105 CFU / ml (CFU - colony forming units).

Obviously, the interpretation of the results of bacterioscopy and sputum culture should be based on clinical evidence.

Seriously ill patients, including the majority of hospitalized patients, should be cultured twice before antibiotic therapy (blood is taken from different places with an interval of at least 10 minutes).

When collecting sputum, the following rules must be observed

1. Sputum is collected before meals, if possible before the start of antibiotic therapy.

2. Before collecting sputum, rinse the mouth thoroughly with boiled water.

3. The patient is instructed to receive the contents of the lower respiratory tract, and not the oronopharynx.

4. Collection of sputum should be done in sterile containers.

5. Duration of storage of samples at room temperature should not exceed 2 hours.

mm. vbavr "re-phju

While it is important to obtain laboratory material prior to antibiotic prescribing, microbiological testing should not delay antibiotic treatment. This is especially true for patients with a severe course of the disease.

Serological diagnostics

infections of Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Legionella are not considered among the mandatory research methods, because, taking into account the repeated sampling of blood serum in the acute period and during the period of convalescence (a few weeks after the onset of the disease), this is not a clinical, but an epidemiological level diagnostics.

Currently, the enzyme immunoassay for the determination of the specific soluble antigen of Legionella pneumophila (serotype 1) in urine with severe CAP has become widespread abroad. Od-

However, in our country, the use of this expensive method of express diagnostics of legionella infection has not gone beyond the framework of individual clinical centers. Determination of Streptococcus pneumoniae antigen in urine is considered as a promising additional method, but the available data are insufficient to give unambiguous recommendations.

The polymerase chain reaction (PCR) method is developing very quickly and seems to be promising for the diagnosis of such causative agents of CpD as C. pneumoniae and M. pneumoniae. However, this method cannot yet be recommended for widespread clinical practice.

Fibrobronchoscopy with a quantitative assessment of the microbial contamination of the obtained material (“protected” brush biopsy, bronchoalveolar lavage) or other methods of invasive diagnostics (transtracheal aspiration, transthoracic

biopsy, etc.) are reserved for individual cases: pneumonia in patients with immunosuppression, suspected pulmonary tuberculosis in the absence of productive cough, obstructive pneumonitis in lung cancer or foreign body aspiration, etc.

Unfortunately, due to subjective and objective difficulties: incorrect sampling or absence of sputum, errors in conducting a microbiological study, the widespread practice of patients taking antibacterial drugs before going to the doctor (for example, taking even one dose of a potentially effective antibiotic makes it unlikely to isolate a pneumococcal culture) - in a large number of cases, the causative agent of pneumonia cannot be identified.

Differential diagnostics will be discussed in the next issue of the journal.

Combination of HPCshockortngosteroid and bronchodilator for basic therapy of bromlial asthma

BrJLÖKOE GLOSTNO0 TAKE YUSPNPISHPINOV AND BRANJOPIPINSNIV ACTION.

National application for "■ -? Inhalation

■ Efficiency of reducing the DOSE I PCSCORTI ’■ OO BRONLOLITIKE G pL-

complete contraction with the symptom of bronchial asthma

Improvement in 2d and p * d

¿Oiikmie Aoimoeti (¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡to a

CONVENIENT AND EFFICIENT i

T'SliV I JSeuihCJiHLS P [imtchkg L H. KCfin W * \ Imnt ^ Ki (0 & 5J SiW-iSiiQ.

PUPMOMED

er and i! 11 "- ■: + h s-a vt- ■: -c -: - r uw u -m ktim

10)! M "Sf" rA. PuAKDOSNTOPN. V Shumel 3 * 2003

For citation: Yu.K. Novikov Pneumonia: complex and unresolved issues of diagnosis and treatment // BC. 2004. No. 21. S. 1226

Pneumonia is an infectious lesion of the alveoli, accompanied by infiltration of inflammatory cells and exudation of the parenchyma, as a response to the introduction and proliferation of microorganisms, into sterile (normal) parts of the respiratory tract. The pneumonia section does not consider lung lesions in infectious diseases related to other nosological forms: plague, typhoid fever, tularemia, etc. If you follow the above definition for the diagnosis of pneumonia, then none of the diagnostic criteria can be objectively proven. Neither inflammation nor damage to the alveoli. And only by indirect data (determination of the pathogen in sputum or an increase in antibody titer in the blood), one can judge the infectious nature of lung damage. Direct evidence of inflammation in the pulmonary parenchyma and identification of the pathogen is possible only with a morphological study of the material obtained from a biopsy. The symptom complex, including cough with sputum and / or hemoptysis, chest pains usually with coughing and deep breathing, fever and symptoms of intoxication, is not characteristic only of pneumonia, but is detected in a number of other lung diseases. The most common are: - lung cancer; - thrombosis and pulmonary embolism; - pulmonary tuberculosis; - ARVI; - acute and infectious exacerbation of bronchitis; - pleurisy; - bronchiectasis; - acute forms of alveolitis; - pulmonary mycosis; - infectious diseases (typhus, tularemia, infectious hepatitis, etc.). The usual algorithm of clinical thinking provides for the solution (often unconscious) of the following questions when meeting with a patient: - is the patient sick; - if sick, what organs and systems are involved in the process; - if the lungs are affected, then what is the nature of the lesion; - if pneumonia, then what is its etiology. Following this algorithm allows you to achieve maximum treatment efficiency. Differential diagnostics play an important role in this.

Differential diagnosis for pneumonia Clinical and anamnestic criteria

Lungs' cancer

Belonging to the risk group: - men over 40; - smokers; - suffering from chronic bronchitis; - with a history of cancer; - have a family history of cancer. A typical picture of anamnesis, in addition to belonging to a risk group, includes a gradual onset of the disease, when symptoms of intoxication, bronchial obstruction, and tumor spread appear and increase: weakness, increasing fatigue, over time, weight loss, dynamics of cough syndrome - from dry hacking unproductive cough , cough with mucous or mucopurulent sputum streaked with blood to sputum like "raspberry jelly", hemoptysis, recurrent inflammation in the same areas of the lung, recurrent pleurisy, symptoms of compression of the superior vena cava. Extrapulmonary symptoms of lung cancer: indomitable skin itching, ichthyosis, drum fingers, progressive dementia, myopathic syndrome, Itsenko-Cushing's syndrome. It should be emphasized that despite a thorough clinical examination, it is not possible to identify a gradual onset of the disease and in 65% of cases the onset is regarded as acute - in the form of cancerous pneumonitis, paracancrotic pneumonia, and in fact, atelectasis-pneumonia in the zone of obturated bronchus.

Pulmonary tuberculosis

Contact with a patient with tuberculosis. More often, even with a visible acute onset, there is a gradual increase in clinical symptoms. ... Relatively easily tolerated intoxication compared to a similar volume of damage to lung tissue of other etiology. ... Scant physical symptoms, inconsistent with significant R-logical changes. ... Dry cough, often mucous than purulent, sputum. ... Isolated pleurisy, especially at a young age.

Infarction pneumonia with pulmonary embolism and pulmonary thrombosis History of lesion of the veins of the lower extremities and pelvis. More often, embologenous thrombosis is localized in the popliteal (20%), iliocaval segments. Veins of the upper extremities (8%) and heart cavities (2%) are less significant as causes of PE. It should be noted that only 40% of venous thrombosis clinic is preceded by pulmonary embolism. The development of the symptom complex of pneumonia (cough, hemoptysis, intoxication) is preceded by shortness of breath and chest pain, the severity of which depends on the caliber of the affected lung vessel. In pulmonary embolism, the presence of an embolism in a large circle should not be confused, since through an open oval window with a changed hemodynamics, emboli enter the large circle.

Pain in pulmonary embolism:

Angina pectoris, infarction with concomitant damage to the coronary arteries; - bursting with increasing pressure in the pulmonary artery; - pleural with the development of infarction pneumonia with pleurisy; - in the right hypochondrium (abdominal) due to acute circulatory failure and stretching of the Glisson capsule of the liver.

Shortness of breath with PE:

Sudden; - not related to physical activity; - uncharacteristic orthopnea position; - shallow breathing.

Hemoptysis with pulmonary embolism:

On the second or third day after the development of infarction pneumonia.

Physical symptoms:

Wheezing, dullness, fever, intoxication, emphasis of the second tone on the pulmonary artery, swelling of the cervical veins - do not have specific features characteristic only of PE and are late signs. It should be noted that all symptoms associated with increased pressure in the pulmonary artery are found only in massive PE (50% vascular lesions).

Fibrosing alveolitis

The gradual but steady progression of shortness of breath, characteristic of interstitial lesions, does not cause difficulties in terms of differential diagnosis with pneumonia. The acute form (Libov desquamative pneumonia, Haman-Rich syndrome) has no significant clinical differences from bacterial pneumonia. Most often, after unsuccessful antibiotic treatment, the appointment of steroids with a pronounced positive effect suggests, and then using objective examination methods to prove the diagnosis of alveolitis.

For allergic exogenous alveolitis:

There is a connection with the allergen; - the elimination effect is noted; - the positive effect of corticosteroid treatment.

With toxic fibrosing alveolitis:

Communication with a toxic agent (drugs, occupational exposure to toxic substances).

Influenza and ARVI

The main difference from pneumonia is the absence of damage to the lung parenchyma and, accordingly, the absence of local physical symptoms. The symptoms of cough and intoxication are not specific. It should be borne in mind that ARVI, influenza are complicated by associated pneumonia. Physical symptoms in this case depend on the size of the pneumonic focus and the depth of its location from the surface of the chest. Often only laboratory and X-ray methods can detect pneumonia (leukocytosis, shift of the formula to the left, increased ESR, infiltrative shadow, bacteriological examination of sputum).

Bronchitis and bronchiectasis

With bronchitis, there are no symptoms of local lung damage (wet wheezing, dullness, increased voice tremor). To a lesser extent than in pneumonia, symptoms of intoxication are expressed. Shortness of breath with obstructive bronchitis is a nonspecific symptom, since up to 80% of cases of pneumonia are accompanied by obstructive changes in the FVD. The final diagnosis is established after laboratory and instrumental examination. With dysontogenetic bronchiectasis, the anamnesis is more often traced from childhood. With acquired - anamnesis of pneumonia, tuberculosis. A variety of physical symptoms (wheezing, moist, sonorous, small-coarsely blistering, dullness, etc.) depends on the prevalence of the process and the phase of inflammation. Cough, the amount of sputum cannot serve as objective symptoms of the diagnosis.

Hereditary-determined lung diseases

Violation of the main defense mechanisms (mucociliary transport in cystic fibrosis and ciliary insufficiency, immune defense in case of deficiency of immunoglobulin, especially immunoglobulin A, T-cell deficiency, pathology from macrophages) leads to damage to the lungs and bronchi, manifested mainly by the clinic of recurrent inflammation in the bronchopulmonary system (bronchitis, acquired bronchiectasis, pneumonia). And only laboratory and instrumental examination can reveal the root cause of nonspecific clinical symptoms.

