Classification of pneumonia by localization. General features of pneumonia, classification. Treatment of acute pneumonia

One of the most dangerous pathologies respiratory tract is pneumonia. The classification of pneumonia helps to study its clinical features, which demonstrate the characteristics of manifestation, severity of development, localization of the source of inflammation and methods of treatment.

In the International Classification of Diseases - according to the ICD-10 classification - diseases are designated under codes j18.0 - j18.9. According to WHO - World Organization healthcare, pneumonia kills 15% of the world's children under the age of five every year.

Types of disease

Pneumonia is an inflammatory process localized in the lungs, in which infiltrative lesions of the lung tissue and respiratory failure are observed. In each patient, the analysis reveals a characteristic feature of the course of the disease. The basis of these features can be recognized by the classification of the disease, which includes:

1. Focal pneumonia - the inflammatory process affects only one area of ​​the lung lobe.
2. Parenchymal pneumonias are lobar, total and confluent, in which inflammation spreads to parts of the lung, nearby lobes and can affect the entire lung on one side.
3. Interstitial pneumonia is characterized by the fact that the infection is localized in the connective tissue of the lung, the alveoli are not affected, as a result of which the process of leakage of blood plasma and fibrin through the walls of blood vessels does not occur.

The modern classification of pneumonia and the correct picture of inflammation help doctors make an accurate diagnosis and prescribe adequate treatment. According to etiology, pneumonia is divided into types that appeared due to the fault of a specific pathogen, therefore, in the classification of pneumonia (according to N.S. Molchanov) they are of a bacterial nature, viral, fungal, mixed and mycoplasma. According to its pathogenesis, pneumonia is distinguished as primary and secondary.

The presence of atypical pneumonia, the cause of which is intracellular microorganisms, is an acute manifestation of this disease. This type of disease is characterized by a high degree of intoxication. In its initial stage, it is difficult to determine infiltrative changes on X-ray of the lungs. Pneumonia can occur with either mild symptoms or all of its main symptoms. Based on localization, pneumonia is divided into unilateral and bilateral, according to severity in the upper, middle and lower segments, as well as basal and central. Pneumonia can be caused by pneumococci and mycoplasma.

Classification of pneumonia in children by origin is divided into:

• community-acquired, occurring at home;
• hospital, which develops after two days of hospital stay or after discharge;
• ventilation, the cause of which is ventilation of the lungs;
• intrauterine, occurring in the first three days of a newborn’s life.

According to radiological indicators, childhood pneumonia can be focal, segmental, lobar and interstitial. Its severity is rated as one that can be treated on an outpatient basis and one that requires hospitalization. It may or may not have complications. According to localization, it can be unilateral or bilateral, according to the course - acute - up to 6 weeks - and protracted - up to two months.

Features of the disease

According to the severity of pneumonia, they are distinguished as:

• lungs;
• average;
• heavy.

Principal criteria for the severity of the disease can be identified on the basis of the clinical picture, which identifies patients who have severe inflammation and require enhanced therapy. The main criteria by which the patient’s condition is assessed upon admission to the hospital can be called:

1. Assessing consciousness. A mild form of the disease demonstrates the patient's clear consciousness. With moderate severity, in clear consciousness may be observed signs of mild euphoria, severe degree demonstrates confusion.
2. With a mild degree, the temperature indicator is up to 38 ° C, with a moderate degree - up to 39 ° C, with a severe degree - much higher.
3. When determining the respiratory rate for moderate severity, the indicator is from 25 to 30 inhalations and exhalations per minute, for severe severity it is above 30.
4. Intoxication of the body in severe pneumonia has a high percentage of severity.
5. As a complication, pneumonia can have pleurisy with a small amount of fluid, and in its severe form, purulent accumulation, abscess formation and infectious-toxic shock can be observed.
6. Indicative criteria arterial pulse with a mild flow they do not exceed 90 beats per minute, with an average flow they reach 100 beats, with a severe flow - more than 100 beats.
7. The blood pressure indicator for mild cases is 110 mm Hg. Art., with moderate it decreases, with severe collapse develops, in which the upper pressure during compression of the heart is 90 mm Hg. Art., and the upper one at the moment of relaxation of the heart shows 50 mm Hg. Art.
8. If pneumonia is mild, the respiratory rate is up to 20 mm per minute, in moderate severity it is up to 30 mm, in severe pneumonia it is more than 30 mm.
9. The severity of cyanosis is cyanosis, demonstrating a lack of oxygen in the blood. If observed mild degree, it is absent, in moderate cases the cyanosis appears only under the nails, in severe cases it has a very pronounced tint.
10. When examining peripheral blood, a mild degree is determined by a leukocytosis index of up to 10x10 9 /l, moderate - up to 20x10 9 /l, severe - more than 20x10 9 /l.

These criteria help determine the picture of the disease and prescribe the necessary therapy to the patient.

Modern classification

Lobar pneumonia is typical sudden appearance, which is accompanied by high fever, cough turning into wet with rusty discharge, severe shortness of breath, chest pain and rapid heartbeat. When breathing, the patient exhales deeply, sometimes wheezing is heard when inhaling. Rapid pulse, arrhythmia, hypotension, dullness of heart sounds are the main symptoms of this type of pneumonia. In a clinical blood test, it predominantly shows ESR, leukopenia and leukocytosis are detected. Biochemical analysis reveals an increase in gamma globulin and alpha-2. Protein is found in the urine.

With focal pneumonia, the onset of the disease is characterized as gradual after acute respiratory viral infection. When coughing, purulent mucus is released, the patient is bothered by weakness, shortness of breath and sweating. This condition is complemented by elevated temperature and shortness of breath, you can hear hard breathing with prolonged exhalation, sometimes dry wheezing. Blood tests show moderate leukocytosis, elevated ESR, gamma globulin and alpha-2, sialic acids. X-ray examination demonstrates strong foci of inflammation in almost all segments, most often the right lung, which have a vague outline.

Pneumonia caused by staphylococcal infection appears after a viral infection. If the infection passed through the blood, then pulmonary damage as a result of this may be a manifestation of sepsis. This is a severe form of pneumonia, characterized by increased general intoxication of the body. The patient has a scanty cough, red sputum, muscle weakness, and confusion. An x-ray shows staphylococcal destruction (resolution) of the lungs. With complete intoxication, the lungs have a complete darkening, which can last up to a month.

Treatment of pneumonia

When treating a patient, it is imperative that he stay in a well-ventilated area, in a bed with hard flooring and an elevated headboard.

During inpatient treatment, the rooms in which patients are located are subjected to constant ultraviolet irradiation. An important role is played by dietary nutrition, which should be rich in vitamins. The first few days, the diet consists of broths and compotes, then the diet is expanded with foods rich in proteins, fats, and carbohydrates. The patient is recommended to drink plenty of fluids - up to 2.5 liters per day.

When determining the nature of the pathogen, antibiotic treatment is prescribed. For viral causes, pneumonia is treated with Ampicillin or Cefaclor. For uncomplicated pneumococcal pneumonia, Amoxicillin, Procaine-penicillin are prescribed. In severe forms of the disease - Rifampicin, cephalosporins. Antibacterial therapy is continued provided that the symptoms of complete intoxication have been relieved in the first 2-3 days.

In addition, antitussive drugs are prescribed: Libexin, Glaucine. Therapy is supplemented with physiotherapeutic measures. Stimulation of the immune system is mandatory. Prevention of pneumonia is of particular importance after recovery. To do this, doctors recommend timely sanitation of foci of infection, hardening, avoiding hypothermia and promptly carrying out therapy chronic diseases.

For quotation: Nikonova E.V., Chuchalin A.G., Chernyaev A.L. PNEUMONIA: EPIDEMIOLOGY, CLASSIFICATION, CLINICAL AND DIAGNOSTIC ASPECTS // Breast cancer. 1997. No. 17. S. 2

The article presents modern data on the epidemiology of pneumonia, morbidity and mortality rates among various age categories of the population both in our country and abroad. The characteristics of various factors predisposing to the occurrence of pneumonia are given, and their role in the development of severe disease and mortality is determined. A modern classification according to the international agreement on pneumonia is presented. The etiological characteristics of community-acquired and nosocomial pneumonia are given, and the role of etiological diagnosis in making a diagnosis is highlighted. The issue of correct diagnosis of pneumonia is discussed, information is provided on the frequency of under- and overdiagnosis, and their causes are indicated. The clinical and radiological picture is described and the basic principles of treatment of pneumonia are given.

The paper presents the currently available data on the epidemiology of pneumonia, morbidity and mortality in different age groups in our and foreign countries. It also characterizes various factors predisposing to pneumonia, defines their contribution to their severity and death. The paper gives the present-day classification according to the international agreement on pneumonia, outlines out hospital and inhospital pneumonias, covers the role of etiological diagnosis in establishing the diagnosis of the disease. It also discusses whether the diagnosis of pneumonia is made correctly, provides data on the frequency of hypo- and hyperdiagnosis, indicates their reasons. The clinical and X-ray of the disease are outlined and the basic principles in the treatment of pneumonia are given.

Research Institute of Pulmonology, Ministry of Health of the Russian Federation, Moscow
A. G. Chuchalin - Director of the Research Institute of Pulmonology of the Ministry of Health of the Russian Federation, Academician of the Russian Academy of Medical Sciences, Professor
A. L. Chernyaev - head. Laboratory of Pathological Anatomy, Research Institute of Pulmonology, Ministry of Health of the Russian Federation, Professor, Doctor of Medicine. sciences
E. V. Nikonova - graduate student of the Research Institute of Pulmonology of the Ministry of Health of the Russian Federation
Research Institute of Pulmonology, Ministry of Health of the Russian Federation, Moscow
Prof. A. G. Chuchalin, Academician of the Russian Academy of Medical Sciences, Director, Research Institute of Pulmonology, Ministry of Health of the Russian Federation
Prof. A. L. Chernyaev, MD, Head, Laboratory of Pathoanatomy, Research Institute of Pulmonology, Ministry of Health of the Russian Federation
Yes. V. Nikonova, Postgraduate Student, Research Institute of Pulmonology, Ministry of Health of the Russian Federation

P Neumonia is one of the most common diseases, occurs at any age, and has certain course characteristics in different age periods. It is a complex of pathological processes developing in the distal parts of the lung tissue. The main manifestation of these processes is infectious, exudative, and less often interstitial inflammation, caused by microorganisms of various natures, and dominant in the entire picture of the disease. From a clinical point of view, the concept of “pneumonia” should be defined as an infectious disease of the lower respiratory tract, confirmed x-ray.

Epidemiology of pneumonia

Modern ideas about pneumonia were formed as a result of their centuries-long study. Hippocrates also described pneumonia, its symptoms and treatment. Ancient authors said that a number of successive stages can be distinguished in the development of pneumonia. The question of the beginning and primary source of development has remained unresolved to this day, although it seems obvious that the primary source of pneumonia as infectious disease is its etiological factor - a pathogenic pathogen.
Epidemiology of pneumonia in modern stage is characterized by a trend towards increasing morbidity and mortality that has emerged since the late 80s, both in our country and throughout the world. In developed countries, the incidence of pneumonia ranges from 3.6 to 16 per 1000 people. Currently, throughout the world, pneumonia ranks 4th - 5th in the structure of causes of death after cardiovascular pathology, cancer, cerebrovascular pathology and chronic obstructive pulmonary diseases (COPD), and among infectious diseases it ranks 1st. In the United States, 3-4 million people fall ill with community-acquired pneumonia annually, 30-40% of them require hospitalization. Approximately 50 - 70% of patients are treated as outpatients, and the mortality rate among them is only 1 - 5%.
The incidence in the age group over 60 years is from 2 0 to 44 per 1000 population per year. The mortality rate from pneumonia in this category of patients is 10 - 33%, and in pneumonia complicated by bacteremia it reaches 50%. The mortality rate from pneumonia is high among newborns and young children and reaches 25% in children under 5 years of age. According to WHO, the mortality rate of children under 1 year in our country is 2-4 times higher (25.1 per 1000 population) than in other economically developed countries.
Great importance is attached to hospital-acquired (nosocomial) pneumonia. It accounts for approximately 10 - 15% of all hospital-acquired infections. The mortality rate for nosocomial pneumonia ranges from 30 - 60 to 80%.
Among patients with pneumonia, men predominate. They constitute, according to many authors, from 52 to 56% patients, while women - from 44 to 48%.
The incidence of pneumonia clearly increases with age. Patients aged 40 to 59 years make up 38.4 - 55.7% of cases, over 60 years old - from 31 to 60%.
The duration of temporary disability is on average 25.6 days and can range from 12.8 to 45 days. According to foreign authors, the average number of bed days for patients over 60 years of age is 21.

