Types of pleuropneumonias

Pneumonias are subdivided according to the degree of lung damage. If the inflammatory process covers only the lobes, without spreading to the vessels and alveoli, then they say about pleuropneumonia, or pneumonia pneumonia - a disease of infectious nature, which can be provoked by viruses, microbes or fungi. In turn, different types of pleuropneumonia are known, which can only be identified by a medical specialist.

To date, there are a number of pleuropneumonias that are distinguished by certain signs. This classification is necessary, above all, for the optimal choice of treatment of the disease.

Forms

The division of different types of pleuropneumonia is based on clinical, etiologic and other features. For example, there are aspiration, posttraumatic, postoperative pleuropneumonia, as well as viral, bacterial, fungal and so on. Let's consider the basic types of pleuropneumonia, their features and main characteristics.

Infectious pleuropneumonia

Many types of pleuropneumonia differ depending on the infectious agent. Identification of the infection is mandatory, as this determines the treatment regimen and the methods and drugs used. Infectious pleuropneumonia is classified as follows:

• Viral pleuropneumonia - caused by viruses, can be a complication of improper treatment or untreated influenza, ARVI. Less often it is a primary infection. Diagnostically, it is quite difficult to identify the virus in pleuropneumonia, so for treatment most often prescribe antiviral agents with a wide range of activity, as well as various symptomatic drugs.
• Mycoplasma pneumonia occurs after penetration into the lung tissue of a special type of microorganism called mycoplasma. This disease is more often recorded in childhood and adolescence. It can occur covertly, without certain symptoms, but is well treated with antibacterial drugs.
• Fungal pneumonia and pleuropneumonia can be provoked by various types of infection, including fungal pathogens. The diagnosis of fungal pleuropneumonia is made only after a complete diagnosis, since the clinical symptomatology of this type of disease is usually scanty, the signs are blurred and vague, often do not correspond to the classic manifestations of microbial lesions. The disease can cause mold fungi, Candida, endemic dimorphic fungi, pneumocysts. Most often the "culprit" is Candida albicans, as well as aspergillus or pneumocysts - that is, an infection focused on lung tissue. The pathogens can enter the respiratory system, either from external foci or from other mycotic foci present in the human body. For example, Candida is a constant component of the skin and mucosal microbiocenosis, but under certain circumstances it can be activated and become pathogenic: as a consequence, pneumomycosis develops. Treatment for fungal infection in the lungs is long-term, using a powerful antimycotic course.
• Actinobacillus pleuropneumoniae is caused by Actinobacillus, a Gram-negative capsule-forming pleomorphic bacillus. This disease affects only ruminants: cattle, pigs and, less frequently, sheep. Other animals and humans are immune to infection and do not become ill. Previously, until 1983, the disease was called "hemophilous pleuropneumonia": at this point, this term is considered obsolete, as the pathogen, which used to be assigned to the genus Haemophilus, has now been moved to the genus Actinobacillus.

Another predominantly veterinary term is "contagious pleuropneumonia". It is a particularly contagious type of pneumonia that is easily transmitted from one animal to another, causing widespread disease. The causative agent is usually Mycoplasma mucoides. Animals that have contracted contagious pleuropneumonia become immune to the infection.

Abscessive pleuropneumonia.

Speaking of abscessed pleuropneumonia, we mean the presence of foci of infectious purulent-necrotic destruction of the lung. These are multiple purulent-necrotic areas of tissue decay, and there is no clear boundary with healthy lung tissue. Because of the presence of characteristic destructive processes, many specialists call this disease by the term "destructive pleuropneumonia".

In the lungs are formed zones of tissue melting of the draining type. The main causative agent of pathology is considered to be Staphylococcus aureus, but it can be affected by Klebsiella and other Enterobacteriaceae, as well as hemolytic streptococcus, pneumococcus and anaerobic microbes.

The most common cause of abscessed pleuropneumonia is considered to be aspiration of oropharyngeal secretions and the presence within the body of foci of purulent infection adjacent to lymphatic and blood vessels.

The symptomatology of the disease is similar to that of total lung inflammation.

Out-of-hospital pleuropneumonia.

Out-of-hospital pleuropneumonia is one of the varieties of inflammatory lung processes, in which the infectious agent enters the respiratory system outside the hospital or other health care facility. This form of pleuropneumonia can be bacterial or viral, and the route of transmission is airborne.

In most patients, the inflammatory response is triggered after an under-treated ARVI or influenza infection, tracheitis or bronchitis.

The pathogen enters the lungs through the descending route - from the upper respiratory organs. If the immune defense is weakened, it becomes difficult for the body to fight new inflammatory foci. As a result, the infection settles on the lung tissue, acute pleuropneumonia develops.