Objective survey data

Pulmonary tuberculosis

X-ray Depending on the form of tuberculosis - focal shadow, infiltrate, infiltrate with decay, cavernous tuberculosis - a path to the root and an increase in root lymph nodes, old foci (petrification), with localization more often in I-III and VI segments, are characteristic. Tomography, including computer Clarification of the number, size of cavities, their walls, bronchial patency, the state of the lymph nodes of the root and mediastinum. Sputum analysis - lymphocytes, erythrocytes (with hemoptysis) Microscopy - tubercle bacilli Sputum culture - tubercle bacilli FBS - scars, fistulas, tubercles with damage to the bronchi Biopsy - tuberculous (caseous) granuloma Blood test Anemia - severe forms, leukocytosis, lymphocytosis, increased ESR Biochemical blood test Dysproteinemia, hypoalbuminemia in severe forms, hypoproteinemia Analysis of urine Nonspecific changes - protein, leukocytes In case of kidney damage, sowing of a tubercle bacillus. Lungs' cancerX-ray Decrease in airiness of lung tissue, atelectasis, infiltrates, focal formations. Tomography, including computer Narrowing of the bronchus or its complete obstruction, enlargement of the lymph nodes of the root. FBS - narrowing of the bronchus, plus tissue Lavage - atypical cells Biopsy - tumor tissue, cells Ultrasound - search for metastases or the main tumor, if metastases in the lungs (liver, kidneys, pancreas) Isotope research - search for metastases (liver bone) or tumors if metastases in the lungs. Fibrosing aulveolitesX-ray Dissemination in the middle and lower sections, "frosted glass", interstitial fibrosis, "cellular lung" CT scan - clarification of pathology FBS - nonspecific inflammatory changes Lavage - neutrophilia - ELISA, lymphocytosis - EAA Biopsy - desquamation, exudation (alveolitis), bronchiolitis, arteritis - ELISA, granulomas with EAA, arteritis with TFA, thickening of the basement membrane, body test - restrictive changes, impaired diffusion. Immunology An increase in IgG - ELISA, an increase in rheumatoid factor - ELISA, an increase in antipulmonary antibodies - ELISA, an increase in IgE - EAA, an increase in mucin antigen.

Congenital pathology

X-ray see bronchitis Immunology IgA or other Ig deficiency, T cell deficiency, macrophage deficiency Sweat analysis - increase in chlorides Genetic research - identification of the gene for cystic fibrosis.

SARS and flu

X-ray - ENT norm - laryngitis, pharyngitis, rhinitis Sputum analysis - neutrophils, columnar epithelium Blood test - lymphocytosis.

Bronchiectasis

X-ray Strengthening, deformation of the pulmonary pattern, depending on the prevalence. Cellularity of the pulmonary pattern in the later stages. Tomography Expansion and deformation of the bronchi (saccular, cylindrical) FBS - indirect signs of bronchiectasis and bronchitis Lavage - macrophages, neutrophils, bacteria Sputum - the same sputum culture - pneumotropic pathogens, more often Gr + and Gr - flora, in credits> 10 CFU / ml Bronchography - saccular bronchiectasis, cylindrical Blood test - nonspecific inflammation Blood chemistry - depending on the severity and duration: hypoproteinemia, hypoalbuminemia, dysgammaglobulinemia. Analysis of urine - nonspecific changes With prolonged course - changes for amyloidosis of the nephrotic syndrome.

Bronchitis

X-ray Strengthening the pulmonary pattern Tomography - too FBS - hyperemia, swelling of the mucous membrane, sputum. Diffuse lesion. Lavage - neutrophils, macrophages Biopsy - metaplasia in chronic bronchitis Sputum culture - non-specific counting CFU / ml of non-specific flora Sputum analysis - macrophages, neutrophils Serology - increased titers of antibodies to pneumotropic pathogens FVD - obstructive type Immunology - various variants of immunological, secondary insufficiency.

TELA

X-ray Non-specific infiltrative shadows Tomogram Does not provide additional information for the diagnosis of PE FBS - contraindicated ECG - symptoms of overload with massive PE (more than 50% of the vessels) SI QIII (neg.) T in V 1 V 2 Perfusion lung scan Focal decrease in isotope accumulation - 100% reliability of the diagnosis in the absence of changes in the R-gram. 15% errors in cancer, tuberculosis, abscess. Angiopulmonography Defective filling of blood vessels, breakage or depletion of blood vessels, delay in filling phases are signs of Westermark. Doppler ultrasonography of veins Search for embologenous thrombosis Phlebography - the same Blood test Anemia with massive lesions, leukocytosis, left shift, increased ESR Blood chemistry Bilirubinemia with massive lesion Analysis of urine Nonspecific changes, protein, leukocytes, oligo-anuria - in shock.

Clinical criteria for pneumonia

Patients complain of: - dry or sputum cough, hemoptysis, chest pain; - fever above 38 °, intoxication. Physical data Crepitation, small bubbling rales, dullness of percussion sound, increased vocal tremor. Objective diagnostic criteria To determine the diagnosis, the following studies are prescribed: - X-ray of the chest organs in two projections is shown with an incomplete set of clinical symptoms; - microbiological examination: Gram smear staining, sputum culture with quantitative determination of CFU / ml and antibiotic sensitivity; - clinical blood test. The listed methods are sufficient for the diagnosis of pneumonia at the outpatient stage and with an uncomplicated typical course of pneumonia in a hospital.

Additional research methods

X-ray tomography, computed tomography are prescribed in case of damage to the upper lobes, lymph nodes, mediastinum, a decrease in the volume of the lobe, suspicion of abscess formation with ineffectiveness of adequate antibiotic therapy. Microbiological examination of sputum, pleural fluid, urine and blood, including mycological examination, is advisable in case of continuing febrile state, suspected sepsis, tuberculosis, superinfection, AIDS. Serological research - determination of antibodies to fungi, mycoplasma, chlamydia and legionella, cytomegalovirus - is indicated for an atypical course of pneumonia in the risk group in alcoholics, drug addicts, with immunodeficiency (including AIDS), in the elderly. A biochemical blood test is prescribed for severe pneumonia with manifestations of renal, hepatic failure, in patients with chronic diseases, decompensation of diabetes mellitus. Cyto- and histological studies are carried out in the risk group for lung cancer in smokers after 40 years, in patients with chronic bronchitis and a cancer family history. Bronchological examination: diagnostic bronchoscopy is carried out in the absence of the effect of adequate therapy for pneumonia, with suspicion of lung cancer in the risk group, the presence of a foreign body, including aspiration in patients with loss of consciousness, if necessary, biopsy. Therapeutic bronchoscopy is performed during abscess formation to ensure drainage. Ultrasound examination of the heart and abdominal organs is carried out with suspicion of sepsis, bacterial endocarditis. Pulmonary isotope scans and pulmonary angiography are indicated for suspected pulmonary embolism (PE). Additional methods included in the examination plan, in fact, allow for differential diagnosis and are carried out in a hospital where the patient is hospitalized depending on the severity of the condition and / or with an atypical course of the disease requiring a diagnostic search.

Determining the severity of pneumonia is one of the key points in the diagnosis and is in the first place before the doctor after determining the nosological form. Subsequent actions (determination of indications for hospitalization, in which department) depend on the severity of the condition.

Hospitalization criteria

Hospitalization of patients with pneumonia is indicated in the presence of the following factors: - age over 70 years; - concomitant chronic diseases (chronic obstructive pulmonary disease, congestive heart failure, chronic hepatitis, chronic nephritis, diabetes mellitus, alcoholism or substance abuse, immunodeficiency); - ineffective outpatient treatment for three days; - confusion or decreased consciousness; - possible aspiration; - the number of breaths is more than 30 per minute; - unstable hemodynamics; - septic shock; - infectious metastases; - multi-lobe lesion; - exudative pleurisy; - abscess formation; - leukopenia less than 4000 / ml or leukocytosis more than 20,000; - anemia: hemoglobin less than 9 g / ml; - renal failure (urea more than 7 mmol); - social testimony.

Indications for intensive care- Respiratory failure - PO2 / FiO2<250 (<200 при ХОБЛ), признаки утомления диафрагмы, необходимость в механической вентиляции; - Недостаточность кровообращения - шок (систолическое АД<90 мм рт.ст., диастолическое АД<60 мм рт.ст.), необходимость введения вазоконстрикторов чаще, чем через 4 часа, диурез < 20 мл/ч; - Острая почечная недостаточность и необходимость диализа; - Синдром диссеминированного внутрисосудистого свертывания; - Менингит; - Кома.

Antibacterial therapy

Lactam antibiotics

Most? -lactam drugs concentration in the lung parenchyma is less than in the blood. Almost all drugs enter the sputum at a concentration much lower than in the bronchial mucosa. Moreover, many causative agents of respiratory diseases ( H. influenzae, Moraxella catarrhalis, Streptococcus spp.) are located precisely in the lumen of the bronchi or in the mucous membrane, therefore, large doses of drugs are required for successful treatment. Uh? -lactam drugs concentration in the liquid covering the epithelium of the lower respiratory tract, more than in sputum, bronchial secretions. However, after concentration? β-lactam drug will exceed the MIC of the pathogen, a further increase in concentration is meaningless, since the effectiveness of these drugs depends mainly on the time during which the concentration of the antibiotic exceeds the MIC. ? β-lactam drugs in high doses retain their effectiveness against pneumococci with intermediate sensitivity, in contrast to macrolides and fluoroquinolones.

Macrolides Macrolides are highly lipophilic, which ensures their high concentration in the tissues and fluids of the respiratory tract. Due to their high diffusion capacity, they accumulate better in the lung tissue, reaching higher concentrations there than in plasma.

Azithromycin (Hemomycin) has approximately the same properties, while its concentration in serum is usually difficult to determine, and in the lung tissue it remains at a very high level for 48-96 hours after a single administration. In general, the concentration of new macrolides in the bronchial mucosa is 5-30 times higher than the serum concentration. Macrolides penetrate better into the epithelial cells than into the liquid on the surface of the epithelium. Azithromycin after a single oral administration at a dose of 500 mg reaches a concentration in the epithelium lining fluid that is 17.5 times higher than the MIC90 for S. Pneumoniae... To combat intracellular pathogens ( Legionella spp., C. pneumoniae) of particular importance is the concentration that antibacterial agents reach in alveolar macrophages. While highly ionized? β-lactam drugs practically do not penetrate intracellularly, macrolides are able to accumulate in macrophages at a concentration that is many times higher than their concentration in the extracellular space.

Fluoroquinolones Fluoroquinolones accumulate in the bronchial mucosa at approximately the same concentration as in plasma. The concentration of fluoroquinolones in the epithelial fluid is very high. The effectiveness of drugs in this group is determined by both the duration of action and the concentration. Since the mid-90s, respiratory fluoroquinolones (levofloxacin, sparfloxacin) have taken a firm place in antibiotic selection algorithms (ABP) based on the principles of evidence-based medicine (recommendations of the Society for Infectious Diseases, USA, 1998; guidelines of the American Thoracic Society, 2001; recommendations of the British Thoracic Society, 2001) But along with this, it must be stated that the cost of respiratory fluoroquinolones is significantly higher than the cost of ABPs used in routine practice. In addition, the ban on the use of drugs of this group for the treatment of children and pregnant women remains.

Aminoglycosides Aminoglycosides show approximately the same tissue and plasma concentrations. When comparing the concentration of gentamicin in bronchial secretions on a biological model with intramuscular multiple, intramuscular single and intravenous bolus administration, the concentration of gentamicin in the bronchi reached the MIC level only with intravenous bolus administration. Aminoglycosides slowly accumulate in macrophages (ribosomes), but at the same time it loses its activity. In the study of vancomycin, it was shown that this antibiotic in the liquid covering the epithelium of the lower respiratory tract reaches the MIC90 value for most Gy + - causative agents of respiratory infections. When conducting empirical antibiotic therapy, it seems rational to use combinations of drugs, which enhances the antimicrobial effect and allows you to fight a wider range of potential pathogens. It should be noted that the existing opinion about the inadmissibility of combining drugs with bacteriostatic and bactericidal action has been revised in relation to combinations of macrolides with cephalosporins. Tables 1-3 show the approach to the choice of an antibiotic in various clinical situations, depending on the age and condition of the patient, the severity of pneumonia.

