Pulmonary syndromes

Based on the data obtained with the help of basic and additional methods of examining the patient, i.e. Specific symptoms and signs, it is possible to single out a number of syndromes in which these signs are linked together by a single mechanism of development, a common pathogenesis, combined with the features of the changes that arise. Such syndromic stage of diagnostics of diseases, although it is intermediate, is very important, since, on the one hand, it allows to eliminate the disparity of the evaluation of each of the revealed signs and give a more complete picture of the disease, on the other hand, it makes necessary the next stage of diagnosis - the nosological nature of the syndrome , because the clinical picture of a particular syndrome can often be characteristic of several different diseases, and one of the ultimate goals of the diagnostic pathway is the determination of a specific nosol ohic form.

There are several pulmonary syndromes: pulmonary dysfunction syndrome , pleural syndrome, cavity syndrome, bronchoobstructive syndrome, lung hyperexcitation syndrome, picqueek syndrome, sleep apnea syndrome (sleep apnea syndrome), respiratory insufficiency syndrome. It should be borne in mind that within the same large syndrome there are a number of options, the diagnosis of which, of course, is important, since the methods of treatment will be different.

Main pulmonary syndromes

Pulmonary heart disease syndrome :

1. Infiltrate (pneumonic, tubercular, eosinophilic).
2. Lung infarction (thromboembolism, thrombosis).
3. Atelectasis (obturation, compression, syndrome of the middle lobe).
4. Congestive heart failure (stagnant fluid in the lower parts of the lungs).
5. Tumor.

Pleural syndrome:

1. Fluid in the pleural cavity (transudate, exudative pleurisy).
2. Air in the pleural cavity (pneumothorax).

Cavity syndrome (disintegrating abscess and swelling, cavern).

Bronchoobstructive syndrome:

1. Obturation or constriction of the bronchus.
2. Bronchial spasm.

Syndrome of hyperemployment of the lungs (various types of emphysema).

Pickwick syndrome and sleep apnea syndrome (sleep apnea syndrome).

Syndrome of respiratory failure:

1. Acute respiratory failure (including adult distress syndrome).
2. Chronic respiratory insufficiency.

The allocation of these syndromes occurs primarily with the use of basic methods of examining the patient - examination, palpation, percussion, auscultation.

Cavity syndrome in the lung

The cavity syndrome includes signs, the appearance of which is associated with the presence of caverns, abscesses, cysts, ie, formations having a dense, more or less smooth wall, often surrounded by an infiltrative or fibrous shaft. The cavity can be filled entirely with air alone (empty cavity) or contain, in addition to air, some amount of liquid, remain closed or communicate with the draining bronchus. All this, of course, affects the characteristics of the symptomatology, which also depends on the size of the cavity and the depth of its location.

With large, superficially located and isolated cavities, regardless of their contents, the voice jitter is weakened. If the cavity communicates with the bronchus and at least partially contains air, the percussion sound will have a tympanic tinge; Above the cavity filled with liquid, there is blunting or absolute dullness. When auscultation over an isolated air cavity, breathing is not heard; if the air cavity has a communication with the draining bronchus, bronchial breathing will be heard, which is easily carried out from the place of formation (the voice gap) through the air column and can acquire a metallic shade (amphoric respiration) as a result of resonance in the smooth-walled cavity. The cavity, partially containing liquid, is the source of the formation of wet wheezes, which, as a rule, have a sonorous character, since their conduct is intensified by the surrounding densified (infiltrated) tissue. In addition, auscultatory it is possible to catch an independent stenotic noise, which enhances bronchial respiration, which occurs at the place of communication of the cavity (cavity) with the draining bronchus.

It should be noted that all these symptoms that characterize the cavity syndrome are often very dynamic, since staging in the development of cavity formation is noted, especially lung abscess : partial or complete emptying is replaced by fluid accumulation, which reflects the characteristics of the above symptoms of a cavity containing a rose or liquid .

