GERMAN PHILOSOPHY

Bronchiectasis is the irreversible morphological changes (dilatation, deformation) and functional inferiority of bronchial tree, resulting in the chronic purulent disease of lungs.

Among other diseases of lungs bronchiectatic disease makes from 10 to 30%, and at fluorography this disease detects approximately at 1-2 from 1000 inspected. More than at the half of patients it is diagnosed under age 5 years and at one third of all patients - on the first year of life. Men are ill in 1,3-1,9 times more frequent, than women. Among the adult population (from sectional information) frequency of bronchiectatic disease makes from 2 to 4%.

Two theories of development of bronchiectasis are most known. According to one of them, they are examined as disease of innate, and on other - acquired character. Most authors adhere to the theory of the acquired origin of this pathology, considering a basic etiologic factor the genetically determined inferiority of bronchial tree (immature of elements of bronchial wall - muscles structures, elastic and cartilaginous tissues, insufficiency of mechanisms of defense and etc), which in combination with disorder of bronchial passage and appearance of inflammation results deformation of bronchial tree.

A left lung is affected in 2-3 times more frequent, than right. In child’s age predominant left-side bronchiectasis. Since 20 years, frequency of affectation of right and left lung becomes equal, and after 30 years right-side processes prevail. The bilateral affectation marked identically often in all ages. Lower lobe localization of process is characteristic mainly. Lower lobes bronchiectasis often combines with the impair of middle lobe on the right and uvular segments on the left. The generalize forms of disease with the total affectation of both lungs meet approximately at 6% of patients.

1. The following classification of bronchiectatic disease is accepted in a clinic and is used:

Originally:

- primary (innate);

- secondary (acquired).

By kinds of dilatation of bronchi:

- cylindrical;

- saccular;

- cyst like form;

- mixed.

By distribution:

- limited;

- widespread;

- one-sided;

- bilateral (with pointing of exact localization according segmental structure).

By expressivity of clinical displays:

- with unexpressed symptomatic;

- mild form;

- middle expressed;

- heavy;

- heavy complicated form.

By the clinical feature:

- phase of remission;

- phase of attack.

2. Peculiarities of inspection of patient with suspicion on bronchiectatic disease.

Bronchiectatic disease is characterized by the protracted flow with periodic intensification (more common in spring and in autumn by intensifications). Most patients with the starting point of origin of disease have pneumonia or chronic bronchitis.

2.1. At questioning of patient:

1). Complaints. Usually the disease flows with alternation of intensifications and remission, therefore a clinical picture directly depends from the period of disease. The moist cough with expectoration of mucous-serous sputum, especially expressed at mornings, evening subfebrile temperature, anorexia, gradually increase pallor of skin covers, asthenia, general weakness are the permanent symptoms in period of intensification.

Discomfort or dull, increasing in the period of intensification of inflammatory process pains in a thorax is connected, mainly, with the affectation of mucous bronchial tree and reactive pleurisy. A pain syndrome is almost marked at every second patient. Dyspnoea is present at 40% of patients and grows as far as making progress of disease.

After such intensifications long time is saved cough with sputum, shortness of breath, indisposition. It is multiplied the amount of sputum gradually, the expressed intensifications in the first years of disease are not observed.

2). Complaints from the side of other organs and systems: on a general weakness, poor appetite, insomnia and other.

3). Anamnesis of disease: patients mark frequent appearance of bronchitis or pneumonia.

4). Anamnesis of life: in anamnesis there can be the frequent cold diseases which can be the cause of lowering of reactivity of organism.

2.2. Clinical physical inspection (characteristic features at this disease):

1). Common state of patient in the period of intensification more frequent of middle degree of heavity. Consciousness, as a rule, is clear. Constitutional features - asthenic is more frequent.

2). Collection of information about original appearance of patient. Skin covers are pale. During intensification is unpleasant smell from mouth, edema of face is marked.

3). Inspection of the state of the cardio-vascular system. Tachycardia is related to the increase of temperature of body. The tones of heart are muffled.

4). Inspection of the state of abdominal organs. Lowering of appetite. Some lowering of mass of body. More frequent than all characteristic changes is not marked.

6). Inspection of the state of bones-muscles systems: at the protracted presence of disease fingers as drumsticks, deformation of nail plates - «watch glasses». Chronic purulent intoxication can be result of affectation of long tubular bones with development of sclerosis of bone tissues and origin of inflammatory changes in joints.

7). «Locus morbi»:

Symptomatic detected at the physical inspection of thorax is very various and is determined by localization of affectation, phase of disease, expressivity of anatomic changes, presence or absence of concomitant changes in surrounding pulmonary tissues.

At examination the affected half of thorax delays in the act of breathing (at the massive affectation).

The percutory changes are not characteristic.

By auscultation: at centrally located or, especially, «dry» bronchiectasis the changes can be absent, but at filling by sputum of saccular bronchiectasis quite often possible listen above affectation the rales which have different calibers, at times of big sonority, sometimes with a «metallic» tint. On the whole an auscultative picture can be described as pied.

8). Leading clinical symptoms:

- obstructive

- intoxication

9). On the basis of findings of questioning and clinical physical inspection of patient it is possible to propose the following clinical diagnosis: BRONCHIECTATYC DISEASE OF (UPPER, MIDDLE, LOWER) LOBE OF RIGHT/LEFT LUNG.

2.3. According to standard charts the plan of additional inspection (laboratory and instrumental) includes:

1). Clinical blood test.

2). Clinical analysis of urine.

3). Biochemical blood test.

4). Coagulogramm.

5). Clinical analysis of sputum.

6). Immunological tests.

7). Bacteriological research of sputum, washing waters of bronchial tubes, content of cavity of abscess.

8). Roentgenologic research of organs of thorax.

9). Spyrography.

10). Fibrobronchoscopy.

11). Bronchography after sanation bronchoscopy.

1. Clinical blood test: in the phase of intensification appears anemia, high leucocytosis of peripheral blood with drumstick deviation, the ESR increase. In a period of remission these changes are expressed indistinctly.

2. Clinical analysis of urine: the changes are unspecific, meet albumin urea, cylinder urea.

3. Biochemical blood test: hypoproteinemia, dysproteinemia.

4. Coagulogramm: violations of coagulation of blood in side hypercoagulation.

5. Clinical analysis of sputum: the presence of a plenty of leucocytes, elastic fibers is marked.

6. Immunological tests: the decline of indexes of reactivity of organism is characteristic, in particular cellular immunity.

