Acute pneumonia is an acute inflammatory process in the parenchyma and interstitium of the lungs, in the etiology of which the infectious factor plays a decisive role. Disease is accompanied by chills, persistent fever, cough with mucopurulent sputum, malaise, headache, shortness of breath and tachycardia. Pneumonia is diagnosed according to the clinical and radiological picture, auscultative data, and laboratory results. Therapy is aimed at all links of etiopathogenesis and includes the appointment of antibiotics, mucolytics, bronchodilators, expectorants and antihistamines, infusion therapy, oxygen therapy, physiotherapy.
J18 Pneumonia without specifying the causative agent
Acute pneumonia is an infectious and inflammatory lesion of the respiratory parts of the lungs, occurring with intoxication and bronchopulmonary syndrome, characteristic radiological changes. Disease is one of the most common diseases of the respiratory system, is often accompanied by complications, causes up to 9% of deaths, which requires increased attention of specialists in the field of therapy and pulmonology. According to the nature of the course, disease is divided into acute (up to 3 weeks) and prolonged (up to 2 months), usually developing against the background of a decrease in the immuno-biological reactivity of the macroorganism. Cases of acute pneumonia are noticeably more frequent in the winter-spring period, especially with sharp fluctuations in the weather, during epidemic outbreaks of respiratory infections.
Causes of acute pneumonia
The dominant role in the etiology of acute pneumonia belongs to infection, primarily bacterial. Usually the causative agents of the disease are pneumococci (30-40%), mycoplasma (6-20%), Staphylococcus aureus (0.4-5%), Friedlander’s bacillus, less often – hemolytic and non–hemolytic Streptococcus, Pseudomonas aeruginosa and Hemophilus bacillus, fungi and their associations; among viruses – influenza virus, MS virus, adenoviruses. Purely viral acute pneumonia is rare, usually acute respiratory viral infections facilitate colonization of lung tissue by endogenous or less often exogenous bacterial microflora. In ornithosis, chickenpox, whooping cough, measles, brucellosis, anthrax, salmonellosis, the development of acute pneumonia is determined by the specific causative agent of this infection. Microorganisms enter the lower respiratory tract by bronchogenic pathways, as well as hematogenic (in infectious diseases, sepsis) and lymphogenic (in chest injury) pathways.
Acute pneumonia can occur after exposure to the respiratory parts of the lungs to chemical and physical agents (concentrated acids and alkalis, temperature, ionizing radiation), usually in combination with secondary bacterial infection with autogenic microflora from the pharynx and upper respiratory tract. Due to the long-term use of antibiotics in the development of acute pneumonia, the role of conditionally pathogenic microflora has become more significant. There are cases of allergic (eosinophilic) acute pneumonia caused by helminthiasis and taking medications. Pathology can occur uncomplicated and with complications; mild, moderate or severe; with the absence or development of functional disorders.
Various factors that reduce the resistance of the macroorganism predispose to the occurrence of acute pneumonia: prolonged intoxication (including alcohol and nicotine), hypothermia and increased humidity, concomitant chronic infections, respiratory allergies, nervous shocks, infancy and old age, prolonged bed rest. The penetration of infection into the lungs is facilitated by a violation of the patency and drainage function of the bronchi, suppression of the cough reflex, insufficiency of mucociliary clearance, defects of the pulmonary surfactant, a decrease in local immunity, including ch., phagocytic activity, lysozyme and interferon levels.
In acute pneumonia, inflammation affects the alveoli, interalveolar septa and the vascular bed of the lungs. Moreover, in different areas of the affected lung, different phases can be observed simultaneously – high tide, red and gray “opechenie”, resolution. Morphological changes are variable depending on the type of pathogen. Some microorganisms (Staphylococcus, Pseudomonas aeruginosa, Streptococcus) secrete exotoxins that cause deep damage to the lung tissue with the appearance of multiple small, sometimes merging foci of abscessing pneumonia. In acute Friedlander pneumonia, extensive infarct-like necrosis in the lungs is organized. Interstitial inflammation dominates in pneumonia of pneumocystic and cytomegalovirus genesis.