Literature
1. Chuchalin A.G. Pneumonia. - M., 2002.
2. A pragmatice guidlines for the managemant of community acquired
pneumonia in adults (in Process Citation). Clin. Inf. Dis. - 2000.
- Vol.31. - P.347.
3. Bartlett J. Management of Respiratory Tract Infections. -
Lippincott W. et Wilkins, 2001.
4. Brevis R.A.L. Lecture notes on respiratory diseases. - Blackwell
scientific publications, 1985.
5. Empiric Treatment of Community-acquired Pneumonia: ATS and IDSA
Guidelines American Thorac. Soc. - 2001.
6. Fein A. et al. Diagnosis and management of pneumonia and other
respiratory infections. - Professional Communications inc., 1999.
7. Inglis T.J.J. Clinical Microbiology. - Churchil Livingston, 1997.
8. Management of adult community-acquired lower respiratory tract
infections. Erohtan Study on Community Acquired Pneumonia (ESOCAP)
committee / Chairmen: Huchon G., Woodhead M. - 1999.
9. Mandel L.A. Community-acquired pneumonia. Etiology, epidemiology
and treatment. Chest. - 1995. - Vol.81. - P. 357.
10. Pneumonia. Ed. by A. Torres and M. Woodhead. - Eropian Respiratory
Monograph., 1997
11.Pulmonary Differential Diagnosis. Harold Zaskon. W.B.Saunders,
2000.
12. Bartlett JG, Gorbach SL, Tally FP, et al. Bacteriology and treatment
of primary lung abscess. Am Rev Respir Dis. 1974; 109: 510-518.
13. Huxley EJ, Viroslav J, Gray WR, et al. Pharyngeal aspiration in
normal adults and patients with depressed consciousness. Am J Med.
1978;64:564-568.
14. Driks MR, Craven DE, Celli BR, et al. Nosocomial pneumonia in
intubated patients given sucralfate as compared with antacids or histamine
type 2 blockers. N Engl J Med. 1987; 317: 1376-1382.
15. Tryba M. Risk of acute stress bleeding and nosocomial pneumonia
in ventilated intensive care unit patients: Sucralfate versus
antacids. Am J Med. 1987; 83 (Suppl 3B): 117-124.
16. Bartlett JG, Finegold SM. Anaerobic infections of the lung and
pleural space. Am Rev Respir Dis. 1974; 110: 56-77.
17. Finegold SM. Anaerobic Bacteria in Human Disease. New York:
Academic Press; 1977.
18. Bartlett JG, Finegold SM. Anaerobic pleuropulmonary infections.
Medicine (Baltimore). 1972; 51: 413-450.

Community-acquired pneumonia: diagnosis and differential diagnosis

A.I. Sinopalnikov

a) community-acquired (acquired outside a medical institution) pneumonia (synonyms: home, outpatient);

b) nosocomial (acquired in a medical institution) pneumonia (synonyms: hospital, nosocomial);

c) aspiration pneumonia;

d) pneumonia in persons with severe immunosuppression (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

The term “community-acquired pneumonia” describes cases of acute illness occurring in community-acquired

Diagnostics

These changes in the lungs make the diagnosis of pneumonia less likely.

In general, the key clinical and radiological signs of community-acquired pneumonia (CAP) can be formulated as follows:

Analysis of clinical features and X-ray data allows in some cases to make an assumption about a particular pathogen, but this information is of relative value;

“Classic” signs of pneumonia (acute febrile onset, chest pains, etc.) may be absent, especially in weak or elderly patients;

Late diagnosis and delay in starting antibiotic therapy lead to a worse prognosis: mortality among patients over 65 reaches 10-25%;

The most common X-ray signs of pneumonia are

Pneumonia should always be suspected if the patient has a fever in combination with complaints of cough, shortness of breath, sputum production and / or chest pain.

aklftsA, [іishmtyupya about «ischplssh 3 * 2003 7

mm. bbavr "FD-pduu

focal blackouts appear in the projection of one or more segments;

In cases of lobar infiltration, the phenomenon of "air bronchogram" is visualized in 33% of patients;

Pleural effusion complicates the course of CAP in 10-25% of cases and is not particularly important in predicting the etiology of the disease;

Chest x-ray

There are several reasons for false negative x-ray results in patients with pneumonia. These include dehydration (however, there is not enough data for this theory), deep neutro-

Sometimes there are diagnostic problems associated with false positive x-ray results (see below).

Other studies

Biochemical blood tests, including liver and kidney function tests, and electrolyte analysis are also standard methods of investigation in patients with CAP requiring hospitalization.

The absence or inaccessibility of radiographic confirmation of focal infiltration in the lungs makes the diagnosis of pneumonia inaccurate / uncertain.

Probable causative agents of CAP, depending on the conditions of its occurrence

Conditions of occurrence Possible pathogens

no Bartlett J.G. Management of Respiratory Tract Infections. Philadelphia, 1999. Mandell L.A. et al. // Clin. Infect. Dis. 2000. V. 31. P 383.

acid-fast bacteria, sowing on aerobes, anaerobes and mycobacteria.

Diagnosing CAP

The diagnosis of CAP is definite if the patient has radiologically confirmed focal infiltration of lung tissue and at least two clinical signs from among the following:

a) acute fever at the onset of the disease (body temperature> 38.0 ° C);

b) cough with phlegm;

c) physical signs (focus of crepitus and / or fine bubbling rales, hard bronchial breathing, shortening of percussion sound);

d) leukocytosis> 10 x 109 / l and / or stab shift (> 10%).

Etiological diagnosis

Obviously, the interpretation of the results of bacterioscopy and sputum culture should be based on clinical evidence.

When collecting sputum, the following rules must be observed

1. Sputum is collected before meals, if possible before the start of antibiotic therapy.

2. Before collecting sputum, rinse the mouth thoroughly with boiled water.

3. The patient is instructed to receive the contents of the lower respiratory tract, and not the oronopharynx.

4. Collection of sputum should be done in sterile containers.

5. Duration of storage of samples at room temperature should not exceed 2 hours.

mm. vbavr "re-phju

Serological diagnostics

Currently, the enzyme immunoassay for the determination of the specific soluble antigen of Legionella pneumophila (serotype 1) in urine with severe CAP has become widespread abroad. Od-

Differential diagnostics will be discussed in the next issue of the journal.

Combination of HPCshockortngosteroid and bronchodilator for basic therapy of bromlial asthma

BrJLÖKOE GLOSTNO0 TAKE YUSPNPISHPINOV AND BRANJOPIPINSNIV ACTION.

National application for "■ -? Inhalation

■ Efficiency of reducing the DOSE I PCSCORTI ’■ OO BRONLOLITIKE G pL-

complete contraction with the symptom of bronchial asthma

Improvement in 2d and p * d

¿Oiikmie Aoimoeti (¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡to a

CONVENIENT AND EFFICIENT i

T'SliV I JSeuihCJiHLS P [imtchkg L H. KCfin W * \ Imnt ^ Ki (0 & 5J SiW-iSiiQ.

PUPMOMED

er and i! 11 "- ■: + h s-a vt- ■: -c -: - r uw u -m ktim

10)! M "Sf" rA. PuAKDOSNTOPN. V Shumel 3 * 2003

Pneumonia

Version: MedElement Disease Handbook

Pneumonia without specifying the causative agent (J18)

Pulmonology

general information

Short description

Pneumonia(pneumonia) - the name of a group of acute local infectious diseases of the lungs, different in etiology, pathogenesis and morphological characteristics, with a predominant lesion of the respiratory parts (alveoli The alveolus is a bubble-shaped formation in the lungs, entwined with a network of capillaries. Gas exchange takes place through the walls of the alveoli (there are over 700 million of them in human lungs).
, bronchioles Bronchioles are the terminal branches of the bronchial tree that do not contain cartilage and pass into the alveolar passages of the lungs
) and intraalveolar exudation.

Note. Excluded from this heading and all subheadings (J18 -):

Other interstitial pulmonary diseases with mention of fibrosis (J84.1);
- Interstitial pulmonary disease, unspecified (J84.9);
- Lung abscess with pneumonia (J85.1);
- Diseases of the lung caused by external agents (J60-J70) including:
- Pneumonitis due to solids and liquids (J69 -);
- Acute interstitial pulmonary disorders caused by drugs (J70.2);
- Chronic interstitial pulmonary disorders caused by drugs (J70.3);
- Unspecified pulmonary interstitial disorder caused by drugs (J70.4);

Pulmonary complications of anesthesia during pregnancy (O29.0);
- Aspiration pneumonitis due to anesthesia during labor and delivery (O74.0);
- Pulmonary complications due to the use of anesthesia in the puerperium (O89.0);
Congenital pneumonia, unspecified (P23.9)
- Neonatal aspiration syndrome, unspecified (P24.9)

Classification

Pneu-monies are subdivided into the following types:
- croupous (pleuropneumonia, with damage to the lobe of the lung);
- focal (bronchopneumonia, with damage to the alveoli adjacent to the bronchi);
- interstitial;
- sharp;
- chronic.

Note. It should be borne in mind that croupous pneumonia is only one of the forms of pneumococcal pneumonia and does not occur in pneumonia of a different nature, and interstitial inflammation of the lung tissue, according to the modern classification, is referred to as alveolitis.

The division of pneumonia into acute and chronic is not used in all sources, since it is believed that in the case of so-called chronic pneumonia, we are usually talking about repeated acute infectious processes in the lungs of the same localization.

Depending on the pathogen:
- pneumococcal;
- streptococcal;
- staphylococcal;
- chlamydia;
- mycoplasma;
- Friedlander.

In clinical practice, it is far from always possible to identify the pathogen, therefore it is customary to distinguish:

1. Community-acquired pneumonia(other names - household, home outpatient) - purchased outside the hospital.

2. NShospital neumonias(nosocomial, nosocomial) - develop after 2 or more days of hospital stay in the absence of clinical and radiological signs of lung damage upon admission.

3. NSnemonia in persons with immunodeficiency states.

4. Atypical pneumonia.

By the mechanism of development:
- primary;
- secondary - developed in connection with another pathological process (aspiration, stagnant, post-traumatic, immunodeficient, infarction, atelectatic).

Etiology and pathogenesis

The occurrence of pneumonia in the vast majority of cases is associated with aspiration Aspiration (lat. Aspiratio) - the effect of "suction" arising from the creation of reduced pressure
microbes (more often - saprophytes) from the oropharynx; less often, infection occurs by the hemato- and lymphogenous pathway or from neighboring foci of infection.

As a causative agent pneumo-pneumonia, stafi-lo- and strep-to-coccus, Pfeiffer's stick, sometimes intestinal stick, klebs-si-el-la pneumonia , pro-tei, he-mophil-naya and blue-noy-naya stick-ki, legi-o-nell-la, plague-ka, who-bu-di-tel Ku-li-ho- rad-ki - rick-ket-sia Ber-ne-ta, not-that-rye vi-ru-sy, vi-rus-no-bak-te-ri-al-nye as-societies, tank -te-ro-i-dy, mi-coplasma, gri-be, pneumocysta, bran-hamell-la, aci-no-bac-te-ri, aspergillus and aero-mo-us.

