Pathogenetic treatment of pneumonia

In severe acute pneumonia, a sharp violation of the drainage function of the bronchi or abscessing, sanative bronchoscopy is performed with a 1% dioxygen solution or 1% furagin solution. Such measures are performed in the department or intensive care unit.

Restoration of drainage function of the bronchi

Restoration of the drainage function of the bronchi promotes the fastest resolution of the inflammatory infiltrate in the lungs. For this purpose, expectorants and mucolytics are prescribed. These remedies are used when the cough becomes "wet". A good effect is a solution of potassium iodide (washed down with alkaline solutions, Borjomi, milk), althaea root, mucaltin, acetylcysteine, bromhexine (bisolvone). Particular importance is given to bromhexine, which stimulates the production of surfactant - an important component of the system of local bronchopulmonary protection. Proteolytic enzymes are also used to dilute sputum and cleanse the bronchi.

Normalization of the tonus of bronchial muscles

Often in patients with acute pneumonia, pronounced bronchospasm is observed, which disturbs the ventilation function of the lungs, promotes the development of hypoxemia, delays the resolution of the inflammatory focus.

Bronchodilators are used to relieve bronchospasm. The most commonly used is intravenous drip, in candles, sometimes inside. In recent years, therapeutics are widely used therapies of prolonged action.

To stop the attack of suffocation, selective stimulators of beta2-adrenoreceptors in the form of metered aerosols (berotek, ventolin, salbutamol, etc.) can also be used, some beta2-stimulants can also be used inside (alupent, etc.).

Immunomodulatory therapy

The functional state of the immune system plays an important role in the development of acute pneumonia. Violation of immunological reactivity is one of the leading causes of protracted flow of acute pneumonia. As a rule, pneumonia, especially acute, proceeds against the background of secondary immunodeficiency with a decrease in the activity of NK cells (natural killers), a violation of activity of T suppressors, T-helpers. There was also a decrease in the phagocytic function of neutrophils.

Antibacterial agents used in pneumonia also affect the state of the body's immune system and non-specific defense mechanisms.

Most beta-lactam antibiotics significantly increase phagocytosis. In recent years, immunomodulating properties of cephalosporins have been revealed. Especially effective in this respect is cefodisin (a variant), which has an immunostimulating ability. A similar effect is present in cefaclor.

Macrolides reduce the resistance of bacteria to the action of bactericidal factors of neutrophils. It has been established that clindamycin and rifampicin stimulate phagocytosis. Fluoroquinolones enhance the production of interleukin-1 and interleukin-2, phagocytosis, the synthesis of antibodies of classes IgG and IgM against bacterial antigens. Along with this, there are reports that tetracyclines and sufanilamides inhibit phagocytosis.

In acute pneumonia, the following immunocorrective agents are used.

Prodigiosan - bacterial polysaccharide, enhances phagocytosis through the production of interleukin-1, increases the activity of various subpopulations of T cells. Due to the fact that interleukin-1 is an endogenous pyrogen, in the treatment with prodigiozanom, an increase in body temperature is possible. Stimulates T-helpers and B-lymphocytes.

Prodigiozan is prescribed in gradually increasing doses from 25 to 100 mcg intramuscularly at intervals of 3-4 days. The course of treatment - 4-6 injections. Treatment with prodigiozan in combination with antibiotics and immunoglobulin leads to a positive dynamics of the disease.

Drugs of immunomodulatory action, obtained from the thymus, are widely used.

T-activin - enhances phagocytosis, production of interferon, stimulates the function of T-killers. Assigned subcutaneously to 100 mcg once a day for 3-4 days.

Timalin - has the same properties as T-activin. It is prescribed for 10-20 mg intramuscularly for 5-7 days.

Timoptin is an effective immunomodulating thymus preparation containing a complex of immunoactive polypeptides, including a-thymosin.

The drug normalizes the parameters of T- and B-systems of immunity, induces the proliferation and differentiation of T-lymphocyte progenitors into mature immunocompetent cells, normalizes the interaction of T and B lymphocytes, activates the phagocytic function of neutrophils, stimulates the megakaryocytic germ.

Timoptin is administered subcutaneously at a rate of 70 μg / m ^{2 of} the body surface, i.e. Adults are usually injected with 100 μg once every 4 days. The course of treatment - 4-5 injections. If necessary, repeat it.

There were no side effects.

It is produced in vials in the form of a sterile lyophilized powder of 100 μg, before dissolving it into 1 ml of isotonic sodium chloride solution.

Anabol is a bacterial polysaccharide produced by lactobacilli. Increases the activity of natural killers, the function of T cells, is low-toxic, well tolerated. Anabol also stimulates the phagocytic function of neutrophils. It is applied 1.5 g per day for 2 weeks.

