The appearance of pulmonary respiration is one of the most important stages in the evolution of animals. It is associated with their access to land. For the first time, L. is found in amphibians, although pulmonary respiration is insufficient in comparison with strongly developed cutaneous respiration. L. amphibians are primitive and are two saccular protrusions. In caudate amphibians there is a pronounced trachea, in tailless amphibians the trachea is very short and L. open almost directly into the larynx. In reptiles, the air sacs are divided by partitions and have a spongy appearance; all airways and passages are lined with ciliated epithelium. Bronchi of birds of more complex branching, L. are divided by furrows into 4-7 metamerically located segments. The main and secondary bronchi outside L. form 5 air sacs, which in birds are reserve reservoirs of inhaled air, providing pneumatization) of the body. In mammals, the evolution of L. is mainly expressed by the further development of the respiratory tract, which acquires the cartilaginous skeleton and smooth muscles inside L., an increase in the area of contact of the lung tissue with air, which is ensured by the fragmentation of the alveolar structures, the division of L. into lobes, and the complication and intensification of the respiratory act associated with with the occurrence of a diaphragm in mammals.
Human L. development begins at the 3rd week. intrauterine life. Their bookmark has the form of an unpaired saccular protrusion of the endoderm of the ventral wall of the pharyngeal intestine, intensively growing caudally. On the 4th week. development at the lower end of the protrusion, two thickenings arise: primary bronchopulmonary kidneys (gemmae bronchopulmonariae) - the rudiments of the bronchi and lungs. From the 5th week. up to the 4th month a bronchial tree is formed. The embryos of the bronchi, actively proliferating and growing into the mesenchyme surrounding the anterior intestine, branch dichotomously, forming spherical extensions at the ends, from which branching of the bronchi of an ever smaller caliber occurs. By the beginning of the 6th week. lobar appear and by the end of the 6th week - segmental bronchi. The mesenchyme surrounding the growing bronchial tree differentiates into connective tissue, smooth muscles and cartilage of the bronchi. Blood vessels pi nerves grow into it. At the 4-5th month. intrauterine development, respiratory bronchioles are laid and the first alveoli appear. Acini found by Boyden (E. A. Boyden, 1974) at the 17th week. development. From the 4th month cartilage and smooth muscle cells are formed in the bronchi up to 4-5th orders. Splanchnopleura and somatopleura of a coelomic cavity, growing L. are pushed into-ruyu, turn into visceral and parietal pleura. By the time of birth, the number of lobes, segments, lobules basically corresponds to the number of these formations in an adult. With the beginning of respiration L. quickly straighten out, fill the pleural cavity; L.'s fabric becomes airy. After birth, the development process of L. continues.
L. in shape is similar to half a dissected cone. In fact, it repeats the form of the pleural space, limited by the parietal pleura. The right lung is shorter and wider than the left and larger in volume. The shape and size of L. are individual. They change in the same person depending on the phase of breathing. L.'s form depends on the shape of the chest. With a long and narrow chest L. is elongated and narrow, with a wide one - shorter and wider. In accordance with measurements made on corpses, the average height of the right L. is 27.1 cm in men and 21.6 cm in women; left L. 29.8 cm in men and 23 cm in women. The average width of the base of the right lung is 13.5 cm in men and 12.2 cm in women; left L. - 12.9 cm in men, 10.8 cm in women. The anteroposterior size of the base is on average 16 cm. According to Simon and Gams (G. Simon, G. Gamsu, 1977), the average length of the right lung in living adults, measured on radiographs, is 24.46 ± 2.39 cm. According to their according to the data, linear sizes of L. change little with age. So, in the same people, with an interval between studies of at least 10 years, the length of the right lung increased by an average of 0.2 cm and a width of 0.47 cm. L.'s dimensions change with a change in body position. According to Miller (W. Miller, 1943), with a horizontal position of the body, the length of the right L. is 17.5 cm, the left is 20 cm, and when vertical, the length of the right L. is 21 cm. Of the left is 23.5 cm. Nivener and Kleinerman (D. E. Niewoehner, J. Kleinerman, 1974) determined the average mass of one L. — 374 ± 14 g. The heaviest L. weighed 470 g. Wimster and Mac-Farlen (VV. Whimster, AJ MacFarlane, 1974) when studying 456 normal L. found that the average weight of right L. in men is 455 g, in women - 401 g, left - 402 g in men and 342 g in women. The ratio of the mass of the left and right L. in men is 0.9, in women is 0.86. According to Nivener and Kleinerman, the average total lung capacity (at an air pressure of 25 cm water column) reaches 2680 ± 120 ml with fluctuations of 1290 - 4080 ml The average minimum lung volume is 712 ± 90 ml with fluctuations of 250 - 1860 ml.
In each L. distinguish a rounded apex (apex pulmonis), base (basis pulmonis), three surfaces - costal (facies costalis), medial (facies medialis), diaphragmatic (facies diaphragmatica) and two edges - front (margo ant.) And lower (margo inf.). On the costal surface of the apex of L. there is a groove corresponding to the subclavian artery, and in front of it there is a groove of the brachiocephalic vein. On the costal surface, a variable imprint of the 1st rib is determined in the form of a subapical groove. The costal and diaphragmatic surfaces of L. are separated by a pointed lower edge. When inhaling and exhaling, the lower edge of the L. moves in the vertical direction by an average of 7-8 cm. The medial surface of the L. in front is separated from the costal surface by a pointed front edge, and below the diaphragmatic surface - by the lower edge. At the front edge of the left L. there is a cardiac notch (incisura cardiaca), passing downward into the tongue (lingula pulmonis sin.). The medial surface by the gates of L. and the pulmonary ligament is divided into 2 parts - the mediastinal (pars mediastinalis), facing the anterior mediastinum, with cardiac impression (impressio cardiaca) clearly visible on it and the vertebral (pars vertebralis) adjacent to the posterior mediastinum and thoracic spine , at left L. along a vertebral part the furrow from a thoracic aorta (sulcus aorticus) is vertically located. On the medial surface of the right L., in front of its gate, there is an impression from the fit of the superior vena cava, and behind the gate there are shallow grooves from the fit of the unpaired vein and esophagus. Approximately in the center of the medial surface of both L. there is a funnel-shaped depression - the gate of L. (hilus pulmonis). Skeletotopically L. gates correspond to the level of V - VII thoracic vertebrae in the back and II - V ribs in front. It is possible to shift the gate above or below the specified level by one vertebra. The roots of the right and left L. are more often at the same level, less often the root of the left L. is projected below the root of the right. The height of the gates of L. ranges from 4.3 to 9 cm. The diameter of the gates in the upper section is 1.5 - 3.5 cm, in the lower - 0.5-1.5 cm. The cross-sectional shape of the gates of L. is also different. In people with a brachymorphic physique, it is often pear-shaped or in the form of an ellipse, in dolichomorphic ones it is narrower oval or in the form of a comma, convex posteriorly convex. The main bronchus, pulmonary artery and veins, bronchial arteries and veins, nerve plexuses, lymph, vessels pass through L.'s gate. Lymph is located in the gates and along the main bronchi. nodes. The listed anatomical formations together make up the root of L. (radix pulmonis). The location of the L. root elements is usually such that the upper bronchial gland, pulmonary artery and lymph, nodes occupy the upper part of the L. gates, with bronchial vessels and a significant part of the branches of the pulmonary nerve plexus adjacent to the bronchus. The lower part of the gate is occupied by pulmonary veins. In the anteroposterior direction, the main bronchus is more posterior than the pulmonary vessels. Most often, in the root of left L., the pulmonary artery or its branches are above, the main bronchus is lower and behind, and the pulmonary veins are below and in front of the bronchus. In the root of the right L., the main bronchus lies behind the pulmonary artery, pulmonary veins - in the lower corner of the gate of L. and partially cover the branches of the pulmonary artery in front. L. root is covered with pleura. Below the root of L., a pleural duplicate forms a triangular shape (lig. Pulmonale), located in the frontal plane and dividing the lower part of the periomediastinal fissure of the pleural cavity into the anterior and posterior divisions.
