Treatment of acute pneumonia

Inflammation of the lungs is often accompanied by signs of respiratory and heart failure. Essentially, shortness of breath is one of the important clinical signs of pneumonia. As a rule, ODN is observed in massive inflammatory processes in the lungs (croupous, polysergment pneumonia) or with complicated pneumonia accompanied by destruction of lung tissue, the development of pleurisy. When pneumonia is rarely observed obstruction of the lower respiratory tract, so the ratio of respiratory phases remains close to normal.

Treatment of pneumonia in children, accompanied by an ODN, has a number of characteristics, but it is usually eliminated with targeted therapy for pneumonia itself. Oxygen therapy is indicated for hypoxemia. Taking into account the large losses of the liquid with excessive ventilation, it is desirable to apply oxygen to the moistened to 90% and warmed to 30-35 ° C. Inhalation of mucolytics is rarely used; on the contrary, with destructive forms of pneumonia, proteolysis inhibitors (countercranial, gordox) are prescribed.

Indications for mechanical ventilation in children may be toxic syndrome, severe hypoxemia due to massive infiltration of pulmonary tissue or pleurisy (restrictive type), as well as their combination, especially in infants. In the latter case, ventilation can not be accompanied by a significant increase in DO and a high PEEP index. Use the inverse mode, high-frequency ventilation or its combination with traditional ventilation, variations in the oxygen regime.

Since in the etiology of community-acquired pneumonia, pneumococcus is still dominant, penicillin or aminopenicillin, protected penicillins (amoxiclav, etc.) are the starting drugs. Secondarily, cephalosporins of the 3rd generation or their combinations with aminoglycosates are prescribed. In especially severe cases, imipenems (thienam, meronem), fluoroquinolones (digitarum, etc.), azlocillin (with synaemic infection) in combination with metronidazole (clion) at a dose of 7.5 mg / kg are intravenously dripped 2-3 times a day.

The main tactics of therapy for acquired pneumonia include the selection of antibiotics that are active against Gram-positive pathogens. Changing the spectrum of pathogens of outpatient pneumonia (rather high specific gravity of hemophilic rod, mycoplasma and other bacteria insensitive to penicillin) made it necessary to change the tactics of intramuscular injection of penicillin used in our country for many years. The appearance of penicillin-resistant strains of pneumococcus, as well as the need for penicillin every 3-4 hours, require the replacement of the 1st line drug for the treatment of outpatient pneumonia.

Ciprofloxacin, ofloxacin and other fluoroquinolones are effective in the treatment of pneumonia caused by H. Influenzae, Legionella pneumoniae and Mycoplasma pneumoniae.

The main group of pathogens with nosocomial pneumonia are anaerobes and gram-negative microorganisms, therefore, cephalosporins and aminoglycosides are used for its treatment without waiting for the results of bacteriological examination. Quinolones are also effective, capable, like macrolides, of concentrating well in the centers of inflammation.

Hyperimmune preparations (anti-staphylococcal Ig, plasma), as well as directed action against Pseudomonas aeruginosa, Klebsiella and other microorganisms, domestic Ig for intravenous administration, octagam, pentaglobin, etc., are of great help.

In patients with immunodeficiency, the choice of antibiotic therapy depends on the nature of the pathogen. More commonly used cephalosporins, in particular cefaclor (verceph), and aminoglycosides. In patients with fungal infection of the respiratory tract, amphotericin B, nizoral and other antimycotic drugs are effective. With pneumocystis pneumonia, biseptol, co-trimoxazole is prescribed.

Rational therapy of secondary pneumonia (taking into account resistant hospital strains and an unfavorable initial state of the patient) provides for a combination of antibiotics (for broadening the spectrum of action and enhancing the effect), as well as the use of antibiotics of new generations (fluoroquinolones, beta-lactamase inhibitors).

In most cases, in the treatment of pneumonia, infusion therapy is not needed. Only with severe and complicated pneumonia, especially with purulent-destructive forms, accompanied by severe intoxication, IT is shown to maintain water balance, BCC and detoxification. In most cases, the infusion volume should not exceed 30 ml / kg per day for infants and 20 ml / kg for older children. The rate of administration of solutions is 2-4ml / (kg h), which helps avoid overloading the heart with volume and moving additional fluid into the inflammation zone. The total volume of liquid (together with food) is determined from the calculation of OP; with the concomitant acute SN (OCH), the volume decreases by uz.

