Pneumonia in children. X-ray features in patients with viral-bacterial pneumonia and prediction of the risk of acute respiratory distress syndrome Clinical and radiological features of focal pneumonia

For citation: Kutkin D.V. Features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome // RMJ. Medical review. 2016. №3. pp. 144-147

The article is devoted to the features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome

For citation. Kutkin D.V. Features of the X-ray picture in patients with viral-bacterial pneumonia and predicting the risk of acute respiratory distress syndrome // RMJ. 2016. No. 3. P. 144–147.

Introduction
Diagnosed by x-rays, pneumonia is traditionally assessed, first of all, quantitatively: the volume of the lesion, the intensity of inflammatory infiltration are reflected. The risk of acute respiratory distress syndrome (ARDS) is expressed as the number of lung quadrants affected. In many manuals, articles, reviews, the X-ray picture is named among the leading criteria for diagnosing severe pneumonia, viral-bacterial pneumonia, viral pneumonia, ARDS, however, the wording in the "Changes in the lungs" section is very scarce - "bilateral infiltrates", "diffuse lesion", "extensive areas of consolidation". It is important to highlight the features of the X-ray picture in these conditions, to use not only quantitative, but also qualitative criteria in the work.
Purpose of the study: to identify the features of the x-ray picture in patients with viral-bacterial pneumonia. To develop criteria for a qualitative assessment of the radiological picture in patients with a pulmonological profile, to use them in predicting the risk of ARDS.

Material and methods
This study uses observations made during the 2009–2010 H1N1 influenza season and a small number of observations during the current 2015–2016 epidemic season. In order to more effectively analyze and compare the X-ray picture of the lungs, 4 criteria for a qualitative assessment (including for CT) have been developed in pulmonological patients, which are designated by the abbreviation TPLS (from Latin - thorax, pulmones, lobules, substratum and Greek - syndrome) (Table 1).

This scale is syndromic, the specification of syndromes is included in the tasks of the descriptive part of the analysis of an x-ray (or CT). To evaluate each criterion, 3 degrees are provided (0, 1, 2), additional transition states are allowed (0–1, 0–2, 1–2). The final assessment for all 4 criteria is supposed to be expressed not as a sum of points (quantitative approach), but as a combination of values ​​of 4 criteria. When choosing a value for the 1st criterion - "impaired pneumatization" - not only obvious signs of emphysema or the phenomenon of atelectasis of the lung tissue were taken into account, but also intermediate conditions in the form of hyperair or hypoair, deep or low degree of inspiration. Local, asymmetric chronic changes (2nd criterion), in our opinion, better reflect the chronic background, since the conclusion "pneumosclerosis" based on the general picture of the pulmonary pattern is very variable and largely depends on the quality of the picture, individual point vision of a specialist and is not always confirmed by the results of CT. Local chronic changes in S1–S2 of the lungs are most often associated with post-tuberculous ones. Bronchiectasis (3rd criterion along with interstitial lesions) are chronic changes, but an exacerbation stage is possible, bronchiectasis can be combined with bronchiolectasis and bronchiolitis. Under the syndrome of interstitial lesions, we mean any thickening of the interstitium (here we also include small-focal dissemination), requiring treatment or mandatory x-ray monitoring in dynamics. The structure of the site of pathological density (4th criterion) can be represented by several components, the activity of the process implies the progression of the process without treatment.

Results and its discussion
More complete results will be obtained after the end of the current epidemic season and comparison of data for several years. At present, the experience of the 2009–2010 epidemic season has been used in the analysis of radiographs of the lungs of patients with a pulmonological profile. and the above criteria.
When using the TPLS criteria to assess the x-ray picture of the lungs in patients with a pulmonological profile, we reflected: asymmetry of pneumatization of the lung fields and the degree of inspiration during the picture, including in dynamics; the presence of local chronic changes as evidence of transferred, as a rule, inflammatory diseases lungs; the presence of signs of compaction of the interstitial component along with parenchymal infiltrates - with this combination, we assume a more severe course of the disease; localization of infiltrates from 2 sides, polysegmentally, which is more typical for the viral component of pneumonia.
In our hospital during the epidemic season of 2009-2010. (influenza H1N1), patients diagnosed with pneumonia were treated in pulmonology departments No. 1 and 2, infectious departments No. 1 and 2, and the department of thoracic purulent surgery. Severe viral-bacterial pneumonia was diagnosed in 54 patients (including 17 pregnant women), these patients were treated in the pulmonary and general intensive care units, 28 (51.9%) people were on artificial lung ventilation (ALV), incl. 7 pregnant. The study group was represented by 54 patients, including 18 (33.3%) men and 36 (66.7%) women. The average age is 35 years (from 15 to 55 years).
All patients had a history of acute respiratory disease. The number of days spent in intensive care, from 3 to 32 days, on average - 17 days. 6 patients died. Some patients were treated in other hospitals from several days to a week and were transferred to us in serious condition. All had bilateral infiltrates in the lungs at the time of admission. All patients underwent X-ray of the lungs, CT was performed in 20 patients. The duration of stay in our hospital in most patients reached 2 months. The onset of clinical manifestations of viral-bacterial pneumonia accounted for an average of 3-5th day (less often - on the 8th day) from the onset of the disease. The indications for transfer to the intensive care unit were the clinical picture of rapidly progressing acute respiratory failure (ARF), ARDS. Signs of ARF developed, as a rule, within 24 hours. ARDS was diagnosed in 37 cases.
In 2009–2010 in the analysis of CT radiographs of the lungs of patients with viral-bacterial pneumonia, the following observations were made: “frozen picture”, a very slow change in the x-ray picture during studies in dynamics for 1–2 weeks; a small degree of inhalation on a lung scan in all patients; bilateral polysegmental lung disease in 46 (85.1%) patients. In all patients, lung damage was asymmetric, there were large intense infiltrates. Absence of pleurisy - in most patients, isolated cases of pleurisy of small volume - in 5 (9.2%) patients. Pneumothorax - in 8 (28.6%) of 28 patients on mechanical ventilation (Fig. 1 and 2).
Lung radiographs: either non-specific with bilateral opacities (inflammatory infiltrates) or showing a combination of interstitial lesions and inflammatory infiltrates, in the latter case a small number of patients had small infiltrations but still had ARDS. Bilateral infiltrates were observed equally often in the upper and lower sections (Fig. 3).
CT scan of the lungs: 2 signs are characteristic - consolidation ( infiltration, filling the lumen of the alveoli with a pathological substrate) of the lung tissue and "frosted glass" ( a sign of alveolitis, thickening of the walls of the alveoli). Consolidation with a tendency to the peribronchial location in most patients prevails over ground glass. Less often - chaotic areas of consolidation. Subpleural consolidation - in all patients (Fig. 4-6).

Thus, the most common variants according to the TPLS scale were TPLS 2002, TPLS 2012, less often variants TPLS 2001, TPLS 2011. Taking into account the greater information content of lung CT compared with traditional radiographs, the TPLS variant can be refined according to the results of CT. As a rule, the syndrome of interstitial lesions, identified on traditional radiographs, corresponded to a combination of mild peribronchial consolidation and small areas of “ground glass” polytopic localization on CT scan of the lungs (i.e., a combination of symptoms of parenchymal compaction of the lung tissue was observed). ARDS corresponded to the TPLS 2002 and TPLS 2022 variants (radiographs of the chest organs were mainly analyzed, since CT was limited by the severity of the patients' condition).
In the dynamics of all patients, both radiographs and CT scans of the lungs showed the absence of a complete restoration of the normal radiographic picture: all of them retained compacted interlobular septa, linear fibrosis/atelectasis, areas of consolidation, but in a much smaller volume (Fig. 7 and 8).

