Transcript Bronchitis chronic

DIFFERENTIAL DIAGNOSTICS OF
DISEASES PROCEEDING WITH THE
COUGH SYNDROME WITH PHLEGM
AND BLOOD SPITTING ALLOCATION.
GP TACTICS
Lectore: N.A. Soliyeva
Cough – one of frequent complaints with which
patients address to the doctor [1]. As a reason for
the address the painful cough breaking quality of
life of patients, or emergence together with
cough of other symptoms disturbing the patient,
for example a blood spitting, as a rule, serve.
Cough – a difficult reflex with afferent ways
from cough receptors of the sensitive
terminations trigeminal, top mountains - ton
and wandering nerves to «the cough center» in a
trunk of a brain and the efferent link of a reflex
including a returnable, guttural nerve and spinal
(С1 and С4) nerves.
The reasons of cough can be:
• - Inhalation various irritating (gases, a dust, but first of all
– a tobacco smoke) substances;
• - pathology of ENT organs (the rhinitis, being
accompanied running off of a separated nose on a back
wall of a throat, – postnasal drip syndrome, sinusitis,
pharyngitis, laryngitis, a cancer of a throat) and also a
sulfuric stopper in an ear and long uvulay;
• - pathology of system of breath (sharp respiratory virus
infections – SRVI, whooping cough and par whooping
cough, defeat of bronchial tubes and a parenchyma of
lungs, including acute and chronic bronchitis, bronchial
asthma, a chronic obstructive illness of lungs, interstitsial
diseases of lungs, a cancer, tuberculosis, etc.) ;
The reasons of cough can be:
• - pathology of the cardiovascular system, being
accompanied development of the warm insufficiency,
stratifying aneurism of an aorta, TELA;
• - pathology of a gastro enteric path, mainly
gastroezofageal reflux illness (GERB); - undesirable
effects at reception of medicinal substances (inhibitor
transform the angiotensine enzyme, amiodarone,
etc.), inhalation of powder forms of medicines,
oxygen;
• - psycho emotional frustration, including psychogenic
(habitual) cough.
At the smoking person as the main reason of
cough chronic bronchitis and chronic obstructive
illnesses of lungs serve. At smokers with
unproductive cough (it is possible, with blood
streaks) it is necessary to suspect a bronkhogen
cancer. Cough in such cases can gain more
painful character. Establishment of the reason of
such cough needs carrying out a diagnostic
bronkhoskopiya, and at pave – biopsies. The most
frequent reasons of chronic cough at non-smoking
are SNZ, bronchial asthma, GERI.
Them treat:
a morning to comb in a throat when
awakening;
repetitive cough;
whistling breath at night and (or) when
awakening;
laryngospasm;
episodes apnoe;
feeling of squeezing in area of jugular
veins;
hyper ventilation manifestations.
The diseases proceeding with cough:
focal pneumonia,
 tuberculoma,
abscess of lungs,
tumor of lungs.
Pneumonia of a different etiology (bacterial, virus,
mikoplazma),
differential diagnostics at to diffuse
dissemination.
Focal pneumonia,
TBK blood-dissemination shape of lungs,
pneumoconiosis,
cancer metastasizes.
To duration of pneumonia:
 to at an easy current – 2-3 weeks;
 to at a middle heavy current – 4-5 weeks;
 to at a heavy current – 6-8 weeks;
To classification of pneumonia (1995):
On emergence conditions:
to extra sick-lists,
to hospital (48-72 hours later after
hospitalization),
 to atypical,
 to aspiration,
 to at patients with the
immunodeficiency’s.
To classification of pneumonia (1995):
On localization and to the extent: right, it
is left, bilateral, total, share, segmentary,
central («radical »).
 On degree weights: a heavy current; to a
middle heavy current; to an easy current.
On existence of complications
(pulmonary and extra pulmonary).
On a disease phase (a heat, permission,
a rekonvalestion, a long current).
Long pneumonia is an acute infectious
and inflammatory disease of lungs at
which pneumonic infiltrate is authorized
not in usual terms (till 4 weeks), and more
slowly, within 5-8 weeks, and comes to an
end, as a rule, with recovery.