The apex of L. in an adult corresponds to the dome of the pleura and protrudes through the upper aperture of the chest into the neck to the level of the apex of the spinous process of the VII cervical vertebra in the back and 2-3 cm above the clavicle in front. The position of the borders of L. and parietal pleura is very similar. The front edge of the right L. is projected onto the anterior chest wall in a line, to-ruy from the apex of L. to the medial end of the clavicle, continuing to the middle of the hilt of the sternum and further down to the left of the sternum to attach the VI costal cartilage to the sternum, where the lower border begins L. The front edge of the left L. from the level of the connection of the IV rib with the sternum deviates arcuately to the left and down to the intersection of the VI rib with the periosternal line. The lower border of the right L. corresponds to the cartilage of the V rib along the sternal line, the VI rib along the midclavicular line, the VII rib along the anterior axillary line, the VIII rib along the axillary axial line, the IX rib along the axillary axillary, and the X axial axillary line rib, along the paravertebral line - the spinous process of the XI thoracic vertebra. The lower border of the left L. differs from the same border of the right in that it begins on the cartilage of the VI rib along the periosternal line.
The subclavian artery is adjacent to the apex of L. from the medial side. The costal surface of L. is in contact with the parietal pleura. At the same time, the intercostal vessels and nerves adjacent to the L. are separated from them by the pleura and intrathoracic fascia. The base of L. lies on the corresponding dome of the diaphragm. The right L. is separated by a diaphragm from the liver, the left - from the spleen, left kidney with adrenal gland, stomach, transverse colon and liver. The medial surface of the right L. in front of the gate is adjacent to the right atrium, and above - to the right brachiocephalic and superior vena cava, behind the gate - to the esophagus. The medial surface of the left L. is adjacent in front of the gate with the left ventricle of the heart, and above - with the aortic arch and left brachiocephalic vein, behind the gate - with the thoracic aorta. The syntopy of the roots of L. is different on the right and on the left. An ascending aorta, superior vena cava, pericardium and partially right atrium are located in front of the root of the right L.; top and back - an unpaired vein. The aortic arch is adjacent to the root of left L. on top, behind the esophagus. Both roots cross the anterior diaphragmatic and posterior vagus nerves.
Lobes and segments of the lungs
Nomenclature of bronchopulmonary segments
L. are divided into lobes by means of interlobar cracks into which the visceral pleura penetrates, covering the interlobar surfaces of L. In the interlobar cracks of the pleura 1-2 cm does not reach the root L. The left L. is divided into upper and lower lobes (lobi sup. Et inf. ) through an oblique slit (fissura obliqua), passing along the surface of L. in the direction from above and behind, down and forward. The projection of the oblique fissure on the chest wall is determined from the spinous process of the III thoracic vertebra from the back to the junction of the bone and cartilage of the VI left rib. Right L. consists of three lobes: upper, middle and lower (lobi sup., Med. Et inf.). The upper and middle lobes are separated from the lower oblique gap, corresponding to the same gap of the left L. The middle share from the upper is separated by a horizontal gap (fissura horizontalis). Its projection onto the chest wall passes from the point of intersection of the projection of the oblique fissure with the middle axillary line almost horizontally forward to the site of attachment of the IV rib to the sternum of the cartilage. The size, shape and number of L. shares vary. So, the average share usually occupies 1/3 of the entire area on the costal surface of the right L., but it can also occupy from 1/4 to 1/2 of this surface. The degree of fusion of the upper and lower lobes of each L. is different, since in about 20% of cases an incomplete interlobular slit is found. The fusion between the upper and middle lobes of the right L. is observed in 10-20% of cases. Sometimes there are additional gaps that form the following more or less separate additional shares:
- the cardiac lobe of the right L., corresponding to the medial basal segment;
- the posterior lobe (lobus post.), Arising from splitting of the apical segment of the lower lobe from the group of basal segments;
- division of the upper lobe of the left L. into the upper and lower halves;
- an additional share of the right L. (lobus azygos), separated from the upper share by a furrow on its medial surface from the anomalously located unpaired vein;
- separation of the middle lobe of the right L. by an additional gap between the medial and lateral segments.
The bronchopulmonary segment is a L. site, more or less completely separated from the same neighboring sites by connective tissue layers, within which the segmental bronchus and the corresponding branch of the pulmonary artery branch. The veins that divert blood from the segments pass through the connective tissue septa between adjacent segments. L. segments are in the form of pyramids or cones, the top of which is directed to the gate, and the base is directed to the surface of L. According to the International Nomenclature of Pulmonary Segments (London, 1949), fixed with slight terminological changes in PNA, 10 bronchopulmonary segments are distinguished in each L.
According to PNA, in the upper lobe of left L. the apical segment is combined with the posterior (segmentum apicoposterius S1-2). The medial basal segment in the left L. can be absent or be poorly expressed.
Most L. segments, especially large ones, are divided into 2-3 sub-segments, ventilated by fourth-order bronchi. In a clinic, the topography of L. segments is very significant.
Upper right lobe. The apical segment is conical in shape, located in the upper front portion of the upper lobe. On the costal and medial surface, L. borders on the anterior and posterior segments. The top of the segment is directed down to the upper lobar bronchus. Segmental bronchus (B1) has a vertical direction and is divided into two subsegmental bronchi.
The posterior segment occupies the dorsal part of the upper lobe, adjacent to the posterolateral chest wall at the level of II – IV ribs. Above it borders with the apical segment, in front - with the anterior one, it is separated from the apical segment of the lower lobe from the bottom by an oblique slit, it borders on the lateral segment of the middle lobe from the bottom and in front. The top of the segment is directed in front of the upper lobar bronchus. B2 goes posteriorly laterally and somewhat upward.
The anterior segment borders on top of the apical, on the back - on the posterior segment of the upper lobe, on the bottom - on the lateral and medial segments of the middle lobe. The top of the segment is facing back and is located medially from the upper lobar bronchus. The anterior segment adjoins the anterior chest wall between the cartilages of the I — IV ribs; the medial surface of the segment faces the right atrium and superior vena cava. B3 goes down, anteriorly and laterally.
Right middle lobe. The lateral segment of the pyramidal shape, the base is located on the costal surface of L., at the level of IV-VI ribs. The segment above is separated by a horizontal slit from the anterior and posterior segments of the upper lobe, below and below by an oblique slit from the anterior basal segment of the lower lobe, and medially borders the medial segment of the middle lobe. The top of the segment is facing upward, medially and backward. B4 goes laterally forward and downward.
The medial segment is determined mainly on the medial and partially on the costal and diaphragmatic surfaces of the middle lobe, facing the anterior chest wall, between the cartilages of the IV-VI ribs, medially adjacent to the heart, from below - to the diaphragm. The segment above is separated by a horizontal slit from the anterior segment of the upper lobe; laterally, the anterior border is adjacent to the lateral segment of the middle lobe. B5 goes forward and down, parallel to the bronchus of the anterior segment of the upper lobe.
Lower right lobe. The apical (upper) segment occupies the upper part of the lower lobe and is adjacent to the posterior chest wall at the level of V - VII ribs, spine and posterior mediastinum. Above, the oblique fissure is separated from the posterior segment of the upper lobe, below it borders on the posterior basal and partially on the anterior basal segment of the lower lobe. B6 is the first posterior branch of the right lower lobar bronchus and extends obliquely to the segment.
The medial (cardiac) basal segment with its base extends to the medial and partially diaphragmatic surface of the lower lobe, adjacent to the right atrium, inferior vena cava and diaphragm. Front, laterally and posteriorly bordered by other basal segments of the lower lobe. The top of the segment faces up to the gate L. B7 is the upper branch of the common trunk of the bronchus segments, goes anteriorly and downward.
The anterior basal segment with its base facing the diaphragmatic surface of the lower lobe. The lateral surface of the segment is adjacent to the lateral chest wall between the VI - VIII ribs. The segment in front with an oblique fissure is separated from the lateral segment of the middle lobe, medially borders with the medial basal segment, at the back with the apical lateral and posterior basal segments. B8 departs from the common bronchus of the basal segments anterolaterally.
The lateral basal segment in the form of a small elongated pyramid is wedged between other basal segments so that its base is on the diaphragmatic surface of the lower lobe, and the lateral surface faces the lateral chest wall between the VII - IX ribs. The top of the segment is directed upward and medially. B9 departs with a common trunk with a posterior basal segment and follows in the posterolateral direction.
