Chronic pneumonia

Chronic pneumonia is a chronic inflammatory localized process in the lung tissue, the morphological substrate of which is pneumosclerosis and (or) carnification of the lung tissue, as well as irreversible changes in the bronchial tree according to the type of local chronic bronchitis, clinically manifested by relapses of inflammation in the same affected part of the lung. Asymptomatic localized pneumosclerosis in the absence of relapses of inflammation in the affected area is excluded from the concept of chronic pneumonia.

Currently, the attitude towards chronic pneumonia is ambiguous. In modern foreign medical literature, such a nosological unit is not recognized and is not covered. In ICD-10, this disease is also not named. However, a number of clinicians still distinguish chronic pneumonia as an independent nosological unit.

In addition, in clinical practice, we often observe patients who, after suffering from acute pneumonia, develop symptoms that correspond to the diagnostic criteria of chronic pneumonia, although previously (before acute pneumonia) the patient was completely healthy.

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Causes of chronic pneumonia

The main etiological and predisposing factors of chronic pneumonia are the same as those of acute pneumonia.

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Pathogenesis of chronic pneumonia

Chronic pneumonia is a consequence of unresolved acute pneumonia. Consequently, the development of chronic pneumonia can be represented in the form of the following stages: acute pneumonia - protracted pneumonia - chronic pneumonia. Therefore, it can be considered that the pathogenetic factors of chronic pneumonia are the same as those of protracted pneumonia, and the main ones are, of course, dysfunction of the local bronchopulmonary defense system (reduced activity of alveolar macrophages and leukocytes, decreased phagocytosis, deficiency of secretory IgA, decreased concentration of bacteriolysins in the bronchial contents, etc. - for details, see "Chronic bronchitis") and weakness of the immune response of the macroorganism. All this creates favorable conditions for persistence of an infectious inflammatory process in a certain area of the lung tissue, which subsequently leads to the formation of a pathomorphological substrate of chronic pneumonia - focal pneumosclerosis and local deforming bronchitis.

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Symptoms of chronic pneumonia

Chronic pneumonia is always the outcome of unresolved acute pneumonia. It should be emphasized that there is no strict time criterion that allows us to assert that acute pneumonia has transformed into a chronic inflammatory process in a given patient. Previous ideas about the terms of 3 months, 1 year have proven to be untenable. It should be considered that the determining role in the diagnosis of chronic pneumonia is not the onset of the disease, but the absence of positive X-ray dynamics and repeated exacerbations of the inflammatory process in the same area of the lung during long-term dynamic observation and intensive treatment.

During the period of exacerbation of chronic pneumonia, the main clinical symptoms are:

• complaints of general weakness, sweating, especially at night, increased body temperature, loss of appetite, cough with the separation of mucopurulent sputum; sometimes pain in the chest in the projection of the pathological focus;
• weight loss (not a mandatory symptom);
• symptoms of a local infiltrative-inflammatory process in the lung tissue (dullness of percussion sound, moist fine-bubble rales, crepitation over the lesion); when the pleura is involved, pleural friction noise is heard.

Instrumental research

1. X-ray examination of the lungs is of crucial importance in the diagnosis of chronic pneumonia. X-ray of the lungs in 2 projections reveals the following characteristic signs:
   • a decrease in the volume of the corresponding section of the lungs, stringiness and deformation of the pulmonary pattern of the small- and medium-cell type;
   • focal darkening of the lungs (they can be quite clear with pronounced carnification of the alveoli);
   • peribronchial infiltration in the affected area of lung tissue;
   • manifestations of regional adhesive pleurisy (interlobar, paramediastinal adhesions, obliteration of the costophrenic sinus).
2. Bronchography is currently considered a mandatory method of diagnostics and differential diagnostics of chronic pneumonia. It reveals the convergence of bronchial branches in the affected area, uneven filling with contrast, unevenness, and deformation of contours (deforming bronchitis). In the bronchiectatic form of chronic pneumonia, bronchiectasis is detected.
3. Bronchoscopy - reveals purulent bronchitis during the period of exacerbation (catarrhal during the period of remission), most pronounced in the corresponding lobe or segment.
4. A study of the external respiratory function (spirography) is mandatory in chronic pneumonia, since patients often suffer from chronic bronchitis and pulmonary emphysema at the same time. In uncomplicated chronic pneumonia (with a small lesion), there are usually no significant changes in spirography indicators (in rare cases, restrictive disorders are possible - a decrease in VC). With concomitant obstructive chronic bronchitis, there is a decrease in FVC indicators, the Tiffno index), with pulmonary emphysema - the VC value is significantly reduced.

