Chronic pneumonia

Chronic pneumonia is a chronic inflammatory localized process in the lung tissue, the morphological substrate of which is pneumosclerosis and / or carnification of the lung tissue, as well as irreversible changes in the bronchial tree of the type of local chronic bronchitis, clinically manifested by recurrence of inflammation in the same affected part of the lung. Asymptomatic localized pulmonary fibrosis in the absence of recurrence of inflammation in the affected area is excluded from the concept of chronic pneumonia.

Currently, the attitude towards chronic pneumonia is ambiguous. In modern foreign medical literature such a nosological unit is not recognized and not covered. In ICD-10, this disease is also not called. However, a number of clinicians still distinguish chronic pneumonia as an independent nosological unit.

In addition, in clinical practice, patients are often observed who, after suffering a history of pneumonia, develop symptoms that meet the diagnostic criteria for chronic pneumonia, and before that (before acute pneumonia) the patient was completely healthy.

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

Causes of Chronic Pneumonia

The main etiological and predisposing factors of chronic pneumonia are the same as acute.

[6], [7]

Pathogenesis of chronic pneumonia

Chronic pneumonia is a result of unresolved acute pneumonia. Therefore, the development of chronic pneumonia can be represented in the form of the following stages: acute pneumonia - prolonged pneumonia - chronic pneumonia. Therefore, we can assume that the pathogenetic factors of chronic pneumonia are the same as protracted, and the main ones are, of course, dysfunctions of the local bronchopulmonary protection system (decreased activity of alveolar macrophages and leukocytes, decreased phagocytosis, secretory IgA deficiency, decrease in bacteriolysins and others - for details, see “Chronic bronchitis”) and the weakness of the immune response of the microorganism. All this creates favorable conditions for the persistence of an infectious inflammatory process in a certain area of the lung tissue, which further leads to the formation of a pathological substrate of chronic pneumonia - focal pneumosclerosis and local deforming bronchitis.

[8], [9], [10], [11], [12], [13],

Symptoms of chronic pneumonia

Chronic pneumonia is always the outcome of unresolved acute pneumonia. It should be emphasized that there is no strict time criterion that suggests that in this patient acute pneumonia transformed into a chronic inflammatory process. The previous ideas about the terms of 3 months, 1 year were untenable. It should be considered that the decisive role in the diagnosis of chronic pneumonia is not played by the onset of the disease, but by the absence of positive x-ray dynamics and repeated exacerbations of the inflammatory process in the same lung area during long-term follow-up and intensive treatment.

In the period of exacerbation of chronic pneumonia, the main clinical symptoms are:

• complaints of general weakness, sweating, especially at night, increased body temperature, decreased appetite, cough with separation of purulent sputum; sometimes chest pain in the projection of the pathological focus;
• weight loss (optional);
• symptoms of local infiltrative-inflammatory process in the lung tissue (dull percussion sound, moist fine bubbling wheezing, crepitus over the lesion), with pleural involvement, pleural friction sounds are heard.

Instrumental studies

1. X-ray examination of the lungs - is crucial in the diagnosis of chronic pneumonia. Radiography of the lungs in 2 projections reveals the following characteristic features:
   • a decrease in the volume of the corresponding lung section, a tightness and deformation of the pulmonary pattern of fine and medium-cell type;
   • focal darkening of the lungs (they can be quite clear with a pronounced carnification of the alveoli);
   • peribronchial infiltration in the affected lung tissue;
   • manifestations of regional adhesive pleurisy (interlobar, paramediastinal adhesions, obliteration of costal-diaphragmatic sinus).
2. Bronchography is currently regarded as a mandatory diagnostic and differential diagnosis method for chronic pneumonia. The convergence of the bronchial branches in the affected area, the unevenness of their filling with contrast, unevenness, deformation of the contours (deforming bronchitis) are detected. In bronchiectasis of chronic pneumonia, bronchiectasis is detected.
3. Bronchoscopy - in the period of exacerbation, purulent (in the period of remission catarrhal) bronchitis is detected, most pronounced in the corresponding lobe or segment.
4. A study of the function of external respiration (spirography) is obligatory in chronic pneumonia, since patients often suffer from chronic bronchitis and pulmonary emphysema at the same time. In the case of an uncomplicated form of chronic pneumonia (in the non-extensive lesion focus), there are usually no significant changes in spirography indicators (in rare cases, restrictive disorders are possible - a decrease in VC). With concomitant obstructive chronic bronchitis, there is a decrease in FVC, Tiffno index), with emphysema, the value of VC is significantly reduced.

