Lobar pneumonia is an acute infectious and allergic inflammation that engulfs one or more lobes of the lung and pleura. Lobar pneumonia is manifested by chills, fever, headache and pleural pain, general weakness, sweating, shortness of breath, wet cough. The diagnosis of lobar pneumonia is made based on anamnesis, auscultation, lung radiography data, clinical blood analysis. In case of lobular pneumonia, it is important to prescribe antibiotics early, conduct symptomatic and detoxification therapy, and physiotherapy.
J18.1 Lobar pneumonia, unspecified
Depending on the clinical and morphological signs in pulmonology, lobar pneumonia (croup, pleuropneumonia) and focal (lobular, bronchopneumonia) are distinguished. The incidence of various forms of acute pneumonia is quite high: among non-specific lung diseases, pneumonia accounts for 29.3% of cases. Lobar or lobar pneumonia is characterized by the defeat of the whole lobe of the lung (respiratory bronchioles and alveolar tissue without the interest of larger bronchi) and the involvement of the pleura. Lobar pneumonia mainly affects adults, less often children.
The causative agents of most cases of lobular pneumonia are various strains of pneumococcus (less often – other microorganisms, for example – Friedlander’s diplobacillus), which can enter the lung usually by bronchogenic, less often by hematogenic or lymphogenic pathways.
The development of lobular pneumonia is closely related to the persistence of pneumococcus in the nasopharynx of a healthy person and the preliminary sensitization of the body to its antigens. Acute onset of the disease is possible against the background of complete health in the absence of contact with patients or with repeated ingestion of pneumococci into the respiratory tract.
The risk of developing lobular pneumonia may increase against the background of:
- transferred flu and SARS
- reduction of general and local immunity
- excessive physical exertion.
Various background conditions contribute to the development of lobular pneumonia:
- diabetes mellitus
- oncological diseases
- chronic alcoholism.
The pathogenetic picture of lobar pneumonia is characterized by the development of hypersensitivity of the immediate type. Hyperergic reaction in the respiratory tract causes acute inflammatory changes in the pulmonary parenchyma, and the process, starting in one or more foci, spreads rapidly through the interalveolar pores of the Cone through the lung tissue. Damage to small blood and lymphatic vessels of the lungs by immune complexes and enzymes of microorganisms in lobular pneumonia leads to pronounced vascular permeability disorders and the appearance of fibrinous exudate.
Depending on the morphological changes in lung tissue in the development of classical lobar pneumonia, there are 4 stages:
- red opechenie
- gray opechenie
Lobar pneumonia is characterized by a sudden, acute onset. Among the early symptoms of the disease are general intoxication (the appearance of severe chills, then constant, for 7-10 days, a feverish state with a rise in temperature above 39 ° C, headache, general weakness, sweating) and bronchopulmonary (shortness of breath, pleural pains on the affected side associated with breathing, cough, sputum separation).
The temperature reaction of the body reflects the nature of the development of the inflammatory process in the lung: with uncomplicated lobar pneumonia, the daily temperature fluctuations are small (0.5-1 °C); with the development of purulent-destructive and septic complications – more than 1-2 ° C with recurrent chills; in elderly and weakened patients – fever may be absent.
Chest pain with lobar pneumonia is acute and intense, has a clear localization, increases at the height of a deep breath and when the body is tilted to the healthy side, so breathing is often shallow.
The cough characteristic of lobar pneumonia in the first two days of the disease is dry and unproductive, often appears on a deep breath together with pleural pains; with the appearance of fibrinous exudate (3-4 days), a small amount of viscous, mucopurulent or “rusty” (with an admixture of blood) sputum begins to separate when coughing.
The severity of dyspnea in lobular pneumonia depends on the stage and severity of the inflammatory process, the presence of a burdened history. Young patients usually have a slight feeling of lack of air and tachypnea during physical exertion; with severe course of lobar pneumonia and concomitant diseases of the lungs and heart, acute respiratory failure (ARF) occurs with shortness of breath at rest, a painful feeling of lack of air, cyanosis of the nasolabial triangle.
Due to intoxication with lobular pneumonia, there is a rapid increase in general weakness, the development of adynamia, neurological symptoms: excitement, insomnia, delirium and hallucinations, loss of consciousness. Various functional disorders are often observed – heaviness in the epigastrium, loss of appetite, flatulence, unstable stools, jaundice staining of the skin, sclera of the eyes and mucous membranes, muscle and joint pain, arrhythmia, tachycardia, deafness of heart tones, decreased blood pressure, vascular and heart failure.
Based on the features of the clinical picture, there are three forms of lobar pneumonia: upper lobe, lower lobe and central.
- In the upper lobe form, the course of the disease is severe with pronounced symptoms, hemodynamic and neurological disorders
- In the lower lobe form, a pseudo–picture of an “acute abdomen” occurs with fever, chills and “rusty” sputum
- In the central form of lobar pneumonia, the inflammatory process develops in the depth of the pulmonary parenchyma and has weakly expressed symptoms.