7. Bacteriological research of sputum, washing waters of bronchial tubes, content of cavity of abscess: allows detecting the microbial flora and defining the sensitiveness of the last to antibiotics preparations.

8. Roentgenologic research of organs of thorax in two projections: diminishment of volume and compression of shade of the affected regions of lung is marked, segmental and lobar atelectasis, presence of pleura adhesions, hyperplasia and compression of lymphatic nodes of root of lung, increase of airiness of his unaffected departments due to vicar emphysema, high standing and limitation of excursion of diaphragm, on the side of affectation.

By a basic roentgenologic method confirmative a presence and specifying localization of bronchiectasis are bronchography with the obligatory and complete contrasting of bronchial tree of both lights. For good filled of bronchial tubes by the roentgen contrast matter, and also for the removal of unfavorable consequences of this research conducting of preliminary careful sanation of tracheobronchial tree with the maximal release from it content. On bronchogramms in the affected section of lung register one or another type of dilatation of bronchial tubes of 4-6th orders.

9. Spyrography are the low indexes LVL, decline of compensate possibilities of lungs in combination with hyperventilation, decline of satiation of arterial blood by oxygen.

10. Fibrobronchoscopy: gives information about the degree of expressivity and localization of inflammatory process in a bronchial tree.

3. Differential diagnostics: bronchiectasis affectation is necessary to differentiate with TB, chronic pneumonia, chronic bronchitis, chronic abscesses, cancer and cysts of lungs.

4. Ground and formulation of clinical diagnosis (taking into account classification of disease, presence of complications and concomitant pathology):

1) basic - bronchiectatic disease of (upper, middle, lower) lobe of right/left lung;

2) complications of basic disease- (if they are);

3) concomitant pathology - (if it is).

5. Treatment of patient with bronchiectatic disease.

5.1. Choice of treatment tactic:

Treatment of patients with bronchiectatic disease is complex, directed on the stragl against an already present infection, on its warning, and also on maintenance of bronchial drainage and restoration of protective forces of organism; the surgical methods of treatment are used if necessary.

5.2. Pathogenetic grounded conservative therapy.

The base directions of conservative treatment are: sanation of tracheobronchial tree, antibacterial, desintoxic, desensibilization and general health improving therapy, physiotherapy, high-calorie diet.

1) The regime is general. Stimulation of motive activity of patients, respiratory gymnastics and physical culture. Treatment by position is used - postural drainage, when chouse such position of trunk which is optimum for expectoration of bronchial content.

2) Diet - with high energy content with high level of albumens and vitamins.

3) Medicaments therapy:

- antibiotics for empiric therapy (before the receipt of results of inoculation and sensitivity of bacterial flora) more frequent than all are used synthetic penicillins, macrolids (sumamed), ftorhinolons of III-IV generations, cephalosporins III-IV generations;

- unspecific anti-inflammatory drags - movalis, ketoprofen and its derivative (oruvel, ketonal);

- immunocorrector therapy (levamisol/decaris for 0,15 in days 3 days with interruptions for 14 days, during 4-6 months, polyoxyzonium, imunofan).

- preparations making better the escalator function of lungs - lasolvan, fluimuzil, ACC and other;

- desintoxic therapy — sorbilact, reosorbilact, reombirin;

- infusion therapy is the Ringer solutions, 5% of glucose, normal saline;

- inhalations - antibacterial preparations (in accordance with the sensitiveness of microflore), muco- and photolytic preparations (tripsin, ribonuclease, desoxyribonuclease, terrytilin), stimulations of cough by daily insufflations of different solutions through a catheter, entered through microtracheostomy;

- bronchoscopy sanation with performing bronchial lavage with solutions of antiseptics.

5.3. Existent types of operative interferences and indication to them:

Operative treatment needs of about 40% patients with bronchiectatic disease. It performing is most optimum in age from 7 to 14 years (at presence of innate bronchiectasis).

Resection methods are used: the volume of operative interference in such cases is the resection of the affected area of lung is lobectomy, bylobectomy.

Indications to the resection of lung are determined on the basis of estimation of spreadness and features of disease, common state of patients and their functional possibility. The basic indications for operative treatment of patients with bronchiectasis:

- one-sided affectation with abscess formation, hemoptysis or bleeding, uncomplying to conservative treatment;

- one-sided processes with the big volume of sputum and expressed intoxication;

- one-sided making progress processes with frequent attack.

Operative treatment is contra-indicated at the bilateral widespread affectation, decompensated pulmonary-cardiac or kidney-hepatic insufficiency.

At bilateral limited bronchiectasis through 6-12 months after the first operation, the resection of lung is possible on an opposite side.

5.4. Rules of conduct of postoperative period, possible postoperative complications.

In a postoperative period, as a rule, the before begun conservative therapy continues to be performed. The base tasks of treatment in a postoperative period are renewal and support of the disordered main systems of life-support - breathing and circulation of blood. After stabilization of the cardio respiratory systems basic direction of intensive therapy is prophylaxis of infectious complications. In late postoperative period in mostly cases is necessary only symptomatic therapy.

Complications after operations concerning to bronchiectatic disease meet in 15-20% of cases. The most frequent postoperative complications are:

- atelectasis;

- pneumonia;

- bronchial fistula;

- empyema of pleura;

- postoperative hemoptysis and pulmonary bleeding.

5.5. Medical diagnostic and treatment manipulations.

6. Diagnostics and treatment of possible complications of bronchiectatic disease.

Bronchiectatic disease can be complicated by the pulmonary bleeding, abscesses and gangrene of lung, by forming of extra lung abscesses and sepsis, by development on a background pneumofibrosis and emphysema of lungs of the expressed pulmonary-cardiac insufficiency and pulmonary heart, sometimes - cancer of lung and amyloidosis of internal organs. Quite often the flow of this disease is burdened by bronchial asthma and TB.

7. Detection of disability and prophylactic medical examination of patients with bronchiectatic disease.

After passing of course of treatment in hospital patients with bronchiectatic disease mast be under observation of pulmonologist in a regional policlinic. The operated patients parallel are observed at a doctor-surgeon.

VІ. Self-control of preparation of student to practical lesson.

1. Control test tasks:

1. What from microorganisms can expose in sputum of patient with the acute post-pneumonic abscess of lung?

A. Pneumococcy.

B. Staphylococci.

C. Streptococci.

D. Bacillus Frydlender.

Е. Bacillus coli.

2. A patient complaints on the acute attack of disease: hyperthermia up to 39°С, acute pains in a thorax, expectoration of putrid sputum with the admixture of blood, to 500 ml in days. During percussion above the affected area, shortening of percutory sound, increase of the vocal fremitus is determined. An anaerobic streptococcus was selected in sputum.

