Chronic pneumonia is a local nonspecific inflammation of the lung tissue, the morphological signs of which are carnification, pneumosclerosis and deforming bronchitis. It is the outcome of acute pneumonia that has not fully resolved. Clinically manifested by periodic relapses of the inflammatory process (fever, sweating, weakness, cough with mucopurulent sputum). Chronic pneumonia is diagnosed taking into account radiological and laboratory signs, the results of bronchoscopy and spirography. During periods of exacerbation, antimicrobial therapy, bronchodilators, mucoregulators are prescribed; bronchoscopic sanitation, massage is performed. With frequent exacerbations, lung resection is indicated.
J18 Pneumonia without specifying the causative agent
Chronic pneumonia is persistent structural changes in the lung, characterized by local pneumosclerosis and bronchial deformity, accompanied by periodic recurrence of inflammation. According to pulmonologists, the transition of acute pneumonia to a chronic form is observed in 3-4% of adults and in 0.6-1% of children’s patients. In the structure of HCL, chronic pneumonia accounts for 10-12% of cases. Over the past decades, due to the improvement of treatment protocols for O.pneumonia, the introduction of new effective antibiotics into clinical practice, the number of cases of chronic pneumonia has significantly decreased.
The concept of “chronic pneumonia” arose in 1810 to designate various non-tuberculosis chronic processes in the lungs. Since then, the concept of chronic pneumonia has been repeatedly discussed and revised by therapists and pulmonologists around the world. To date, chronic pneumonia, as a nosological unit, has not been reflected in the ICD-10 and is not recognized by most American doctors.
Causes of chronic pneumonia
Chronic pneumonia develops in the outcome of acute or prolonged pneumonia with their incomplete resolution, especially when areas of hypoventilation or atelectasis are preserved in the lung. Exacerbations of chronic pneumonia are most often provoked by acute respiratory viral infections (parainfluenza, adenovirus infection), in children also by childhood infections (measles, whooping cough, chickenpox).
The bacterial landscape sown during microbiological examination of sputum or bronchial flushes is represented by a diverse flora (pathogenic Staphylococcus, pneumococcus, hemolytic streptococcus, Hemophilus Pfeiffer, Pseudomonas aeruginosa, Candida fungi, etc.). In most cases, these agents are mixed coccal flora (Staphylococcus in association with other microbes). The etiological role of mycoplasmas has been proven in 15% of patients with chronic pneumonia.
Inadequate and untimely treatment of the acute process, early discharge, as well as factors reducing the reactivity of the body (old age, hypovitaminosis, alcoholism, smoking, etc.) can contribute to the chronization of pulmonary inflammation. It is proved that chronic pneumonia develops more often in patients with concomitant chronic bronchitis. In children, care defects, hypotrophy, exudative diathesis, primary tuberculosis, timely untreated foreign bodies of the bronchi, chronic nasopharyngeal infections (adenoiditis, tonsillitis, sinusitis, etc.) play an important role.
The morphological basis of chronic pneumonia is irreversible changes in lung tissue (pneumosclerosis and/or carnification) and bronchi (deforming bronchitis). These changes lead to a violation of respiratory function mainly of the restrictive type. Hypersecretion of mucus in combination with ineffective drainage capacity of the bronchi, as well as violation of aeration of the alveoli in the zone of pneumosclerosis lead to the fact that the affected area of the lung becomes the most vulnerable to various kinds of adverse effects. This is expressed in the occurrence of repeated local exacerbations of the bronchopulmonary process.
The lack of common views on the essence of chronic pneumonia has led to the existence of many classifications, but not one of them is generally accepted. The “Minsk” (1964) and “Tbilisi” (1972) classifications are currently of historical interest and are not used in everyday practice.
Depending on the prevailing pathomorphological changes, chronic pneumonia is usually divided into carnificative (carnification prevails – overgrowth of the alveoli with connective tissue) and interstitial (interstitial pneumosclerosis prevails). These forms correspond to their own clinical and radiological picture.
According to the prevalence of changes, focal, segmental (polysegmental) and lobar chronic pneumonia are distinguished. Taking into account the activity of the inflammatory process, the phases of remission (compensation), sluggish inflammation (subcompensation) and exacerbation (decompensation) are distinguished.
Symptoms of chronic pneumonia
The criteria for the transition of acute pneumonia to chronic is the absence of positive radiological dynamics in the period from 3 months to 1 year or longer, despite prolonged and intensive therapy, as well as repeated relapses of inflammation in the same area of the lung.