At the onset of the disease and by the time of discharge, the airiness of the lung fields is diffusely reduced (we emphasize that all studies are done on the patient’s inspiration), therefore, it is not always possible to determine by CT: this is “frosted glass” ( a sign of alveolitis, fibrosis of the interalveolar septa) or severe hypopneumatization (absence full breath).
Among all patients who had pneumonia during the 2009–2010 epidemic season, there was no absolutely similar CT picture, despite the same CT symptoms. When comparing CT images in patients with viral-bacterial pneumonia diagnosed with ARDS and without ARDS, we did not reveal a significant difference in the ventral-dorsal lung tissue density gradient. The ventral-dorsal gradient on CT examination is clearly expressed in patients with manifestations of heart failure. In addition, patients with heart failure on CT often had a symptom of mosaic perfusion, which was not found in any of the patients with viral-bacterial pneumonia and ARDS.
In observations for the epidemic season of 2015–2016. we met 12 cases of viral-bacterial pneumonia, not all of them confirmed H1N1 influenza, however, all patients had a history of acute respiratory disease and a similar radiological picture. In the study group of 12 patients, 8 (66.7%) men and 4 (33.3%) women. The average age is 51 years (from 28 to 79 years). When examining the first images, one can speak of a dubious, but still probable picture of pneumonia or bilateral pneumonia of a small volume. At the control study after 3-6 days (X-rays or CT scans of the lungs), bilateral large-volume polysegmental pneumonia with several infiltrates is observed. There are no large lobar high-intensity infiltrates. The parts of the lungs below the level of the tracheal bifurcation are predominantly affected. According to the results of CT, the volume of the lesion is much larger than according to x-rays, the compaction of the lung tissue is of a parenchymal nature. Positive dynamics against the background of antibiotic treatment took place in all patients on the 8th–12th day; no “frozen picture” was noted. Pleurisy and cases of ARDS were not identified.
According to the TPLS scale in the initial x-ray examination TPLS 000 (0-1), i.e. doubtful infiltration in a small volume, in the control study TPLS 002 (0-2) or TPLS 2012. Against the background of the regression of pneumonia TPLS 000 (1-2 ), i.e. medium volume infiltration, transient changes are present. The most characteristic variant of viral-bacterial pneumonia for the epidemic season of 2015-2016. – TPLS (0–2)002, i.e. the degree of inhalation is moderately affected, there are no chronic changes, there is no interstitial lesion syndrome, a large volume of bilateral uneven infiltration.

conclusions
Based on observations for 2009–2010. and analysis of a small number of cases of viral-bacterial pneumonia in the epidemic season of 2015-2016. we have made the following conclusions.
1. Viral-bacterial pneumonia is more common in people of working age without background chronic changes in the lungs.
2. Cases of viral-bacterial pneumonia in the 2009-2010 epidemic season. more often observed in women, with a high incidence in pregnant women.
3. For viral-bacterial pneumonia, concomitant pleurisy is not typical.
4. "Frozen picture" on lung images in dynamics can be regarded as an independent criterion for viral-bacterial pneumonia and ARDS.
5. Irregularity, polytopicity, small size and different intensity of areas of parenchymal compaction (infiltration) of the lung tissue on x-rays form, along with the picture of infiltrates, a picture of interstitial lesions in viral-bacterial pneumonia.
6. Viral-bacterial pneumonia often has an asymmetric picture according to the results of radiography and CT, there is no tendency to damage the basal parts of the lungs, which can be used in the differential diagnosis with bilateral pneumonia after an episode of pulmonary edema in severe patients with severe hemodynamic disorders.
7. Viral and bacterial pneumonia of the epidemic seasons of 2009–2010. and 2015–2016 have a similar radiographic picture, but for pneumonia in 2015–2016. a long course is not typical, there are no cases of ARDS, a violation of lung excursion is less pronounced, large high-intensity infiltrates are not characteristic, a lesion of mainly the lower parts of the lungs is detected.
Based on the results of work with patients with a pulmonological profile, in particular with patients with viral-bacterial pneumonia, we put forward several hypotheses.
1. Background chronic changes in the lungs, perhaps not only an indicator of "abnormality", but also an indicator of the "preparedness" of the lungs for repeated inflammatory diseases. It is possible that the absence of a chronic background in the lungs is a greater risk factor for viral-bacterial pneumonia than the presence of chronic changes.
2. The volume of lung tissue damage does not always play a decisive role in the occurrence of ARDS. Perhaps, with a large amount of inflammatory infiltration in the lungs, there is a TPLS value at which ARDS rarely occurs.
3. It is possible that with statistical analysis over a long period it will be possible to identify the most frequent variants of TPLS in viral-bacterial pneumonia that accompanied influenza outbreaks at different times.
4. Mosaic Perfusion Phenomena May Not Only Be an Option pathological changes, but also evidence of the operation of the adaptive mechanisms of the surfactant system.
5. Probably, in ARDS, there is a tendency to equalize the density of the lung tissue and reduce the gradient between different parts of the lungs compared with the density of the lung tissue in pulmonary patients without ARDS.

Conclusion
Viral bacterial pneumonia associated with severe course, can be figuratively compared with pneumonia in the “pre-antibacterial era”, which is expressed in bilateral polysegmental lung damage, a “frozen” x-ray picture, high risk development of ARDS, residual post-inflammatory changes.
Perhaps it is advisable to use the criterion of the absence of dynamics - the "frozen picture" - to be used for classification within the group of viral-bacterial pneumonias.
In our opinion, the prospects for diagnosing viral and bacterial pneumonia, predicting the risk of ARDS are largely associated with the improvement of the leading method, the radiation method of diagnosis, which should be expressed in the analysis of X-ray images of the lungs using qualitative criteria, detailing the most characteristic features under dynamic observation.

Section 1. Lectures on radiodiagnosis of lung diseases

Introduction.

annotation

Arkhangelsk publishing house SSMU, 2011

Tutorial on X-ray diagnostics

Koposova R.A., Zhuravleva L.M.

Published by decision of the publishing board

Arkhangelsk 2011

UDC Reviewers - Doctor of Medical Sciences, Head of the Department of Trauma

BBC tology SSMU R.P. Matveev, Head of the Department of Hospital Therapy of the SSMU Professor S.I. Martyushov.

Northern State Medical University

Under the general editorship of Professor Valkov M.Yu.

ISBN detailed description radiodiagnostic methods.

The indications and application of X-ray diagnostics in the complex of diagnostic measures for the most common pathology are determined. The manual is intended for classes of students of medical faculties, interns, clinical residents and doctors of primary specialization in radiology.

Every year, at the Department of Radiation Diagnostics, Radiation Therapy and Clinical Oncology, students of all faculties of the SSMU, interns and clinical residents receive a course in radiology and radiotherapy, and receive training for work as a radiologist. In addition, doctors of other specialties in Arkhangelsk, the Arkhangelsk region and adjacent regions undergo primary retraining in the specialty "radiology".

The textbook was compiled at the initiative of studying doctors who, unfortunately, have short term preparation.

This manual is not a textbook on radiology. It presents selected lectures on the most frequent and difficult diagnostic issues that future radiologists will meet in practical work. Lectures will help radiologists and oncologists in the correct and timely diagnosis of diseases, and therefore in their adequate treatment.

Section 1. Lectures on X-ray diagnostics of lung diseases………….

1.1. X-ray diagnostics of acute pneumonia………………………….

1.2. X-ray diagnostics of lung abscesses…………………………...

1.3. X-ray diagnostics of pleurisy………………………………….

1.4. X-ray diagnostics of chronic lung diseases (chronic bronchitis, pulmonary emphysema, bronchiectasis).

1.5. Radiodiagnosis of central lung cancer………………….

1.6. X-ray diagnostics of peripheral lung cancer, benign tumors. Differential diagnosis of spherical formations in the lungs…………………………………………………

1.7. X-ray diagnosis of pulmonary tuberculosis…………………………..

1.8. X-ray diagnostics of diseases of the mediastinal organs…………..

Section 2. Lectures on X-ray diagnostics of diseases of the heart and large vessels………………………………………………………………………………...

2.1. X-ray diagnosis of acquired heart defects…………….

2.2. X-ray diagnostics birth defects hearts………………

Section 3. Lectures on X-ray diagnostics of diseases of the gastrointestinal tract………………………………………………………………..

3.1. X-ray diagnosis of cancer of the esophagus……………………………….

3.2. X-ray diagnosis of peptic ulcer……………………………

3.3. X-ray diagnosis of gastric cancer……………………………………

Section 4. Lectures on X-ray diagnostics of kidney diseases…………….

4.1. Methods of X-ray examination of the kidneys and urinary tract…………………………………………………………….

4.2. Normal radioanatomy of the kidneys……………………………….

4.3. X-ray diagnostics of anomalies in the development of the kidneys……………………

4.4. X-ray diagnostics of hydronephrosis, lithiasis, chronic pyelonephritis, paranephritis, kidney tuberculosis, kidney tumors, damage (injury) to the kidneys, ureters, Bladder…………………………………………………………

Section 5. X-ray diagnostics of diseases of bones and joints……………

5.1. X-ray diagnostics of inflammatory diseases of bones and joints (hematogenous osteomyelitis, tuberculosis of bones and joints, syphilis)………………………………………………………………….

5.2. X-ray diagnostics of benign and malignant tumors of bones and soft tissues…………………………………...

Section 6. Schemes and drawings for lectures and classes on easy……………..