Atypical pneumonia
is pneumonia which is called by the
microorganisms which have bred
intracellular: legionella, Chlamydia,
mycoplasma. Such pneumonia proceeds
without typical clinical and radiological
(infiltrative) manifestations, on pathogenic –
mainly secondary, badly gives in to
treatment by antibiotics of a penicillin and
cephalosporin row.
Atypical pneumonia
CLINIC: Characteristic syndromes:
 sharp intoxication syndrome (weakness,
decrease in appetite, headache, mialgiya, short
wind, palpitation, pallor and falling HELL,
consciousness frustration);
 inflammations of a pulmonary fabric syndrome
(local bronchitis, consolidation of a pulmonary
fabric, pleura involvement);
 syndrome of the general clinical inflammatory
manifestations (temperature increase, a fever,
the expressed night perspiration);
a changes of sharp phase indicators
(leikocytosis with neutrofil shift to the left,
SOE acceleration, level hanging α2globulin more than 10 %, emergence of
SRB).
The main radiological displays: focal
shadows, to are caused by an exudate in
alveoluses, to the small sizes (to 12-15
mm), roundish; to can merge (focal -drain
shadows);
Minor radiological manifestations
to a syndrome of pathological changes of
pulmonary drawing (consolidation of an
interstitsial fabric, its change,
strengthening, enrichment, deformation,
an illegibility);
to expansion of a root of a lung on the
defeat party (2-4 between the edge); to
increase in lymph nodes (though usually it
isn't present);
to pleura reaction (a thickening,
solderings, shvart, parapneumonic
pleurisy).
Dependence on an etiology:
 - to share and the multishare infection – is more often a
pneumococcus, is more rare legionelles, anarobe;
 - to nidal and nidal -drain – a pneumococcal,
staphylococcus;
 - to the miliarny – mushrooms, a tuberculosis
mikobakteriya;
 - to multiple per bronchitis abscesses – staphylococcus;
 - to one round abscess in the top share – Friedlander's
stick;
 - to for the purpose of etiologic search it is desirable to
make phlegm crops, and at heavy pneumonia – blood
crops on sterility.
Differential diagnostics
to acute bronchitis (or aggravation
chronic);
to exsudativ pleurisy of other etiology;
to tuberculosis of lungs;
to a cancer of a lung or more often)
metastasises in lungs;
to a lung heart attack;
to pulmonary eozinofil infiltrate;
to atelektas a lung;
to stagnant changes.
TREATMENT
It is also a basis of immunokorrigition therapy:
 Polymisinformation of 2-4 ml/kg/days,
intravenously 3-4 days in a row are carried out.
 Nativ donor plasma (in the absence of a
bronkhoobstruktsiya syndrome) 3-5 transfusions
(there antibodies),
 anti-staphylococcal plasma (200-300 ml), antistaphylococcal polyglobulin (50-70 ml
intravenously every other day).
 EMD (A gemosorbtsiya 1-2 sessions with an
interval 1-3 days) are applied also.
TREATMENT
At a long current:
to timogene 100 mkg intramuscularly daily
(about 10-14 days of an illness) 5-10
intramuscularly;
to timalini 20 mg intramuscularly;
to antioxidants: ascorbic acid in/in 50
mg/kg + routines in 2 mg/kg; tocopherol of
60 mg/kg/days.
The pneumonia caused by a hemophilic
stick
Arises at the persons having chronic diseases of
lungs more often. Inflammatory changes are
usually localized in the bottom shares of lungs: the
individual centers, quickly merging, can grasp all
share of a lung. The long current is quite often
noted. Probably it is promoted by existence at a
hemophilic stick of the general anti-genes with a
pulmonary fabric. The item is often accompanied
laryngotracheobronchitis (sharp stenos). Comes to
an end practically always favorably. The outcome
in chronic pneumonia.
The pneumonia caused by Chlamydia
Сan develop as an independent disease (primary
chlamydia the Item, caused chlamydia pneumony) or as
manifestation of zoonotic chlamydioses, for example
an ornithosis which activator is chlarnydia psittaci.
They are characterized by a various current. Expressed
symptoms of intoxication poor and changeable physical
changes and distinct radiological signs are more often
noted.
Changes of a interweft fabric in the beginning prevail,
then the parenchyma is involved in process. An
important symptom is the increase in a liver, a spleen.