During periods of remission, symptoms are scarce or absent. The general condition is satisfactory, an unproductive cough is possible in the morning. With the exacerbation of chronic pneumonia, a subfebrile or febrile temperature, sweating, weakness appears. The cough intensifies and becomes permanent, sputum acquires a mucopurulent or purulent character. There may be chest pains in the projection of a pathological focus, occasionally there is hemoptysis.
The severity of exacerbations can vary significantly: from relatively mild forms to severe, occurring with the phenomena of cardiopulmonary insufficiency. In the latter case, patients have severe intoxication, shortness of breath at rest, cough with a large amount of sputum. The exacerbation resembles a severe form of croup pneumonia.
With insufficiently complete or too short treatment, the exacerbation does not go into remission, but is replaced by sluggish inflammation. During this phase, mild fatigue persists, periodic cough with dry or sputum, shortness of breath with physical effort. The temperature can be normal or subfebrile. Only after additional, carefully conducted therapy, the sluggish process is replaced by remission.
The most important complications of disease affecting its subsequent course are pulmonary emphysema, diffuse pneumosclerosis, bronchiectasis, asthmatic bronchitis.
Mandatory methods of confirmatory diagnostics include X-ray, endoscopic, functional, laboratory examination:
- X-ray. Lung x-ray in 2 projections is crucial in the verification of chronic pneumonia. Radiographs may reveal the following signs: a decrease in the volume of the lung lobe, deformation and heaviness of the pulmonary pattern, focal shadows (during carnification), peribronchial infiltration, pleural changes, etc. In the exacerbation phase, fresh infiltrative shadows are detected against the background of pneumosclerosis. Bronchography data indicate deforming bronchitis (uneven contours and uneven contrast distribution are determined).
- Bronchoscopy. Bronchological examination may reveal catarrhal (without exacerbation) or purulent (with exacerbation) bronchitis, more pronounced in the corresponding segment or lobe.
- Spirometry. In uncomplicated forms of chronic pneumonia, FER indicators may vary insignificantly. With concomitant diseases (obstructive bronchitis, emphysema), the FVCL and VCL, the Tiffno index and other values decrease.
- Analyzes. Changes in general and biochemical blood tests are more characteristic of the exacerbation phase of chronic pneumonia. During this period, there is an increase in ESR, leukocytosis with a shift to the left, an increase in fibrinogen, alpha and gamma globulins, seromucoid, haptoglobin. Sputum microscopy reveals a large number of neutrophils; bacanalysis allows you to determine the nature of pathogenic microflora.
Thorough differential diagnosis should be carried out with lung cancer, chronic bronchitis, BEB, chronic lung abscess, pulmonary tuberculosis. This may require additional examination (X-ray tomography, CT of the lungs, a trans-bronchial or transthoracic lung biopsy, tuberculin tests, thoracoscopy).
Treatment for chronic pneumonia
The principles of therapy during the exacerbation of chronic pneumonia fully comply with the rules of treatment of acute pneumonia. Antibacterial drugs are selected taking into account the sensitivity of pathogens, while two antibiotics of different groups (penicillins, cephalosporins of the II-III generation, macrolides) are often used simultaneously. Antibiotic therapy is combined with infusion, vitamin, immunocorrective therapy, intravenous administration of calcium chloride, taking bronchodilator and mucolytic drugs.
Much attention is paid to endotracheal and endobronchial sanitation (washing of the bronchial tree with sodium bicarbonate solution and administration of antibiotics). During the period when the exacerbation subsides, inhalations, respiratory gymnastics, chest massage, physiotherapy (CMV, inductothermy, medicinal electrophoresis, UHF, hydrotherapy) are added. With frequent and severe exacerbations caused by complications of chronic pneumonia, the issue of resection of the lung area is resolved.
Prognosis and prevention
In the remission phase, the patient should be observed by a pulmonologist and a local therapist at the place of residence. To prevent exacerbations of chronic pneumonia, it is recommended to stop smoking, rational employment, treatment of nasopharyngeal infection, rehabilitation in sanatoriums-dispensaries. With properly organized treatment and follow-up, the prognosis of chronic pneumonia is relatively favorable. If it is impossible to achieve full compensation for the inflammatory process, patients are assigned group III-II disability. The prognosis worsens due to the development of concomitant complications and cardiopulmonary insufficiency.