Actuallity of the problem of chronic bronchopulmonary pathology.
•
a considerable incidence - 0.2-1% among children (according to the
pathologists,
in adults it occurs in 1.5-12% dead)
• severe
•
irreversible complications (sclerosis, bronchiectasis, cardiovascular
failure, brain abscess, abscess lung
formation, amyloidosis)
•
disability of children and later adults, possible adverse health effects
The problem of chronic
bronchopulmonary pathology always aroused the attention of pulmonologists.
Perhaps no disease of bronchopulmonary system has caused so much discussion and debate among scientists
as chronic bronchopulmonary pathology. The term "chronic bronchopulmonary
disease" has been repeatedly revised, but attempts to replace it by bronchiectasis,
pneumosclerosis or chronic bronchitis have been in vain. After all, none of
them could not reflect the depth of pathomorphologic changes, but was only
evidence of adverse trends (bronchiectasis, pneumosclerosis) or a component of
the pathological process (chronic bronchitis). The term "chronic
bronchopulmonary disease" encompasses a range of morphological changes in all
anatomical structures of the lung.
Now scientists abroad again reject the term
"chronic bronchopulmonary disease", finding him an alternative -
chronic bronchitis.
Statistics say that over the past years
there was no increase in chronic bronchopulmonary diseases among children. But
this is not indicative of its absence. Timely diagnosis and treatment of acute
pneumonia, the effectiveness of antibacterial new generation medicines significantly
reduced risk of chronic inflammatory process.
At
the same time, the effects of environmental catastrophes, increasing the number
of sick children was continued, and especially during the first 3-5 years of
life. Reduced immunological resistance of the organism, the low sensitivity of
the respiratory tract flora to antibiotics and the increasing allergy to them
create the complete objective prerequisites for the emergence of chronic
bronchopulmonary pathology. Clinical experience proves that, the more so that
the low social and cultural level of the population today leads to an increase
in incompletely treated patients with acute pneumonia.
Etiology,
pathogenesis and pathomorphology
The etiology, pathogenesis and morbid anatomy
are complex and many aspects were studied. The factors that cause
predisposition to the development of chronic respiratory pathology, are:
·
prematurity
·
anomalies of the
constitution, especially exudative-catarrhal
·
malnutrition
·
rickets
·
artificial feeding
·
pollution of the
atmosphere
·
bad living conditions.
Promotion factors:
• acute pneumonia (80%)
• whooping cough, measles
• frequent ARI
• foreign body of airway
• congenital and acquired malformations of the bronchopulmonary system
• hereditary diseases (cystic fibrosis).
This factors
contribute:
·
reducing overall
reactivity (resistance)
·
violation of local
immunity
·
disorders of drainage
(evacuation) and the barrier function of bronchi.
The reason
supporting a chronic inflammatory process is the microflora (inflyuenza coli,
streptococci, staphylococci, pneumococci, Gram-negative bacteria) or its α-forms
which are in bronchopulmonary lymph nodes, in foci of chronic infection
(tonsillitis, adenoids, sinusitis, carious teeth, cholecystitis). In children,
the main way of spreading of infection is bronchogenic.
The inflammatory process is consistent and progressive in nature:
single-layered ciliated epithelium is replaced by a cubic (violation of
bronchial drainage function) → damage nerve endings bronchi (disturbed
peristalsis), connective tissue is developing, changing the size, form and
elasticity of the bronchi → development of panbronchitis facilitates the
induction of inflammation in the lung interstitium in intraalveolar septums,
directly into the alveoli. Thus, in chronic respiratory pathology all
structures of the bronchopulmonary system are affected (bronchi, interstitial
tissue, parenchyma, vessels, nerves, pleura), but according to the clinic we
may only speak about the prevalence of changes in the bronchi, interstitium or
parenchyma of the lung.