What disease can be suspected?

А. Abscessed pneumonia.

В. Bronchiectatic illness.

С. Abscess of the lung.

D. Tuberculosis.

Е. Gangrene of the lungs.

3. A patient 28 years has the increase of temperature of body to 38,5 C, cough with expectoration of big volume of purulent sputum, expressed general weakness, shortness of breath, pain in a thorax during breathing. By percussion- shortness of percutory sound in lower part from left side, with tympanitis in center. By auscultation – different caliber moist rales

What additional diagnostic method is most essential for establishment of diagnosis?

A. Spyrography.

B. Bronchography.

С. Roentgenologic inspection.

D. Pneumotachometry.

Е. Control of microflore of sputum.

4. At a patient pneumonia is diagnosed. In spite of the conducted treatment appears hectic temperature and than expectoration of sputum by a «full mouth».

What disease can be suspected?

А. Croupous pneumonia.

В. Bronchiectatic illness.

С. Abscess of the lung.

D. Caseous pneumonia.

Е. Gangrene of the lungs.

8. A man 52 years became ill acutely. During 2 weeks got treatment due to acute post pneumonic abscess of the lower lob of left lung. The temperature of body is increased to 38 –39оС. Suddenly appeared pain in right side of the chest, increases shortness of breathing. Objectively: the left side of chest delay in act of breathing, the vocal fremitus over the left lung not conducted. By percussion is marked dullness more intensive in lower segments from left side, deviation of right border of the hart to right, lowering of sound of breathing over the left lung. Tones of heart is muted, there is tachycardia.

What complication of abscess is most credible?

A. Pneumothorax.

B. Pyopneumothorax.

C. Pyothorax.

D. Edema of the lung.

Е. Gangrene of the lungs.

6. A patient,19 years, complaints on a cough with expectoration of purulent sputum up to 150 ml in days, hemoptysis, expiratory shortness of breathing, subfebrile temperature, general weakness, loss of weight. Repeatedly is suffered by pneumonia. Objectively: a skin is pale, cyanosis of lips, fingers as drumsticks. Tympanic tint of pulmonary sound, weakening of the vesicular breathing, multiply different caliber moist rales. In a blood: red corpuscles - 3,2x10 12/l, leucocytes – 5,4 9/l ERS – 56 mm/h. X-ray – emphysema of pulmonary fields, left root is deformed, extended.

What is the most credible diagnosis?

А. Bronchiectatic illness of left lung.

В. Chronic left-side pneumonia.

С. Chronic abscess of left lung.

D. Left-side cyst dysplasia.

Е. Left- side bronchopneumonia.

7. At a patient in a state of alcoholic intoxication had the repeated vomiting, the spontaneous breathing was violated, artificial ventilation of lights was used. In 4 days a cough appeared with the expectoration of purulent sputum to 170 ml a day, shortness of breathing. Objectively: the state is heavy, forced position on right side; a skin is pale, frequency of breathing - 26 in min. By percussion: under a right clavicula there is dulling, there weakening of the vesicular breathing, there are rales. Roentgenologic: on the right in the II and III segments inhomogeneous intensive darkening with the multiple brightening.

What most credible diagnosis?

А. Central cancer of right lung.

В. Infiltrative tuberculosis in the phase of disintegration.

С. Peripheral cancer of upper lobe of right lung.

D. Multiple aspiration abscesses.

Е. Right side upper lobar pneumonia.

8.During the epidemic of flu at a patient of 57 years after lowering of temperature appeared in a thorax, cough with expectoration mucous-purulent sputum to 100 ml per day with the admixture of blood. Objectively: rite of breathing– 34 in min. Over the lung from right side below the scapula is dullness of percutory sound with moderate tympanitis in a center, hard breathing, different caliber rales. In a blood: leucocytes – 15,6х109/l, ESR – 58 mm/h. Analysis of sputum: leucocytes -80-100 in field of vision, red corpuscles -30-40 in field of vision, elastic fibers, coccy. X-ray – roots are extended, on the right lower lobe darkened with two areas of brightening.

What is the most credible preliminary diagnosis?

А. Central cancer of right lung.

В. Infiltrative tuberculosis in the phase of disintegration.

С. Peripheral cancer of lower lobe of right lung.

D. Right-side lower lobar pneumonia with abscess.

Е. Infarction-pneumonia.

9. A patient is 52 years, suffering by chronic alcoholism, complains on strong cough with expectoration of big volume of purulent sputum. Disease became acutely from chill, high temperature (38 C -40 C), which detected during 3 weeks. Objectively: by auscultation in lower lobe of right lung there are multiple different caliber rales, near the angle of right scapula detects amphoral breathing. On X-ray film: in a 6 segment of right lung determined the big cavity 6x7 cm with the horizontal level of fluid. Bacteria of tuberculosis are not microscopically determined.

What is the most credible preliminary diagnosis?

А. Tumor of the right lung with disintegration.

В. Cavernous TB.

С. Purulent cyst of lung.

D. Bullous emphysema of lung.

Е. Acute abscess of right lung.

10. During the percussion of pulmonary fields an area with a tympanic sound is determined, by auscultation is amphoral breathing.

What disease can be suspected?

А. Gangrene of the lung.

В. Break of the abscess of lung to bronchi.

С. Dray pleurisy.

D. Bronchiectatic illness.

Е. Pneumonia.

11. After the carried cold a patient is hospitalized after 4 days with complaints on a cough with the insignificant expectoration of mucous sputum. Through 2 days suddenly discharged about 250 ml purulent sputum with streaked of blood. The condition of the patient is middle gravity. The rite of breathing is 28-З0 in 1 min., pulse – 96 heart bits in 1 min., B/P- 110/70 mm of Hg column. Breathing above the left lung is vesicular, above right is weakened, there are multiple different moist rales over the lower departments of lung and amphoryc breathing at the lower angle of clavicula.

What is the preliminary diagnosis?

A. Acute focal pneumonia.

B. Pyopneumothorax.

С. Acute abscess of the lung.

D. Empyema of pleura.

Е. Exudates pleurisy.

12. A patient 42 years treats dye to the acute abscess of middle lobe of right lung in the stage of draining. A patient suddenly had great pain in the right half of chest, shortness of breath, the common state became worse sharply. Objectively: rite of breathing - 28 in 1 min., cyanosis, participation of additional muscles in the act of breathing, asymmetry of thorax. Above a right lung is dullness of percutory sound in lower parts and tympanitis in upper parts. By auscultation: strongly weakened vesicular breathing with middle- and big bubbling rales.

