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Публикации / ЗА ПНЕВМОНИЯТА НАКРАТКО

ЗА ПНЕВМОНИЯТА НАКРАТКО
06.02.10 22:25

Автор:д-р Атанас Янев, доц. Коста Костов Клиника по белодробни болести Военномедицинска Академия - София
Публикация в списание МЕДИКАРТ брой №1 март 2008г. 10 - 14стр.
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ЗА ПНЕВМОНИЯТА ВО КРАТЦЕ
 
д-р Атанас Янев, доц. Коста Костов
Клиника по белодробни болести
Военномедицинска Академия, София
 
 
                Определение. Остро протичаща възпалителна болест, инфилтрираща белия дроб, ангажираща алвеолите и интерстициума, с предхождащо или последващо засягане и на бронхиалното дърво.
                Епидемиология. Широко разпространение на болестта се обуславя от многообразието на причинителите, климатични и географски особености на ареала. Наблюдава се повишена честота в зимните месеци в нашите географски ширини, когато рискът от простуда е повишен, а от друга страна и социалния контакт в затворени помещения е увеличен. В последните десетилетия се отбелязва неколкократно нарастване на заболеваемостта, като в момента е от 6/1000 до 34/1000 в зависимост от възрастта, географската локализация, превантивни мероприятия и нивото на медицинско обслужване. При различни проучвания процента хоспитализирани, болни от пневмония, се движи между 10% до 42%. Болестта заема четвърто място при хоспитализираните болни  и пето по смъртност, като процентно е 5% при млади, неувредени хора, 30-40% при възрастни и с придружаваща болест и достига до 50% при вътреболнични инфекции. Честотата на пневмониите преобладава в рискови общности, социални домове, съпътсваща патология, алкохолици, наркомани, имунокомпромитирони.
                Класификация. Класификациите на болестта са многобройни, патологоанатомични, клинични, имунологични, но в практиката намират приложение етиологичната класификация, според причинителите – бактириални, атипични, микотични, вирусни, алергични, причинени от физически и химически агенти, смесени и неуточнена етиология /П.Добрев/. Другакласификация намерила практичаско приложение и наложила се в последните година е на Morton и Schwerzбазирана на мястото и  начина на заболяване: пневмония придобита в обществото /ППО/, пневмонии придобити в болница /нозокомиални/, пневмонии при механична вентилация, пневмонии при пациенти с имунен дефицит, аспирационни и рецидивиращи пневмонии.
                Патагенеза. Различни са пътищата на проникване на причинителите в белия дроб, като най –чест е въздушно капковия, чрез инхалация на инфектиран аерозолен облак. При заболяване на горните дихателни пътища става аспирация на орофарингеалната секреция и това е втория път на попадане на инфекциозен причинител в белия дроб. Ятрогенно при интервенционални манипулации, може де инокулира директно причинител, например при нестерилен бронхоскоп, интубационна тръба. При хронични заболявания на белия дроб става  колонизация с микробен агент, които се потиска при лечение, но с невъзможност за пълна ерадикация. При възпалителен процес в самия организъм белия дроб може да се засегне по съседство, при наличие на възпалително огнище в близост /субдиафрагмален абсцес, медиастинит/, така и при далечно огнище, чрез хематогенна или лимфогенна десиминация.
                Клинична картина. Клиничната характеристика на състоянието на пациента в голям процент от случаите се владее от бронхо-белодробен и фебрилно-интоксикационен синдроми. В първия, анамнестично пациентите съобщават за кашлица, експекторация, с вариабилност на цвета, диспное, гръдна болка, често и шумно дишане, а при втория са налице астено-адинамия, висок фебрилитет, главоболие, болка в мускули и стави, намален апетит, както и извънбелодробна симптоматика като промяна в сънанието при възрастни пациенти и коремвни болки при деца. При засягане от възпалителния процес на други органи и системи, съответните локални оплаквания. Интензитета на изява на клиничната картине е различна в зависимосто от възрастта, имуно-биологичното състояние на пациента и невинаги в корелация с обективната находка.
