Pathogenetic treatment of pneumonia

In severe acute pneumonia, severe impairment of bronchial drainage function or abscess formation, sanitation bronchoscopies are performed with a 1% solution of dioxidine or a 1% solution of furagin. Such measures are performed in the intensive care unit or block.

Restoration of bronchial drainage function

Restoration of the drainage function of the bronchi promotes the fastest resorption of the inflammatory infiltrate in the lungs. For this purpose, expectorants and mucolytics are prescribed. These agents are used when the cough becomes "wet". A good effect is provided by a solution of potassium iodide (washed down with alkaline solutions, Borjomi, milk), marshmallow root, mucaltin, acetylcysteine, bromhexine (bisolvon). Particular importance is given to bromhexine, which stimulates the production of surfactant - an important component of the local bronchopulmonary defense system. Proteolytic enzymes are also used to liquefy sputum and cleanse the bronchi.

Normalization of bronchial muscle tone

Often, patients with acute pneumonia experience severe bronchospasm, which disrupts the ventilation function of the lungs, contributes to the development of hypoxemia, and delays the resolution of the inflammatory focus.

Bronchodilators are used to relieve bronchospasm. Most often, euphyllin is used intravenously by drip, in suppositories, and sometimes orally. In recent years, prolonged-release theophylline preparations have been widely used.

To relieve an attack of suffocation, selective beta2-adrenergic receptor stimulants can also be used in the form of metered aerosols (berotek, ventolin, salbutamol, etc.); some beta2-stimulants can also be used internally (alupent, etc.).

Immunomodulatory therapy

The functional state of the body's immune system plays a major role in the development of acute pneumonia. Impaired immunological reactivity is one of the leading causes of prolonged acute pneumonia. As a rule, pneumonia, especially acute pneumonia, occurs against the background of secondary immunodeficiency with decreased activity of NK cells (natural killers), impaired activity of T-suppressors, T-helpers. A decrease in the phagocytic function of neutrophils is also noted.

Antibacterial agents used for pneumonia also affect the state of the body's immune system and non-specific defense mechanisms.

Most beta-lactam antibiotics significantly enhance phagocytosis. In recent years, the immunomodulatory properties of cephalosporins have been identified. Cefodisine (Modivid), which has an immunostimulating ability, is especially effective in this regard. Cefaclor has a similar effect.

Macrolides reduce the resistance of bacteria to the action of neutrophil bactericidal factors. It has been established that clindamycin and rifampicin stimulate phagocytosis. Fluoroquinolones enhance the production of interleukin-1 and interleukin-2, phagocytosis, and the synthesis of IgG and IgM antibodies to bacterial antigens. Along with this, there are reports that tetracyclines and sufanilamides inhibit phagocytosis.

For acute pneumonia, the following immunocorrective agents are used.

Prodigiosan is a bacterial polysaccharide that enhances phagocytosis through the production of interleukin-1 and increases the activity of various T-cell subpopulations. Since interleukin-1 is an endogenous pyrogen, prodigiosan treatment may cause an increase in body temperature. Stimulates T-helpers and B-lymphocytes.

Prodigiosan is prescribed in gradually increasing doses from 25 to 100 mcg intramuscularly at intervals of 3-4 days. The course of treatment is 4-6 injections. Treatment with prodigiosan in combination with antibiotics and immunoglobulin leads to positive dynamics of the disease.

Immunomodulatory drugs obtained from the thymus are widely used.

T-activin - enhances phagocytosis, interferon production, stimulates T-killer function. It is administered subcutaneously at 100 mcg once a day for 3-4 days.

Timalin - has the same properties as T-activin. Prescribed 10-20 mg intramuscularly for 5-7 days.

Timoptin is an effective immunomodulatory drug for the thymus, containing a complex of immunoactive polypeptides, including a-thymosin.

The drug normalizes the parameters of the T- and B-immune systems, induces proliferation and differentiation of T-lymphocyte precursors into mature immunocompetent cells, normalizes the interaction of T- and B-lymphocytes, activates the phagocytic function of neutrophils, and stimulates the megakaryocytic lineage.

Timoptin is administered subcutaneously at a rate of 70 mcg/m2 ^of body surface, i.e. adults are usually administered 100 mcg once every 4 days. The course of treatment is 4-5 injections. If necessary, it is repeated.

No side effects were identified.

It is produced in vials in the form of a sterile lyophilized powder of 100 mcg, before administration it is dissolved in 1 ml of isotonic sodium chloride solution.

Anabol is a bacterial polysaccharide produced by lactobacilli. Increases the activity of natural killers, T-cell function, is low-toxic, and is well tolerated. Anabol also stimulates the phagocytic function of neutrophils. It is used orally at 1.5 g per day for 2 weeks.