[14], [15], [16], [17], [18], [19], [20], [21], [22]

Laboratory data

1. General and biochemical blood tests reveal the following changes in the exacerbation phase: an increase in ESR, leukocytosis with a shift of the leukocyte formula to the left, an increase in the content of fibrinogen in the blood, alpha2 and gamma globulins, haptoglobin, seromcoid. However, it should be noted that these changes are expressed, as a rule, only with a significant exacerbation of the disease.
2. Microscopy of sputum - in the period of acute illness revealed a large number of neutrophilic leukocytes.
3. Bacteriological examination of sputum - allows you to determine the nature of the microflora. The number of microbial bodies more than 10 in 1 μl of sputum indicates the pathogenicity of the identified microflora.

In the remission phase of chronic pneumonia, the patient feels satisfactory, the patients show almost no complaints, or these complaints are very insignificant. A typical is only unproductive cough mainly in the morning due to the presence of local bronchitis. Physical examination of the lungs determines dullness of percussion sound and fine bubbling rales, crepitus in the lesion focus, however, the auscultatory data in the remission period are much less bright compared with the acute phase. In the remission phase there are also no laboratory manifestations of the inflammatory process.

[23], [24], [25], [26], [27]

Bronchiectasis

Bronchiectasis of chronic pneumonia has the following manifestations:

• cough with a large amount of purulent sputum (200-300 ml per day or even more) with an unpleasant odor, most pronounced in a certain position of the patient;
• frequent episodes of hemoptysis;
• frequent exacerbations and even a continuous course of an active inflammatory process, periodic delays in the separation of sputum, accompanied by a significant increase in body temperature; night sweats;
• loss of appetite and pronounced weight loss of patients;
• nail changes (they take the form of watch glasses) and thickening of end phalanges in the form of “drumsticks”;
• listening to the lesion not only finely bubble, but often medium-wheezing rales, they are abundant and consonant;
• more frequent occurrence compared with the form without bronchiectasis such complications as empyema, spontaneous pneumothorax, amyloidosis of the kidneys;
• low effectiveness of conservative therapy;
• the identification of bronchiectasis (in the form of cylindrical, spindle-shaped, saccular extensions) during bronchographic and tomographic studies.

[28], [29], [30], [31], [32]

Classification of chronic pneumonia

Currently, there is no generally accepted classification of chronic pneumonia. This is due to the fact that not all recognized nosological independence of this disease. For purely practical purposes, you can use the following classification.

1. Prevalence of chronic inflammation in the lung:
   • focal
   • segmental
   • lobar
2. Process Phase:
   • aggravation
   • remission
3. Clinical form:
   • bronchiectatic
   • without bronchiectasis

[33], [34], [35], [36], [37]

Diagnostic criteria for chronic pneumonia

1. A clear connection of the development of the disease with acute acute pneumonia, which took a protracted course, but was not resolved.
2. Recurrent inflammation within the same segment or lobe of the lung.
3. Focal nature of the pathological process.
4. The presence in the period of exacerbation of clinical symptoms: cough with mucopurulent sputum, chest pain, fever, weakness.
5. Detection of stethoacoustic symptoms of focal pathological process - fine bubble (and in case of the bronchiectatic form of the disease - and medium-bubble) wheezing and crepitus.
6. Radiographic, bronchographic and tomographic signs of focal infiltration and pneumosclerosis, deforming bronchitis (and in the case of the bronchial form - bronchiectasis), pleural fusion.
7. Bronchoscopic picture of local purulent or catarrhal bronchitis.
8. The absence of tuberculosis, sarcoidosis, pneumoconiosis, congenital anomalies of the lungs, tumors and other pathological processes causing the long-term existence of the syndrome of focal compaction of the lung tissue and laboratory manifestations of inflammation.

[38], [39], [40], [41]

Differential diagnosis of chronic pneumonia

The diagnosis of chronic pneumonia is rare and very responsible; it requires careful exclusion of other diseases that are manifested by focal lung tissue seals, primarily lung tuberculosis and lung cancer.

