Graduation qualifying (thesis) work on the topic: "Pneumonia. Pneumonia Relevance of the disease Relevance of the topic of pneumonia today

The date: 08.03.2020

Content
p.
Introduction 3.
Chapter 1. Pneumonia, like respiratory disease 5
1.1. Classification of the disease 5.
1.2. Clinic of the disease 8.
Chapter 2. Diagnosis of pneumonia in young children 13
2.1. Signs of pneumonia in young children 13
2.1. Pediatrician actions 15.
Chapter 3. Results of own studies 17
3.1. Tactics of patients with early childhood pneumonia 17
3.2. Primary patient status assessment 20
3.3. Results and discussion 22
Conclusion 26.
References 28.
Appendix 29.

Introduction

The relevance of this work is due to the fact that pneumonia is an infectious inflammatory process in the lungs, in young children, accompanied by violations of the functions of various organs and organism systems. The inflammatory process is localized in alveoli, bronchioles with a reaction of a vascular system of interstitial tissue, with disorders in a microcirculatory line. Pneumonia can be primary or secondary as a complication of any disease.
The object of study of this work is pneumonia in young children.
The subject of the study is the features of the flow of pneumonia in young children.
According to the adopted classification (1995), in morphological forms, children differ in focal, segmental, focal and drain, bruboral and interstitial pneumonia. Interstitial pneumonia is a rare form with pneumocystosis, sepsis and some other diseases. The release of morphological forms has a certain prognostic value and can affect the choice of starting therapy.
Pneumonia can be sharp or protracted. The protracted pneumonia is diagnosed in the absence of permission of the pneumonic process in terms of 6 weeks to 8 months from the beginning of the disease; This should be a reason for finding the possible causes of such a flow.
With recurrence of pneumonia (with the exclusion of re- and superinfection), it is necessary to examine the child for the presence of fibrosis, immunodeficiency state, chronic food aspiration, etc.
The purpose of this work is to study the peculiarities of the flow of pneumonia in young children.
The achievement of this goal contributes to the solution of the following tasks:
- explore the classification of pneumonia;
- consider the diagnosis of pneumonia;
- to conduct a study of young children with this disease.
The methods of research in this paper were used as follows:
- study of special literature on this issue;
- Conducting a study within the framework of a given topic in DRKB of Kazan to identify and treatment of pneumonia in young children.
The theoretical significance of this work is to study the course of the disease, identifying the peculiarities of pneumonia in young children.
The practical significance of this work: Materials of this work can be used as a lecture by a teacher of therapeutic case, also materials of this work can be used as an abstract students of a medical college.
The history of this issue is studied and covered in the works of a number of scientists. These studies are applied in practice the treatment of patients with pneumonia.
The degree of study is high enough, since pneumonia in young children is a common disease.
When writing a job, special literature, research data, periodic printing materials, with a description of the newest developments in the field of research, identifying and treating the disease were used.
The structure of the work is due to the goals and tasks. Work consists of introduction, three chapters with paragraphs, conclusion, literature of literature, applications.
Chapter 1. Pneumonia like respiratory disease
1.1. Classification of the disease

The problem of diagnosis and treatment of pneumonium is one of the most relevant in modern therapeutic practice. Only over the past 5 years in Belarus, incidence growth was 61%. Mortality from pneumonia, according to various authors, fluctuates from 1 to 50%. In our republic, mortality has increased by 52% in 5 years. Despite the impressive progress of pharmacotherapy, the development of new generations of antibacterial drugs, the proportion of pneumonia in the structure of morbidity is large enough. Thus, in Russia annually more than 1.5 million people are observed by doctors about this disease, of which 20% are hospitalized in connection with the severity of the state. Among all hospitalized patients with bronchopulmonary inflammation, not counting ORVI, the number of patients with pneumonia exceeds 60%.

In modern conditions of the "economical" approach to health financing, priority is the most appropriate spending of allocated budgetary funds, which predetermines the production of clear criteria and testimony to hospitalize patients with pneumonia, optimizing therapy in order to obtain a good end result by lower costs. Based on the principles of evidence-based medicine, it seems important to discuss this problem due to the urgent need to introduce clear criteria for the hospitalization of patients with pneumonia in the everyday practice, which would facilitate the operation of the precinct therapist, save budget funds, timely predict possible outcomes of the disease.

Mortality from pneumonia today is one of the main indicators of the activities of therapeutic and preventive institutions. From health organizers and doctors, a constant decrease in this indicator is required, unfortunately, without taking into account objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, global statistics indicate an increase in mortality from pneumonia, despite the successes in its diagnosis and treatment. In the US, this pathology occupies a sixth place in the mortality structure and is the most common cause of death from infectious diseases. Over 60,000 fatal outcomes from pneumonia and its complications are recorded annually.

It should be processed from the fact that in most cases pneumonia is a serious and severe ailment. Under her mask, tuberculosis and lung cancer are often hidden. The study of the protocols of the opening of the dead from pneumonia for 5 years in Moscow and St. Petersburg showed that the correct diagnosis during the first day after admission to the hospital was installed in less than a third of patients, during the first week - in 40%. In the first day of stay in the hospital died 27% of patients. The coincidence of clinical and pathologist diagnoses was noted in 63% of cases, with the hypodiagnosis of pneumonia amounted to 37%, and hypendiagnosis - 55% (!). It can be assumed that the detectability of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the cause of such depressing numbers is the change in the modern stage of the "Gold Standard" diagnosis of pneumonia, which includes a sharp beginning of the disease with a fever, cough with a spray, chest pain, leukocytosis, less commonly leukopenia with a neutrophilic shear in the blood, radiologically detected infiltrate in pulmonary tissue which was not previously defined. Many researchers also note the formal, surface attitude of doctors to the issues of diagnosis and treatment of such a "long-known and well-studied" disease like pneumonia.