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Laboratory data

1. General and biochemical blood tests reveal the following changes in the acute phase: increased ESR, leukocytosis with a left shift in the leukocyte formula, increased blood fibrinogen, alpha2- and gamma-globulins, haptoglobin, and seromucoid. However, it should be noted that these changes are usually expressed only with a significant exacerbation of the disease.
2. Sputum microscopy - during the period of exacerbation of the disease, a large number of neutrophilic leukocytes are detected.
3. Bacteriological examination of sputum - allows to determine the nature of microflora. The number of microbial bodies more than 10 in 1 μl of sputum indicates the pathogenicity of the identified microflora.

In the remission phase of chronic pneumonia, the patients feel satisfactory, they practically do not complain or their complaints are very insignificant. Only a low-productive cough, mainly in the morning, is typical due to the presence of local bronchitis. Physical examination of the lungs reveals dullness of percussion sound and fine bubbling rales, crepitus in the lesion, but auscultatory data in the remission period are significantly less vivid compared to the exacerbation phase. There are also no laboratory manifestations of the inflammatory process in the remission phase.

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Bronchiectatic form

The bronchiectatic form of chronic pneumonia has the following manifestations:

• cough with the release of a large amount of purulent sputum (200-300 ml or even more per day) with an unpleasant odor, most pronounced in a certain position of the patient;
• frequently observed episodes of hemoptysis;
• frequent exacerbations and even continuous course of the active inflammatory process, periodic delays in the separation of sputum, accompanied by a significant increase in body temperature; sweating at night;
• decreased appetite and significant weight loss in patients;
• changes in the nails (they take on the appearance of watch glasses) and thickening of the terminal phalanges in the form of “drumsticks”;
• listening to not only small bubbling rales, but often also medium bubbling rales over the lesion, they are abundant and consonant;
• more frequent occurrence of complications such as pleural empyema, spontaneous pneumothorax, and renal amyloidosis compared to the form without bronchiectasis;
• low efficiency of conservative therapy;
• detection of bronchiectasis (in the form of cylindrical, spindle-shaped, saccular expansions) during bronchographic and tomographic examination.

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Classification of chronic pneumonia

There is currently no generally accepted classification of chronic pneumonia. This is explained by the fact that not everyone recognizes the nosological independence of this disease. For purely practical purposes, the following classification can be used.

1. Prevalence of chronic inflammatory process in the lung:
   • focal
   • segmental
   • share
2. Process phase:
   • exacerbation
   • remission
3. Clinical form:
   • bronchiectatic
   • without bronchiectasis

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Diagnostic criteria for chronic pneumonia

1. There is a clear connection between the development of the disease and a previous case of acute pneumonia, which became protracted but did not resolve.
2. Recurrent inflammation within the same segment or lobe of the lung.
3. Focal nature of the pathological process.
4. The presence of clinical symptoms during the exacerbation period: cough with mucopurulent sputum, chest pain, increased body temperature, weakness.
5. Identification of stethoacoustic symptoms of a focal pathological process - small-bubble (and in the bronchiectatic form of the disease - medium-bubble) wheezing and crepitations.
6. X-ray, bronchographic and tomographic signs of focal infiltration and pneumosclerosis, deforming bronchitis (and in the bronchoectatic form - bronchiectasis), pleural adhesions.
7. Bronchoscopic picture of local purulent or catarrhal bronchitis.
8. The absence of tuberculosis, sarcoidosis, pneumoconiosis, congenital lung anomalies, tumors and other pathological processes that cause the long-term existence of focal compaction syndrome of lung tissue and laboratory manifestations of inflammation.

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Differential diagnosis of chronic pneumonia

The diagnosis of chronic pneumonia is rare and very important, requiring careful exclusion of other diseases that manifest as focal compaction of lung tissue, primarily pulmonary tuberculosis and lung cancer.