This is
confirmed by pathological data, when according to the severity of the
pathological process such consecutive changes are observed: 1) chronic
bronchitis with bronchiectasis and emphysema, 2) chronic bronchitis with bronchiectasis
and atelectasis, and 3) chronic deforming bronchitis.
Pathoanatomic
examination provides a diverse macroscopic picture in conjunction with the
histological heterogeneity of lesions in chronic bronchopulmonary disease. In
the same case different changes are revealed: chronic inflammation of the
interstitium, carnification, sclerosis, deforming bronchitis, bronchiectasis,
emphysema, atelectasis, worsening the inflammatory process. There are
lymphangitis, abscesses, etc.
The main among the histological changes are:
organization of exudate in the alveoli, chronic inflammation of the
intermediate tissue, chronic bronchitis with bronchiectasis (or deforming
bronchitis), foci of acute inflammation.
Chronic bronchitis. Bronchoectasis.
Lung emphysema.
Pneumosclerosis.
Micropreparation of lung in
diffuse interstitial pneumosclerosis: intraalveolar septums are greatly
thickened and sclerotic; coloured by Van Gieson; × 24.
Micropreparation of lung at local pneumosclerosis: substitution of the
alveoli, bronchioles, alveolar ducts by proliferation of connective tissue; coloured
by Van Gieson; × 24.
Morphological studies indicate that at the presence of purulent bronchitis
lymph capillaries and efferent lymphatic vessels are constantly
involved in the inflammation process. This is explained by the fact that the
resorption of purulent exudate and the output is mainly done by lymphatic
pathways. Later purulent lymphangitis is changed by lymphangiosclerosis,
obliteration of the lumen, causing resorption and mechanical failure. At the
same time, disruption of lymphatic drainage of the bronchial wall is of
particular importance, since sharply reduced ability to clean itself, and
therefore, there is stagnation of secretions, especially in the bronchioles,
activation of the microflora and the development of peribronchial inflammation.
Arround the lymphatic
capillaries there is observed infiltration by lymphocytes and plasmocytes with
the formation of lymphomas. In addition to induction of cellular elements,
lymphostasis sharply violates vascular tissue ratio, tissue metabolism, which
lead to degeneration of the structural components of the bronchi with
subsequent development of cylindrical bronchiectasis and reticular
pneumosclerosis. Thus, there is convincing evidence: bronchitis is only the
initial phase, followed by involvement in the process lung parenchyma, which is
more appropriate to designate as a chronic inflammation of the structural
components of the lungs (chronic bronchopulmonary disease). In contrast to
acute pneumonia, respiratory failure (ventilation, diffusion, distribution) develops
gradually, slowly.
Circulatory hypoxia also
slowly joins respiratory one with the development of hypertension in the
pulmonary circulation and pulmonary heart. Hypoxia is defined already in the
preterminal stage of disease. Prolonged hypoxemia leads to disruption of all
metabolic functions of organs and systems, and in severe cases - to
morphological changes. This manifests itself in reducing the child's memory,
his irritability, aggression (CNS), liver enlargement and functional disability
decrease enzymatic function of the stomach and intestines (digestion tract),
dryness of the skin, mucous membranes, papillae atrophy of tongue
(hypovitaminosis), etc.
Thus, the basis of chronic
bronchopulmonary pathology is organic and functional changes in the
bronchopulmonary system and the subsequent development of hypoxemia and
hypoxia. Now there is reason to talk about the distortion of the immunological
status and surfactant deficiency in chronic bronchopulmonary disease. However,
their role in the deep pathological, progressive changes has not been fully established.
We can only assume their genetically determined deficiency, which causes
chronization and progression of the process.
Clinic
The clinic is
manifested as symptoms of a general nature and directly related with the
bronchopulmonary system. It must be remembered that chronic bronchopulmonary
pathology in 80% of cases occurs in the first 3 years of life and approximately
50% - in the first year of life, when its diagnosis at the initial stage is
difficult. It is necessary
to clarify the frequency of respiratory episodes in a child, and their
duration. With increasing frequency of these episodes, their duration
and the probability of chronization of the process increase.
