Purulent pleurisy of the lungs: treatment, symptoms, consequences. Causes of purulent pleurisy, characteristic symptoms, possible consequences and methods of treatment Purulent lung damage in which pneumonias
Content
Inflammation of the lung tissue, which results in cell death and the formation of purulent necrotic cavities, is called a lung abscess: only correct diagnosis and adequate subsequent treatment of the disease can save the patient’s life. The causative agents of this disease are often harmful anaerobic and other bacteria, but the development of the disease is also possible due to injury (bruise, wound), bronchial aspiration (foreign body, vomit or tumor) or against the background of an untreated disease (pneumonia, tuberculosis).
What is a lung abscess
After the pathogen enters the airways, the process of tissue inflammation and cell death in certain areas of the organ (lung abscess) may begin. Harmful bacteria are often transferred to the bronchi from other organs or systems of the body (the main focus is created by periodontal disease, tonsillitis, gingivitis). Sometimes the cause of the formation of necrotic cavities can be sepsis. Features of the flow:
- The period of formation = directly depends on the cause and the body’s immunity. On average, it lasts from 3 days to 3 weeks.
- The next stage is the opening of the cavity with pus and the outflow of sputum through the bronchi.
This disease has several course options, so you need to carefully monitor your health during treatment and changes in symptoms:
- with a mild course, the clinical signs of the disease are mild, there are no sudden changes in temperature or severe cough (favorable course);
- with a moderate course of the disease, symptoms are moderately expressed;
- in severe cases, all symptoms are pronounced, and complications of the disease may occur.
Symptoms
In the initial stage, tissues become inflamed within one area, and infiltration of this area occurs. As a result of the spread of pus from the center to the peripheral areas, a cavity (abscess) appears. After breakthrough, the sputum is removed from the body through the bronchi. Gradually, the inflamed area is filled with granulation tissue and a zone of pneumosclerosis appears. When a cavity with fibrous walls is formed, the purulent process has the opportunity to be maintained independently for a long period.
During the period of formation and breakthrough of suppuration, the symptoms of the disease differ significantly; often after the breakthrough, the patient’s well-being noticeably improves, as described in the table:
Manifestations of the disease during formation | Symptoms of a lung abscess after a breakthrough of a purulent cavity |
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Acute form
An abscess of an area of the lung in acute form at the initial stage is manifested by several symptoms at once. With a favorable course, the entire period from the onset of the disease to recovery lasts no more than 6 weeks; with proper drainage, all sputum is removed from the organ, and only a thin-walled small cyst remains in place of the cavity. After the abscess breaks through, the patient’s condition immediately improves. In 80% of cases, this form of the disease is characterized by a single abscess. An abscess of the right lung often occurs in men aged 30 to 50 years.
Chronic form
If a lung abscess is not cured within 2 months, it becomes chronic. This form is characterized by cyclical alternation of periods of remission and exacerbations. During the activation of the purulent process, fever appears and the amount of purulent sputum increases. The duration of each period depends on the ability of the bronchi to drain and empty the lung abscess cavity. During the period of remission, the patient may complain of:
- bouts of barking cough;
- increased sputum production when changing body position;
- fatigue, weakness.
Often, the transition of a disease to a chronic form has reasons related to the individual characteristics of the patient’s disease or errors in the doctor’s prescription of treatment:
- purulent cavities more than 6 cm in diameter;
- sequestration in the abscess;
- there are no conditions for good drainage of sputum, the area is located in the lower lobe of the organ;
- insufficient immunity;
- incorrectly (or late) prescribed antibacterial therapy;
- insufficient therapeutic procedures to improve drainage;
- lack of restorative drugs for the patient’s body.
Sputum from lung abscess
Doctors often say that the first sign of the disease can be found in the cuspidor. And this is true, because after a breakthrough through the respiratory tract, a lot (up to 1 liter) of specific sputum is released. This discharge after standing for a long time consists of three layers of liquid - yellow mucus, pus and a watery layer (the lower layer is denser and thicker). This sputum has a strong putrid odor, so the patient is provided with a separate room. Sometimes a small amount of blood is mixed with purulent discharge.
Causes of pus in the lungs
The appearance of pus in the tissues and subsequent decomposition of the lungs is often associated with the deprivation of air in areas of the organ. There are many factors for such a process. An abscess of a section of the lung can develop due to harmful microorganisms entering the respiratory system (bronchogenic method). If there are foci of infection in other organs of the body, it can reach the respiratory system through the hematogenous route of infection (through the bloodstream). Often, a lung abscess can begin as a result of injury or blockage of the respiratory system by foreign objects.
The likelihood of development is very high in people with bad habits and untreated diseases (risk group):
- alcoholism, smoking, taking drugs;
- neoplasms;
- diabetes;
- sinusitis, otitis;
- periodontal disease;
- disruption of the gastrointestinal tract as a result of operations (chest and abdominal cavity);
- immunodeficiency;
- epilepsy.
In children
Acute or chronic forms of lung abscesses in children are much less common than in adults. They often arise due to the entry of a pathogen of bacterial or fungal etiology into the child’s body. The clinical picture and causes of purulent inflammation in a small patient are practically no different from the etiology of the disease in adults. In children, common symptoms often include vomiting or diarrhea. Purulent formations often do not merge into an abscess; tissue damage occurs in small foci (spots).
Classification
An abscess of a section of the lung can be considered primary (if the disease arose as a result of damage to the parenchyma) and secondary (if the inflammatory process began as a result of another disease). There are different types of disease depending on the type of pathogen and the mode of infection. In addition, in the classification of the disease, depending on the location, abscesses are distinguished between central (located closer to the middle of the organ) and peripheral (located at the edges of the lung). In this case, ulcers:
- may be single or multiple;
- located in one or both paired respiratory organs.
Diagnostics
When the first signs of the disease appear, you should consult a pulmonologist. He will prescribe all the necessary tests and studies, with the help of which you can diagnose the degree of tissue damage, the body’s general response to the disease and choose an appropriate treatment regimen. You need to pay very close attention to the symptoms if you have a history of chronic respiratory diseases or other predisposing factors. If purulent inflammation of other organs is detected, the likelihood of damage to the respiratory system increases.
To obtain a clear clinical picture, it is necessary to conduct a number of tests and studies:
- general blood test, paying special attention to the number of leukocytes;
- blood chemistry;
- sputum analysis, identifying pathogens and determining their sensitivity to the effects of drugs (antibiotics);
- X-ray examination of the chest (localization of the lesion);
- computed tomography (more detailed diagnosis of the abscess);
- fibrobronchoscopy (to determine the condition of the respiratory tract tissues).
Treatment of lung abscess
When choosing a treatment regimen for a lung abscess, it is necessary to follow an integrated approach. In most cases, you can manage with conservative methods of treatment, in which the doctor prescribes large doses of broad-spectrum antibiotics and general restorative therapy. The patient must be hospitalized and therapy must be started immediately. It is very important that the sick body receives high-quality (mainly protein with the required amount of vitamins) nutrition and has constant access to fresh, oxygen-rich air.
A conservative treatment method is a complex of hygienic procedures (drainage, massage, gymnastics) and medications aimed at alleviating the patient’s condition:
- antibiotics (broad-spectrum, sensitivity tests are carried out before prescription);
- antiseptics;
- mucolytics (to thin out purulent sputum);
- expectorants;
- medications to relieve intoxication;
- inhalation with oxygen;
- means aimed at stimulating the body's immune system (immunostimulants).
Operation
If the tried conservative treatment methods do not produce results and the progression of inflammation continues, doctors recommend removal of the pathological cavities. Surgical intervention is required in cases where treatment does not produce results within 2-3 months, in case of pulmonary bleeding or a large purulent cavity. If, during an active infectious process, the number of foci increases, gangrene develops, or destructive collapse of the lung is possible, doctors recommend puncture or removal of the affected lung.
Complications
Often, complications of a lung abscess occur as a result of untimely or poor-quality treatment. It is very important to begin taking therapeutic measures (taking antibacterial drugs and other methods of therapy) when the first signs characteristic of this disease are detected. We must try to prevent the disease from becoming chronic, because it is then less treatable. An abscess of lung tissue can cause complications that can be fatal.
If you do not consult a doctor with the first signs of the disease, the risk of developing such consequences from a lung abscess increases sharply. Noted:
- insufficient amount of oxygen in the respiratory system;
- pneumothorax (break of pus into the pleural cavity), pleurisy;
- opening of pulmonary hemorrhage;
- tumor formation;
- spread of infection to other organs and systems of the body;
- emphysema;
- bronchial deformation.
