Tuesday, April 2, 2013

Major Complications Of Pneumonia (Pneumothorax & Acute Abscess Of The Lungs) And Pneumonia Prevention In Children

TENSE PNEUMOTORAX

Pneumothorax is accumulation of air in a pleura cavity with the valvular mechanism of its receiption, wich makes increasing of pleura pressure with the following stipulations of collaps of lungs, by displacement of mediastinum in a healthy side and development of acute respiratory and cardio-vascular insufficiency on the type of cardio-pulmonary shock. At the simultaneous receipt in a pleura cavity puss together with air pyopneumothorax occurs. The reason of disease can be a breach in the pleura cavity of lungs abscess and staphyloccocus bulles, exydative pleurisy, empyema of pleura; tense mediastinum emphysema, asthmatic state, trauma of thorax which is accompanied by the closed damage of lungs.
                                          Clinic
At the acute form of syndrome  tension is sudden acutely, pallor of skin, sticky death-damp, sick seizes air by the opened mouth, frightened, breathing is hard, cold sweat , suffering face; cyanosis, with increases; a pulse is weak, threadlike, increased shallow hard breathing, arterial hypotension, hypoxic comma.
At the subacute form of syndrome there is slow progressive worsening of the state, pain in a thorax and in a stomach during breathing, sickly cough, increase of pallor of skin, cyanosis, sweating, shortness of breath, tachycardia.
A chest on a sick side falls behind in breathing, intraribs intervals are extended. Percussion sound above lungs is tympanic, in lower regions (in pyopneumothorax) is shortened, respiratory noises on a sick side are absent.
The tones of heart are displaced to a healthy side, tones of heart are muffled.
X-ray shows the depression of lung, absent pulmonary pattern, flat diaphragm,
level of liquid or total darkening in pyopneumothorax.


A classic anteroposterior view of the chest showing pneumomediastinum. The lifted thymic shadow above the heart is a typical presentation of pneumomediastinum. (From Vidyasagar D: Respiratory disease in the newborn. <IT+>In:<IT-> Holbrook PR (ed): Textbook of Pediatric Care. Philadelphia, WB Saunders, 1993, pp 551.)

Right sided pneumothorax




Right sided emphysema with displacement of mediastenum and heart to healthy side


Help on prehospital stage.
1.           To release from clothes.
2.           To give the promoted position of body to the child.
3.           Permanent  moistened oxygen through a mask.
4.           20 % solution of Oxybutirati sodium  50-100 mg/kg of mass  for one
                    dose intramuscular or intravenously streamly on 10-15 ml  of 10 %
                    Glucose solution .
5.           At fasty growth of cardio-vascular and respiratory insufficiency punction
                    of pleura cavity must be conducted: for destroying of air- the place of
                    punction is III-IV intraribs intervals on a front or middle of axillary line;
                    for the delete of liquid (blood, pus) – in IV-VI intraribs intervals on a
                    middle or back axillary line. A puncture is conducted on the overhead
                   edge of lowlised rib on a depth of 2-3cm after analgesia by 0,5 %
                    Novocaine solution . At valvular pneumothorax  Bylau drainage  is
                    imposed.
6.           Immediate hospitalization in the surgical unit.

Help on a hospital stage.
1.           Oxygentherapy with moistened oxygen through a nasal catheter -40 %
                     oxygen constantly.
2.           20 % solution of sodium Oxybutirati 100 mg/kg (0,5 ml/kg) of mass is
                    for one  dose of intravenously very slowly on 10 % Glucose solution
                    20 ml; or 0,25 % solution of Droperidoli 0,1 ml/kg of mass
                    intravenously streamly slowly on 10 % glucose solution  15-20 ml.
3.           Pleura punction (look on prehospital stage).
4.           Solution of Corgliconi  0,06 % or Strophantini 0,05 %  0,01-0,015 mg/kg
                      of  the masses (but not more than 0,3 ml) for one dose on a 10 ml of
                      10% glucose solution  intravenously streamly slowly.
5.           Cocarboxilazae 50-100 mg, 5 % solution of sodium ascorbinaty 2,0-5,0
                      ml, Panangini 0,5 ml per year of life intravenously streamly on 10 ml of
                     10 % solution of glucose in separate syringes.
6.           Infusion therapy for desintoxication – 10 % Glucose solution 10-15ml/kg
                     of  mass.
7.           Antibiotics.