You read the topic:

To the problem of diagnosis and treatment of pneumonia

Complete Pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

Relevance. Respiratory diseases occupy one of the leading places in the structure of morbidity and mortality of children. An important role among them is played by pneumonia. This is due to both the high frequency of lesions of the respiratory tract in children, and with the seriousness of the forecast of many late diagnosed and untreated pneumonia. In the Russian Federation, the incidence of pneumonia children is within 6.3-11.9%. From the main reasons for increasing the number of pneumonium, is a high level of diagnostic error and late diagnosis. Significantly increased the proportion of pneumonium, under which the clinical picture does not correspond to radiological data, the number of small-axipput forms of the disease has increased. There are also difficulties in the etiological diagnosis of pneumonium, since over time there is an expansion and modification of the lision of pathogens. Relatively recently community-wide pneumonia has been binding mainly from Streptococcus Pneumoniae. Currently, the ethiology of the disease has expanded significantly, and in addition to bacteria can also be represented by atypical pathogens (Mycoplasma Pneumoniae, Chlamydophila Pneumoniae), mushrooms, and viruses (influenza, paragrippa, metapneummiruses, etc.), the role of the latter is especially great in children up to 5 Years 4. All this leads to untimely correction of treatment, weighing the patient's state, the appointment of additional drugs, which ultimately affects the disease forecast. Thus, despite a sufficiently detailed study of the problem of pneumonia of children's age, there is a need to clarify the modern clinical features of pneumonia, the study of the importance of various pathogens, including pneumatic viruses, with this disease.

Purpose of the study: Detection of modern clinical and laboratory and etiological features of the flow of pneumonia in children. Materials and methods. A comprehensive survey of 166 children with community-hospital pneumonias aged from 1 to 15 years, which was treated in the pulmonological department of the children's hospital GAUZ "Children's City Clinical Hospital" of Orenburg. Among the examined children were 85 boys (51.2%) and 81 girls (48.8%). All patients were divided into 2 groups on the morphological forms of pneumonia (patients with focal pneumonia and segmental pneumonia) and in 4 years of age - young children (1 - 2 years), preschoolers (3 - 6 years old), younger students (7 - 7 - 10 years) and senior schoolchildren (11 - 15 years). For all patients, the following examination was carried out: a clinical analysis of blood, a common urine analysis, a biochemical analysis of blood with determination of the level of C-reactive protein (CRH), radiography of the chest organs, microscopic and bacteriological examination of sputum on the flora and sensitivity to antibiotics. To identify respiratory viruses and S. pneumoniae 40 patients, a study of tracheobronchial aspirates was conducted by polymerase chain reaction (PCR) in real time in order to detect ribonucleic acid (RNA) respiratory syncytial virus, rhinovirus, metapneummirus, paragrippa virus 1, 2, 3, 4 types, deoxyribonucleic acid (DNA) of adenovirus and pneumococcus. The data obtained during the study were treated with the help of the software product Statistica 6.1. During the analysis, the calculation of elementary statistics, the construction and visual analysis of the correlation fields of communication between the analyzed parameters was performed, the frequency characteristics comparison was carried out using non-parametric methods of chi-square, chi-square with the correction of Yets, the exact Fisher method. A comparison of quantitative indicators in the studied groups was performed using the Student T-criterion during the normal distribution of sample and the criterion U Wilkoxon-Mann-Whitney with not normal. The relationship between individual quantitative features was determined by the river correlation method of the spirit. The differences in average values, correlation coefficients were recognized as statistically significant at the level of significance P 9 / l, segmental - 10.4 ± 8.2 x10 9 / l.

In the segmental pneumonium group, the SE value was higher than during focal pneumonia - 19.11 ± 17.36 mm / h against 12.67 ± 13.1 mm / h, respectively (p 9 / l to 7.65 ± 2.1 10 9 / l (p

List of sources used:

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

2. Sinopalnikov A.I., Kozlov R.S. Complete respiratory tract infections. Guide for doctors - M.: Premier MT, our city, 2007. - 352 p.

Hospital pneumonia

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Introduction

Pneumonia is currently a very relevant problem, as despite the ever-growing number of new antibacterial drugs, high mortality from this disease remains. Currently, the practical purposes of pneumonia are divided into community-friendly and internal hospitals. In these two large groups, still aspiration and atypical pneumonia (caused by intracellular agents - mycoplasma, chlamydia, legionells), as well as pneumonia in patients with neutropenia and / or against various immunodeficiency.

International statistical classification of diseases provides for the definition of pneumonium exclusively for etiological grounds. More than 90% of cases of GP has a bacterial origin. Viruses, mushrooms and simplests are characterized by a minimum "contribution" into the etiology of the disease. Over the past two decades, significant changes have occurred in the epidemiology of the GP. This is characterized by the increased etiological significance of such pathogens, such as mycoplasma, legionells, chlamydia, mycobacteria, pneumocists and a significant increase in resistance of staphylococci, pneumococcal resistance, streptococci and hemophilic sticks to the most widely used antibiotics. The acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta lactamases that destroy the structure of beta-lactam antibiotics. High resistance is usually different non-hospital strains of bacteria. In part, these changes are associated with selective pressure on the microorganisms of the widely used new antibiotics of a wide range of action. Other factors are an increase in the number of multi-resistant strains and an increase in the number of invasive diagnostic and therapeutic manipulations in modern hospital. In an early antibiotic era, when the doctor was only available to Penicillin, about 65% of all nosocomial infections, including GP, accounted for staphylococci. The introduction of penicillin-sensitive conchalactam in the clinical practice has reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%), which pushed gram-positive pathogens (30%) and anaerobes (3%). Since that time, multi-resistant gram-negative microorganisms (intestinal aerobes and a cinema wand) are nominated among the most relevant nosocomial pathogens. Currently, the revival of gram-positive microorganisms is noted as relevant nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

On average, the frequency of hospital pneumonia (GP) is 5-10 cases of the disease per 1000 hospitalized patients, however, in patients who are on mechanical ventilation of the lungs, this indicator increases 20 times or more. Mortality for GP, despite objective achievements in antimicrobial chemotherapy, today is 33-71%. In general, nosocomial pneumonia (NP) is about 20% of all nosocomial infections and ranks third after wound infections and urinary tract infections. NP frequency increases in patients long in the hospital; when applying immunosuppressive drugs; in persons suffering from severe diseases; In elderly patients.