Very high speed of subsidence of erythrocytes — to 60
mm in 1 hour is characteristic.
Focal pneumonia
The inflammation centers in the struck
segments are in a different stage of
development, these can explain gradual (in
some cases) illness development, its wavy
current with change of the periods of
improvement and deterioration of a condition
of the patient, inconstancy of fever,
variability of physical changes and their
mosaicity caused by existence near struck
sites of lungs of normally functioning or
emphysematous fabric.
Focal pneumonia
At an arrangement of the infectious centers on
depth more than 4 cm from a surface of a lung
and at their central arrangement can not be
defined obtusion of a perkutor sound and
strengthening of voice trembling.
The most constant symptoms of nidal pneumonia
are rigid breath, damp rattles (as a rule, little
bubbles, sonorous).
Symptoms of defeat of a bronchial tree are more
constant for nidal pneumonia: dry and damp
(average and big bubbles) rattles.
The pleura isn't always involved in process.
Bronchitis sharp
A diffusing acute inflammation of a
traсheobronсhialy tree.
Treats frequent diseases.
Etiology, patogenesis.
A disease viruses (cause flu viruses,
parainfluenzal, adenovirusis,
respiratornosintsitialny, clumsy, whooping
cough, etc.), bacteria (staphylococcus,
streptococci, pneumococci, etc.); physical
and chemical factors (dry, cold, hot air,
nitrogen oxides, sulphurous gas, etc.) .
Bronchitis sharp
Symptoms, current.
Bronchitis of an infectious etiology quite
often begins against sharp rhinitis,
laryngitis.
At the easy course of a disease arise
sadneniye behind a breast, dry, damp
cough, feeling of weakness, weakness is
more rare.
Physical signs are absent or over lungs
cruel breath, dry rattles are defined.
Body temperature subfebrily or normal.
Bronchitis sharp
 At the medium-weight current the general
malaise, weakness are considerably expressed,
are characteristic strong dry cough with difficulty
of breath and short wind, pain in the bottom
departments of a thorax and the belly wall,
connected with an overstrain of muscles at
cough.
 Cough gradually becomes damp, the phlegm
gains mucopurulent or purulent character.
 Over a surface of lungs rigid breath, dry and
damp little bubble rattles are listened.
Bronchitis sharp
 Body temperature remains within several days
subfebrilny.
 The expressed changes of composition of
peripheral blood aren't present.
 The heavy clinical course is observed, as a rule,
at primary defeat bronchioles.
 Sharp symptoms of an illness abate by 4th day
and at a favorable outcome completely
disappear by 7th day.
 The acute bronchitis with violation of bronchial
passableness tends to a long current and
transition to chronic bronchitis.
Bronchitis sharp
Treatment.
Confinement to bed in fever, plentiful warm drink
(to 2,5 l per day) with honey, raspberry, lime color;
warmed-up alkaline mineral water.
At badly transferable fever — acetilsalicylic acid
on 0,5 g each 4-6 h.
At dry hoarse cough — protivokashlevy means.
Narcotic preparations (3 times per day) use a
codeine of 0,1 g at painful cough with a breast
pain, possible side effects — breath oppression,
nausea, vomiting, a lock, accustoming and
addiction at long application.
Bronchitis sharp
Treatment.
Application of not narcotic anti-cough
preparations central (for example, tusuprex on
0,01-0,02 g 34 times per day) and peripheral (for
example, libexin on 0,1-0,2 g 3-4 times per day)
actions is safer.
To improvement of an leave of a phlegm apply
expectorant means of reflex action (infusion
termopsis 0,8 g on 200 ml on 1 tablespoon of 68
times per day, mucaltini on 2-4 tablets 3-4 times
per day, etc.)
Bronchitis sharp
Treatment.
At a viscous phlegm use mucolyticum—
bromgexin on 8 mg 3-4 times per day or
ambroxol on 30 mg 3 times per day within 7
days. 2 % of solution of a hydrocarbonate of
sodium, evkalipt, anisic oil by means of a steam
or pocket inhaler are shown to the inhalation of
expectorant means warmed-up of mineral
alkaline water. Inhalations carry out 5 mines 34
times per day within 3-5 days.
Bronchitis sharp
Treatment.