                                           Acute abscesses of lungs

                    Destruction of lung parenchyma under the influence of pathogens and emissions of their enzymes leads to the formation of delineated foci of fusion of lung tissue in the form of cavities filled with purulent exudate and detritus, and sometimes containing fragments of the sequestered lung tissue.
                 Abscess formation in the lung develops in the presence of several conditions, foremost of which, besides purulent creating pathogenic organisms, are the violation of bronchial patency and local disorder of pulmonary circulation. On the mechanism of development there are distinguished bronchogenic (including aspiration), hematogenoembolic, post-traumatic and lymphogenous lung abscesses. The allocation of so-called para- and postpneumonic abscess is incorrect, because initial phase of any of lung abscess is inflammation of lung tissue, and therefore any genesis abscess is para- or postpneumonic.
                Moments predisposing to the development of lung abscesses are low immunity, weakening of the child's body. Acutely affects the general resistance of the organism and thus contribute to the development of lung abscesses and infectious diseases, primarily such conditions as epidemic influenza, severe injury, blood diseases, hypovitaminosis, prematurity, hypotrophy. A major predisposing factor for the development of septic complications, including lung abscesses, is diabetes.
                 Lung abscess may be caused by various microorganisms and therefore are polyetiologic disease. An important role in the development of lung abscesses, especially in childhood, play pyogenic cocci, especially Staphylococci. These microbes emit a large amount of toxins and enzymes that contribute to necrotic and destructive changes in lung tissue. Some rarer causes of pulmonary abscess formation are streptococci, Klebsiella pneumoniae, Enterobacter, Pseudomonas aeruginosa, or their combination with Staphylococcus. In the past 30 years in the development of lung abscesses there was significantly increased the role of anaerobic infection, which most often detected in aspiration genesis abscess. Many patients have a combination of various microorganisms, and they may vary in different periods of the disease.
             In addition to the already mentioned division of the mechanism of development, acute lung abscesses are divided into simple (pus), and gangrenous. The latter include abscesses, containing parts torn away as a result of necrotic ihorosic inflammation of lung tissue, known as sequestration. In addition, abscesses are single and multiple, central and peripheral, unilateral and bilateral, uncomplicated and complicated. 
             The disease usually starts on the background of one or bilateral pneumonia, most commonly aspiration genesis or influenza. The clinical picture in the formative stage of purulent cavities in the lung is determined purulent resorbtion fever, which is based on three factors: suppurant factor, due to the presence of necrosis and melting of the lung tissue, a factor of resorption, resulting in absorption of the decay products of tissue and microbial metabolism, and loss factor, due to loss of protein with purulent discharge. The patients in this period have a high, sometimes hectic fever, chills, excessive sweating, signs of intoxication. Patients are often concerned about a dry cough, chest pain. Physical examination reveal larger or smaller area blunting percussion sounds over which the breath is weakened, and enhanced voice trembling. After breaking an abscess in the bronchus cough becomes wet, sometimes suddenly cough up a large amount of pus, often hemorrhagic sputum, after which the temperature may decrease.
            
                 The most severe and protracted are multiple (especially bilateral) and gangrenic abscesses. The latter most often become chronic or complicated by a breakthrough in the pleural cavity, haemorrhage and sepsis. In severe, progressive course and the ongoing decay and suppuration of lung tissue on a background of increasing intoxication functional disorders of the cardiovascular system, liver and kidneys arise, which with the progression of the disease may be replaced by organic changes in the internal organs, characteristic of the septic condition.
                    Pronounced loss of protein and electrolytes during the acute phase of inflammation with its insufficient compensation leads to volemic and hydroelectrolitic disorders, reduces muscle mass and weight loss. On this background, there may be swelling of the lower extremities.
              As the disease progresses and complications develop the purulent resorbtion fever replaces purulent resorbtion exhaustation. Typically, this occurs in children with extensive destruction of the lung complicated with pleural empyema. On the background of progressive hypoproteinemia patients lose weight and grow thin. High temperature is replaced subfebril or normal, that is a poor prognostic sign, indicates a acute decrease in reactivity.
               The suspection of the beginning of abscess formation in a patient with severe pneumonia may be based on changes in clinical and physical examination data, but the main role in the diagnosis of lung abscesses has X-ray, which is preferably performed in a vertical position the patient. The appearance of one or more translucencies on the background of a homogeneous darkening of lung indicates the formation of single or multiple abscesses. The widely used term abscess pneumonia means only a certain period during the inflammatory process in the lungs and is not an independent nosological form. Later multiple small cavities may influent  into larger, in which, after coughing up sputum levels of the liquid begin to determine. To refine the localization of abscesses multi-axial fluoroscopy and radiography in frontal and lateral projections must be performed.