Etiology and pathogenesis of hospital pneumonia

Hospital (nosocomial, nosocomial) pneumonia (interpreted as the appearance after 48 hours or more of the hospitalization of the new pulmonary infiltration in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sprome, leukocytosis, etc.) and with the exclusion of infections, which were in the incubation period when the patient arrived in the hospital) is the second most prevalence and the leading cause of death in the structure of nosocomial infections.

Studies conducted in Moscow showed that the most frequent (up to 60%) bacterial causative agents of community-hospital pneumonia are pneumococci, streptococci and hemophilic sticks. Less often - Staphylococcus, Klebsiella, Enterobacter, Legionella. For young people, pneumonia is more often caused by the pathogen monoculture (usually pneumococcus), and in the elderly - Bacteria Association. It is important to note that these associations are presented with a combination of gram-positive and gram-negative microorganisms. The frequency of mycoplasma and chlamydial pneumonia varies depending on the epidemiological situation. More often than this infection is susceptible to young people.

Respiratory tract infections occur in the presence of at least one of three conditions: the violation of the protective forces of the body, entering the lower parts of the respiratory tract of patient pathogenic microorganisms in an amount exceeding the protective forces of the body, the presence of a high-voluminous microorganism.
The penetration of microorganisms into the lungs can be carried out in various ways, including through the micro-planning of the rotoglotter secret, colonized by pathogenic bacteria, aspiration of the contents of the esophagus / stomach, inhaled by the infected aerosol, penetration from the remote infected hematogenic portion, exogenous penetration from the infected site (for example, pleural cavity) , direct contamination of the respiratory tract in intubated patients from the staff of the chambers of intensive therapy or, which remains doubtful, by transferring from the gastrointestinal tract.
Not all of these paths are equally dangerous in terms of penetration of the pathogen. Of the possible ways of penetration of pathogenic microorganisms in the lower respiratory tract departments, the micro-planning of small volumes of the rotoglotum secretary previously infected with pathogenic bacteria is. Since the micro-space takes place quite often (so, the microapission in a dream is noted at least 45% of healthy volunteers), it is the presence of pathogenic bacteria that can overcome protective mechanisms in the lower airways plays an important role in the development of pneumonia. In one of the studies, the contamination of the rotogling of intestinal gram-negative bacteria (KGB) was noted relatively rarely (

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

Pneumonia is now one of the most common diseases. Despite the success of medication therapy, pneumonia is still considered dangerous, and sometimes even a deadly disease. Patients with pneumonia constitute a significant percentage of medical care to polyclinics, therapeutic and pulmonary departments of hospitals, which is associated with high morbidity, especially during the flu epidemic and outbreaks of sharp respiratory diseases.

This is an acute infectious disease, mainly bacterial (viral) etiology, characterized by the focal damage to respiratory departments of the lungs, the presence of intrastallyolar exudation, detected in physical and instrumental studies, expressed in varying degrees of fever and intoxication.

To suspect the inflammatory lung disease in the presence of the following signs:

Fever (temperature rise above 38 degrees);
Intoxication, general ailment, decreased appetite;
Pain in breathing on the side of the affected lung, amplifying with cough (when involving pleura in the process of inflammation);
Cough dry or with a mocroid;
Dyspnea.

The diagnosis is made by a doctor. It is important to seek medical attention to the first day of the disease. To diagnose the doctor helps radiography of the organs of the chest, computed tomogram, auscultative data. Selection of drug therapy is strictly individually depending on the intended pathogen of the disease. Pneumonia treatment is carried out outpatient or stationary depending on the severity of the disease. The testimony for hospitalization is determined by the doctor.

The relevance of the problem of pneumonium

You read the topic:

To the problem of diagnosis and treatment of pneumonia

Complete Pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

In the segmental pneumonium group, the SE value was higher than during focal pneumonia - 19.11 ± 17.36 mm / h against 12.67 ± 13.1 mm / h, respectively (p 9 / l to 7.65 ± 2.1 10 9 / l (p

List of sources used:

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

2. Sinopalnikov A.I., Kozlov R.S. Complete respiratory tract infections. Guide for doctors - M.: Premier MT, our city, 2007. - 352 p.

Hospital pneumonia

Main tabs

Introduction

Etiology and pathogenesis of hospital pneumonia

Study of factors contributing to the development of community-hospital pneumonia and analysis of effective treatment

Description: In recent years, the number of patients with a severe and complicated course of community-acquired pneumonia is growing. One of the main reasons for the severe flow of pneumonia is the underestimation of the severity of the state when entering the hospital, due to a scarce clinical and laboratory and X-ray picture in the initial period of development of the disease. In Russia, medical personnel are actively involved in conferences on the prevention of pneumonia.

Date added: 2015-07-25

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Chapter 1. What is the community-friendly pneumonia?