Prognosis and prevention
In most cases, with adequate treatment, the outcome is favorable; after one and a half to two months, the infiltrate around the abscess resolves and the cavity is restored. The main way to protect yourself from this process is a gradual transition to a healthy lifestyle. It is necessary to give up bad habits, fatty and unhealthy foods. Regular medical examination will help to identify almost any negative processes in the body and will allow you to eliminate them in a timely manner, preventing them from becoming chronic.
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A lung abscess is a purulent-destructive cavity filled with pus, surrounded by an area of inflammatory perifocal infiltration of the lung tissue.
Lung abscess is a polyetiological disease. Acute pulmonary pleural suppuration occurs as a result of polymicrobial infection by aerobic-anaerobic associations of microorganisms. Among them, pneumococcus, non-spore-forming anaerobic microorganisms (bacteroides, peptococcus, etc.), Staphylococcus aureus, and gram-negative aerobic rod microflora (Proteus, less often Escherichia coli, etc.) predominate.
Staphylococcus and pneumococcus are found in association with Klebsiella, Enterobacter, Serration, and Bacteroides. With lung abscesses, high bacterial contamination is noted (1.0 x 10 4 - 1.0 x 10 6 microbial bodies in 1 ml).
Diseases of the following groups lead to the development of acute abscesses or gangrene of the lung:
. lobar or viral pneumonia. This is the most common, if not the main, cause of lung abscesses;
. aspiration of foreign bodies, tumors or scars that narrow the bronchial lumen and thereby disrupt its drainage function with conditions for the development of microflora penetrating from the bronchi;
. septicopyemia, thrombophlebitis, other purulent diseases that can lead to damage to the lungs by hematogenous or lymphogenous route with the development of a pneumonic focus;
. traumatic injuries (open and closed) of lung tissue with primary or secondary infection.
Embolic lung abscesses are often multiple and localized in the peripheral parts of both lungs. Aseptic pulmonary infarctions develop abscesses extremely rarely.
In acute purulent lesions of the lungs, infection most often occurs through the aerogenous route. This is a transbronchial entry of microorganisms with the development of pneumonia, when the infectious agent is mixed in the direction of the respiratory sections with the air flow. The aspiration route of infection is rare, and hematogenous-embolic infection is extremely rare.
The process of abscess formation in the lung can occur in different ways. I.S. Kolesnikov, M.I. Lytkin (1988) identifies three possible options (types) for the development of a destructive process in the lung.
Abscess formation of type 1 develops against the background of the usual favorable dynamics of the inflammatory process in the lung 1.5-3 weeks from the onset of pneumonia. After the patient’s condition improves, the body temperature rises again, chest pain increases, and the general condition worsens with manifestations of increasing intoxication. This all ends with the release of purulent sputum.
Abscess formation of type 2 usually occurs within 3-4 weeks from the onset of pneumonia and clinically manifests itself as prolonged pneumonia if treatment fails. A constantly high body temperature remains throughout the entire period of the disease, severe intoxication, then purulent sputum appears, the amount of which increases.
Abscess formation of these types leads to post-pneumonic abscesses.
Type 3 abscess formation leads to aspiration abscesses. In these cases, destruction in the lung begins in the first days, and an abscess forms 5-10 days after the onset of the disease.
Classification of lung abscesses
. By etiology: staphylococcal, pneumococcal, colibacillary, anaerobic, etc., mixed.. By origin: post-pneumonic, aspiration, retrostenotic, metastatic, infarction, post-traumatic.
. According to the clinical course: acute, chronic, complicated (pleural empyema, pyopneumothorax).
. By localization: right-sided, left-sided, apical, basal, central, single, multiple, bilateral.
Clinical picture
Destructive lung diseases often affect socially unsettled people, many of whom suffer from alcoholism. In recent years, attention has been drawn to the increase in the number of young patients who use drugs. Patients are admitted to the hospital, as a rule, late; treatment is either not carried out before hospitalization or is carried out inadequately.The disease occurs predominantly in men (80-85%), most often at the age of 20-50 years (80-90%). The right lung is most often affected. An abscess can be localized in various parts of the lungs, but is most often found in the upper lobe of the right lung. Clinical manifestations of an abscess develop against the background of a previous pathological process in the lung. Most often this is lobar, influenza pneumonia or atelectasis of pulmonary tissue. The semiotics of an acute abscess is determined by many factors, but primarily by the phase of development of the process, the general condition of the body, and the virulence of the flora.
The formation of an abscess is accompanied by purulent infiltration and melting of the lung tissue, when there is no communication between the abscess cavity and the bronchial lumen. In this phase, the clinical picture of a lung abscess is very similar to the clinical picture of severe pneumonia. A lung abscess is accompanied by a general severe condition, pain when breathing on the affected side of the chest, high body temperature, cough, dullness of percussion sound and bronchial and sometimes weakened breathing over the abscess; leukocytosis increases to 16-30 x 109/l, a pronounced shift in the leukocyte formula to the left is noted.
An X-ray examination reveals a limited shadow of varying intensity and size.
The described phenomena increase over 4-10 days, then usually the abscess breaks into the bronchus and the second phase of acute abscess begins with coughing and the release of copious (up to 200-800 ml/day) fetid purulent sputum containing many leukocytes, red blood cells, bacteria and elastic fibers , as well as tissue detritus. When necrosis predominates in the abscess cavity, the sputum is especially foul-smelling, often mixed with blood. When settling, the sputum is divided into three layers: the lower layer of pus and disintegrated tissue, the middle layer of yellowish transparent liquid, and the upper layer of foamy liquid.
The amount of sputum discharge from a lung abscess does not correspond to the size of the abscess cavity. With small abscesses there can be a lot of sputum and, conversely, with a large abscess cavity the amount of sputum can be insignificant. The amount of sputum discharge depends on concomitant bronchitis, the prevalence of pneumonic changes, and the patency of the draining bronchi.
Diagnosis of a lung abscess is difficult in the early phase of development before it breaks through into the bronchus. Often an abscess is confused with focal pneumonia and other diseases. The most constant symptoms: cough with sputum, chest pain, increasing as the pleura is involved in the inflammatory process, high temperature, constant or with large fluctuations and heavy sweats. In the blood there is high leukocytosis with neutrophilia, increased ESR.
Data from percussion, auscultation and x-ray examination, although not pathognomonic for acute lung abscess, in some cases suggest a diagnosis before opening the abscess into the bronchus or pleural cavity. CG performed during this phase of abscess development often resolves diagnostic doubts, since the identified heterogeneous structure of the inflammatory infiltrate with areas of different density indicates the beginning of the process of destruction in the lung.
After opening an abscess in the bronchus, its diagnosis is greatly facilitated: the diagnosis is established on the basis of the discharge of copious sputum, which was preceded by a severe inflammatory process in the lung. Physical examination usually confirms the diagnosis of a lung abscess. An important role in clarifying the nature and localization of the process is played by x-ray examination and CT, which make it possible to accurately determine the cavity in the lung with gas and liquid.
The main method for diagnosing purulent lung diseases is x-ray; identifying the focus of destruction in the lung plays a major, but not exhaustive, role. Topical diagnostics are important - determining the localization of the pathological process in the lung, the condition of the lung tissue.
X-ray changes in lung abscess vary. The most common option (up to 70% of observations) is a single cavity in the lung with fluid and inflammatory infiltration of the lung tissue around. The cavity is often round in shape with clear contours of the internal walls, but irregular shape and uneven contours of the walls are also possible.
In 10-14% of cases of acute abscess, massive darkening of the lung tissue is determined, caused by the inflammatory process without signs of disintegration of the infiltrate. Changes also occur in prolonged pneumonia with severe purulent pneumonitis, damage to interstitial tissue and impaired drainage function of the bronchi, pronounced regional lymphadenitis in the root of the lung.
In such cases, CT makes it possible to identify cavities of destruction of lung tissue in the area of inflammatory infiltration. Clinically, such changes correspond to a long-term, chronic inflammatory process in the lung. In doubtful cases, CT increases the diagnostic capabilities of x-ray examination.
All these methods do not provide clear information about the state of the bronchial tree of the lung being studied. The absence of any changes in the pulmonary pattern during X-ray examination and CT is the basis for refusing bronchography. For “closed” (not communicating with the bronchus) abscesses, CT helps to resolve doubts regarding the presence of destruction of lung tissue in the area of inflammatory infiltration.