Section 7. Atlas of radiographs……………………………………………………

Section 8. References………………………………………………………

In the monograph L.S. Rosenstrauch gives a classification of acute pneumonia presented at the X All-Union Congress of Radiologists and Radiologists in 1977 (classification by R. Hegglinia, supplemented and modified by L.S. Rosenstrauch).

According to this classification, all acute pneumonias are divided into 2 groups: primary and secondary.

Primary pneumonias occur in previously healthy lungs and are caused by pathogens that have a tropism for lung tissue.

Secondary pneumonia develops on the basis of changes that previously existed in the lungs or other organs and created the conditions for their occurrence.

A. primary pneumonia.

I. Bacterial.

1. Pneumococcal.

a. lobar pneumonia;

b. bronchopneumonia.

2. Streptococcal and staphylococcal pneumonia.

3. Friedlander's pneumonia.

4. Legionnaires' disease (legionellosis).

II. Viral.

1. Acute interstitial pneumonia. Influenza pneumonia.

2. Ornithosis pneumonia.

3. Pneumonia with adenoviruses.

III. Mycoplasma pneumonia.

IV. Pneumocystis pneumonia.

V. Allergic pneumonia.

VI. Rickettsial pneumonia. Q fever.

VIII. Fungal pneumonia.

B. secondary pneumonia.

I. Pneumonia in violation of blood circulation in the small circle.

1. Congestive.

2. Hypostatic.

3. Heart attack.

II. Pneumonia in violation of bronchial patency (cancer, adenoma).

III. aspiration pneumonia.

IV. Pneumonia in diseases of other organs and systems.

1. Pneumonia in purulent diseases.

2. Pneumonia in infectious diseases.

3. Pneumonia in other primary processes.

V. Traumatic pneumonia.

VI. Postoperative pneumonia.

In clinical practice, most often you have to deal with lobar and focal pneumonia (bronchopneumonia). However, at present, in most cases, it is very difficult to separate these 2 forms of pneumonia. Classic lobar pneumonia is now rare. The widespread use of antibiotics and sulfonamides affected the reactivity of the organism and the bacterial flora, so the clinical and radiological picture changed. The role of pneumococcus decreased, increased specific gravity staphylococcus, streptococcus, influenza and parainfluenza virus, mycoplasmas, etc. Some authors believe that in half of the patients pneumonia is caused by atypical agents. The full set of classical clinical signs of pneumonia (fever, cough with sputum, leukocytosis, increased ESR) became less common. Increasingly, pneumonia with an atypical, sluggish course is encountered (Vlasov P.V., 1998).

Croupous pneumonia (lobar, fibrinous, pleuropneumonia)

Known since the time of Hippocrates. In typical cases, the disease is characterized by a rapid, sudden onset, severe course, critical resolution and a certain sequence of pathological changes.

The infection enters the body by aerogenic means and quickly spreads through the lung tissue, affecting the lobe, and sometimes the entire lung.

Pathologically, there are 4 stages of development:

high tide(hyperemia). The capillaries are dilated and filled with blood, serous fluid begins to accumulate in the alveoli with a small amount of erythrocytes and leukocytes.

On the 2nd - 3rd day, the disease passes into red hepatization stage. At this stage, the alveoli are filled with fibrin with a significant admixture of erythrocytes. The affected lobe is enlarged, dense, airless. On the pleura surrounding the affected lobe, there are fibrinous overlays. This stage lasts 2-3 days and turns into gray hepatization stage. The share is still tight. In the alveoli - fibrin with an admixture of leukocytes.

On the 7th - 9th day, a crisis occurs in the development of the disease and begins resolution stage. Proteolytic enzymes liquefy fibrin, leukocytes undergo decay. The liquefied exudate is expectorated and absorbed through the lymphatic tract.

X-ray picture lobar pneumonia is characteristic and corresponds to pathoanatomical changes.

In the tide- strengthening of the pulmonary pattern in the affected lobe due to hyperemia. The transparency of the lung is normal or slightly evenly reduced. The root of the lung on the side of the lesion expands somewhat, its structure becomes less distinct. With the defeat of the lower lobe, the mobility of the corresponding dome of the diaphragm decreases.

In the stage of red hepatization- intense uniform darkening, which corresponds to the localization of the affected lobe. Darkening with lobar pneumonia differs from lobar atelectasis in that there is no decrease in the volume of the lobe in pneumonia. The share has the usual size or even a little more. Toward the periphery, the intensity of the shadow increases, and the uniformity increases. Against the background of darkening in the medial sections, light strips of bronchi of large and medium caliber are visible, the lumen of which in lobar pneumonia in most cases remains free (Fleischner's symptom, air bronchography symptom according to Vlasov).

The root of the lung on the side of the lesion is expanded and becomes non-structural. The adjacent pleura thickens. In some cases, an effusion is noted in the pleural cavity, which is better detected in lateroposition.

The median shadow (mediastinum) with croupous pneumonia is not displaced. There are no radiological differences between the stages of red and gray hepatization. At the resolution stage- gradually, but rather quickly, the intensity of the shadow decreases, its fragmentation and reduction in size occur. Inflammatory infiltration resolves in the direction from the root to the periphery. The root of the lung may remain enlarged and non-structural for a long time. The pulmonary pattern remains enhanced for another 2-3 weeks after clinical recovery. The pleura bordering the share is sealed even longer. The reaction of the pleura is expressed in the form of pleural layers. In 15% of cases, exudate in the pleural cavity. Fluid is well defined on laterograms. Even better, exudate is detected by ultrasound (even 10 ml of fluid can be detected).

Sometimes changes in the lungs with croupous pneumonia are bilateral, more often they are not synchronous.

Complete resolution of lobar pneumonia occurs within 3 to 4 weeks. But sometimes, radiographically, perivascular and peribronchial infiltration and delayed restoration of the structure of the lung tissue can be observed within 2 months.

Massive pneumonia is a type of lobar pneumonia. With this pneumonia, unlike ordinary pneumonia, the lumens of the lobar and segmental bronchi are blocked by a fibrin plug. Therefore, in the stage of hepatization, light stripes of the bronchi are not visible, the shadow is uniform throughout.

IN last years croupous pneumonia in most cases does not proceed according to the lobar type, but begins with a segmental lesion. If treatment is started early, then the lobe may not be affected. In these cases, all stages of the development of pneumonia are determined in 1-2 segments - segmental and polysegmental pneumonia.

In other words, lobar pneumonia is not necessarily lobar. With early treatment (from the 1st day of the disease), the process sometimes develops even within a part of the segment, usually in areas of the lobe adjacent to the interlobar fissure. These are pericissurites. They are characterized by poor physical data, since the inflammatory process lies deep. Previously they were called central pneumonia. In the diagnosis of "central pneumonia" radiological method is decisive (especially lateral images).

The differential diagnosis of lobar pneumonia is carried out with atelectasis, pulmonary infarction, tuberculous pneumonia.

Outcomes of croupous pneumonia are currently generally favorable. In most cases, pneumonia completely resolves, the structure of the lungs is restored.

Bad outcomes:

Suppuration of the infiltrate with the development of abscess pneumonia, sometimes with a breakthrough into the pleural cavity and the formation of pneumothorax;

transition to a chronic form with the subsequent development of bronchiectasis, cirrhosis, sometimes carnification. An example of a transition to a chronic form is the middle lobe syndrome.

A few words about carnification. In some cases, during the period of gray hepatization, the leukocyte reaction is weakly expressed, so the resorption of alveolar exudate is delayed. There is an organization of fibrinous exudate, its replacement with connective tissue (carnification). Radiologically, wrinkling of the affected lobe is observed. In hard images, heterogeneous darkening is determined, the morphological basis of which is areas of uneven fibrosis, alternating with areas of enlightenment (dystrophic cysts and bronchiectasis).

Complications of croupous pneumonia: pleurisy, less often pericarditis and mediastinitis.

Bronchopneumonia (lobular, catarrhal, focal pneumonia)

Occurs most often. The etiological factors are varied. Like croupous pneumonia, it is a classic form of pneumonia and has been known since antiquity.

Unlike croupous pneumonia, with bronchopneumonia, the wall of the bronchus is first affected and only secondarily, per continuitatem, the lung parenchyma. Infected sputum is sprayed when coughing, therefore, various parts of the bronchial tree are affected, from where the inflammation passes to the lung tissue (endobronchitis - panbronchitis - pneumonic focus). Since, when coughing, the air moves through the bronchi with great speed, multiple inflammatory foci quickly appear in various parts of the lungs.

