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BRONCHEECTATIC DISEASE is an acquired (in some cases congenital) disease characterized by a chronic suppurative process in irreversibly altered (dilated, deformed) and functionally defective bronchi, mainly of the lower parts of the lungs.
The main morphological substrate of the pathological process are primary bronchiectasis (bronchiectasis), which determine the occurrence of a characteristic symptom complex. So called
The primary bronchiectasias that are being identified are essentially not primary and usually develop as a result of infections of the bronchopulmonary system, mainly of viral etiology, transferred in childhood. I At the same time, with primary bronchiectasis there are signs that make it possible to distinguish an independent nosological form - bronchiectasis, since they are not significantly involved in the pathological process of lung tissue, and exacerbations of bronchiectasis occur mainly in the form of exacerbation of purulent bronchitis without infiltration lung parenchyma.
Secondary bronchiectasis is also distinguished, arising as a complication or manifestation of another disease, most often chronic pneumonia (CP); they are not classified as bronchiectasis. In secondary bronchiectasis, pronounced changes in the respiratory department are revealed, corresponding to the localization of bronchiectasis, which qualitatively distinguishes them from primary bronchiectasis [Putov N.V., 1978] and allows attributing CP to the bronchiectasis [Paleev N.R., 1985].
The independence of bronchiectasis as a separate nosological form is disputed until recent years [Uglov F.G., 1977]. This discussion has practical significance: the fact is that the diagnosis of "chronic pneumonia" in patients with bronchiectasis often calms both the doctor and the patient, as a result of which the consultation of a specialist surgeon and bronchological examination are not carried out on time and the optimal terms for the operation are missed . Since the 70s of the XX century. a decrease in the incidence of bronchiectasis is noted. This is due to a pronounced decrease in the number of childhood infections (whooping cough, measles) and childhood tuberculosis, and the success of drug therapy.
Etiology. The reasons for the development of bronchiectasis to date can not be considered sufficiently clarified. Probably a decisive role in their occurrence is played by the combination of the pathogen and the genetic inferiority of the bronchial tree.
• Microorganisms that cause acute respiratory processes (pneumonia, measles, whooping cough, etc.) in children can only be regarded as conditionally etiological factors, since in the vast majority of patients these processes are completely stopped.
• Infectious pathogens that cause suppurative process in already changed bronchi (pneumococcus, staphylococcus, hemophilic bacillus, etc.) can be considered as the cause of exacerbations, but not development
• A significant role in the formation of bronchiectasis is played by a genetically determined inferiority of the bronchial tree, which leads to a violation of the mechanical properties of the bronchial walls when they are infected, especially in early childhood.
• There is a connection between the development of bronchiectasis and diseases of the upper respiratory tract: a) it is possible that in their pathogenesis insufficiency of the same protective mechanisms of the respiratory tract is important; b) there is a constant mutual infection of the upper and lower respiratory tract.
Pathogenesis. The most important role in the pathogenesis of bronchiectasis is given to bronchiectasias and their suppuration.
Obstructive atelectasis resulting in violation of bronchial obstruction leads to the formation of bronchiectasis. The development of atelectasis can be facilitated by a decrease in surfactant activity (congenital or acquired, due to local inflammatory processes).
In children, the causes of impaired patency of large bronchi (and, thus, the formation of atelectasis) can be: a) compression of pliable, and possibly congenitally inferior bronchi with hyperplastic radical lymph nodes (their hyperplasia is observed in cases of radical pneumonia, with tuberculous bronchoadenitis); b) prolonged obstruction of the bronchi with a dense mucous plug in acute respiratory infections.
Decreased (congenital? Acquired?) Resistance of the bronchial walls to the action of the so-called bronchodilating forces (increased intra-bronchial pressure during coughing, stretching of the bronchi by accumulating secretions, increased negative intrapleural pressure due to a decrease in the volume of the atelectasized part of the lung) contributes to a persistent expansion of the lumen of the bronchi.
The expansion of the bronchi and the delay in bronchial secretion contribute to the development of inflammation. Subsequently, with the progression of the latter, irreversible changes occur in the walls of the bronchi (restructuring of the mucous membrane with complete or partial death of the ciliated epithelium and impaired cleansing function of the bronchi; degeneration of cartilaginous plates, smooth muscle tissue with the replacement of fibrous tissue and decreased resistance, the ability to perform basic functions) and develop bronchiectasis.
Bronchiectasis leads to a violation of the mechanism of coughing, stagnation and infection of the secretion in the expanded bronchi, the development of a chronically current, periodically exacerbating suppurative process, which is the second most important factor in the pathogenesis of bronchiectasis. Suppuration of the formed bronchiectasis is the essence of bronchiectasis.
The altered secret usually accumulates in the lower parts of the bronchial tree (from the upper it flows freely due to severity). This explains mainly the lower-lobe localization of the process.