Often patients with out-of-hospital pleuropneumonia already have various chronic respiratory processes - for example, chronic bronchitis. The disease enters an active stage when certain conditions are created, when the immune system weakens. If treatment is delayed or ignored, pleuropneumonia may develop.

Hypostatic pneumonia

A special form of the disease is hypostatic pleuropneumonia, which is predominantly secondary in nature. Most often, the disease develops as a result of prolonged stagnation of blood circulation in the small circulatory system, which should provide trophism of lung tissue. Disturbed blood flow leads to the accumulation of intoxication products in the lungs. Viscous sputum is formed, to which microorganisms actively multiply - usually streptococci and staphylococci, which causes a new inflammatory process.

Hypostatic or congestive pleuropneumonia usually occurs in long-lying patients who are unable to move and lead a normal life as a result of injuries or somatic pathologies. Thus, primary diseases can be heart attacks, strokes, diabetes mellitus, oncopathologies, etc. Prolonged horizontal posture impairs blood flow and causes stagnation in the tissues.

Types of pleuropneumonias depending on the volume of the lesion

Three lobes are distinguished in the right lung and two lobes in the left lung. In turn, each lobe is subdivided into segments - parenchymatous zones ventilated by a segmental bronchus and a certain branch of the pulmonary artery.

When the inflammatory reaction is located in one lung lobe, we speak of lobular pleuropneumonia, and in both lobes - about bidol pleuropneumonia. Also distinguish unilateral and bilateral lobular pleuropneumonia. The clinical picture and treatment measures are similar to other types of the disease.

In addition, specialists have distinguished such types of lobe pathology:

• Segmental pleuropneumonia - characterized by the lesion of one segment of the lung lobe;
• Polysegmental pleuropneumonia - indicates the lesion of several lobe segments at once;
• Upper lobe pleuropneumonia can be either right- or left-sided and indicates involvement of the upper lobe of the lung;
• Lower lobe pleuropneumonia is also right or left-sided, depending on the localization of the pathological process;
• middle lobe pleuropneumonia is an inflammatory process in the middle lobe of the right lung (in the left lung there is no middle lobe);
• total - occurs with lesions of the entire lung field (all lobes of both the right and left lung);
• subtotal pleuropneumonia - for this form, it is typical for both lobes of one lung to be affected;
• focal pleuropneumonia indicates a clear localization of the inflammatory focus, without spread to nearby tissues;
• Subpleural pleuropneumonia is an inflammatory process localized in the subpleural region of the lung;
• Basal pleuropneumonia - characterized by an inflammatory reaction in the lower part of the lung.

This classification is based on the degree of spread of the inflammatory reaction. In this case, the severity of symptoms depends on the extent of the lesion: the more extensive the inflammation, the deeper and brighter the clinical picture. [1]

Draining pleuropneumonia

In the confluent form of pleuropneumonia, painful disorders cover several parts of the lung at once, or even the lung lobe. There is a pronounced lag in the process of breathing on the affected side, the symptoms of respiratory failure (dyspnea, lividity) increase.

Draining pleuropneumonia is characterized by infiltrative changes, against the background of which there are thickened zones of infiltration and (or) destructive cavities. The term "draining" in this case means the merging of multiple or single small pathological foci into larger formations. Given this feature of the development of pleuropneumonia, it is considered by specialists as a relatively peculiar form of pulmonary inflammatory process.

Complications and consequences

If therapeutic measures were prescribed in time, and the treatment itself was competent, the course of pleuropneumonia usually loses its typical cyclic nature and is interrupted at the initial stage of development.

If the process of resorption of exudate is disturbed, then complications of pleuropneumonia develop. In some cases, connective tissue grows in the pathological focus: carnification with further pulmonary cirrhosis occurs. In some patients there are purulent processes with destruction (melting) of tissues, and pleuropneumonia passes into an abscess or gangrene of the lung.

In pleuropneumonia, there are manifestations of dry pleurisy with fibrinous layering and the formation of adhesions. Lymphogenic spread of infection leads to the development of purulent mediastinitis and pericarditis. If the spread of microbes occurs through the circulatory system, then can be formed

Metastatic purulent foci in the brain and other organs and tissues: the development of purulent meningitis, peritonitis, acute polyposis-ulcerous or ulcerative endocarditis, purulent arthritis begins.