Risk factors for pneumonia

In the occurrence of pneumonia, predisposing factors, or risk factors, leading to damage to one or more protective mechanisms play a significant role. Most often, pneumonia occurs in the cold season, i.e. the incidence is seasonal, but it should be noted that the disease can occur at any time of the year. One of the most common provoking factors is hypothermia. Viruses are of great importance in the occurrence of pneumonia, especially during influenza epidemics, most often these are influenza viruses A, B, C, parainfluenza, adenoviruses, respiratory syncytial viruses and coronaviruses. Age over 60 years is another important risk factor, which is primarily associated with suppression of the cough reflex, impaired mucociliary clearance, and changes in microbial flora. In addition, at this age, a risk factor is the presence of COPD, pathology of cardio-vascular system, kidney, gastrointestinal tract. Another important factor is smoking: smoking up to 15 - 20 cigarettes per day leads to impaired mucociliary clearance, increased chemotaxis of macrophages and neutrophils, their activation, destruction of elastic tissue, and decreased efficiency mechanical protection. The occurrence of pneumonia is predisposed by disturbances of consciousness, alcohol intoxication, brain injury, epileptic seizure, anesthesia, overdose of sleeping pills and narcotic drugs. In all these cases, aspiration of the contents of the oropharynx and gastrointestinal tract, carrying large quantities of various aerobic and anaerobic flora, can occur. Pneumonia can also develop in the postoperative period, primarily through operations on the chest and abdominal organs; in this case, nosocomial pneumonia occurs, the frequency of which ranges from 20 to 50%, and the mortality rate ranges from 19.2 to 80%. A big problem is the occurrence of pneumonia in patients on mechanical ventilation (ALV) for more than a day. At the same time, the probability of nosocomial pneumonia is extremely high, its frequency ranges from 13 to 55%.
An important role in the occurrence of pneumonia is played by the primary and secondary immunodeficiency. The main contingent is patients with various tumor diseases: hematological malignancies, myelotoxic agranulocytosis, autoimmune diseases, patients receiving chemotherapy, radiation, immunosuppressive therapy, drug addiction and AIDS. The main pathogens are opportunistic, gram-negative flora, fungi (often Aspergillus spp.), Pneumocystis, cytomegalovirus, Noca rdia. One cannot fail to mention pneumonia in severe neutropenia caused by the use of chemotherapy for malignant neoplasms, the causative agents of which are both gram-positive cocci and gram-negative flora. Against the background of these pneumonias, septic conditions develop; the mortality rate is high. Risk factors for pneumonia may also include contact with birds, rodents, and travel.

Classification of pneumonia

The current division of pneumonia according to the clinical and pathomorphological principle into parenchymal - lobar and focal, as well as the identification of interstitial and mixed pneumonia is not very informative in terms of choosing the optimal etiotropic therapy. Recent advances in microbiology, pulmonology and pharmacotherapy dictate the need to develop the concept and classification of various types of pneumonia. The division of pneumonia should be based on the etiological principle, which will allow for targeted etiotropic pathogenetic treatment. Today, within the framework of the European Society of Pulmonologists and the American Thoracic Society, a discussion continues on the issue of classification of pneumonia. To streamline diagnostic methods and especially treatment methods, a clinical classification of pneumonia is recommended. There are four forms of pneumonia:

• community-acquired (home-acquired);
• in-hospital (nosocomial);
• against the background of immunodeficiency states;
• atypical pneumonia.

This classification reflects not only the place of origin of the disease, but also significant features (epidemiological, clinical and radiological), and most importantly - a certain range of pathogens, the course, outcome and treatment programs for patients with pneumonia. In foreign classifications and in periodical literature, pneumonia is divided into primary (community-acquired) and secondary (nosocomial-acquired).
Recently, medical practice requires greater detail of pneumonia, taking into account their diversity and wide range of pathogens. It is necessary to distinguish between aspiration pneumonia, post-traumatic pneumonia, postoperative pneumonia, pneumonia developing against the background of COPD, chronic alcoholism, malignant neoplasms, immunodeficiency, and nosocomial pneumonia. Risk factors for the occurrence of pneumonia of the latter group are the presence of patients on mechanical ventilation, the presence of a tracheostomy, the postoperative period, and massive antibacterial therapy.
Of great importance is the grouping of pneumonia by severity, which makes it possible to identify patients in need of intensive care, outline the most rational therapy, and assess the prognosis. The main clinical criteria for the severity of the disease are the degree respiratory failure, severity of intoxication, presence of complications, decompensation of concomitant diseases.

Etiology of pneumonia

The etiological approach in diagnosing pneumonia is extremely important. A practicing doctor almost always has to prescribe antibacterial therapy to a patient, not only in the absence of verification of the pathogen in the first days, but also without any prospects for obtaining microbiological data about the pathogen. The first publicly accessible and mandatory step is to establish a presumptive etiological diagnosis based on clinical and epidemiological data, taking into account the etiological structure of modern pneumonia. Of great importance for the diagnosis of pneumonia upon admission of a patient to a hospital is Gram staining of a sputum smear, which makes it possible to identify gram-positive and gram-negative pathogens, intracellular and extracellular localization of microorganisms. Comparison of bacterioscopy data with clinical and radiological features makes it possible to make an early clinical and bacteriological diagnosis in 86% of all patients with pneumonia and in 70% of patients with pneumococcal pneumonia. When diagnosing pneumonia, bacteriological examination of sputum (culture on media) and determination of sensitivity to antibiotics, identification of pathogens are important quantitative method in diagnostically significant titers (10 6 microbial cells or more in 1 ml of sputum). Abroad, along with the study of sputum, studies of aspirate, washings obtained during fiberoptic bronchoscopy, materials obtained during transtracheal aspiration, blood culture, and determination of antibodies to antigens of various pathogens in blood serum are widely carried out. The division of pneumonia into community-acquired and nosocomial is justified primarily by differences in the etiological structure. In the occurrence of community-acquired pneumonia, the leading role belongs to Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus occupies a certain place. The occurrence of community-acquired pneumonia can also be caused by atypical pathogens: Mycoplasma pneumoniae, Legionella pneumophilla and Chlamydia pneumoniae.
In the occurrence of nosocomial pneumonia, the role of opportunistic and gram-negative flora is great. This is primarily S. aureus, the occurrence of which ranges from 2.7 to 30%. The pathogen of the Enterobacteriacea family, Klebsiella pneumoniae, accounts for from 9.8 to 1 2.6% of pneumonia, with mortality ranging from 40 to 71%. The specific gravity of E.coli ranges from 17.3 to 32.3%, Proteus vulgaris - from 8.2 to 24%. Pseudomonas aeruginosa is responsible for the development of nosocomial pneumonia in 17% of cases, mortality reaches 80%. The share of Legionella pneumophilla as the causative agent of nosocomial pneumonia reaches 33%.
The role of viral pneumonia increases during epidemics of influenza A, B and ranges from 8.6 to 35%. The presence of purely viral pneumonia is not recognized by all authors. It is believed that they are conductors who prepare the “soil” for the addition of bacterial and mycoplasma flora.
The relevance of the problem of mixed infections in recent years is determined primarily by the fact that they account for up to 30 - 50% of cases of the disease, monoculture occurs in 40.5 - 50% of cases.
The etiology of pneumonia in more than 50% of cases cannot be established at all. The reasons are most often the following:

• lack of microbial research;
• improper collection of material;
• pathogen unknown;
• previous treatment with antibiotics (before taking material);
• uncertain clinical significance of the isolated pathogen;
• use of an inadequate treatment method.

Diagnosis of pneumonia

There is the concept of a “gold standard” in the diagnosis of pneumonia, which includes the assessment of five signs: fever, cough, sputum, leukocytosis and radiologically detectable infiltrate. However, following only this standard leads to diagnostic errors.
Despite significant achievements in the study of pneumonia, the synthesis of new antibacterial drugs, their wide selection, expansion of the spectrum laboratory diagnostics, the level of correct diagnosis of pneumonia remains insufficient.
The frequency of overdiagnosis of pneumonia ranges from 16 to 55%, and underdiagnosis - from 2.2 to 30.5%. The most common discrepancies in diagnoses are in clinics. An analysis of materials dating back to the 70s showed that a complete coincidence of the outpatient diagnosis with the clinical diagnosis is observed in only 20% of cases.
It should be noted that one of the important reasons for untimely diagnosis is the late presentation of patients for medical care both at the prehospital and hospital stages.
Underdiagnosis of pneumonia is largely due to defects in x-ray examination - both x-ray underdiagnosis and the lack of lung x-rays. Although we must not forget about the so-called X-ray negative pneumonia, which accounts for accounts for about 20%.
Things are bad with differential diagnosis between influenza and pneumonia, while instead of pneumonia, influenza or acute respiratory infection are mistakenly diagnosed. This is most often observed at the prehospital, outpatient stage, especially during influenza epidemics. Pneumonia, which occurs in various severe concomitant diseases: COPD, cardiovascular, cerebrovascular, oncological diseases, as well as in weakened and elderly patients who abuse alcohol. The severity and danger of death from pneumonia is not given due importance.
In hospital patients over 60 years of age, errors in diagnosing pneumonia are associated with concomitant pathology, since in this case extrapulmonary symptoms come to the fore, such as cardiovascular failure, impaired consciousness, exacerbation and decompensation of concomitant diseases.
Daily mortality in hospital ranges from 6 to 1 4% . Incorrect interpretation of the clinical picture can also occur in young patients and in patients under 50 years of age. Myocardial infarction (5.1%), acute abdomen (3.1%), acute cerebrovascular insufficiency (7.1%), and other diseases (29.6%) are often diagnosed.
Reliable etiological diagnosis is currently difficult. Epidemiological, clinical, X-ray laboratory criteria, of course, in a number of cases allow, with varying degrees of probability, the etiological diagnosis of pneumonia, but cannot serve as the basis for a reliable conclusion about the agent. Often in Russian hospitals, sputum bacterioscopy is not performed, which makes it possible to determine gram-positive and gram-negative flora; bacteriological control is poorly developed and practically absent in urgent situations. Often sputum examination is not performed and treatment usually remains empirical. Due to erroneous diagnosis of pneumonia, antibacterial therapy is either started late or it is inadequate to the clinical picture, which also leads to the development of complications and increased mortality.
Subjective and objective reasons for errors in the diagnosis of pneumonia are identified.
Subjective reasons include:

• loss of clinician interest in patients over 60 years of age;
• negligence and haste during the examination;
• illogical understanding of the obtained clinical and laboratory data;
• overestimation and underestimation of research methods, consultations with specialists;
• lack of a survey system and poor knowledge of survey methods;
• ignoring or inept use of medical history data;
• incorrect and incomplete formulation of the final diagnosis.

Objective reasons include:

• severity of the patient's condition;
• lack of time for correct diagnosis;
• atypical course of the disease;
• limited medical capabilities.

If it is true that no kind of human activity can do without mistakes, then this is also true for healing. According to I.V. Davydovsky (1928), “medical errors” are a type of conscientious errors made by a doctor in his judgments and actions when performing special medical duties. Despite the enormous achievements of modern therapy, the rule remains: “bene diagnostitur, bene curatur” - without a good diagnosis there cannot be a high level of the treatment process. It must be said that an exhaustively collected anamnesis allows one to establish the correct diagnosis in 50% of cases, while a clinical examination - in 30%, additional research - in 20% . A diagnosis made based on clinical data is often a presumptive diagnosis that requires confirmation. Diagnostic errors reduce the effectiveness of treatment and in 30 - 40% lead to a protracted course of pneumonia.

Clinical course of pneumonia

The clinical picture of pneumonia is determined by the characteristics of the pathogens and the state of the macroorganism. The main manifestations include various combinations of bronchopulmonary and extrapulmonary symptoms. Bronchopulmonary symptoms include cough, shortness of breath, chest pain, sputum production, which can be mucous, mucopurulent, and sometimes bloody. Dullness of percussion sound, weakened vesicular and bronchial breathing, crepitus, and pleural friction noise are also determined. Extrapulmonary include hypotension, weakness, tachycardia, chills, myalgia, fever, confusion, meningism, changes in peripheral blood parameters. In some patients, mainly in weakened and elderly patients, as well as in the presence of severe concomitant pathology, extrapulmonary symptoms prevail over bronchopulmonary ones.
The clinical and radiological picture of pneumonia depends primarily on the etiological agent. The division of pneumonia according to etiology is of fundamental importance for determining the course, prognosis and treatment. Diagnosis of pneumonia is based primarily on establishing the presence of pneumonia as an independent nosological form: analysis of clinical and radiological data with mandatory consideration of etiological characteristics inflammatory process. When diagnosing this nosology, the doctor must make a differential diagnosis with a number of diseases that have syndromic-similar symptoms, but differ in essence and require different treatment. The doctor has to solve the following differential diagnostic problems:

• distinguishing pneumonia from extrapulmonary diseases;
• differentiation of pneumonia from other respiratory diseases;
• differentiation of pneumonia according to various criteria (etiology, extent of the process, complication).

Pneumonia should be distinguished from diseases of the cardiovascular system, pulmonary embolism, viral infection, chronic nonspecific lung diseases, tuberculosis, lung cancer, interstitial lung diseases, pneumonitis with systemic vasculitis, drug-induced lung damage, atelectasis, infarction and pulmonary contusion.
With pneumonia, recovery occurs within up to 4 weeks. Clinical criteria for recovery are considered to be the normalization of the patient’s well-being and condition, the disappearance of physical and radiological signs of inflammation, and the normalization of blood counts. However, often the dynamics of clinical signs of recovery do not agree with the X-ray picture of the lungs. It may take from 3 weeks to 6 months to restore the structure of the lung tissue. The prolonged course of pneumonia is characterized by the absence of normalization of the clinical and radiological picture within 4 weeks.

Treatment of pneumonia

It seems necessary to discuss the issue of where to treat a patient with pneumonia. According to the current situation in our country, this diagnosis is a mandatory indication for hospitalization of the patient. This position is controversial. In foreign guidelines, inpatient treatment of community-acquired pneumonia is reserved for patients with severe disease, in the presence of complications, bilateral lesions, serious concomitant diseases, for elderly patients, as well as for situations where there is no effect of treatment or there are social indications for hospitalization. The basis for the treatment of pneumonia is rational antibacterial therapy.
Treatment should begin without waiting for the results of a microbiological study, i.e. empirically. Upon receipt of bacteriological data, treatment is adjusted if it is insufficiently effective.
When choosing antibacterial drugs, one should take into account: the type of pathogen (probable, determined by clinical data), the severity of the disease, the potential toxicity of the drugs and possible contraindications. In addition, it is necessary to take into account allergy history.