It is considered reasonable to prescribe to children with pneumonia eufillina (2-3 mg / kg) intravenously drip or inward (up to 12 mg / kg per day) 2-3 times a day, vitamin C (100-300 mg), cocarboxylase (up to 5 ED / kg) once a day; the duration of the course is 7-10 days.

Treatment of complications of pneumonia in children

Violation of water balance (exsicosis); excisiousness of the first degree (up to 5% of body weight) is caused by perspiratory water losses, accompanied by oliguria due to the release of antidiuretic hormone (ADH) into the blood:

• intravenously injected liquid - no more than 20-30 ml / kg (better inside). The total volume of liquid in the first day should not exceed the AF.

With NAM apply:

• oxygen 30-40% in a tent, through a mask or nasal catheter prior to elimination of DN;
• IVL if necessary.

With SN use antispasmodics, diuretics, potassium preparations. The persisting and increasing phenomena of heart failure require the appointment of cardiac glycosides (preferably digoxin with a slow saturation or immediately in a maintenance dose). In cases of hypysystole, signs of vascular insufficiency, cardiotonics (dopmin, dobrex) are shown.

Pulmonary edema as a syndrome of left ventricular failure, usually develops with "volume overload", excessive intravenous fluids (mostly crystalloids) in the volume of more than 50 ml / kg day for older children and 80 ml / kg day for young children:

• temporary cancellation of infusion, use of diuretics, a-adrenolytic drugs (droperidol), analgesics (promedol);
• IVL in PEEP mode.

DIC-Syndrome:

• in the case of hypercoagulability (hyperfibrinogenemia, increase in platelet count, decrease in VSC, increase in infiltration, sharp pallor of the skin, marbling) - heparin at a dose of 200-400 U / (kg day) in 4 doses or continuously with a doser, reopolyglucin (10-15 ml / kg ), quarantil, trental;
• in the case of hypocoagulation (bleeding, decreased PTI, increased VSC) - heparin in a dose of 50-100 EDDkg day), inhibitors of proteolysis (countercritic - up to 1000 units / kg, gondoks - 10 000 units / kg per day), SZP - 10-20 ml / (kg-day).

Toxic syndrome (intoxication) - lethargy or irritability, high temperature, marbling, cyanosis of the skin, toxic shifts in the blood test:

• oral detoxification within 0.5-1.0 of the volume of age diuresis; intravenously in the same volumes evenly during the day with stimulation;
• plasmapheresis in a volume of 0.5-1.0 VCP per day;
• immunoglobulins, plasma.

Neurotoxicosis

• anticonvulsants in combination with droperidol (neurovegetative blockade) intravenously;
• oxygen therapy or ventilation in the mode of hyperventilation;
• struggle with brain edema (GCS, better dexazone at a dose of 0.5-1.5 mg / kg-day), mannitol and lasix (1-2 mg / kg);
• craniohypothermia, physical methods of cooling, the introduction of antipyretic agents (analgin intravenously), microcirculants.

Pleurisy:

• non-steroidal anti-inflammatory drugs (brufen, voltaren, indomethacin) or prednisolone at a dose of 1-2 mg / (kgs) in a short course (3-7 days) are indicated.

The basic principle of treating acute pneumonia is to prescribe only what you can not do without.

In the pathogenetic aspect, it is of primary importance to isolate primary and secondary pneumonia. The latter includes pneumonia due to circulatory circulatory disorders (congestive), aspiration, postoperative, hospital, pneumonia, AIDS patients, embolic with septicopyemia, infarct-pneumonia (pulmonary embolism of the pulmonary artery - PE), etc.

Treatment programs for patients necessarily include antibiotic therapy, taking into account a specific etiological agent (at the stage of colonization of microorganisms), with preference given to monotherapy; combinations of antibiotics (penicillins with aminoglycosides or cephalosporins), as well as reserve antibiotics (fluoroquinolones, beta-lactamase inhibitors, macrolides and cephalosporins of the latest generations, rifampicin, vancomycin, etc.) are used only in severe cases.

The effectiveness of antibiotic therapy is assessed during the first 2-3 days (with the replacement or combination of antibiotic in necessary cases, especially in cases of unspecified pathogen).

Criteria of treatment effectiveness

• Clinical signs: a decrease in temperature, a decrease in intoxication, an improvement in the general condition, a simplification of sputum discharge, a reduction in cough,
• Laboratory indicators: normalization of the leukocyte formula, CBS, reduction of the degree of purulence of sputum, etc.
• Radiological picture: positive dynamics of X-ray data until the disappearance of the infiltrate in 2-4 weeks from the onset of the disease.
• Functional parameters: normalization of FVD indices.

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