Classification of acute pneumonia is based on differences in etiology, pathogenesis, anatomical and clinical manifestations. According to clinical and morphological properties, parenchymal and interstitial pneumonia are distinguished; croup (lobar or pleuropneumonia) and focal (bronchopneumonia); according to the prevalence of inflammation – small focal, focal (within the boundaries of several lobules), large focal and drain (covering most of the lobe).
Acute pneumonia occurs primarily or secondarily as complications of infectious diseases (ARVI, influenza, measles), chronic pathology of the respiratory system (bronchitis, tumors), cardiovascular system, kidneys, blood, systemic diseases, metabolic disorders. Taking into account epidemic criteria, community-acquired and hospital forms of acute pneumonia are distinguished.
According to the causal factor, infectious (bacterial, viral, mycoplasma, rickettsiosis, fungal, mixed), allergic, stagnant, post-traumatic acute pneumonia, as well as pneumonia caused by chemical or physical stimuli are distinguished. Aspiration pneumonia can develop when inhaling foreign bodies (food particles, vomit); infarction-pneumonia – due to thromboembolism of the pulmonary vascular network.
Symptoms of acute pneumonia
The clinical picture of acute pneumonia may differ in the level of severity of general and bronchopulmonary manifestations, which is largely determined by the pathogen, the patient’s state of health, the course of concomitant pathology. Most forms of disease are characterized by the constant presence of common disorders: chills, a sharp rise in temperature and persistent fever, general weakness, sweating, headache, tachycardia, agitation or adynamia, sleep disorders. Cough in acute pneumonia has a different character, accompanied by the release of mucopurulent sputum, rapid breathing (up to 25-30 per minute), pain in the chest or under the shoulder blade. Focal pneumonia (bronchopneumonia) in most cases begins against the background of bronchitis or acute catarrh of the upper respiratory tract. Febrile fever of the wrong type is typical, the elderly and weakened individuals may have a normal or subfebrile temperature.
Influenza pneumonia usually develops acutely on the first or third day of the flu. Flowing, as a rule, easier than bacterial, sometimes it can acquire a severe course with significant intoxication and high fever, persistent cough, rapid development of pulmonary edema. Late pneumonia, which occurs during the recovery from influenza, is caused by bacterial microflora.
Staphylococcal pneumonia often occurs as a complication of sepsis. It is characterized by a tendency to abscess, accompanied by a severe general condition, febrile fever, cough with purulent or mucopurulent sputum, and in children and the elderly – a severe lightning course. Possible development of empyema of the lungs. The number of deaths in this type of acute pneumonia remains high. Streptococcal pneumonia is observed less frequently, complicating the course of acute respiratory viral infections, measles, whooping cough, chronic lung diseases, accompanied by necrosis of lung tissue, exudative pleurisy. Pneumonia caused by Pseudomonas aeruginosa is severe: with the risk of dissemination, abscess formation, and with the breakthrough of the abscess into the pleura – the development of pyopneumothorax.
A pronounced clinic of croup pneumonia unfolds suddenly, expressed in terrific chills, fever up to 39-40 ° C, increasing shortness of breath, cough with rusty sputum, tachypnea (30-40 in min.) and tachycardia (100 – 120 beats . in min.), severe chest pains (with involvement of the diaphragmatic pleura – with irradiation into the abdominal cavity). The high temperature can persist for several days, then subside for 1-3 days. With a severe course of croup pneumonia, diffuse cyanosis, hypotension appears, patients may experience agitation, lethargy, a state of acute psychosis; elderly people with concomitant pathology have suppurative processes in the lungs and pleura; the risk of death is high.