A bronchospasm stop inhalation badrenomymetics (salbutamol) or mcholinoblokator (atrovent).
At a heavy form of the bronchitis, persistent high
fever, office of a purulent phlegm, and also at
patients with an accompanying chronic
obstructive illness of lungs the antibiotikotherapy
is shown.
Bronchitis sharp
Treatment.
Usually aminopenicillini (ampicillin of 0,5 g 4
times per day, amoxacillini 3 times per day) or
macroleads (erythromycin of 0,5 g 4 times per
day, sumamed 0,5 g of 1 times per day, steer
the wheel 150 mg 2 times per day, etc.) apply
0,25-0,5 g within 7-12 days.
Bronchitis sharp
Prevention.
Elimination of a possible etiology factor of an
acute bronchitis (a dust content and a gas
contamination of working rooms,
overcooling, smoking, abuse of alcohol, a
chronic and focal infection in respiratory
ways, etc.), and also the measures
directed on increase of resilience of an
organism to an infection (a hardening,
food vitaminization).
Bronchitis chronic
The diffusion progressing inflammation of
the bronchial tubes which has not been
connected with local or generalization
defeat of lungs and being shown cough.
It is accepted to tell about chronic nature of
process, if the productive cough which has
not been connected with any by other
disease, not less than 3 months in a year
within 2 years in a row proceed.
Bronchitis chronic
Etiology, pathogenesis.
 The disease is connected with long irritation of
bronchial tubes various harmful factors
(smoking, inhalation of the air polluted by a dust,
a smoke, a carbon oxide, sulphurous anhydride,
oxides of nitrogen and other chemical
compounds)
 A relapsing respiratory infection (the leading role
belongs to respiratory viruses, Pfeyffer's stick,
pneumococci), arises at mucoviscidosis, an
alpha anti-tripsini of insufficiency less often.
Bronchitis chronic
Etiology, pathogenesis
 Contributing factors — chronic inflammatory and
pyesis process in lungs, the chronic centers of
an infection in the top respiratory ways,
decrease in reactance of an organism,
hereditary factors.
 To the main pathogenetic mechanisms the
hypertrophy and hyperfunction of bronchial
glands treat with strengthening of secretion of
slime, relative reduction of serous secretion,
change of structure of secretion — significant
increase in it sour mucopolysaccharide that
increases viscosity of a phlegm.
Bronchitis chronic
Symptoms, current.
Beginning gradual.
The first symptom is cough in the mornings with
office of a mucous phlegm.
Gradually cough starts to arise both at night and in
the afternoon, amplifying in cold weather, in the
course of time becomes constant.
The quantity of a phlegm increases, it becomes
mucilage-pyesis or purulent.
Short wind appears and progresses.
Bronchitis chronic
Allocate 4 forms of chronic bronchitis:
Simple (catarrhal) bronchitis proceeds with
allocation of a small amount of a mucous
phlegm without bronchial obstruction.
At purulent bronchitis constantly or the
purulent phlegm is periodically allocated,
but the bronchial obstruction isn't
expressed.
Bronchitis chronic
Chronic obstructive bronchitis is
characterized by permanent obstructive
violations, together with emphysema of
lungs and bronchial asthma treats chronic
obstructive diseases of lungs.
Purulent- obstructive bronchitis proceeds
with allocation of a purulent phlegm and
obstructive violations of ventilation.
Bronchitis chronic
Laboratory diagnostics.
The leucocytosis formula and speed of
subsidence of erythrocytes more often remain
normal; it is possible small leucocytosis with
palochkoyaderny shift in a leucocytosis formula.
Phlegm research: macroscopical, cytologic,
biochemical. At the expressed aggravation find
purulent character of a phlegm, mainly
neytrofilny leukocytes, increase of the contents
sour mucopolysaccharides and the DNA fibers
strengthening viscosity of a phlegm, decrease in
the contents lysozyme etc.
Bronchitis chronic
Laboratory diagnostics.
Exacerbations of chronic bronchitis are
accompanied by accruing disorders of function
of breath, and in the presence of pulmonary
hypertension — and disorders of blood
circulation.
At it is long the current chronic bronchitis on
bronchograms breaks of bronchial tubes of
average calibre and absence of filling of small
branchings (owing to obstruction) can to come to
light that creates a picture of «a dead tree».