1.6. Differential diagnosis

1.8. Antibacterial therapy

1.9. Complex treatment of community-hospital pneumonia

1.10. Socio-economic aspects

1.11. Preventive measures

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

The results of the work performed

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

In recent years, the number of patients with severe and complicated passage of community-hospital pneumonia is growing. One of the main reasons for the severe flow of pneumonia is the underestimation of the severity of the state when entering the hospital, due to a scarce clinical and laboratory and X-ray picture in the initial period of the disease. However, in a number of work, the underestimation of these clinical and laboratory research is traced, complex methods of forecast are proposed, and a comprehensive approach to the survey of patients is also ignored. In this regard, the relevance of the problem of a comprehensive quantitative assessment of the severity of the patient's state with community-hospital pneumonia and forecasting the course of the disease in the early hospital rates is increasing.

In Russia, medical personnel are actively involved in conferences on the prevention of pneumonia. In medical institutions, surveys are held annually. But, unfortunately, despite this work, the number of sick pneumonia remains one of the main problems in our country.

The relevance of the problem. This work focuses on the seriousness of the disease due to the large number of cases of severe consequences. Continuous control of the situation is underway, incidence statistics, in particular, pneumonia are studied.

Given this situation on pneumonia, I decided to do this problem.

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

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

Subject of study. The role of the Feldscher in the timely identification of community-hospital pneumonia and adequate therapy.

1) reveal and explore the causes contributing to the disease of community-friendly pneumonia.

2) Determine the risk factors of the incidence of non-hospital pneumonia.

3) Assess the comparative clinical, bacteriological efficacy and safety of various antibacterial therapy regimes in the treatment of hospitalized patients with community-hospital pneumonia.

4) Acquaintance with the role of the Feldscher's role in the prevention and treatment of community-hospital pneumonia.

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

The practical significance of my work concludes that the population is well-oriented in the symptoms of pneumonia, understood the risk factors for the occurrence of the disease, prevention, of importance in the timely and effective treatment of this disease.

Complete-headed pneumonia refer to the most common infectious diseases of the respiratory tract. Most often, this ailment is the cause of death from various infections. This occurs as a result of a decrease in immunity of people and rapidly addictive pathogens for antibiotics.

Complete pneumonia is an infectious disease of the respiratory tract of the lower departments. Complete-housing pneumonia in children and adults develops in most cases as a complication of transferred viral infection. The name of pneumonia characterizes the conditions for its occurrence. There is a person at home, without any contacts with a medical facility.

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

Easy pneumonia is the largest group. It is treated outpatient, at home.

Middle severity. Such pneumonia is treated in the hospital.

Heavy form of pneumonia. It is treated only in the hospital, in the separation of intensive therapy.

What is community-friendly pneumonia?

Complete-headed pneumonia - an acute infectious inflammatory disease of predominantly bacterial etiology, which emerged in community-friendly conditions (outside the hospital or later than 4 weeks after discharge from it, or diagnosed in the first 48 hours from the moment of hospitalization, or developed in a patient who was not in the homes of nursing care / offices long-term medical observation over 14 days), with damage to respiratory departments of the lungs (alveoli, bronchi small caliber and bronchiole), frequent presence of characteristic symptoms (acutely occurring fever, dry cough with the subsequent selection of sputum, chest pain, shortness of breath) and previously absent clinical -rengenic signs of local lesions that are not related to other known reasons.

Complete pneumonia is one of the most common diseases of the respiratory organs. The incidence of it is 8-15 per 1000 population. The frequency of it is significantly increased among the elderly and senile individuals. The list of major risk factors for the development of disease and death includes:

Habit of smoking,

Chronic obstructive lung diseases

Stagnant heart failure

Immunodeficiency states, crowded residence, etc..

More than a hundred microorganisms (bacteria, viruses, mushrooms, simplest) are described, which under certain conditions may be causative agents of community-hospital pneumonia. However, most cases of the disease are associated with a relatively small circle of pathogens.

In some categories of patients - recent techniques of systemic antimicrobial drugs, long-term therapy with systemic glucocorticosteroids in pharmacodynamic doses, fibrousosis, secondary bronchiectases - the relevance of Pseudomonas Aeruginosa is significantly increasing in etiologia.

The significance of the anaerobes, the colonixions of the oral cavity and the upper respiratory tract in the etiologists of the community-acquired pneumonia to the present is finally not defined, which is primarily due to the restrictions of traditional culture methods for the study of respiratory samples. The probability of infection with anaerobes may increase in persons with a proven or alleged aspiration due to episodes of a disturbance of consciousness in convulsions, some neurological diseases (for example, stroke), dysphagia, diseases accompanied by a violation of the motility of the esophagus.

The frequency of occurrence of other bacterial pathogens - Chlamydophila Psittaci, Streptococcus Pyogenes, Bordetella Pertussis, etc. Usually does not exceed 2-3%, and the lungs caused by endemic micromycetes (Histoplasma Capsulatum, Coccidioides Immitis and others) are extremely rare.

Complete-headed pneumonia can cause respiratory viruses, the most often influenza viruses, coronaviruses, a rhinosinecitic virus, a man metapnemovirus, a man's balusur. In most cases, infections caused by a group of respiratory viruses are characterized by a not heavy course and are self-restrictive, however, in individuals of elderly and senile age, in the presence of concomitant bronchopulmonary, cardiovascular diseases or secondary immunodeficiency, they can be associated with the development of severe, threatening life of complications.

The growth of the relevance of viral pneumonia in recent years is due to the appearance and distribution in the population of the pandemic flu virus A / H1N1PDM2009, which can cause the primary lesion of the pulmonary tissue and the development of rapidly progressive respiratory failure.