In differential diagnosis with lung cancer, it should be noted that chronic pneumonia is a rare disease, lung cancer is very common. Therefore, as N. V. Putov (1984) rightly writes, “in any cases of a prolonged or recurring inflammatory process in the lung, especially in elderly men and smokers, a tumor, stenotic bronchus and causing phenomena of the so-called paracanterous pneumonia should be excluded.” To exclude lung cancer, it is necessary to apply special research methods - bronchoscopy with biopsy, transbronchial or transthoracic biopsy of the nidus, regional lymph nodes, bronchography, computed tomography. The absence of positive x-ray dynamics in patients with lung cancer during active anti-inflammatory and antibacterial treatment, including endoscopic bronchial sanation, is also taken into account. In addition, it should be noted that if you suspect cancer, you should not lose precious time on conducting long-term follow-up.

When conducting a differential diagnosis of chronic pneumonia and pulmonary tuberculosis, the following circumstances should be taken into account:

• in pulmonary tuberculosis, there is no acute non-specific inflammatory process at the onset of the disease;
• tuberculosis is characterized mainly by upper lobe localization of the pathological process; petrification in the lung tissue and basal lymph nodes;
• in tuberculosis, tuberculosis bacteria and tuberculin tests are often found in the sputum.

Chronic pneumonia has to be differentiated from congenital anomalies of the lungs, most often with simple and cystic hypoplasia and sequestration of the lungs.

Simple lung hypoplasia - hypoplasia of the lung without the formation of cysts. This anomaly is accompanied by the development of the suppurative process in the lung, which leads to the development of intoxication syndrome, an increase in body temperature, the appearance of physical symptoms of inflammation of the lung tissue - a clinical picture similar to the exacerbation of chronic pneumonia. Simple lung hypoplasia is diagnosed based on the results of the following research methods:

• radiography of the lungs - signs of a decrease in lung volume are detected;
• bronchography - only bronchi of 3–6 orders of magnitude are contrasted, then the bronchogram seems to be broken (symptom of a “burnt tree”);
• bronchoscopy - catarrhal endobronchitis, narrowing and atypical location of the mouths of the lobar and segmental bronchi are determined.

Cystic hypoplasia of the lung is a hypoplasia of the lung or part of it with the formation of many thin-walled cysts. The disease is complicated by the development of a secondary infectious-inflammatory process and chronic bronchitis. The diagnosis of cystic hypoplasia is made on the basis of the results of the following studies:

• radiography of the lungs - in the projection of the hypoplastic lobe or segment of the lung visible deformity or enhancement of the pulmonary pattern of cellular nature; tomographic examination reveals multiple thin-walled cavities with a diameter of 1 to 5 cm;
• bronchography reveals hypoplasia of the lung and a multitude of cavities partially or completely filled with contrast and having a spherical shape. Sometimes spindle-shaped extensions of segmental bronchi are determined;
• Angiopulmonography - detects hypoplasia of the small circle of blood circulation in the hypoplastic lung or its lobe. Arteries and veins (subsegmental prelobular and lobular) bend around the air cavity.

Lung sequestration is a malformation in which part of the cystic-altered lung tissue is separated (sequestered) from the bronchi and vessels of the small circle and is supplied with blood by the large arteries extending from the aorta.

Distinguish between intra-lobe and non-lobe sequestration of the lung. In intralobular sequestration, anomalous lung tissue is located within the lobe, but is not in communication with its bronchi and is supplied with blood from the arteries extending directly from the aorta.

In non-field sequestration of the lung, the aberrant portion of the lung tissue is located outside the normal lung (in the pleural cavity, in the thick of the diaphragm, in the abdominal cavity, on the neck and in other places) and is supplied with blood only by the arteries of the pulmonary circulation.

Off-lobar sequestration of the lung is not complicated by the suppressive process and, as a rule, does not manifest clinically.

Intra lobar sequestration of the lung is complicated by the suppressive process and requires differential diagnosis with chronic pneumonia.

Lung sequestration is diagnosed based on the results of the following studies:

• radiography of the lungs reveals the deformation of the pulmonary pattern and even a cyst or group of cysts, sometimes obscuring the irregular shape; peribronchial infiltration is often detected;
• tomography of the lungs reveals cysts, cavities in the sequestered lung and often a large vessel that goes from the aorta to the pathological formation in the lung;
• bronchography - in the zone of sequestration, deformation or expansion of the bronchi;
• Selective aortography - reveals the presence of an abnormal artery, which is a branch of the aorta and supplies the sequestered lung with blood.