In differential diagnostics with lung cancer, it should be taken into account that chronic pneumonia is a rare disease, while lung cancer is quite common. Therefore, as N. V. Putov (1984) rightly writes, "in any case of a protracted or recurrent inflammatory process in the lung, especially in older men and smokers, it is necessary to exclude a tumor that stenoses the bronchus and causes the phenomena of the so-called paracancerous pneumonia." To exclude lung cancer, it is necessary to use special research methods - bronchoscopy with biopsy, transbronchial or transthoracic biopsy of the pathological focus, regional lymph nodes, bronchography, computed tomography. The absence of positive X-ray dynamics in patients with lung cancer during active anti-inflammatory and antibacterial treatment, including endoscopic bronchial sanitation, is also taken into account. Along with this, it should be taken into account that if cancer is suspected, precious time cannot be lost on long-term dynamic observation.

When conducting differential diagnostics of chronic pneumonia and pulmonary tuberculosis, the following circumstances should be taken into account:

• in pulmonary tuberculosis there is no acute non-specific inflammatory process at the onset of the disease;
• tuberculosis is characterized by predominantly upper lobe localization of the pathological process; petrifications in the lung tissue and hilar lymph nodes;
• In tuberculosis, tuberculosis bacteria are often found in sputum and tuberculin tests are positive.

Chronic pneumonia must be differentiated from congenital lung anomalies, most often simple and cystic hypoplasia and pulmonary sequestration.

Simple pulmonary hypoplasia is underdevelopment of the lung without the formation of cysts. This anomaly is accompanied by the development of a suppurative process in the lung, which leads to the development of intoxication syndrome, an increase in body temperature, the appearance of physical symptoms of inflammation of the lung tissue - a clinical picture similar to an exacerbation of chronic pneumonia. Simple pulmonary hypoplasia is diagnosed based on the results of the following research methods:

• chest x-ray - signs of decreased lung volume are revealed;
• bronchography - only the 3rd-6th order bronchi are contrasted, then the bronchogram seems to break off (the “burnt tree” symptom);
• bronchoscopy - catarrhal endobronchitis, narrowing and atypical location of the mouths of the lobar and segmental bronchi are determined.

Cystic hypoplasia of the lung is hypoplasia of the lung or part of it with the formation of multiple thin-walled cysts. The disease is complicated by the development of a secondary infectious and inflammatory process and chronic bronchitis. The diagnosis of cystic hypoplasia is based on the results of the following studies:

• X-ray of the lungs - in the projection of the hypoplastic lobe or segment of the lung, deformation or enhancement of the cellular pattern of the lungs is visible; tomographic examination reveals multiple thin-walled cavities with a diameter of 1 to 5 cm;
• bronchography - reveals hypoplasia of the lung and multiple cavities, partially or completely filled with contrast and having a spherical shape. Sometimes spindle-shaped expansions of the segmental bronchi are determined;
• angiopulmonography - reveals underdevelopment of the vessels of the pulmonary circulation in a hypoplastic lung or its lobe. Arteries and veins (subsegmental prelobular and lobular) encircle the air cavities.

Pulmonary sequestration is a developmental defect in which part of the cystically altered lung tissue is separated (sequestered) from the bronchi and vessels of the pulmonary circulation and is supplied with blood by the arteries of the systemic circulation, which branch off from the aorta.

A distinction is made between intralobar and extralobar pulmonary sequestration. In intralobar sequestration, abnormal lung tissue is located inside the lobe, but does not communicate with its bronchi and is supplied with blood from arteries that branch directly from the aorta.

In extralobar pulmonary sequestration, the aberrant area of lung tissue is located outside the normal lung (in the pleural cavity, in the thickness of the diaphragm, in the abdominal cavity, on the neck and in other places) and is supplied with blood only by the arteries of the systemic circulation.

Extralobar pulmonary sequestration is not complicated by a suppurative process and, as a rule, does not manifest itself clinically.

Intralobar pulmonary sequestration is complicated by a suppurative process and requires differential diagnosis with chronic pneumonia.

The diagnosis of pulmonary sequestration is made based on the results of the following studies:

• Chest X-ray reveals deformation of the pulmonary pattern and even a cyst or group of cysts, sometimes irregularly shaped darkening; peribronchial infiltration is often revealed;
• tomography of the lungs reveals cysts, cavities in the sequestered lung and often a large vessel leading from the aorta to the pathological formation in the lung;
• bronchography - in the sequestration zone there is deformation or expansion of the bronchi;
• Selective aortography - reveals the presence of an abnormal artery, which is a branch of the aorta and supplies blood to the sequestered part of the lung.