Bronchial contrast (bronchography) allows you to determine the condition of the bronchi, but the method is ineffective for identifying abscesses in the lung, since the abscess cavities are not filled with a contrast agent due to swelling of the mucous membrane of the draining bronchi, as well as due to the filling of the abscess with pus and tissue detritus.
The transition from an acute lung abscess to a chronic one is characterized not only by a temporary factor, but also by certain morphological changes in the abscess itself, the surrounding lung tissue and adjacent bronchi and vessels.
X-ray semiotics of long-term both single and multiple abscesses includes shadows of uneven intensity and varying prevalence. The pulmonary tissue surrounding the abscess cavity has a medium compaction with a sharply deformed pulmonary pattern and connective tissue cords.
The condition of the lymph nodes in nonspecific lymphadenitis is revealed by X-ray examination. The expansion of the shadow of the lung root and the blurring of its structure are determined. Tomography and CT make it possible to differentiate such changes and determine the enlargement of bronchopulmonary lymph nodes. Such changes in regional lymph nodes are a constant sign of lung abscess.
This picture does not play a significant diagnostic role, but changes in the nodes during treatment are assessed as an indicator of the effectiveness of the therapy. Reducing the size and disappearance of nodes is a favorable prognostic criterion. Lymph nodes remain enlarged for another 1-2 months after scarring of the abscess.
Bronchoscopy allows you to assess the condition of the bronchi, determine the draining bronchus, take material for bacteriological examination, debride the abscess or catheterize the draining bronchus.
Modern research methods (CT, bronchoscopy) practically eliminate the need for a diagnostic puncture, since the risk of complications, in particular purulent pleurisy, significantly exceeds the diagnostic value of the method.
Lung abscess in 30% of cases is complicated by pleural empyema or pyopneumothorax. In these cases, thoracoscopy is performed, which often reveals bronchopleural fistulas and makes it possible to determine their location and size, and perform a biopsy of the pleura or lung to clarify the etiology of the disease. Pleuroabscessography reflects the state of the empyema cavity.
To verify the pathogen and establish a bacteriological diagnosis, cultures of bronchial washings and punctate from the zone of lung destruction are used. Among the isolated flora, pneumococcus, staphylococcus, and Proteus predominate (1 x 10 4 - 1 x 10 6 microbial bodies in 1 ml) in association with Klebsiella, Enterobacter, Serration, Bacteroides; in some cases, Escherichia coli is detected. The results of microbiological examination of coughed up sputum must be treated critically due to its mixing with the contents of the oral cavity.
Acute lung abscesses must be differentiated from cavernous tuberculosis, actinomycosis, echinococcosis, suppuration of a lung cyst, interlobar encysted pleurisy, focal pneumonia, as well as secondary abscesses in lung tumors. Cavernous tuberculosis is usually excluded by determining the history of the disease, the absence of mycobacterium tuberculosis, and characteristic X-ray and CT changes in the lungs outside the cavity containing the fluid.
In actinomycosis, the causative agent of drusen is found in the sputum. However, they are not easy to detect and therefore require repeated careful studies. With actinomycosis, neighboring organs and the wall of the difficult cell are involved in the process.
The differential diagnosis of an abscess is especially difficult with interlobar pleurisy that has opened into the bronchus, and with other encysted pleurisy. In such cases, CT is of great benefit, as it allows one to clarify the true nature of the disease.
It is necessary to differentiate a lung abscess from disintegrating peripheral lung cancer. It should be noted that it is not always possible to differentiate an abscess and lung cancer by the appearance of the decay cavity during X-ray examination. The wall of the cavity with cancer is thicker, there is no purulent sputum, but there is hemoptysis. In the differential diagnosis of disintegrating peripheral cancer and a lung abscess, what is more important is not the type of cavity and the condition of its internal walls, but the external outlines of the darkening in the lungs and the clinical manifestations of the disease.
The cavity during tumor disintegration, according to X-ray and CT scans, contains little fluid, but this is taken into account only if the tissue surrounding the cavity is tuberous and the wall of the disintegration cavity is thick. The drainage “paths” identified in cancer play a role, connecting the tumor with the root of the lung, like cancer implantation along the path of lymphatic drainage.
In the differential diagnosis of lung abscess and tuberculosis with a cavity, microbiological testing plays a role.
Lung abscess must also be differentiated from aspergillosis. The disintegration of aspergiloma leads to the formation of a cavity. The mycelium of the fungus in sputum, washing water during bronchoscopy, and the contents of the decay cavity makes it possible to clarify the diagnosis of pulmonary aspergillosis.
In the differential diagnosis of a lung abscess, data from a comprehensive examination of patients are taken into account: anamnesis, clinical manifestations, course of the disease, instrumental and laboratory data. The results of bacteriological research play a certain role. Biopsy samples obtained during bronchoscopy, thoracoscopy, and transparietal puncture are also examined. Wash waters and impression smears obtained during bronchoscopy are subjected to cytological examination.
Treatment
For acute purulent-destructive lung diseases, active complex conservative therapy is indicated. Indications for surgical treatment arise when conservative therapy fails, the disease becomes chronic, complications develop (breakthrough of an abscess into the pleural cavity, mediastinum with the development of pleural empyema or pyopneumothorax, purulent mediastinitis, formation of bronchial fistulas, pulmonary hemorrhage).Complex intensive therapy includes:
. optimal drainage and sanitation of the decay cavity in the lung;
. antibacterial therapy, selection of antibiotics taking into account the sensitivity of the isolated microflora to them;
. correction of volemic and electrolyte disturbances, elimination of hypo- and dysproteinemia;
. detoxification therapy: forced diuresis, plasmapheresis, indirect electrochemical;
. blood oxidation using sodium hypochlorite, ultraviolet irradiation of blood, hemofiltration;
. immunotherapy;
. high-calorie balanced nutrition, according to indications - parenteral nutrition and infusion of blood components;
. symptomatic treatment.
Rational antibiotic therapy, along with active local treatment (bronchoscopic aspiration, sanitation, etc.) is the basis for effective conservative therapy and preoperative preparation of patients with purulent lung diseases. The use of proteolytic enzymes with necrolytic and anti-inflammatory properties has improved the results of conservative treatment and preoperative preparation of patients with purulent lung diseases. The dissolution of the thick contents of the bronchi and cavities and the anti-edematous effect of enzyme therapy help restore the drainage function of the bronchi, the disruption of which plays a leading role in the pathogenesis of pulmonary suppuration.
Thus, the combination of antibiotic and enzyme therapy is a successful combination of etiotropic and pathogenetic treatment.
To restore the patency of the bronchi draining the abscess, complex bronchological sanitation is carried out, the leading role in which is played by bronchoscopy. Taking into account the data of a preliminary X-ray examination, bronchoscopy allows you to catheterize the bronchus draining the purulent focus, wash it and administer antiseptics, proteolytic enzymes, and antibiotics.
If necessary, therapeutic bronchoscopy is repeated, which allows in most cases to achieve a positive effect. To improve sputum discharge, proteolytic enzymes, expectorants, and mucolytics are used. Proteinases have a proteolytic effect - they dilute sputum and lyse necrotic tissue. Proteinases have an anti-inflammatory effect and affect the drainage function of the bronchi.
In acute lung abscess, endobronchial use of enzymes and antiseptics (along with general antibiotic therapy) quickly eliminates purulent intoxication. A course of complex bronchological sanitation, as a rule, leads to complete clinical recovery with scarring of the abscess. Enzyme therapy also gives a pronounced effect for giant lung abscesses, when there is little hope of cure without surgery.
One of the components of complex bronchological sanitation is the inhalation administration of drugs. Mucolytics, antiseptic drugs, proteolytic enzymes, etc. are administered in inhalations. Inhalation therapy has a number of valuable properties, but plays only an auxiliary role in the conservative treatment and preparation for surgery of patients with purulent lung diseases.
The main advantages of endotracheal drug infusions are simplicity and the absence of the need for x-ray monitoring. To administer the drug correctly, you need to know exactly the location of the purulent process and carefully observe the appropriate positions of the chest. With endotracheal administration of drugs, unfortunately, it is not possible to accurately deliver drugs to the draining bronchus, but the drugs are distributed throughout the entire bronchial mucosa, which is important for diffuse bronchitis.
Inhalations, endobronchial infusions of proteolytic enzymes, mucolytics, antiseptics are simple methods of sanitation, but in terms of their effectiveness and speed of achieving results, they are inferior to therapeutic bronchoscopy. Bronchoscopy is the main method of bronchological sanitation.