Pulmonary complications of lobular pneumonia are caused by a violation of the fibrinolytic function of neutrophils. They include:
- abscess and gangrene of the lung
- parapneumonic pleurisy
- empyema of the pleura
Extrapulmonary complications occur with the spread of infection by lymphogenic or hematogenic pathways. These include:
- purulent mediastinitis and pericarditis
- purulent arthritis
- brain abscess
- purulent meningitis
- endocarditis with aortic valve lesion
- the development of heart failure.
The difficulties of early diagnosis of lobular pneumonia in modern conditions are due to the rather diverse clinical picture of the disease and the erasure of symptoms. Diagnosis of lobar pneumonia begins with questioning the patient (presence of complaints, risk factors, concomitant diseases, etc.) and his physical examination. Suspicion of lobular pneumonia should cause the presence of high fever and other symptoms of intoxication, shortness of breath, cough, pleural pain, cyanosis of the lips and tip of the nose.
- Physical data. Diagnostic signs of lobar pneumonia during physical examination are: the presence of tachycardia and rapid shallow breathing; chest lag on the side of the lesion in the act of breathing; local chest soreness; increased vocal tremor and bronchophony, percussion dullness. During auscultation, in the case of lobar pneumonia, characteristic inspiratory crepitation and pleural friction noise are heard, later pathological bronchial breathing (stiff or weakened vesicular), moist deaf or sonorous small-bubbly wheezes can be determined.
- Radiological data. Of particular importance for confirming the diagnosis of lobar pneumonia are the results of lung radiography in 2 projections: radiographs reveal an increase in the pulmonary pattern and non-structural root in the affected area at the beginning of the disease; homogeneous segmental foci of infiltration on the periphery of the pulmonary fields on day 4-6.
- Laboratory data. When examining the peripheral blood of a patient with lobular pneumonia, leukocytosis with a shift of the formula to the left (in very severe cases – leukopenia), an increase in ESR, hyperfibrinogenemia are noted. To identify the causative agent of lobular pneumonia, sputum sowing on the microflora helps to determine sensitivity to antibiotics.
Differential diagnosis of lobular pneumonia is necessary with acute cholecystitis, gastric ulcer or 12-pert intestine, acute appendicitis or pancreatitis (with acute pain in various parts of the abdomen); with lung infarction (with prolonged cough and separation of bloody sputum); bronchiectatic disease, hemorrhagic tracheobronchitis, tuberculosis and bronchogenic lung cancer (with hemoptysis).
In the treatment of lobular pneumonia, antibiotic therapy plays a leading role, which must be started immediately, without waiting for the results of sputum back-sowing, using an empirical method taking into account the resistance of the pathogen to the most commonly used drugs. With community-acquired lobar pneumonia, aminopenicillins (ampicillin, ticarcillin), fluoroquinolones of the third generation (ciprofloxacin, ofloxacin) are used, sometimes with severe disease and penicillin intolerance – macrolides and cephalosporins of the III – IV generation.
In case of hospital lobar pneumonia, the treatment regimen includes penicillins, cephalosporins, fluoroquinolones, carbapenems, aminoglycosides (sometimes in combination with each other or with the replacement of one with another). The duration of antibiotic therapy depends on the severity and nature of the course of lobular pneumonia, the adequacy and timeliness of the treatment, the rate of normalization of the patient’s condition, the dynamics of laboratory, radiological indicators and can range from 7-10 to 14-21 days.
In the acute period of lobular pneumonia, bed rest, abundant warm drinking and full nutrition are indicated. Additionally, with lobular pneumonia, anti-inflammatory therapy, taking antipyretics, antihistamines, mucolytics, immunostimulants are carried out. Physiotherapy procedures are prescribed: medicinal electrophoresis (with calcium chloride, hyaluronidase), UHF, medicinal inhalations, chest massage and exercise therapy.
Treatment of complications
Treatment of ARF for lobular pneumonia includes, according to indications: ventilator, therapeutic bronchoscopy, oxygen therapy. In the presence of infectious-toxic shock, blood pressure stabilization, correction of metabolic acidosis and microcirculatory disorders, infusion therapy, inhibition of proteolytic enzymes are carried out.
Prognosis and prevention
The prognosis of lobular pneumonia is determined by the presence of risk factors for complications (children under 5 years of age and the elderly, people with severe concomitant diseases, decreased immunity, bacteremia, etc.). The outcome is favorable with timely access to a pulmonologist, adequate therapy, as well as in young patients without concomitant pathology. Longer treatment of lobular pneumonia is required when more than one lobe of the lung is affected, as well as in patients with concomitant diseases (CHD, COPD, hepatitis) or suffering from alcoholism.
Hardening, physical activity, prevention of hypothermia and stress, rehabilitation of foci of chronic infection can serve as preventive measures for lobar pneumonia.
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