Most often, these radiological changes are detected in the posterobasal regions of the lower lobes of the lungs.

Chronic pneumonia should also be differentiated from cystic fibrosis, bronchiectasis, and chronic lung abscess. The diagnosis of these diseases is described in the relevant chapters.

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Survey program

1. General blood and urine tests.
2. Biochemical blood test: content of total protein, protein fractions, sialic acids, fibrin, seromucoid, haptoglobin.
3. X-ray of the lungs in 3 projections.
4. Lung tomography.
5. Fiberoptic bronchoscopy, bronchography.
6. Spirometry.
7. Sputum examination: cytology, flora, sensitivity to antibiotics, detection of Mycobacterium tuberculosis, atypical cells.

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Example of diagnosis formulation

Chronic pneumonia in the lower lobe of the right lung (in segments 9-10), bronchiectatic form, exacerbation phase.

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Treatment of chronic pneumonia

Chronic pneumonia is a chronic inflammatory localized process in the lung tissue, the morphological substrate of which is pneumosclerosis and (or) carnification of the lung tissue, as well as irreversible changes in the bronchial tree according to the type of local chronic deforming bronchitis, clinically manifested by relapses of inflammation in the same affected part of the lung.

When treating a patient with chronic pneumonia, it should be assumed that chronic pneumonia is the result of unresolved acute pneumonia. Stages of disease development: acute pneumonia → protracted pneumonia → chronic pneumonia.

Using modern examination methods (X-ray of the lungs in 3 projections, X-ray tomography, computed tomography, bronchoscopy with cytological examination of bronchial secretions, bronchography), it is necessary to make sure that the diagnosis of "chronic pneumonia" does not hide tuberculosis or a malignant disease of the bronchopulmonary system, a congenital lung disease (developmental anomaly, cyst, etc.).

The treatment program for chronic pneumonia is completely consistent with the program for acute pneumonia. However, when organizing treatment for a patient with chronic pneumonia, the following features must be taken into account.

1. During the period of exacerbation of chronic pneumonia, antibacterial therapy is carried out similar to that in acute pneumonia. It should be remembered that chronic pneumonia is characterized by the constant presence of potentially active microflora in the inflammation site, and in recent decades the composition of pneumonia pathogens has expanded. In addition to bacterial flora, pneumotropic viruses have acquired great importance, causing severe viral and viral-bacterial pneumonia, especially during influenza epidemics. The spectrum of bacterial flora has also changed. According to A. N. Kokosov (1986), during an exacerbation of chronic pneumonia, hemolytic streptococcus, Staphylococcus aureus, pneumococcus are most often isolated from sputum and bronchial contents of patients, microbial associations of 2-3 microorganisms, staphylococcus with pneumococcus, with hemolytic streptococcus, with Friedlander's bacillus, intestinal and Pseudomonas aeruginosa are often found. In 15% of patients with exacerbation of chronic pneumonia, the role of mycoplasmas has been proven.

When prescribing antibacterial therapy in the first days of exacerbation of chronic pneumonia, it is advisable to focus on these data, but then it is imperative to conduct a sputum test, bacteriological, bacterioscopic, for sensitivity of flora to antibiotics and make adjustments to antibacterial therapy depending on the results of the study. It is better to examine the sputum obtained during a fibrobronchoscopy; if this is not possible, sputum collected by the patient and processed using the Mulder method is examined.

It is necessary to emphasize the important role of endotracheal and bronchoscopic sanitation in the treatment of chronic pneumonia. This is of great importance, especially in case of frequent and long-term exacerbations, since chronic pneumonia is a localized inflammatory process with the development of pneumosclerosis in the inflammation focus. With oral or parenteral antibacterial therapy, drugs do not penetrate sufficiently into the inflammation focus and only endotracheal and endobronchial administration of antibacterial drugs allows obtaining the required concentration in the lung tissue in the inflammation focus. The most appropriate combination of parenteral and eudobronchial antibacterial therapy. This is especially important in the bronchiectatic form of chronic pneumonia.

In very severe cases of the disease, there is positive experience with the introduction of antibiotics into the pulmonary hemodynamic system.