Most often, these radiological changes are detected in the posterior basal regions of the lower lobes of the lungs.

Chronic pneumonia should also be differentiated from cystic fibrosis, bronchiectasis, and chronic lung abscess. The diagnosis of these diseases is described in the respective chapters.

[42], [43], [44], [45], [46], [47], [48]

Survey program

1. General blood and urine tests.
2. Biochemical analysis of blood: total protein content, protein fractions, sialic acids, fibrin, seromucoid, haptoglobin.
3. Radiography of the lungs in 3 projections.
4. Tomography of the lungs.
5. Fibrobronchoscopy, bronchography.
6. Spirography.
7. Sputum examination: cytology, flora, sensitivity to antibiotics, detection of Mycobacterium tuberculosis, atypical cells.

[49], [50], [51],

Example of a diagnosis wording

Chronic pneumonia in the lower lobe of the right lung (in 9-10 segments), bronchiectatic form, acute phase.

[52], [53], [54], [55], [56]

Treatment of chronic pneumonia

Chronic pneumonia is a chronic inflammatory localized process in the lung tissue, the morphological substrate of which is pneumosclerosis and / or carnification of the lung tissue, as well as irreversible changes in the bronchial tree of the type of local chronic deforming bronchitis, clinically manifested by recurrent inflammation in the same affected part of the lung.

When treating a patient with chronic pneumonia, it should be assumed that chronic pneumonia is the result of an unresolved acute pneumonia. Stages of development of the disease: acute pneumonia → prolonged pneumonia → chronic pneumonia.

With the help of modern methods of examination (radiography of the lungs in 3 projections, x-ray tomography, computed tomography, bronchoscopy with a cytological study of bronchial secretions, bronchography) it is necessary to make sure that tuberculosis or a malignant disease of the bronchopulmonary system, congenital lung disease (anomaly) does not hide the diagnosis of chronic pneumonia. Development, cyst, etc.).

The treatment program for chronic pneumonia is fully consistent with the program for acute pneumonia. However, when organizing treatment of a patient with chronic pneumonia, the following features should be considered.

1. In the period of exacerbation of chronic pneumonia, antibacterial therapy is carried out similarly to that in acute pneumonia. It should be remembered that chronic pneumonia is characterized by the constant presence of potentially active microflora in the inflammatory focus, and in recent decades the composition of the causative agents of pneumonia has expanded. In addition to the bacterial flora, pneumotropic viruses that cause severe viral and viral-bacterial pneumonia, of particular importance during periods of influenza epidemics, have acquired great importance. The spectrum of bacterial flora has also changed. According coconut AN (1986), with exacerbation of chronic pneumonia from sputum and bronchial content patients frequently sown hemolytic Streptococcus, Staphylococcus aureus, Streptococcus pneumoniae, Microbial frequent association of 2-3 microorganisms with Staphylococcus pneumoniae, with hemolytic streptococcus, with Friedlander's wand, intestinal and Pseudomonas aeruginosa. In 15% of patients with exacerbation of chronic pneumonia, the role of mycoplasmas has been proven.

Assigning antibiotic therapy in the first days of exacerbation of chronic pneumonia, it is advisable to focus on these data, but then it is imperative to make a sputum test, bacteriological, bacterioscopic, on the sensitivity of the flora to antibiotics and make adjustments to antibiotic therapy depending on the results of the study. It is better to examine the sputum obtained by fibrobronchoscopic examination; if this is not possible, sputum collected by the patient and processed according to the Mulder method is examined.

The large role of endotracheal and bronchoscopic rehabilitation in the treatment of chronic pneumonia should be emphasized. This is of great importance, especially with frequent and prolonged exacerbations, since chronic pneumonia is a localized inflammatory process with the development of pneumosclerosis in the inflammatory focus. In oral or parenteral antibacterial therapy, drugs do not penetrate sufficiently into the focus of inflammation and only endotracheal and endobronchial administration of antibacterial drugs allows them to receive the desired concentration in the lung tissue in the focus of inflammation. The most appropriate combination of parenteral and eudobronchial antibiotic therapy. This is especially important in case of bronchiectasis of chronic pneumonia.

With very severe disease there is a positive experience of introducing antibiotics into the pulmonary hemodynamic system.