Sodium nucleinate - obtained by hydrolysis of yeast. Available in powders. Taken orally 0.2 g 3-4 times a day after meals. The drug stimulates cooperation of T- and B-lymphocytes, increases the phagocytic function of macrophages, including alveolar ones, interferon production and lysozyme content in the bronchi.

Zixorin - stimulates the function of T-lymphocyte killers and is an inducer of cytochrome P450 in the liver. It is used 0.2 g 3 times a day for 1-2 weeks.

Zaditen (ketotifen) - moderately increases the function of T-lymphocyte suppressors and inhibits the degranulation of mast cells, thereby preventing the release of leukotrienes and other mediators of allergy and inflammation.

The drug is prescribed at 0.001 g 2 times a day, primarily to patients with protracted pneumonia accompanied by bronchospastic syndrome.

Katergen is a hepatoprotector, in addition, it has an antioxidant effect, increases the activity of natural killers. It is prescribed in tablets of 0.5 g 3 times a day for 3-4 weeks. It has virtually no side effects.

Levamisole (Decaris) - restores the function of T-lymphocytes, primarily by stimulating suppressor T-lymphocytes.

Prescribed 150 mg once a day for 3 days, then a 4-day break. The courses are repeated 3 times, for the entire course of treatment 1350 mg of the drug is prescribed.

During treatment with levamisole, one should be aware of the possible development of leukopenia and agranulocytosis.

Diucifon is available in 0.1 g tablets, stimulates the function of T-lymphocytes (mainly T-suppressors), prescribed 0.1 g 3 times a day for 5-7 days followed by a break of 4-5 days. The number of courses is determined by the course of the disease.

The drug is inferior to levamisole in immunocorrective activity, but does not cause the development of agranulocytosis.

Indications for the use of immunomodulators

Preparation	Indications for use
Levamisole	Decreased number of T-lymphocytes, T-suppressors, natural killers
Diucifon	Decreased number of T-lymphocytes, T-suppressors, natural killers
Prodigiosan	Decreased T-helpers, decreased activity of T-cells and B-lymphocytes, decreased phagocytic activity of leukocytes
Zixorin	Decreased activity of natural killers, increased activity of T-suppressors
Katergen	Selective reduction of natural killer cell activity
Zaditen (ketotifen)	Decreased activity of T-suppressors
Sodium nucleinate	Moderate decrease in the content of T- and B-cells and their functional activity, decrease in the phagocytic activity of macrophages and leukocytes
Anabol	Decreased activity of natural killers, functional activity of T cells, phagocytic activity of leukocytes
T-activin, thymalin	Decreased phagocytic activity of leukocytes, decreased function of T-killers, decreased total population of T-lymphocytes

Oxymethacyl, echinocin, licopid, and ribomunil are also used.

Before prescribing immunocorrectors, it is necessary to determine the patient’s immune status and differentially prescribe immunomodulators taking into account immunological disorders.

According to V. P. Silvestrov (1985), the use of immunoregulatory drugs is justified even in the initial period of the infectious process with sharply reduced indicators of individual links of the immune system. In the recovery stage, these drugs are used when incomplete restoration of the activity of immunocompetent cells is noted. During the period of remission of the chronic process, stimulation of the body's defense reactions with the help of immunostimulants can prevent an exacerbation of the disease. Immunostimulants are especially indicated for patients with protracted pneumonia, when the lack of complete restoration of the immune status indicators contributes to a significant extension of the recovery period.

E. V. Gembitsky, V. G. Novozhenov (1994) recommend the use of Sandoglobult at a dose of 0.1-0.4 g/kg/day intravenously by drip (10-30 drops/min) for the following indications:

• antibiotic resistance;
• generalization of infection;
• severe staphylococcal destruction of the lungs;
• deficiency of IgG3 and IgG4 - subclasses of Ig.

Elderly people should be prescribed the immunoregulators levamisole and diucifon with caution, since, on the contrary, they may experience suppression of the immune mechanism that the drug is aimed at. In these cases, it is more appropriate to use "soft" immunomodulators - anabole, sodium nucleinate.

Adaptogens have a weak immunocorrective effect with virtually no side effects. They are useful to prescribe for any type of acute pneumonia. Use eleutherococcus extract 1 teaspoon 2-3 times a day, ginseng tincture 20-30 drops 3 times a day, Chinese magnolia vine tincture 30-40 drops 3 times a day, saparal 0.05-0.1 g 3 times a day, pantocrine 30 drops 3 times a day. Adaptogens are prescribed for the entire duration of the disease, until recovery.

A positive but weak effect on the immune system can be provided by agents that increase non-specific resistance - aloe extract, vitreous body, fibs, biosed. They are administered subcutaneously or intramuscularly, 1 ml once a day for 15-20 days.