Hi-mi-ch-skie and fi-zi-ch-skie agents: impact on the lungs of chemical substances, thermal factors (burn or cooling), radio-active iz- ray-ch-niya. Chi-mi-ch-sk and physical agents as ethiological factors usually coincide with infectious ones.

Pneumonia can arise as a result of allergic reactions in the lungs or be a manifestation of a si-with-dark ill-va-nia ( in-ter-stitsi-al-nye pneumonia with over-le-va-ni-yah so-e-di-ni-tel-noy tissue-ni).

Voz-bu-di-te-li get into the lung tissue by bron-ho-gene, hemato-gene and-lympho-gene pathways from the upper dy-ha-tel- pathways, as a rule, in the presence of acute or chronic foci of infection in them, and from infectious foci in the bronchi (chronic bronchitis , bron-ho-ak-ta-zy). A viral infection contributes to the activation of bacterial infection and the emergence of new bacterial focal or pre-levied pneumonic mon-ny.

Chronic pneumonia may be the result of unresolved acute pneumonia during delay and termination of resorption Resorption - resorption of necrotic masses, exudate by absorption of substances into blood or lymphatic vessels
exudate Exudate is a protein-rich fluid released from small veins and capillaries into the surrounding tissues and body cavities during inflammation.
in alve-o-lakh and form-ro-va-nii pneumoscle-ro-za, inflammatory-cell-accurate changes in in-ter-stitsi-al-noy tissue nor is it rare for an immunological character (lymphocytic and plasma-cell infiltration).

Pe-re-go-du acute pneumonia in a chronic form or their over-hard te-th-ni are able to be helped by immunologic -skie disorders, trained-with-lo-in-flax-ny-in-tore-spi-r-spi-ra-tory vi-rus-ny infection, chronic che-sk infection of the top-ni-x-dy-ha-tel-paths (chro-ni-tones-zil-li-you, si-nu-si-you and others) and bron -khov, me-ta-bo-li-che-mi na-ru-she-ni-yami with sa-khar-n dia-be-te, chron-ni-ch-al-lysm and other things.

Community-acquired pneumonia develop, as a rule, against the background of a violation of the protective mechanisms of the bronchopulmonary system (often after the flu). Their typical pathogens are pneumococci, streptococci, Haemophilus influenzae and others.

In origin hospital pneumonia suppression of the cough reflex and damage to the tracheo-bronchial tree during artificial ventilation, tracheostomy, bronchoscopy are important; violation of humoral Humoral - referring to the liquid internal media of the body.
and tissue immunity due to severe diseases of internal organs, as well as the very fact of patients being in the hospital. In this case, the role of the pathogen, as a rule, is the gram-negative flora (E. coli, Proteus, Klebsiella, Pseudomonas aeruginosa), staphylococci and others.

Nosocomial pneumonia is often more severe than community-acquired pneumonia, is more likely to develop complications and higher mortality. In people with immunodeficiency conditions (with cancer, due to chemotherapy, with HIV infection), gram-negative microorganisms such as staphylococcus, fungi, pneumocysts, cytomegalovirus and others can become causative agents of pneumonia.

Atypical pneumonia more often occur in young people, as well as in travelers, are often epidemic in nature, possible pathogens are chlamydia, legionella, mycoplasma.

Epidemiology

Pneumonia is one of the most common acute infectious diseases. The incidence of community-acquired pneumonia in adults ranges from 1 to 11.6 ‰ - young and middle age, 25-44 ‰ - older age group.

Factors and risk groups

Risk factors for protracted pneumonia:
- age over 55;
- alcoholism;
- smoking;
- the presence of concomitant disabling diseases of internal organs (congestive heart failure, COPD Chronic obstructive pulmonary disease (COPD) is an independent disease characterized by a partially irreversible restriction of airflow in the airways
, diabetes mellitus and others);

Virulent pathogens (L. pneumophila, S. aureus, gram-negative enterobacteria);
- multilobar infiltration;
- severe course of community-acquired pneumonia;
- clinical ineffectiveness of the treatment (leukocytosis and fever persist);
- secondary bacteremia Bacteremia is the presence of bacteria in the circulating blood; often occurs in infectious diseases as a result of the penetration of pathogens into the blood through the natural barriers of the macroorganism
.

Clinical picture

Clinical diagnostic criteria

Fever over 4 days, tachypnea, shortness of breath, physical signs of pneumonia.

Symptoms, course

The symptoms and course of pneumonia depend on the etiology, nature and phase of the course, the morphological substrate of the disease and its prevalence in the lungs, as well as the presence of complications (pleurisy Pleurisy - inflammation of the pleura (the serous membrane that covers the lungs and lining the walls of the chest cavity)
, pulmonary suppuration and others).

Croupous pneumonia
As a rule, it has an acute onset, which is often preceded by cooling.
Pain-noy experience-wa-et oz-nob; temp-ra-tu-ra body rises to 39-40 o C, less often to 38 o C or 41 o C; pain with dy-ha-nii on a side-ro-not-affected lung-who-if-wa-th-Xia when coughing. Cough vna-cha-le su-hoi, then with pus or "rusty" viscous mo-to-ro-toi with an admixture of blood. An analogous or not so stormy on-cha-lo sickness is possible in the outcome of an acute re-spi-ra-torous for-bo-le-va-nia or against the background of a chro-ni-che-sky bron-hi-ta.

The condition of the patient is usually heavy. Skin-nye-cut-you faces hype-remi-ro-va-ny and tsi-a-no-tich-ny. From the very na-cha-la bo-lez-no, there is a quickened, upper-nost breathing, with one-du-va-no wings of no-sa. Herpes infection is often noted.
As a result of the impact of anti-bak-te-ri-al-preparations, a warm (li-ti-th) decrease in temperature is observed ...

The chest-cage leaves in ak-those dy-ha-niya on the side of the affected lung. Due to the morpho-logical stage of the disease, the percussion of the affected lung reveals an obtuse tympanitic (stage of VA), shortening (at-dull-lening) of the pulmonary sound (stages of red and gray care) and pulmonary sound ( stages of resolution).

At auscultation Auscultation is a method of physical diagnostics in medicine, which consists in listening to sounds generated during the functioning of organs.
in dependence from the stage of morpho-logical changes so-o-t-vet-but they reveal an enhanced ve-zi-cool dy-ha-nie and crepitatio indux Crepitatio indux or Laenek murmurs - crunching or crunching rales in the initial stage of croupous pneumonia.
, bron-khi-al-noe dy-ha-nie and ve-zi-ku-lyar-nye or donkey-b-flax-nye ve-zi-ku-lar-noe dy-ha-nie, against the background of ko- then-rogo listen-shi-wa-em-Xia crepitatio redus.
In the phase of the operation, there is an intensified head trembling and broncho-phobia. Due to the unevenness of the development of morpho-logical changes in the lungs of the per-ku-tor-naya and auscult-tive card ty-nes can be one-st-rye.
Due to the defeat of the pleura (para-rap-nev-mon-ni-che-skmy gray-rose-no-fib-ri-nous pleural-rit) hear-shi-wa-et-Xia noise pleural friction.
In the midst of a sickness, the pulse is quickened, soft, co-o-t-vet-stvuet reduced blood pressure. Not-rarely, the attenuation of the I tone and the emphasis of the II tone on the pulmonary ar-theory. Po-vysha-et-Xia ESR.
When x-ray-logic research-up-to-va-ny, it is determined-de-la-et-Xia homo-gene-no-ness of all affected to-whether or parts of it, especially on the big X-rays. X-ray scopy may turn out to be not-to-hundred-accurate at the first hours of the disease. In persons suffering from alcoholism, more often than not, there is an atypical course of the disease.

Pneumococcal croupous pneumonia
It is characterized by an acute onset with a sharp rise in temperature up to 39-40˚ C, accompanied by chills and sweating. Headache, significant weakness, lethargy also appear. With severe hyperthermia and intoxication, cerebral symptoms such as severe headache, vomiting, patient deafness or confusion, and even minengeal symptoms can be observed.

Pain occurs early in the chest on the side of the inflammation. Often, with pneumonia, the pleural reaction is very pronounced, so chest pain is the main complaint and requires emergency assistance. A distinctive feature of pleural pain in pneumonia lies in its connection with breathing and coughing: there is a sharp increase in pain during inhalation and cough thrust. In the early days, a cough may appear with the release of rusty sputum from an admixture of erythrocytes, sometimes an abundant hemoptysis.

On examination often draws attention to the forced position of the patient: often he lies exactly on the side of the inflammation. The face is usually hyperemic, sometimes a febrile blush is more pronounced on the cheek corresponding to the side of the lesion. Typical shortness of breath (up to 30-40 breaths per minute) is combined with cyanosis of the lips and swelling of the wings of the nose.
In the early period of the disease, bubble rashes on the lips (herpes labialis) often occur.
When examining the chest, a lag of the affected side during breathing is usually revealed - the patient seems to regret the side of the inflammation due to severe pleural pain.
Over the area of inflammation on percussion of the lungs, the acceleration of percussion sound is determined, breathing acquires a bronchial hue, and small-bubble moist crepitant rales appear early. Characterized by tachycardia - up to 10 beats per minute - and a slight decrease in blood pressure. Muffling of I and emphasis of II tone on the pulmonary artery are not uncommon. A pronounced pleural reaction is sometimes combined with reflex pain in the corresponding half of the abdomen, pain on palpation in its upper parts.
Icterus Icterus, otherwise - yellowness
mucous membranes and skin may appear due to the destruction of erythrocytes in the affected lobe of the lung and, possibly, the formation of focal necrosis in the liver.
Characterized by neutrophilic leukocytosis; its absence (especially leukopenia Leukopenia - a decreased content of leukocytes in the peripheral blood
) may be a prognostically unfavorable sign. ESR rises. X-ray examination determines a homogeneous darkening of the entire affected lobe and its part, which is especially noticeable on lateral radiographs. In the first hours of the disease, fluoroscopy may be uninformative.

At focal pneumococcal pneumonia symptoms are usually less pronounced. There is a rise in temperature up to 38-38.5 ° C, a cough is dry or with the separation of mucopurulent sputum, pain is likely to appear when coughing and deep breathing, signs of inflammation of the lung tissue are objectively revealed, expressed to one degree or another, depending on the extent and location (superficial or deep) focus of inflammation; the focus of crepitant wheezing is most often revealed.

Staphylococcal pneumonia
Can pro-te-kat similar-logical-but pneumo-kok-ko-howl. However, more often it has a more severe course, accompanying the de-structuring of the lungs with an shady airy po-lo-s-tei, abs-cess-sov lungs. With the manifestations of a pronounced in-tok-si-kation pro-te-ka-e stafi-lo-kok-ko-vaya (usually many-o-chago-vaya) pneumo- niya, which lays down vi-rus-ny infection of the bron-ho-pulmonary si-s-theme (vi-rus-no-bak-te-ri-al-naya pneumonia). During epidemics of influenza, it is often the case that vi-rus-no-bak-te-ri-al-pnev-mo-niy is significant, but it will grow.
For such a kind of pneumonia, a pronounced in-tok-si-katsi-on-syndrome, which is manifested by hyper-term, oz-no-bom, hyperemia Hyperemia - increased blood filling in any part of the peripheral vascular system.
skin-to-skin and slimy ob-lo-check, head-pain, head-in-lace, ta-hi-kar-di-ei , pronounced shortness of breath, tosh-but-that, vomit, blood-in-har-ka-nyem.
In case of severe infection, on-but-to-si-che-si-sho-ke develops-va-wa-em-sya so-su-di-flock not-to-a-hundred-accuracy (HELL 90-80 ; 60-50 mm Hg, pallor of the skin, cold limbs, the appearance of a sticky po-ta).
As the progress-si-ro-va-ni-i-tok-si-katsi-on-nogo-sin-drom-ma, tse-re-brah-nye frustrations, na-races appear - a heart-heart not-to-a-hundred-accuracy-sti, disturbance of the heart rhythm, development of a sho-lung, hepa-then - urinary syndrome, disseminated intravascular coagulation Consumption coagulopathy (DIC syndrome) - impaired blood clotting due to massive release of thromboplastic substances from tissues
, tok-si-che-sky en-te-ro-ko-li-ta. Such pneumonia can lead to a quick lethal outcome.