• It is necessary to decide on the use of monotherapy or a combination of several antibacterial drugs.
• It is very important to take into account the resistance of microbial flora to antibacterial therapy.
• The dose and frequency of drug administration should be commensurate with the intensity of the pathological process.
• The therapeutic effect of the drug should be monitored and possible adverse reactions should be monitored.
• When choosing antibacterial treatment, it is advisable to also use the results of sputum examination using Gram staining.
• The cost of the drug used cannot be ignored.

Thus, the treatment of pneumonia remains a pressing problem at the present stage of development. clinical medicine. Diagnosing pneumonia is still quite a difficult task, which dictates the need for continuous improvement of diagnostic and treatment methods, as well as advanced training for doctors of all specialties.

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(N.S.Molchanov, 1965; E.V.Gembitsky, 1983)

By etiology:

Bacterial (indicating the pathogen)

Viral (indicating the pathogen)

Mycoplasma

Rickettsial (pulmonary form of Q fever)

Ornithosis

Fungal

Mixed (viral-bacterial)

Unknown etiology

By pathogenesis:

Primary

Secondary (stagnant-hypostatic, infarction-pneumonia, postoperative, burn, septic-metastatic, etc.)

With the flow:

Protracted (more than 4 weeks)

By localization:

One- and two-sided

According to clinical and morphological characteristics:

Parenchymatous:

a) lobar, segmental (lobar)

b) focal (bronchopneumonia)

Interstitial

By severity:

Mild degree

According to the state of external respiration function:

No functional impairment

Respiratory failure I, II, III degrees.

Sample formulation of the diagnosis of pneumonia:

Basic: Community-acquired pneumococcal pneumonia of the lower lobe of the right lung, moderate severity

Complication: DN – II Art. Exudative pleurisy on the right

Many authors dispute the validity of the independent diagnosis of “interstitial pneumonia,” since reactive changes in the interstitial tissue are observed in many pulmonary and extrapulmonary diseases. This form of pneumonia is diagnosed more often with a viral or psittacosis infection.

Clinical picture. Clinical manifestations of pneumonia depend on epidemiological conditions, the clinical and morphological form of the disease, the type of pathogen and the state of the macroorganism.

In all cases it is possible to distinguish main clinical syndromes:

1) intoxicating(weakness, weakness, headaches and muscle pain, pallor);

2) general inflammatory changes(chills, increased body temperature, neutrophilic leukocytosis with a shift in the leukocyte formula to the left, increased ESR, levels of seromucoids, fibrinogen, appearance of C-reactive protein);

3) inflammatory changes in lung tissue(cough with sputum, chest pain, increased vocal tremors, dullness of percussion sound, changes in breathing patterns, the appearance of crepitus or moist fine rales, radiological signs of infiltration of the lung tissue);

4) involvement of other organs and systems(cardiovascular system, nervous, digestive, kidney, blood system).

The most typical clinical picture is community-acquired pneumococcal (lobar) pneumonia, which develops more often in young and middle-aged men.

It begins acutely against the background of complete health, usually after hypothermia. The patient develops severe chills, severe weakness, headache and muscle pain, increased body temperature to 39-40°. Shortness of breath is a concern with light exertion or even at rest. There is pain in the chest on the affected side, which intensifies with deep breathing or coughing and is associated with the involvement of the pleura in the pathological process. With lower lobe localization of pneumonia due to damage to the diaphragmatic pleura, pain radiates to the abdominal wall, simulating the picture of an acute abdomen. The cough appears at first dry, and from the 2-3rd day - with no discharge large quantity viscous sputum streaked with blood - “rusty”. Subsequently, the sputum becomes purulent or mucopurulent in nature.

When examining the patient, pale skin, cyanosis of the nasolabial triangle, and herpetic rashes on the lips and wings of the nose (due to an exacerbation of persistent herpetic infection) are noted. At severe course illness, disturbances of consciousness and delirium are possible. The body position is often forced - lying on the affected side - to reduce respiratory excursions of the affected lung. Breathing is shallow, increased to 30-40 per minute. Participation in breathing of the wings of the nose and other auxiliary respiratory muscles, and lag of the diseased half of the chest are observed. Palpation of the intercostal spaces in the area of ​​the affected lobe of the lung is painful. Voice tremors increased. Percussion of the lungs reveals shortening and then a pronounced dullness of the percussion sound.

During auscultation in the initial stage of pneumonia, somewhat weakened vesicular breathing is heard, which, with inflammatory compaction of the lung tissue (on the 2-3rd day of illness), is replaced by bronchial breathing. From the first days of the disease (in the flushing stage) it is heard crepitus– characteristic crackling sound when swollen alveoli dissolve at the height of inspiration (crepitatio indux). It is a pathognomonic sign of lobar pneumonia. At the peak of pulmonary inflammation, when the alveoli are filled with inflammatory exudate (red and gray liver stage), crepitus disappears. Pleural friction rub is often detected. With the discharge of sputum, scattered dry and sonorous fine-bubbly, moist rales appear, caused by local bronchitis.

From the cardiovascular system, tachycardia and hypotension are usually detected, up to collapse.

When adequate treatment of pneumonia is started in a timely manner, the patient’s body temperature quickly decreases and signs of intoxication decrease. As the source of inflammation resolves, percussion dullness is limited, breathing becomes vesicular and harsh. The amount of moist rales decreases, and crepitatio redux reappears. Uncomplicated lobar pneumonia resolves by the end of the 2-3rd week.

Community-acquired focal pneumococcal pneumonia is diagnosed in 80-85% of all cases of pneumonia. In terms of pathogenesis, it is usually secondary - it develops against the background of an acute respiratory infection, exacerbation of chronic bronchitis or other somatic pathology. It is more common in children and the elderly, weakened by frequent colds or other factors predisposing to pneumonia. The clinical picture of the disease is variable due to the variety of its pathogens (bacteria, including pneumococci, mycoplasma pneumoniae, viruses, rickettsia). The cyclical nature of the disease, characteristic of lobar pneumonia, is absent. The severity of the condition and physical findings depend on the extent of the process.

The disease can begin acutely, after hypothermia, with an increase in body temperature to 38-39 o, or gradually against the background of prodromal phenomena. In weakened patients, the body temperature may be low-grade. A dry cough or with mucopurulent sputum, shortness of breath, general weakness, sweating, and headache appear. If pneumonia is associated with an exacerbation of chronic bronchitis, an increase in “bronchitis” cough or an increase in the amount of mucopurulent sputum discharge is noted. Chest pain with focal pneumonia is usually absent, since the inflammatory process does not involve the pleura. Sweating is common with little physical activity.

Objective data are more scarce than for lobar pneumonia. On examination, pallor of the skin is observed, and with concomitant chronic diseases of the respiratory system or cardiovascular system - cyanosis, increased breathing. There is some lag in the diseased half of the chest when breathing. Above the areas of infiltration, an increase in vocal tremors and a shortening of the percussion sound are determined. On auscultation, against the background of hard vesicular breathing, dry and sonorous fine-bubbly, moist rales are heard. Large-focal (confluent) infiltration of lung tissue, according to physical data, resembles lobar pneumonia, but crepitus is not typical for focal pneumonia. With small inflammatory foci, a “mosaic” picture is possible - alternating areas of dullness of percussion sound with areas of normal or boxy, hard breathing with weakened breathing.

Pneumococcal pneumonia, both lobar and focal, is not characterized by destruction of lung tissue, since pneumococci do not produce exotoxins. This practically explains full recovery lung tissue structure and external respiration function.

Community-acquired pneumonia caused by other infectious agents has its own clinical characteristics.

Mycoplasma pneumonia is caused by an “atypical” intracellular pathogen, devoid of a cell membrane and approaching the size of viruses. It most often affects young people and is characterized by epidemic outbreaks in organized groups, reaching a frequency of 30%. It usually begins with a picture of an acute respiratory infection, then a painful, often paroxysmal cough appears with scanty mucopurulent sputum, and a disturbing feeling of “soreness” in the throat. Physical data are scarce due to the predominantly interstitial localization of inflammation. Against the background of hard breathing, a few dry rales are heard in the lower parts of the lungs. It is possible that focal infiltration of the lung tissue may occur with the appearance of dullness of percussion sound and moist fine rales over the affected area. Characteristic is the dissociation of clinical manifestations of the disease (severe intoxication, prolonged low-grade fever, heavy sweats), X-ray picture (only increased pulmonary pattern and interstitial changes) and laboratory data (absence of leukocytosis and neutrophilic shift). Extrapulmonary manifestations of mycoplasma infection are often detected - myalgia, arthralgia, myocarditis. The resolution of mycoplasma pneumonia is delayed, and the asthenic syndrome persists for a long time.

Rickettsial pneumonia (Q fever) has an acute onset, with a temperature of 39-40 o and repeated chills for 10-12 days. Severe intoxication, muscle pain, especially lumbar and calf pain, insomnia, and dyspeptic symptoms are observed. Worried about cough a small amount phlegm, chest pain. The cervical lymph nodes are often enlarged. Characterized by slight jaundice and hepatolienal syndrome. Physical data are scarce. Diagnosis is helped by a positive epidemiological history (contact with farm animals) and the complement fixation reaction with Qui-rickettsia antigens.

Legionella pneumonia(legionnaires' disease ) usually develops in epidemic individuals , staying in air-conditioned rooms, in the water systems of which favorable conditions for the life of a virulent gram-negative bacillus - Legionella. It is characterized by the fusion of foci of inflammation and high mortality of patients (15-30%). The clinical picture of the disease is characterized by prolonged fever (15 days or more), frequent extrapulmonary lesions, prolonged course, leukocytosis in combination with lymphopenia.

Ornithosis pneumonia caused by chlamydia psittacosis due to contact with infected birds. More often it occurs as interstitial pneumonia with poor physical data. The clinical picture is dominated by general toxic signs of infection - headache and muscle pain, fever, vomiting, sleep disturbances. Characterized by bradycardia, hypotension, dry tongue, flatulence, enlarged liver and spleen. The diagnosis is confirmed by an epidemiological history (contact with birds) and a skin allergy test.

Pneumonia due to respiratory viral infections develop under the influence of viral-bacterial associations. They are more often diagnosed during epidemics of viral infections. The main role of respiratory viruses is to damage the bronchial epithelium and suppress general and local immunity, which leads to the activation of opportunistic microorganisms and the penetration of infection (most often pneumococcus and Haemophilus influenzae) into the respiratory sections of the lungs. The diagnosis of viral-bacterial pneumonia is usually based on an assessment of the epidemiological conditions of the disease. Clinically, viral-bacterial pneumonia occurs as focal or focal-confluent with a noticeable reaction of the interstitial tissue of the lungs. With various viral infections, pneumonia has its own clinical characteristics. To detect and identify viruses, serological methods, enzyme-linked immunosorbent assay and polymerase chain reaction (PCR) are used.

Pneumonia due to influenza infection usually develop in the first three days from the onset of the disease and are characterized by severe intoxication and symptoms of hemorrhagic bronchitis. A two-wave fever is characteristic - the first wave reflects a viral infection, and the second - a bacterial infection.

Pneumonia due to adenovirus infection accompanied by symptoms typical of adenovirus infection - conjunctivitis, pharyngitis, enlarged peripheral lymph nodes.

Pneumonia due to respiratory syncytial virus infection is characterized by the development of bronchiolitis and obstructive bronchitis with intoxication and severe broncho-obstructive syndrome.

Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa in most cases are the causes of nosocomial pneumonia.

Staphylococcal pneumonia characterized by a severe course and rapid development of purulent destructive complications - lung abscesses, pleural empyema. Often develops after influenza with a decrease in general and local bronchopulmonary protective mechanisms. It begins acutely, with chills and high fever, cough with purulent sputum, shortness of breath, chest pain, which resembles lobar pneumonia. The severity of the condition does not always correspond to physical data. Characterized by a clear segmentation of the lesion involving several segments of the lungs and a tendency to rapid abscess formation with the formation of multiple thin-walled cavities. When abscesses open into the pleural cavity, pyopneumothorax occurs.

Friedlander's pneumonia Caused by Gram-negative endotoxin-producing Friedlander's bacillus or Klebsiella pneumoniae. It often affects people who abuse alcohol, the elderly, people with diabetes, and injection drug addicts. Men get sick 5-7 times more often. An acute onset with severe intoxication, an increase in body temperature to 38-39 o, the appearance of chest pain when breathing, and a painful cough resembles severe pneumococcal pneumonia. From the first day, profuse, viscous, bloody sputum appears with the smell of burnt meat. Due to the large amount of exudate clogging the lumen of the alveoli and bronchi, a small amount of wheezing is heard. The appearance of early multiple destruction of lung tissue (in the first two days) is convincing evidence in favor of pneumonia caused by Klebsiella. Frequent involvement of the upper lobe of the lung may cause an erroneous diagnosis of tuberculosis. Friedlander's pneumonia is characterized by a protracted course with the outcome in pneumofibrosis of the affected lobe.

Pneumonia caused by Pseudomonas aeruginosa stick usually develops in the postoperative period, in patients on mechanical ventilation (ventilator-associated pneumonia). It begins acutely with high fever with chills, severe intoxication, and respiratory failure. Physical examination reveals signs of focal lung damage. Pleural complications and abscess formation are typical. The disease is characterized by a particularly severe course and high mortality, reaching 50–70% in elderly weakened patients.

