Treatment of acute pneumonia

Pneumonia is often accompanied by signs of respiratory and cardiac failure. In fact, dyspnea is one of the important clinical signs of pneumonia. As a rule, ARF is observed in massive inflammatory processes in the lungs (croupous, polysegmental pneumonia) or in complicated pneumonia, accompanied by destruction of lung tissue, the development of pleurisy. In pneumonia, obstruction of the lower respiratory tract is rarely observed, so the ratio of respiratory phases remains close to normal.

Treatment of pneumonia in children, which is accompanied by ARF, has a number of features, but it is usually eliminated with targeted therapy of the pneumonia itself. Oxygen therapy is indicated for hypoxemia. Given the large fluid losses during excessive ventilation, oxygen should preferably be supplied humidified to 90% and warmed to 30-35 °C. Inhalations of mucolytics are rarely used; on the contrary, in destructive forms of pneumonia, proteolysis inhibitors (contrycal, gordox) are prescribed.

Indications for artificial ventilation in children may include toxic syndrome, severe hypoxemia due to massive infiltration of lung tissue or pleurisy (restrictive type), as well as their combination, especially in infants. In the latter case, artificial ventilation cannot be accompanied by a significant increase in DO and a high PEEP value. Inverted mode, high-frequency artificial ventilation or its combination with traditional artificial ventilation, variations of the oxygen regime are used.

Since pneumococcus still plays a dominant role in the etiology of community-acquired pneumonia, the starting drugs are penicillin or aminopenicillins, protected penicillins (amoxiclav, etc.). In the second place, cephalosporins of the 3rd-4th generation or their combinations with aminoglycosides are prescribed. In especially severe cases, imipenems (tienam, meronem), fluoroquinolones (tsifran, etc.), azlocillin (for pseudoaeruginosa infection) are used in combination with metronidazole (klion) at a dose of 7.5 mg / kg intravenously by drip 2-3 times a day.

The main tactics of therapy for acquired pneumonia include the choice of antibiotics active against gram-positive pathogens. The change in the spectrum of pathogens of outpatient pneumonia (a fairly high proportion of Haemophilus influenzae, mycoplasma and other bacteria insensitive to penicillin) forced us to change the tactics of intramuscular penicillin administration used in our country for many years. The emergence of penicillin-resistant strains of pneumococcus, as well as the need to administer penicillin every 3-4 hours, require a change in the first-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 in hospital-acquired pneumonia are anaerobes and gram-negative microorganisms, so cephalosporins and aminoglycosides are used for its treatment, without waiting for the results of bacteriological examination. Quinolones are also effective, as they are capable, like macrolides, of concentrating well in the foci of inflammation.

Great help is provided by hyperimmune drugs (anti-staphylococcal Ig, plasma), as well as those with targeted action against Pseudomonas aeruginosa, Klebsiella and other microorganisms, domestic Ig for intravenous administration, octagam, pentaglobin, etc.

In patients with immunodeficiency, the choice of antibacterial therapy depends on the nature of the pathogen. Cephalosporins, in particular cefaclor (vercef), and aminoglycosides are most often used. In patients with fungal infection of the respiratory tract, amphotericin B, nizoral and other antifungal drugs are effective. In case of pneumocystis pneumonia, biseptol and co-trimoxazole are prescribed.

Rational therapy of secondary pneumonia (taking into account resistant hospital strains and the unfavorable initial condition of the patient) involves a combination of antibiotics (to expand the spectrum of action and enhance the effect), as well as the use of new generation antibiotics (fluoroquinolones, beta-lactamase inhibitors).

In most cases, infusion therapy is not needed to treat pneumonia. Only in severe and complicated pneumonia, especially in purulent-destructive forms accompanied by severe intoxication, is IT indicated to maintain water balance, BCC and detoxification. In most cases, the infusion volume should not exceed 30 ml/kg per day for young children and 20 ml/kg for older children. The rate of administration of solutions is 2-4 ml/(kg h), which helps to avoid overloading the heart with volume and moving additional fluid to the inflammation zone. The total volume of fluid (together with food) is determined based on the AF; in concomitant acute heart failure (AHF), the volume is reduced by Uz.