The posterior basal segment is located behind other basal segments, below the apical segment of the lower lobe. It is determined on the costal, medial and partially on the diaphragmatic surfaces of the lower lobe, adjacent to the posterior chest wall at the level of VIII - X ribs, to the spine, to the posterior mediastinum. The upper part of the segment is sometimes separated in the form of an independent subarcotic segment. B10 continues the direction of the lower lobar bronchus and spreads posteriorly and downward.
Upper left lobe. The apical segment in shape and position corresponds to the apical segment of the right L. The posterior segment is adjacent to the posterior chest wall at the level of the first II - III ribs, medially - to the aortic arch and left subclavian artery. B1 often departs from the common bronchus with the posterior bronchus (apical posterior bronchus).
The posterior segment in position is also similar to a similar segment of the right lung. It is adjacent to the posterolateral chest wall at the level of III — V ribs. B2 branches off from the apical posterior bronchus.
The anterior segment is one of the largest segments of the left L. It is adjacent to the anterior and lateral chest wall at the level of I - IV ribs. The medial surface is in contact with the left ventricle of the heart. B3 from the upper trunk of the upper lobar bronchus goes anteriorly, upward and laterally.
The upper reed segment is located under the anterior and posterior segments and is adjacent to the anterior chest wall at the level of III – IV ribs, and to the side wall at the level of IV – VI ribs. B4 departs from the lower (reed) trunk of the upper lobar bronchus and goes up, anteriorly and laterally.
The lower reed segment is located under the upper reed segment. From below and behind, the segment is separated by an oblique fissure from the anterior and medial basal segments of the lower lobe. B5 arises from the reed bronchus and extends downward, anteriorly and laterally.
Lower left lobe. The apical (upper) segment along the borders and topography is similar to the same segment of the right lung. B Q departs from the lower lobar bronchus 1 cm below the mouth of the upper lobar bronchus and extends posteriorly.
The medial (cardiac) basal segment is inconstant. It is located on the medial surface of the lung anterior to the pulmonary ligament in the form of a narrow wedge. B7 departs from the common trunk along with the bronchus for the lateral basal segment and usually lies anterior to it.
The anterior, lateral and posterior basal segments in position and boundaries are similar to the basal segments of the right lung. Segmental bronchi of the anterior and posterior basal segments are the final divisions of the lower lobar bronchus.
L.'s blood supply is carried out by pulmonary and bronchial vessels. Pulmonary vessels make a small circle of blood circulation and carry out hl. arr. gas exchange function between blood and air. Bronchial vessels provide nutrition L. and belong to a large circle of blood circulation. Between these two systems, there are quite pronounced anastomoses. Bronchial branches branch only to the respiratory bronchioles, and alveolar wall nutrition occurs through the capillary network of the pulmonary vessels. The right and left pulmonary arteries are branches of the pulmonary trunk. Pulmonary arteries in L. are divided into lobar, and then segmental branches. From the right pulmonary artery, the anterior trunk (truncus ant.) Departs upward, dividing into the apical and anterior segmental arteries (aa. Segmentales apicalis et ant.). The posterior segmental artery (a. Segmentalis post.) Departs independently distal to the beginning of the anterior trunk. The segment of the pulmonary artery after the anterior trunk has left is called the interlobar trunk (truncus interlobaris). At the level of the middle lobe bronchus, the middle lobar artery (a. Lobaris media) originates from the interlobar trunk, dividing into the lateral and medial segmental arteries (aa. Segmentales lat. Et med.). After the middle lobar artery leaves, the interlobar trunk continues downward in the form of the lower lobar artery (a. Lobaris inf.), The edge gives off the apical segmental artery (a. Segmentalis apicalis) and continues as the basal part. Four segmental arteries depart from it to the basal segments of the lower lobe: medial, anterior, lateral and posterior basal (aa. Segmentales basales med., Ant., Lat. Et post.). The left pulmonary artery at the gate of L. lies on the upper semicircle of the left main bronchus, goes around the left upper bronchus and goes down. The apical and posterior segmental arteries depart from the front of the left pulmonary artery (aa. Segmentales apicalis et post.), From the interlobar part - the anterior segmental artery (a. Segmentalis ant.) And the common reed artery (a. Lingularis communis), edge divided into upper and lower reed segmental arteries (aa. segmentales lingulares sup. et inf.). The interlobar part passes directly to the lower lobar artery (a. Lobaris inf.), Segmental arteries depart from a cut: apical (a. Segmentalis apicalis) and 4 basal arteries - medial, anterior, lateral and posterior (aa. Segmentales basales med., ant., lat. et post.). The division of the pulmonary artery into segmental branches is individually variable. Different can be the number of branches, their length, levels and angles of departure. Branching of segmental arteries occurs mainly dichotomously and corresponds to branching of the bronchial tree. Branches of the pulmonary artery of various orders up to intralobular vessels are arteries of the muscular-elastic type, arteries accompanying terminal bronchioles are arteries of the muscular type. In the arterioles and at the beginning of the precapillaries, smooth muscle sphincters lie in their wall, which ensure the regulation of blood flow. In the wall of the arterioles, the non-muscular sections alternate with the muscle ones, and in the precapillaries (diam. 40–70 μm) there are no muscle cells. Precapillaries are located between the alveolar passages and give 12-20 capillaries to dia. 6 - 12 microns in the interalveolar septum. The capillaries form 4-12 loops on the wall of the alveoli merge into postcapillaries. The network of capillaries in L. is very dense. The total area of the capillary network of one L. is 35–40 m2. Not all capillaries are open to blood flow. At rest, most of the capillaries drop, and blood flows in a short way from precapillaries to postcapillaries. Width of post capillaries approx. 50 microns, in their walls there are no smooth muscle cells. Postcapillaries continue into venules with a width of 50-80 microns, containing individual muscle cells in the wall.
Intralobular veins, leaving the lobules, flow into the veins of the interlobular septa. The veins of the subpleural connective tissue also enter here. From interlobular veins intersegmental veins, veins of segments and lobes are formed, which at the gates of L. merge into the upper and lower pulmonary veins. The formation of pulmonary veins is complex and highly variable. In the right L. the superior pulmonary vein is formed from the veins of the upper and middle lobes, the lower - from the veins of the lower lobe. In left L. the upper and lower pulmonary veins are formed by merging inside the pulmonary veins of the upper and lower lobes, respectively. In the formation of pulmonary veins, 2 to 5 large tributaries can participate. The upper and lower pulmonary veins of both L. flow into the left atrium. The left pulmonary veins often merge into the common trunk before entering the atrium. The number of right pulmonary veins flowing into the left atrium can increase to six.
The bronchial branches extend from the posterior surface of the aorta, most often on the border between its arch and the beginning of the descending aorta: On the right, bronchial arteries can depart from the first intercostal artery and the internal thoracic artery. The total number of bronchial arteries is most often equal to 4 (2 for each lung), but can range from 2 to 6. In addition to the bronchial branches, the esophageal and pericardial arteries, the branches of which penetrate into the L. through the pulmonary ligament, take part in the blood supply to the lung. Bronchial branches in L. follow along the bronchi. One bronchus is often accompanied by 2-3 branches. A peribronchial arterial network forms on the bronchi, giving arterioles and capillaries, connecting to the capillaries of the pulmonary arteries. In the lung tissue, the bronchial branches anastomose with the branches of the pulmonary artery; numerous arteriovenous anastomoses were discovered - the passage of closure arteries into the veins of the bronchi, subpleural veins, interlobular veins - inflows of pulmonary veins.
The bronchial veins of right L. fall into an unpaired, rarely into the internal chest vein; left L. - in a semi-unpaired or less often directly in the left brachiocephalic vein. Some small bronchial veins arising from the peribronchial venous plexus of the bronchi, bifurcation of the trachea, from the lymph nodes, flow into the pulmonary veins at the gates of L. In the pulmonary ligaments and fiber of the mediastinum, bronchial veins anastomose with the mediastinal veins.