Laboratory and instrumental diagnosis of pneumonia:

General blood analysis reveals neutrophilic leukocytosis with a shift in the leukocyte formula to the left, an increase in ESR. The degree of these changes determines the prevalence and severity of the process: with lobar pneumonia, leukocytosis reaches 20-30 thousand with a shift of the leukocyte formula to the left to juvenile forms. Toxic granularity of neutrophils (++++), aneosinophilia are detected. With focal bacterial pneumonia, the changes are less pronounced - leukocytosis in the range of 10-12 thousand, a shift to the left up to 10% of stabs, toxic granularity of neutrophils (++). Viral pneumonia is characterized by leukopenia with a low ESR. With mycoplasma and psittacosis infections, a normal leukocyte count or leukopenia can be combined with a high ESR.

Blood chemistry reveals an increase in α 2 - globulins, sialic acids, seromucoids, and the appearance of C-reactive protein. In severe pneumonia, signs of blood hypercoagulation are revealed - the level of fibrinogen increases 2-3 times, the platelet count decreases. When the inflammatory process resolves, the fibrinolytic activity of the blood increases sharply.

Sputum analysis detects leukocytes, erythrocytes (with lobar, Friedlander, post-influenza pneumonia), elastic fibers (with abscess formation). During its bacteriological examination, the type of pathogen and its sensitivity to antibiotics are determined.

X-ray of the lungs is the most informative diagnostic method. With lobar pneumonia, an intense, uniform darkening is determined within a lobe or segment, which completely resolves under the influence of treatment within 2-3 weeks. Lobar lesions (usually the upper lobe) are characteristic of Friedlander pneumonia, and segmental lesions are characteristic of staphylococcal pneumonia. The last two variants of pneumonia are characterized by the rapid development of multiple destruction of lung tissue.

With focal pneumonia, foci of infiltration of various sizes and intensity are detected, most often in the lower parts of the lungs. With adequate treatment, pulmonary infiltrates resolve within 7-10 days. Viral, rickettsial and mycoplasma pneumonias are characterized by a severe pulmonary pattern due to the interstitial component of inflammation.

Spirography detects disturbances in the function of external respiration of a restrictive type, which is manifested by a decrease in minute volume of respiration (MVR), vital capacity (VC) and maximum pulmonary ventilation (MVL). In case of focal pneumonia that has developed against the background of chronic obstructive bronchitis, disturbances in the function of external respiration of the obstructive type are detected, as evidenced by a decrease in the forced expiratory volume in 1 second (FEV 1) and the Votchal-Tiffen test (FEV 1 / VC).

Serological studies blood help in the diagnosis of mycoplasma, rickettsial, legionellosis, ornithosis and viral pneumonia. The titer of antibodies to the pathogen is determined by the method of paired sera (an increase in titer of 4 times or more is reliable).

Sometimes, with severe or atypical pneumonia, it becomes necessary to use more complex methods examinations such as bronchoscopy with biopsy, computed tomography of the lungs, examination of pleural fluid, ultrasound of the heart and abdominal organs.

Summarizing the above data, we can determine “gold” diagnostic standard(A.G. Chuchalin, 2000) for early diagnosis of pneumonia already at outpatient stage:

1. Acute onset of the disease with fever and intoxication.

2. The appearance of a dry cough or with phlegm, chest pain.

3. Dullness of percussion sound and the appearance of auscultatory phenomena of pneumonia (crepitus, fine moist rales).

4. Leukocytosis or, less commonly, leukopenia with a shift to the left.

5. Detection of infiltrate in the lung during x-ray examination.

By severity all pneumonias are conditionally divided into three groups:

1. Pneumonia with a light current, not requiring hospitalization. This group accounts for up to 80% of all pneumonias. Patients can be treated on an outpatient basis under the supervision of a doctor or in a day hospital at a clinic. Mortality in this group does not exceed 1-5%.

2. Moderate pneumonia, requiring hospitalization patients to the hospital. This group includes about 20% of all pneumonias, which usually occur against the background of chronic diseases of internal organs and have pronounced clinical symptoms. The mortality rate of hospitalized patients reaches 12%.

Direct indications for hospitalization for pneumonia are: age of patients over 70 years old, obstructive respiratory diseases, chronic diseases of internal organs and nervous system, diabetes mellitus, pleural pain, disturbances of consciousness, tachycardia (more than 125 beats per minute), tachypnea (more than 30 breaths per minute), cyanosis, arterial hypotension(90/60 mm Hg and below), the inability to provide effective care on an outpatient basis or the lack of effect of treatment within three days, the appearance of complications of the disease, such as exudative pleurisy, abscess formation, infectious metastases.

3. Severe pneumonia, requiring hospitalization sick in intensive care and resuscitation departments. The mortality risk in this group is high - about 40 - 50%.

The criteria for intensive care are: acute respiratory failure (hypoxemia, signs of respiratory muscle fatigue, need for artificial ventilation), unstable hemodynamics (shock, need for vasopressors for more than 4 hours, urine output less than 20 ml/hour), acute renal failure requiring hemodialysis, disseminated intravascular coagulation syndrome, meningitis, coma.

Differential diagnosis pneumonia held:

With infarction pneumonia with thromboembolism of the pulmonary artery (PE) mainly of its small and medium branches. Characterized by a sudden, often paroxysmal appearance of shortness of breath and dry cough with sharp chest pain, and after 2-3 days - an increase in body temperature and the appearance of hemoptysis in the absence of severe intoxication. Physical data are scarce. Clinical and ECG signs acute overload of the right heart (P-pulmonale, inversion of the T wave in the right chest leads, right bundle branch block). An important role for diagnosis is played by the x-ray picture - bulging of the pulmonary cone and regional disappearance of the pulmonary pattern, and then the appearance of darkening of the lung tissue in the shape of a triangle, pear or rocket with the apex directed towards the root. A general blood test is nonspecific. The diagnosis is helped by identifying risk factors for pulmonary embolism: peripheral phlebothrombosis, prolonged immobilization, abdominal surgery, bone fractures, intravenous drug use, etc.

With peripheral and central lung cancer. The peripheral form of cancer is characterized by focal darkening of the lung tissue of a polydiagonal shape, and the central form is characterized by the development of atelectasis of the lung lobe due to obstruction of the lobar bronchus by a growing tumor. In areas of the lung tissue that are hypoventilated due to the neoplasm, secondary pneumonia often develops. In differential diagnosis, it is necessary to take into account the presence of risk factors for cancer in the patient (long-term smoking, family history, unfavorable environmental and professional conditions), the early appearance of a dry cough that worsens in a horizontal position, hemoptysis, chest pain, and weight loss. To clarify the diagnosis, fibrobronchoscopy with biopsy and computed tomography of the lungs are used.

With infiltrative tuberculosis lungs, which is characterized by a gradual onset, absence of severe fever and intoxication, paucity of physical data, lack of effect from conventional antibacterial therapy, and a certain social status of the patient. In the decay stage, hemoptysis appears, and sometimes pulmonary hemorrhage. At general analysis In the blood, neutrophilic leukocytosis with a shift to the left, lymphopenia, and monocytosis are determined. X-ray reveals large-focal inhomogeneous infiltration of the lung tissue, usually in the poorly ventilated upper lobes, with a “path” to the root (due to lymphangitis) and foci of screening in the parts of the lung adjacent to the infiltrate. Calcifications are often detected in the affected area or roots of the lungs. VK can be detected in sputum. Caseous specific pneumonia clinically resembles lobar pneumonia, but the sputum quickly becomes greenish-purulent, hectic fever, and night sweats are noted. Early signs of decay of the lung tissue appear with the release of VK in the sputum. Positive tuberculin tests help diagnose tuberculosis.

With exudative pleurisy. In the lower parts of the affected side of the chest, weakened vocal tremor, percussion dullness with an oblique upper border along the Demoiseau line and the absence of respiratory sounds are detected. The mediastinal organs shift to the healthy side. X-ray examination reveals a homogeneous darkening with a characteristic oblique upper border. The results of pleural puncture are of decisive importance in diagnosis.

Complications of pneumonia (pulmonary and extrapulmonary):

1. Acute respiratory failure.

2. Acute respiratory distress syndrome– non-cardiogenic pulmonary edema associated with increased permeability of the alveolo-capillary membrane under the influence of toxins of infectious microorganisms and endogenous inflammatory mediators.

3.Parapneumonic pleural effusion and much less often–empyema of the pleura.

4. Lung abscess.

5 . Bronchospastic syndrome.

6. Infectious-toxic shock with symptoms of acute vascular, left ventricular and renal failure, ulceration of the mucous membrane of the digestive tract and bleeding, the development of disseminated intravascular coagulation.

7. Acute cor pulmonale with total pneumonia.

8. Infectious-allergic myocarditis.

9. Intoxication psychoses.

10.Toxic hepatitis.

It is also possible to develop infective endocarditis, pericarditis, meningitis, and sepsis against the background of pneumonia.

Treatment for patients with pneumonia should be early, rational and comprehensive, affecting the infection, various parts of pathogenesis and individual manifestations of the disease (etiotropic, pathogenetic and symptomatic).

Treatment options include treatment regimen and a balanced diet rich in proteins and vitamins, drug therapy and physiotherapy.

Antibacterial therapy according to the Russian therapeutic protocol, it is prescribed taking into account the epidemiological characteristics of pneumonia. At the first stage of treatment, before the etiology of pneumonia is clarified, the choice of antibacterial drugs is based on an empirical approach, since a delay in antibacterial therapy for several hours leads to the development of complications and increased mortality.

I. For community-acquired pneumonia Taking into account the most likely etiology of the disease, the drugs of choice are aminopenicillins, including those “protected” by clavulonic acid, modern macrolides and cephalosporins of II–III generations. The method of administration and dose of drugs depend on the severity of pneumonia.

At lung pneumonia currents that do not require hospitalization are prescribed oral monotherapy amoxicillin 0.5–1.0 g 3 times a day or modern macrolides – clarithromycin 0.25 – 0.5 g 2 times a day, azithromycin 0.5–1 g 1 time per day for 3 days, roxithromycin 0.15 g 2 times a day. It should be noted that azithromycin ( sumamed) is the only oral antibiotic that is taken once a day for only three days for pneumonia. The average treatment time with other antibiotics is 7-10 days.

In outpatients with risk factors for the emergence of antibiotic-resistant strains of pneumococci, gram-negative bacteria and atypical microorganisms as pneumonia pathogens (age over 65 years, β-lactam therapy within the last three months, alcoholism, immunodeficiency states, therapy with systemic corticosteroids), combination oral therapy is prescribed. The following schemes are most effective:

1) amoxicillin/clavulonate ( amoxiclav, augmentin) 0.625 g 3 times a day in combination with macrolides or doxycycline ( vibramycin) 0.1 g 2 times a day;

2) second generation cephalosporin cefuroxime ( zinacef, ketocef) 0.5 g 2 times a day in combination with macrolides or doxycycline;

3) possible monotherapy with “respiratory” fluoroquinolones – levofloxacin (tavanik) 0.5 g 1 time per day or moxifloxacin (avelox) 0.4 g 1 time per day.

In some cases, if parenteral therapy is necessary, a third generation cephalosporin is prescribed ceftriaxone (lendacin), which has high activity against pneumococcus and a long half-life, due to which it is administered intramuscularly once a day, 1-2 g.

For pneumonia with atypical intracellular pathogens (mycoplasma, chlamydia, legionella), the drugs of choice are macrolides and doxycycline, which are used for 14-21 days.

Antibacterial therapy severe community-acquired pneumonia includes parenteral use of the following drugs:

1) III-IV generation cephalosporins ( cefotaxime 1–2 g 3 times a day or ceftriaxone 1–2g 1 time per day or cefepime 1 g 2 times a day) in combination with macrolides ( clarithromycin intravenously 0.5 g 1 time per day);

2) amoxicycline/clavunate 1.2 g intravenously 3 times a day in combination with macrolides;

3) monotherapy with modern fluoroquinolones – levofloxacin (tavanik) 0.5 g intravenously 1 time per day, moxifloxacin (avelox) 0.4 once a day) and less effective ciprofloxacin (tsiprolet, tsiprobay) 0.2 - 0.4 g intravenously 2 times a day.

The use of sulfamethoxazole/trimethoprim is not recommended ( biseptol) and other sulfonamide drugs due to the high resistance of pneumonia pathogens to it (up to 52%) and frequent allergic skin reactions. It is a mistake to prescribe aminoglycosides and lincomycin for community-acquired pneumonia, since they have very low activity against pneumococci, Haemophilus influenzae, intracellular pathogens and other most common etiological factors of community-acquired pneumonia. To cephalosporins of the first generation ( cefazolin), the spectrum of action of which differs little from benzylpenicillin, many strains of pneumonia pathogens are resistant, which determines the low activity of the drug.

Old antibacterial drugs - ampicillin and combination drug ampiox or oxapm(ampicillin + oxacillin) are slightly toxic and are sometimes used in clinical practice, but are inactive against many gram-positive and gram-negative microorganisms and inactive against intracellular pathogens. When using “protected” ampicillin ( ampicillin/sulbactam) the spectrum of action of the drug is expanding in relation to penicillin-resistant strains of microorganisms. ABOUT xacillin in the maximum permissible dose can be used in the treatment of staphylococcal pneumonia.

Against the background of adequate antibacterial therapy, after 2-3 days the body temperature decreases and intoxication decreases; if there is no effect, the drugs are replaced. The average duration of antibacterial treatment is 7-10 days.

The main criterion for discontinuing an antibiotic is regression of clinical symptoms with possible persistence of individual laboratory or radiological changes.