What is the most credible complication arose up at a patient?

А. Right side total pyopneumothorax.

С. Right side empyema of pleura.

D. Right-side partial pyopneumothorax.

Е. Right side effusion pleurisy.

2. Standards of right answers on the control test tasks

Part ІІ. Acute and chronic empyema of pleura.

І. Actuality of theme.

The problem of diagnostics and treatment of acute and chronic empyema of pleura is actual and on a modern time, as frequency of acute empyema of pleura after radical interferences on lungs hesitates from 6,7% to 15% . And at the patients operated due to purulent diseases of lungs, disintegrating tumors this number achieves at 23-24%. In spite of successes in treatment of acute empyema of pleura from 20 to 30%, and according to information of same authors up to 50% supervisions, acute forms transform to chronic.

ІІ. Concrete aims of study of theme.

1. To know the anatomic- physiological features of lungs.

2. To interpret etiology, pathogenesis and classification of acute and chronic empyema of pleura.

3. To be able to conduct questioning and physical inspection of patients with acute and chronic empyema of pleura.

4. To be able to determine clinical symptoms and syndromes which are characteristic the typical clinical picture of acute and chronic empyema of pleura.

5. To be able to detect different clinical variants and complications at acute and chronic empyema of pleura.

6. To be able to select a leading clinical symptom or syndrome of disease and to put most credible or syndrome diagnosis of disease at a patient.

7. To be able to appoint the plan of laboratory and instrumental inspection of patients with the purulent diseases of lungs and pleura, using standard schemes, and also to conduct estimation of results of researches.

8. To be able to conduct differential diagnostics of the supposed disease and put a preliminary clinical diagnosis.

9. To be able on the basis of preliminary clinical diagnosis on existent algorithms by standard charts to define character of treatment of patient with acute and chronic empyema of pleura.

10. To know principles of the pathogenetic grounded conservative therapy and types of operative interferences at patients with acute and chronic empyema of pleura.

11. Using standard methods, to be able to execute diagnostic and medical doctor’s manipulations necessary at this disease.

12. If a patient with this disease is subject to the clinical supervision, to be able to define tactic of inspection and second prophylaxis.

13. To be able to determine a prognosis for life and examine disability at a patient at this disease.

14. To demonstrate the domain by deontology principles of medical worker and principles of medical deference to the rank, ability of conduct of medical document in a surgical clinic.

III. Educational tasks for independent preparation of student to practical lesson.

III.1. Minimal base level of knowledges and abilities, which necessary for mastering of theme.

4. Topographic – anatomical peculiarities of lungs and pulmonary vessels.

5. Pathomorphology and pathophysiology changes at acute and chronic empyema of pleura.

6. Method of questioning and physical inspection of surgical patient with the purulent diseases of lungs and pleura.

III.2. Concrete aims of self preparation of student to practical lesson.

III.2.1. Using the base level of knowledges, to learn theoretical material on the theme of lesson and know answers for control questions on a theme:

9. Classification and etyopathogenesis of acute and chronic empyema of pleura.

10. Clinical symptomatic and features of acute and chronic empyema of pleura.

11. Modern diagnostics of this pathology (laboratory, instrumental).

12. List of similar diseases with which necessary to perform diagnostic of acute and chronic empyema of pleura.

13. Existent methods of treatment of acute and chronic empyema of pleura. Choice of medical tactic.

14. Basic principles of the pathogenetic grounded conservative therapy at acute and chronic empyema of pleura.

15. Types of operative interferences and indications to their application at acute and chronic empyema of pleura.

16. Examination of disability of patients with the purulent diseases of lungs and pleura, principles of rehabilitation, indications for the clinical supervision.

III.2.2. Using theoretical knowledges on a theme, to know in theory the technique of implementation and be ready to mastering on practical lesson of practical skills (abilities) on the theme of lesson:

1. Conducting of clinical inspection of patient with acute and chronic empyema of pleura in a ward: questioning (complaints, questioning on the systems, anamnesis of disease and lives); estimation of the common state and original appearance; inspection of the state of the cardio-vascular system, respiratory and abdominal organs, bones-muscles systems.

2. Selection of leading clinical symptom or syndrome of disease and «Locus morbi», determination of specific symptoms at acute and chronic empyema of pleura.

3. To put most credible or syndromes diagnosis of disease at a patient.

4. To appoint the plan of additional inspection (laboratory and instrumental) and estimate its results.

5. To conduct differential diagnostics of diseases with the diseases, which have similar clinical manifestation.

6. To formulate the clinical diagnosis of patient taking into account classification of disease, presence of complication and concomitant pathology.

7. To be able to give first urgent medical help to the patient with acute and chronic empyema of pleura.

8. To define individual medical tactic for a patient.

9. To appoint the pathogenetic grounded conservative therapy at acute and chronic empyema of pleura.

To choose the method of operation if there is indication to it.

IV. Educational information generators.

1. Base literature:

1) Alfagene I, Munoz F. Pena N. at al. Empyema of the thorax in adults. Etiology< microbiologic findings and management.- Chest.-1993, 3, p. 839-843.

2) Aquilar M.M., Datlistelle F.D. at al. Posttraumatic empyema. Risk factors, analysis.- Arch. Surg.,- 1997, 6, p.647-650.

3) Balk R., Bone R. Classification of acute respiratory failure.- Med. Clin. N. Ann.-1983, Vol. 67, 3, p. 647-650.

4) Barilett J. Anaerobic bacterial infections of the lung and pleural space.- Clin. Infect. Dis., 2001, 6, suppl 4, p. 248-255.

5) Lung abscesses.- Medical Staff Conference. University of California, San Francisco.- West J. Med., 1986, Vol. 124, 6 p. 476-482.

6) RafaelyY, Weissber D. Gangrene of the lungs: treatment in two stages.- Annals of thoracal surgery.- 1998, Vol. 64, 4, p. 970 -973.

V. Informative block for independent preparation of students to practical lesson/

Acute empyema of pleura.

Acute empyema of pleura is the limited or diffuse inflammation of visceral and parietal pleura, characteristic by accumulation of pus in a pleura cavity and accompanying by the signs of purulent intoxication and quite often respiratory insufficiency.