Morphologically, in croupous pneumonia, inflammatory infiltration occupies a subsegment, segment or lobe in a short time, and in bronchopneumonia, the inflammatory focus is limited to a lobule (lobular pneumonia).

Another feature of bronchopneumonia is the occurrence of multiple foci at different times, so the change in morphological stages in them does not occur simultaneously; in some foci there may be a tide stage, in others - hepatization, in the third - resolution.

Exudate in bronchopneumonia is mostly serous, there is no or very little fibrin.

Along with lobular foci, there may be smaller foci - acinous and larger - confluent.

The clinical picture of bronchopneumonia is not so typical. The disease begins gradually, often in the form of catarrh of the upper respiratory tract or bronchitis. Then comes weakness, headache, temperature up to 37 - 40 ° C, but rarely reaches 40 ° C. In debilitated and elderly people, the temperature may remain normal. In most cases, the condition of patients is less severe.

X-ray picture. Bronchopneumonia is characterized by the presence of bilateral multiple focal shadows. The sizes, localization and quantity of the centers vary. The size of the foci is usually 1 - 1.5 cm (lobule), but can be very small - from 2 to 5 mm, sometimes they resemble miliary tuberculosis. The contours of the foci are indistinct, the intensity of the shadow is small.

Focal pneumonias tend to be located in the lower (basal) sections. The tops of the lungs in most cases are not affected. When localized at the apex, they are difficult to distinguish from tuberculosis. Anti-inflammatory treatment for 3-4 weeks allows you to get the dynamics and exclude tuberculosis.

With bronchopneumonia, the foci can merge with each other, then they form large infiltrates that occupy one or more segments. In such cases, bronchopneumonia is difficult to distinguish from lobar pneumonia (pseudo-lobar pneumonia). The affected area usually has a heterogeneous structure. The reason for the heterogeneity is the unevenness of inflammatory infiltration, the alternation of lobules filled with exudate with areas that have retained airiness. Small, low-intensity foci are not always detected on the pictures.

It is said above that there is another variant of bronchopneumonia, when the foci are very small - 4 - 5 mm and even 2 - 3 mm (miliary bronchopneumonia). Large and medium focal confluent pneumonia may resemble , metastases of malignant tumors.

Unlike tuberculosis and tumors, bronchopneumonia is characterized by rapid dynamics of the process, negative tuberculin tests, and the absence of damage to other organs. But if the study is single, then the diagnosis is difficult. With bronchopneumonia, the pulmonary pattern is enhanced throughout the lungs (hyperemia). The roots are expanded, not structural. As a rule, there is a reaction of the pleura, there may be exudative pleurisy.

Bronchopneumonia is characterized by rapid dynamics of the x-ray picture. Within 5 - 6 days, it changes significantly, and after 8 - 10 days, the foci often resolve.

Bronchopneumonia (focal pneumonia), with a certain similarity of the clinical and radiological picture, is actually a collective concept, with a variety of etiological factors, focal pneumonia has a different course and outcomes. But in general, the outcomes and complications of bronchopneumonia are the same as with croupous pneumonia.

It should be noted that often due to the summation of inflammatory foci with air areas, a subtraction effect (subtraction) occurs. The shadows of inflammatory foci at the same time become low-intensity and may even completely disappear from the field of view. This is especially the case in patients with emphysema. This explains the frequent discrepancy between auscultatory data and X-ray data.

Pneumonia is a group of infectious diseases, the main morphological substrate of which is inflammatory exudate in the respiratory sections of the lungs. On x-ray examination, pneumonia manifests itself in the form of extensive shapeless blackouts with many of their variants. The shadow-forming substrate of pneumonia is inflammatory infiltration, which is an overflow of the alveoli or interstitial tissue of the lungs with a liquid inflammatory exudate. The main radiological criterion for the presence of pneumonia is the detection of inflammatory infiltration.

Acute pneumonia n n In practical medicine, for the formulation of a diagnosis, acute pneumonia is divided according to clinical and morphological features: - parenchymal; -bronchopneumonia; -interstitial. downstream: - acute - protracted.

Parenchymal pneumonia n Lobar (lobar, parenchymal, pleuropneumonia, alveolar, fibrinous, croupous) P. is more often observed in the most severe and rapidly developing forms of pneumococcal and Klebsiella P. Croupous P. is characterized by a pronounced exudative reaction with a high content of fibrin in the alveolar effusion, involvement in the process of the adjacent pleura (pleuropneumonia); inflammation can capture a lobe of the lung or several of its segments.

n On early stages development of alveolar, parenchymal pneumonia macroscopically lung tissue in the foci of bacterial P. is edematous, red, later becomes drier, gray and dense. If there are erythrocytes in the exudate, the foci have a gray-red or red color. In the case of fibrin admixture, the cut surface is fine-grained. In the later stages of the disease, the lungs regular color, flabby.

n In the initial stages of croupous P., X-ray reveal local amplification lung pattern and a slight decrease in lung transparency due to increased blood supply to the affected lobe or segment.

n In the stage of exudative inflammation, intense shading of the corresponding area of ​​the lung occurs, especially pronounced along the periphery: towards the root of the lung, the intensity of shading gradually decreases. The volume of the affected area of ​​the lung (lobe, segment) is not reduced (as in atelectasis), and in some cases even slightly increased; against the background of shading on the roentgenogram in direct projection, radially located light stripes are visible - segmental and subsegmental bronchi that preserve airiness. The boundaries of the affected area of ​​the lung are especially clearly defined in cases where they correspond to the interlobar fissures.

n X-ray of the chest organs in direct projection with lobar right-sided upper lobe pneumonia: in the region of the upper lobe of the right lung, shading is determined, limited by the interlobar pleura, the volume of the lobe is not reduced, the lumen of the bronchi in it is transparent.

n At the stage of resolving croupous P., the shading is fragmented, its intensity progressively decreases until it disappears completely. In place of the former shading, an enhanced pulmonary pattern remains for 3-4 weeks, the shadow of the lung root on the side of the lesion during this period also remains expanded and non-structural. Often there is a thickening of the interlobar and parietal pleura, limited mobility of the diaphragm, incomplete opening of the costophrenic sinuses. With a favorable course of the process, the x-ray picture returns to normal in 1-2 months. If croupous P. is complicated by abscess formation, against the background of the remaining shading of the lung tissue, one or more enlightenments appear with a horizontal lower border.

Lung abscess n The structure of the abscess is not the same in different stages and depends mainly on the presence of contents in the cavity. Prior to a breakthrough in the bronchus, i.e., in the first days of observation, the shadow of the abscess can be quite uniform, but later, when the abscess breaks, more or less air enters its cavity. Air is either located in the form of a sickle in the presence of dense contents in the abscess cavity, or causes a characteristic picture of the horizontal level of fluid in the cavity. The optimal method for studying the structure of abscesses is tomography, better in orthoposition.

n Abscess of the right lung n AP tomogram, performed in vertical position sick. Abscess of the right lung: blurred external contours, decay cavity, clearer internal contours, fluid level, changes in lung tissue around.

n Destructive P., the causative agents of which can be, in particular, staphylococcus, streptococcus, are characterized by a peculiar x-ray picture. Already in the first days of the disease, against the background of massive shading of the lung tissue, enlightenments appear, indicating its melting. The lower boundary of these enlightenments often has a horizontal direction. If the fluid in the formed cavities is well drained, they are cleared and can take on a rounded shape. In severe cases, the cavities merge with each other due to the ongoing melting of the lung tissue, and large, sometimes gigantic, enlightenments are formed. The outcome of destructive P. is often gross pneumosclerosis (cirrhosis) of the lung, and sometimes chronic pneumonia.

n On a chest radiograph in direct projection with left-sided upper lobe staphylococcal pneumonia: against the background of massive shading in the region of the upper lobe of the left lung, multiple rounded enlightenments - cavities are visible.

n The criterion for distinguishing between protracted and chronic P. is not so much the period that has passed since the moment of the disease, but the results of dynamic monitoring of patients. The absence, despite long-term and intensive treatment, of positive clinical and radiological dynamics, the appearance of signs of pneumosclerosis and local deforming bronchitis with repeated exacerbations of the inflammatory process in the same area of ​​the lungs makes it possible to diagnose chronic pneumonia.

n In modern medical practice total P., capturing the entire lung, are rare, limited processes are more often observed, located along the interlobar fissures and occupying the marginal sections of the lobes. Such limited infiltrates (periscissuritis) are radiographically manifested by elongated shading with clear rectilinear contours at the border with the interlobar fissure; the opposite contour is fuzzy, here the intensity of shading gradually decreases until it disappears.

n Periscissurites are more clearly visible in the lateral projections, since in this case the interlobar fissures are better defined. Unlike segmental P., periscissuritis is often not limited to one segment, but accompanies the interlobar fissure throughout its entire length. The longest periscissurites are better seen on tomograms. Since the inflammatory areas in periscissuritis are located in the thickness of the lung and often do not extend to its surface, percussion and auscultatory data are scarce or completely absent. In these cases, a reliable diagnosis without X-ray examination is difficult.

n X-ray of the chest organs in the right lateral projection with periscissuritis in the region of the base of the upper lobe of the right lung: shading is located along the oblique interlobar fissure along its entire length.