The primary viral pneumonia is distinguished (develops as a result of direct viral lung damage, is characterized by a rapidly progressive course with the development of pronounced respiratory failure) and secondary bacterial pneumonia, which can be combined with primary viral damage to the lungs or to be an independently late complication of influenza. The most frequent pathogens of secondary bacterial pneumonia in influenza patients are Staphylococcus aureus and Streptococcus Pneumoniae. The frequency of revealing respiratory viruses in patients with communal-hospital pneumonia is pronounced seasonal character and increases during the cold season.

With community-friendly pneumonia, a co-infection can be detected with two or more pathogens, it can be caused by both the association of various bacterial pathogens and their combination with respiratory viruses. The frequency of occurrence of non-hospital pneumonia caused by the association of pathogens varies from 3 to 40%. According to a number of studies, community-acquired pneumonia caused by the causative agent association tends to a heavetable course and worse forecast.

The most frequent penetration of microorganisms into a lightweight fabric is:

1) bronchogenic - and this contributes to this:

Inhalation of microbes from the environment,

Resettlement of pathogenic flora from the upper departments of the respiratory system (nose, throat) in the lower,

Medical manipulations (bronchoscopy, trachea intubation, artificial ventilation of the lungs, inhalation of medicinal substances from the ammored inhalers), etc.

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

3) The lymphogenic path of penetration is very rare.

Further, with pneumonia of any etiology, there is fixation and reproduction of the infectious agent in the epithelium of respiratory bronchiol - develops acute bronchitis or bronchiolitis of various types - from a slight catarrhal, to necrotic. The spread of microorganisms beyond respiratory bronchiole causes inflammation of light tissue - pneumonia. Due to the impairment of bronchial passability, the foci of atelectasis and emphysema arise. Reflexo, with the help of cough and sneezing, the body is trying to restore the brightness of the bronchi, but as a result, infection is spreading to healthy fabrics, and new foci of pneumonia is formed. Oxygen deficiency develops, respiratory failure, and in severe cases and heart failure. The most affects the II, VI, X segments of the right light and VI, VIII, IX, X the segments of the left lung.

Aspiration pneumonia are distributed in mentally ill; In persons with diseases of the central nervous system; In persons suffering from alcoholism.

Pneumonia in immunodeficiency states are characteristic of oncological patients receiving immunosuppressive therapy, as well as drug addicts and HIV-infected.

The great importance of the classification of pneumonium is attached to the diagnosis of the severity of pneumonia, the localization and length of lung damage, the diagnosis of pneumonia complications, which makes it possible to more objectively to pull the disease prediction, choose a rational program of complex treatment and allocate a group of patients in need of intensive therapy. There is no doubt that all these rubrics, along with empirical or objectively confirmed information about the most likely causes of the disease, should be presented in the modern classification of pneumonia.

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

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

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

Etiology of pneumonia (verified or alleged pathogen of infection);

Localization and length;

Clinical and morphological version of the flow of pneumonia;

Severity of pneumonia;

Degree of respiratory failure;

The presence of complications.

Table 1. Related diseases / risk factors associated with certain pathogens of community-hospital pneumonia.

It is one of the most relevant in modern therapeutic practice. Only over the past 5 years in Belarus, incidence growth was 61%. Mortality from pneumonia, according to various authors, fluctuates from 1 to 50%. In our republic, mortality has increased by 52% in 5 years. Despite the impressive progress of pharmacotherapy, the development of new generations of antibacterial drugs, the proportion of pneumonia in the structure of morbidity is large enough. Thus, in Russia annually more than 1.5 million people are observed by doctors about this disease, of which 20% are hospitalized in connection with the severity of the state. Among all hospitalized patients with bronchopulmonary inflammation, not counting ORVI, the number of patients with pneumonia exceeds 60%.

Citation:Complete pneumonia. Interview with prof. L.I. Poleelae // RMW. 2014. №25. P. 1816.

Interview with the head of the department of internal diseases of the GBOU VPO "First MIMM named after I.M. Sechenova, "D.M., Professor L.I. Butler

Pneumonia, being for centuries heavy, often a fatal disease, continues to remain a serious clinical problem, many aspects of which and in our days require careful analysis. What is due to the relevance of the problem of pneumonia today?
- The incidence of non-hospital pneumonia (VP) in our country reaches 14-15%, and the total number of patients exceeds 1.5 million people annually. In the United States, more than 5 million cases of EP are diagnosed annually, of which more than 1.2 million people need hospitalization, and more than 60 thousand of them are dying. If the mortality with VI among young and middle ages without concomitant diseases does not exceed 1-3%, then patients over 60 years old in the presence of serious concomitant pathology, as well as in cases of severe disease, this indicator reaches 15-30%.

Are there any risk factors for pneumonia, which should be taken into account by practical doctors, first of all an outpatient link?
- To such factors that, unfortunately, are not always taken into account by doctors include the male floor, the presence of serious concomitant diseases, a large prevalence of pneumonic infiltration, according to X-ray research, tachycardia (\u003e 125 / min), hypotension (<90/60 мм рт. ст.), одышка (>30 / min), some laboratory data.

One of the important aspects of the problem of pneumonia is timely and proper diagnosis. What is the situation about the diagnosis of pneumonia today?
- The level of diagnosis of pneumonia, unfortunately, turns out to be low. So, out of 1.5 million pneumonia, the disease is diagnosed less than 500 thousand, i.e., only 30% of patients.