Sodium nucleate - obtained by hydrolysis of yeast. Produced in powders. It is taken orally by 0.2 g 3-4 times a day after meals. The drug stimulates the cooperation of T and B lymphocytes, increases the phagocytic function of macrophages, including alveolar, interferon production and lysozyme content in the bronchi.

Zixorin - stimulates the function of T-lymphocyte-killers and is the inducer of cytochrome P450 in the liver. It is applied to 0.2 g 3 times a day for 1-2 weeks.

Zaditen (ketotifen) - moderately increases the function of T-lymphocytes-suppressors and inhibits the degranulation of mast cells, thereby preventing the escape from them of leukotrienes and other mediators of allergy and inflammation.

The drug is prescribed to 0.001 g 2 times a day, primarily to patients with prolonged pneumonia, which proceeds with bronchospastic syndrome.

Catergene - hepatoprotector, in addition, has an antioxidant effect, increases the activity of natural killers. It is prescribed in tablets of 0.5 g 3 times a day for 3-4 weeks. There are practically no side effects.

Levamisol (decaris) - restores the function of T-lymphocytes, primarily by stimulating T-lymphocytes-suppressors.

It is prescribed for 150 mg once a day for 3 days, then 4 days for a break. The courses are repeated 3 times, for the entire course of treatment 1350 mg of the drug are prescribed.

In the course of treatment with levamisole, one should remember the possible development of leukopenia and agranulocytosis.

Dyuzifon is produced in tablets of 0.1 g, stimulates the function of T-lymphocytes (mainly T-suppressors), is prescribed 0.1 g 3 times a day for 5-7 days, followed by a break of 4-5 days. The number of courses is determined by the course of the disease.

The drug is inferior to the immunocorrecting activity of levamisole, but does not cause agranulocytosis.

Indications for the appointment of immunomodulators

A drug	Indications for prescription
Levamisole	Reducing the number of T-lymphocytes, T-suppressors, natural killers
Diucifone	Decrease in the number of T-lymphocytes, T-suppressors. Natural killers
Prodigiosan	Decrease in T-helpers, decrease in activity of T-cells and B-lymphocytes, decrease in phagocytic activity of leukocytes
Zixorin	Reduced activity of natural killers, increased activity of T-suppressors
Catergen	The selective decrease in the activity of natural killers
Zaditen (ketotifen)	Reduction of T-suppressor activity
Sodium nucleate	Moderate decrease in the content of T- and B-cells and their functional activity, decrease in the phagocytic activity of macrophages, leukocytes
Anabol	The decrease in the activity of natural killers, the functional activity of T cells, the phagocytic activity of leukocytes
T-activin, thymalin	Decrease in phagocytic activity of leukocytes, decrease in function of T-killers, decrease in the general population of T-lymphocytes

Also used are oxymetacil, echinocin, lycopide, ribomunil.

Before the appointment of immunocorrectors it is necessary to determine the immune status of the patient and to differentially designate immunomodulators taking into account immunological disorders.

In the opinion of VP Sil'vestrov (1985), the appointment of immunoregulatory drugs is justified even in the initial period of the infectious process with sharply lowered indices of individual parts of the immune system. In the stage of convalescence, these drugs are used when there is an incomplete recovery of the activity of immunocompetent cells. In the period of remission of the chronic process, stimulation of the body's protective reactions with the help of immunostimulants can prevent the exacerbation of the disease. Immunostimulants are especially indicated for patients with prolonged pneumonia, when the lack of complete recovery of immune status indices contributes to a significant lengthening of the recovery period.

EV Gembitsky, VG Novozhenov (1994) recommend the use of sandoglobult in a dose of 0.1-0.4 g / kg / day intravenously drip (10-30 drops / min) according to the following indications:

• antibiotic resistance;
• generalization of infection;
• severe staphylococcal destruction of the lungs;
• deficiency of IgG3 and IgG4 - subclasses of Ig.

The elderly, immunoregulators, levamisole and diuziphon should be administered with caution, since they, on the contrary, can suppress the immune mechanism, to which the action of the drug is directed. In these cases, it is more appropriate to use "soft" immunomodulators - anabol, sodium nucleate.

A weakly expressed immunocorrective action with practically no side effects is possessed by adaptogens. They are useful in all cases of acute pneumonia. Apply eleutherococcus extract 1 teaspoon 2-3 times a day, tincture of ginseng 20-30 drops 3 times a day, tincture of Chinese magnolia vine 30-40 drops 3 times a day, saparal to 0.05-0.1 g 3 times a day, pantocrine 30 drops 3 times a day. Adaptogens are prescribed for the entire duration of the illness, until recovery.

Positive, but weakly expressed influence on the immune system can be provided by means that increase nonspecific resistance - aloe extract, vitreous, fibs, biodoside. They are administered subcutaneously or intramuscularly 1 ml 1 time per day for 15-20 days.