Disintegration and melting of the lung tissue in Friedlander's pneumonia n This type of pneumonia is often a lobar process, but in some cases, especially in the early stages of development, radiographically manifests itself in the form of blackouts without anatomical boundaries. Friedlander's pneumonia accounts for no more than 0.5 - 1% of cases of acute pneumonia, is caused by the gram-negative bacillus Klebsiella pneumoniae, affects more often men aged 40 years and older. n In the x-ray picture, several stages of development are distinguished. Initially, focal shadows are detected, which differ from those in pneumococcal bronchopneumonia by location on the periphery of the lung field. Then the foci merge with each other, forming infiltrates without anatomical boundaries. Further development of the process is accompanied by the appearance of pseudolobar, and then lobar opacities. The intensity of these blackouts is high, they are homogeneous. The dimensions of the affected lobe of the lung increase, its borders become convex, the median shadow shifts in the opposite direction. Finally, in the last stage, multiple abscesses appear; mortality reaches 70%.

Bronchopneumonia n Focal P. usually develops after the defeat of the bronchi (bronchopneumonia) in cases where the pathogen is not able to cause intense serous inflammation in large areas of the lung tissue due to low virulence or a rapid and intense protective cellular response of the macroorganism. Most bacterial P. (including chlamydial, mycoplasmal), protozoal P., as well as fungal infections of the lungs (pneumomycosis) have a focal character. The volume of damage at focal P. can vary from a part of a segment to the whole share or several shares of a lung.

n With focal P., foci of inflammation in the affected segments are at different stages of development (hot flush, cr. or ser. Hepatization, resolution), this can explain the gradual (in some cases) development of the disease, its undulating course with alternating periods of improvement and deterioration patient, inconstancy of fever, variability of physical changes and their mosaic, due to the presence of normally functioning or emphysematous tissue next to the affected areas of the lungs. When infectious foci are located at a depth of more than 4 cm from the surface of the lung and at their central location, dullness of percussion sound and increased voice trembling may not be determined. The most constant symptoms of focal P. are hard breathing, wet rales (usually finely bubbling, sonorous). More constant for focal P. symptoms of lesions of the bronchial tree: dry and moist (medium and large bubbling) rales. The pleura is not always involved in the process.

X-ray of the chest organs in a direct projection with focal pneumonia: in both lungs, indistinctly defined shading with a diameter of 1-2 cm is visible.

n n With focal P., many small areas of shading are revealed radiologically, more often in both lungs, the size of the foci usually does not exceed 1-2 cm, which corresponds to the size of the pulmonary lobules. Quite often the centers merge among themselves that leads to their considerable increase and increase in intensity of shadows (drain P.). In this case, shading can sometimes occupy the entire segment or lobe, resembling croupous pneumonia. They are distinguished from true lobar processes by a not entirely homogeneous structure, since it is often possible to determine on hard images and especially on tomograms that the darkening consists of several foci that merge with each other. In addition, in most cases, more or less transparent areas can be found along the edges of the lobe.

n Acute pneumonia n Plain radiographs of the lungs, performed at an interval of 2 weeks. in acute bilateral bronchopneumonia. Rapid process regression. Recovery.

n n With miliary P., the size of the foci does not exceed 1-2 mm, which imitates tuberculosis, tumor and other miliary dissemination. Significantly helps in the differential diagnosis in this case, the dynamics of the process. Unlike most miliary disseminations, which are characterized by a fairly stable x-ray picture, changes in miliary P., as a rule, undergo a rapid reverse development: after 2 weeks, the foci usually resolve. The reaction of the roots of the lungs and pleura with focal P. in most cases is less pronounced than with croupous pneumonia. Large-focus confluent pneumonias resemble metastases of malignant tumors. The difference is in the rapid reverse development.

n Confluent bronchopneumonia n Plain radiograph: darkening is projected onto the shadow of the root and the root zone - the so-called central pneumonia of the right lung.

n In most cases, on radiographs in direct projection, such a picture is the result of a projection overlay of the infiltrate on the root and root region. When the patient is turned to the lateral position, it turns out that in fact the infiltrate is located in the anterior or posterior part of the lung (segment III, IV or VI), often in the form of periscissuritis. This is especially evident on computed tomograms.

Interstitial pneumonia n The so-called interstitial P. is characterized by pronounced structural changes in the interstitial tissue of the lung. True inflammation with the presence of a significant number of pathogens and a leukocyte reaction in the affected areas is rare. Much more often, they have accumulation of lymphocytes, histiocytes and plasmocytes as a manifestation of a local immune response, followed by moderate fibrosis. This is often combined with focal dystelectasis (a site of incomplete collapse of the lung tissue). Such changes are observed with a long course of a respiratory infection.

n n Fragment of a chest x-ray in direct projection with interstitial pneumonia: in the lower zone of the right lung field, the pulmonary pattern is strengthened and deformed, its radial direction is not traced. with interstitial pneumonia, multiple taut shadows are mainly found, located both radially and in the form of thin-walled rings surrounding the lobules and acini.

n Pneumonia, in which the interstitial tissue of the lung is predominantly affected, is manifested by an increase and deformation of the pulmonary pattern, mainly in the lower and middle zones of the lung fields. The pattern loses its radial orientation and acquires a cellular character due to infiltration of the interstitial tissue located around the lung acini and lobules. With P.'s further development, focal changes often join the interstitial changes and the process acquires a mixed interstitial-parenchymal character.

n X-ray of the chest in direct projection with interstitial focal pneumonia: against the background of an enhanced and deformed lung pattern in both lung fields, mainly in the right, focal shadows of different sizes are visible.

n At the suggestion of O. V. Korovina (1978), acute P., which developed against the background of chronic respiratory diseases or as a complication of infectious diseases, diseases of the cardiovascular system, chronic diseases of other organs and systems, operations and injuries of the chest, are considered secondary in contrast from primary acute P. that occur in the absence of pathology of the respiratory system and other diseases that contribute to the development of pneumonia.

n Congestive P. are more often localized in the lower lobes of the lungs, mainly in the right lung, often develop against the background of hydrothorax. Their course is sluggish, protracted, without pronounced signs of intoxication and high fever. Physical signs against the background of congestive changes in the lungs are difficult to identify, and the decisive diagnostic method is radiological.

Aspiration pneumonia n Aspiration pneumonitis, which occurs due to inhalation or inhalation of foreign bodies or substances, usually develops in seriously ill patients who are unconscious, after anesthesia, and also when intoxicated. Accession of infection naturally complicates it, and in the later stages we can talk about aspiration pneumonia. The clinic and the course of aspiration pneumonitis and pneumonia largely depend on the aspirated substance. The most common symptoms are pain in chest, shortness of breath, cough, purulent and bloody sputum. Sometimes there are attacks of suffocation and coughing, resembling attacks of bronchial asthma, with simultaneous separation of mucopurulent sputum. Body temperature rises to 39-40°C. An objective examination of the lungs determines the dullness of percussion sound and often bronchial breathing, sonorous diverse moist rales in one or both lungs. The focus of inflammation, like the foreign body itself, is often localized in the lower parts of the right lung.

n X-ray picture of AP of the lower lobe of the right lung in an 18-year-old man, which occurred after aspiration during alcohol intoxication

n Gasoline P. has a peculiar course. The first symptom of aspiration of gasoline and other hydrocarbons is a sharp painful cough to vomiting, lasting 20-30 minutes. The specific effect of hydrocarbons is manifested by headache, sleep disturbance, nightmares, arterial hypotension. From the moment of hydrocarbon aspiration to the development of P., 2-8 hours pass, less often this period is extended to 2 days. P. begins, as a rule, with a sharp pain in the chest (often on the right), significantly limiting breathing, coughing and movement. Signs of intoxication increase (headache, dizziness, weakness), chills, fever (up to 38-39 °) may appear. Breathing becomes superficial, frequent (up to 40 or more in 1 min), the chest on the side of the affected lung lags behind when breathing. cyanosis occurs. On the first day of the disease, auscultatory and percussion signs of P. are absent. On the second or third day, signs of respiratory failure (cyanosis, shortness of breath) increase, physical changes appear: shortening of percussion sound, weakened or hard breathing, moist rales and pleural friction noise. Gasoline P. is characterized by rapid positive dynamics. Already by the end of the 3rd-4th day of illness, the state of health improves, the body temperature decreases or normalizes, shortness of breath and cyanosis disappear. Clinical recovery usually occurs on the 8-12th day. Possible complications: pulmonary bleeding, lung abscess, exudative pleurisy.