Coughing is a reflex act aimed at
self-purification of the respiratory tract of mucus, pus, blood, foreign body,
and other particles, which are normally not present in the bronchial tree. In
chronic respiratory pathology there is occurrence of the proliferation of the bronchial mucosa in
relation to the inflammatory reaction, hypersecretion of glands, a violation of
peristalsis, the accumulation of mucus and pus, compression of the bronchi and
trachea by enlarged lymph nodes. Cough, mostly wet, accompanied by sputum, in
the presence of emphysema is severe, unproductive, in remission - dry.
Sputum is puromucous or purulent, more in
the morning. It is not a three-layer, as in adults, in small quantities (30-50
ml), it is difficult to obtain it, because in most cases children can not
expectorate. For bacteriological examination sputum is taken during
bronchoscopic lavage or after digital pressure with a spatula on the tongue
root, which causes reflex cough with expectoration.
Cyanosis appears at exacerbation of chronic
respiratory pathology or with the development of chronic pulmonary vascular
disease, when it is constant and, depending on the activity of the pathological
process, only its intensity changes. Often there is observed increase in body
temperature, the phenomenon of hyperhidrosis.
We must always pay attention at
the form of a chest.
Its deformation is evident in moderate and severe cases. It indicates a
significant area of the pathological process in the lungs and long-term
hypoxemia. "Chicken", "pigeon" chest, depressed sternum are
signs of chronic bronchopulmonary diseases in preschool age; barrel - in
schoolchildren. The asymmetry of the chest, deformation, a marked decrease in
the size of a half part in measuring by centimeter tape - all this makes it
possible to analyze during the inspection the severity, duration and
localization of process.
Shortness of breath at chronic
bronchopulmonary disease is mixed, sometimes expiration. Deformation of the
fingers in the form of drum sticks and nails in the form of watch glass
reflects the duration of hypoxemia.
Percussion reveals bandbox
sound (emphysema), at marked sclerotic changes shortening is detected.
Auscultation (at
exacerbation) reveals diversity of dry and moist rales. Constant local fine
bubbling moist rales is the criteria of chronic bronchopulmonary disease.
Cardiovascular system: expansion of the right
heart, accent of the second tone in the pulmonary artery, weak tones and
functional systolic murmur, the ECG changes shows myocardial hypoxia.
Digestive system. Appetite is
reduced, the liver is increased in size, its function is
disrupted, there are disorders in hydrolysis and absorption of food, in severe
cases, a child retards in the mass and growth. The skin is dry, visible pallor,
reduced flexibility, opacity and the fragility of the hair.
Sometimes there is short-term allergic rash, once rising
of high temperature (due to a violation of drainage of purulent sputum).
Headache, fatigue, irritability, aggression, memory decline indicate CNS
violation. Pulmonary hemorrhage is very rare in children.
X-rays changes are different: increased lung
pattern, its deformation, cyst enlightenments, volume reduction of segment,
lobe, mediastinal shift toward pathology, disateleсtasis
(airless areas alternate with emphysema). Characteristic for this disease is
that they are sustainable. They can only increase at exacerbation, but remain
in remission.
Left side chronic
bronchopulmonary Direct radiogram of chest.
disease.
Decreasing of left lung field,
shadowing in the middle areas.
Detail of chest radiograph at peribronchial pneumosclerosis in patient
with chronic obstructive bronchitis: lung pattern is reinforced and deformed, there
are clearly distinguished bronchial lumen, bordered by thickened walls.
Detail of chest radiographs in a direct projection at chronic
bronchopulmonary disease: at low part of the right lung field lung pattern is
reinforced and deformed, its radial direction can not be seen.