Streptococcal pneumonia develops sharply, in some cases - in connection with the transferred sore throat or with sepsis. The disease is accompanied by fever, cough, chest pain, shortness of breath. Significant pleural effusion is often found; with thoracocentesis, serous, serous-hemorrhagic or purulent fluid is obtained.

Pneumonia caused by Klebsiella pneumonia (Friedlander's stick)
It is relatively rare (more often with alcoholism, in debilitated patients, against the background of a decrease in immunity). There is a severe course; lethality reaches 50%.
It proceeds with pronounced symptoms of intoxication, the rapid development of respiratory failure. The phlegm is often jelly-like, viscous, with an unpleasant smell of burnt meat, but may be purulent or rusty in color.
Scanty auscultatory symptoms, polylobar spread with more frequent, compared with pneumococcal pneumonia, involvement of the upper lobes is characteristic. Typical abscess formation and complication of empyema Empyema - a significant accumulation of pus in any body cavity or in a hollow organ
.

Legionella pneumonia
It develops more often in people living in air-conditioned rooms, as well as those engaged in earthworks. Characterized by an acute onset with high fever, shortness of breath, bradycardia. The disease has a severe course, often accompanied by such complications as intestinal damage (pain, diarrhea appears). The analyzes reveal a significant increase in ESR, leukocytosis, neutrophilia.

Mycoplasma pneumonia
The disease is more likely to affect young people in closely interacting groups, more common in the autumn-winter period. Has a gradual onset, with catarrhal symptoms. Characteristic is the discrepancy between severe intoxication (fever, severe malaise, headache and muscle pain) and the absence or weakness of symptoms of respiratory damage (local dry wheezing, hard breathing). Skin rashes, hemolytic anemia are often observed. Radiographs often show interstitial changes and increased pulmonary pattern. Mycoplasma pneumonia, as a rule, is not accompanied by leukocytosis, there is a moderate increase in ESR.

Viral pneumonia
With viral pneumonia, subfebrile condition, chilliness, rhinopharyngitis, hoarseness, signs of myocarditis can be observed Myocarditis - inflammation of the myocardium (the middle layer of the heart wall, formed by contractile muscle fibers and atypical fibers that make up the cardiac conduction system.); manifests itself as signs of a violation of its contractility, excitability and conductivity
, conjunctivitis. In the case of severe influenza pneumonia, severe toxicity, toxic pulmonary edema, and hemoptysis appear. During the examination, leukopenia is often detected with normal or increased ESR. X-ray examination determines the deformation and mesh of the pulmonary pattern. The issue of the presence of purely viral pneumonia is controversial and not recognized by all authors.

Diagnostics

Pneumonia is usually recognized on the basis of a characteristic clinical picture of the disease - a combination of its pulmonary and extrapulmonary manifestations, as well as an X-ray picture.

The diagnosis is made on the basis of the following clinical signs:
1. Pulmonary- cough, shortness of breath, sputum production (can be mucous, mucopurulent and other), pain when breathing, the presence of local clinical signs (bronchial breathing, dullness of percussion sound, crepitant wheezing, pleural friction noise);
2. Vnonpulmonary- acute fever, clinical and laboratory signs of intoxication.

X-ray examination organs of the chest in two projections is carried out to clarify the diagnosis. Reveals infiltration in the lungs. With pneumonia, there is an increase in ve-zi-kulyar-nogo dy-ha-nia, sometimes with foci of bron-chi-al, krepitatsiya, small and medium not-pu-zyr-cha-ty wheezing, focal after-dark-nia on roentgenograms.

Fibrobronchoscopy or other invasive diagnostic methods are performed if pulmonary tuberculosis is suspected in the absence of a productive cough; with "obstructive pneumonia" due to bronchogenic carcinoma, aspirated foreign body of the bronchus, etc.

Vi-rus-ny or rick-ket-si-oz-ny etiology of for-bo-le-va-nia can be assumed by the non-co-o-t-vet-stv between the island of the car -n-ni-ni-ni-ni-ni-ni-ni-ni-ni-ni-ni-ti with non-average research (x-ray-logical research reveals focal or in-ter-stiitsi-al-ni in lungs).
It should be taken into account that pneumonia can occur atypically in elderly patients suffering from severe somatic diseases or severe immunodeficiency. In such patients, fever may be absent, while extrapulmonary symptoms (disorders of the central nervous system, etc.) predominate, and physical signs of pulmonary inflammation are weak or absent, it is difficult to determine the causative agent of pneumonia.
Suspicion of pneumonia in elderly and debilitated patients should appear when the patient's activity is significantly reduced for no apparent reason. The patient grows weak, he lies all the time and stops moving, becomes indifferent and drowsy, refuses to eat. A close examination always reveals significant shortness of breath and tachycardia, sometimes there is a one-sided blush of the cheek, dry tongue. Auscultation of the lungs usually reveals a focus of ringing moist rales.

Laboratory diagnostics

1. Clinical blood test. The analysis data do not allow to draw a conclusion about the potential causative agent of pneumonia. Leukocytosis more than 10-12x10 9 / l indicates a high probability of bacterial infection, and leukopenia below 3x10 9 / l or leukocytosis above 25x10 9 / l are unfavorable prognostic signs.

2. Biochemical blood tests do not give specific information, but they can indicate damage to a number of organs (systems) with the help of detected abnormalities.

3. Determination of arterial blood gas composition necessary for patients with symptoms of respiratory failure.

4. Microbiological research are carried out e-ed at-cha-lom-ch-niya to establish the etiological diagnosis. A study of mo-to-ro-you or smears from the throat, gor-ta-no, bron-khov on the tank-theory, including vi-ru-sy, mi-ko-bak-te is carried out -riy tu-ber-ku-le-za, my-coplasm of pneumonia and rick-ket-sii; also use immunological methods. Recommended bacterioscopy with Gram stain and culture of sputum obtained with deep coughing.

5. Pleural fluid examination... Performed in the presence of pleural effusion Effusion is the accumulation of fluid (exudate or transudate) in the serous cavity.
and the conditions for safe puncture (visualization on the laterogram of a freely displaceable fluid with a layer thickness greater than 1 cm).

Differential diagnosis

Differential diagnosis must be carried out with the following diseases and pathological conditions:

1. Tuberculosis of the lungs.

2. Neoplasms: primary lung cancer (especially the so-called pneumonic form of bronchioloalveolar cancer), endobronchial metastases, bronchial adenoma, lymphoma.

3. Pulmonary embolism and pulmonary infarction.

4. Immunopathological diseases: systemic vasculitis, lupus pneumonitis, allergic bronchopulmonary aspergillosis, bronchodilator obliterans with organizing pneumonia, idiopathic pulmonary fibrosis, eosinophilic pneumonia, bronchocentric granulomatosis.

5. Other diseases and pathological conditions: congestive heart failure, drug (toxic) pneumopathy, foreign body aspiration, sarcoidosis, pulmonary alveolar proteinosis, lipoid pneumonia, rounded atelectasis.

In the differential diagnosis of pneumonia, the greatest importance is attached to a carefully collected anamnesis.

With acute bron-chi-te and exacerbation of the chronic bron-chi-ta in comparison with pneumonia, it is less expressed in in-tok-sy-cation. When X-ray-no-logical research does not reveal foci of over-darkening.

Tuberculous exudative pleurisy can begin as acutely as pneumonia: shortening of the first sound and bron-khi-al-noe dy-ha-nie over the area of the count bi-ro-van-leg to the root of the lung can im-ti-ro-vat to-le-vu pneumonia. Mistakes will be avoided by a careful percussion, revealing downward from the dullness of the tu-poi sound and the donkey-b-flaxy dy-ha-nie (with empi-em - donkey-b-flax-nye bron-khi-al-noe dy-ha-nye). Pleural puncture with subsequent examination of ex-su-da-ta and a radiograph in the side projection help to carry out differentiation (an in-ten gray shadow in the armpit).

Unlike neutrophilic leukocytosis with pre-left (less often focal) pneumonia, hemogram with ex-su-da-tive plev-ri-te tu-ber-cu-lez-noy etiology, as a rule, is not change-not-on.

In the difference from to-le-s and seg-men-tary pneumo-niy p ri tu-ber-ku-lez-nom infiltra-te or focal tu-ber-ku-le-ze usually there is a less acute onset of the disease. Pneu-mony is resolved in the next 1.5 weeks under the influence of non-special-fi-chi-ch-te-rapy, while tu-ber-ku -the lazy process does not lend itself to such a quick effect even with tu-ber-ku-lo-sto-ti-tic therapy.

For mi-li-ar-nogo tu-ber-ku-le-za ha-rak-ter-na heavy barking in-tok-si-kation with you-so-ho-rad-coy with weakly pronounced physical symptoms, therefore, its differentiation with the small-to-chago-racial racial pneumonia is required.

Acute pneumonia and ob-structural pneumonia in bronchogenic cancer they can start sharply against the background of visible well-being, not rarely in-with-le cooling-de-nia are noted li-ho-rad-ka, oz- nob, chest pain. However, with ob-structural pneumatic-ni-those coughs are more often dry, stupid-ob-different, subsequently with a small amount of Th-st-va mo-to-ro-you and blood-in-har-ka-nyem. In unclear cases, clarify the thread of di-ag-noses poses only bronchoscopy.

When involved in the inflammatory process of the pleura, the endings of the right phrenic and lower intercostal nerves, which are also involved in the innervation of the upper parts of the anterior abdominal wall and abdominal organs, are irritated. This causes the pain to spread to the upper abdomen.
When they are palpated, pain is felt, especially in the area of the right upper quadrant of the abdomen; when tapping along the right costal arch, pain intensifies. Patients with pneumonia are often referred to surgical departments with diagnosis of appendicitis, acute cholecystitis, perforated stomach ulcer... In these situations, the diagnosis is helped by the absence of symptoms of irritation of the peritoneum and tension of the abdominal muscles in most patients. However, it should be borne in mind that this feature is not absolute.

Complications

Possible complications of pneumonia:
1. Pulmonary: exudative pleurisy, pyopneumothorax Pyopneumothorax - an accumulation of pus and gas (air) in the pleural cavity; occurs in the presence of pneumothorax (the presence of air or gas in the pleural cavity) or with putrid pleurisy (inflammation of the pleura caused by putrefactive microflora with the formation of a fetid exudate)
, abscess formation, pulmonary edema;
2. Extrapulmonary: infectious toxic shock, pericarditis, myocarditis, psychosis, sepsis and others.

Exudative pleurisy manifested by pronounced dullness and weakening of breathing on the affected side, lagging of the lower chest on the affected side during breathing.