n Gasoline P. can be diagnosed radiographically 1-2 hours after the onset of chest pain. Shading is localized more often on the right in the lower medial section of the lung field, intense, homogeneous, as in croupous P., but in contrast to it, there are signs of atelectasis of the affected parts of the lung (reduction in size, compaction, displacement of the mediastinal organs towards the lesion) and signs of emphysema on a healthy side. X-ray changes can persist up to 20-30 days.

n n Septic metastatic P., which develops when purulent emboli from various purulent foci are transferred by blood flow (for example, furuncle, carbuncle, pleural empyema, purulent salpingiophoritis, pyelonephritis), is characterized by bilateral lesions, multiple infiltrates of the lung tissue, their tendency to decay with the formation of abscesses, rapid dynamics and the emergence of long-lasting thin-walled obedient cavities X-ray of the chest organs in direct projection with septic pneumonia: in both lung fields numerous rounded enlightenments are visible - thin-walled cavities, in some cavities fluid is determined - shading with a horizontal upper border.

n Pulmonary infarction develops as a result of thromboembolism of the branches of the pulmonary artery, which often occurs in patients with thrombophlebitis of the lower extremities. With a lung infarction, shortness of breath suddenly appears, chest pain, hemoptysis are possible. There are no signs of intoxication, body temperature rises later. X-ray in the zone of lung infarction, depletion of the lung pattern, shading (in typical cases of a triangular shape with the apex facing the root of the lung) can be determined. The ECG reveals signs of overload of the right heart, these signs can be of decisive diagnostic importance for thromboembolism (thrombosis) of small branches of the pulmonary artery, when there are no symptoms such as chest pain, hemoptysis, triangular shading of the lung tissue on the x-ray.

n P. quite often arise in the postoperative period (postoperative P.). More often they develop after operations on the chest, spine, abdominal cavity. The etiological factor in most cases is the endogenous microflora that enters the lungs from the upper respiratory tract or, less commonly, hematogenously. Possible exogenous infection (for example, through contact with infectious patients). Predisposing factors for the development of postoperative P. are anesthesia, pain, depression, blood loss, starvation, the formation of protein breakdown products during tissue damage. Changes in the lungs of varying severity are also of great importance, which can occur during any surgical intervention as a result of reflex reactions: a focus of hyperemia, necrosis, atelectasis, impaired mucociliary clearance due to inhibition of the secretory function of the bronchial mucosa, narrowing of their lumen due to spasm and edema, decreased cough reflex, circulatory disorders in the lungs with the development of stagnation.

n In recent years, hospital-acquired or nosocomial P. have been especially distinguished. As a rule, they are caused by opportunistic microflora resistant to many antibiotics, and develop in people with impaired immunity, have an atypical, sluggish or protracted course.

• Despite the fact that modern classifications of pneumonia are surprisingly little interested in the radiological characteristics of the process, the determination of the predominant pathoanatomical picture and complications of pneumonia certainly remains the primary task of radiological examination.

What are we dealing with

• We are dealing with an amazingly delicate and well-oiled respiratory mechanism that ensures not only successful gas exchange, but also a number of complex hormonal functions.

• When immunity is weakened, the lung often becomes a battlefield on which "warfare" is played out.

Lungs normal

Modern technologies

Anatomy of the alveoli

Substrate of pneumonia

Required Component

• Exudate in the lumen of the alveoli - a mandatory sign of pneumonia - always gets displayed on a high-quality radiograph

• For all types of infiltration, it is mandatory to go through 4 pathological stages of the process

The possibility of establishing the etiology of pneumonia

• The X-ray method does not provide reliable signs for distinguishing pneumonia caused by different pathogens.

Process steps

• Tide - increased lung pattern

• Red and gray hepatization - radiologically indistinguishable, but their substrate - effusion in the lumen of the alveoli necessarily darkens against the background of healthy lung tissue

• Resolution stage - similar to the tide stage, with a gradual normalization of the picture

Upper lobe pneumonia

Upper lobe pneumonia

Middle lobe pneumonia

• An example of middle lobe pneumonia

Middle lobe pneumonia

Middle lobe pneumonia

Middle lobe pneumonia

Lower lobe pneumonia

Segmental pneumonia

Segmental pneumonia

• Areas of confluent infiltration are visible in the axillary segment on the left and focal infiltration in the reed segments

Unilateral defeat

• Pneumonia in 95% of cases is a unilateral process

• Bilateral lesion is a sign of an atypical course, which should alert the attention of the radiologist and the attending physician

Upper lobe pneumonia (klibsiela), onset of resolution

Resolution phase

Middle lobe pneumonia

Pneumonia resolution phase

• After the resolution of pneumonia for several weeks or more, residual pleural layers, local areas of increased pulmonary pattern may remain.

Focal pneumonia

• The site of infiltration is visible behind the shadow of the heart

Focal pneumonia

Focal mycoplasmal pneumonia

Focal aspiration pneumonia

• The lower sections of the right lung were affected.

• Postoperative period

Interstitial pneumonia

• Multiple pneumonic areas in the lung fields on both sides

Interstitial adenoviral pneumonia

Interstitial pneumonia

• Almost total lesion of the lungs with Pneumocystis carinii Pneumonie

Toxic pneumonia

• Almost total infiltration of lung tissue

• Develops after aspiration of toxic substances

Abscessing pneumonia

• A crescent-shaped strip of gas appeared in the area of ​​infiltration on the right - a sign of abscess formation

Abscessing pneumonia

Abscessing pneumonia

• Bilateral pneumonia, on the left with abscess formation

Abscessing pneumonia

Abscessing pneumonia

• A large area of ​​destruction with the presence of torn masses in the cavity - sequestrum

Abscessing pneumonia

• Dynamics in pneumonia, in contrast to disintegrated peripheral cancer, is faster, the clinical picture in cancer is more “erased”

Abscessing pneumonia

Abscessing pneumonia

• CT is the most revealing method of research in destructive pneumonia

Abscessing pneumonia

Abscessing pneumonia

Abscess dynamics

Abscessing pneumonia

• Dynamics of the course of pneumonia (dates are visible on the pictures)

• The multiplicity and uniformity of lesions in pneumonia is evidence in favor of hematogenous dissemination of the process, which is usually a manifestation of sepsis

Septic “metastatic” pneumonia

Pulmonary embolism

The main morphological substrate of which is inflammatory exudate in the respiratory sections of the lungs.

On x-ray examination, pneumonia manifests itself in the form of extensive shapeless blackouts with many of their variants.

The shadow-forming substrate of pneumonia is inflammatory infiltration , which is an overflow of the alveoli or interstitial tissue of the lungs with a liquid inflammatory exudate.

The main radiological criterion for the presence of pneumonia is the detection of inflammatory infiltration.

Chest radiograph. direct projection. Norm

Chest radiograph. direct projection. Pneumonia.

• According to the clinical course and morphological features, acute and chronic pneumonia are distinguished.

Acute pneumonia

• In practical medicine, to formulate a diagnosis, acute pneumonia is divided according to clinical and morphological features:
• - parenchymal;
• -bronchopneumonia;
• -interstitial.
• with the flow:
• - acute
• - lingering.

Parenchymal pneumonia

• Lobar (lobar, parenchymal, pleuropneumonia, alveolar, fibrinous, croupous) P. is more often observed in the most severe and rapidly developing forms of pneumococcal and Klebsiella P. Croupous P. is characterized by a pronounced exudative reaction with a high content of fibrin in the alveolar effusion, involvement of the adjacent pleura in the process (pleuropneumonia); inflammation can capture a lobe of the lung or several of its segments.

• In the early stages of the development of alveolar, parenchymal pneumonia, macroscopically, the lung tissue in the foci of bacterial P. is edematous, red, and later becomes drier, gray and dense. If there are erythrocytes in the exudate, the foci have a gray-red or red color. In the case of fibrin admixture, the cut surface is fine-grained. In the later stages of the disease, the lungs are of a normal color, flabby.