In case of decreased B-lymphocyte function and immunoglobulin deficiency, it is advisable to treat with immunoglobulin, γ-globulin, 3-4 ml once every 3 days (4-5 injections). There are also γ-globulin preparations for intravenous administration - 0.2-0.4 g/kg daily or every other day.

Interferon preparations are also used as immunomodulatory agents.

Interferons are endogenous low-molecular proteins with a molecular weight of 15,000 to 25,000, possessing antiviral, immunomodulatory and anti-inflammatory properties. α-, β- and γ-interferons are known.

α-Interferon is produced by B-lymphocytes and lymphoblasts, β-interferon by fibroblasts, and γ-interferon by T-lymphocytes.

Using genetic engineering, a drug called Reaferon was obtained that corresponds to human a2-interferon.

Interferons are administered intramuscularly (the contents of 1 ampoule are dissolved in 1 ml of isotonic sodium chloride solution) at 1,000,000 ME 1-2 times a day every day or every other day for 10-12 days. The drug is highly effective, non-toxic, and the combination of reaferon with antibiotics increases their effectiveness. The best results are achieved with the simultaneous use of interferon and antibiotics.

In the complex therapy of acute pneumonia, especially in its protracted course, it is possible to use such immunomodulatory methods as laser and ultraviolet irradiation of blood. The latter method also has a bactericidal effect. The use of these methods is especially advisable when it is necessary to quickly affect the immune status.

Multivitamin complexes have a positive effect on the immune system.

Antioxidant therapy

Activation of peroxidation processes with the formation of excess free radicals has an important pathogenetic significance in the development of acute pneumonia, as it leads to damage to the membranes of the bronchopulmonary system. Correction of membrane disorders is carried out using an exogenous antioxidant - vitamin E.

Vitamin E can be taken orally, 1 capsule 2-3 times a day for 2-3 weeks, or its oil solution can be injected intramuscularly, 1 ml per day.

For the same purpose, it is advisable to include Essentiale in capsules in the complex therapy of acute pneumonia, 2 capsules 3 times a day during the entire period of the disease. The drug contains essential phospholipids, which are part of cell membranes, vitamin E, and other vitamins (pyridoxine, cyanocobalamin, nicotinamide, pantothenic acid). The drug has a membrane-stabilizing and antioxidant effect.

In recent years, emoxipin 4-6 mg/kg/day intravenously by drip in isotonic sodium chloride solution has been used as antioxidant therapy.

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Improving the function of the local bronchopulmonary defense system

Disruption of the function of the local bronchopulmonary defense system is of great importance in the pathogenesis of acute pneumonia. The local bronchopulmonary defense system includes the normal function of the ciliated epithelium, production of surfactant, lysozyme, interferon, protective immunoglobulin A, normal functioning of alveolar macrophages and the bronchopulmonary immune system, represented by all subpopulations of T-lymphocytes, a large number of natural killers, and B-lymphocytes. In acute pneumonia, the function of the local bronchopulmonary defense system is sharply reduced, which facilitates the introduction of an infectious agent into the lung tissue and the development of inflammation in it.

Normalization of the function of the local bronchopulmonary defense system promotes the fastest possible recovery of the patient. But the doctor's capabilities in this regard are still limited.

To a certain extent, the improvement of the function of the local bronchopulmonary defense system occurs with treatment with immunomodulators, the use of bromhexine, ambroxol (stimulates the formation of surfactant). Surfactant is a superficial monomolecular film on the surface of the alveoli, which consists mainly of phospholipids, produced by alveocytes. It regulates the surface tension of the alveoli and prevents their collapse, prevents the collapse of small bronchi, counteracts the development of pulmonary emphysema, participates in the absorption of oxygen, has bactericidal activity.

Research is underway on the endobronchial use of alveolar macrophage culture, interferon, and immunoglobulin.

Fight against intoxication

As detoxification measures for acute pneumonia, especially severe and with pronounced intoxication, intravenous drip infusion of hemodesis (400 ml once a day), isotonic sodium chloride solution, 5% glucose solution, as well as treatment with coenzymes (cocarboxylase, pyridoxal phosphate, lipoic acid) are used, which significantly improves tissue metabolism and helps reduce intoxication. In case of pronounced secondary hypoxemic and toxic encephalopathy, intravenous infusion of 5 ml of 20% piracetam solution in 10 ml of isotonic sodium chloride solution once a day for 5-6 days is recommended, then 0.2 g of piracetam in tablets 3 times a day.

For the purpose of detoxification, the patient is recommended to drink cranberry juice, rosehip decoctions, fruit juices, mineral waters. In case of intoxication syndrome resistant to detoxification therapy, plasmapheresis and hemosorption are used, which also have an immunomodulatory effect.

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