[1], [2], [3], [4], [5]

Bronchoobstructive syndrome

Bronchoobstructive syndrome ( bronchial obstruction syndrome ) manifests itself as a severe productive, rarely unproductive cough, as well as symptoms of regularly developing consequences of its long existence - signs of emphysema. At the heart of clinical manifestations of bronchial obstructive syndrome lie the violation of bronchial patency, associated with it difficult and uneven ventilation (mainly due to the restriction of expiratory flow) and an increase in the residual volume of the lungs. With a true syndrome of bronchial obstruction, it is a question of changing the patency of the small bronchi (they are called in connection with this the "achilles heel" of the bronchi). Violation of the patency of small bronchi arises most often due to inflammation and swelling of the bronchial mucosa ( chronic bronchitis, allergic component), bronchospasm, usually with mucosal edema (bronchial asthma), less often - with diffuse peribronchial fibrosis, compressing bronchi from the outside.

Chronic bronchitis most often leads to the development of irreversible inflammatory-cicatricial changes in small bronchi and represents the basis of chronic obstructive pulmonary disease, the main clinical signs of which are the following:

1. cough with thick and viscous sputum;
2. clinical and functional signs of airway obstruction;
3. increasing shortness of breath;
4. development of " pulmonary heart " (cor pulmonale), terminal respiratory and heart failure.

Cigarette smoking is the most frequent etiologic and disease-supporting factor. Due to the frequency of cyanosis and heart failure patients with chronic obstructive bronchitis are described as "blue fathers". With this variant of the obstructive syndrome following inflammatory edema of the mucous membrane of terminal bronchioles, leading to hypoventilation of the alveoli, a decrease in the partial pressure of oxygen and an increase in the partial pressure of carbon dioxide - hypoxemia and hypercapnia, there are spasms of the alveolar capillaries and hypertension of the small circulation. A pulmonary heart is formed, the decompensation of which is manifested by peripheral edema.

Another common cause of chronic obstructive pulmonary disease is obstructive emphysema, in which cyanosis is usually not expressed, the patients are called "pink thighs". In this case, bronchial obstruction is also noted, but it is especially evident in exhalation when there is a decrease in bronchioles with loss of the elastic properties of the alveoli, which is associated with an increase in the volume of the alveoli, a decrease in the number of alveolar capillaries, the absence of blood bypass (in contrast to the first option, preservation of ventilation-perfusion relations) and its normal gas composition. Smoking with pulmonary emphysema is the main etiologic factor, although in some patients, the cause of the disease can be inhalation of air pollutants and a1-antitrypsin deficiency.

Most often chronic obstructive pulmonary disease is a combination of these conditions, which makes bronchial obstruction; the syndrome is very common, and, given the severity of the consequences, the timely detection of the syndrome and the underlying diseases, their treatment, and most importantly, prevention is of utmost importance.

Since there are significantly fewer objective symptoms in bronchoobstructive syndrome than with other large pulmonary syndromes, it is necessary to note the extreme clinical significance of cough, not only as a patient's complaint and as a sign of bronchial injury, but also as a factor aggravating the changes in pulmonary parenchyma in bronchial obstruction syndrome. The main symptoms of this syndrome are the symptoms of its complication, the emblems of lung emphysema, which are described below. But still there are signs of impaired bronchial patency as such. These include, first of all, those detected with the help of auscultation - rigid vesicular breathing with an expiratory elongation, wheezing, and by the characteristics of wheezing one can judge not only the degree of constriction of the bronchi, but also the level of obstruction. An important auscultatory index of bronchial obstruction is a violation of the ratio of inhalation and exhalation, the appearance of an elongated coarse exhalation. Finally, the parameters of the function of external respiration, especially high-speed ones, are of great clinical importance for the detection of impaired bronchial patency, in particular with the use of a formed expiration (the above-mentioned Tiffno et al. Test).

[6], [7], [8]

Hyperfusion syndrome

The syndrome of lung hyperresponsiveness is most often the result of a long-term labored exhalation (bronchial obstruction), which leads to an increase in the residual volume of the lungs, chronic mechanical action on the elastic apparatus of the alveoli, their stretching, irreversible loss of ability to fall, increasing the residual volume. A typical variant of this syndrome is emphysema, which usually develops gradually. Acute swelling of the lungs is rare.