At bronchographic observation (which is obligate)
there are the deformation of the bronchi, cylindrical and saccular
bronchiectasis, reducing the angle of the bronchi branching.
Bronchiectasis. Coloured bronchogram (X-ray) of a human lung showing
bronchiectasis.Bronchiectasis is a lung disorder in which the bronchi and
bronchioles (airways of the lungs, red) are permanently dilated and distorted.
In this case, some of the bronchi have terminal bulbous enlargements, a
condition known as fusiform (saccular) bronchiectasis.
Normal bronchogram. Varicose bronchoectasis.
Representative CT scan image from a
person with advanced CBPD shows emphysematous changes and subpleural blebs.
Identification of chronic
bronchopulmonary diseases at the level of deforming bronchitis without
bronchiectasis may be conventionally considered
because the stabilization of the pathological process in these
conditions is more likely. Clinical experience shows that bronchiectasis is
less evident than deforming bronchitis.
Deforming
bronchitis.
Deformations of the bronchi may
be different: the broadening or narrowing of the lumen, presence of granulation
and follicular polyps, false cysts, bronchiectasis (cylindrical, saccular,
mixed), which lead to varying degrees of obstruction of small bronchi. Chronic
process in the lung tissue in combination with deforming bronchitis or
bronchiectasis becomes stable, leads to irreversible changes in the affected
area of lungs.
It is believed that chronic
bronchopulmonary diseases are characterized by the local endobronchitis.
However, at the severe forms with involvement in the pathological process of
many segments of the left and right lungs endobronchitis becomes diffuse.
Modern classification of chronic
pulmonary disease involves the next indicators:
1. Localization and extent of
pathological process (segment or segments, lobe).
2. The nature of bronchial
lesions:
- Deformation
- Bronchiectasis: cylindrical,
saccular, varicose, mixed
- Bronchostenosis
3. Nature of endobronchitis:
- Catarrhal
- Purulent
- Local
- Diffuse
4. Current:
- With occasional
exacerbations
- With frequent exacerbations
- Continuously recurring
5. Severity:
- Mild
- Moderate
- Severe
6. Period of illness:
- Exacerbation
- Recovery
- Remission
7. The degree of respiratory
failure.
8. Complications:
- Pulmonary (emphysema,
obstructive syndrome,
abscess, pulmonary hemorrhage, pleurisy,
pyopneumothorax etc.)
- Extrapulmonary (pulmonary
heart, amyloidosis, brain abscess)
Diagnostic criteria
of chronic bronchopulmonary disease:
1. Anamnesis:
a) direct link with a previous
acute pneumonia;
b) recurrent inflammation in
the same area of the lungs.
2. Clinical:
a) cough (mostly wet);
b) sputum (mucous-purulent);
c) hyperhydrosis, intermittent
fever;
d) deformation of the thorax
(in particular, flattening on the side of lesion;
d) the presence of stable
local fine bubbling moist rales.
3. Radiographic:
a) strengthening and
deformation of the pulmonary pattern;
b) thickening of the bronchial
walls;
a) reducing of fibrosic lung
segments;
d) infiltration of lung tissue
in the focus of the lesion in the acute phase.
4. Bronchologic:
a) Bronchoscopy - a localized
endobronchitis;
b) Bronchography:
- Cylindrical or saccular
bronchiectasis;
- Curvature, the convergence
of bronchial trunks (deforming bronchitis)
- Bronchostenosis.
Pneumothorax
WHO Strategy for prevention
and control of Chronic Respiratory Diseases:
Introduction
The Global Strategy for the
prevention and control of noncommunicable diseases, developed in direct
response to the global threat posed by noncommunicable diseases and endorsed by
the Fifty-Third World Health Assembly, cites chronic respiratory disease as one
of the four priority disease groups to be addressed.
Factors
contributing to the burden of CRDs
Goal
of the strategy
Objectives
of the strategy
General
principles
Strategic
directions
Referens:
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.
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