With a decrease in the function of B-lymphocytes and a lack of immunoglobulins, it is advisable to use immunoglobulin, γ-globulin 3-4 ml once every 3 days (4-5 injections). There are also preparations of γ-globulin for intravenous administration - 0.2-0.4 g / kg daily or every other day.

As immunomodulating agents, interferon preparations are also used.

Interferons are endogenous low molecular weight proteins with a molecular weight of 15,000 to 25,000, which have antiviral, immunomodulatory and anti-inflammatory properties. Α-, β- and γ-interferons are known.

α-Interferon is produced by B-lymphocytes and lymphoblasts, β-interferon-fibroblasts, γ-interferon-T-lymphocytes.

The preparation of reaferon, corresponding to human a2-interferon, was obtained by genetic engineering.

Interferons are injected intramuscularly (the contents of 1 ampoule are dissolved in 1 ml of isotonic sodium chloride solution) to 1,000,000 IU 1-2 times a day, daily or every other day for 10-12 days. The drug is highly effective, non-toxic, combining reaferon with antibiotics increases their effectiveness. The best results are achieved with the simultaneous use of interferon with antibiotics.

In the complex therapy of acute pneumonia, especially with prolonged flow, it is possible to use such immunomodulating methods as laser and ultraviolet irradiation of blood. The latter method also has a bactericidal effect. The use of these methods is especially useful when it is necessary to quickly influence the immune status.

Multivitamin complexes have a positive effect on the immune system.

Antioxidant therapy

Activation of the processes of peroxidation with formation of excess free radicals has an important pathogenetic significance in the development of acute pneumonia, as it leads to damage to the membranes of the bronchopulmonary system. Correction of membrane disorders is carried out with the help of an exogenous antioxidant - vitamin E.

Vitamin E can be taken orally 1 capsule 2-3 times a day for 2-3 weeks or injected intramuscularly with its oil solution 1 ml per day.

With the same purpose in complex therapy of acute pneumonia, it is expedient to include Essential in capsules 2 capsules 3 times a day during the entire period of the disease. The drug contains essential phospholipids, which are part of cell membranes, vitamin E, other vitamins (pyridoxine, cyanocobalamin, nicotinamide, pantothenic acid). The drug has a membrane-stabilizing and antioxidant effect.

In recent years, as an antioxidant therapy is used emoksipin 4-6 mg / kg / day intravenously drip on isotonic sodium chloride solution.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Improvement of the function of the local bronchopulmonary protection system

Violation of the function of the system of local bronchopulmonary protection is important in the pathogenesis of acute pneumonia. The local bronchopulmonary defense system includes the normal function of the ciliated epithelium, the production of surfactant, lysozyme, interferon, protective immunoglobulin A, the normal functioning of alveolar macrophages and the bronchopulmonary immune system represented by all T-lymphocyte subpopulations, a large number of natural killers, and B-lymphocytes. In acute pneumonia, the function of the local bronchopulmonary protection system is sharply reduced, which facilitates the introduction of an infectious agent into the lung tissue and the development of inflammation in it.

Normalization of the function of the system of local bronchopulmonary protection promotes the fastest recovery of the patient. But the physician's possibilities in this respect are still limited.

To a certain extent, the improvement of the function of the local bronchopulmonary protection system occurs in the treatment with immunomodulators, the use of bromhexine, ambroxol (stimulates the formation of surfactant). Surfactant - a surface monomolecular film on the surface of the alveoli, which consists mainly of phospholipids, produced by alveocytes. It regulates the surface tension of the alveoli and prevents their collapse, prevents the collapse of small bronchi, counteracts the development of emphysema, participates in the absorption of oxygen, has bactericidal activity.

Studies are underway on endobronchial use of alveolar macrophage, interferon, immunoglobulin.

Fighting intoxication

As detoxification measures for acute pneumonia, especially severe and with severe intoxication, intravenous drip infusion of hemodeza (400 ml once a day), isotonic sodium chloride solution, 5% glucose solution, as well as treatment with coenzymes (cocarboxylase, pyridoxalphosphate, lipoic acid), which significantly improves tissue metabolism and helps reduce intoxication. In severe cases of secondary hypoxemic and toxic encephalopathy, an intravenous infusion of 5 ml of a 20% solution of piracetam in 10 ml of isotonic sodium chloride solution is recommended once a day for 5-6 days, then 0.2 g of piracetam in tablets 3 times a day.

With the aim of detoxification, the patient is recommended to drink cranberry mors, decoction broths, fruit juices, mineral waters. With an intoxication syndrome resistant to detoxification therapy, plasmapheresis, hemosorption, which also have an immunomodulatory action, is used.

[10], [11], [12], [13]