• In the initial stages of croupous P., a local increase in the pulmonary pattern and a slight decrease in the transparency of the lungs due to increased blood filling of the affected lobe or segment are revealed radiographically.

• In the stage of exudative inflammation, intense shading of the corresponding area of ​​the lung occurs, especially pronounced along the periphery: towards the root of the lung, the intensity of shading gradually decreases. The volume of the affected area of ​​the lung (lobe, segment) is not reduced (as in atelectasis), and in some cases even slightly increased; against the background of shading on the roentgenogram in direct projection, radially located light stripes are visible - segmental and subsegmental bronchi that preserve airiness. The boundaries of the affected area of ​​the lung are especially clearly defined in cases where they correspond to the interlobar fissures.

• X-ray of the chest in direct projection with lobar right-sided upper lobe pneumonia: in the area of ​​​​the upper lobe of the right lung, shading is determined, limited by the interlobar pleura, the volume of the lobe is not reduced, the lumen of the bronchi in it is transparent.

• On a transverse computed tomogram, bronchial lumens are clearly visible against the background of darkening (“air bronchography”).

• At the stage of resolution of croupous P., the shading is fragmented, its intensity progressively decreases until it completely disappears. In place of the former shading, an enhanced pulmonary pattern remains for 3-4 weeks, the shadow of the lung root on the side of the lesion during this period also remains expanded and non-structural. Often there is a thickening of the interlobar and parietal pleura, limited mobility of the diaphragm, incomplete opening of the costophrenic sinuses. With a favorable course of the process, the x-ray picture returns to normal in 1-2 months. If croupous P. is complicated by abscess formation, against the background of the remaining shading of the lung tissue, one or more enlightenments appear with a horizontal lower border.

Abscessing pneumonia

• Abscessing pneumonia

lung abscess

• The structure of the abscess is not the same in different stages and depends mainly on the presence of contents in the cavity. Prior to a breakthrough in the bronchus, i.e., in the first days of observation, the shadow of the abscess can be quite uniform, but later, when the abscess breaks, more or less air enters its cavity. Air is either located in the form of a sickle in the presence of dense contents in the abscess cavity, or causes a characteristic picture of the horizontal level of fluid in the cavity. The optimal method for studying the structure of abscesses is tomography, better in orthoposition.

• Right lung abscess
• Tomogram in direct projection, performed in the vertical position of the patient. Abscess of the right lung: blurred external contours, decay cavity, clearer internal contours, fluid level, changes in lung tissue around.

• Destructive P., the causative agents of which can be, in particular, staphylococcus, streptococcus, are characterized by a peculiar x-ray picture. Already in the first days of the disease, against the background of massive shading of the lung tissue, enlightenments appear, indicating its melting. The lower boundary of these enlightenments often has a horizontal direction. If the fluid in the formed cavities is well drained, they are cleared and can take on a rounded shape. In severe cases, the cavities merge with each other due to the ongoing melting of the lung tissue, and large, sometimes gigantic, enlightenments are formed. The outcome of destructive P. is often gross pneumosclerosis (cirrhosis) of the lung, and sometimes chronic pneumonia.

• On the roentgenogram of the chest organs in direct projection with left-sided upper lobe staphylococcal pneumonia: against the background of massive shading in the region of the upper lobe of the left lung, multiple rounded enlightenments - cavities are visible.

• The criterion for distinguishing between protracted and chronic P. is not so much the period that has passed since the moment of the disease, but the results of dynamic monitoring of patients. The absence, despite long-term and intensive treatment, of positive clinical and radiological dynamics, the appearance of signs of pneumosclerosis and local deforming bronchitis with repeated exacerbations of the inflammatory process in the same area of ​​the lungs makes it possible to diagnose chronic pneumonia.

• In modern medical practice, total P., capturing the entire lung, are rare, more often there are limited processes located along the interlobar fissures and occupying the marginal parts of the lobes. Such limited infiltrates (periscissuritis) are radiographically manifested by elongated shading with clear rectilinear contours at the border with the interlobar fissure; the opposite contour is fuzzy, here the intensity of shading gradually decreases until it disappears.

• Periscissurites are more clearly visible in lateral projections, because at the same time interlobar cracks are better defined. Unlike segmental P., periscissuritis is often not limited to one segment, but accompanies the interlobar fissure throughout its entire length. The longest periscissurites are better seen on tomograms. Since the inflammatory areas in periscissuritis are located in the thickness of the lung and often do not extend to its surface, percussion and auscultatory data are scarce or completely absent. In these cases, a reliable diagnosis without X-ray examination is difficult.

• X-ray of the chest organs in the right lateral projection with periscissuritis in the region of the base of the upper lobe of the right lung: shading is located along the oblique interlobar fissure along its entire length.

• On a CT scan, periscissuritis located in front of the main interlobar fissure.

Disintegration and fusion of lung tissue in Friedlander's pneumonia

• This type of pneumonia is often a lobar process, but in some cases, especially in the early stages of development, radiologically manifests itself in the form of blackouts without anatomical boundaries. Friedlander's pneumonia accounts for no more than 0.5 - 1% of cases of acute pneumonia, is caused by the gram-negative bacillus Klebsiella pneumoniae, affects more often men aged 40 years and older.
• In the x-ray picture, several stages of development are distinguished. Initially, focal shadows are detected, which differ from those in pneumococcal bronchopneumonia by location on the periphery of the lung field. Then the foci merge with each other, forming infiltrates without anatomical boundaries. Further development of the process is accompanied by the appearance of pseudolobar, and then lobar opacities. The intensity of these blackouts is high, they are homogeneous. The dimensions of the affected lobe of the lung increase, its borders become convex, the median shadow shifts in the opposite direction. Finally, in the last stage, multiple abscesses appear; mortality reaches 70%.

Bronchopneumonia

• Focal P. usually develops after the defeat of the bronchi (bronchopneumonia) in cases where the pathogen is not able to cause intense serous inflammation in large areas of the lung tissue due to low virulence or a rapid and intense protective cellular reaction of the macroorganism. Most bacterial P. (including chlamydial, mycoplasmal), protozoal P., as well as fungal lesions of the lungs (pneumomycosis) have a focal character. The volume of damage at focal P. can vary from a part of a segment to the whole share or several shares of a lung.

cm

• With focal P., foci of inflammation in the affected segments are at different stages of development (hot flush, cr. or ser. Hepatization, resolution), this can explain the gradual (in some cases) development of the disease, its undulating course with alternating periods of improvement and deterioration of the patient's condition , inconstancy of fever, variability of physical changes and their mosaic, due to the presence of normally functioning or emphysematous tissue next to the affected areas of the lungs. When infectious foci are located at a depth of more than 4 cm from the surface of the lung and with their central location, dullness of percussion sound and increased voice trembling may not be determined. The most constant symptoms of focal P. are hard breathing, wet rales (usually finely bubbling, sonorous). More constant for focal P. symptoms of lesions of the bronchial tree: dry and moist (medium and large bubbling) rales. The pleura is not always involved in the process.

• X-ray of the chest organs in direct projection with focal pneumonia: in both lungs, indistinctly defined shading with a diameter of 1-2 cm is visible.

• With focal P., many small areas of shading are revealed radiologically, more often in both lungs, the size of the foci usually does not exceed 1-2 cm, which corresponds to the size of the lung lobules. Quite often the centers merge among themselves that leads to their considerable increase and increase in intensity of shadows (drain P.). In this case, shading can sometimes occupy the entire segment or lobe, resembling croupous pneumonia.
• They are distinguished from true lobar processes by a not entirely homogeneous structure, since it is often possible to determine on hard images and especially on tomograms that the darkening consists of several foci that merge with each other. In addition, in most cases, more or less transparent areas can be found along the edges of the lobe.

Acute pneumonia

• Acute pneumonia
• Plain radiographs of the lungs, performed at intervals of 2 weeks, in acute bilateral bronchopneumonia. Rapid process regression. Recovery.

• With miliary P., the size of the foci does not exceed 1-2 mm, which mimics tuberculosis, tumor and other miliary dissemination. Significantly helps in the differential diagnosis in this case, the dynamics of the process. Unlike most miliary disseminations, which are characterized by a fairly stable x-ray picture, changes in miliary P., as a rule, undergo a rapid reverse development: after 2 weeks, the foci usually resolve. The reaction of the roots of the lungs and pleura with focal P. in most cases is less pronounced than with croupous pneumonia.
• Large-focus confluent pneumonias resemble metastases of malignant tumors. The difference is in the rapid reverse development.