Abscessing characterized by increasing intoxication, profuse night sweats appear, the temperature acquires a hectic character with daily ranges of up to 2 ° C and more. The diagnosis of a lung abscess becomes apparent as a result of the breakthrough of the abscess in the bronchus and the discharge of a large amount of purulent fetid sputum. A breakthrough of an abscess into the pleural cavity and a complication of pneumonia by the development of pyopneumothorax may be indicated by a sharp deterioration in the condition, an increase in pain in the side when breathing, a significant increase in shortness of breath and tachycardia, a drop in blood pressure.

In the appearance pulmonary edema in pneumonia, toxic damage to the pulmonary capillaries with an increase in vascular permeability plays an important role. The appearance of dry and especially moist wheezing over a healthy lung against the background of increased shortness of breath and worsening of the patient's condition indicates a threat of pulmonary edema.

Sign of occurrence infectious toxic shock should be considered the appearance of persistent tachycardia, especially over 120 beats per minute. The development of shock is characterized by a strong deterioration in the condition, the appearance of a sharp weakness, in some cases - a decrease in temperature. The patient's facial features sharpen, the skin becomes gray, cyanosis intensifies, dyspnea increases significantly, the pulse becomes frequent and small, blood pressure drops below 90/60 mm Hg, urination stops.

Alcohol abusers are more likely to be psychosis against the background of pneumonia. It is accompanied by visual and auditory hallucinations, motor and mental agitation, disorientation in time and space.

Pericarditis, endocarditis, meningitis at the moment are rare complications.

Treatment abroad

Undergo treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

With an unidentified pathogen treatment is determined:
1. The conditions for the occurrence of pneumonia (community-acquired / nosocomial / aspiration / congestive).
2. The age of the patient (over / under 65 years old), for children (under one year old / after one year old).
3. The severity of the disease.
4. The place of treatment (outpatient clinic / general department / intensive care unit).
5. Morphology (bronchopneumonia / focal pneumonia).
For details, see the subheading Bacterial pneumonia, unspecified (J15.9).

Pneumonia in COPD, bronchial asthma, bronchiectasis etc. are considered in other subheadings and require a separate approach.

In the midst of the disease, patients need a s-tel-ny regimen, good-hearted (me-ha-ni-che-ski and he-mi-che-ski) di-e-ta, including ogre -no-che-no-e-boiled-salt and up to a hundred-point number of vitamins, especially A and C. Gradually with by the disappearance or significant decrease in the phenomena of intoxication, the regime is expanded, in the absence of contraindications (heart disease, digestive organs), the patient is transferred to diet No. 15, which provides for an increase in the sources of vitamins and calcium, fermented milk drinks (especially in antibiotic treatment), exclusion of fatty and hard-to-digest foods and dishes.

Drug therapy
For-tank-the-rio-logical-research-to-va-niya pro-from-to-dit-Xia taking mo-to-ro-you, smears, washes. After that, etiotropic therapy is started, which is carried out under the control of clinical efficacy, taking into account the seeded microflora and its sensitivity to antibiotics.

With a mild course of pneumonia in outpatients, preference is given to antibiotics for oral administration, in severe cases, antibiotics are administered intramuscularly or intravenously (it is possible to switch to the oral route of administration when the condition improves).

If pneumonia occurs in young patients without chronic diseases, treatment can be started with penicillin (6-12 million units per day). In patients with chronic obstructive pulmonary diseases, it is preferable to use aminopenicillins (ampicillin 0.5 g 4 times a day by mouth, 0.5-1 g 4 times a day parenterally, amoxicillin 0.25-0.5 g 3 times a day). In case of intolerance to penicillins in mild cases, macrolides are used - erythromycin (0.5 g orally 4 times a day), azithromycin (sumamed - 5 g per day), roxithromycin (rulid - 150 mg 2 times a day), etc. pneumonia in patients with chronic alcoholism and severe somatic diseases, as well as in elderly patients, are treated with cephalosporins of the II-III generation, a combination of penicillins with beta-lactamase inhibitors.

For bipartite pneumonia, as well as pneumonia, accompanied by a severe course with pronounced symptoms of intoxication, and with an unknown pathogen, a combination of antibiotics is used (ampiox or II-III generation cephalosporins in combination with aminoglycosides - for example, gentamicin or netromycin), fluoroquinolones, carbapenems are used.

For nosocomial pneumonia, III generation cephalosporins (cefotaxime, cefuroxime, ceftriaxone), fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin), aminoglycosides (gentamicin, netromycin), vancomycin, carbapenems, and also, in determining the fungal pathogen, are used. In persons with immunodeficient conditions, during empiric therapy of pneumonia, the choice of drugs is determined by the pathogen. For atypical pneumonia (mycoplasma, legionellosis, chlamydia) macrolides, tetracyclines (tetracycline 0.3-0.5 g 4 times a day, doxycycline 0.2 g per day in 1-2 doses) are used.

The effectiveness of treatment with anti-bio-tics with pneumonia, is mainly revealed by the end of the first days, but no later than three days of their notation. After this period, in the absence of a therapeutic effect, the prescribed drug should be replaced with another. The indicators of the effectiveness of therapy are considered to be the normalization of body temperature, the disappearance or reduction of signs of intoxication. In uncomplicated community-acquired pneumonia, antibiotic therapy is carried out until a stable normalization of body temperature (usually about 10 days), with a complicated course of the disease and nosocomial pneumonia, the duration of antibiotic therapy is determined individually.

With severe vi-rus-no-bak-te-ri-al-pneum-mon-ni-y, by-ka-za-but introduction of special Norwegian anti-flu gamma-glo-bu-lin, 3-6 ml, with no-flow, every 4-6 hours, in the first 2 days sick.

In addition to antibiotic therapy, symptomatic and pathogenetic treatment pneumonia. In the case of respiratory failure, oxygen therapy is used. In case of high, severely tolerated fever, as well as with severe pleural pain, non-steroidal anti-inflammatory drugs are indicated (paracetamol, voltaren, etc.); to correct microcirculatory disorders, heparin is used (up to 20,000 units per day).

Patients are placed in pa-la-ty in-ten-siv-noy therapy for severe acute and exacerbation of chronic pneumonia , os-false-n-nyh acute or chro-none-che-dy-ha-tel-noy not-to-a-hundred-accurate-ness. Can be pro-ve-den bron-ho-scopic-dre-nazh, with ar-te-ri-al-hyper-cap-nia - an auxiliary artificial ven- ty-llation of the lungs. In the case of the development of pulmonary edema, infectious-on-no-tok-si-ch-ch-sh-ka and other severe asp-lodges, no-treatment of patients pneu-mo-no-it is conducted together with re-a-nima-to-log.

Patients who have had pneumonia and were discharged from the hospital during the period of clinical recovery or remission should be taken under dispensary observation. For rehabilitation, they can be sent to a sanatorium.

Forecast

In the bulk of cases of community-acquired pneumonia in immunocompetent young and middle-aged patients, on the 2-4th day of treatment, the body temperature normalizes, and the X-ray "recovery" occurs within 4 weeks.

The prognosis for pneumonia became more favorable by the end of the 20th century, however, it remains serious for pneumonia caused by stafi-lo-kok-m and Klebsiella pneumonia (Friedlander's stick), with often recurrent chronic pneumonia, wasps-false-ob-structural process, dy-ha-tel- noisy and pulmonary-heart-heart-no-up-to-hundred-accuracy, and also with the development of pneumonia in persons with severe heart disease -so-su-di-stay and other si-s-that. In these cases, lethality from pneumonia remains vigorous.

PORT scale

In all patients with community-acquired pneumonia without exception, it is recommended to initially determine whether there is an increased risk of complications and death in the patient (class II-V) or not (class I).

Step 1. Stratification of patients into risk class I and risk classes II-V

At the time of inspection
Age> 50 years	Well no
Consciousness disturbances	Well no
Heart rate> = 125 bpm	Well no
Respiratory rate> 30 / min.	Well no
Systolic blood pressure< 90 мм рт.ст.	Well no
Body temperature< 35 о С или >= 40 o C	Well no
History
	Well no
	Well no
	Well no
Kidney disease	Well no
Liver disease	Well no

Note... If there is at least one "Yes", you should go to the next step. If all answers are “No,” the patient is classified as risk class I.

Step 2. Scoring the degree of risk

Patient characteristics	Score in points
Demographic factors
Age, men	Age (years)
Age, women	Age (years) - 10
Stay in nursing homes
Accompanying illnesses
Malignant neoplasm
Liver disease
Congestive heart failure
Cerebrovascular disease
Kidney disease
Physical examination data
Impaired consciousness
Heart rate> = 125 / min.
Respiratory rate> 30 / min.
Systolic blood pressure< 90 мм рт.ст.
Body temperature< 35 о С или >= 40 o C
Laboratory and instrumental research data
pH arterial blood
Urea nitrogen level> = 9 mmol / L
Sodium level< 130 ммоль/л
Glucose level> = 14 mmol / L
Hematocrit< 30%
PaO 2< 60 mmHg Art.
Presence of pleural effusion

Note. The column "Malignant neoplasms" takes into account the cases of tumor diseases, manifesting an active course or diagnosed during the last year, excluding basal cell and squamous cell carcinoma of the skin.

The column "Liver diseases" includes cases of clinically and / or histologically diagnosed liver cirrhosis and active chronic hepatitis.

The column "Chronic heart failure" takes into account cases of heart failure due to systolic or diastolic dysfunction of the left ventricle, confirmed by history, physical examination, chest x-ray, echocardiography, myocardial scintigraphy or ventriculography.

The column "Cerebrovascular diseases" includes cases of recent stroke, transient ischemic attack and residual effects after acute cerebrovascular accident, confirmed by CT or MRI of the brain.

The column "Diseases of the kidneys" takes into account cases of anamnestically confirmed chronic kidney disease and an increase in the concentration of creatinine / urea nitrogen in the blood serum.

Step 3. Risk assessment and choice of treatment site for patients

Points total	Class risk	Degree risk	30-day mortality 1%	Treatment site 2
< 51>		Low	0,1	Outpatient
51-70		Low	0,6	Outpatient
71-90	III	Low	0,9-2,8	Closely monitored outpatient or short hospital stay 3
91-130		Average	8,2-9,3	Hospitalization
> 130		High	27,0-29,2	Hospitalization (ICU)

Note.
1 Based on Medisgroup Study (1989), PORT Validation Study (1991)
2 E.A. Halm, A.S. Teirstein (2002)
3 Hospitalization is indicated when the patient's condition is unstable, there is no response to oral therapy, the presence of social factors

Hospitalization

Indications for hospitalization:
1. Age over 70 years, pronounced infectious-toxic syndrome (respiratory rate is more than 30 in 1 min., BP is below 90/60 mm Hg, body temperature is above 38.5 o C).
2. The presence of severe concomitant diseases (chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, severe liver and kidney disease, chronic alcoholism, substance abuse and others).
3. Suspicion of secondary pneumonia (congestive heart failure, possible pulmonary embolism, aspiration, and others).
4. Development of complications such as pleurisy, infectious-toxic shock, abscess formation, impaired consciousness.
5. Social indications (it is not possible to organize the necessary care and treatment at home).
6. Ineffectiveness of outpatient therapy within 3 days.

With a mild course and favorable living conditions, treatment of pneumonia can be carried out at home, but the bulk of patients with pneumonia need stationary treatment.
Patients with pre-lev and other pneumonia and severe infection-on-but-to-c-sy-droma are followed by an emergency li-zi-ryat. The choice of the place of treatment and (partially) the prognosis can be made according to status assessment scales CURB-65 / CRB-65.