Thus, there is a close relationship between bronchial obstructive syndrome and pulmonary emphysema, which is therefore most often obturation (obstructive). Significantly less common compensatory (including vicarious) emphysema, which develops in response to a slow increase in diffuse pulmonary fibrosis. Due to the fact that the bronchial obstruction syndrome is more generalized, emphysema is a two-way process. Clinical signs of it are barrel chest with reduced respiratory mobility, poor holding of voice jitter, the presence of a widespread boxed percussion sound that can replace the zone of absolute cardiac dullness, the displacement of the lower edge of the lungs down, uniform weakening of vesicular breathing, auscultatory signs of bronchial obstructive syndrome (wheezing, elongated exhalation).

It should be emphasized that these signs are revealed when the emphysematous process is far gone; of course, it is important to detect earlier symptoms, which are essentially the same - a reduction in the respiratory excursion of the lower pulmonary margin, which gradually grows over time, which is found long before the appearance of signs of marked swelling of the lungs.

The Pickwick syndrome and sleep apnea syndrome

Interesting are the Pickwick syndrome and sleep apnea syndrome (a symptom of nocturnal apnea), which are commonly mentioned in the respiratory system diseases section (although they do not directly concern lung diseases), since their main manifestation is respiratory failure with hypoxia and hypoxemia - develops in the absence of primary lung disease.

The Pickwick syndrome is a symptomatic complex, including pronounced alveolar hypoventilation and hypoxia and hypercapnia caused by it (RNO ₂ above 50 mm Hg), respiratory acidosis, and insuperable daytime drowsiness, polycythemia, high hemoglobin, episodes of apnea. The reason for this hypoventilation is considered to be significant obesity with a predominant fat deposition in the abdominal region with a slight growth; apparently, genetic sensitivity to such hypoventilation matters. These patients are characterized by a prolonged period of severe (morbid) obesity with an additional sharp increase in body weight, pulmonary heart development, dyspnea with exercise, cyanosis, leg edema, morning headaches, but the most typical symptom is pathological drowsiness, including during a conversation, for food, reading, and in other situations. Of interest is the fact that a decrease in body weight leads in some patients to reverse development of the main signs of the symptom complex.

Although for the first time the connection between sudden drowsiness and periodic apnea with massive obesity was indicated at the beginning of the 19th century, the term "Pickwick syndrome" began to be used after W. Osler discovered these symptoms in the character of Charles Dickens's "posthumous notes of the Pickwick Club" boy Joe: "... On the box was a fat red-faced guy, lost in drowsiness ..." "An unbearable boy," said the elderly gentleman, "he fell asleep again!" "Awesome boy," said Mr. Pickwick. "Does he always sleep like that?" "He's asleep!" the old gentleman confirmed. "He always sleeps." In a dream, he obeys orders and snores, serving at the table. "

The Pickwick syndrome, as well as the general presence of excess body weight, is often accompanied by a recurring nocturnal apnea.

Currently, more attention is paid to breathing disorders during sleep, in particular, obstructive sleep apnea syndrome. It is believed that 1% of the population suffers from such violations. The most important anamnestic sign of this syndrome is a disorderly and loud snoring ("heroic" snoring), interrupted by long pauses, sometimes reaching 2 minutes. Such stopping of breathing leads to hypoxia, which causes cerebral and cardiac disorders. In addition to this feature, these people during the day, at first glance, unmotivated significantly limited performance.

Sleep apnea is a syndrome characterized by episodes of breathing lasting 10 s or more, periodically recurring during sleep, hypoxemia, and hysterectomy. Pathogenetically, there are 2 types of nocturnal sleep apnea: central, caused by violations of the central regulation of breathing, as well as obstructive, leading to the possession of the soft palate, the root of the tongue, hyperplasia of palatine tonsils, adenoids, defects in the development of the lower jaw, tongue, ways. From practical points of view, it is important to distinguish the obstructive mechanism of respiratory arrest during sleep, as it significantly increases the risk of sudden death, especially in persons with excessive body weight, as well as in alcohol abusers. This risk can be reduced by persistently conducted treatment for weight loss.

The clinical picture of the syndrome of nocturnal sleep apnea consists of the described episodes of cessation of breathing, loud snoring, drowsiness during the day, memory loss and the ability to concentrate attention, increased daytime fatigue, and hypertension in the morning hours, not controlled by conventional treatment. It is more common in middle-aged men, as already noted, with excessive body weight, but it can also occur in children. It should be noted a possible combination of hypothyroidism and obstructive type of sleep apnea.