Agree that the situation should be considered clearly unsatisfactory, if not just anxious. After all, now the XXI century, and we would have to advance in improving the diagnosis of such a disease like pneumonia. What is the reason for so unsatisfactory diagnostics?
- along with subjective factors caused to a certain extent unsatisfactory diagnostics of the EP, it is necessary to take into account the objective reasons. The diagnosis of pneumonia is hampered by the fact that there is no specific clinical sign or a set of such signs, which could be reliably relying on suspected pneumonia. On the other hand, the absence of any symptom from among non-specific symptoms, as well as local changes in the lungs (confirmed by the results of clinical and / or x-ray) makes an assumption about the diagnosis of pneumonia unlikely. During the diagnosis of pneumonia, the doctor should be based on the main signs, among which it is necessary to allocate the following:
1. Sudden start, febrile fever, stunning chills, chest pain characteristic of pneumococcal ethiology VP (often it is possible to highlight Streptococcus Pneumoniae from blood), partly for Legionella Pneumophila, less common - for other pathogens. On the contrary, this picture of the disease is absolutely atypical for Mycoplasma Pneumoniae and Chlamydophila Pneumoniae infections.
2. "Classic" signs of pneumonia (an ominant beginnings, chest pain, etc.) may be absent, especially in weak patients and elderly / senile people.
3. Approximately 25% of patients under the age of 65 years carrying VE, there is no fever, and leukocytosis is recorded only in half cases. At the same time, clinical symptoms can be represented by nonspecific manifestations (fatigue, weakness, nausea, anorexia, violation of consciousness, etc.).
4. Classical objective signs of pneumonia are shortening (stupidity) of the percussion tone above the affected lung plot, locally listening bronchial breathing, focus of sonorous small-pushed wheels or crepitations, amplification of the bronchophone and voice trembling. However, in a considerable part of patients, objective signs of pneumonia may differ from typical, and approximately 20% of patients - and there is no absence.
5. Taking into account the significant clinical variability of the painting of the EF and the ambiguity of the results of the physical examination, it is almost always a radiographic study that confirms the presence of focal-infiltrative changes in the lungs.

What is the diagnostic value of the radiation research methods, including and with a highly agreed ability, in patients with VP? You can again ask a banal, often the result is: diagnosis of pneumonia is a clinical or radiological?
- One of the diagnostic criteria of pneumonia is the presence of pulmonary infiltration detected using radiation diagnostics methods, in particular with a radiographic study of the patient. Meanwhile, the analysis of the quality of maintaining patients of patients does not indicate the insufficient use of this research method before appointing the ABP. According to S.A. Rachina, the radiographic study of the patient before the start of therapy was carried out only in 20% of patients.
X-ray pneumonia, apparently, exist, although from the point of view of modern pulmonary representations, the diagnosis of inflammation of the pulmonary tissue without a radiation study, primarily X-ray, cannot be considered fairly reasonable and accurate.

The key problems of antibacterial therapy (ABT) in patients with PP are the choice of the optimal ABP, the deadlines for the appointment, control over efficiency and tolerance, the decision to change the ABP, the duration of receiving an ABP. S.A. Ranchin, conducted an analysis of the quality assistance to patients in various regions of Russia, showed that, when choosing an ABP, doctors are guided by different criteria. At the same time, the penetration of the AbP into the pulmonary fabric, and the availability in oral form, and the cost of the drug, and the other are appeared. Is there any general one, the common principle of the choice of ABP in patients with VP?
- When choosing an ABP, this category of patients should be first oriented, on the one hand, on the clinical situation, and on the other, on the pharmacological properties of the assigned ABP. It is necessary to make aware that the ABT of the patient of the PA begins (at least it should start) immediately after the clinical and x-ray diagnosis of the disease, in the absence of data of a bacteriological study of sputum. Maximum, which can be performed - bacterioscopy of sputum samples painted in gram. Therefore, we are talking about indicative etiological diagnostics, that is, the probability of the presence of a particular pathogen depending on the particular clinical situation. It is shown that a certain pathogen is usually "tied" to the appropriate clinical situation (the age, the nature of the concomitant and background pathology, epide-anamnesis, the risk of antibiotic resistance and other). On the other hand, the doctor is important to have comprehensive information about the ABP, which is supposed to be appointed. It is especially important to be able to correctly interpret this information in relation to a specific patient VP.
To date, there is an opportunity "antigenic" express diagnosis of pneumonia using immunochromatographic determination in the urine of soluble antigens Streptococcus Pneumoniae and Legionella Pneumophila. However, this diagnostic approach is justified, as a rule, with a severe course of the disease. In practice, the antimicrobial therapy of the VI in the overwhelming majority of cases is empirical. Agreeing with the fact that even the scrupulous analysis of the clinical picture of the disease hardly allows you to reliably determine the etiology of pneumonia, it should be reminded that Streptococcus PNEUMONIAE is a pathogene on 50-60% of cases. In other words, VP is primarily a pneumococcal infection of the lower respiratory tract. And hence the obvious practical conclusion - the appointed ABP must have an acceptable antiphenococcal activity.

Is it possible to talk about the "most efficient" or "ideal" drug among the available APP ASENAL for the treatment of HP, taking into account the results of the clinical research conducted to date?
- The desire of doctors to have an "ideal" antibiotic for all occasions of life is understandable, but practically difficult to implement. In a patient with a VP of a young or middle age without a comorbidity, an optimal antibiotic is amoxicillin - based on the presumptive pneumococcal etiology of the disease. In patients of older age groups or with chronic obstructive pulmonary disease, the optimal antibiotic will be amoxicillin / clavulanic acid or parenteral cephalosporin III of generation - taking into account the likely role in the etiology of the EP, along with the pneumococcal, hemophilic sticks and other gram-negative bacteria. In patients with risk factors infections caused by antibiotic resistant pathogens, the comorbidity and / or severe VE, the optimal antibiotic will be "respiratory" fluoroquinolone - Moxifloxacin or Levofloxacin.