Unspecific empyema of pleura is caused different purulent or putrid microorganisms. From a pleura cavity more frequent than all staphylococci is revealed - to 77%. It is explained the expressed their virulence and stability to most antibacterial medicines. In 30-45% of cases at inoculation of pus from pleura cavity gram-negative microorganisms get growth, which are different cultures of intestinal, blue pus bacillus, Bacillus proteus. Up to 80% of cases an anaerobic nonclostridial flora is detected (bacteroids, fuzobacterias, peptococcy, peptostreptococcy and others).

According to pathogenesis distinguished primary and secondary empyema of pleura. At primary empyema of pleura from the beginning of the disease the inflammatory focus is localized in a pleura cavity, at the secondary - it is complication of some other purulent-inflammatory disease.

Primary empyema of pleura arises up on a background unchanged, healthy pleura due to disorder of their barrier function with bringing of microbial flora. It is at the trauma of the chest, after manipulations in a pleura cavity and operations on a lung.

According to information of many authors in 85-90% of cases secondary empyema of pleura was complication of pneumonia, acute and chronic purulent diseases of lungs. Pneumonia can from the beginning flow with development of festering pleurisy (Para pneumonic empyema of pleura or empyema of pleura develops in period of ending of pneumonia and evolution to independent disease (meta pneumonic empyema).

At the abscesses of lungs empyema of pleura develops at 8-11% of patients, and at the gangrene of lung - at 55-90%.

In single case empyema can develop, as complication of purulent or parasite cyst, disintegrating cancer, spontaneous pneumothorax.

Secondary empyema of pleura can develops by a contact way, at suppuration of wounds of chest, osteomyelitis of ribs, spine, breastbones, chondritis, lymphadenitis, mediastinitis, pericarditis.

The acute inflammatory diseases of abdominal region can be the source of infection of pleura in rare case (subdiaphragmal abscess, purulent cholecystitis, pancreatitis and others). Penetration of microbes from an abdominal region to pleura takes place through lymphatic vessels and fissures in a diaphragm, or through hematogenic way.

1. The following classification of empyema of pleura is accepted in a clinic and is used:

I. By etiology:

II. By pathogenesis:

III. By the clinical feature:

IV. By the presence of destruction of lung:

1. Empyema of pleura without destruction of lung (simple)

2. Empyema of pleura with destruction of lung.

3. Pyopneumothorax.

V. According to connection with an external medium:

1. Closed.

2. Opened:

- with bronchopleural fistula;

- with pleurodermal fistula;

- with bronchopleurodermal fistula;

- by the latticed lung;

- with other hollow organs.

VI. By spreads

2. Features of inspection of patient with suspicion on acute empyema of pleura.

2.1. At questioning of patient:

1). Complaints on the basic disease. Usually the disease begins acutely. The permanent symptoms are: increase of temperature up to 38-39о C, pain in the chest and shortness of breathing. The pain syndrome – arises up, as a rule on the side of affectation and has permanent character, increasing at the deep breathing, cough, at change position of body. Sometimes may be present pain in upper part of abdomen due to irritation of diaphragm. Cough – quite often with expectoration plenty of sputum, the volume depends from intensivety affectation of lung’s parenchyma, presence of bronchopleural fistula.

2). Complaints from the side of other organs and systems: on a general weakness, bad appetite, insomnia and other, evidences of intoxication.

3). Anamnesis of disease: the disease begins suddenly: on a background a trauma or preceding acute inflammation of pulmonary tissues.

4). Anamnesis of life: in anamnesis there can be the frequent cold diseases which can be result of lowering the reactivity of organism. It is necessary to pay the special attention to social status of patient.

2.2. Clinical physical inspection (characteristic peculiarities at this disease):

1). The common state of patient more frequent middle or heavy gravity. Consciousness as a rule is clear. Constitutional features – asthenic is more frequent.

2). Collection of information about original appearance of patient. Skin covers are pale. A bad breath from mouth is marked. A patient prefers to be in the forced position - sitting or lying on healthy side.

3). Inspection of the state of the cardio-vascular system. Tachycardia is characteristic and in mostly cases is related to the increase of temperature of body. The tones of heart are weak. There is tendention to hypotony. Development of pulmonary-cardiac insufficiency with increasing decompesation of circulation of blood and hypertension in a small circle is possible, to what indicated in an accent of the 2 tones on a pulmonary artery.

4). Inspection of the state of organs of abdomen. Decline of appetite. Some lowering of mass of body. More frequent than all characteristic changes is not marked.

6). Inspection of the state of bones – muscles system - the characteristic changes are not present.

7). «Locus morbi»:

Limitation of respiratory excursion of the affected half of thorax, smoothed out of intercostal intervals, local edema of skin and hypodermic cellulose above the region of accumulation of pus in a pleura cavity is marked. In future tissues of pectoral wall in this area become dense, painfulness increases, hyperemia of skin appears.

At percussion dullness above the area of accumulation of liquid is determined. In absence of air and adhesions in a pleura cavity the upper border corresponds to the Ellys- Damuazo line.

At auscultation weakening of the vesicular breathing up to complete it absence over big accumulation of liquid is marked. Above the area of the compressed lung is bronchial breathing, is sometimes there are moist rales of different calibers, sometimes sound of friction of pleura due to a fibrin’s pleurisy around the cavity of empyema. If there is bronchopleural fistula and cavity it is good draining through bronchi, can be listens the amphoryc breathing. Increase of bronchophony sound above the region of accumulation of liquid is very characteristic.

8). Leading clinical symptoms:

- intoxication

- respiratory insufficiency

9). On the basis of findings of questioning and clinical physical inspection of patient it is possible to propose the following clinical diagnosis: ACUTE RIGHT-SIDE/LEFT-SIDE EMPYEMA OF PLEURA.

2.3. In accordance to standard charts there is the plan of additional inspection (laboratory and instrumental) of patient with acute empyema pleura:

1). Clinical blood test.

2). Clinical analysis of urine.

3). Biochemical blood test.

4). Coagulogramm.

5). Research of electrolytes of blood.

6). Immunological tests.

7). Bacteriological research of sputum, washing waters of bronchial tree, content of cavity of abscess.

8). Roentgenologic research of organs of thorax.

9). Spyrography.

10). Fibrobronchoscopy.

1). Clinical blood test: moderate anemia, leucocytosis with neutrophilia, by the change of leukocyte formula to the left, the ESR increase.

2). Clinical analysis of urine: the changes are unspecific is presence of signs of toxic nephropathy: albuminuria, cylindruria.

3). Biochemical blood test: it is sharply expressed hypoproteinemia, dysproteinemia.

4).Coagulogramm: disorder of coagulative function of blood to side hypercoagulation with diminishment of time of coagulation of blood, considerable increase of level of fibrinogen.