                Диагноза. След анамнеза и клинично съмнение за пневмония преминаме към втората стъпка с провеждане на физикален преглед, при който при огледа установяваме, зачервена или бледовата, изпотена кожа, чест херпес симплекс на устата, лигавиците могат да бъдат ливидни при дихателна недостатъчнаст, учестена дихателна дейност. При аускултация класическите признаци на инфилтрат, усилен гласов фремитус, притъпление при перкусия и бронхо-везикуларно или бронхиално дишане при аускултация. Поява на дребни влажни хрипове в фазата на инфилтрация или всмекване с различна интензивност. Промяна на аускултаторната находка при усложнения, поява на плеврален излив с плевралното триене в началните етапи, скъсения перкуторен тон и отслабено везикуларно дишане при набиране ексудата. Но често в практиката липсва физикална находка или тя е много бедна и при тежка клинична картина и неповлияване от предписаното антибиотично лечение трябва да се суспектира пневмония и премине към пинструментална и лабораторна диагностика.
                Рентгенографията на бял дроб е основното и задължително изследване тъй като диагнозата е предимно рентгенологична. Разбира се в дсиференциално диагностично отношение могат да стоят и други заболявания, но диагностиката тръгва от най-вероятнотои най–честото заболяване представено като рентгенологично засенчване - пневмония.
                На второ място идват лабораторните изследвания като пьлна кръвна картина, урина и биохимични изследвания. Скоростта на утаяване на еритроцитите може да ни послужи, не само за индикация на възпаление, но и за преценка тежестта на процеса, като връзката е не винаги право пропорционална, при имунодефицитни състояния, тежки хронични заболявания и др. Метод с по –голяма сензибилност е CRP/ С – реактивния протеин/. Диференциалното броене на левкоцитете дава представа за тежестта на възпалението, понякога ориентира за етиологията, бактериална, гнойна с олевяване или атипична, вирусна при увеличавене броя на лимфомононуклеарите, а понякого дава основната диагноза довела до пневмония, левкемия, инфекциозна мононуклеоза и др. Урината е тъмна, конциентрирана с високо отнжосително тегло поради дехидратиране, тенденция към подкисляване. Може да се установи протеинурия, уробилинурия, хипохлорурия, хипофосфатурия поради токсико-инфекциозно засягане на бъбреците. Задължителни биохимични изследвания при диагностика на пневмония са кръвна захар /при ззахарен диабет е намален клетъчения имунитет/, креатинин и чернодробни проби / уточнямане на евентуално токсико- инфекциозно засягане на бъбреци и черен дроб/, протеинограма / е обуславят възможността за пренасяне на антибиотичната молекула а понякотга и основната диагноза напр. Миелом/. Най-честата причина за сърдечни усложнения, ритъмни, проводни а и смърт е диселектролитемията, затова важно е изследването и проследяването нивото на калий, натрий, калций
                След поставяне на диагноза идва проблема със съответната преценка за хоспитализацияна пациентаи стратификация на риска от смърт, като се отчита наличието на модифициращи фактори, като възраст над 65 години, лечение с вета-лактами през последните три месеца, хроничен етилизъм, имуносупресивни състояния, множествена медицинска коморбидност, деца в детски градини, жеивеещи в социални домове иппридружаващи хронични заболявания от други органи и системи (Табл.1).
 
               Табл.1.  Точкова система PORT(Patient Outcomes ResearchTeam)
                       Група за изследване на изхода при пациенти с пневмония
ХАРАКТЕРИСТИКИ
ТОЧКИ
Демографски фактори
Мъж
Жена
Възраст (години)
Възраст (години) – 10
Старчески дом, хоспис
+ 10
Придружаващи заболявания
  • Неоплазма
  • Чернодробно заболяване
  • Застойна сърдечна слабост
  • Мозъчно-съдова болест
       ●     Бъбречно заболяване
 
+ 30
+ 20
+ 10
+ 10
+ 10
Физикално изследване(признаци)
Дир ID: 
Парола: Забравена парола
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