The beginning of lymph, L.'s ways are superficial and deep networks of limf, capillaries. The superficial network is located in the visceral pleura and consists of thin lymphs, capillaries of dia. 9-25 microns, from which the lymph passes into the plexus of the lymph vessels of the 1st, 2nd and 3rd orders. The deep capillary network is located in the connective tissue inside the pulmonary lobes, in the interlobular septa, in the submucosal base of the bronchial wall, around the intracellular blood vessels and bronchi. According to D.A. Zhdanov, in the pulmonary lobule, lymph, capillaries are located in the interalveolar septa and continue into the capillaries accompanying the alveolar passages and small blood vessels. Croqueatto (O.S. Croxatto, 1972) claims that in the distal parts of L. lobules near the alveoli, there are no limbs, there are no capillaries, but Lawers (J. M. Lauweryns, 1974) described juxtalveolar lymphs, capillaries as the most distally located lymph, formations of L Perivascular and peribronchial lymph, capillaries and vessels anastomose inside the lobules and on the way to the gates of L., where they merge together to form collector lymph, vessels L. Lymph, vessels located in the visceral pleura, anastomose with interlobular and intralobular lymph capillaries and coc rows. Thanks to these connections, lymph flow from the superficial lymph, the L. network can go into the deep lymph, network and further to the gate of L. Regional lymph, the nodes of L. by PNA are combined into the following groups:
- pulmonary (nodi lymphatici pulmonales) located in the parenchyma L., Ch. arr. in places of division of the bronchi;
- bronchopulmonary (nodi lymphatici bronchopulmonales), lying in the gates and adjacent areas of L .;
- upper tracheobronchial (nodi lymphatici tracheobronchiales sup.), Associated by location with the trachea and the upper part of the main bronchi;
- lower tracheobronchial - bifurcation (nodi lymphatici paratracheobronchiales inf.) Located on the lower surface of the bifurcation of the trachea and on the main bronchi;
- near tracheal (nodi lymphatici tracheales) located along the trachea.
By the paths of lymph outflow, each L. is divided into three areas: upper, middle and lower, which do not coincide with the lobes. In the right L. lymph from the upper region, including the anteromedial part of the upper lobe, flows into the right peritracheal and upper tracheobronchial lymph nodes. From the middle region, which occupies the posterolateral sections of the upper lobe, the middle lobe and the upper part of the lower lobe, the lymph goes partially to the upper right, and mostly to the lower tracheobronchial lymph. nodes. From the lower region, that is, from the remaining sections of the lower lobe, lymph flows into the lower tracheobronchial lymph nodes. part of the lymph goes down to the diaphragmatic lymph. nodes. In left L., lymph from the upper region enters the left tracheal and upper tracheobronchial lymph. nodes, as well as in the anterior mediastinal nodes. From the middle region, including the uvula of the upper, the apex and the middle part of the lower lobe, lymph spreads in two directions: to the left upper tracheobronchial, upper anterior mediastinal and lower tracheobronchial lymph nodes. From the lower region of the lymph flows into the lower tracheobronchial lymph. nodes. In addition, from the lower lobes of both L. lymph go out, the vessels going down between the sheets of the pulmonary ligament to the posterior mediastinal nodes located behind the esophagus at the diaphragm. The lymphatic vessels of these nodes are sent to the abdominal cavity to the celiac lymph nodes. Lymph, nodes of the left and right L. widely anastomose among themselves, with front and back mediastinal lymph nodes. In the lower tracheobronchial lymph, the nodes of the path of the outflow of lymph from the lungs are connected to the vessels from the heart and esophagus. The efferent vessels of the left peritracheal and upper tracheobronchial lymph nodes are directed mainly to the same right nodes, which, according to D. A. Zhdanov, are "the main lymph station of both lungs". From the right lymph nodes, the right bronchial mediastinal trunk (truncus bronchomediastinalis dext.) Begins, flowing into the corresponding jugular trunk (truncus jugularis) or into the deep cervical nodes. Thus, the lake, most of the lymph from both L., flows into the right lymph, duct (ductus lymphaticus dext.). From the upper parts of the left L. lymph often flows directly into the thoracic duct (ductus thoracicus).
L.'s nerves are separated from the vagus nerve, the nodes of the sympathetic trunk, as well as the phrenic nerve in the form of bronchial and pulmonary branches forming the pulmonary plexus (plexus pulmonalis) at the gates of L., cut into anterior and posterior. Their branches in L. form the peribronchial and perivasal plexuses accompanying the branching of the bronchi and blood vessels. In the course of the plexuses, small accumulations of nerve cells of parasympathetic nature are found. Three nerve plexuses are distinguished in the bronchi: adventitial, muscular and subepithelial; the last on bronchioles extends up to alveoli. Interoceptors are located in the bronchi, blood vessels, alveolar parenchyma, visceral pleura, connective tissue L.
Glaucoma cells are found in adventitia vessels. Sensitive innervation of L. is carried out by dendrites of cells of the lower node of the vagus nerve and cells of the lower cervical and upper thoracic spinal nodes. V.F. Lashkov established the possibility of participating in the innervation of the lung spinal nodes from C5 up to L2. Nerve impulses from the bronchi are carried out by hl. arr. but to the afferent fibers of the vagus nerves, and from the visceral pleura, along the afferent spinal fibers. The sympathetic innervation of L. comes from the cells of the lateral horns of the gray matter of the Th2-5 segments of the spinal cord. The path of parasympathetic innervation begins in the medulla oblongata from the cells of the posterior nucleus of the vagus nerve. Axons of these cells pass in L. as a part of branches of a vagus nerve.
Establishment of breathing and straightening of L. leads to an increase in its vertical size, smoothing of the edges, the gradual appearance of impressions on the pulmonary surface from the aorta, the common carotid and subclavian arteries, heart, and domes of the diaphragm. The top of L. gradually rises above level I of the rib and collarbone, the front edges of L. approach the midline, fill the rib-mediastinal sinuses, and their projection on the anterior chest wall is combined with the projection of the anterior pleural borders. The lower border L. of the breathing child falls on one rib in comparison with the not breathing. Syntopia L. of a newborn has a relatively large area of contact with the thymus and heart. In newborns, the lower lobes of both L. are much larger than the upper. By about 2 years, the proportions of the sizes of the shares become the same as in adults. The specific gravity (mass) of L. breathing newborn is 0.49. The mass of both L. in a newborn with steady breathing ranges from 39 to 70 g, including the right - from 21 to 37 g, the left - from 18 to 33 g. In the aerated L. of the newborn, most of the alveoli straightens, but there is some a swarm of atelectatic alveoli containing fluid. The elements of acinus in a newborn are not fully differentiated. L.'s growth is caused by hl. arr. an increase in the number and volume of alveoli, and consequently, the volume of L. By the age of 8 years, L. increases by 8 times, in a child of 12 years of age - by 10 times, in an adult - by 20 times. After birth, L. mass grows very rapidly, especially in the first 3 months. of life. On average, the mass of both L. in newborns is 57 g, in children of 1 year old - 225 g, 6 years old - 350-400 g, by the age of 15 it reaches 600-900 g, and the right L. in all ages is about 1.2 times heavier than the left. The pulmonary segments of the child and adult are outwardly similar, but in the first years of life they are delimited by more abundant layers of loose connective tissue. Up to 8 years of age, intensive processes of differentiation of the epithelium, cartilage, elastic fibers, and muscle bundles of the bronchi occur in L. From the age of 12 years old L. in external and internal structure are similar to L. adult.