5). Research of electrolytes of blood: hyperpatassemia explainable by disintegration of tissues and elements of blood is marked.

6). Immunological tests: the decline of indexes of reactivity of organism is characteristic.

7). Bacteriological research of sputum, washing waters of bronchial tree, content of pleura cavity: allows to detect the microbial flora, which are the cause of inflammatory process and define the sensitiveness of the last to antibacterial preparations.

8). Roentgenologic research of organs of thorax: roentgenologic research at acute empyema of pleura and pyopneumothorax has most value, allows performs exact verification of diagnosis and detect the nearest tactic of treatment of patient. Polypositional roentgenoscopy is more informing allowing to localize the region of affectation, exactly to define the degree of collapse of lung and displacement of mediastinum, amount of liquid, to expose the pathological changes in pulmonary parenchyma, to choose a point for adequate draining of pleura cavity, especially at limited empyema.

At rarely meeting interlobar empyema is possible punction of affect under the control roentgenoscopy. It should be noted that roentgenoscopy quite often is diagnostically sufficient research for the decision about implementations of urgent medical measures - punction or draining of pleura cavity for its decompression at tense pyopneumothorax. In the case of its absence, if allows the state of patient, implementation of lateroscopy allowing exactly to define the vertical sizes of cavity is possible, to estimate the state of the basal sections of lung, «covered» by the level of liquid. If implementation of lateroscopy on the healthy side is risky due to the danger of aspiration of content of abscess (at the loosened patients), for determination of lower point of cavity there is enough roentgenoscopy in a lateral projection at inclination of trunk ahead or in a direct projection with inclination of trunk in a healthy side.

Tomography allows to answer on foregoing questions; however, this research is not so informative if there is collapse of lung or presence considerable quantity of liquid in a pleura cavity. It is therefore expedient to execute it after draining of pleura cavity and liberation of it from pus. If the lung of collapsed more than on a 1/4 volume, interpretation of tomography information is difficult.

Pleurography in 3 projections is the very informing method of research. It allows to estimate the sizes of cavity, character of its walls, presence of sequesters and fibrins stratifications.

9). Spyrography are the low indexes VVL, decline of compensate possibilities of lungs in combination with hyperventilation, decline of satiation of arterial blood by oxygen.

10). Fibrobronchoscopy: gives information about the degree of expressed of inflammatory process in a tracheobronchial tree, allows defining the mouth of draining bronchi (at presence of destruction in pulmonary tissues). Ability of bronchoscopy rises at introduction of painting substance (water solution of methylen dark blue) to the pleura cavity in position on healthy side. It allows to define, what bronchial tubes participate in draining of area of destruction of pulmonary tissues, that is very important for planning of level of temporal endobronchial occlusion.

3. Differential diagnostics: it is conducted with pneumonia, obturated atelectasis of lung, hydrothorax, by the abscesses of lung, subdiaphragmal abscess, with the cancer of lung in the stage of disintegration and presence of cancer pleurisy, tumors of pleura, purulent cysts, echinococcus, diaphragmal hernia.

4. Ground and formulation of clinical diagnosis (taking into account classification of disease, presences complication and concomitant pathology):

1) basic - pneumonia /abscess/ of (upper, middle, lower) lobe of right/left lung;

2) complications - acute empyema of pleura;

3) concomitant pathology - (if it is).

5. Treatment of patient with acute empyema of pleura

5.1. Choice of medical tactic: presently in treatment of acute empyema of pleura is used combination of the surgical methods of treatment, directed on evacuation of purulent content of pleura cavity, and conservative therapy which is observed as basic part of preoperative preparation and postoperative conduct of patients.

5.2. The pathogenetic grounded conservative therapy is directed on the straggle against three basic pathological factors — suppurations, losses and resorption. Only by local treatment (surgical methods of sanation) - without influence on all organism, without normalization of the disordered functions of organs and liquidation of remaining complications, without therapy of primary and concomitant diseases - it is impossible to treat patients with empyema of pleura.

Such patients indicated complex therapy including etiologic, pathogenetic, symptomatic and local treatment. Intensity of treatment is depending on the common state of patient, presence of concomitant diseases and complications, from the stage of purulent process and character of empyema.

Application of antibiotics, sulfanilamides and antiseptic facilities is the basic method of therapy. Antibiotic therapy must include 2-3 preparations, which operate on pathogenic aerobic and anaerobic microorganisms.

Pathogenetic therapy consists in application of anti-inflammatory facilities, broncholitics (lasolvan, bronchobru, fluimuzil), in conducting of the measures directed on correction of violations of proteins (transfusions of fresh-frozen plasma, solutions of aminoacids), mineral (infusion of crystalloid solutions), carbohydrate exchanges (infusion of solution of the glucose 5%); oxygen therapy (5-7 litres per minute), desintoxic treatment (sorbilact, reosorbilact, reombirin).

In complex treatment of patients with empyema of pleura mast be included diet with rich content of proteins and vitamins. For the improvement of appetite at the exhausted patients anabolic hormones are used (retabolil for 50 mgs, superanabolon for 1-2 ml 1 times per a week, nerobol for 0,002 three times per a day and other).

5.3. Existent methods of operative treatment and indications to them.

Basic local treatments are surgical manipulations (punction of pleura cavity) and different methods of draining of empyema cavity.

Pleural punction, as independent method of treatment, has enough limited positions and can be used only in case without the presence of bronchopleural fistula (at primary empyema of pleura). During conducting of punction evacuation of purulent content is performs, lavage and sanation of cavity of empyemy by solutions of antiseptics and antibiotics, abandonment of the last in the cavity of empyema, In absence of effect after the punction treatment during 5-7 days need to change the treatment on the drainage methods.

Drainage of pleural cavity with the permanent sucking of exudate and air (at presence of bronchopleural fistula) consider as more effective method of treatment. Methodic of draining: after conducting of roentgenologic research a point for introduction of drainage is detected, on possibility at the bottom of empyema cavity. If there is a necessity in the second tube, it is entered under the apical region of cavity. Under local anesthesia conduct thoracocentesis of cavity and enter a drain tube. The internal channel of drainage must not be less than 0,6-0,8 cm. For the improvement of quality of procedure recommend to apply roentgencontrast drainages and draining under the ULTRASONIC control.

If the defect of bronchi (at presence of bronchopleural fistula) is considerable and a plenty of air passed through it, active aspiration from a pleura cavity does not make sense, because formation of vacuum is impossible, and the intensive sucking of air conduces only to strengthening of disorders of the external breathing. In similar cases uses valvular siphon drainage but Bulau.