Bronchitis chronic
Treatment
Expectorant preparations - for improvement of
an expectorantion of a phlegm, use reflex action
(infusion of thermopsis, an altey root, leaves
tussilago farfara a plantain), mucolyticums and
derivatives cysteinum.
Proteolytic enzymes (trypsin, chymotrypsin,
chymopsin) reduce viscosity of a phlegm, but
now aren't applied in connection with threat of a
blood spitting and development of allergic
reactions, a bronchospasm.
Bronchitis chronic
Treatment
 Acetilcysteinum possesses ability to break disulfidny
links of proteins of slime and causes strong and fast
dilution of a phlegm, including purulent. Apply in the form
of an aerosol (300 mg per day) and inside (on 200 mg 3
times per day).
 The bronchial drainage improves when using the
mukoregulyator influencing both a secret, and on
synthesis of glycoproteids in bronchial epiteliya
(Bromhexine, Ambroxol). Bromhexine is appointed on 8
mg by 3-4 times per day within 7 days in, on 4 mg (2 ml)
2-3 times per day hypodermically or in inhalations (2 ml
of solution of bromhexini plant 2 ml of the distilled water)
2-3 times per day.
Bronchitis chronic
Treatment
Before inhalation of expectorant means in aerosols
bronchial spasmolytics apply to the prevention of a
bronchospasm and effect strengthening from applied
means.
At a viscous phlegm and insolvency of cough after
inhalation 2 times per day carry out an item drainage
with preliminary reception of expectorant means and
400-600 ml of warm tea. Thus the patient serially adopts
provisions the bodies promoting allocation of a phlegm
by gravity (at an angle 30-45 ° to a floor), takes 4-5 times
a slow deep breath through a nose and an exhalation
through close lips, then after a slow deep breath
superficially coughs 45 times.
Bronchitis chronic
Treatment
 In the presence of symptoms of bronchial obstruction
and insufficiency of a bronchial drainage to therapy add
bronkhodilatator — cholinoblokator (atrovent in
aerosols); at its insufficient efficiency to therapy serially
add бетаадреномиметики (сальбутамол, беротек),
preparations теофиллина long action (ретафил,
теопэк, etc.) .
 Trial therapy by inhalation glucocorticoids is possible at
an inefficiency of therapy by cholinoblokators and badrenomimetics at patients with small (to 50 ml per day)
phlegm office; in the absence of effect during 12 weeks
glucocorticoids cancel. Application of system
glucocorticoids at chronic obstructive bronchitis is
inexpedient.
Bronchitis chronic
Treatment
Restoration of drainage function of bronchial
tubes is promoted by also physiotherapy
exercises, thorax massage, physiotherapy.
Restoration or improvement of bronchial
passableness — an important link in complex
therapy of chronic obstructive bronchitis both at
an aggravation, and in remission. Continuous
supporting therapy by bronkhodilatator is shown
at chronic obstructive bronchitis with the
constant cough, being accompanied short wind
at small physical activity or in rest.
Bronchitis chronic
Treatment
At emergence of a purulent phlegm, symptoms of
intoxication, leucocytosis antimicrobic therapy
(aminopenicyllini, it it is more best in a
combination to inhibitors betalactamses,
macroleads, phtorchinolones, etc.) by courses,
sufficient for suppression of activity of an infection
is shown. An antibiotic select taking into account
sensitivity of microflora of a phlegm (a bronchial
secret), appoint to a thicket inside; at a heavy
aggravation probably parenteral introduction of
preparations. Duration of antibacterial therapy is
individual (usually — 7-14 days).
Bronchitis chronic
Treatment
At stable pulmonary hypertension it is long
antagonists of ions of calcium (for example,
verapamil) apply; diuretics (furosemide, a
hydrochlorothiazide, veroshpironi) use at
stagnant warm insufficiency. The important
place in treatment of chronic bronchitis is
occupied by the measures directed on
normalization of reactance of an organism:
the direction in sanatoria, a dispensary, an
exception of professional harms, addictions
(first of all, smoking) etc.
Унг упка юкори булак зотилжами
УПКА РАКИ рен-си
THANK You FOR Attention
Be healthy, and
take care of
yourself