II. For nosocomial pneumonia Taking into account the most typical pathogens, parenteral antibacterial drugs with high activity against gram-negative microflora, staphylococcus and anaerobic bacteria are prescribed - amoxicillin / clavulanate, cephalosporins of III-IV generations, modern aminoglycosides, “respiratory” fluoroquinolones, carbapenems, metronidazole. Usually a combination of two, or less often three, antibacterial agents is used:

1) amoxicycline/clavunate ( amoxiclav 1.2 g intravenously 3 times a day) + aminoglycosides ( gentamicin intramuscularly 80 mg 3 times a day or amikacin 0.5 g 2 – 3 times a day);

2) cephalosporins of III-IV generations ( cefotaxime, ceftriaxone. klaforan, fortum)+ aminoglycosides;

3) “respiratory” fluoroquinolones + aminoglycosides;

4) “protected” antipseudomonas ureidopenicillins (azlocillin)+ aminoglycosides.

If there is no effect, monotherapy with carbapenems is indicated. Their combination with aminoglycosides is possible.

For possible anaerobic infection, a combination of cephalosporins with macrolides or metronidazole or “respiratory” fluoroquinolones with aminoglycosides is indicated.

In case of particularly severe Pseudomonas aeruginosa infection, the likelihood of which is high in pneumonia that has developed in patients on mechanical ventilation, antibiotics with high anti-Pseudomonas aeruginosa activity are prescribed - ceftazidime (fortum), azlocillin, carbapinems in combination with fluoroquinolones or aminoglycosides.

For staphylococcal pneumonia, treatment regimens include clindamycin and vancomycin.

It must be remembered that the wider the spectrum of action of the antibiotic, the more side effects he renders. The prescription of broad-spectrum antibacterial drugs and reserve drugs must be strictly justified.

III. Pneumonia due to immunodeficiency conditions are treated with broad-spectrum antibiotics, antimycotic and antiviral drugs against the background of immunoreplacement or immunomodulatory therapy. The antifungal drug of choice is fluconazole (mycocyst mycoflucan) 0.1–0.2 g per day

III. Aspiration pneumonia, usually associated with anaerobic and gram-negative microflora, require the administration of III-IV generation cephalosporins and aminoglycosides in combination with metronidazole ( metrogil 0.5 g intravenously drip 2-3 times a day) or clindamycin ( dalacin 0.3 - 0.6 g intravenously 2 times a day). Carbapenems are highly active ( tienam intravenously or intramuscularly 0.5 - 1 g every 8 hours).

Pathogenetic therapy. In order to restore bronchial patency, bronchodilators are used ( aminophylline, teopec, broncholitin) and mucolytics ( bromhexine, ambroxol, ambrobene, mucaltin, acetylcysteine). For bronchospastic syndrome, β 2 - adrenergic agonists are prescribed ( Berotek), M-anticholinergic atrovent, combination drug berodual.

With the development of infectious-toxic shock or severe obstructive syndrome, corticosteroids are used (60 - 90 mg prednisolone intravenously), refortan(HES 10%) and other plasma substitutes.

For the purpose of detoxification, saline solutions (up to 1–2 liters per day), 5% glucose solution (0.4–0.8 liters per day), rheopolyglucin (400 ml), 20% albumin (100 ml) are administered intravenously.

To improve microcirculation, heparin or low molecular weight heparins are prescribed ( fraxiparine, clexane), disaggregants ( chimes, trental, acetylsalicylic acid).

Weakened patients are given immunoreplacement therapy - donor immunoglobulin, normal intramuscularly 1.5 - 3.0 ml daily during the first 5-7 days of illness or immunovenin intravenously, for staphylococcal pneumonia - anti-staphylococcal immunoglobulin or hyperimmune plasma. In severe cases, possible intravenous infusions native or fresh frozen plasma (150–200 ml). for immunoglobulin 5.0 ml.

For indolent pneumonia, immunomodulators are used ( Thymalin, bronchomunal, immunal). Stimulates leukopoiesis during leukopenia methyluracil.

Symptomatic therapy. For a non-productive dry cough, antitussives are prescribed in the first days of illness. (codelac, libexin, broncholitin), if there is difficulty in sputum discharge, expectorants (infusion of thermopsis herb, marshmallow root, licorice).

For fever and pain syndrome antipyretics and analgesics are prescribed ( acetylsalicylic acid, paracetamol, diclofenac (ortofen, voltaren).

For elderly patients and for concomitant diseases of the cardiovascular system, injections of camphor or sulfocamphocaine are sometimes used, and for heart failure - cardiac glycosides (korglukon).

For hemoptysis, add to treatment ascorutin or dicynone. In case of respiratory failure, oxygen therapy is performed.

Physiotherapeutic treatment is prescribed when the temperature is less than 38 o, there is no hemoptysis, heart failure and severe intoxication. IN acute period pneumonia, to improve microcirculation and reduce inflammatory exudation, UHF therapy is prescribed in a low-thermal dose. The restoration of bronchial patency is facilitated by inhalation with alkalizing, mucolytic and bronchodilator agents or with an antibacterial drug - bioparox. Resorption of pneumonia is facilitated by inductothermy, microwave (deci- and centimeter-wave) therapy, electrophoresis with potassium iodide, calcium chloride, hydrocortisone, etc. Along with the effect on the source of inflammation, decimeter therapy of the adrenal glands is used to activate their glucocorticoid function. To hyposensitize the body, ultraviolet irradiation of the chest with separate fields is performed. Resolution of pneumonia is facilitated by chest massage and early physical therapy, primarily breathing exercises.

To accelerate the resorption of inflammatory changes, thermal procedures are also used: paraffin and ozokerite applications on the chest, irradiation with a Sollux lamp.

After recovery, patients with pneumonia move to the dispensary and polyclinic stage of rehabilitation, which should last at least 6 months. In case of residual clinical and radiological phenomena of the disease or persistent asthenia of the body, sanatorium-resort treatment is recommended both in local sanatoriums (Yumatovo, Green Grove) and in climatic resorts (Anapa, Gelendzhik, Kislovodsk, Southern Coast of Crimea, etc.).

Prevention. It consists of general sanitary and hygienic measures and personal preventive measures (hardening the body, physical education, sanitizing foci of infection, giving up bad habits, etc.). Prevention and timely treatment of acute respiratory diseases, including annual influenza vaccination, are of great importance.

Classification of pneumonia

Until recently, our country used the classification of acute pneumonia (AP) proposed by E.V. Gembitskiy et al. (1983), which is a modification of the classification developed by N.S. Molchanov (1962) and approved by the XV All-Union Congress of Therapists
In this classifications The following sections are distinguished.

Etiology:
1) bacterial (indicating the pathogen);
2) viral (indicating the pathogen);
3) ornithosis;
4) rickettsial;
5) mycoplasma;
6) fungal (indicating the species);
7) mixed;
8) allergic, infectious-allergic;
9) unknown etiology.

Pathogenesis:
1) primary;
2) secondary.

Clinical and morphological characteristics of pneumonia:
1) parenchymatous - large, focal;
2) interstitial.

Localization and extent:
1) one-sided;
2) bilateral (1 and 2 with lobar, focal;)

Heaviness:
1) extremely heavy;
2) heavy;
3) moderate severity;
4) light and abortive.

Flow:
1) sharp;
2) protracted.

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

The division of acute pneumonia into focal and lobar is valid only in relation to pneumococcal pneumonia.

The diagnosis of interstitial PN must be approached with great responsibility. This caution is due to the fact that interstitial processes in the lung accompany a large group of both pulmonary and extrapulmonary diseases, which can contribute to overdiagnosis interstitial pneumonia(Mon).

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

Due to the need to carry out early etiotropic therapy of pneumonia(Mon) and the impossibility in most cases of timely verification of its causative agent by the European respiratory society(1993) proposed a working group of pneumonia (Pn), based on the clinical-pathogenetic principle, taking into account the epidemic situation and risk factors:

I. Community acquired pneumonia.
II. Hospital acquired (hospital or nosocomial) pneumonia
III. Pneumonia in immunodeficiency states.
IV. Aspiration pneumonia.

Such a grouping clinical forms pneumonia(Mon) allows you to identify a certain spectrum of pathogens characteristic of each form of the disease. This makes it possible to make a more targeted empirical choice of antibiotics at the initial stage of treatment of pneumonia (Pn).

In recent years, in the previously existing understanding, it has been excluded from the working group atypical pneumonia(Mon) as pneumonia caused by atypical pathogens and having an atypical clinical picture of the disease. This term (atypical pneumonia) in Russia currently means “severe acute respiratory syndrome - SARS”.

Community-acquired pneumonia(Pn) - an acute disease that arose in a community setting, is one of the most common forms of pneumonia (Pn) and has the most characteristic clinical picture.
As before, pneumonia (Pn), which occurs in closed youth groups (schoolchildren, students, soldiers) and often has the character of an epidemic outbreak, occurs with atypical symptoms.

TO in-hospital (nosocomial) include those pneumonias (Pn) that developed within 48-72 hours or more after the patient was admitted to the hospital for another disease.

If a reduced immune status is detected, the meeting of AIDS patients in persons receiving immunosuppressive therapy in patients with systemic diseases is classified as pneumonia (Pn) in immunodeficiency states.

Aspiration pneumonia occurs most often in persons suffering from alcoholism and drug addiction, less often after anesthesia.

Pneumonia is one of the most common diseases. The incidence of pneumonia among adults in developed countries is 3-16‰ per year (more in elderly patients and children). At the same time, according to experts, in approximately 60% of cases the disease remains unrecognized. Hospitalization is required in 20 to 50% of patients. About 1% of patients of any profile admitted to hospitals develop nosocomial pneumonia. The mortality rate from pneumonia in Europe ranges from 7.1 (Hungary) to 55.4 (Great Britain) per 100 thousand population (among the elderly - 10 - 15 times higher).

The difficulties faced by clinicians in the diagnosis and treatment of pneumonia are due to the variety of pathogens and clinical variants of the disease, the emergence of many new drugs, the need to begin therapy with an empirical approach (before identifying the pathogen), the complexity of differential diagnosis and the relatively rapid change in the clinical picture of the disease over last years.

Definition

Pneumonia is a group of acute infectious (mainly bacterial) diseases, different in etiology, pathogenesis, and morphological characteristics, characterized by focal damage to the respiratory parts of the lungs with the obligatory presence of intra-alveolar exudation.

In the International Classification of Diseases, Injuries and Causes of Death, 10th revision (ICD-10, 1992), pneumonia is clearly distinguished from focal non-infectious inflammatory diseases of the lungs. Thus, diseases caused by physical and chemical factors (radiation pneumonitis, gasoline pneumonia), lung lesions of an allergic nature (eosinophilic pneumonia), vascular origin (infarction-pneumonia against the background of thromboembolism of the branches of the pulmonary artery) are coded, according to ICD-10, in the appropriate sections. Inflammatory processes in the lungs caused by obligate infectious agents (Q fever, measles, rubella, influenza, etc.) are also excluded from the “Pneumonia” heading. These diseases are considered as a complicated course of the corresponding nosological forms.

Classification

Traditionally, the classifications of domestic scientists (N.S. Molchanov, 1964; E.V. Gembitsky, O.V. Korovina, 1968; V.P. Silvestrov, 1982) divided pneumonia according to etiology, morphology, course, and complications. In summary, these classifications are as follows:

· By etiology: bacterial; viral; mycoplasma; others.

· According to clinical and morphological characteristics: parenchymal: lobar and focal; interstitial; mixed.

· Downstream: acute; protracted.

· According to the presence of complications: uncomplicated; complicated: pulmonary complications (abscess formation, destruction of lung tissue, pleurisy, pleural empyema, etc.), extrapulmonary complications (infectious toxic shock, collapse, nephropathy, glomerulonephritis, myocarditis, etc.).

Currently, it is recommended to use a classification of pulmonary inflammation that takes into account the conditions in which the disease developed, some features of infection of the lung tissue, as well as the state of the patient’s immunological reactivity (clinical and epidemiological principle). In accordance with this classification, the following types of pneumonia are distinguished:

· Community-acquired pneumonia (CP). Synonyms: home, outpatient, outpatient.

· Hospital-acquired pneumonia (HP). Synonyms: nosocomial, intrahospital, in-hospital. It is diagnosed if clinical and radiological signs of pulmonary inflammation appear after 48 hours of the patient’s hospital stay.

· Aspiration pneumonia.

· Pneumonia in persons with severe immune defects (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

Etiology

The main causative agents of CAP are Str. pneumoniae (30—50 %), Mycoplasma pneumoniae (2—30 %), Chlamydophila pneumoniae (2—20 %), Haemophilus influenzae(2-18%). A more modest role in the etiology of CAP is played by Moraxella catarrhalis (1—10 %), Staph. aureus (2—10 %), Legionella pneumophila(2-10%), gram-negative microorganisms ( Klebsiella pneumoniae, E. coli, Pseudomonas aeruginosa- up to 5%), anaerobes.

The role of viruses can be considered as a factor contributing to bacterial superinfection, but the possibility of “pure” viral pneumonia cannot be ruled out.

The dominant causative agents of nosocomial pneumonia are gram-negative microorganisms ( Ps. aeruginosa, E. coli, K. pneumoniae, Proteus mirabilis, Acinetobacter spp..), and Staph. aureus and anaerobes. A special feature of pathogens is their high resistance to many antibacterial drugs.

Aspiration pneumonia is almost always caused by anaerobic and/or gram-negative microflora. In the etiology of pneumonia in people with immunodeficiencies, in addition to the standard hospital flora (Gram-negative bacteria and staphylococci), the role of relatively low-pathogenic microorganisms - streptococci group Viridans, mushrooms ( Candida spp., Aspergillus spp.) and etc.