The involution of the lungs during aging is most pronounced after 70 years, but in different ways in people of the same age and even within the same L. It covers all structures. The bronchial epithelium becomes lower, polyploidy is determined in the nuclei, the basement membrane thickens, the glands atrophy, the secret thickens, the muscle layer atrophies, cartilage undergoes necrosis, calcification, and ossification. All this violates the purification of the bronchi and, together with the thinning of the walls of the alveoli, a change in their elasticity, contributes to the development of hron, bronchitis and emphysema L. The walls of respiratory bronchioles are atrophied and sclerosed, which also contributes to emphysema. However, emphysema does not always develop, but only in cases of accession of chron, bronchitis or violation of bronchial secretion in coronary heart disease "
On a roentgenogram of L. in a direct projection, the peripheral sections are occupied by the shadow of the soft tissues of the lower section of the neck, chest, and shoulder girdle. In women, shadows of the mammary glands are projected onto the lower sections of the pulmonary fields. Under the array of soft tissues is the skeleton of the chest. L. form in the picture the so-called. pulmonary fields - right and left. Normally, the right pulmonary field is shorter and slightly wider than the left. The sections of these fields projecting above the shadow of the clavicle are called the apices of L. Each pulmonary field is conditionally divided into three sections: the upper, middle and lower. The upper section is located between the upper edge of the pulmonary field and the horizontal line drawn at the level of the lower edge of the anterior end of the II rib. The middle section is located between this line and a parallel line drawn at the level of the lower edge of the front end of the IV rib. The lower section occupies the remainder of the pulmonary field to the diaphragm. In addition, vertically directed parallel lines drawn respectively to the border between the thirds of the clavicle, the pulmonary field is divided into three zones: internal, or basal, middle and external.
L. of a healthy person are filled with air and therefore appear bright on the radiograph. But pulmonary fields are not structureless. In their inner sections, between the front ends of the II and IV ribs, an intense shadow of the roots of L. is visible. On the right, it has the shape of a crescent, separated from the mediastinum by a transparent strip of the intermediate and lower lobar bronchus. The shadow of the left root is located slightly higher and partially hidden by the shadow of the heart. The image of a normal body is differentiated. In its upper part, the shadow of the pulmonary artery with a vessel departing from it is determined for the upper lobe. From this shadow, the trunk of the lower lobar artery is projected downward, giving the branches to the other departments of L. The lower border of the root is the shadow of large pulmonary veins, going almost horizontally to the left atrium at the level of VIII - IX thoracic vertebrae.
Against the background of pulmonary fields, a peculiar pulmonary pattern looms. It is formed normally by the shadows of arteries and veins; bronchi, interstitial tissue and lymph, the system weakly participate in its formation. The largest vessels are located in the basal region, and the pattern here is clearly expressed. To the periphery, the caliber of the vessels decreases, and in the outer zone of the pulmonary field, only small vascular branches are outlined. The density of the pattern in different departments is not the same - wedge-shaped areas with an abundance of vascular shadows and non-vascular zones naturally alternate. This is because the lobar and segmental vessels come from the root in the form of several beams diverging at an angle. At the same time, segmental arteries are projected in the upper sections of the pulmonary fields inward from the veins of the same name, in the middle sections above them and in the lower sections outside them. For pulmonary drawing, normal branching, clarity of contours and a decrease in the caliber of blood vessels to the periphery are normal. Depending on the location of the vessels with respect to x-rays, they give a display in the form of stripes, circles and ovals.
Each half of the diaphragm determines an arc on a direct radiograph, going from the shadow of the mediastinum to the lateral part of the chest, with a contour cut, it makes an angle corresponding to the costal-diaphragmatic sinus. The upper point of the right half of the diaphragm lies at the height of the front end of the VI rib, and the left - 1-2 cm lower. In individuals, the diaphragm folds when inhaled; in these cases, the outline of half of the diaphragm consists of 2–4 arcs.
On a radiograph in a lateral projection, both L. are projected onto each other, making up one pulmonary field. Two large light areas are distinguished in it: the posteriorchondral (retrosternal) space - between the sternum and the shadow of the aorta and heart; postcardiac (retrocardial) space - the area between the heart and spine. Between these areas is the shadow of the heart and large vessels. In the upper part of the pulmonary field, anterior to the shadow of the spine, there is a light stripe of the trachea a few more than 2 cm wide. Heading down, the trachea narrows at the level of the lower contour of the aortic arch and is divided here into two main bronchi. The right one, as it were, continues the light strip of the trachea, and the left one moves backward at an acute angle. At the end of the image of the right main bronchus, circular enlightenment from the axial section of the right upper lobe bronchus is usually visible.
L.'s roots give on a lateral roentgenogram a total shadow 2.5–3 cm wide. Its upper part is formed by hl. arr. left and right branches of the pulmonary artery, and the image of the left branch is almost parallel to the lower contour of the aortic arch. The lower border of the root shadow is considered the image of wide venous trunks, visible against the background of retrocardial space at the level of VIII and IX thoracic vertebrae. These veins merge into the lower pulmonary vein. The pulmonary pattern on the lateral radiograph is also represented mainly by the shadows of the blood vessels; the vessels of the adjacent L. are more clearly visible. Vascular bundles are better defined, which are sent to the front and rear sections of L., in particular the arteries and veins of the anterior segments, middle lobe, tongue, and upper segments. Arteries and veins of the segments of the lower downstream make up a complex bundle of vascular shadows against the background of retrocardial space, in which large vessels of the lower group of veins stand out most clearly.
Both halves of the diaphragm cause running above each other or intersecting arcs. The front part of each arch forms a shallow angle with the contour of the anterior chest wall, corresponding to the anterior part of the rib-phrenic sinus, and the rear part forms a deep angle with the contour of the chest wall, corresponding to the posterior sinus.
For an in-depth study of X-ray anatomy and X-ray physiology of L. special methods are used: tomography, bronchography, etc. On tomograms of L. roots, bronchi of the 1st and 2nd order, the main branches of the pulmonary artery and large pulmonary veins are distinguished. On pictures of various layers of L. it is possible to identify all lobar and segmental arteries and veins, and also the main, lobar and segmental bronchi (bronchi of the 3rd, 4th, 5th, 6th and 7th segments are visible hl. Obr. On lateral tomograms). From the photographs through the grating applicators, it is possible to evaluate the mechanism of external respiration (using x-ray), and by densitometry - ventilation of the lungs. The structure of inhalation and exhalation, ventilation of different zones of L. and the speed of propagation of a pulse wave in L. are examined by means of electrocography and video densitometry. The study of a series of broncho-grams allows one to get an idea of the morphology and function of the bronchial tree, and a series of L. angiograms — about the morphology and function of the vessels of the pulmonary circulation and bronchial arteries.
The boundaries of the lobes and segments on radiographs of L. of a healthy person, as a rule, are not visible, since the interlobar pleura is thin and does not give an independent image. The location of the lobes and segments is determined approximately, guided by the data of topographic anatomy. Figure 23 shows the projection of the lobes and segments on the front and side radiographs. It can be seen that in the front image, the image of the various lobes is largely the same. The pulmonary tissue of the upper lobe is isolated in projection only in the apical lateral part of the pulmonary zero, and the lower lobe - in the non-lateral part. Therefore, for topical diagnostics, lateral radiographs are of greater importance; on them L.'s shares are projected basically separately. The projection of the oblique interlobar fissure in the lateral image comes from the highest point of the diaphragm, i.e., usually from the posterior end of its anterior third, up through the middle of the root shadow and further to the intersection with the shadow of the spine. The horizontal interlobar fissure goes from the front end of the 4th rib to the middle of the root shadow to the intersection with the oblique fissure.
In a breathing stillborn child, the pulmonary fields on radiographs do not differentiate; only the bones of the chest are visible. In a newborn, a bright strip of the trachea and gaps of the large bronchi are determined. Pulmonary fields are relatively small due to the large width of the middle shadow and the high position of the diaphragm. L.'s roots are represented by narrow stripes and rounded shadows of the branches of the pulmonary artery. Due to the small caliber of the vessels, the pulmonary pattern is poorly distinguishable. In early childhood, as the diaphragm lowers and the thymus gland decreases, the shadows of L.'s roots become more visible, but are still located at the same height (sometimes the left root is even lower than the right). With the cry, cough and stress of the child, the shadow of the roots becomes wider and more intense, which can simulate the presence of patol, changes.
In children of the first years of life, the anatomical feature of L. is the deviation of the trachea to the right of the midline of the body and the high position of its bifurcation. By the age of 10-12, bifurcation drops from level III of the thoracic to level VI of the thoracic vertebra. In young children, respiratory fluctuations in the caliber of the bronchi are pronounced. With a strong exhalation, the lumen of even relatively large bronchi can disappear. L. in children are more full-blooded than in adults; veins are relatively narrow; blood flow in them is faster. In children aged 7 years and older, the shadow of the normal pleura is often visible in the form of an arched strip above the apex of L. and a narrow line in the outer zone of the pulmonary field in the region of the I and II ribs. The diaphragm is located high, more flattened than in adults, pleural sinuses less deep. During the first 12 years of life, the diaphragm descends from level VIII to XI of the thoracic vertebra and becomes more convex, in connection with which the pleural sinuses deepen. With a large thymus gland, the extension of the shadow of the upper mediastinum in the anterior radiograph and the dimming of the retrosternal space in the lateral image are determined.