To diagnose the syndrome, monitor monitoring during sleep with the recording of an electroencephalogram, the nature of breathing, ECG (for recording possible arrhythmias), oxygenometry to determine the level of hypoxemia.

The syndrome of nocturnal apnea is considered significant and potentially dangerous at a frequency of more than 5 attacks per hour and lasting more than 10 seconds each. Some authors believe that a prolonged attack can lead to sudden death during sleep.

Reducing body weight, refusing alcohol and sedatives, but especially constant breathing during sleep with a special mask that provides air through the nose under pressure, are now considered the most effective treatment for obstructive sleep apnea syndrome. The optimal level of inspiratory pressure selected by means of monitoring observation allows the flow of inhaled air to overcome resistance, apnea does not arise, daytime sleepiness decreases, blood pressure normalizes.

Syndrome of respiratory failure

The respiratory insufficiency syndrome is one of the largest and most important pulmonological syndromes, since its appearance indicates the appearance of changes in the basic function of the respiratory system, a function of gas exchange, including, as already mentioned, pulmonary ventilation (air supply to the alveoli), diffusion (gas exchange in the alveoli) and perfusion (oxygen transport), as a result of which the maintenance of the normal gas composition of blood is disturbed, which in the first stages is compensated by a more intensive work of the external respiration system and with heart. Usually, respiratory failure develops in patients suffering from chronic lung diseases leading to emphysema of lungs and pneumosclerosis, but it can also occur in patients with acute illnesses, accompanied by the deactivation of large masses of lungs (pneumonia, pleurisy) from respiration. Recently, a special acute distress syndrome of adults has been singled out .

Respiratory failure is primarily a consequence of impaired lung ventilation (alveoli), so there are two main types of this syndrome - obstructive and restrictive.

At the heart of obstructive respiratory failure is the violation of patency of the bronchi, so the most common diseases that lead to the development of obstructive type of respiratory failure are chronic bronchitis and bronchial asthma. The most important clinical sign of obstructive respiratory failure is dry wheezing with elongation of exhalation. The Tiffno test and pneumotachometry are important methods for confirming and assessing the dynamics of bronchial obstruction, as well as for clarifying the degree of bronchoconstriction as a cause of obstruction, since the introduction of bronchodilators in these cases improves the Tiffno test and pneumotachometry.

The second type of violation of the respiratory function - restrictive - arises from the impossibility of full alveolar expansion when air enters them freely flowing through the respiratory tract. The main causes of restrictive respiratory failure are diffuse lesions of the pulmonary parenchyma (alveolus and interstitium), for example fibrosing alveolitis, multiple pulmonary infiltrates, difficult to straighten massive lung compression atelectasis with pleurisy, hydrotorax, pneumothorax, tumors, severe limitation of lung mobility in the widespread adhesion process in the pleura and pronounced obesity (Pickwick syndrome), as well as paralysis of the respiratory muscles, including impairment of the function of the diaphragm (cent respiratory disorders, dermatomyositis, poliomyelitis ). At the same time, the Tiffno test and pneumotachometry parameters were not changed.

A consequence of the discrepancy between ventilation of the lungs and the metabolism of tissues during respiratory failure is a violation of the blood gas composition, manifested by hypercapnia, when RNO ₂ is more than 50 mm Hg. Art. (the norm is up to 40 mm Hg) and hypoxemia - a decrease in PO2 up to 75 mm Hg. Art. (the norm is up to 100 mm Hg).

Most often, hypoxemia (usually without hypercapnia) occurs with a restrictive type of respiratory failure, in contrast to situations where there is a pronounced hypoventilation that causes hypoxemia and hypercapnia.

Hypoxemia and hypercapnia are especially dangerous for brain and heart tissues, since they cause significant and even irreversible changes in the function of these organs - up to a deep cerebral coma, terminal cardiac arrhythmias.