Sanitation bronchoscopy is performed under local anesthesia. Therapeutic bronchoscopy with aspiration of the contents of the bronchial tree, its washing and administration of medicinal substances is widely used in the surgical clinic and is part of a comprehensive bronchological sanitation.
Modern bronchoscopy allows for transnasal insertion of a fiberscope and continuous lavage of the bronchi with instillation of the drug through one channel and aspiration through the other. Anesthesia is performed with an aerosol preparation of 10% lidocaine.
In patients who produce purulent sputum, bronchial contents are aspirated during diagnostic endoscopy in order to provide conditions for examination. The next stage of sanitation is the removal of fibrinous deposits and purulent plugs from the bronchial orifices.
The next stage of bronchoscopic sanitation is washing the bronchi with a solution of enzymes. The table position is changed to the opposite to the drainage position. A special tube is inserted into the bronchus draining the purulent cavities and 25-30 mg of chymopsin or trypsin, chymotrypsin, ribonuclease or 1 dose of terrilitin per 4-10 ml of sterile isotonic sodium chloride solution is infused.
The number of washes depends on the extent of the purulent process and the general condition of the patient. Therapeutic bronchoscopy should be as effective as possible, and the risk associated with hypoxemia and hypercapnia during repeated endobronchial manipulations should be minimal. In seriously ill patients, therapeutic bronchoscopy should be carried out under the control of oxygemography or oxygemometry.
Sanitation bronchoscopy with catheterization of the abscess through the segmental bronchus is indicated when conventional sanation bronchoscopy is ineffective. They are carried out under X-ray and computed tomography control.
Abscess drainage during bronchoscopy to a certain extent replaces conventional bronchoscopic sanitation.
In some cases, it is not possible to perform bronchoscopic sanitation (lack of a bronchoscope, technical difficulties, categorical refusal of the patient). This serves as an indication for sanitation of the bronchial tree through a microtracheostomy.
Special tactics are used in the most severely ill patients with decompensation of external respiration, severe pulmonary heart failure, when severe shortness of breath and hypoxemia at rest are an obstacle to endotracheal administration of drugs. Bronchoscopy is contraindicated for these patients; in some of them, inhalation of the aerosol alone causes increased shortness of breath and cyanosis.
In such a situation, along with parenteral administration of antibiotics, detoxification therapy, etc. local enzyme and antibacterial therapy is carried out by transparietal puncture of the abscess with aspiration of pus, washing the cavity with an antiseptic solution and subsequent administration of proteolytic enzymes. Thanks to this, purulent intoxication usually decreases, the general condition of the patient improves, external respiration and hemodynamic disturbances are partially compensated, which allows a gradual transition to comprehensive bronchological rehabilitation.
Puncture of acute abscesses is performed in case of complete obstruction of the draining bronchus (“blocked abscess”) or insufficient evacuation of pus through it in case of ineffective bronchoscopic sanitation. The point for puncture is marked under X-ray control or during ultrasound, which visualizes the position of the needle directly during puncture.
By transparietal puncture, enzyme preparations can be injected into the abscess cavity: chymopsin, trypsin, chymotrypsin, ribonuclease, terrilitin. Solutions of sodium hypochlorite, dioxidine, potassium furagine, and chlorhexidine are used as antiseptics.
Transparietal punctures, aspiration of pus and administration of medications are repeated daily for 3-4 days. If the patient's condition improves, they move on to bronchological rehabilitation. The ineffectiveness of the puncture method in complex treatment is an indication for external drainage of the abscess. A contraindication to the administration of proteolytic enzymes by puncture method is excessive hemoptysis or pulmonary hemorrhage.
Transparietal drainage of an abscess or decay cavity in lung gangrene is carried out when bronchial drainage is insufficient or completely impaired, when bronchoscopic sanitation does not give the desired effect.
Drainage is performed under local infiltration anesthesia under multi-axial X-ray control. Due to its invasiveness, drainage is performed in the cath lab. It is possible that pus or blood (if a pulmonary vessel is damaged) enters the bronchial tree, so it is necessary to provide equipment for emergency bronchoscopy or tracheal intubation.
Microdrainage is used for lung abscesses with a diameter of up to 5-8 cm with insufficient or completely impaired bronchial drainage. The drainage is inserted along a line drawn through the lumen of the puncture needle and fixed with a suture to the skin. Drainage for lung abscesses with a diameter of more than 8 cm and lung gangrene with a decay cavity is carried out using a trocar or a special needle.
Drainage using a trocar is used for large superficial intrapulmonary purulent cavities. The drainage tube is passed through the trocar sleeve.
Drainage with a long puncture needle with a diameter of 2 mm, on which a drainage tube is attached, is used for deeply located intrapulmonary abscesses.
After draining the purulent cavity, its contents are completely evacuated. The cavity is washed with a solution of antiseptic and proteolytic enzymes. The free end of the drainage can be left open under a thick cotton-gauze bandage or connected to a tube inserted under a solution of aseptic liquid according to Bulau-Petrov. The use of continuous vacuum aspiration depends on the size of the purulent cavity. The vacuum during vacuum aspiration should not exceed 50 mm of water. Art., so as not to provoke arrosive bleeding.
The purulent cavity is washed through drainage 3-4 times a day. The amount of solution administered simultaneously through the drainage depends on the size of the cavity, but during the first rinses no more than 20-30 ml.
The drainage can be removed after the body temperature has normalized and the separation of purulent sputum and pus through the drainage has stopped. An X-ray examination should verify the disappearance of inflammatory infiltration around the cavity, a decrease in its size and the absence of a horizontal fluid level in the cavity.
Complications of puncture and drainage of lung abscesses include hemoptysis, pneumothorax and chest wall phlegmon, but these are rare.
The combination of therapeutic fibrobronchoscopy with punctures or drainage of a lung abscess creates optimal conditions for removing purulent contents and stopping inflammation, and as a result, for scarring of the abscess. A double version of sanitation is effective for sequestration in the destruction cavity in the lung: sanitation is performed through a drainage tube during transparietal drainage of the abscess cavity and through the draining bronchus.
For patients with acute destruction of the lungs admitted to the thoracic surgical department, it is difficult to select antibiotics, since most of them received massive antibacterial therapy in therapeutic departments or on an outpatient basis. Before identifying the pathogen and the pathogen, empirical antimicrobial therapy with broad-spectrum drugs is carried out.
In the future, the selection of antibiotics depends on the sensitivity of the pathogens. In severe cases of the disease, intravenous administration of antibiotics is recommended, and to create the maximum concentration at the site of inflammation, catheterization of the bronchial arteries is possible, followed by regional antibiotic therapy.
An important place in complex treatment is occupied by detoxification therapy, which is carried out according to general rules for patients with severe purulent diseases. The effectiveness of therapy is significantly higher if a session of plasmapheresis, hemofiltration, and indirect electrochemical oxidation of blood is preceded by drainage of a purulent focus, removal of pus, and necrectomy. Plasmapheresis has clear advantages over other methods, but its use is not always possible for economic reasons.
Immunotherapy is carried out taking into account the immunocorrective effect of drugs - hyperimmune specific plasma, gamma globulins, pentaglobin, gabriglobin.
The option of complex conservative therapy, sanitation of acute lung abscess depends on the drainage function of the bronchi. It is possible to distinguish patients with good, insufficient bronchial drainage and with completely impaired bronchial drainage.
Indications for surgery include the ineffectiveness of conservative therapy and minimally invasive surgical procedures and the development of complications. Complex therapy before and after surgery allows you to perform both resection operations and the original version of thoracoabscessostomy developed in our clinic, followed by necrosequestrectomy and sanitation of the decay cavity using various methods of chemical and physical necrectomy and the use of videoscopic technologies. Thoracoabscessostomy is the main operation for gangrenous abscesses.
With successful treatment of acute lung abscesses using complex therapy, the abscess is replaced by a scar, clinical symptoms completely disappear, and upon X-ray examination, fibrous tissue is detected at the site of the abscess cavity. If it was possible to completely eliminate the clinical manifestations, but X-ray examination reveals small thin-walled cavities in the lung, the treatment result is considered satisfactory (clinical recovery).
These patients are discharged from the hospital for outpatient observation. The remaining cavities close on their own after 1-3 months. We observed good and satisfactory results in 86% of patients, the process became chronic in 7.8% of cases.
13.3% of patients require surgical treatment.