In case of severe relapse of chronic pneumonia caused by staphylococcal, pseudomonas and other superinfection, passive specific immunotherapy is successfully used along with antibacterial drugs - the administration of appropriate antibacterial antibodies in the form of hyperimmune plasma, gamma and immunoglobulin. Anti-staphylococcal-pseudo-purulent-proteic plasma is injected intravenously in a dose of 125-180 ml 2-3 times a week. Treatment with hyperimmune plasma is combined with intramuscular administration of antistaphylococcal γ-globulin. Prior to the start of immunotherapy, the patient should be advised by an allergist and antihistamines should be prescribed to prevent allergic complications.

2. The most important direction in chronic pneumonia is the restoration of the drainage function of the bronchi (expectorant drugs, bronchodilators, positional drainage, fibronchoscopic sanation, classical and segmental chest massage). See details in "Treatment of chronic bronchitis".
3. Immensely important in the treatment of chronic pneumonia are immunocorrective therapy (after studying the immune status) and increasing the overall reactivity and non-specific protective reactions of the body (see "Treatment of acute pneumonia"). It is extremely important to annually conduct spa treatment.
4. Much attention should be paid to the rehabilitation of the oral cavity, the fight against nasopharyngeal infection.
5. In the absence of contraindications, physiotherapy with a focus on a local inflammatory process (SMW therapy, inductothermia, UHF therapy, and other physiotherapy methods) must necessarily be present in the treatment program. Ultraviolet and laser irradiation of blood should also be widely used.
6. With frequent recurrences of chronic pneumonia in young and middle-aged people and a clearly localized bronchiectatic form of the disease, the question of surgical treatment (lung resection) should be resolved.

Prevention of chronic pneumonia

• healthy lifestyle, physical activity;
• early onset and proper treatment of acute pneumonia; effective treatment of acute and chronic bronchitis; timely and effective treatment of nasopharyngeal foci
• chronic infection; thorough oral sanitation;
• correct and timely clinical examination of patients with acute pneumonia;
• elimination of occupational hazards and factors causing irritation and damage to the respiratory tract;
• smoking cessation.

The same measures are also prevention of relapses of exacerbations of chronic pneumonia. In addition, anti-relapse courses are recommended (the so-called anti-relapse prophylaxis during follow-up).

L. N. Tsarkova identifies 4 groups of patients with chronic pneumonia who are subject to dispensary registration, depending on the degree of compensation of the inflammatory process in the remission phase, the patient’s ability to work, and the presence of complications.

1. The first group includes patients with chronic pneumonia, who in the remission phase can be considered practically healthy and whose working capacity is fully preserved. Patients are observed 2 times a year.
2. The second group includes patients who have a rare cough (dry or with a small amount of sputum), and especially - a vegetative syndrome, while preserving the ability to work. Patients are observed 2 times a year.
3. The third group includes patients with persistent wet cough, severe asteno vegetative syndrome, and decreased working ability (Group III disability). Patients are observed 4 times a year.
4. The fourth group consists of patients with persistent cough, with a large number of sputum, low-grade fever, short remissions, complications of the disease, with a decrease in working capacity (Group II disability). Patients are observed 4 times a year.

Dispensary observation is carried out by a pulmonologist, a district therapist. Recommended methods of examination: radiography of the lungs (large-frame fluorography), spirography, pneumotachometry, ECG, complete blood count, sputum, urine, allergic examination in the presence of allergic manifestations.

Anti-relapse complex for patients with chronic pneumonia includes the following activities:

• the first group - breathing exercises, massage, multivitamin therapy, adaptogens; in patients with frequent relapses, immunomodulators (N. R. Paleev, 1985); rehabilitation of the nasopharynx; UFO chest, galvanization;
• the second and third groups are the same measures as in the first group, but, in addition, measures to improve the drainage function of the bronchi (positional drainage, intratracheal washing, inhalation of bronchodilator aerosols during the development of broncho-obstructive syndrome, mucolytics, expectorant);
• the fourth group - all of the above measures, but, in addition, means of preventing the progression of complications already present in the patient (obstructive bronchitis, myocardial dystrophy, amyloidosis, etc.): metabolic therapy, calcium antagonists, bronchodilators, etc.

An important measure of anti-relapse prevention is the annual sanatorium-resort treatment in all groups of patients.

Indicators of the effectiveness of clinical examination are: a decrease in the frequency of exacerbations of the inflammatory process and the period of temporary disability, stabilization of the process.

[57], [58]