In severe cases of recurrent chronic pneumonia caused by staphylococcal, pseudomonas and other superinfections, passive specific immunotherapy is successfully used along with antibacterial drugs - the introduction of appropriate antibacterial antibodies in the form of hyperimmune plasma, γ- and immunoglobulin. Antistaphylococcal-pseudomonas-proteus plasma is administered intravenously at 125-180 ml 2-3 times a week. Treatment with hyperimmune plasma is combined with intramuscular administration of antistaphylococcal γ-globulin. Before starting immunotherapy, the patient should consult an allergist and prescribe antihistamines to prevent allergic complications.

2. The most important direction in chronic pneumonia is the restoration of the drainage function of the bronchi (expectorants, bronchodilators, positional drainage, fibrobronchoscopy sanitation, classical and segmental chest massage). For more details, see "Treatment of chronic bronchitis".
3. Of great importance in the treatment of chronic pneumonia are immunocorrective therapy (after studying the immune status) and increasing the general reactivity and non-specific protective reactions of the body (see "Treatment of acute pneumonia"). It is extremely important to undergo annual spa treatment.
4. Much attention should be paid to oral hygiene and the fight against nasopharyngeal infections.
5. In the absence of contraindications, the treatment program must necessarily include physiotherapy aimed at the local inflammatory process (SMV therapy, inductothermy, UHF therapy and other physiotherapy methods). Ultraviolet and laser blood irradiation should also be widely used.
6. In case of frequent relapses of chronic pneumonia in young and middle-aged individuals and a clearly localized bronchiectatic form of the disease, the issue of surgical treatment (lung resection) should be decided.

Prevention of chronic pneumonia

• healthy lifestyle, physical activity;
• early onset and proper treatment of acute pneumonia; effective treatment of acute and chronic bronchitis; timely and effective treatment of nasopharyngeal lesions
• chronic infection; thorough sanitation of the oral cavity;
• correct and timely medical examination of patients who have had acute pneumonia;
• elimination of occupational hazards and factors that cause irritation and damage to the respiratory tract;
• smoking cessation.

These same measures are also a preventive measure against relapses of exacerbations of chronic pneumonia. In addition, anti-relapse courses are recommended (the so-called anti-relapse prophylaxis during dispensary observation).

L. N. Tsarkova identifies 4 groups of patients with chronic pneumonia subject to dispensary registration, depending on the degree of compensation of the inflammatory process in the remission phase, the patient's ability to work, and the presence of complications.

1. The first group includes patients with chronic pneumonia, who in the remission phase can be considered practically healthy and whose ability to work is fully preserved. Patients are observed twice a year.
2. The second group includes patients who have a rare cough (dry or with a small amount of sputum) and especially vegetative syndrome while maintaining their ability to work. Patients are observed twice a year.
3. The third group includes patients with persistent wet cough, pronounced asthenovegetative syndrome and decreased ability to work (disabled persons of group III). Patients are observed 4 times a year.
4. The fourth group consists of patients with a constant cough, with a large amount of sputum, subfebrile temperature, short remissions, complications of the disease, with a decrease in working capacity (II group of disability). Patients are observed 4 times a year.

Outpatient observation is carried out by a pulmonologist and a local therapist. Recommended examination methods: chest radiography (large-frame fluorography), spirography, pneumotachometry, ECG, general blood, sputum, urine analysis, allergy testing in the presence of allergic manifestations.

The anti-relapse complex for patients with chronic pneumonia includes the following measures:

• the first group - breathing exercises, massage, multivitamin therapy, adaptogens; in patients with frequent relapses - immunomodulators (N. R. Paleev, 1985); sanitation of the nasopharynx; ultraviolet irradiation of the chest, galvanization;
• the second and third groups - the same measures as in the first group, but, in addition, measures to improve the drainage function of the bronchi (positional drainage, intratracheal lavage, inhalation of bronchodilator aerosols in the development of broncho-obstructive syndrome, mucolytics, expectorants);
• the fourth group - all of the above measures, but, in addition, means of preventing the progression of complications already present in the patient (obstructive bronchitis, myocardial dystrophy, amyloidosis, etc.): metabolic therapy, calcium antagonists, bronchodilators, etc.

An important measure of relapse prevention is annual spa treatment in all groups of patients.

The indicators of the effectiveness of medical examination are: a decrease in the frequency of exacerbations of the inflammatory process and the duration of temporary disability, stabilization of the process.

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