After implementation of draining daily 3-4 times per days the fraction lavage of empyemy cavity executes.

Considerably improve the results of aspirating methods of treatment at the use of methods of temporal occlusion of bronchial fistula by porolon (foam robber) or collagen obturators. Selective hermetization of the bronchial system by temporal occlusion of bronchial tubes allows differentiating a purulent process in a lung and pleura. Indications for application of this method are acute empyema of pleura with destruction of pulmonary tissues and big outflow of air through drainages, acute incompetence of bronchial stump or pulmonary tissues in the conditions of acute empyema after operation on lungs.

Lately wide application got thoracoscopy methods, which allow execute aspiration of pus, washing of empyema cavity, destruction of intrapleural encapsulations, deleting of fibrinous membranes from a visceral pleura, destruction of adhesions between pleura membranes, directed draining of empyema cavity. To the patients with bronchopleural fistulas electro-coagulation of fistula or (at a big their diameter) temporal occlusion of bronchial tubes is executed.

At ineffectivety of micro invasive methods of treatment thoracotomy with plevrectomy is executed and possible resection of area of lung affected by fistula.

5.4. Rules of conduct of postoperative period, possible postoperative complications.

In a postoperative period, as a rule, continues the previous conservative treatment. The basic tasks of treatment in a postoperative period are: providing of valuable ventilation of lungs and prophylaxis of hypoxia; correction of water-electrolyte disorders and restoration of adequate hemodynamic; prophylaxis of hypercoagulation and infectious complications.

Possible postoperative complications:

- postoperative bleeding;

- development of remaining cavity;

- suppuration of postoperative wound;

- insufficiency of bronchial stump after resection methods;

- development of stump region abscess.

5.5. Medical diagnostic and medical manipulations.

Puncture of pleura cavity

7. Principles detection of disability and prophylactic medical examination of patient’s with acute empyema of pleura.

After passing of course of treatment in hospital the patients with acute empyema of pleura mast be under observation of pulmonologist in a regional policlinic. The operated patients parallel are observed at a doctor-surgeon.

Chronic empyema of pleura

The generally accepted presently clinical term "chronic empyema of pleura" designates the purulent-destructive process in a remaining pleura cavity with the rough and stable morphological changes, characterized by the protracted flow with periodic intensifications.

Frequency appearance of chronic empyema is marked at 4-20% of patients with acute empyema of pleura. Big distinctions in frequency of chronic empyema of pleura of such origin are conditioned, foremost, by absence of single picture of criteria of transition of acute form of this disease in chronic. By histological researches of the material, got during pleurectomy, decortications and resections of lung, it is proved, that the stable and irreversible morphological changes of pleura and underlying tissues develop only to the end 2-3 months from the beginning of disease. The signs of disorder of regenerative mechanisms and intensification of purulent process appear in the same terms.

Unlike from acute empyemy of pleura considerably more frequent detects the mixed flora with predominance of Gram-negative bacterias (intestinal, blue pus bacillus).

Forming of remaining cavity can be conditioned by a few reasons:

1. Not spreading fully lung due to a presence in the pleural cavity of exudate.

2. Presence of adhesions, which prevent spreadness of lung.

3. Considerable compression and sclerosis of pulmonary tissues.

4. Disparity of volumes of resected lung and pleura cavity.

5. Atelectasis of part of lung due to the obstruction of bronchial tree.

If at sharp empyema a lung did not fall out fully, between pleura covers there is a cavity the walls of which are covered by granulation tissues. In course of time this tissues transform to fibred connective tissues, which is denser. A lung in the initial stage of disease is mobile and at the release of cavity of pleura from exudate spreading, and at accumulation of exudate again collapsed. At the protracted flow of exudate inflammation a lung is covered by connective tissues, as by an armour, and loss possibility to fall out. These fibrose impositions on pleura carry the name of shvart. At the protracted flow of illness they achieve a considerable thickness (2-3 cm and more) and density. Consequently, the protracted inflammation is one of reasons of chronic empyemy of pleura.

1. In the clinic accepted and is used a next classification of empyema of pleura (see the page 5).

2. Features of inspection of patient with suspicion on chronic empyema of pleura.

The clinical picture of chronic empyema of pleura develops gradually. There is no clear border between the clinical demonstration of acute and chronic empyema of pleura, as acute inflammation transforms to chronic. The expressed different of clinical features is characteristic only for the extreme forms of acute and chronic empyema of pleura.

2.1. At questioning of patient:

1). Complaints on the basic disease. Usually the disease begins gradually. The permanent symptoms are: increase of temperature of body to 37-38°С, moderate pains in a chest, shortness of breath, cough, presence of discharge from pleura fistula. Pain syndrome - arises up on the side of affectation, aching character, increasing at the deep breathing, cough, at the change of position of body. Cough - quite often with the expectoration of a plenty of sputum, that depends on the degree of affectation of lung, presence of bronchopleural fistula.

2). Complaints from the side of other organs and systems: on a general weakness, poor appetite, insomnia, display of intoxication and other.

3). Anamnesis of disease: the disease begins gradually, in anamnesis there is information about acute empyema of pleura.

4). Anamnesis of life: in anamnesis there can be the frequent cold diseases which can lower the reactivity of organism. It is necessary to pay the special attention on social status of patient.

2.2. Clinical physical inspection (characteristic features at this disease):

1). Common state of patient more frequent of middle gravity. Gravity of the state is related to the size of remaining cavity, in which pus detained, and is determined, by the degree of intoxication. Consciousness is clear. Constitutional features are asthenic, possibly expressed exhaustion.

2). Collection of information about original appearance of patient. Skin covers is pale, puffiness, cyanotic'.

3). Inspection of the state of the cardio-vascular system. Palpitation is characteristic. Tachycardia is related to the increase of temperature of body. The tones of hearts are weakened. There is tendention to hypotony. Displacement of heart is possible.

4). Inspection of the state of organs of abdominal cavity. Lowering of appetite. Lowering of mass of the body.

6). Inspection of the state of bones–muscles system - fingers as drumsticks, deformation of nail plates is «watch glasses». Purulent intoxication quite often results of affectation of long tubular bones with development of sclerosis of bone tissues and origin of inflammatory changes in joints.

7). «Locus morbi» - inspection of organs of the respiratory system

Limitation of respiratory motions of the affected half of thorax is marked, diminishment of the affected half in a volume, intercostal intervals are narrowed. There is pleural fistula with a purulent discharge.