It is customary to identify a number of clinical situations in which pneumonia is more often caused by certain agents. In young people who are not burdened concomitant diseases, pneumonia is often caused by pneumococci, mycoplasma, and chlamydia. In people over 60 years of age, with pneumonia, pneumococci and Haemophilus influenzae are usually isolated from sputum. In case of previous pulmonary-cardiac diseases, especially in those suffering from chronic obstructive pulmonary disease, the probable pathogens are pneumococci, Haemophilus influenzae, and moraxella. The development of pneumonia in the context of a family outbreak of acute respiratory viral infection is alarming regarding not only the viral nature of the disease, but also such agents as mycoplasma and chlamydia. When contacting birds, there is a high probability of chlamydial infection. The presence of upper lobe pneumonia requires clarification of possible contacts with tuberculosis patients and the exclusion of this specific infection. In aspiration syndrome, the cause of pneumonia is often anaerobes. Alcoholics often develop pneumonia caused by Klebsiella and other gram-negative bacilli. Cases of pulmonary tuberculosis, staphylococcal and anaerobic pneumonia have been reported among drug addicts. HIV-infected people are characterized by Pneumocystis pneumonia and mycobacteriosis. In long-term immobilized patients (stroke, hip fractures), pneumonia is often caused by streptococci, staphylococci, and gram-negative bacilli.

Seasonal fluctuations in incidence have been identified for some pneumonia pathogens. Thus, most cases of pneumonia caused by Legionella occur in the summer and autumn months, and infection caused by M. pneumoniae, is subject to cyclicity with a period of 3 to 5 years.

Pathogenesis

There are four main pathogenetic mechanisms for the development of pneumonia:

—aspiration of oropharyngeal secretions;

—inhalation of aerosol containing microorganisms;

—hematogenous spread of microorganisms from an extrapulmonary source of infection (for example, in infectious endocarditis, septic thrombophlebitis);

—direct spread of infection from neighboring affected organs (for example, with a liver abscess) or as a result of infection from penetrating wounds of the chest.

The main route of infection and the most important pathogenetic mechanism for the development of pneumonia, as has been established by recent studies, is aspiration of the contents of the oropharynx. An equally common mechanism for the development of pneumonia is the activation of the patient’s own microflora of the lower respiratory tract, which can occur in weakened individuals, against the background of decreased immunity, under the influence of factors that damage the epithelium of the respiratory tract, as well as in dysbacteriosis (including iatrogenic).

Risk factors for developing pneumonia

The most important risk factors for the development of CAP include smoking, immune disorders (GCS therapy, etc.), a history of pneumonia and some occupational factors. Patients receiving intravenous injections and injection drug users are especially at risk of developing pneumonia. Each risk factor corresponds to certain potentially significant pathogens.

Risk factors for nosocomial pneumonia are age over 60 years; severity of condition as assessed on the APACHE II scale > 16; traumatic brain injury; coma; bronchoscopy; nasogastric tube; endotracheal intubation; surgery on the organs of the upper abdominal cavity or chest; hypoalbuminemia; neuromuscular disorders; the presence of chronic obstructive pulmonary diseases (COPD) and respiratory failure; prescribing intravenous drugs; the patient has a monitor intracranial pressure; multiple organ failure; aspiration of gastric contents in large volumes; previous use of antibiotics; appointment N 2-histamine blockers; Stomach pH > 4.0; development of the disease in the autumn-winter period. For patients on mechanical ventilation, additional risk factors include reintubation; mechanical ventilation lasting more than 2 days; tracheostomy; low pressure in the endotracheal tube cuff; passive head position; failures with aspiration from the subglottic space.

Clinical picture

Pneumonia is characterized by a relatively acute onset of the disease, fever, intoxication, cough with purulent or mucopurulent sputum (brown-red, “rusty” in color, which is more often observed with lobar inflammation). There may be pain in the chest associated with coughing and breathing.

In the elderly, as well as in patients with acute cerebrovascular accident, only impaired consciousness or deterioration in general well-being may be observed.

Inspection, palpation, percussion and auscultation data for pneumonia depend on the size of the affected area of ​​the lungs, its location and the phase of the inflammatory process. Medical workers are required to know not only the symptoms of a detailed clinical picture, but also the early signs of the disease. A cyclic course is more typical for lobar pneumonia. In the first days of the disease, the percussion sound over the affected lobe has a tympanic tone, and breathing is weakened. Subsequently, the percussion tone quickly becomes dull, and bronchial breathing characteristic of lobar inflammation appears. During the same period, crepitation (crepitatio index) can be heard. Voice tremors increased. The bronchophony phenomenon is positive. In the resolution phase, intense dullness is gradually replaced by a pulmonary sound, breathing during auscultation changes its character from bronchial to hard. Final crepitation (crepitatio redux) appears, subsequently turning into sonorous moist fine- and medium-bubble rales. Herpetic rashes are observed on the lips and wings of the nose, and a lag in breathing on one side of the chest is characteristic.

Focal pneumonia is characterized by less severe intoxication. Physical symptoms are often scanty. Dullness of pulmonary sound and increased vocal tremors are not determined in all cases. During auscultation, in addition to wet ones, scattered dry (buzzing and whistling) wheezing can be heard.

Scanty symptoms are typical for hospital, postoperative and traumatic pneumonia, for pulmonary inflammation in persons with damage to the central nervous system. The main clinical manifestations of postoperative pneumonia are often fever unexplained by a local process in the postoperative wound, general intoxication, shortness of breath, and tachycardia. Diagnosis of nosocomial pneumonia is difficult due to the impossibility of an adequate physical examination of the patient due to his low mobility, impaired consciousness or inability to deep breathe.

It is customary to distinguish between typical and atypical pneumonias, which require different antibacterial therapy. Classic typical pneumonia occurs in the form of an acute focal disease characterized by a sudden onset, high fever, chills, productive cough, chest pain, auscultatory signs of focal damage to the lung tissue, neutrophilic leukocytosis, the presence of an x-ray focus and darkening and a positive cytobacteriological analysis of sputum. The most common pathogens are extracellular microorganisms - Str. pneumoniae or (less often) H. influenzae, Staph. aureus, anaerobes. Atypical pneumonia is characterized by an increasing onset, fever not accompanied by chills, nonproductive cough, headaches, myalgia, diffuse crepitant wheezing, slight leukocytosis, the presence of interstitial infiltrates, negative bacteriological analysis of sputum; An upper respiratory tract infection is often observed. The etiological agents of atypical pneumonia are intracellular pathogens ( M. pneumoniae, C. pneumoniae etc.) or viruses.

However, pneumonia caused by viruses or intracellular pathogens can resemble typical pneumonia in clinical picture, and vice versa, diseases associated with extracellular agents can imitate atypical pneumonia. Thus, based only on the clinical picture, it is impossible to reliably identify the type of pathogen, and the division of pneumonia into typical and atypical has no special clinical meaning. Moreover, a certain confusion in terminology was caused by the outbreak of severe acute respiratory distress syndrome (SARS) recorded in 2003, which received the name “atypical pneumonia” in the media and a number of medical publications.

Diagnostic methods

All patients with clinical and physical symptoms of pneumonia are advised to undergo X-ray of the lungs in frontal and lateral projections. Radiologically detectable infiltration of lung tissue is the main diagnostic criterion for pneumonia.

Radiography makes it possible to assess the severity of pneumonia (by the volume of damage to the lung tissue, the presence of complications), tentatively suggest the etiology of the disease, carry out differential diagnosis, determine the prognosis and effectiveness of treatment. X-ray examination of the lungs is also indicated for long-lasting fever (more than 5 days) in patients with acute respiratory viral infection.

At the same time, the diagnosis of pneumonia cannot be considered inappropriate if for one reason or another there is no X-ray confirmation of it, i.e. The diagnosis of pneumonia can be established only on the basis of the clinical picture of the disease and physical examination data.

Despite the high diagnostic value of the method, one should remember the existence of X-ray negative pneumonia. The latter may occur in cases where radiography was performed in the first hours after the onset of the disease, when clinical signs of pneumonia are already being determined, and radiologically significant infiltration in the lungs has not yet formed. In this regard, and in order to avoid additional radiation exposure to the patient, it is not advisable to perform X-rays of the lungs in the first 12 to 24 hours of the disease. X-ray changes may not be detected or may not be expressed in viral interstitial pneumonia. In such cases, computed tomography may be useful to clarify the diagnosis. Compared to radiography, it has 2 times higher sensitivity in diagnosing pneumonia and is indispensable in differential diagnosis with tumors and a number of other diseases.

Each pneumonia requires an etiological diagnosis. Clinical and epidemiological data have some, albeit limited, value in solving this problem. The leading role belongs to microbiological methods. Biological material for research can be sputum, blood, pleural fluid, bronchoalveolar lavage fluid, punctate of infiltrate or abscess of the lungs, tissue (biopsy) of the lung. The most accessible material is sputum, but due to the fact that it is easily subject to contamination by the microflora of the upper respiratory tract, the interpretation of the results of microbiological research is not always unambiguous. The following rules for collecting sputum must be observed: before starting antibacterial therapy after rinsing the pharynx and mouth boiled water or solution baking soda Freely coughed up sputum (preferably the first portion in the morning, before meals) is collected in a sterile container with a tight-fitting lid. To improve the discharge of sputum, the patient is given expectorants on an empty stomach and inhaled with ultrasound of a saline solution. The delivery time for sputum to the laboratory should not exceed 1.5 - 2 hours from the moment it is received (storage in the refrigerator for no more than 6 hours is allowed).

Gram staining of a smear before microbiological examination is considered quite informative and justified. It is advisable to carry it out in the express laboratory of the emergency department. Detection of a significant number of gram-positive or gram-negative bacteria in a smear can serve as a guide for empirical therapy.

It should be noted that the interpretation of the results of bacterioscopy and sputum culture should be carried out taking into account clinical data. The distinction between a “witness microbe” and a “pathogen microbe” in some cases causes considerable difficulties.

Although it is important to obtain laboratory material (sputum, blood) before prescribing antibiotics, microbiological testing should not cause a delay in starting antibiotic therapy. This especially applies to patients with severe disease.

Carrying out invasive procedures to obtain diagnostic material (needle expiration, bronchoalveolar lavage - BAL, biopsy, etc.) is not indicated for most patients with CAP, but may be justified in cases of severe disease and ineffective therapy.

General clinical and biochemical blood tests are not decisive for verifying the diagnosis and establishing the etiology of pneumonia. However, leukocytosis is more than (10 - 12)x10 9/L indicates high probability bacterial infection, and leukopenia below 3x109/l or leukocytosis above 25x109/l are unfavorable prognostic signs. Deviations in functional tests of the liver, kidneys, and glycemic levels may indicate damage to a number of organs/systems, which has a certain clinical and prognostic significance.

Study of the gas composition of arterial (not capillary!) blood indicated for patients with symptoms of respiratory failure caused by widespread pneumonic infiltration, massive pleural effusion, and the development of pneumonia against the background of chronic obstructive pulmonary disease. These tests help determine the need for hospitalization of the patient and indications for prescribing oxygen inhalations.

Serological diagnostics, developed for legionella, mycoplasma, chlamydial and pneumococcal infections, is retrospective in nature and is not considered among the mandatory research methods.

A promising method for diagnosing pathogens such as C.pneumoniae And M. pneumoniae, is polymerase chain reaction(PCR). However, the location of PCR has not yet been determined, so the method cannot be recommended for implementation in widespread clinical practice.

Diagnosis criteria

Diagnosis of pneumonia in most cases does not cause difficulties if you follow certain rules. There is a concept of a “gold standard” when diagnosing pneumonia; it consists of the following five signs (A.G. Chuchalin, 1997):

1)acute onset of the disease, accompanied by fever and increased temperature;

2)the appearance of cough and purulent sputum;

3)shortening of the lung sound, the appearance of auscultatory phenomena of pneumonia over the affected area of ​​the lung;

4)leukocytosis with a neutrophil shift or, less commonly, leukopenia;

5)an infiltrate in the lungs detected using an x-ray method, which was not previously detected.

In recent years, many foreign clinical guidelines Depending on the degree of reliability of the diagnosis of pneumonia, it is proposed to use the terms “definite”, “uncertain”, “unlikely”.

The diagnosis of pneumonia is considered certain if the patient has radiologically confirmed focal infiltration of the lung tissue and at least two clinical signs of the following: a) acute fever at the onset of the disease (t > 38.0 °C); b) cough with sputum; c) physical signs (focus of crepitus and/or fine rales, harsh bronchial breathing, shortening of percussion sound); d) leukocytosis (> 10x10 9/l) and/or band shift (> 10%).

The absence or unavailability of radiological confirmation of focal infiltration in the lungs makes the diagnosis of pneumonia imprecise/uncertain. In this case, the diagnosis of the disease is based on taking into account the epidemiological history, complaints and relevant local symptoms.

If, when examining a patient with fever, complaints of cough, shortness of breath, sputum production and/or chest pain, an X-ray examination of the chest organs is not available and there are no corresponding local symptoms (shortening/dullness of percussion sound over the affected area of ​​the lung, locally auscultated bronchial breathing, focus of sonorous fine bubbling rales or inspiratory crepitus, increased bronchophony and vocal tremor), then the assumption of pneumonia becomes unlikely.

