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Bronchiectasis

BRONCHOECTATIC DISEASE - an acquired (in some cases congenital) disease characterized by a chronic suppurative process in the irreversibly changed (expanded, deformed) and functionally defective bronchi, mainly the lower lung.

The main morphological substrate of the pathological process is the primary bronchiectasis (bronchiectasis), which cause the occurrence of a characteristic symptom complex. So called

Essential primary bronchiectasis is essentially not primary and usually develops as a result of bronchopulmonary system infections that were transferred in childhood, mainly of viral etiology. I However, in primary bronchiectasia there are signs that allow to distinguish an independent nosological form - bronchiectasis, since they do not notice significant involvement in the pathological process of lung tissue, and exacerbations of bronchiectasis occur mainly according to the type of exacerbation of purulent bronchitis without infiltration lung parenchyma.

There are also secondary bronchiectasis, arising as a complication or manifestation of another disease, most often chronic pneumonia (CP); they are not classified as bronchiectasis. In secondary bronchiectasia, pronounced changes in the respiratory compartment are revealed, corresponding to the localization of bronchiectasis, which qualitatively distinguishes them from primary bronchiectasis [Putov N.V., 1978] and can be attributed to CP bronchiectasis [Paleev NR, 1985].

Independence of bronchiectasis as a separate nosological form until recent years has been disputed [Angles F., 1977]. This discussion is of practical importance: 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 a bronchological study are not carried out in time and the optimal terms for the operation are lost. . Since the 70s of XX century. there is a decrease in the frequency of bronchiectasis. 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 so far can not be considered sufficiently clarified. Perhaps the decisive role in their occurrence is played by a combination of the effect 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 inhibited.

• Infectious pathogens causing the suppurative process in the already altered bronchi (pneumococcus, staphylococcus, haemophilus bacillus, etc.) can be considered as the cause of exacerbations, but not the development

bronchiectasis.

• A significant role in the formation of bronchiectasia is played by the genetically determined inferiority of the bronchial tree, leading to a violation of the mechanical properties of the walls of the bronchi 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) perhaps, in their pathogenesis, the insufficiency of the same protective mechanisms of the respiratory tract; 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 assigned to bronchiectasis and their suppuration.

Obstructive atelectasis resulting in the violation of the bronchial patency leads to the formation of bronchiectasis. Reduction of surfactant activity (congenital or Acquired, due to local inflammatory processes) may contribute to the development of atelectasis.

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In children, the causes of impaired patency of the large bronchi (and, thus, the formation of atelectasis) can be: a) compression of malleable, and possibly congenital defective bronchi hyperplastic root lymph nodes (hyperplasia occurs in cases of root pneumonia, with tuberculous bronchoadenitis); b) long-term occlusion of the bronchi with a dense mucous plug in acute respiratory infections.

A decrease (congenital? Acquired?) Resistance of the bronchial walls to the action of so-called bronchodilating forces (increased intra-bronchial pressure when coughing, stretching the bronchi by accumulating secretion, an increase in negative intrapleural pressure due to a decrease in the volume of the atelectised part of the lung) contributes to a stable expansion of the bronchial lumen.

The expansion of the bronchi and the retention of bronchial secretions contribute to the development of inflammation. Further, with the progression of the latter, irreversible changes occur in the walls of the bronchi (restructuring of the mucous membrane with complete or partial destruction of the ciliated epithelium and impaired cleansing function of the bronchi; degeneration of cartilage plates, smooth muscle tissue with replacement of fibrous tissue and a decrease in stability, ability to perform basic functions) and develop bronchiectasis.

Bronchiectasia leads to a violation of the coughing mechanism, stagnation and infection of the secret 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. The suppuration of formed bronchiectasis is the essence of bronchiectasis.

The modified secret usually accumulates in the lower parts of the bronchial tree (from the upper flows freely due to severity). This explains the predominantly lower lobe localization of the process.

Classification.
Depending on the nature of the expansion of the bronchi, cylindrical, saccular, spindle-shaped and mixed bronchiectasis are isolated.

According to the prevalence of the process, it is advisable to distinguish between single and bilateral bronchiectasis (indicating exact localization by segment).