It is considered justified to prescribe euphyllin (at a dose of 2-3 mg/kg) intravenously by drip or orally (up to 12 mg/kg per day) 2-3 times a day, vitamin C (100-300 mg), cocarboxylase (up to 5 U/kg) 1 time per day to children with pneumonia; the course duration is 7-10 days.

Treatment of complications of pneumonia in children

Disturbance of water balance (exicosis); grade I exicosis (up to 5% of body weight) is caused by perspiratory water loss, accompanied by oliguria due to the release of antidiuretic hormone (ADH) into the blood:

• fluid is administered intravenously - no more than 20-30 ml/kg (preferably orally). The total volume of fluid on the 1st day should not exceed FP.

For DN the following is used:

• oxygen 30-40% in a tent, through a mask or nasal catheter until respiratory failure is eliminated;
• Artificial ventilation if necessary.

In case of heart failure, antispasmodics, diuretics, and potassium preparations are used. Persistent and increasing symptoms of heart failure require the administration of cardiac glycosides (preferably digoxin with slow saturation or immediately in a maintenance dose). In case of hyposystole, signs of vascular insufficiency, cardiotonics (dopamine, dobutrex) are indicated.

Pulmonary edema as a syndrome of left ventricular failure usually develops with “volume overload”, excessive intravenous fluid administration (mainly crystalloids) in a volume of more than 50 ml/kg per day for older children and 80 ml/kg per day for young children:

• temporary cancellation of infusion, use of diuretics, alpha-adrenergic blockers (droperidol), painkillers (promedol);
• Mechanical ventilation in PEEP mode.

DIC syndrome:

• in case of hypercoagulation (hyperfibrinogenemia, increased platelet count, decreased blood cell count, increased infiltration, severe pallor of the skin, mottling) - heparin at a dose of 200-400 U/(kg/day) in 4 doses or continuously with a dispenser, rheopolyglucin (10-15 ml/kg), curantil, trental;
• in case of hypocoagulation (bleeding, decreased PTI, increased VSC) - heparin at a dose of 50-100 U/kg/day), proteolysis inhibitors (contrycal - up to 1000 U/kg, gordox - 10,000 U/kg per day), FFP - 10-20 ml/(kg-day).

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

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

Neurotoxicosis

• anticonvulsants in combination with droperidol (neurovegetative blockade) intravenously;
• oxygen therapy or mechanical ventilation in hyperventilation mode;
• combating cerebral edema (GCS, preferably dexazone at a dose of 0.5-1.5 mg/kg per day), mannitol and lasix (1-2 mg/kg);
• cranial hypothermia, physical cooling methods, administration of antipyretic drugs (intravenous analgin), microcirculators.

Pleurisy:

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

The main principle of treating acute pneumonia is to prescribe only what is absolutely necessary.

In the pathogenetic aspect, it is fundamentally important to distinguish between primary and secondary pneumonia. The latter includes pneumonia due to circulatory disorders of blood circulation (congestive), aspiration, postoperative, hospital, pneumonia in AIDS patients, embolic pneumonia in septicopyemia, infarction pneumonia (pulmonary embolism - PE), etc.

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

The effectiveness of antibacterial therapy is assessed during the first 2-3 days (with replacement or combination of antibiotics if necessary, especially with an unspecified pathogen).

Treatment effectiveness criteria

• Clinical signs: decrease in temperature, reduction of intoxication, improvement of general condition, easier expectoration, reduction of cough, etc.
• Laboratory indicators: normalization of the leukocyte formula, acid-base balance, reduction in the degree of purulent sputum, etc.
• Radiological picture: positive dynamics of radiological data up to the disappearance of the infiltrate 2-4 weeks after the onset of the disease.
• Functional parameters: normalization of respiratory function indices.

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