                                             
                          An acute abscess of upper lobe of left lung.
                          Visible massive inflammatory infiltration
                          around the abscess cavity.

                                 
                          An acute abscess of middle lobe of right lung.

                                
                               Empty abscess cavity in the S6 of the right
                              lung. Thickening of the wall cavity is seen
                              almost throughout the full length.

                    Lung abscess should be differentiated from tuberculous cavities, purulant cysts,  abscess of bronchiectasis and cavitary form of lung cancer. Important role has bronchoscopy with biopsy, allows to exclude the presence of a foreign body, tumor of the bronchus, identify signs of specific inflammation in the bronchi, to obtain material for morphological and bacteriological studies.
                     Very often during the development of the abscess on the periphery of the lung there are difficulties in its differential diagnosis with encysted pleural empyema and pneumoempyema. Sometimes it is very difficult to determine where is the purulent cavity: in the lung or pleura, especially when these cavities are numerous. If on the multi X-ray scopy the shadow of the visceral pleura or the edge of the lung are seen, the presence of empyema may be probably excluded. Spherical or slightly oval form of the cavity is an evidence of lung abscess, elongated in the caudocranial direction –of  empyema. At empyema cavity width at low of the pole is always greater than that of the upper. The walls of the abscess cavity approximately have the same thickness, whereas the medial wall of the empyema cavity formed by the visceral pleura, usually thinner than the lateral. Internal contours of wall abscess are hilly and rough. At the massive destruction of lung internal boundary of encysted empyema cavity may not be the visceral pleura but destroyed and distorted lung parenchyma. The characteristic radiological signs such abscessempyema is unflat, eroded and thickened medial wall of the cavity. More precisely localize the cavity is due to a computer and NMR tomography.

                           
                          Encysted pneumoempyema. The rear cavity
                         contours influent with the chest wall. Vertical
                         cavity size significantly exceeds the horizontal.


                  To complications of acute lung abscesses include empyema, pleural pneumoempyema, pulmonary hemorrhage and septic conditions. The development of any complications greatly aggravates the course of the disease and worsens its prognosis. Outcome of acute lung abscess in addition to a full recovery with empting and scarring (obliteration) of purulent cavity, may be so called "Clinical recovery " with the cleanup of well drained through the bronchi cavity, its stabilization and transformation on the thin-walled air cysts. Such a cyst in her relatively small size may be completely asymptomatic, but in adverse circumstances (activation of infection, the violation of cross-draining bronchi) in it may appear fluid and cause relapse of suppuration. Less favorable development is the chronical inflammation and its progression with associated complications leads to death.

                       Prevention of pneumonia in children
 
                     Prevention is the rational  feeding, active treatment of diseases, promoting the appearance of pneumonia (prematurity, malnutrition, rickets, birth trauma, anemia, abnormalities of the constitution, ARVI, etc.).

Primary. Nutrition, strengthening of the child, active treatment of diseases, leading to the pneumonia.
Secondary. Clinical supervision for convalescents during the year, restorative therapy 2-4 weeks after discharge from hospital and dynamic monitoring (paying attention to the nature of repeated respiratory infections); chest X-ray in the dynamics according indications.

REFERENCES
A - Basic:

1.      Pediatrics. Textbook. / O. V. Tiazhka, T. V. Pochinok, A. N. Antoshkina et al. / edited by O. Tiazhka – Vinnytsia : Nova Knyha Publishers, 2011 – 584 pp. : il.

2.      ISBN 978-966-382-355-3Nelson Textbook of Pediatrics, 19th Edition Kliegman, Behrman. Published by Jenson & Stanton, 2011, 2608.  ISBN: 978-080-892-420-3.

3.      Illustrated Textbook of Paediatrics, 4th Edition.  Published by  Lissauer & Clayden, 2012, 552 p. ISBN: 978-072-343-566-2.

4.      Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.

B - Additional: 1.http://intranet.tdmu.edu.ua/data/kafedra/internal/pediatria2/classes_stud/шпитальна%20педіатрія/6%20курс/English/Theme%2001%20Differential%20diagnosis%20of%20pneumonia%20in%20children.htm

2. http://www.merckmanuals.com/professional/index.html

3. Lichtenstein, et al. Pediatric Pneumonia. Emergency medicine clinics of north America.  2010.

4. Barson.  Clinical manifestations and diagnosis of community-aquired pneumonia in children. UpToDate.com., 2009. 

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