CURB-65 and CRB-65 scales for community-acquired pneumonia

Factor	Points
Confusion of consciousness
Blood urea nitrogen> = 19 mg / dL
Respiratory rate> = 30 / min.
Systolic blood pressure< 90 мм рт. ст Diastolic blood pressure< = 60 мм рт. ст.
Age > = 50
Total

CURB-65 (points)	Mortality (%)
	0,6	Low risk, outpatient treatment possible
	2,7	Low risk, outpatient treatment possible
	6,8	Short hospitalization or close outpatient follow-up
		Severe pneumonia, hospitalization or ICU follow-up
4 or 5	27,8	Severe pneumonia, hospitalization or ICU follow-up

CRB-65 (points)	Mortality (%)
	0,9	Very low risk of mortality, usually does not require hospitalization
	5,2	Uncertain risk, requires hospitalization
		Uncertain risk, requires hospitalization
3 or 4	31,2	High risk of death, urgent hospitalization

Prophylaxis

In order to prevent community-acquired pneumonia, pneumococcal and influenza vaccines are used.
Pneumococcal vaccine should be given when there is a high risk of developing pneumococcal infections (as recommended by the Committee of Advisers on Immunization Practices):
- persons over 65;
- persons aged 2 to 64 years with diseases of internal organs (chronic diseases of the cardiovascular system, chronic bronchopulmonary diseases, diabetes mellitus, alcoholism, chronic liver diseases);
- persons aged 2 to 64 with functional or organic asplenia Asplenia - developmental anomaly: absence of the spleen
(with sickle cell anemia, after splenectomy);
- persons from 2 years old with immunodeficiency conditions.
Influenza vaccine administration is effective in preventing the development of influenza and its complications (including pneumonia) in healthy individuals under 65 years of age. Vaccination is moderately effective in people aged 65 and over.

Information

Sources and Literature

A complete guide to the practicing physician / edited by A.I. Vorobiev, 10th edition, 2010
1. pp. 183-187
Russian therapeutic reference book / edited by Academician RAMS A.G. Chuchalin, 2007
1. pp. 96-100
www.monomed.ru
1. Electronic medical reference book

Attention!

Self-medication can cause irreparable harm to your health.
The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace an in-person consultation with a doctor. Be sure to contact a healthcare provider if you have any medical conditions or symptoms that bother you.
The choice of medicines and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" are exclusively information and reference resources. The information posted on this site should not be used to unauthorized changes in the doctor's prescriptions.
The MedElement editors are not responsible for any damage to health or material damage resulting from the use of this site.

Community-acquired pneumonia is one of the most common respiratory infections. Most often, this ailment 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.

What is community-acquired pneumonia?

It 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 previous viral infection. The name of pneumonia characterizes the conditions for its occurrence. A person gets sick at home, without any contact with a medical institution.

Pneumonia in an adult

Adults most often get pneumonia as a result of bacteria entering the body, which are the causative agents of the disease. Community-acquired pneumonia in adults is independent of geographic areas and socioeconomic relationships.

What is pneumonia?

This disease is conventionally divided into three types:

Mild pneumonia is the largest group. She is treated on an outpatient basis at home.
The disease is of moderate severity. Such pneumonia is treated in a hospital. The peculiarity of this group is that most patients have chronic diseases.
Severe form of pneumonia. She is treated only in the hospital, in the intensive care unit.

Community-acquired pneumonia is:

Focal. A small area of the lungs is inflamed.
Segmental. Characterized by the defeat of one or several parts of the organ at once.
Equity. Some part of the organ is damaged.
Total. The whole lung is affected.

Community-acquired pneumonia is unilateral and bilateral, right-sided and left-sided.

Symptoms

The body temperature rises.
Chills and weakness appear.
Decreased efficiency and appetite.
Sweating appears, especially at night.
The head, joints and muscles hurt.
Consciousness is confused and orientation is disturbed if the disease is severe.
Pain in the chest area.
Herpes may appear.

Abdominal pain, diarrhea and vomiting.
Shortness of breath that occurs during exercise. When a person is at rest, this does not happen.

Causes

Community-acquired pneumonia develops when germs enter a weakened human body that cause inflammation. The causes of the disease are as follows:

Hypothermia of the body.
Viral infections.
Concomitant diseases: diabetes mellitus, heart, lungs and others.
Weakened immunity.
Excessive consumption of alcoholic beverages.
Prolonged bed rest.
Transferred operations.
Elderly age.

Causative agents of the disease

Pneumococci (most often the cause of the disease).
Staphylococci.
Atypical pathogens: mycoplasma and chlamydia.
Klebsiella.
Viruses.
Pneumocysts.
Escherichia coli.
Haemophilus influenzae.

Diagnostics

During the examination, it is very important to identify and evaluate the clinical symptoms of the disease, such as fever, chest pain, cough with phlegm. Therefore, if a person has community-acquired pneumonia, a medical history is necessarily started for each patient. In it, the doctor writes down all the patient's complaints and appointments. To confirm the diagnosis, a radiation examination is performed: a chest x-ray. Clinical manifestations in community-acquired pneumonia are:

Cough with discharge of mucopurulent sputum, in which blood streaks are present.
Chest pain during breathing and coughing.
Fever and shortness of breath.
Trembling voice.
Wheezing.

Sometimes the symptoms differ from those typical for the disease, making it difficult to make a correct diagnosis and determine the method of treatment.

Radiation examination

The patient is assigned an x-ray if he has community-acquired pneumonia. Diagnostics by the radiation method involves the study of the organs of the chest cavity in the front of it. The picture is taken in frontal and lateral projection. The patient undergoes an X-ray examination as soon as he seeks a doctor, and then half a month after the treatment with antibacterial agents has begun. But this procedure can be carried out earlier if complications have arisen during treatment or the clinical picture of the disease has changed significantly.

The main symptom of community-acquired pneumonia during an X-ray examination is the compaction of lung tissue, a darkening is determined in the picture. If there are no signs of compaction, then there is no pneumonia.

Lower lobe right-sided pneumonia

Many patients go to the hospital when they are worried about symptoms such as shortness of breath, cough accompanied by mucous sputum, fever up to 39 degrees, pain with a tingling sensation on the right side under the rib. After listening to the patient's complaints, the doctor examines him, listens and probes where necessary. If there is a suspicion that the patient has community-acquired right-sided pneumonia, which, as a rule, occurs much more often (which is why we pay special attention to it), he is assigned a full examination:

Laboratory tests: general, clinical and biochemical blood tests, urine and sputum analysis.
Instrumental studies, which include chest x-ray, fiberoptic bronchoscopy and electrocardiogram. The form of darkening on the X-ray image allows you to clarify the diagnosis, and fibroscopy - to reveal the involvement of the bronchi and trachea in the process of inflammation.

If the results of all tests confirm that the patient has right-sided community-acquired pneumonia, the medical history is supplemented. Before starting therapy, the results of studies for all indicators are recorded in the patient's card. This is necessary in order to make adjustments as needed during treatment.

Laboratory and instrumental studies can show inflammation of the lower right lobe of the lung. This is another case history. Community-acquired lower lobe pneumonia - this will be the diagnosis. When it is precisely established, the doctor prescribes a treatment that is individual for each patient.

How is community-acquired pneumonia treated?

Patients with such a diagnosis can be treated both in a hospital and at home. If the patient has community-acquired pneumonia, the history of the disease must be started, regardless of the place of treatment. Patients on outpatient treatment are conventionally divided into two groups. The first group includes people under 60 years of age who do not have concomitant diseases. The second - over 60 or people with concomitant diseases (of any age). When a person has community-acquired pneumonia, treatment is carried out with antibacterial drugs.

For patients of the first group, the following are prescribed:

"Amoxicillin" with a dosage of 0.5-1 g or "Amoxicillin / clavulanate" - 0.625 g at a time. Accepted 3 times during the day.
An alternative to these drugs can be: "Clarithromycin" or "Roxithromycin" with a dosage of 0.5 g and 0.15 g, respectively. Take twice a day. Can be prescribed "Azithromycin", which is taken once a day in an amount of 0.5 g.
If there is a suspicion that the disease is caused by an atypical pathogen, the doctor may prescribe "Levofloxacin" or "Moxifloxacin" 0.5 g and 0.4 g, respectively. Both drugs are taken once a day.

If patients of the second group have community-acquired pneumonia, treatment is carried out using the following drugs:

"Amoxicillin / clavulanate" is prescribed three times a day at 0.625 g or twice a day at 1 g, "Cefuroxime" should be taken in an amount of 0.5 g at one time twice a day.
Alternative drugs may be prescribed: "Levofloxacin" or "Moxifloxacin" 0.5 g and 0.4 g, respectively, once a day by mouth. "Ceftriaxone" is prescribed 1-2 g intramuscularly, too, once a day.

Treatment of the disease in children

Community-acquired pneumonia in children with an uncomplicated form of the development of the disease, depending on age, is treated with the following drugs:

Children under 6 months are prescribed: "Josamycin" twice a day for a week at the rate of 20 mg per kilogram of body weight. Maybe "Azithromycin" - the daily rate should not exceed 5 mg per kilogram of body weight, the duration of treatment is 5 days.
Children under 5 years of age are prescribed "Amoxicillin" by mouth 25 mg / kg twice a day, the duration of treatment is 5 days. They can prescribe "Amoxicillin / clavulanate" in terms of 40-50 mg per kilogram of body weight or "Cefuroxin axetil" at a dosage of 20-40 mg / kg, respectively. Both drugs are taken twice a day, the duration of treatment is 5 days.
Children over 5 years of age are prescribed "Amoxicillin" at a dosage of 25 mg / kg in the morning and evening. If there is a suspicion of atypical pneumonia, appoint "Josamycin" inside, increasing the dosage to 40 mg / kg per day for a week or "Azithromycin" according to the scheme: 1 day - 10 mg / kg, then 5 mg / kg for 5 days. If there is no positive result in treatment, you can replace "Amoxicillin" at the rate of 50 mg / kg once a day.

Preventive measures to prevent the disease

Prevention of community-acquired pneumonia is carried out using pneumococcal and influenza vaccines. If necessary, they are administered simultaneously, only in different hands. For this purpose, a 23-valent unconjugated vaccine is used. It is introduced:

People over 50 years old.
Persons living in nursing homes.
Adults and children with chronic diseases of the lungs, heart and blood vessels or under constant medical supervision.
Children and adolescents (from six months to the age of majority) taking aspirin for a long time.
Pregnant women of the 2-3rd trimester.
Doctors, nurses and other hospital and dispensary staff.
Nursing staff.
Family members of those people who are at risk.
Home care providers.

Prevention of community-acquired pneumonia is:

A correct lifestyle, which involves physical exercise, regular long walks in the fresh air, active rest.
A balanced healthy diet with a normalized content of proteins, vitamins and microelements.
Annual flu vaccination for children and adults, which is given before the onset of the cold season. The flu is very often a complication. A person gets sick with pneumonia, which is difficult.
Life without hypothermia and drafts.
Daily cleaning and airing of the room.
Frequent hand washing and rinsing of the nasal passages.
Limitation of contacts with patients with ARVI.
During the period of mass spread of infection, taking honey and garlic. They are excellent immunostimulating agents.
If you or your child are sick with the flu, do not self-medicate, but call a doctor.