At percussion above the area of accumulation of liquid dullness is determined, above the area of accumulation of air - tympanitis.

At auscultation weakening of the vesicular breathing up to complete it absence above the big accumulation of liquid is marked. Above the area of the suppressed lung is bronchial breathing, sometimes possible detecting moist rales of different caliber. Over region of the accumulated fluid possible listened bronchophony.

8). Leading clinical symptoms:

- intoxication;

- respiratory insufficiency

9). On the basis of findings of questioning and clinical physical inspection of patient it is possible to propose the following clinical diagnosis:CHRONIC RIGHT-SIDE /LEFT SIDE/ EMPYEMA OF PLEURA

2.3. According to standard charts the plan of additional inspection (laboratory and instrumental) of patient with chronic empyema of pleura:

1). Clinical blood test.

2). Clinical analysis of urine.

3). Biochemical blood test.

4). Coagulogramm.

5). Research of electrolytes of blood.

6). Immunological tests.

7). Bacteriological research of sputum, washing waters of bronchial tree, content of cavity of abscess.

8). Roentgenologic research of organs of thorax.

9). Spyrography.

10). Fibrobronchoscopy.

1). Clinical blood test: moderate anemia, leucocytosis with neutrophilia, by the change of leucocytes formula to the left, the ESR increase.

2). Clinical analysis of urine: the changes are unspecific is presence of signs of toxic nephropathy: albumynuria, cylyndruria.

3). Biochemical blood test: it is sharply expressed hypoproteinemia, dysproteinemia.

4).Coagulogramm: violations of coagulation to side of hypercoagulation with diminishment of time of clot formation increase of level of fibrinogen.

5). Research of electrolytes of blood: hyperpatassemia explainable by disintegration of tissues and elements of blood is marked.

6). Immunological tests: the decline of indexes of reactivity of organism is characteristic.

7). Bacteriological research of sputum and content of remaining cavity allows detecting the exciters of inflammatory process and defining the sensitiveness of the last to antibacterial preparations.

8). Roentgenologic research of organs of thorax: roentgenologic research at chronic empyema of pleura has big value, allows exactly make of diagnosis and define the nearest tactic of treatment of patient. Polyposition roentgenoscopy allowing localizing of the affectation is most informing, exactly to define the degree of collapse of lung and displacement of mediastinum, amount of liquid, to expose the pathological changes in pulmonary parenchyma, to detect a point for adequate draining of remaining cavity.

Tomography allows to answer on foregoing questions. Pleurography in 3 projections is the very informing method of research. It allows to estimate the sizes of remaining cavity, character of its walls, presence of sequesters and fibrinous stratifications. At pleurography in position on healthy side the areas of bronchial tree are contrasted quite often, that matters very much for further medical measures (implementation of temporal endobronchial occlusion, optimization of the regime of washing of pleural cavity).

Bronchography allows to estimate the state of bronchial tree, to detect localization and character of bronchopleural fistula, to found the reason of chronic flow of process (bronchiectasis, chronic abscess, etc.). The bronchography signs of heavy changes in lungs are: 1) presence of «empty area» from the uncontrasted bronchial tree in the collapsed segments of lung; 2) convergence of bronchial tubes with diminishment of angles of their branching; 3) different types of deformations, bends of bronchial tree, quite often with formation of bronchiectasis.

9). Spyrography are the low indexes VVL, decline of compensate possibilities of lungs, decline of satiation of arterial blood by oxygen.

10). Fibrobronchoscopy gives information about the degree of expressed of inflammatory process in a tracheobronchial tree, allows to define the mouth of draining bronchi (at presence of destruction in pulmonary tissues). Ability of bronchoscopy rises at introduction of dye-stuff material (water solution of methylen dark blue) to the pleura cavity in position on healthy side. It allows to define, what bronchial tubes participate in draining of area of destruction of pulmonary tissues, that is very important for planning of level of temporal endobronchial occlusion.

3. Differential diagnostics: it is conducted with osteomyelitis of ribs, breastbone and spine.

4. Ground and formulation of clinical diagnosis (taking into account classification of disease, presence of complications and concomitant pathology):

1) basic - Chronic empyema of pleura;

2) complications - (if it is);

3) concomitant: pathology- (if it is).

5. Treatment of patient with chronic empyema of pleura

5.1. Choice of medical tactic: presently combination of the surgical methods of treatment, directed on evacuation of purulent content of pleura cavity, and conservative therapy which is examined as basic part of preoperative preparation and postoperative conduct of patients, is used in treatment of chronic empyema of pleura. At the choice of methods of treatment at chronic empyema of pleura it should be remembered that conservative treatment rarely conduces to convalescence. The special difficulties arise up in that case, when bronchial fistula is opened in a remaining cavity. Only operation in such cases can gives success of treatment.

5.2. The pathogenetic grounded conservative therapy is directed on the straggle against three basic pathological factors - suppurations, losses and resorption. Only by local treatment (surgical methods of sanation) - without influence on all organism, without normalization of the disordered functions of organs and liquidation of remaining complications, without therapy of primary and concomitant diseases - it is impossible to treat patients with chronic empyema of pleura.

To such patients indicated complex therapy including etiologic, pathogenetic, symptomatic and local treatment. Intensity of treatment changes depending on the common state of patient, presence of concomitant diseases and complications, from the stage of purulent process and character of empyema.

Application of antibiotics is the basic method of therapy, sulfanilamide and antiseptic facilities. Antibiotic therapy must include 2-3 preparations, which operate on pathogenic aerobic and anaerobic microorganisms.

Pathogenetic therapy consists in application of anti-inflammatory facilities broncholitics (lasolvan, bronchobru, flumuzil), in conducting of the measures directed on correction of violations of proteins (transfusions of fresh-frozen plasma, solutions of amino acids), mineral (infusion of crystalloid solutions), carbohydrate exchanges (infusion of solution of the glucose 5%); oxygen therapy (5-7litres in a minute), desintoxic treatment (sorbilact, reosorbylact, reombirin).

In complex treatment of patients with empyema of pleura the big value has the valuable feed with the rich content proteins and vitamins. At the exhausted patients anabolic hormones are used (retabolil for 50 mgs, superanabolon for 1-2 ml in 1 times per a week, nerobol for 0,002 three times per a day and others).

5.3. Existent methods of operative treatment and indications to them:

To operative treatment usually used, when the conservative treatment does not give success due to rigidity pectoral wall, in case fixation of collapsed lung by adhesions, at presence of big bronchial fistula opened in a pleura cavit

Date: 2014-12-21; view: 1296