The sensitivity to ABAP key respiratory pathogens acquires an important value when choosing a start-up Abp. To what extent is the presence of antibiotic resistance can correlate the choice of ABP?
- There are such concepts as the microbiological and clinical stability of pathogens to antibiotics. And they do not always coincide in relation to some groups of antibiotics. Thus, with a low level of resistance to pneumococcal to Penicillin, amoxicillin and cefalosporins III of generations retain clinical efficacy, though at higher doses: amoxicillin 2-3 g / day, ceftriaxone 2 g / day, cefotaxim 6 g / day. At the same time, the microbiological stability of the pneumococcus to macrolides, generation cephalosporins II or fluoroquinolones is accompanied by the clinical inefficiency of treatment.

What are the approaches to the choice of an adequate ABP for the treatment of patients with VP? What are they based on and are implemented in clinical practice?
- In order to optimize the selection of an APC for the treatment of a patient VP, several groups of patients should be distinguished on the basis of the severity of the disease. This determines the prediction and decision on the site of treatment of the patient (outpatient or stationary), makes it possible to approximately assume the most likely causative agent and, taking into account this, develop Abt tactics. If patients with non-heavy pneumonia have no differences in the effectiveness of aminopenicillins, as well as individual representatives of the class of macrolides or "respiratory" fluoroquinolones, which can be prescribed inside, and the treatment is to carry out an outpatient basis, then with a more severe course of the disease, hospitalization is shown, and it is advisable to start with parenteral therapy Antibiotics. After 2-4 days of treatment, when normalizing the body temperature, a decrease in intoxication and other symptoms, a transition to the oral use of antibiotics is recommended until the full course of therapy (step therapy) is completed. Patients with severe pneumonia prescribe drugs active with respect to "atypical" microorganisms, which improves the disease forecast.
- How often is the treatment of pneumonia in step therapy?
- Clinical practice indicates that the mode of stepped therapy in the treatment of hospitalized patients is used infrequently. According to S.A. Radina, stepped therapy is carried out by no more than 20% of cases. This can be explained by insufficient awareness and inertia doctors, as well as their underlining conviction that parenteral medicines are obviously more efficient than oral administration. It is not always and not quite so. Of course, in a patient with polyorgan deficiency, the method of introducing an antibiotic can only be parenteral. However, at a clinically stable patient without a violation of the function of the GTS, significant differences in the pharmacokinetics of different dosage forms of antibiotics is not marked. Therefore, the presence of an antibiotic oral dosage form with good bioavailability is a sufficient basis for transferring a patient with parenteral treatment to oral, which can also be significantly cheaper for it and more convenient. Oral dosage forms with high bioavailability (more than 90%) have many parenteral antibiotics: amoxicillin / clavulanic acid, levofloxacin, moxifloxacin, clarithromycin, azithromycin. You can also carry out stepped therapy in the case of a parenteral antibiotic application that does not have a similar form for intake with high bioavailability. In this case, an oral antibiotic is prescribed with identical microbiological characteristics and optimized pharmacokinetics, for example, cefuroxime V / B - cefuroxime Axethyl inside, ampicillin in / B - amoxicillin inside.

How important is the time of the start of antimicrobial therapy after the diagnosis is made?
- At the time before the first introduction of the antibiotic, patients with VP paid special attention relatively recently. In 2 retrospective studies, a statistically significant decrease in mortality among hospitalized patients with early start of antimicrobial therapy was managed to demonstrate. The authors of the first of the studies were offered a threshold time of 8 hours, but the subsequent analysis showed that lower mortality is observed at a time threshold not exceeding 4 hours. It is important to emphasize that in mentioned studies, patients receiving antibiotics in the first 2 h after medical examination turned out to be We are clinically more severe than patients who have begun to spend the antimicrobial therapy after 2-4 hours after receipt of the hospital department. Currently, experts, not counting it possible to determine the specific time interval from the beginning of the patient's inspection before the introduction of the first dose of the antibiotic, call on as early as possible the beginning of treatment after the preliminary diagnosis of the disease.

The assignment of the ABP, even in the greatest time, of course, does not exhaust the mission of the choring physician and finally does not solve all the questions. How to estimate the effect of the appointed ABP? What are the criteria for efficiency? What time frame should be considered critical for making a decision on the absence of the effect, and consequently, about the change of ABP?
- There is a third-day rule, according to which the effectiveness of antimicrobial therapy should be estimated 48-72 hours after its start. If the patient had normalization of the body temperature or it does not exceed 37.5 ° C, the signs of intoxication decreased, there are no respiratory failure or hemodynamic disorders, the effect of the treatment carried out should be regarded as a positive and antibiotic reception. In the absence of an expected effect, it is recommended to add oral macrolides (preferably azithromycin or clarithromycin) to add oral macrolides (preferably azithromycin or clarithromycin). With the ineffectiveness of such a combination, an alternative group of drugs should be applied - "Respiratory" fluoroquinolones. In the case of the initially irrational appointment of the antibiotic to the preparations of the first line, as a rule, no longer appeal, but are transferred to the reception of the "respiratory" fluoroquinolones.