In elderly people (60–74 years), an increase in the intensity of the shadow of L. roots and a decrease in their differentiation are noted. This is even more pronounced in persons of senile age (75-89 years). The transverse dimensions of large bronchi and veins during aging do not change, the arteries in the roots of L. expand, to a greater extent in men. On tomograms in the walls of the trachea and large bronchi, lime deposits are detected. The transparency of the pulmonary fields is increased, moderate diffuse enhancement of the pulmonary pattern is determined without its deformation. In senile age, the tortuosity of the bronchi increases, their lumen becomes uneven, in places clearly distinct.
L. consists of branches of the bronchi forming the bronchial tree (airways of L.), and the alveolar system, which together with the respiratory bronchioles, alveolar passages and alveolar sacs make up the alveolar tree (L. respiratory parenchyma). As a result of 8 - 10 branches of the main bronchus, small bronchial diameters are formed. OK. 1 mm, the wall of which still contains cartilaginous plates. Branching of each of them forms secondary pulmonary lobules (lobuli pulmonales secundarii). According to Hayek (H. Hayek, 1960), in both L. there are approx. 1000 lobular bronchi. However, according to modern theory, lobular bronchi and pulmonary lobes in L. more - approx. 800 in each. Neighboring lobes are separated from one another and from the visceral pleura by interlobular septa, consisting of loose fibrous connective tissue connected by subpleural and peribronchial connective tissue. In interlobular partitions pass lobular veins and a network of limf, capillaries. The lobules are located in two or three rows in the peripheral layer of the lobe of L. up to 4 cm thick, surrounding the central part of the lobe, where the branches of the lobar bronchus, branches of the pulmonary artery and vein, lymph, vessels and nerves pass in the connective tissue. The surface segments are similar to polygonal pyramids 21–27 mm high and 9–21 mm wide. Deep slices are shallower, have a complex multifaceted shape. The smallest lobes with a width of 5 mm are located in the region of the apex and lower edge of L. Inside the lobule, the branch lobar bronchus further branches up to the terminal bronchiole (bronchiolus terminalis). End bronchioles are dichotomously divided into respiratory (respiratory) bronchioles (bronchioli respiratorii) of the 1st-4th order. Respiratory bronchioles, in turn, are divided into alveolar passages (ductuli alveolares), branching from one to four times and ending with alveolar sacs (sacculi alveolares). On the walls of the alveolar passages and alveolar sacs, and on the tatka of the respiratory bronchioles, L. alveoli (alveoli pulmonis) are opened in their lumen.
The morphofunctional unit of the respiratory department of L. is acinus (acinus pulmonaris).
The data of morphology and physiology suggest that the acinus begins from the terminal bronchiole. The term "acinus" includes all branches of one terminal bronchiole - respiratory bronchioles of all orders, alveolar passages and alveoli. In one pulmonary lobule, there are 16 - 18 acini. According to Hansen (J. E. Hansen) et al. (1975), the acinus contains one terminal bronchiole, 14–16 respiratory bronchioles, 1200–1500 alveolar passages, 2500–4500 alveolar sacs and 14,000–20,000 alveoli. On average, one alveolar sac accounts for 3.5 alveoli with a maximum of 8 alveoli. The calculated acinus volume is 182.8 mm3. A. G. Eingorn (1956), Ryan (S. Ryan, 1973), Raskin and Herman (SP Raskin, PG Herman, 1975) distinguish smaller structural parts in L. - primary pulmonary lobules (lobuli pulmonales primarii), which include one respiratory bronchiole and associated alveolar passages and alveoli. One acinus contains up to 16 such lobules. In total in one L. apprx. 15,000 acini, 300-350 million alveoli. The general surface of all alveoli of one L. is very significant. However, the data on this issue are mixed. According to Haysleton (P. S. Hasleton, 1972), the internal area of L., fixed during inflation by formalin vapor, is 24–69 m2. According to Weibel (E. R. Weibel, 1963), it is 95 m2, and according to Hills (B. A. Hills, 1973) - 146 m2.
The terminal bronchioles are lined with a single-layer secretory epithelium. In bronchioles, there are two types of cells: ciliated and non-ciliated. A thin intrinsic plate of the mucous membrane contains longitudinal elastic, collagen, reticular fibers and spiral bundles of smooth muscle cells, which in places form a continuous layer. There are no glands and cartilaginous plates in the wall of the terminal bronchioles. The connective tissue surrounding the bronchioles passes into the connective tissue base of the respiratory parenchyma L. In the respiratory bronchioles, cubic epithelial cells lose cilia; upon transition to the alveolar passages, cubic epithelial cells are replaced by respiratory alveolocytes. The muscular plate in the respiratory bronchiole becomes thinner and breaks up into separate spiral muscle smooth muscle cells. They are especially pronounced in the annular sections of the respiratory bronchioles, free of alveoli. The walls of the alveolar passages and alveolar sacs, in the form of a hemi-spheroid or a truncated cone, are entirely occupied by the alveoli. Six types of alveoli were distinguished in shape: spheroid with 3/4 sphere, spheroid with 1/4 sphere, truncated cone, cylindroid with a hemispherical bottom, cylindroid with a flat bottom, truncated long ellipsoid. In cross section, their shape varies from hexagon to ellipse. According to Hansen, the size of the mouth of an adult alveolus is 0.15-0.25 mm, and its depth is 0.06-0.3 mm. In old age, the diameter of the mouth of the alveoli increases. The alveoli are closely adjacent to each other, so their walls are in contact and serve as interalveolar septa. The edges of these partitions, protruding into the lumen of the alveolar passage, are somewhat thickened and form, as it were, rings surrounding the entrances to the alveoli. In the alveolar passages in these rings are bundles of smooth muscle cells that form the muscles of the respiratory parenchyma L. In the alveolar sacs, the entrance to the alveoli is surrounded only by rings of elastic reticular fibers. Neighboring alveoli are interconnected by alveolar pores (pori alveolares), holes of dia. OK. 10-15 microns. The wall of the alveoli is lined with a single-layer flat respiratory alveolar epithelium and contains two types of cells: respiratory (scaly) and large (granular). It was found that the cells of the alveolar lining on the air side are covered with a thin non-cellular layer or film. According to most researchers, this layer partially or entirely consists of a surfactant - a substance with well-defined surface-active properties. The third type of alveolar cells - alveolar phagocytes (macrophages) - is located in the air space of the alveoli, almost always adjacent to the alveolar wall. The cells of the alveolar epithelium form a continuous layer, Thinning to 0.2 μm, but not interrupted at the points of contact with the capillaries. The alveolar epithelium is located on the basement membrane with a thickness of 0.05-0.1 microns. Outside, blood capillaries adjacent to the alveolar septum, as well as a network of elastic fibers surrounding the alveoli, are adjacent to the basement membrane. In addition, around the alveoli there is a supporting network of reticular and collagen fibers. All fibers and blood capillaries are immersed in the main intercellular substance, which is a complex complex of proteins and mucopolysaccharides. In the interalveolar septa (septi interalveolares) several forms of cells are found. Among them are sentimental cells that have phagocytic properties. They, penetrating into the lumen of the alveoli, become alveolar phagocytes. White blood cells are also found in the interalveolar space. Since the alveoli are closely adjacent to each other, the capillaries braiding them border one surface with one alveoli, and the other with the neighboring one. This ensures optimal gas exchange conditions. The boundary between the blood flowing through the blood capillaries and the air filling the cavities of the alveoli is the capillary endothelium, its border membrane, the border membrane of the alveoli and alveolar epithelium. Both boundary membranes can merge into one. In the places where capillaries fit, the barrier between blood and air is thinned due to a significant decrease in the cytoplasm layer of alveolar and endothelial cells. The thickness of the barrier, according to various authors, is from 0.1 to 4 microns. The thin part of the blood-air barrier accounts for 60% of the total area of the alveoli. This part of the barrier is the site of the most intense gas exchange between blood and air.