Indications for surgical treatment of acute lung abscesses: ineffectiveness of a complex of conservative and minimally invasive surgical treatment methods for 6-8 weeks, development of complications (pulmonary hemorrhage, recurrent hemoptysis, persistent bronchopleural fistulas), transition to a chronic abscess.
The prognosis for acute lung abscesses, if complex conservative treatment is started in a timely manner, is favorable for most patients (up to 90%). In other patients, successful treatment is possible using surgical methods.
Prevention of acute lung abscesses is closely related to the prevention of pneumonia (lobar, influenza), as well as timely and adequate treatment of pneumonia.
BRONCHIECTATIC DISEASE.
Chronic suppurative process in pathologically altered and functionally defective bronchi.
Men get sick more often.
Causes:
1. congenital weakness of the bronchial wall (insufficient development of smooth muscles, cartilage tissue)
2. frequent bronchopulmonary infections.
Pathogenesis: The inflammatory process in the bronchi leads to the death of elastic fibers . Under the influence of intrabronchial pressure, the bronchial wall protrudes, where purulent secretions accumulate. The bronchus is deformed, which leads to disruption of the drainage and ventilation functions.
Clinic:
Cough with purulent sputum, especially in the morning with a mouth full and when taking a drainage position
Symptoms of intoxication
Hemoptysis
Objectively:
The skin is pale cyanotic
“Drumstick” finger shape, “watch glass” nail shape
Barrel chest
Percussion - sound with a boxy tint or dullness
Auscultation: moist rales in the same areas of the lungs, dry scattered rales.
Additional methods:
CBC: anemia, leukocytosis with a shift to the left, increased ESR.
OAM: proteinuria
OA sputum: purulent, many leukocytes
Rg of the lungs: cellularity and deformation of the pulmonary pattern.
Bronchography: normally the bronchial tree looks like a “tree in winter”, and with BEB it looks like a “tree with leaves”, “honeycombs”, “bird’s nests”.
Bronchoscopy: endobronchitis
Complications:
Pulmonary hemorrhage
Lung abscess
Pleurisy (empyema)
Pulmonary heart
Treatment:
Surgical: remove the segment or lobe with bronchiectasis
In case of exacerbation of a/b, taking into account the tank. sputum culture
Mucolytics
Bronchodilators
Vitamin therapy
Detoxification therapy
Cardiovascular drugs
Drainage position 2-3 times a day in combination with taking mucolytics, bronchodilators and vibration massage
Therapeutic bronchoscopy
Breathing exercises, massage, exercise therapy
Oxygen therapy.
Dispensary observation: see a pulmonologist.
LUNG ABSCESS.
Purulent melting of the lung tissue in the form of a limited focus (abscess) and the formation of one or more cavities filled with pus and communicating with the bronchus and emptying through it.
Etiology:
Bacterial pyogenic flora: Staphylococcus aureus, Streptococcus, Klebsiella, etc.
Injuries: bruises, compression, penetrating wounds
The infection penetrates bronchogenically (aspiration of mucus, pus), hematogenously, lymphogenously, by spreading from neighboring organs.
Clinic:
1st period – until the abscess breaks into the bronchus:
Intoxication syndrome (fever, chills, heavy sweats, weakness)
Dry cough
Chest pain associated with breathing, coughing
Percussion - dullness of sound on the affected side
Chest lag on the affected side
Auscultation - weakened breathing on the affected side
2nd period – after the abscess breaks into the bronchus:
– A coughing attack with the discharge of purulent, foul-smelling sputum in an amount of 100-500 ml.
With good drainage (emptying) of the abscess, your health improves and your temperature drops
Percussion - dullness of sound on the affected side, less often - tympanitis
Auscultation - moist rales.
Additional methods:
CBC: leukocytosis with a shift to the left, increased ESR
OAM: proteinuria
OA sputum: purulent, many leukocytes
Rg before breakthrough: pneumonic infiltration with clear contours, after: cavity with a horizontal fluid level
Bronchoscopy
Puncture with biopsy.
Complications:
Pulmonary hemorrhage
Empyema of the pleura
Pneumothorax
Development of new abscesses during aspiration of pus
Ulcers in distant organs
Exodus:
Recovery
Pneumosclerosis
Chronic abscess (after 2-3 months)
Treatment:
Hospitalization in the pulmonology department or in the thoracic surgery department.
A diet rich in proteins and vitamins.
Postural drainage and bronchial lavage.
Antibiotics
Detoxification therapy
Cardiovascular drugs
Vitamins
Immunotherapy (plasma, Ύ-globulin...)
Bronchodilators, expectorants
Oxygen therapy
Surgical treatment (lobectomy, pneumonectomy)
LUNG GANGRENE.
purulent - putrefactive necrosis of lung tissue without clear boundaries.
Caused by anaerobic infection.
The current is severe. Mortality is high.
Sputum is foul-smelling with pieces (sequestrum) of lung tissue. Treatment in thoracic surgery.
PLEURITIS.
- inflammation of the pleura.
Dry pleurisy
Exudative (exudative)
Causes:
1. Pneumonia, lung abscess
2. Tuberculosis
3. Lung cancer
4. Rheumatism
6. Pulmonary embolism, etc.
Pathogens (bacteria, viruses, fungi, etc.) penetrate the pleura by contact (pneumonia, tuberculosis), hematogenously, lymphogenously, from the external environment (trauma, wounds).
Suppurative processes of the lungs include:
1 Gangrene of the lung
2 Bronchiectasis
3 Chronic obstructive pulmonary disease
4 Lung abscess
5 Suppurating lung cysts
Development of lung surgery
The development of lung surgery is characterized by a certain stage.
4 stages:
1 Pre-antiseptic - until the middle of the 19th century. By this time, Hippocrates proposed the method of pneumotomy - opening the chest or burning
it in order to remove pus
2 From the 50-60s of the 19th century to the end of the 19th century - the introduction of asepsis, antiseptics, and general anesthesia, which made it possible to widely use pneumotomy
reduce mortality to 40%. The first attempts at lung resection appeared. In Russia, the first lung resection was performed by P.I. Dyakonov in 1898
3 From the end of the 19th century to the 40s of the 20th century - famous for the theoretical developments of pulmonary surgery, methods of partial and complete removal were introduced
lung
4 From the 40s of the 20th century to the present - the rapid development of radical interventions on the lungs
What unites this group of lung diseases?
1 Discharge of purulent sputum from the lungs
2 Similarity of general manifestations to the suppurative process on the part of the macroorganism
3 Presence of foci of infection in one or both lungs
4 Pathogens - mainly gram-positive cocci: pneumococci, hemolytic streptococcus, Staphylococcus aureus
Purulent lung diseases (according to A. V. Kupriyanov)
I Abscesses and gangrene of the lungs
1) Purulent abscesses
A) spicy
B) chronic: single, multiple
2) Gangrenous abscesses
3) Widespread gangrene
II Pneumosclerosis after lung abscesses
III Bronchiectasis
IV Suppurating lung cysts
1) Single cysts
2) Multiple cysts (“cystic lung”)
Abscesses and gangrene of the lungs
Abscesses and gangrene of the lungs are a severe suppurative process in the lung tissue, accompanied by the phenomena of necrosis and
melting the fabric with the formation of cavities. Abscesses and gangrene of the lungs were identified as separate nosological forms by Laennec in 1819. In our
days are more common than in the past due to increased flu epidemics.
Common in all age groups (more often after 20 - 50 years), 5 - 8 times more often among men, because more unfavorable working conditions, a number
abuse.
The nature of the local reaction of the tissues surrounding the pathological focus is important. In some cases, elements of purulent fusion predominate
(abscess formation), in others - elements of necrosis (gangrenization of lung tissue). In the first case, the purulent cavity in the lung is most often delimited from
unaffected areas with a pyogenic capsule, and the cavity with gangrene of the lung contains sequesters of lung tissue.
The most typical localization of acute abscesses is I, II, IV, VI segments of the right lung. The abscess cavity is filled with purulent masses mixed with
blood and is surrounded by a two-layer pyogenic capsule, the inner layer of which is represented by massive deposits of fibrin, and the outer layer consists
from connective tissue.
Classification of acute lung abscesses
I According to clinical and morphological characteristics:
1 - acute purulent lung abscesses:
a) according to the course: acute and chronic (in the acute stage, in the remission stage)
b) by localization:
Central and peripheral (cortical);
Single, multiple, bilateral (indicating the segment and lobe);
c) according to the presence of complications:
No complications;
Complicated: pleural empyema, pyopneumothorax, pulmonary hemorrhage, metastatic abscesses to other organs, bronchial
fistulas, aspiration of pus into a healthy lung, sepsis.