• Confluent bronchopneumonia
• Plain radiograph: darkening is projected onto the shadow of the root and the root zone - the so-called central pneumonia of the right lung.

• In most cases, on radiographs in direct projection, such a picture is the result of a projection overlay of the infiltrate on the root and basal region. When the patient is turned to the lateral position, it turns out that in fact the infiltrate is located in the anterior or posterior part of the lung (segment III, IV or VI), often in the form of periscissuritis. This is especially evident on computed tomograms.

Interstitial pneumonia

• The so-called interstitial P. is characterized by pronounced structural changes in the interstitial tissue of the lung. True inflammation with the presence of a significant number of pathogens and a leukocyte reaction in the affected areas is rare. Much more often, they have accumulation of lymphocytes, histiocytes and plasmocytes as a manifestation of a local immune response, followed by moderate fibrosis. This is often combined with focal dystelectasis (a site of incomplete collapse of the lung tissue). Such changes are observed with a long course of a respiratory infection.

• A fragment of a chest radiograph in direct projection with interstitial pneumonia: in the lower zone of the right lung field, the lung pattern is strengthened and deformed, its radial direction is not traced.
• with interstitial pneumonia, multiple taut shadows are mainly found, located both radially and in the form of thin-walled rings surrounding the lobules and acini.

• Pneumonia, in which the interstitial tissue of the lung is predominantly affected, is manifested by an increase and deformation of the lung pattern, mainly in the lower and middle zones of the lung fields. The pattern loses its radial orientation and acquires a cellular character due to infiltration of the interstitial tissue located around the lung acini and lobules. With P.'s further development, focal changes often join the interstitial changes and the process acquires a mixed interstitial-parenchymal character.

• X-ray of the chest in direct projection with interstitial focal pneumonia: against the background of an enhanced and deformed lung pattern in both lung fields, mainly in the right, focal shadows of different sizes are visible.

• At the suggestion of O.V. Korovina (1978), acute P., which developed against the background of chronic respiratory diseases or as a complication of infectious diseases, diseases of the cardiovascular system, chronic diseases of other organs and systems, operations and injuries of the chest, consider secondary Unlike primary acute P., arising in the absence of pathology of the respiratory system and other diseases that contribute to the development of pneumonia.

• Congestive P. are more often localized in the lower lobes of the lungs, mainly in the right lung, often develop against the background of hydrothorax. Their course is sluggish, protracted, without pronounced signs of intoxication and high fever. Physical signs against the background of congestive changes in the lungs are difficult to identify, and the decisive diagnostic method is radiological.

Aspiration pneumonia

• Aspiration pneumonitis, which occurs in connection with inhalation or inhalation of foreign bodies or substances, usually develops in seriously ill patients who are unconscious, after anesthesia, and also when intoxicated. Accession of infection naturally complicates it, and in the later stages we can talk about aspiration pneumonia. The clinic and the course of aspiration pneumonitis and pneumonia largely depend on the aspirated substance. The most characteristic symptoms are chest pain, shortness of breath, cough, purulent and bloody sputum. Sometimes there are attacks of suffocation and coughing, resembling attacks of bronchial asthma, with simultaneous separation of mucopurulent sputum. Body temperature rises to 39-40°C. An objective examination of the lungs determines the dullness of percussion sound and often bronchial breathing, sonorous diverse moist rales in one or both lungs. The focus of inflammation, like the foreign body itself, is often localized in the lower parts of the right lung.

• X-ray picture of AP of the lower lobe of the right lung in an 18-year-old man, which arose after aspiration during alcohol intoxication

min h, less often this period is extended to 2 days. P. begins, as a rule, with a sharp pain in the chest (often on the right), coughing and movement. Signs of intoxication increase (headache, dizziness, weakness), chills, fever (up to 38-39 °) may appear. Breathing becomes superficial, frequent (up to 40 or more in 1 min

• Gasoline P. has a peculiar course. The first symptom of aspiration of gasoline and other hydrocarbons is a sharp painful cough to vomiting, lasting 20-30 min. The specific effect of hydrocarbons is manifested by headache, sleep disturbance, nightmares, arterial hypotension. From the moment of hydrocarbon aspiration to the development of P., 2-8 h, less often this period is extended to 2 days. P. begins, as a rule, with a sharp pain in the chest (often on the right), significantly limiting breathing, coughing and movement. Signs of intoxication increase (headache, dizziness, weakness), chills, fever (up to 38-39 °) may appear. Breathing becomes superficial, frequent (up to 40 or more in 1 min), the chest on the side of the affected lung lags behind when breathing. cyanosis occurs. On the first day of the disease, auscultatory and percussion signs of P. are absent. On the second or third day, signs of respiratory failure (cyanosis, shortness of breath) increase, physical changes appear: shortening of percussion sound, weakened or hard breathing, moist rales and pleural friction noise. Gasoline P. is characterized by rapid positive dynamics. By the end of the 3-4th day of the disease, the state of health improves, the body temperature decreases or normalizes, shortness of breath and cyanosis disappear. Clinical recovery usually occurs on the 8-12th day. Possible complications: pulmonary bleeding, lung abscess, exudative pleurisy.

• Gasoline P. can be diagnosed radiographically after 1-2 h after the onset of chest pain. Shading is localized more often on the right in the lower medial section of the lung field, intense, homogeneous, as in croupous P., but in contrast to it, there are signs of atelectasis of the affected parts of the lung (reduction in size, compaction, displacement of the mediastinal organs towards the lesion) and signs of emphysema on a healthy side. X-ray changes can persist up to 20-30 days.

• Septic metastatic P., which develops during the transfer of purulent emboli from various purulent foci (for example, furuncle, carbuncle, pleural empyema, purulent salpingiophoritis, pyelonephritis), is characterized by bilateral lesions, multiple infiltrates of the lung tissue, their tendency to disintegrate with the formation of abscesses, rapid dynamics and emergence of long-lasting thin-walled obedient cavities
• X-ray of the chest in direct projection with septic pneumonia: in both lung fields, numerous rounded enlightenments are visible - thin-walled cavities, in some cavities fluid is determined - shading with a horizontal upper border.

• Pulmonary infarction develops as a result of thromboembolism of the branches of the pulmonary artery, which often occurs in patients with thrombophlebitis of the lower extremities. With a lung infarction, shortness of breath suddenly appears, chest pain, hemoptysis are possible. There are no signs of intoxication, body temperature rises later. X-ray in the zone of lung infarction, depletion of the lung pattern, shading (in typical cases of a triangular shape with the apex facing the root of the lung) can be determined. The ECG reveals signs of overload of the right heart, these signs can be of decisive diagnostic importance for thromboembolism (thrombosis) of small branches of the pulmonary artery, when there are no symptoms such as chest pain, hemoptysis, triangular shading of the lung tissue on the x-ray.

Items quite often arise in the postoperative period (postoperative P.). More often they develop after operations on the chest, spine, abdominal cavity. The etiological factor in most cases is the endogenous microflora that enters the lungs from the upper respiratory tract or, less commonly, hematogenously. Possible exogenous infection (for example, through contact with infectious patients). Predisposing factors for the development of postoperative P. are anesthesia, pain, depression, blood loss, starvation, the formation of protein breakdown products during tissue damage. Changes in the lungs of varying severity are also of great importance, which can occur during any surgical intervention as a result of reflex reactions: a focus of hyperemia, necrosis, atelectasis, impaired mucociliary clearance due to inhibition of the secretory function of the bronchial mucosa, narrowing of their lumen due to spasm and edema, decreased cough reflex, circulatory disorders in the lungs with the development of stagnation.

• Items quite often arise in the postoperative period (postoperative P.). More often they develop after operations on the chest, spine, abdominal cavity. The etiological factor in most cases is the endogenous microflora that enters the lungs from the upper respiratory tract or, less commonly, hematogenously. Possible exogenous infection (for example, through contact with infectious patients). Predisposing factors for the development of postoperative P. are anesthesia, pain, depression, blood loss, starvation, the formation of protein breakdown products during tissue damage. Changes in the lungs of varying severity are also of great importance, which can occur during any surgical intervention as a result of reflex reactions: a focus of hyperemia, necrosis, atelectasis, impaired mucociliary clearance due to inhibition of the secretory function of the bronchial mucosa, narrowing of their lumen due to spasm and edema, decreased cough reflex, circulatory disorders in the lungs with the development of stagnation.

• In recent years, hospital-acquired, or nosocomial P., have been especially distinguished. As a rule, they are caused by opportunistic microflora resistant to many antibiotics, and develop in people with impaired immunity, have an atypical, sluggish or protracted course.