In the same way etiological In recent years, the diagnosis of pneumonia has been divided into definite, probable and possible. About certain diagnosis is indicated by discharge Staph. aureus,Str. pneumoniae, N. influenzae, M. catarrhalis, enterobacteria, Ps. aeruginosa from blood or pleural fluid, i.e. from those environments in which contamination by microorganisms is impossible. Other cases where the diagnosis seems definite are a fourfold increase in the antibody titer to L. pneumophila (>1:128), M. pneumoniae (>1:64), C. pneumoniae; detection of a significant influenza virus titer (>1:32); allocation Legionella spp.. from respiratory secretions and positive antigen test results L. pneumophila in urine (enzyme immunoassay method). ABOUT probable diagnosis can be made by isolating Staph. aureus, Str. pneumoniae, N. influenzae, M. catarrhalis, enterobacteria or Ps.aeruginosa from purulent sputum containing moderate or significant numbers of neutrophils on Gram stain. In this case, a moderate or significant number of pathogens are detected bacterioscopically. Finally, about possible diagnosis is usually made when a potential causative agent of pneumonia is isolated from purulent sputum (but not Legionella spp..), and bacterioscopy of a Gram-stained sputum smear revealed a moderate number of morphologically similar microorganisms. Single determination of high titer antibodies to L. pneumophila (>1:1024), M. pneumoniae(>1:64) and C. pneumoniae(IgG>1:512 or IgM>1:16) is also a criterion for a possible diagnosis.

For nosocomial pneumonia, diagnostic criteria have been developed, presented in Table. 1.

Reliable diagnosis	X-ray signs of an abscess Obtaining a culture of the pathogen during a needle biopsy of the lung · Histological confirmation of the diagnosis based on open biopsy of lung tissue (including autopsy) in combination with positive results of microbiological examination of lung tissue (>104 CFU in 1 g of lung tissue)
Probable diagnosis	· Determination of the pathogen in sputum, BAL (obtained with minimal risk of contamination of the respiratory tract by microorganisms from the outside, i.e., as a rule, sampling of material with protected brushes) · Positive results in the study of blood cultures in two consecutive samples obtained at an interval of 48 hours and after 48 hours from the onset of respiratory symptoms Isolation of pathogen culture in pleural fluid · The presence of a histological picture of pneumonia in open lung biopsy materials or autopsy materials in combination with negative results of microbiological examination of lung tissue (<104 КОЕ в 1 г легочной ткани)
Reliable exclusion of the diagnosis	· Autopsy materials carried out later than 3 days from the moment of making the presumptive diagnosis of pneumonia do not reveal a picture of inflammation in the lungs Identification of alternative etiologies in combination with negative microbiological findings · Cytological detection of a pathological process in lung tissue other than pneumonia, combined with negative microbiological data
Possible exclusion of the diagnosis	· The patient’s recovery occurred in the absence of antibiotic therapy, and there is an alternative diagnostic concept · There is an alternative diagnosis that explains the persistence of fever and infiltrative changes in the lungs

Table 1. Criteria for the diagnosis of nosocomial pneumonia

Differential diagnosis

In terms of differential diagnosis, it should be taken into account that under the mask of pneumonia that is difficult to treat, oncological (bronchogenic or bronchoalveolar cancer, lymphoma), immunological (vasculitis, alveolitis, eosinophilic pneumonia, alveolar proteinosis) diseases, as well as cardiovascular pathology - congestive heart failure may be hidden. and pulmonary embolism.

X-ray tomography and CT of the lungs are used as additional objective criteria to clarify the diagnosis; cultures of blood, sputum, urine; culture and cytological examination of pleural fluid; serological studies (determination of antibodies to mycoplasma, chlamydia, legionella, cytomegalovirus) in atypical cases and immunodeficiencies, in the elderly, alcoholics, drug addicts; biochemical blood test for severe pneumonia, concomitant diseases, renal failure, diabetes, liver failure. Cytological examination of sputum is carried out in smokers of older age groups with a family history of cancer. Bronchoscopy is indicated if there is no effect of treatment, if lung cancer, a foreign body, or aspiration are suspected. In the differential diagnosis of sepsis and endocarditis, an ultrasound examination of the heart and abdominal organs is performed. Isotope scanning of the lungs and angiopulmonography are indicated to exclude pulmonary embolism.

Severity assessment and prognosis

According to the severity of pneumonia, it is advisable to divide it into mild, moderate and severe. The purpose of such a group is to determine the prognosis of the disease, choose rational treatment tactics, the scope of rehabilitation measures, and resolve expert issues. The severity of the condition of patients with pneumonia is assessed by the severity of general intoxication, the presence and degree of respiratory failure, complications of the cardiovascular system (shock, collapse), local complications (pleurisy, destruction of lung tissue, pneumothorax, etc.), infectious-allergic complications from other organs and systems (glomerulonephritis, myocarditis, endocarditis, etc.).

Heavy pneumonia is characterized by severe intoxication, accompanied by hyperthermia, adynamia, acute vascular and cardiovascular failure (collapse, shock, pre-edema and pulmonary edema), and severe respiratory failure. It is possible that destructive processes and infectious and allergic complications from various organs and systems may develop in the lungs.

Pneumonia moderate severity characterized by febrile fever, headache, weakness and other manifestations of moderate intoxication. Respiratory failure is not expressed and is detected during instrumental examination and physical activity.

Lightweight pneumonia is characterized by the absence of pronounced symptoms of intoxication and minor deviations from the cardiovascular system. Respiratory failure is usually absent.

An algorithm for objectifying the severity of a patient’s condition with CAP, developed in 1997 by M. Fine et al., has become widespread throughout the world, according to which the severity of the patient’s condition is divided into five classes. This scale for assessing patient severity and prognosis is recommended by a number of reputable clinical practice guidelines. A study using the M.Fine scale showed that the mortality rate of patients classified as risk classes I-II is 0.1-0.6%, with risk class IV - 8.2%. The maximum mortality rate (29.2%) was observed in risk class V. The outcome score, risk classes and algorithm for assessing the prognosis of the course of CAP are presented in Table. 2, 3 and in the figure.

Characteristics of the patient	Score in points
Demographic factors
Age
	Age (years)
	Age (years)-10
Residents of a nursing home
Accompanying illnesses
Malignant neoplasms
Liver diseases
Congestive heart failure
Cerebrovascular diseases
Kidney pathology
Physical signs
Impaired consciousness
Tachypnea > 30 min
Hypotension (BP syst.)<90 мм рт. ст.
Hypothermia (< 35o C) or hyperthermia ( > 40 o C)
Tachycardia > 125/min
Laboratory signs
Blood urea nitrogen >10.7 mmol/l
Na+<130 мэкв/л
Glucose > 13.9 mmol/l
Hematocrit<30%
RaO 2<60 мм рт. ст.
Pleural effusion

Table 2. Outcome assessment of community-acquired pneumonia (M. Fine et al., 1997)

Table 3. Risk classes for community-acquired pneumonia (M. Fine et al., 1997)

In Belarus, a fairly simple and accessible gradation of pneumonia by severity, proposed by N.F., is increasingly being used. Soroka and M.A. Savchenko in 2001 (Table 4).

Indicators		Lightweight	Average	Heavy
Fever
	Number of breaths per minute
	Heart rate per minute
	Systolic blood pressure, mm Hg.
	Leukocytes, x10 9 /l			>20 or<4
General blood analysis	Band neutrophils, %
	Toxogenic granularity of neutrophils
X-ray of the lungs (volume of lesions)		1-2 segments	> 2 segments or polysegmental	Polysegmental, lobar, bilateral (with lesion volume > 2 segments)

Table 4. Degrees of severity of pneumonia (N.F. Soroka, M.A. Savchenko, 2001)

Prolonged (slowly resolving/not resolving) pneumonia

In most patients with pneumonia, by the end of the 3rd - 5th day from the start of potentially effective antibacterial therapy, body temperature normalizes and other clinical manifestations of the disease regress. In this case, radiological recovery, as a rule, lags behind the clinical one. In those cases when, against the background of an improvement in the clinical picture, by the end of the 4th week from the onset of the disease it is not possible to achieve complete radiological resolution of focal infiltrative changes in the lungs, we should speak of non-resolving (slowly resolving) or prolonged pneumonia.

In such a clinical situation, it is necessary first of all to establish possible risk factors for the protracted course of the disease: a) age over 55 years; b) chronic alcoholism; c) the presence of concomitant disabling diseases of internal organs (COPD, congestive heart failure, renal failure, malignant neoplasms, diabetes mellitus, etc.); d) severe pneumonia; e) multilobar prevalence of pneumonic infiltration; f) virulent pathogens ( L. pneumophila, Staph. aureus, gram-negative enterobacteria); g) smoking; h) clinical ineffectiveness of the therapy (persistent leukocytosis and fever); i) secondary bacteremia.

Among the possible reasons for the slow resolution of pneumonia may be antibiotic resistance acquired by the causative agent of the disease. In this regard, known risk factors for resistance of leading pathogens should be taken into account. Of exceptional importance is the differential diagnosis of prolonged pneumonia with focal infiltrative pulmonary tuberculosis. In addition, it is necessary to keep in mind the wide range non-communicable diseases, sometimes very reminiscent of pneumonia (Table 5).

Neoplasms — Primary lung cancer (especially the so-called pneumonic form of bronchiolo-alveolar cancer) — Endobronchial metastases — Bronchial adenoma — Lymphoma Pulmonary embolism and pulmonary infarction Immunopathological diseases — Systemic vasculitis — Lupus pneumonitis — Allergic bronchopulmonary aspergillosis — Bronchiolitis obliterans with organizing pneumonia — Idiopathic pulmonary fibrosis — Eosinophilic pneumonia — Bronchocentric granulomatosis Other diseases/pathological conditions — Congestive heart failure — Drug-induced (toxic) pneumopathy — Foreign body aspiration — Sarcoidosis — Pulmonary alveolar proteinosis — Lipoid pneumonia — Rounded atelectasis

Table 5. Non-infectious causes focal infiltrative changes in the lungs

Formulation of diagnosis

When formulating a diagnosis, the clinical and morphological variant of pneumonia (lobar, focal, interstitial), the etiology of the disease (if it can be established), the localization of the inflammatory process (segments, lobe, side of the lesion), severity, complications are indicated. Considering that pneumonia, in principle and in accordance with the above definition, is an acute infectious process, and the diagnosis “chronic pneumonia” has practically fallen out of use, it is currently considered inappropriate to use the combination “acute pneumonia”; it is better to replace it with the term “pneumonia”. When formulating the diagnosis of pneumonia, the terms “community-acquired,” “household,” and “acquired” may also be omitted.

Examples of clinical diagnosis formulation:

Lobar pneumococcal pneumonia in C 8, C9, C10 of the lower lobe of the right lung with a severe protracted course, complicated by infectious-toxic shock, right-sided parapneumonic exudative pleurisy.

· Focal pneumonia in C 4, C5 of the upper lobe of the left lung of moderate severity.

Treatment

In cases of mild uncomplicated pneumonia, patients can be treated on an outpatient basis or in a day hospital of a medical institution.

Indications for hospitalization:

—age over 60 years;

—respiratory rate - 30 or more per minute;

—disturbance of consciousness;

—severe concomitant diseases (COPD, diabetes mellitus, chronic renal failure, alcoholism, drug addiction, nutritional dystrophy, hepatitis, liver cirrhosis, osteomyelitis, heart failure, history of splenectomy, cerebrovascular diseases, etc.);

—moderate (in most cases) and severe pneumonia;

—lobar and polysegmental pneumonia;

—rapid progression of the process (increase in infiltration in 2 days by more than 50%);

—systolic blood pressure< 90 мм рт.ст., диастолическое АД < 60 мм рт.ст., температура тела < 35°С или >40°C, blood hemoglobin less than 90 g/l;

—leukopenia (leukocyte count less than 4x109/l) or leukocytosis (leukocyte count more than 25x109/l);

—teenagers, homeless people, lonely elderly people and those living in a hostel;

—in case of difficulties in differential diagnosis;

—if outpatient treatment is ineffective for 3 - 5 days;

—inability to provide adequate care and treatment at home;

—preference of the patient or his family.

Patients should be hospitalized in intensive care and resuscitation units if the following signs are present:

—disturbance of consciousness;

—RR more than 30 per minute;

—the need for artificial ventilation;

— state of shock(systolic blood pressure< 90 мм рт. ст. и/или диастолическое АД < 60 мм рт. ст.);

- diuresis< 20 мл/ч;

—PaO 2 of arterial blood is less than 50 - 60 mm Hg. Art., PaCO2 > 50 mm Hg;

—need for vasopressors > 4 hours;

—reliable spread of pulmonary tissue infiltration within 48 hours from the moment of admission.

The basis of treatment for pneumonia is the prescription of antibacterial agents. Etiotropic therapy must satisfy following conditions(E.N. Gaidar, 2000):

1.Empirical approach to choosing the optimal antibacterial agent.

2.Identification of two types of pneumonia according to the conditions of occurrence (community-acquired and hospital-acquired) and taking into account additional factors (age, severity of the disease, concomitant pathology).

3.Before prescribing antibacterial therapy in inpatients, it is necessary to collect sputum (and preferably blood) for bacterial testing.

4.Treatment of patients with pneumonia in a hospital should be carried out with bacteriological control during and after the end of antibacterial therapy.

5.Upon receipt of the results of bacteriological examination, it is possible to adjust treatment for more targeted antibacterial therapy, taking into account the sensitivity of the isolated microorganisms.

6.The availability of modern highly effective broad-spectrum antibacterial agents makes it possible to carry out monotherapy for pneumonia, with the exception of particularly severe forms of the disease (resuscitation, immunodeficiency, bacteremia, the presence of multidrug-resistant strains of microorganisms or infection caused by Pseudomonas aeruginosa).