2 - Acute gangrenous lung abscesses (limited gangrene) - distribution according to the course, localization and complications as in acute purulent
abscess.
3 - Widespread gangrene of the lung.
II According to pathogenetic characteristics:
1 - Bronchogenic abscesses and gangrene of the lungs:
A) post-pneumonic;
B) aspiration;
B) obstructive.
2 - Thromboembolic:
A) aseptic;
B) infected.
3 - Post-traumatic.
III According to the stages of the destructive process:
1 Atelectasis - pneumonia.
2 Necrosis and breakdown of necrotic lung tissue.
3 Sequestration of necrotic areas and formation of a pyogenic capsule.
4 Purulent melting of necrotic areas with the formation of an abscess or, in the absence of demarcation, gangrene.
IV Depending on the general condition of the body:
A) Without severe intoxication
B) With severe intoxication
B) With sufficient compensation
D) With unstable compensation
D) With insufficient compensation
V According to the clinical course:
A) With a tendency to heal
B) With a tendency to chronicity
B) Progressive
VI According to severity:
1 - Lungs;
2 - Moderate;
3 - Heavy.
Etiology and pathogenesis
Pyogenic microorganisms can be in the form of a monoculture or in the form of microbial associations.
Routes of penetration into the lung parenchyma:
Through the bronchi (bronchopulmonary tract, aspiration)
Hematogenous-embolic route
Lymphogenic
In case of traumatic damage to lung tissue
Currently, the most common cause of acute abscess development is considered to be focal pneumonia after influenza.
Viral infection causes extensive destructive changes with necrosis of the bronchial mucosa with subsequent spread
inflammation of the peribronchial tissue, sharp inhibition of the drainage function of the bronchi with the development of atelectasis and suppuration of the lung tissue.
Factors contributing to the development of acute abscess
1 Acute infectious inflammatory process in the lungs;
2 Impaired bronchial obstruction;
3 Impaired blood circulation in the area of inflammation with the development of necrosis of lung tissue;
4 Impaired lymph circulation and innervation in the affected area;
5 Decreased immunity
Clinic
In the clinical picture of acute lung abscess, 3 periods or phases are distinguished:
1st period - closed stage of formation of a pulmonary abscess - purulent infiltration with melting of the lung tissue until the abscess opens into the bronchus;
period 2 - the open stage of the pulmonary abscess, after its complete formation, opening of the abscess into the bronchus and its subsequent course;
3rd period - stage of healing or transition to a chronic process
After the development of period 2 - the open stage - a typical clinic of acute pulmonary suppuration unfolds. There are 3 options for further
course of an acute process in the lung:
1 - while maintaining patency of the bronchi draining the abscess and adequate therapy, the condition and well-being of patients quickly improves;
2 - with poor bronchial drainage - fever persists, sputum up to 100 - 150 ml with an unpleasant odor, changes in the blood increase, increase
anemia;
3 - with a blocked abscess, the clinical picture is especially severe - severe intoxication comes to the fore: fever, chills,
weight loss, high leukocytosis with a shift of the formula to the left, a decrease in the amount of sputum, a debilitating, often painful cough.
Sputum examination is valuable. In the first days after the abscess breaks through, there is often an admixture of blood in the sputum. Usually sputum
purulent, yellowish or brown in color, often foul-smelling. When settled, it becomes three-layered: at the bottom there is thick pus, above it there is a cloudy liquid, on
foamy mucus surface.
In the case of the development of pulmonary suppuration of the gangrene type, the disease is characterized by even more severe general toxic manifestations and
rapid course: hectic fever, severe shortness of breath, constant tachycardia, tendency to hypotension, copious fetid sputum, which
has a dirty gray or chocolate color, liquid consistency, when settled, 3 layers, when examined microscopically in sputum
scraps of necrotic lung tissue are revealed. In the blood there is severe anemia, leukocytosis, toxic granularity. Join
complications in the form of bleeding, putrefactive pleural empyema.
X-ray examination plays a primary role in the diagnosis of acute abscesses and gangrene of the lung.
In phase I of an acute abscess, limited inflammatory infiltration is noted in one or another zone of the pulmonary field of varying intensity and
quantities. It is often confused with the picture of acute pneumonia
In phase II, against the background of pneumonic infiltration, a round or oval cavity with a horizontal fluid level is revealed. Wherein
the study is performed with the patient in an upright position.
With a gangrenous abscess, intense darkening is detected on the affected side, followed by the formation of a giant
cavities with a fluid level containing sequestration of dead lung tissue. With widespread gangrene, there is a continuous darkening
of the affected lung with the subsequent formation of multiple poorly draining abscesses.
Additional methods: ultrasound of the lungs, fibrobronchoscopy if necessary with a biopsy, bronchography, CT, lung scanning.
Differential diagnosis (one of the most difficult problems of clinical pulmonology), with chronic abscess in the acute stage,
specific lung lesions (tuberculosis, cancer).
Treatment
Main areas of treatment:
1) measures aimed at maintaining and restoring general condition and correcting disturbed homeostasis - regimen, care, high-calorie
food rich in proteins and vitamins;
2) measures to correct the immunological reactivity of patients;
3) measures aimed directly at suppressing microorganisms - causative agents of the infectious process (antibiotics, chemotherapy drugs);
4) measures aimed at ensuring optimal drainage of foci of destruction in the lung - respiratory therapy; patient education
postural drainage; sanitary bronchoscopy with catheterization of purulent cavities; microtracheostomy (percutaneous catheterization of the trachea);
5) radical surgical treatment.
“Minor” surgical interventions:
1. Intrapulmonary transthoracic daily administration of antibiotics by:
a - puncture (microthoracentesis) through the chest wall.
Indications for it are:
Any form of suppurative process in the peripheral parts of the lungs;
The presence of a large area of perifocal inflammation around the abscess;
Lung abscesses complicated by purulent pleurisy.
b - drainage of the abscess with a thick drainage inserted through a special Monaldi trocar.
Drainage and lavage of the abscess through a thick drain according to Monaldi
Vacuum drainage of an abscess using a three-can system according to Perthes-Subbotin
c - thoracoabscessoscopy - examination of the abscess cavity using a thoracoscope
d - transthoracic (closed) microdrainage.
2. Sanitation of the tracheobronchial tree through:
A. - a catheter inserted into the trachea through the nose;
b. - laryngeal syringe;
V. - inhalations;
g. - by puncture of the trachea;
d. - microtracheostomy (percutaneous catheterization of the trachea);
e. - endoscopic sanitation of the tracheobronchial tree.
The method of percutaneous tracheal catheterization, or microtracheostomy, was described in 1947 by B. E. Linberg. This technique allows the introduction into the lumen
trachea sanitation solutions (single dose or slow drip), stimulate the cough reflex. If there are managed
radiopaque catheters through microtracheostomy can be done under X-ray control with an electron-optical converter
(EOP) to drain the abscess cavity without resorting to bronchoscopy.
3. Methods of infusion therapy for administering antibiotics by:
A. Regional infusion into the pulmonary artery through the elbow vein (high concentration of antibiotics).
b. Use of pulmonary artery occlusion through a catheter with a balloon.
V. Infusion into the bronchial artery.
patients can achieve a cure of 85% or more.
Surgery. All types of surgical treatment of destructive lung diseases are divided into emergency and planned.
Emergency operations include:
Drainage of pleural cavities;
Video thoracoscopic sanitation of the pleural cavity;
Pneumoabscessotomy;
Thoracostomy;
Pulmonary artery ligation;
Lung resection (lobectomy, bilobectomy, pneumonectomy).
Pulmonary hemorrhages
Small (mild) 50 - 100 ml
Medium (medium level) 100 - 500 ml
Copious (severe) more than 500 ml
CAUSES:
I Diseases or damage to the respiratory system
Suppurative (abscess, gangrene, bronchiectasis, necrotizing pneumonia)
Tuberculosis, pneumosclerosis, neoplasms
Pulmonary infarction, angiomatosis
Lung injury (including during medical procedures)
II Extrapulmonary diseases
Heart defects (with pulmonary congestion)
Vascular diseases (angiomatosis, vasculitis, aneurysm)
Blood diseases (thrombocytopenia, leukemia)
Endometriosis
Infectious diseases
II Unknown causes (idiopathic)
Treatment
Conservative therapy: drug and invasive. Invasive methods - X-ray endovascular occlusion of bronchial arteries. IN
In most cases, occlusion of the bronchial arteries allows the bleeding to stop.