The main function of L. is respiratory. It consists in blood arterialization in the capillaries of the pulmonary circulation. Three processes are necessary for its implementation: ventilation of the alveoli with air or a gas mixture with a sufficiently high partial pressure of oxygen and a low partial pressure of carbon dioxide; diffusion of oxygen and carbon dioxide through the pulmonary membrane; blood flow through the capillaries of the pulmonary circulation. All three processes are closely related. L.'s ventilation is provided by a periodic change of inspiration and exhalation - external respiration. During inspiration, due to an increase in the volume of the chest cavity, the pressure in the pleural cavity decreases. This leads to stretching of the walls of the alveoli, which have elastic properties, and an increase in the volume of L. During exhalation, the elastic forces of the lungs and the walls of the chest cavity accumulated during inhalation provide a decrease in lung volume. At the end of a quiet exhalation, when almost all the respiratory muscles are relaxed, L.'s elastic thrust is balanced by the tension of the walls of the chest cavity. The amount of gas in L. at this time is called the functional residual capacity. If the pressure around L. becomes atmospheric (open pneumothorax, isolated lungs), then L. almost completely subsides. Only the so-called remains in them. minimum air volume. Under normal conditions, when L. are in the closed chest cavity, pleural pressure in the highly located departments is most negative due to an increase in pressure in the pleural cavity from top to bottom. This pressure gradient (approx. 0.23 cm water column per cm) is due to the severity of the lungs and the hydrostatic pressure of the pleural fluid column. The consequence is a greater degree of static stretching of the lung tissue in the upper areas of L. than in the lower, although ventilation is carried out more intensively in the lower parts of L. than in the upper.
The elastic properties of L. by about 1/3 are due to the presence of elastic fibers in the walls of the alveoli and by 2/3 of the surface tension at the boundary of the concave surface of the alveoli with air. If the alveoli were wetted from the inside with blood plasma, the surface tension would be large, approximately 0.4-0.5 mn / cm. In reality, this force is much less (0.05-0.1 mn / cm). The low surface tension is due to the fact that the surface of the alveoli and the walls of the bronchioles is covered with a lining of a surfactant - surfactant. Lining thickness 20-100 nm. It consists of lipids (mainly dipalmitoyllecithin) in complex with proteins. Surfactant is formed in type II pneumocytes. An increase in the size of the alveoli during inspiration is accompanied by an increase in surface tension.
Surfactant formation is regulated by parasympathetic nerve fibers. Surfactant is necessary to stabilize the state of the alveoli. With a lack of surfactant, L.'s extensibility decreases, atelectases are formed, fluid flows into the alveoli.
Air is transported to and from the alveoli by airways. Gas exchange through the walls of the airways is not of practical importance, the volume of the cavity of the airways is called anatom with a clear dead space. The lumen of the intrapulmonary bronchi depends on the elastic traction of the lung parenchyma surrounding the bronchi, and on the tone of the smooth muscles of the bronchi. Elastic traction expands the bronchi, smooth muscle tone narrows them. The lumen of the bronchi increases on inhalation and decreases on exhalation. Cholinergic (parasympathetic) fibers enhance the contraction of the smooth muscles of the bronchi, adrenergic (sympathetic) fibers weaken it (beta-adrenergic receptors predominate in the bronchial muscles). There are two methods for moving gas molecules ("transverse" and "longitudinal" diffusion). The first - convective - is due to the movement of the gas mixture along the gradient of the pressure common to the mixture.
In addition, gas molecules diffuse in the airways and alveoli due to the difference in the partial pressure of the gases. The presence of connections between neighboring areas of the lungs was established. Air introduced into the segmental bronchus iodine with a pressure of 4-8 cm of water. Art., penetrates into adjacent segments (the phenomenon of collateral ventilation). Compounds are at the level of the alveolar passages and bronchioles.
Between the alveolar air and the blood of capillaries of the small circle there is a pulmonary membrane consisting of a surface-active lining, pulmonary epithelium, capillary endothelium and two border (basal) membranes. The thickness of the pulmonary membrane is 0.4 - 1.5 microns. The area through which gas exchange takes place is approximately 90 m2. The transfer of gases through the pulmonary membrane is carried out by diffusion of gas molecules due to the gradient of their partial pressure. Each capillary passes over 5 to 7 alveoli. The passage of blood through the capillaries of 0.35 - 1.7 seconds. (average 0.8 sec.). The large contact surface, the small thickness of the pulmonary membrane, the relatively low speed of blood flow through the capillaries provide gas exchange between the alveolar air and blood. The permeability of the pulmonary membrane for gas is expressed by the diffusion capacity of L. The condition for complete gas exchange is uniform ventilation of all alveoli and blood flow throughout all capillaries of the alveoli, as well as the same ratio between alveolar ventilation and blood flow. In fact, this condition is not fully observed. The uneven relationship between ventilation and blood flow is considered on model L. It consists of anatomical dead space (the volume of airways in which there is no gas exchange), effective alveolar space (ventilated and perfused alveoli), ventilated but not perfused alveoli (alveolar dead space) non-ventilated but perfused alveoli (alveolar venoarterial shunt). Alveoli of the alveolar dead space are ventilated, but gas exchange does not occur in them. In the capillaries of the alveolar venoarterial shunt, the blood does not arterialize. In real conditions, there are gradual transitions from alveoli with appropriate ventilation and perfusion to alveoli without blood flow and without ventilation. The unevenness of ventilation and blood flow is normal. In the apex area, the alveoli are ventilated less efficiently than at the base of L. But the differences in blood flow between these areas are even more pronounced. Therefore, in the region of the apices, ventilation relatively prevails over the bloodstream, and in the lower parts of L. the ratio of ventilation to blood flow is less than unity. As a result, the oxygen tension of arterial blood flowing from the region of the tops is higher, and from the lower parts of L. — below the average. The uneven distribution of ventilation and blood flow in individual parts of L. is one of the main causes of the arterioalveolar difference in the tension of oxygen and carbon dioxide. Unevenness increases with pulmonary pathology.
L. equipped with a kind of receptor apparatus. In L. mammals, there are three types of sensitive nerve endings: stretching receptors, irritant receptors, juxtacapillary alveolar receptors. Their afferent fibers are located in the vagus nerves. When the left atrium and pulmonary veins overflow with blood, a narrowing of the arterioles of the pulmonary circulation occurs.
The intensity of blood circulation in a small circle is affected by respiratory movements and the composition of the alveolar air. The effect of respiratory movements is that when inhaling, when the pressure in the chest cavity and vena cava decreases, blood flow to the right half of the heart increases. As a result, blood flow to the right ventricle, systolic pressure in the right ventricle and pulmonary artery increase.
With forced expiration, opposite shifts are observed and the amount of blood flow decreases. The influence of the composition of the alveolar air is determined by the fact that not all L. alveoli are ventilated under normal conditions, and their significant part is L.'s functional reserve. If blood flowed evenly through the capillaries of the pulmonary alveoli (both ventilated and non-ventilated), then a significant part blood would not be enriched in the lungs with enough oxygen and arterial hypoxia would inevitably occur. However, this does not happen, because the blood flow in the lungs is not uniform and the blood flows only through those sections of the lung tissue, whose alveoli are currently well ventilated. The increase in pulmonary blood flow in intensively ventilated areas of lung tissue and its cessation in areas where ventilation is absent does not depend on mechanical factors - inflation and decay of L. during the respiratory cycle. Even with intensive ventilation of one L. with hydrogen, nitrogen and neon, there is a sharp decrease in blood flow through this L. It is established that the factor determining the amount of blood flow through each section of lung tissue, ceteris paribus, is the air composition in the alveoli of this section. With a high partial pressure of oxygen in the alveolar air, the arterioles of the corresponding section of the lung tissue expand, and blood flow through the pulmonary capillaries increases; with a low partial pressure of oxygen, on the contrary, there is a narrowing of the arterioles and blood flow decreases. The amount of blood, on average, contained in L., is 8 - 10% of the volume of all circulating blood. At the time of physical. work, during digestion, with blood loss and other cases, a significant part of the blood leaves the pulmonary vessels and is used in those tissues whose activity is most intense. When returning to a state of rest or with an increase in the volume of circulating blood, its excess again accumulates in the pulmonary vessels. Of the total blood volume of the blood vessels of the lungs in gas exchange with alveolar air, no more than 60 l-l is simultaneously involved. From this it follows that blood that is not involved in gas exchange is the deposited blood, and L. perform the function of a blood depot.