An equally important issue of Abt tactics of patients VP is the duration of treatment. Doctors often have a fear - to notice the disease. Is there any danger to "unlapping" and "passing" the patient?
- There are many patients with VP, who will have a clinical effect on the background of ABT, are sent to the hospital to continue treatment. From the point of view of the doctor, the reasons for this are a subfebrile temperature, which remains, although decreasing in the volume of pulmonary infiltration, according to the X-ray study, increasing the SE indicators. At the same time, either ABT is carried out in the same mode, or a new ABP is appointed.
In most cases, antimicrobial therapy of patients with EP continues within 7-10 days or more. Comparative studies of the effectiveness of short and familiar (on duration) of antibiotic courses did not reveal reliable differences in both ambulatory and hospitalized patients in the event that the treatment was adequate. According to modern ideas, antimicrobial therapy EP can be completed under the condition if the patient received treatment for at least 5 days, he normally normalized the body temperature and there are no clinical instability criteria (tachipne, tachycardia, hypotension, etc.). A more prolonged treatment is necessary in cases where the designated ABT did not have an impact on a dedicated pathogen or in the development of complications (abscess, empty of pleura). The preservation of individual clinical, laboratory or radiological signs of the PP is not an absolute indication to continue the antimicrobial therapy or its modification.
According to some data, up to 20% of patients with a nongendent PP are not responding properly on the treatment. This is a serious figure that determines the feasibility of more thorough and, possibly, more frequent radiation control over the state of the lungs. The protracted resolution of focal-infiltrative changes in the lungs found at the radiation study in the lungs, even against the background of a distinct reverse development of clinical symptoms, the disease often serves as a reason for the continuation or modification of ABT.
The main criterion of the effectiveness of ABT is the opposite development of clinical manifestations of the VP, primarily normalization of body temperature. The terms of x-ray recovery, as a rule, are lagging behind the time of recovery of clinical. Here, in particular, it is appropriate to recall that the completeness and timing of the x-ray permission of pneumonic infiltration depend on the type of pathogen VP. So, if with mycoplasma pneumonia or pneumococcal pneumonia without bacteremia, the timing of x-ray recovery is on average 2 weeks. - 2 months. and 1-3 months. Accordingly, in cases of the disease caused by gram-negative enterobacterium, this time interval reaches 3-5 months.

What can you say about pneumonia with a slow clinical response and a delayed x-ray resolution in immunocompetent patients?
- In such situations, doctors often covers panic. Consultants are called for help, first of all phthisiators, oncologists, new antibiotics are appointed, etc.
In the majority of patients with VP to the outcome of 3-5 days from the beginning of the ABT, the body temperature normalizes and regress other manifestations of intoxication. In the same cases, when on the background of improving the state to the outcome of the 4th week. From the beginning of the disease, it is not possible to achieve complete x-ray permission, it is necessary to talk about unresolving / slowly permitted or protracted VP. In such a situation, it should be primarily possible to establish possible risk factors of the Poor Power VP, which include old age, comorbidity, severe CAP, multilicar infiltration, secondary bacteremia. In the presence of the above risk factors for the slow resolution of the VP and simultaneous clinical improvement, it is advisable after 4 weeks. Conduct control x-ray examination of the chest organs. If the clinical improvement is not marked and / or the patient has no risk factors for the risk of slow permission of the VP, then in these cases it is shown to carry out computer tomography and fibrobronchoscopy.

In the clinical practice, diagnostic and therapeutic errors are inevitable. We discussed the reasons for late or erroneous diagnosis of pneumonia. What errors of ABT patients are the most typical?
- The most common mistake should be considered the inconsistency of the starting antibiotic adopted clinical guidelines. This may be due to an insufficient acquaintance of doctors with existing clinical guidelines or their ignoring, or even simply ignorance about their existence. Another error is the lack of a timely shift of the ABP in case of its obvious inefficiency. It is necessary to deal with such situations when ABT continues for 1 week, despite the lack of a clinical effect. Less often occur errors in the dispensing of the ABP, the duration of ABT. At the risk of the appearance of antibiotic-resistant pneumococci, penicillins and cefalo-disposims should be used in an increased dose (amoxicillin 2-3 g / day, amoxicillin / clavulanic acid 3-4 g / day, ceftriaxone 2 g / day), and some antibiotics are not assigned (cefuroxime, Macrolids). In addition, it is necessary to recognize the erroneous appointment with antibiotics in subterapeutic doses for pneumococci, for example, azithromycin in a daily dose of 250 mg, clarithromycin in a daily dose of 500 mg, amoxicillin / clavulanic acid in dosage form 625 mg (and more than 375 mg) . Currently, an increase in the dose of levofloxacin to 750 mg can be justified.

Often, we are witnessing the unreasonable hospitalization of patients with Pos, which, according to some data, takes place in almost half of the cases of VP. It seems that when making a decision on hospitalization of a patient, most doctors are guided by subjective assessments, although there are specific, primarily clinical, readings.
- The main indication for hospitalization is the severity of the patient's condition, which can be due to the pulmonary inflammation itself, leading to the development of respiratory failure and decompensation of the accompanying pathology available in patient (agility of heart failure, renal failure, diabetes decompensation, strengthening cognitive disorders and rows other signs). When making a decision on hospitalization, it is important to estimate the state of the patient and determine the testimony for hospitalization into the separation of resuscitation and intensive therapy. There are various scales of gravity of pneumonia. The most acceptable for this purpose is the CURB-65 scale, which provides for an assessment of the level of consciousness, respiratory rate, indicators of systolic blood pressure, the content of urea in the blood and age of the patient (65 years or more). The high correlation between the scores of the CURB-65 scale and death is shown. Ideally, it should be introduced a standardized approach to the patient's maintenance of the PA based on the Bal-flax assessment of CURB-65: the number of points 0-1 - the patient can be treated with an outpatient basis, above - should be hospitalized, and in the hospital if there are 0-2 points, the patient is in the hospital Therapeutic (pulmonological) department, if there are 3 or more points - should be transferred to the resuscitation and intensive therapy.

There are practical recommendations for the maintenance of patients VP. How important to follow these recommendations and does the evidence of more favorable results of treatment in such cases?
- The recommendations include the principles of the patient's survey and a unified approach to the maintenance of this category of patients is presented. It is shown that following the individual provisions of the recommendations reduces the likelihood of early therapeutic failure (in the first 48-72 h) by 35% and the risk of fatal outcome by 45%! Therefore, in order to improve the diagnosis of VP and the treatment of this category of patients, you can encourage doctors to follow clinical guidelines.