By the severity of the main clinical signs, such as dyspnea, cyanosis, tachycardia, usually judge the degree of respiratory failure. An important criterion for the degree of respiratory failure is the effect on them of exercise, which primarily refers to the dyspnea that occurs at the beginning (degree I respiratory failure) only with physical stress; II degree - the appearance of dyspnea with insignificant physical exertion; at the third degree, dyspnoea disturbs the patient and at rest. Synchronously with shortness of breath, tachycardia increases. The gas composition of the blood varies with grade II, but especially with grade III respiratory failure, when it remains altered and at rest.

To be able to distinguish between the main types of respiratory failure is extremely important, especially in its early stages, when the impact on the mechanisms of the development of obstruction or restriction can prevent the progression of functional disorders.

Respiratory distress syndrome in adults is the most common cause of acute respiratory failure with severe hypoxemia developing in a person with previously normal lungs due to rapid accumulation of fluid in the lung tissue at the usual pressure in the pulmonary capillaries and the sharply increasing permeability of the alveolar-capillary membranes. This state is affected by the damaging effect of toxins and other agents (drugs, especially drugs, toxic products formed with uremia), heroin, aspirated stomach contents, water (drowning), excessive formation of oxidants, trauma, sepsis caused by gram-negative bacteria, fat embolism, acute pancreatitis, inhalation of smoky or hot air, CNS trauma, and also, apparently, direct action on the alveolar membrane of the virus. As a result, the extensibility of the lungs and gas exchange are violated.

Acute respiratory failure develops very quickly. Appears and rapidly increases shortness of breath. The work includes additional muscles, a picture of non-cardiogenic pulmonary edema develops, and a variety of moist rattle rises are heard. X-ray reveals a picture of interstitial and alveolar edema of the lung (diffuse infiltrative changes in the form of a "white shutdown" of pulmonary fields). There are signs of respiratory failure with hypoxemia, and then hypercapnia, fatal heart failure is increasing, it is possible to join disseminated intravascular coagulation (DIC) and infection, which makes the forecast very difficult.

In clinical practice, it is often necessary to isolate and evaluate the activity of bronchopulmonary infection, which accompanies acute and chronic bronchitis, bronchiectasis, lung abscesses, pneumonia. Some of these diseases have a chronic course, but with periodic exacerbations.

Signs of bronchopulmonary infection and its exacerbations are fever (sometimes only mild subfebrile condition), the appearance or intensification of cough, especially with sputum, the dynamics of the auscultatory pattern in the lungs, especially the appearance of wet, sonorous rales. Pay attention to changes in the hemogram (leukocytosis more than 8.0-10 ⁹ / L) with neutrophilia, an increase in ESR. With viral infection, leukopenia and neutropenia are more common.

It is more difficult to assess the changes in the radiographic picture, especially with a prolonged course of the underlying disease.

Especially important is the detection of active bronchopulmonary infection in patients with bronchial asthma (with severe obstructive syndrome), exacerbations of which are sometimes associated with exacerbation of chronic bronchitis or pneumonia. In this case, especially pay attention to the temperature increase, the appearance of a patch of moist sonorous wheezing in the lungs, changes in blood.

When assessing the dynamics of signs of bronchopulmonary infection, attention should be paid to the amount and nature of sputum, especially to the abundant secretion of purulent sputum. Its significant decrease along with the dynamics of other symptoms allows us to discuss the question of the abolition of antibiotics.

It is always important to have data on the nature of the bacterial flora (sputum culture) and its sensitivity to antibiotics.

Thus, diseases of the respiratory system are manifested by a large variety of symptoms and syndromes. Identification of them is carried out with a thorough clinical study, including a detailed analysis of complaints, flow characteristics, as well as data of examination, palpation, percussion and auscultation. With the skillful application of these methods can provide information, the importance of which is difficult to overestimate. It is very important to attempt to unite in the syndromes the detected signs by the generality of the mechanisms of occurrence. First of all, these syndromes are a complex of symptoms, revealed as a result of a traditional examination of the patient. Certainly, the corresponding additional methods (X-ray, radionuclide, etc.) are necessary to confirm the detected features, refinement, detailing the mechanisms of their development, although sometimes special methods can become the only ones to detect the described changes, for example, with small dimensions or deep localization of the compaction.

Syndrome isolation is an important stage in the diagnostic process, which ends with the definition of the nosological form of the disease.