Often patients are concerned about the question of why the temperature does not drop while taking antibiotics for pleuropneumonia: can this indicate the development of complications? In pleuropneumonia, the temperature usually fluctuates between 37-38°C. Against the background of antibiotic therapy, a high temperature can be maintained for 2-3 days, and in bilateral pathological process - up to 10-14 days (at the same time does not exceed 38 ° C). If the indicators overcome the boundary of 39-40°C, it indicates an increase in the inflammatory response and the loss of the body's ability to fight the pathogen. In such a situation, the doctor should immediately review the treatment and possibly change the antibiotic. [2]

Diagnostics of the pleuropneumonias

Examination of a patient with suspected pleuropneumonia is carried out according to an individual plan drawn up by a doctor. This plan includes, as a standard, the following:

General blood tests, urine, sputum, blood biochemistry (determination of total protein, protein electrophoresis, determination of bilirubin, fibrinogen);

Sputum bacteriopsy with determination of sensitivity of bacterial flora to antibiotic therapy;

EKG.

Chest X-ray is almost always the basic way of diagnosing all types of pleuropneumonia. The study is done in two projections:

• during the tidal stage there is a strengthening and enrichment of the pulmonary pattern, which is explained by tissue hyperemia;
• the degree of transparency is normal or slightly reduced;
• a homogeneous shadow is present, and the pulmonary root is slightly dilated on the affected side;
• if the pathological reaction is localized in the lower lobe sector, a reduced excursion of the corresponding diaphragmatic dome is observed;
• a pronounced decrease in the transparency of the lung tissue (according to the affected area) is detected during the opacification stage;
• the affected area of the lung is normal or slightly enlarged;
• the shadow intensity increases slightly towards the periphery;
• in the medial areas of darkening, there are areas of lucidity;
• The pulmonary root on the affected side is enlarged, characterized by homogeneity of the shadow;
• there's a thickening of the adjacent pleura;
• during the resolution phase, there is a decrease in the intensity of the shadow of the pathologically altered area;
• The fragmented shadow is reduced, the pulmonary root is dilated.

If pleuropneumonia is suspected, it is preferable to perform a full radiologic examination rather than standard fluorography, which is considered a prophylactic rather than therapeutic and diagnostic method. Pneumonia on fluorography is not always traced properly, because it depends on both the severity of the pathological process, and on the condition and density of tissues through which the X-rays penetrate. With the help of fluorography it is possible to prevent the development of chronic pneumonia in advance, to protect against an atypical course of the inflammatory process, but this procedure does not allow you to note the localization of inflammation and assess the degree of complexity of the process.

Patients with any type of pleuropneumonia are recommended to examine the external respiratory function, and if indicated, perform pleural puncture.

Multispiral CT is indicated in these cases:

• If there are obvious clinical symptoms of pleuropneumonia but no typical abnormalities on radiologic imaging;
• if the diagnosis of pleuropneumonia reveals atypical abnormalities such as atelectasis obturatorum, abscess, or pulmonary infarction;
• in a recurrent course of pleuropneumonia, if pathologic infiltrates are found in the same area of the lung;
• in prolonged pleuropneumonia, if pathologic infiltrates do not resolve for a month.

Additional instrumental diagnostics can be represented by fiberoptic bronchoscopy, transthoracic biopsy, transtracheal aspiration. The presence of pleural effusion against the background of the possibility of safe pleuropuncture is an indication for the study of pleural fluid. [3]

At each stage of pleuropneumonia, auscultation is mandatory:

• at the tidal stage is noted weakness of vesicular respiration, crepitation;
• at the stage of stupor it is possible to listen to clear fine bubbling rales, with increased bronchophony;
• crepitation is also present at the resolving stage.

Differential diagnosis

Different types of pleuropneumonia are usually differentiated with tuberculous bronchopneumonia (caseous pneumonia). The particular difficulty of such diagnosis is observed in cases where pleuropneumonia affects the upper lobes, and tuberculosis - the lower lobes: the fact is that at the initial stage of tuberculosis does not detect itself with mycobacteria in the sputum, and the clinical and radiological signs of these pathologies are very similar. Sometimes it is possible to make a correct diagnosis of tuberculosis, if there is a typical early onset of the disease: early weakness, increased sweating, constant unmotivated fatigue. Pleuropneumonia is characterized by an acute development of symptoms, including a sharp rise in temperature, chest pain, cough with sputum. As for the tuberculous infiltrate, it differs from pleuropneumonic in that it has a clear outline.

Blood analysis in patients with tuberculosis demonstrates leukopenia against a background of lymphocytosis, and pleuropneumonia is typified by significant leukocytosis and accelerated SLE.

Tuberculin tests (+) are another confirmation of tuberculous lesions.

Various types of pleuropneumonia are also differentiated from bronchogenic cancer and small branch pulmonary embolism.