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Пульмонология, гематология (англ,рус)

 the drugs should be continued for 4—8 weeks. If the patient fails to respond significantly to the initial treatment, laboratory results may suggest other antimicrobials, eg, nafcillin for staphylococci, cefotaxime for Klebsiella, cefoxitin or metronidazole for mixed anaerobes. Postural drainage is important adjunctive treatment. Percutaneous catheter drainage has been used successfully in selected cases. Surgical therapy is indicated mainly for severe hemoptysis and for me infrequent abscesses that fail to respond to antimicrobial management. Failure of fever to subside after 2 weeks of therapy, abscess diameter of more than 6 cm, and very thick cavity waits are all factors that lessen the likelihood of success with nonsurgical treatment alone.

B. Chronic Abscess: After acute systemic man­ifestations have subsided, the abscess may persist. Although many patients with chronic lung abscess can be cured with long-term treatment with antibacterial agents, surgery may occasionally be required.

Complications

Rupture of pus into the pleural space (empyema) causes severe symptoms: increase in fever, marked pleural pain, and sweating; the patient becomes “tox­ic" in appearance. Adequate drainage of empyema is mandatory. In chronic abscess, severe and even fatal hemorrhage may occur. Metastatic brain abscess is a well-recognized complication, and the infection may seed other organ sites. Bronchiectasis may occur as a sequela to lung abscess even when the abscess itself is cured.

Prognosis   

The prognosis in acute abscess is excellent with prompt and intensive antibiotic therapy. About 80% of patients are healed within 7-8 weeks. The incidenee of chronic abscess is consequently low; In chronic cases, surgery is curative.

BRONCHIECTASIS

Essentials of Diagnosis:

• Chronic cough with expectoration of large amounts  of purulent sputum; hemoptysis.

• Rales and rhonchi over lower lobes.

• X-ray of chest reveals little; bronchograms show characteristic dilatations.

General Considerations

Bronchiectasis is a dilatation of small and medium-sized bronchi resulting from destruction of bronchial elastic and muscular elements. It may be, caused by pulmonary infections (eg, pneumonia, per­tussis, tuberculosis) or by a bronchial obstruction (eg, foreign bodies or extrinsic pressure). In many patients, a history of onset following one or more episodes of pulmonary infection, usually in early childhood, is obtained. However,since infection does not regularly produce significant bronchiectasis, unknown intrinsic host factors presumably are present. The incidence of

the disease has been reduced by treating pulmonary infections with antibiotics.

Clinical Findings

A. Symptoms and Signs: Most patients with bronchiectasis have a history of chronic cough with expectoration of large volumes of sputum, especially upon awakening. The sputum has a characteristic qual­ity of "layering out" into 3 layers upon standing, a frothy top layer, a middle clear layer, and a dense particulate bottom layer. It is usually purulent in ap­pearance and foul-smelling.

Intermittent hemoptysis, occasionally in dangerous proportions, is often combined with intercurrent respiratory infections. Symptoms occur most often in patients with idiopathic bronchiectasis (ie, childhood respiratory infections). However, patients who have bronchiectasis secondary either to tuberculosis or chronic obstruction may not exhibit characteristic symptoms. Idiopathic bronchiectasis occurs most fre­quently in the middle and lower lobes and posttuberculous bronchiectasis in the upper lobes.

Hemoptysis is thought to result from erosion of bronchiolar mucosa with resultant destruction of un­derlying blood vessels. Pulmonary insufficiency may result from progressive destruction of pulmonary tis­sue.

Physical findings consist primarily of rales and rhonchi over the affected segments. If the condition is far-advanced,emaciation, cyanosis, and digital club­bing may appear.

B. Laboratory Findings: There are no charac­teristic laboratory findings. If hypoxemia is chronic and severe, secondary polycythemia may develop. There may be either restrictive or obstructive pulmo­nary function defects associated with bronchiectasis. Hypoxemia and hypocapnia or hypercapnia may also be associated with the disease, depending on the se­verity of the underlying condition. .

C.X-Ray Findings: Plain films of the chest often show increased bronchopulmonary markings in af­fected segments; in severe cases  there may be areas of radiodensities surrounding portions of radiolucency. Early in the  course of bronchiectasis, however, the chest x-ray may be normal.

Iodized contrast media instilled into the bronchial tree (a bronchogram) demonstrates saccular, cylindric, or fusiform dilatation of small and medium bronchi with consequent loss of the normal branching pattern. Cylindric changes of bronchiectasis that may result from acute pneumonia will revert to normal after 6-8 weeks, but saccular dilatations represent long-standing damage and permanent disease.          .

Differential Diagnosis

The differential diagnosis includes other disorders that lead to chronic cough, sputum produc­tion, and hemoptysis, ie, chrome bronchitis, tuber­culosis, and bronchogenic carcinoma. The diagnosis of bronchiectasis is suggested by the patient's history and can be confirmed only by bronchographic examination or histopathologic examination of surgically removed tissue.

Complications

Recurrent infection in poorly drained pulmonary segments leads to chronic suppuration and may cause pulmonary insufficiency. Complications include hemoptysis, respiratory failure, chronic cor pulmonale, and amyloidosis. There is also an increased incidence of brain abscess, which is thought to be secondary to abnormal anastomoses between bron­chial (systemic) and pulmonary venous circulation. These anastomoses produce right-to-left shunts and allow for the dissemination of septic emboli.

Treatment

A. General Measures and Medical Treatment:

1. Environmental changes- The patient should  avoid exposure to all common pulmonary irritants such as smoke, fumes, and dust and should stop smoking cigarettes.

2. Control of bronchial secretions (improved drainage)-

a. Postural drainage often gives effective relief of symptoms and should be utilized in every case. The patient should assume the position that gives maximum drainage, usually lying on a bed in the prone, supine, or right or left lateral decubitus position with the hips elevated on several pillows and no pillow under the head. Any effective position should be main­tained for 10 minutes, 2-4 times a day. The first drainage should be done upon awakening and tee last drainage at bedtime. Family members can be trained in the art of chest percussion to facilitate drainage of secretions.

 

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