If conservative therapy is ineffective and the bleeding site is clearly localized, surgical treatment is indicated:
Palliative - ligation of the pulmonary artery.
Radical - forehead - and bilobectomy, less often pneumonectomy.
For pyofibrinothorax, the operations of choice are the use of videothoracoscopic technologies; in the absence of this possibility, they resort to
thoracotomy.
In case of pyopneumothorax - adequate drainage of the pleural cavity with filling of the affected bronchus, if conservative measures are ineffective
measures - surgical treatment.
Treatment outcomes. Acute abscesses turn into chronic abscesses in 7-10% of patients, and into cysts in 5% of patients.
Mortality is:
For acute purulent abscesses - no more than 1%;
With widespread gangrene of the lung - 90% of cases.
Chronic lung abscess
The period for the formation of a chronic abscess in the lung is considered to be 3 months from the start of adequate therapy for an acute disease, but not from the moment
diseases, because with intensive complex treatment, sometimes even started at a later date, it is possible to achieve recovery.
Reasons for the transition to a chronic form of lung abscess:
a) periodic outbreaks of exacerbation of inflammation in the residual cavity;
b) retention of pus due to poor bronchial drainage of the acute abscess cavity;
c) the presence of sequesters in the abscess cavity, closing the mouths of the draining bronchi;
d) inadequate conservative treatment in the acute period;
e) epithelization of the abscess cavity from the mouths of the draining bronchi;
f) formation of pleural adhesions in the area affected by the abscess of lung segments;
g) increased pressure in the abscess cavity.
Pathological anatomy of a chronic abscess
Purulent cavities have dense scar tissue. Their inner surface is uneven, covered with fibrinous-purulent or ichorous
necrotic deposits. The abscess cavity usually communicates with several bronchi, i.e. there are internal bronchial
fistulas, contains liquid pus or crumbly detritus with an unpleasant odor. Around the abscess there are extensive areas of pneumosclerosis with
secondary bronchiectasis. Some patients may develop a bronchopulmonary pleural fistula and chronic pleural empyema.
Classification of chronic lung abscesses
Divided into:
1 - single;
2 - multiple:
A) not complicated;
B) complicated by pleural empyema, secondary bronchiectasis, pulmonary hemorrhage, metastatic ulcers,
amyloidosis, etc.
Clinic, diagnosis, course
Chronic abscess is characterized by a cyclical nature of the disease - with periods of exacerbation and remission. During remission, chronic abscess
does not manifest itself clinically. Complaints most often include a cough with purulent or mucopurulent sputum, sometimes a slight
hemoptysis, periodic low-grade fever, weakness, sweating, tendency to colds. Secondary diffuse disease develops
obstructive bronchitis with corresponding ventilation disorders (thickening of the terminal phalanges of the fingers in the form of “drum sticks” with
deformation of nails in the form of “watch glasses”).
An X-ray examination of the lungs reveals an area of pneumosclerosis with an irregularly shaped cavity, often determined only with
using computed tomography.
With bronchography, the abscess cavity cannot always be filled with contrast. In the circumference of the abscess, a picture of the presence of deformed
bronchi, sometimes with secondary bronchiectasis.
Bronchoscopically, phenomena of local or diffuse bronchitis are noted, and pus is often released from the bronchus draining the abscess.
During the period of exacerbation, an increase in the separation of purulent sputum, an increase in body temperature, and increasing symptoms of purulent
intoxication. Physical symptoms become clear: dullness, sonorous moist rales are heard. X-ray picture
characterized by tissue infiltration, the abscess cavity increases in size and acquires a rounded outline, and
horizontal level. In the blood, leukocytosis with neutrophilia increases, band and young forms of leukocytes appear, ESR increases,
a decrease in hemoglobin occurs.
Differential diagnosis. The greatest difficulties arise in differentiating an abscess from lung cancer (cavitary forms) and
pulmonary tuberculosis. We must remember about the possibility of combined forms of the disease, that is, when specific and chronic nonspecific
processes can occur simultaneously.
TREATMENT
Conservative treatment is the same as for acute lung abscess.
Surgery. The main method of treatment is resection of the affected parts of the lung (removal of a segment, lobe or the entire lung). Operation
Absolutely indicated for young and mature people, for the elderly - taking into account compensation for concomitant pathology. It is best to operate in
period of stable remission.
Palliative operations are aimed at:
a) compression of lung tissue (various thoracoplastic interventions);
b) pneumotomy, pneumoabscessotomy;
c) ligation of the pulmonary artery;
d) X-ray endovascular occlusion of the bronchial arteries.
Treatment outcomes. Mortality after lung removal is 15-20%, after resection - 7-10%. In 94% of cases, patients become healthy, and in 75%
80% - good long-term results are noted.
Bronchiectasis
Bronchiectasis is an independent bronchopulmonary disease that usually occurs in childhood or adolescence.
The main pathomorphological substrate is regional expansion of the bronchi, mainly in the lower segments of the lungs, accompanied by
chronic nonspecific suppurative process in the wall of the dilated bronchi.
The largest number of patients with bronchiectasis is observed between the ages of 10 and 30 years. Men predominate over the age of 10-15 years.
In adults, the incidence of bronchiectasis, according to sectional data, is about 4%.
Etiology and pathogenesis
The cause of congenital bronchiectasis (4-10% of cases) is a congenital anomaly of the bronchial walls or interstitial tissue, often combined
other malformations (Sievert syndrome - Kartagener: including dextrocardia, polysinusitis and bronchiectasis).
Acquired bronchiectasis is more correctly considered as a special localized form of purulent bronchitis. A purulent process developing in
lumen of the bronchial tree, affects the bronchial wall, causing degeneration of its elements (cartilaginous plates, smooth muscles,
elastic fibers) and their replacement with scar tissue. As a result, the bronchi lose their normal elasticity, gradually expand and
become functionally inferior, i.e., bronchial obstruction slowly progresses. This is facilitated by impaired drainage
bronchial function and secretion retention, which leads to activation of infection distal to the level of obstruction.
The most commonly affected areas are the basal segments of the lower lobe of the left lung and the middle lobe of the right lung.
With a long course of the disease, the pulmonary parenchyma is involved in the inflammatory process, pneumofibrosis gradually develops, the lung
decreases in volume. As a result, the patient develops respiratory failure and, along with this, cor pulmonale is formed.
Pathological anatomy Characteristic microscopic signs of bronchiectasis:
a) change in the color of the lung tissue (affected areas are pink or cherry);
b) reduction in the volume of the affected part of the lung (atelectasis, atrophy, fibrosis of the parenchyma);
c) enlarged lymph nodes in the root of the lobe or lung, in the pulmonary ligament.
Histologically, the bronchi show a picture of chronic inflammation, peribronchial and perivascular sclerosis. Bronchial epithelium in
bronchiectasis may be absent in some areas, proliferation of granulations, a tendency to metaplasia into multirow or
multilayer flat.
Stages of development:
I. Moderate expansion of the lumen of small bronchi without changes in the epithelium;
II. The occurrence of purulent inflammation in the occluded section of the bronchial tree (changes in the bronchial wall with loss of muscle elements);
III. Pathological changes in all layers of the bronchial wall and their spread beyond the bronchial tree with the development of pneumofibrosis
and a decrease in lung size.
Clinic
Cough and purulent sputum are classic symptoms of bronchiectasis. The cough is persistent and recurrent, with purulent sputum, usually
has been going on since childhood. Many of them have hemoptysis, i.e. streaks of blood in the sputum (10-66% of those examined). Much less common
pulmonary hemorrhages. In some cases, they may be the only sign or manifestation of bronchiectasis.
Patients often complain of shortness of breath, chest pain, fatigue, low-grade fever, lethargy, irritability, decreased
performance, headaches, mental depression (especially with foul sputum) and bad breath when breathing. Approximately
half of the patients have fingers in the form of “drumsticks” and nails in the form of “watch glasses”.
Locally: the configuration of the chest in most patients is not changed. Breathing over the affected parts of the lung is harsh, during
exacerbations, wheezing is heard, which disappears after coughing. When examining peripheral blood: leukocytosis, increased ESR,
with general intoxication - anemia, there may be erythrocytosis with an increased hemoglobin content.