7.Aminoglycoside antibiotics should not be used to treat community-acquired pneumonia; in the case of hospital-acquired pneumonia, aminoglycosides can only be prescribed in combination with other antibacterial agents.

8.If there are two alternative drugs with the same antibacterial activity and tolerability, preference should be given to the drug with a lower cost, and if this parameter is equal, with a more convenient dosage regimen.

9.An initial assessment of the effectiveness of antibacterial therapy for pneumonia should be carried out 48 - 72 hours from the start of treatment when fever decreases and intoxication decreases. If there is no clinical effect within this period, it is necessary to replace the antibacterial drug.

10. The optimal duration of antibacterial therapy is in most cases 5 - 7 days for community-acquired pneumonia (with the exception of atypical and complex pneumonia) and 7 - 10 days for hospital-acquired pneumonia. Long duration of antibiotic therapy increases the risk of superinfection and significantly increases the cost of treatment.

11. Reducing the cost of treating patients with pneumonia in a hospital can be achieved with sequential (parenteral - oral) use of antibacterial agents.

In the structure of pneumonia, the leading place is occupied by community-acquired pneumonia, acquired outside the medical institution.

For rational empirical antibiotic therapy, CAPs are divided into three subgroups:

1)Non-severe pneumonia in patients under 60 years of age without concomitant diseases. Drugs of choice: penicillin, aminopenicillins, macrolides (ampicillin, amoxicillin, erythromycin, azithromycin, clarithromycin). Doxycycline can be used as a backup antibiotic.

2)Pneumonia in patients over 60 years of age and/or with concomitant diseases (diabetes mellitus, heart failure, chronic liver disease, chronic renal failure, alcoholism, low nutrition, mental illness, condition after splenectomy, suspected aspiration, hospitalization within the last year for pneumonia) . It is recommended to start treatment with “protected” oral aminopenicillins (ampicillin/sulbactam, amoxicillin/clavulanate) or second generation cephalosporins also in oral form (cefuroxime). Considering the likelihood of chlamydial and legionella etiology of CAP in this group, combining these β-lactams with macrolide antibiotics is justified.

3)Clinically severe pneumonia regardless of age. Drugs of choice: third generation parenteral cephalosporins (cefotaxime, ceftriaxone) in combination with macrolides for parenteral administration (erythromycin, spiramycin).

The use of gentamicin as monotherapy in patients with pneumonia is inappropriate due to the inactivity of aminoglycoside antibiotics against pneumococci.

Empirical antibiotic therapy nosocomial pneumonia should be carried out taking into account local data on the etiological structure of hospital infections and the frequency of antibiotic resistance among their pathogens.

The most common form of hospital-acquired pulmonary inflammation is ventilator-associated pneumonia (VAP), which occurs in patients receiving mechanical ventilation.

In order to conduct rational antibacterial therapy, hospital-acquired pneumonia is divided into two subgroups:

1) Pneumonia that develops in patients in general departments without risk factors, as well as early VAP (with a duration of mechanical ventilation of less than 5 - 7 days), which developed in intensive care and resuscitation departments. The drugs of choice for empirical therapy are third-generation parenteral cephalosporins (cefotaxime or ceftriaxone) in maximum doses. As an alternative, fluoroquinolones (ciprofloxacin, ofloxacin, etc.) can be used. In the case of a high probability of pseudomonas etiology of HP, it is advisable to prescribe antipseudomonal cephalosporins of III-IV generations (ceftazidime, cefoperazone, cefpirome, cefepime) in combination with aminoglycosides (amikacin, tobramycin, netilmicin).

2) Late VAP in intensive care units and pneumonia in patients in general departments in the presence of risk factors (previous antibiotic therapy or antibiotic prophylaxis). In this subgroup, the likelihood of the etiological role of pseudomonas and multidrug-resistant strains of microorganisms is especially high. The following options for empirical therapy can be used: intravenous carbapenems (imipenem, meropenem), antipseudomonal cephalosporins of III-IV generations (ceftazidime, cefepime) + aminoglycosides, antipseudomonal penicillins (azlocillin, mezlocillin, piperacillin) + aminoglycosides, aztreonam + aminoglycosides, qi profloxacin (as monotherapy or in combination with aminoglycosides); if Legionella infection is suspected, macrolides (erythromycin, azithromycin, clarithromycin, etc.); with a high probability or confirmation of the etiological role of methicillin-resistant staphylococci and enterococci - glycopeptides (vancomycin); if previous therapy, including glycopeptides, is ineffective, antifungal drugs (amphotericin B, fluconazole) are used.

Aspiration pneumonia can be either community-acquired or hospital-acquired. In their treatment, protected β-lactams, carbapenems, cephamycins (cefoxitin, cefotetan, cefmetazole) in combination with metronidazole, lincosamides are used.

Pneumonia in immunocompromised individuals are more often hospital-acquired. Empirical antibiotic therapy is carried out according to treatment regimens for HP in the presence of risk factors (subgroup 2).

For reasons of phthisiatric alertness and in order to prevent the resistance of Mycobacterium tuberculosis to antibiotics in the treatment of pneumonia, it is irrational to use drugs with anti-tuberculosis activity (streptomycin, kanamycin, rifampicin).

Drugs of choice for treatment pneumonia of known etiology are presented in table. 6. However, the list of drugs with proven clinical effectiveness in the treatment of pneumonia of known etiology is not limited to those given in this table. The selection of drugs for inclusion in the table as a choice is based on expert assessment of published clinical trial results.

Etiological agents		Drugs
Str. pneumoniae	Sensitive Penicillin resistant	Benzylpenicillin, amoxicillin, parenteral cephalosporins of the third generation, cephalosporins of the fourth generation, carbapenems, vancomycin
H. influenzae	Sensitive Producing β-lactamases	Aminopenicillins
M. catarrhalis	Sensitive Producing β-lactamases	Aminopenicillins Protected aminopenicillins, oral cephalosporins of II-III generations, parenteral cephalosporins of II-III generations
Staph. aureus	Sensitive Producing β-lactamases	Benzylpenicillin, aminopenicillins Oxycillin, protected aminopenicillins, parenteral cephalosporins of I-II generations
M. pneumoniae C. pneumoniae Legionella spp.	Methicillin-resistant	Vancomycin, fusidic acid Macrolides, doxycycline Macrolides, doxycycline Erythromycin ± rifampicin
Enterobacteriaceae	Sensitive Multidrug-resistant	Third generation parenteral cephalosporins IV generation cephalosporins, protected aminopenicillins, aztreonam, carbapenem, aminoglycosides, fluoroquinolones
Ps. aeruginosa	Sensitive Multidrug-resistant	Ceftazidime + tobramycin III generation antipseudomonal cephalosporins + aminoglycosides, antipseudomonas penicillins + aminoglycosides, IV generation cephalosporins, aztreonam, carbapenems, ciprofloxacin

Table 6. Drugs of choice for the treatment of pneumonia of known etiology

Criteria for the effectiveness of antibacterial therapy are primarily clinical signs: a decrease in body temperature, a decrease in intoxication, an improvement in general condition, leukocyte count, a decrease in the amount of pus in the sputum, positive dynamics of auscultatory and radiological data. Efficacy is assessed after 24 - 72 hours. Treatment does not change unless there is deterioration.

Fever and leukocytosis can persist for 2 - 4 days, physical findings - more than a week, radiological signs of infiltration - 2 - 4 weeks from the onset of the disease. Radiological findings often deteriorate during the initial period of treatment, which is a serious prognostic sign in patients with severe disease.

Methods of administering antibiotics . For pneumonia of the lung, and in young patients - of moderate severity, tablet forms of drugs are used. The safety and clinical effectiveness of parenteral and oral antibiotic therapy are comparable. Drugs are administered parenterally in the following cases: 1) when there is doubt about the patient’s regularity of taking medications; 2) if there is doubt about the complete absorption of the oral form; 3) if the patient for a number of reasons cannot take the tablet drug; 4) if an antibiotic is used that is available only in a form for parenteral administration.

Modern tactics of using antibiotics provide for two fundamentally different approaches (schemes) of antimicrobial therapy:

—The escalation (increase) scheme is used in the treatment of outpatient, non-severe patients. If there is no effect from the initial therapy with the antibiotic of choice, a transition is made to the use of an antibacterial drug (or combination of antibiotics) with a wider spectrum of action.

—The de-escalation (lowering) scheme can be used in the treatment of seriously ill patients in a hospital setting, intensive care units and resuscitation units. In de-escalation therapy, treatment begins immediately with a broad-spectrum antibiotic (for example, a carbapenem), and then, as the patient's condition improves and results of antibiotic sensitivity of the pathogen are obtained, an antibiotic with a more narrowly targeted spectrum of action is prescribed.

The desire to ensure high effectiveness of treatment while reducing its cost and reducing the number of injections has led to the creation of step-down antibacterial therapy, which can be considered as one of the options for the de-escalation regimen. When using this technique, treatment begins with parenteral administration of an antibiotic, followed by an early transition to oral administration. The criteria for transition are a decrease in cough intensity, sputum volume, shortness of breath; stable normalization of body temperature, high bioavailability of the oral form of the antibiotic. Usually, the opportunity to switch to oral antibiotics appears 2 to 3 days after the start of treatment. In the United States, step therapy is approved by the FDA and is outlined in the organization's General Guidelines for Clinical Trials (1992).

Pathogenetic therapy. Along with antibacterial drugs, other directions are used in the treatment of pneumonia. In all cases, it is necessary to prescribe expectorants (3% solution of potassium iodide, infusion of marshmallow herb, thermopsis, etc.). The prescription of mucolytics (bromhexine, acetylcysteine, ambroxol, etc.) is indicated, and in the presence of clinical signs of bronchospasm - bronchodilators.

In severe cases of the disease and the severity of intoxication, detoxification therapy is carried out (saline solutions, rheopolyglucin, 5% glucose solution) - up to 1.5 - 2.0 liters of fluid under the control of central venous pressure and diuresis.

Planned use is contraindicated antihistamines due to increased viscosity of sputum.

Physiotherapeutic treatment of pneumonia is carried out after normalization of body temperature and in the absence of hemoptysis. Thermal procedures, inhalations, and electrophoresis of absorbable drugs are used.

Recovery criteria:

· Normalization of the patient’s well-being and condition

· Disappearance of signs of pneumonia during percussion and auscultation of the lungs

· Disappearance of radiological signs of pulmonary tissue infiltration

· Disappearance of laboratory signs of an inflammatory blood reaction.

Errors in the treatment of patients with pneumonia

Currently, there is no appropriate evidence for the advisability of prescribing various biogenic stimulants, antihistamines, vitamins, nystatin, immunomodulators (excluding granulocyte colony-stimulating factor and IgG preparations for intravenous administration), as well as long-term use of non-steroidal anti-inflammatory drugs and non-narcotic analgesics. The effectiveness and safety of these drugs have not been confirmed by the results of randomized controlled trials, which requires further study and does not provide grounds for recommending them for the treatment of pneumonia.

Errors in antibacterial therapy for pneumonia can be grouped as follows:

—incorrect choice of antibiotic for empirical antibacterial therapy;

—inadequate dose of antibiotic;

—inadequate route of antibiotic administration;

—unreasonable duration of antibacterial therapy;

—incorrect replacement of one antibiotic with another;

—unjustified combination of antibiotics;

—underestimation of toxicity and tolerability of antibiotics;

—underestimation of antibiotic resistance.

It should be emphasized that in case of community-acquired pneumonia, the following situations are not an indication for changing the antibiotic or continuing antibiotic therapy:

—preservation low-grade fever(37.0-37.5°C) in the absence of other signs of bacterial inflammation;

—preservation of residual changes (infiltration, increased pulmonary pattern) on the radiograph;

—persistence of a dry cough or production of non-purulent sputum;

—persistence of wheezing on auscultation;

—increased ESR;

—persistent weakness, sweating.

This is explained by the fact that the nonbacterial inflammatory reaction of the lung tissue itself, which is manifested by various clinical and radiological signs, regresses more slowly and does not require continued antibacterial therapy. In addition, some clinical symptoms after pneumonia (low-grade fever, weakness, sweating, decreased performance) are usually caused by autonomic dysfunction (post-infectious asthenia) and can persist for several weeks.

Prevention of pneumonia

The first and main way to prevent pneumonia is to predict the occurrence and spread of epidemic outbreaks of acute respiratory viral diseases, timely and reliable isolation of sick people and carrying out immunoprophylaxis.

The second way is to increase the body’s nonspecific resistance, as well as prevent the action of the cold factor.

All preventive measures should be applied to the so-called “risk groups” for pneumonia:

· suffer from ARVI three or more times a year;

· having foci of infection in the upper respiratory tract (chronic tonsillitis, sinusitis, carious teeth);

· those suffering from chronic bronchitis;

· persons working in unfavorable conditions.

Currently, pneumococcal and influenza vaccines are used to prevent pneumonia. The expediency of using the pneumococcal vaccine is explained primarily by the fact that Str. pneumoniae remains the leading causative agent of pneumonia in adults and, despite the availability of effective antibacterial therapy, causes significant morbidity and mortality. For the purpose of specific prevention of pneumococcal infections, a 23-valent unconjugated vaccine containing purified capsular polysaccharide antigens of 23 serotypes is used Str. pneumoniae Because patients who require pneumococcal vaccine often also require influenza vaccine, keep in mind that both vaccines can be given simultaneously (in different arms) without increasing the incidence of adverse events or reducing the immune response.

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