According to the clinical course of V.F. Zelenin and E.M. Gelltein (1952) distinguish three stages of bronchiectasis: I - bronchitis; II - stage of pronounced clinical manifestations; III - stage of complications.

Clinical picture. Manifestations of bronchiectasis are extremely similar to those with bronchiectasis of CP. It is necessary to allocate only a number of features of bronchiectasis at each stage of the survey.

At stage I of the diagnostic search, sputum cough is noted in childhood after suffering Mo, measles, whooping cough or severe flu and frequent repeated Mon during the subsequent period of life.

At stage II of the diagnostic search, almost always (and in the period of remission), upon auscultation of the lungs, foci of persistent wet voiced finely wheezing are detected.

Often there are complications of bronchiectasis: 1) hemoptysis; 2) asthmatic component; 3) focal (perifocal) Mon; 4) lung abscess; 5) pleurisy (empyema); 6) kidney amyloidosis, less often

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spleen and liver (taking into account the effective treatment of the underlying disease amyloidosis is currently developing 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 disease, often often 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 stage III of the diagnostic search, when analyzing radiological data, it is necessary to take into account that, in contrast to the bronchiectatic form of CP, a certain localization of the process is characteristic of bronchiectasis; most often affects the basal segments of the left lung and the middle lobe of the right lung.

In addition to the previously described methods of laboratory and instrumental diagnostics (see “Chronic pneumonia”), in some cases additional studies are required.

Bronchokinematography makes it possible to isolate bronchiectasis with mobile and "rigid" walls, to distinguish deforming bronchitis from bronchiectasis.

Serial angiopulmonography helps to determine the anatomical changes of the pulmonary vessels and to identify hemodynamic disturbances in the pulmonary circulation in various forms of bronchiectasis.

Bronchial arteriography allows to detect blood bypass through pathologically expanded bronchial-pulmonary anastomoses.

Scanning the lungs revealed marked violations of the capillary blood flow in bronchiectasis.

All these methods of examination carried out according to indications in the preoperative period, as they help to accurately determine the amount of surgery.

Diagnostics. The diagnosis of bronchiectasis is made in the presence of certain signs:

• clear indications of sputum cough in childhood after acute respiratory illness;

• frequent outbreaks of pneumonia of the same localization;

• detection of persistently holding hot spots of wheezing during physical examination during the remission of the disease;

• radiographic signs of gross deformation of the pulmonary pattern, usually in the area of ​​the lower segments or the middle lobe of the right lung, tomo- and bronchographic signs of bronchiectasis.

The wording of a comprehensive clinical diagnosis, in addition to specifying nosology, includes: 1) process localization (indicating the affected segments); 2) process stage; 3) phase of the flow (exacerbation or remission); 4) complications.

Treatment. Perhaps conservative and surgical treatment.

Conservative treatment is indicated for patients with minor or clinically poor manifestations of changes in the bronchi; with a common and insufficiently clearly localized process (when surgical treatment is not possible); in preparation for bronchography and radical surgery.

The main part of the conservative treatment is the rehabilitation of the bronchial tree: a) effects on pyogenic microflora (instillation of antimicrobial agents through a transnasal catheter, bronchoscope); b) removal of purulent bronchial contents and sputum (respiratory

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gymnastics, chest massage, postural and bronchoscopic drainage, the use of mucolytic agents). (For more information about drug therapy, see the treatment in the Pneumonia section.) The upper respiratory tract should be sanitized, general bracing should be carried out; need to provide good nutrition.

Surgical treatment is best done at a young age. Persons older than 45 years old are operated less frequently, since by this period of life they already have complications that impede the operation. A resection of the lobe of the lung or individual segments is carried out 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 extent of the process and the presence of complications. Moderate damage, provided systematic treatment provides a long period of compensation and the preservation of disability.

Prevention. The primary prevention of the disease is the correct treatment of OP, especially in childhood, often developing on the background of infections (measles, whooping cough, flu). Secondary prevention is a rational way of life, the treatment of intercurrent infections, the fight against focal infection of the upper respiratory tract
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