Community-acquired pneumonia

About article

For citation: Novikov Yu.K. Community-acquired pneumonia // BC. 1999. No. 17. P. 825

Department of Pulmonology, FUV RSMU

There are many options for defining pneumonia as a nosological form. Regardless of the style of the authors, in most cases the definition contains the keywords: inflammation, infectious, alveoli, inflammatory cells and exudate. Thus, the definition of pneumonia can be presented as follows: pneumonia is an infectious lesion of the alveoli, accompanied by infiltration of the parenchyma with inflammatory cells and exudation in response to the introduction of microorganisms into the sterile (normal) parts of the respiratory tract. Pneumonia does not include lung damage in infectious diseases (plague, typhoid fever, tularemia, etc.). These are other nosological forms.

Traditionally, classification (N.V. Molchanov, 1964; E.V. Gembitsky and O.V. Korovina, 1968, V.P. Silvestrov, 1982) subdivided pneumonia by etiology (in the first place) due to the importance of the microbial factor in the genesis of the disease , morphology and flow. Localization and complications were described in detail in various classifications. Focusing the doctor's attention on these aspects, the authors did not take into account the course of his clinical thinking: the doctor saw in front of him a child, an elderly or young person suffering from concomitant diseases or initially healthy, and the place where pneumonia developed - at home or in a hospital - was ignored. Therefore, even before the adoption of the modern classification of pneumonia, attempts were made to generalize clinical data for the possible identification of microorganisms that caused pneumonia (Fig. 1). Actually, this is the prototype of the classification, in which, first of all, the hospital and community-acquired pneumonia... Isolation of pneumonia in patients with immunodeficiency, but a separate consideration of atypical pneumonia is inappropriate, since in essence these are community-acquired pneumonia. Allocation of aspiration pneumonia into an independent heading also raises doubts, since aspiration is present in the genesis of both hospital and community-acquired pneumonia. Leaving aside the confusion of criteria given in one classification: on the one hand - anamnestic (community-acquired and hospital), on the other - pathogenetic (aspiration and in people with immunodeficiency), one can imagine classification in the following form:

community-acquired pneumonia (including atypical);

nosocomial (hospital, nosocomial) pneumonia;

pneumonia in persons with immunodeficiency (congenital or acquired).

The localization and prevalence of the process, the presence of complications are still indicated in the diagnosis.

An example of a diagnosis formulation:

Community-acquired lobar (pneumococcal) pneumonia of the lower lobe of the right lung. Heavy current. Right-sided exudative pleurisy. Infectious toxic kidney. Respiratory failure of the II degree.

In community-acquired pneumonia, the most common pathogens are:

Nosocomial pneumonia

Nosocomial pneumonia- pulmonary infection that developed two or more days after the patient was admitted to the hospital, in the absence of signs of the disease at the time of hospitalization. The manifestations of nosocomial pneumonia are similar to those in other forms of pneumonia: fever, cough with sputum, tachypnea, leukocytosis, infiltrative changes in the lungs, etc., but can be mild, erased. Diagnosis is based on clinical, physical, radiographic, and laboratory criteria. Treatment of nosocomial pneumonia includes adequate antibiotic therapy, airway sanitation (lavage, inhalation, physiotherapy), and infusion therapy.

Nosocomial pneumonia

Nosocomial (nosocomial, hospital) pneumonia is a hospital-acquired infection of the lower respiratory tract, the signs of which develop no earlier than 48 hours after the patient is admitted to a hospital. Nosocomial pneumonia is one of the three most common nosocomial infections, second only to wound infections and urinary tract infections in prevalence. Nosocomial pneumonia develops in 0.5-1% of patients undergoing treatment in hospitals, and in patients in intensive care and intensive care units it occurs 5-10 times more often. Mortality in nosocomial pneumonia is extremely high - from 10-20% to 70-80% (depending on the type of pathogen and the severity of the patient's background condition).

Classification of nosocomial pneumonia

According to the timing of the onset, nosocomial infection is divided into early and late. Nosocomial pneumonia is considered early if it occurs in the first 5 days after admission to the hospital. As a rule, it is caused by pathogens that were present in the patient's body even before hospitalization (St. aureus, St. pneumoniae, H. influenzae, and other representatives of the microflora of the upper respiratory tract). Usually, these pathogens are sensitive to traditional antibiotics, and pneumonia itself is more favorable.

Late nosocomial pneumonia manifests itself after 5 or more days of inpatient treatment. Its development is due to the actual hospital strains (methicillin-resistant St. aureus, Acinetobacter spp., P. aeruginosa, Enterobacteriaceae, etc.), exhibiting highly virulent properties and multi-resistance to antimicrobial drugs. The course and prognosis of late nosocomial pneumonia are very serious.

Taking into account the causal factors, there are 3 forms of nosocomial respiratory tract infection: ventilator-associated, postoperative and aspiration pneumonia. At the same time, quite often, various forms are superimposed on each other, further aggravating the course of nosocomial pneumonia and increasing the risk of death.

Causes of nosocomial pneumonia

The main role in the etiology of nosocomial pneumonia belongs to gram-negative flora (Pseudomonas aeruginosa, Klebsiella, Escherichia coli, Proteus, Serration, etc.) - these bacteria are found in the secretions of the respiratory tract in 50-70% of cases. In 15-30% of patients, methicillin-resistant Staphylococcus aureus is the leading pathogen. Due to various adaptive mechanisms, these bacteria develop resistance to most of the known antibacterial agents. Anaerobes (bacteriodes, fusobacteria, etc.) are the etiological agents of 10-30% of nosocomial pneumonia. Legionella pneumonia develops in about 4% of patients - as a rule, it proceeds as mass outbreaks in hospitals, the cause of which is the contamination of air conditioning and water supply systems with Legionella.

Significantly less frequently than bacterial pneumonia, nosocomial infections of the lower respiratory tract caused by viruses are diagnosed. Among the causative agents of nosocomial viral pneumonia, the leading role belongs to influenza A and B viruses, the RS virus, in patients with weakened immunity - to cytomegalovirus.

Long-term hospitalization, hypokinesia, uncontrolled antibiotic therapy, old and senile age are common risk factors for infectious complications from the respiratory tract. The severity of the patient's condition, caused by concomitant COPD, postoperative period, trauma, blood loss, shock, immunosuppression, coma, etc., is essential. Medical manipulations can contribute to colonization of the lower respiratory tract with microbial flora: endotracheal intubation and reintubation, tracheostomy, bronchoscopy, bronchoscopy. The main routes of entry of pathogenic microflora into the respiratory tract are aspiration of secretions of the oronosopharynx or stomach contents, hematogenous spread of infection from distant foci.

Ventilator-associated pneumonia occurs in ventilated patients; at the same time, every day spent on apparatus breathing increases the risk of developing nosocomial pneumonia by 1%. Postoperative, or congestive pneumonia, develops in immobilized patients who have undergone severe surgical interventions, mainly on the chest and abdominal cavity. In this case, the background for the development of pulmonary infection is a violation of the drainage function of the bronchi and hypoventilation. The aspiration mechanism of nosocomial pneumonia is typical for patients with cerebrovascular disorders, in whom there are disorders of the cough and swallowing reflexes; in this case, the pathogenic effect is exerted not only by infectious agents, but also by the aggressive nature of the gastric aspirate.

Nosocomial pneumonia symptoms

A feature of the course of nosocomial pneumonia is the blurring of symptoms, which makes it difficult to recognize a pulmonary infection. First of all, this is due to the general severity of the patient's condition associated with the underlying disease, surgery, old age, coma, etc.

Differential diagnosis of pneumonia: a table of the main diagnostic criteria

Pneumonia is an inflammatory lung disease that occurs when an organ is damaged by a bacterium, virus, or fungal infection. To select an adequate treatment, it is necessary to correctly and promptly establish a diagnosis. In some cases, the symptoms of pneumonia may overlap with other respiratory diseases, but the methods of treatment will differ. In this case, the doctor needs to carry out a differential diagnosis to clarify the correct diagnosis. To obtain a high-quality diagnosis, it is recommended to undergo an examination at the Yusupov hospital.

Differential diagnosis of community-acquired pneumonia in the form of a table

Community-acquired pneumonia (that is, pneumonia that originated outside the hospital; synonym: outpatient, home) is a very serious disease and can be fatal, so it is important to start treatment as early as possible. The effectiveness of treatment will depend on the correct diagnosis. Differential diagnosis is aimed at comparing diseases according to certain criteria (symptoms, research results) and excluding unsuitable diseases in order to obtain the only correct diagnosis. With pneumonia, differential diagnosis will help exclude the following diseases:

They have a similar clinical picture at the onset of the disease.

Differential diagnosis of pneumonia and tuberculosis

Most often, mistakes in diagnosis are made when comparing pneumonia and tuberculosis. It is important to distinguish between these two diseases, since the therapeutic regimens for their treatment differ significantly. Therapies that work for pneumonia will not work for tuberculosis. Also, most physiotherapy methods for pneumonia cannot be used for tuberculosis (it is only possible to aggravate the condition).

Differential diagnosis of pneumonia and obstructive bronchitis

Both pathologies most often begin with acute respiratory infections. With obstructive bronchitis and pneumonia, the main symptom is a cough with sputum production. However, pneumonia is usually more difficult: the patient has severe intoxication, high body temperature. In some cases, pneumonia in a patient who smokes will have the same clinical picture as the chronic bronchitis of a smoker. With obstructive bronchitis, the temperature can rise within two to three days and then does not exceed subfebrile values. During the differential diagnosis, the nature of the origin of the disease is taken into account: in pneumonia - mainly bacterial, in obstructive bronchitis - pulmonary.

Differential diagnosis of pneumonia and lung cancer

The initial manifestations of pneumonia and the development of the oncological process do not differ. If pneumonia is suspected, the patient is prescribed a course of antibiotics. If after a week they do not show a result, the patient is sent for examination to confirm or exclude a malignant neoplasm. Differential analysis is carried out at an early stage of cancer, since characteristic symptoms will appear in the future. With metastasis and growth of the tumor into the pleural tissue, the disease has a pronounced clinical picture. There are severe pains when coughing, there is blood in the sputum. Joint pain occurs.

Dif. diagnosis of pneumonia: table of pneumonia pathogens

Differential diagnosis of pneumonia allows you to accurately diagnose for the appointment of the necessary therapy. However, it is important to consider the cause of pneumonia in order to use effective medications. Below is a table with the main causative agents of pneumonia and how they manifest themselves:

Pneumonia treatment

Timely and accurate diagnosis is performed at the Yusupov hospital. The clinic performs all the necessary diagnostic measures to detect pneumonia: examination by a therapist, laboratory tests, X-ray. High-quality diagnostics allows you to determine the type of pneumonia, which is important when prescribing therapy.

Inflammation of the lungs is treated with medication with antibiotic therapy. The choice of drug will depend on the causative agent of the disease. Additionally, drugs are used to eliminate symptoms: antipyretic, analgesic, expectorant drugs. After receiving the first positive results of treatment and stabilization of normal temperature, special massages and breathing exercises are prescribed. A patient with pneumonia must stay in bed, eat well, take vitamins, and drink enough fluids.

Yusupov Hospital offers its patients inpatient treatment with comfortable wards. The patient is provided with round-the-clock medical care by experienced therapists and qualified nursing staff. The wards have all the necessary hygiene items; a special ventilation system provides air purification in every room of the hospital. Patients are provided with a balanced diet, which is selected by a nutritionist, taking into account the wishes of the patient.

The Yusupov Hospital is located near the center of Moscow and accepts patients around the clock. You can call for help, make an appointment and get expert advice by phone.