The amount of sputum varies during different periods of the disease; 25-30% of patients have sputum with an unpleasant odor. When standing in a bank
sputum becomes two-layered - the upper layer is opalescent (liquid and saliva), the lower layer is purulent sediment.
Microscopic and bacteriological examination of sputum requires determination of the nature of the microflora and the degree of its sensitivity
to various antibiotics, as well as establishing the cellular composition of sputum.
Differential diagnosis: with fibrous-cavernous form of pulmonary tuberculosis, chronic bronchitis, pneumosclerosis, polycystic disease
lungs, cancer with secondary bronchiectasis.
In these cases, they resort to ultrasound, CT, MNR, scintigraphy, angiopulmonography, and bronchoscopy.
Without adequate treatment, patients die from pulmonary heart failure, renal amyloidosis, and massive pulmonary hemorrhages.
Instrumental diagnostic methods
1) Plain radiography or fluoroscopy of the lungs - rough heaviness, radially converging to the root of the lung. Characterized by mesh or
a cellular pattern of the affected parts of the lung, and in the atelectatic parts of the lung there is a darkening and a decrease in their volume.
Prolapse of the opposite lung towards the lesion with the formation of a so-called “pulmonary hernia”;
2) The decisive method in the diagnosis of bronchiectasis is a contrast study of the bronchi - bronchography. With her in the zone
lesions reveal dilated bronchi;
3) Fiberoptic bronchoscopy;
4) Spirography - characterizes respiratory dysfunction.
Based on the severity of the disease, there are 4 forms of the disease:
a) with a mild form, there are 1-2 exacerbations during the year; during the period of remission, such patients are quite capable of working;
b) with a severe form of the disease, exacerbations of the disease are more frequent and prolonged, with the release of 50 to 200 ml of sputum per day. During
In remission, cough persists with expectoration of up to 50-100 ml of discharge. Performance decreases;
c) patients with severe bronchiectasis suffer from frequent and prolonged exacerbations, with increased body temperature and discharge of up to 200 ml
One of the important systems of the body is the respiratory system. A person cannot live without air. Its main free resource is oxygen. As long as a person breathes, he lives. If we remember the structure of the body, we can remember that the lungs take an active part in the exchange of gases inside.
It is their health that should be taken care of first. It is their diseases that can lead to disability or adverse consequences such as death. One of these dangerous diseases is pulmonary abscess. We will talk about it in this article.
What is it - a lung abscess? This is the decay and inflammation of the lung tissue and the formation of limited cavities filled with pus. The causative agents of the disease are microorganisms (bacteria). However, frequent factors of the disease are vomit, mucus that enters the lungs, and foreign bodies.
The melted lung tissue turns into a purulent mass, which is limited by the capsule from the rest of the lung. When the capsule breaks, pus enters the bronchi, which provokes coughing. The affected area collapses and a scar or hardening of the lung tissue forms.
Forms
According to the factors of occurrence, the following are distinguished:
- Primary – develops as a result of physical damage after bruises penetrating into wounds;
- Secondary - develops against the background of existing abnormalities in the respiratory canals: pneumonia, blockage in the bronchi with tumors or foreign bodies.
Based on location, the abscess is divided into:
- Central;
- Peripheral – located on the edge.
According to the duration of development and course they are divided into:
- Acute (about 6 weeks), which ends with recovery;
- Chronic (more than 6 weeks), which is characterized by periodic improvements and exacerbations of the disease.
According to the nature of the course, the abscess is distinguished:
- Mild, in which the clinical picture is not pronounced;
- Moderate, in which symptoms are moderately severe;
- Severe, in which all symptoms are clearly expressed and complications are expected.
Symptoms
Lung abscess is characterized by two stages:
- Formation (before breakthrough) of an abscess, which lasts from 7 days to 3 weeks;
- Opening of a purulent cavity.
A purulent cavity in the chest area causes a certain pain discomfort (a feeling of fullness). The main symptoms of the first stage of the disease are:
- The cough is dry;
- Temperature (up to 40ºС);
- Fever;
- Dyspnea;
- Chills;
- Loss of appetite;
- Sweating;
- Weakness;
- Nausea;
- Headache;
- Retarded movement of the affected lung;
- Asymmetric movement of the chest with bilateral abscess.
In the second stage, symptoms intensify or change:
- The cough is wet;
- Sputum (pus) is removed “by mouthful”;
- Sputum is dark in color and has an unpleasant odor;
- Decrease in temperature;
- Feeling better.
Causes
The infectious nature of a lung abscess is characterized by the causes of its origin - bacteria or fungi: bacteroides, streptococcus, pneumococcus, Staphylococcus aureus, fungi, Pseudomonas aeruginosa, Klebsiella or mixed flora.
The inflammatory process begins with infection entering the lungs through the bronchi or blood. The main factors contributing to the decrease in protective functions and the formation of lung abscesses are: alcohol abuse, hypothermia, smoking, weak immunity, poor circulation in the pulmonary area that is inflamed, bronchial blockage, which does not allow purulent formations to be removed, the presence of influenza or chronic diseases.
The disease often develops:
- when stomach contents enter the respiratory canals;
- with progression of pneumonia;
- when there is blockage in the bronchi or obstruction occurs, which leads to stagnation of mucus and the occurrence of infection;
- against the background of sepsis - inflammatory processes of a purulent nature in various organs, in which microorganisms enter the blood.
Diagnostics
If a patient has symptoms similar to pneumonia, and for unknown reasons he is unconscious, abuses medications or alcohol, then you should go to the doctor. X-ray analysis and computed tomography are performed. X-ray shows massive darkening in the lungs.
Also carried out:
- Sputum analysis to identify the microorganism that caused the disease;
- Physical examination;
- History and collection of complaints;
- Bronchoscopy to exclude malignancy;
- Blood and urine tests;
- Spirography;
- Fiberoptic bronchoscopy is a method of examining the inside of the chest using a device that is inserted into the respiratory tract.
Treatment
Prevention of lung abscess is not carried out, since treatment is prescribed to eliminate infections, pneumonia, and prevent aspirations after injuries or operations. There is also an active fight against alcoholism.
Since patients turn to doctors when they cannot cope with the symptoms of the disease themselves, which leads to late detection of lung disease, treatment becomes lengthy and difficult. How to treat an abscess?
- Respiratory hygiene:
- Postural drainage in a certain body position, which promotes better removal of sputum;
- Breathing exercises and constant coughing to facilitate the outflow of pus;
- Vibration massage;
- Sanitation bronchoscopy to eliminate obstruction through removal of sputum by administering antibiotics, antiseptics and mucolytics.
- Medicinal procedures:
- Antibiotics are administered intramuscularly, intravenously or orally over several months;
- Antiseptics;
- Mucolytics to thin mucus;
- Expectorants to remove mucus;
- Detoxification drugs to eliminate intoxication and restore the functioning of internal organs;
- Immunomodulators to boost the immune system;
- Oxygen therapy is an inhalation procedure for introducing oxygen through a device.
- Surgical therapy:
- Puncture - piercing an abscess with a needle to remove pus and cleanse with antiseptics, administer antibiotics;
- Drainage and thoracentesis - a tube is inserted through the chest into the lungs and the pus is sucked out;
- Removal of a lobe or the entire lung if it is impossible to cure the disease;
- Secretion suction and tracheostomy;
- Pulmonectomy.
Complications
What are the complications of lung abscess?
- Lack of oxygen;
- Transition to the chronic stage;
- Breakthrough of the abscess, accumulation of air and pus;
- Purulent inflammation of the lining of the lungs;
- Transition of purulent inflammation to healthy areas;
- Bleeding inside the lungs;
- Deformation of the bronchial tree with the formation of purulent inflammation in it;
- Penetration of infection into the blood with spread to all organs.
Prevention of lung abscess can include timely and correct treatment of the respiratory system, avoidance of alcohol and smoking, and avoidance of hypothermia.
Lifespan
Lung abscess is a curable disease if you begin to eliminate all the causes of the disease in a timely and correct manner. Recovery usually occurs after 6-8 weeks.
The life prognosis can be joyful if you are constantly treated by a doctor. How long do they live? There are patients who live for many years if they constantly undergo treatment, prevent the disease and perform breathing exercises.
If the disease is not treated, then the result can be fatal. It all depends on how the disease develops and whether pus breaks through into the pulmonary cavity.
Damage to healthy areas of the organ leads to oxygen starvation. All these signs are not conducive to a healthy existence. Fatalities account for 5-10% of all cases. In 20%, the abscess becomes chronic.