In the outcome of acute pneumonia , possible:
- complications from the lungs (para- and metapneumonic pleurisy, acute respiratory failure, pneumosclerosis, atelectasis, lung abscess)
- extrapulmonary complications (infectious-toxic shock, purulent and fibrinous serositis, meningitis, infectious-allergic myocarditis, etc.).
In 1-4% of cases, the transition of acute pneumonia to a chronic form is likely.
The diagnosis of acute pneumonia is based on clinical and radiological data, the results of the assessment of the FER, the study of laboratory parameters. Evaluation of percussion in croup pneumonia reveals a dulling of the tone of sound as the exudation of the alveoli increases. Auscultation during inspiration is heard crepitation, sometimes small bubbly wheezing, later – bronchial breathing, bronchophony, pleural friction noise.
In the blood, leukocytosis, accelerated ESR, positive acute phase reactions are indicative; in the urine, proteinuria, cylindruria and microhematuria are possible. In sputum with acute focal pneumonia, a lot of bacteria, leukocytes and the exfoliated epithelium of the respiratory tract are found, with the croup form – erythrocytes.
If acute pneumonia is suspected, lung x-ray is prescribed in two projections in dynamics (on day 7-10 and week 3-4). Radiological evidence of infiltrative changes in croup and large–focal pneumonia is segmental or lobular homogeneous intense shading of the lung tissue; in bronchopneumonia – heterogeneous shading of a portion of the lobe of medium and low intensity with the capture of peribronchial and perivascular areas. In the case of slowing the resorption of infiltrates in acute pneumonia, CT of the lungs is indicated.
Bacposev sputum, blood, urine allows you to establish the pathogen and its antibiotic sensitivity. Changes in the restrictive type of FER are characteristic of extensive drainage focal and croup pneumonia. Bronchoscopy and bronchography are performed with a prolonged course of acute pneumonia, which makes it possible to detect the presence of bronchiectasis, decay cavities in the lung tissue. As part of the diagnosis, bronchitis, lung cancer, tuberculosis, lung infarction, atelectatic bronchiectasis are excluded.
Treatment of acute pneumonia
Patients with acute pneumonia require an early start of treatment, usually in a hospital setting. During the feverish period, bed rest, abundant drinking and easily digestible high-calorie nutrition, vitamins are shown. In acute pneumonia, etiotropic therapy with antibacterial drugs prescribed based on clinical and radiological features is effective. Semi-synthetic penicillins, aminoglycosides, cephalosporins, macrolides, tetracyclines are used, rifampicin, lincomycin as backup. In the acute phase and in severe cases, 2-3 antibiotics or a combination of an antibiotic with metronidazole, sulfonamides may be prescribed. The intensity of the course of antibiotic therapy depends on the severity and prevalence of lung damage.
Patients with acute pneumonia are shown bronchodilators and expectorants, mucolytics. To eliminate intoxication, infusions of saline solutions, rheopolyglucine are carried out, in case of shortness of breath and cyanosis, oxygen therapy is required. In case of cardiovascular insufficiency, cardiac glycosides, sulfocamphocaine are prescribed. In addition to antibiotic therapy, anti-inflammatory and antihistamines, immunocorrectors are used. At the stage of acute pneumonia resolution, physiotherapy is effective (inhalation, electrophoresis with calcium chloride, UHF, vibration massage, exercise therapy).
Prognosis and prevention
The prognosis of acute pneumonia with early full-fledged treatment is quite favorable. Foci of fibrinous inflammation undergo resorption within 2-4 weeks, destructive ones – within 4-6 weeks. Residual phenomena may persist for six months or longer. Extremely severe course with complications and fatal outcome is more common in infants, the elderly and the elderly, weakened patients with serious concomitant diseases.
Measures for the prevention of acute pneumonia include giving up bad habits, exercising and hardening, proper nutrition, rehabilitation of chronic foci of infection, vaccination against influenza, prevention of stress. Those who have had acute pneumonia are on the dispensary register with a pulmonologist for six months.