Depending on the nature of the expansion of the bronchi, cylindrical, saccular, spindle-shaped and mixed bronchiectasias are distinguished.
According to the prevalence of the process, it is advisable to distinguish between single and bilateral bronchiectasis (indicating the exact localization by segments).
According to the clinical course of V.F. Zelenin and E.M. Göltein (1952) distinguishes three stages of bronchiectasis: I - bronchitis; II - stage of expressed clinical manifestations; III - stage of complications.
The clinical picture. Manifestations of bronchiectatic disease are extremely similar to those with the bronchiectatic form of CP. Only a number of features of bronchiectatic disease at each stage of the examination should be highlighted.
At the first stage of the diagnostic search, the appearance of cough with sputum in childhood after the postponed Mon, measles, whooping cough, or severe influenza and frequent repeated Mon during the subsequent period of life are noted.
At the II stage of the diagnostic search, almost always (and during the period of remission) during auscultation of the lungs, foci of persistently retaining moist, sonorous, small-bubble rales are revealed.
Often there are complications of bronchiectasis: 1) hemoptysis; 2) asthmatic component; 3) focal (perifocal) Mon; 4) lung abscess; 5) pleurisy (empyema of the pleura); 6) renal amyloidosis, less commonly
spleen and liver (given the effective treatment of the underlying disease, amyloidosis currently develops in the late stages of the disease and is extremely rare); 7) secondary chronic bronchitis. The latter is the most frequent and usually progressive complication leading to respiratory and pulmonary heart failure, which often turns out to be the direct cause of death of patients. The cause of death may be pulmonary hemorrhage or chronic renal failure as a result of secondary renal amyloidosis.
At the III stage of the diagnostic search, when analyzing the X-ray data, it must be taken into account that, in contrast to the bronchiectatic disease, a certain process localization is characteristic; most often the basal segments of the left lung and the middle lobe of the right lung are affected.
In addition to the previously described methods of laboratory and instrumental diagnostics (see "Chronic pneumonia"), in some cases, additional studies are required.
Bronchokinematography allows you to distinguish bronchiectasis with moving and "rigid" walls, to distinguish deforming bronchitis from bronchiectasis.
Serial angiopulmonography helps to determine the anatomical changes in the vessels of the lungs and identify hemodynamic disorders in the pulmonary circulation with various forms of bronchiectasis.
Bronchial arteriography can detect blood bypass through pathologically expanded bronchial pulmonary anastomoses.
When scanning the lungs, pronounced disturbances in capillary blood flow in bronchiectatic disease are detected.
All these examination methods are performed according to indications in the preoperative period, as they help to accurately determine the volume of the operation.
Diagnostics. The diagnosis of bronchiectasis is made in the presence of certain signs:
• clear indications of cough with sputum in childhood after acute respiratory illness;
• frequent outbreaks of pneumonia of the same localization;
• detection of persistently retained foci of wet rales during physical examination during the period of remission of the disease;
• radiological signs of severe deformation of the pulmonary pattern, usually in the region of the lower segments or the middle lobe of the right lung, tomographic and bronchographic signs of bronchiectasis.
The formulation of a detailed clinical diagnosis, in addition to indicating nosology, includes: 1) localization of the process (indicating the affected segments); 2) the stage of the process; 3) the phase of the course (exacerbation or remission); 4) complications.
Treatment. Perhaps conservative and surgical treatment.
Conservative treatment is indicated for patients with minor or clinically poorly manifested changes in the bronchi; with a common and insufficiently clearly localized process (when surgical treatment is impossible); in preparation for bronchography and radical surgery.
The main element of conservative treatment is the rehabilitation of the bronchial tree: a) exposure to pyogenic microflora (instillation of antimicrobial agents through a transnasal catheter, bronchoscope); b) removal of purulent bronchial contents and sputum (respiratory
gymnastics, chest massage, postural and bronchoscopic drainage, the use of mucolytic agents). (For more information on drug therapy, see the treatment in the Pneumonia section.) The upper respiratory tract should be sanitized, general strengthening measures should be carried out; it is necessary to provide good nutrition.
Surgical treatment is best done at a young age. Persons older than 45 years are operated less frequently, since by this period of their life they already have complications that impede surgery. Resection of the lobe of the lung or individual segments is performed with unilateral bronchiectasis. With bilateral bronchiectasis, the most affected part of the lung is removed (on the one hand).
Forecast. The outcome of the disease depends on the prevalence of the process and the presence of complications. Moderate damage under the condition of systematic treatment provides a long period of compensation and the preservation of working capacity.
Prevention The primary prevention of the disease is the correct treatment of OP, especially in childhood, often developing against infections (measles, whooping cough, flu). Secondary prevention consists in a rational lifestyle, treatment of intercurrent infections, the fight against focal infection of the upper respiratory tract
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