In the pulmonary capillaries, microorganisms and cellular detritus are retained. In the process of phylogenesis, L. acquired the ability to defend against an alien protein that enters them. A number of authors note that, upon intravenous immunization with microbial bodies, a significant amount of antibodies is synthesized in L. A particularly large number of antibodies occurs when pneumococcus is immunized, which has a pronounced tropism for L. tissue. Volatiles (acetone, methyl mercaptan) are removed from the blood through L. , ethanol, ether, nitrous oxide, etc.). In L. intensive energy processes proceed. They consume approx. 4% of the oxygen received by the body absorbs a lot of fatty substances from the blood. In L., glycolysis processes predominate.
Mast cells L. form heparin, histamine, serotonin. The mucous membrane of the bronchi ensures the removal from L. of dust particles, desquamated epithelium, leukocytes, etc. The mucous and goblet cells of the integumentary epithelium constantly form mucus. Mucus secretion is enhanced by both parasympathetic and sympathetic nerve fibers. Accordingly, atropine and beta-adrenolytics weaken it. Atrial epithelium of the mucosa, bronchial membrane moves the mucus towards the large airways at a speed of 7 - 19 mm / min. L. participate in the process of heat transfer, they lose heat when heated air and water evaporation.
Among the research methods of L. include questioning, physical methods, functional, instrumental and laboratory; X-ray and radioisotope research occupies a special place. The tasks of L.'s research include the assessment of their anatomical and physiological characteristics, and functions, conditions, pathophysiol, disorders, the nature of pathomorphol, the process and etiology of the disease.
Physical methods: examination, palpation, percussion, auscultation. These methods have independent diagnostic value, and also determine the amount of additional research. The inspection requires compliance with certain conditions (warm room, accessibility of inspection from all sides, diffused daylight or artificial white). During a general examination, attention is drawn to the forced position on the sore side (croupous pneumonia, effusion and dry pleurisy), sitting - with severe shortness of breath (pneumothorax, an attack of bronchial asthma, stenosis of the larynx, etc.); swelling of the cervical veins and epigastric pulsation (pulmonary heart decompensation); changes in fingers in the form of drumsticks and nails in the form of watch glasses (chronic, especially purulent, processes in the lungs); signs of deep vein thrombosis of the legs (a possible source of thromboembolism in the pulmonary artery system); cyanosis (one of the signs of respiratory failure); blush on the cheeks (in febrile patients with tuberculosis and pneumonia).
At a local examination pay attention to the shape and symmetry of the chest. The shape of the chest may depend on patol, changes in the lungs, pleura or its skeleton. A combination of both factors is possible. Of great diagnostic importance are violations of the symmetry of the chest. The latter is assessed and revealed both during static and dynamic inspection. During a dynamic examination, attention is drawn to the degree of participation of each half of the chest in the act of breathing.
In diseases of the respiratory system, one half of the chest or part of it can be increased or decreased compared to the other; the degree of participation of various parts of the chest in the act of breathing also changes. An increase in the size of one half of the chest is observed with exudative pleurisy, pneumothorax. In this case, there is an expansion of intercostal spaces and smoothing them on the sore side, as well as a higher position of the shoulder and shoulder blades.
A decrease in the size of one half of the chest is observed with extensive processes of wrinkling of the lung tissue, after the resorption of extensive pleural exudates, with atelectasis of L., after operations on L. The patient half of the chest lags in the act of breathing, which is also observed with inflammatory infiltration of fairly large sections of L. , at L. neoplasms, at dry pleurisy, fracture of ribs, intercostal neuralgia and myositis of intercostal muscles. A diagnostic sign can be the ratio of the duration of inspiration and expiration (1: 2; 1: 3 for obstructive processes), frequent shallow breathing with short inspiration and expiration in restrictive diseases of L. With severe violations of the function of the respiratory center, respiratory rhythm disturbances are observed.
Palpation of the chest allows you to clarify its shape, volume and symmetry of the respiratory movements (for this, both hands are placed with palms on the examined sections of the chest symmetrically from two opposite sides, as if covering it); identify and localize painful places with myositis, intercostal neuralgia, fractures of the ribs, as well as their compaction and tuberosity; establish resistance of the chest and intercostal spaces; in some cases, feel low dry rales and a loud noise of friction of the pleura, as well as subcutaneous emphysema; identify voice trembling, which is of great diagnostic value.
L. percussion is most conveniently produced in the vertical (standing or sitting) position of the patient. In a standing position, the patient's hands should be lowered, in a sitting position - lie on his knees.
In topographic percussion, the determination of the boundaries of L. is of diagnostic value (the lower border and its mobility when breathing is used to diagnose pleural adhesions); the width and symmetry of the Krenig fields. Their symmetric expansion is characteristic of emphysema; asymmetric narrowing - for wrinkling of the lung tissue, which is observed with tuberculosis. Comparative percussion reveals: foci of infiltration and compaction by the relative blunting of percussion in unusual places; hepatization zones with croupous and heart attack pneumonia, the presence of fluid in the pleural cavity - by a dull percussion sound, pneumothorax - by a tympanic percussion sound; with emphysema L. the classic percussion feature is increased sonority, turning into a boxed shade. In cases where emphysema is a syndrome that accompanies pneumosclerosis with repeated pneumonia in the past and the development of gross focal changes, uneven shade of percussion sound is observed ("mosaic", as B. Votchal puts it) - sections of box sound alternating with areas of blunting.
Auscultation is the most informative physical research method of L., which allows to determine the nature of changes in respiratory sounds, wheezing, bronchophony.
Functional methods are usually classified depending on which of the main functions of external respiration - ventilation, diffusion, pulmonary blood flow - they are studying.
Ventilation status is assessed using the following methods.
1. Spirography allows you to determine the amount of tidal volume, forced expiratory volume in 1 second — FVC1, maximum ventilation of the lungs - MBL, respiratory coefficient, etc. These indicators carry great information about the anatomical and physiological properties of ventilation. In young children, the method of pneumography is used to study ventilation function. 2. Methods for assessing the structure of total lung capacity (OEL). In obstructive and / or restrictive (restrictive) disorders of external respiration, the structure of the OEL often changes characteristically. Restrictive processes lead predominantly to a decrease in OEL and VC, and the residual lung volume (OOL) and function, residual capacity (OEC) change little, only a relative increase in OOL in the structure of OEL is observed. In obstructive disorders, OOL increases significantly. An increase in OOL in absolute value and its share in OEL is characteristic of emphysema. With far-reaching obstruction, VC decreases. Of the many methods for determining OOL, FOE and OEL, the most common and accessible method is based on mixing helium in a closed system using a commercially available POOL-1 unit. 3. The study of the uniformity of ventilation. The method is based on determining the time of mixing or washing out the indicator gases from L. The most common method is mixing helium using the POOL-1 device, which allows to determine the period of leveling of the helium concentration between the known volume of the spirograph and the lungs of the subject. 4. Pneumotachometry — a method for measuring peak airflow velocities achieved by performing forced inspiration and expiration using commercially available pneumotachometers PT-1 and PT-2, which assess bronchial patency. Complexes of simple methods to perform - measuring VC using a spirometer and pneumotachometry or determining VC and FVC1 during spirography - are sufficient to solve a wide range of issues and, in particular, in a large number of cases allow differential diagnostics between the obstructive and restrictive types of ventilation disorders. The use of pharmacol. samples (measuring the above indicators before and after the use of bronchodilators with various mechanisms of action and, in some cases, bronchoconstrictors) further expands the possibilities of these methods in terms of studying the nature of bronchial obstruction, selecting the most effective bronchodilator. 5. Pneumotachography, impedance pneumography and plethysmography. Pneumotachography allows you to measure the volumetric rate of inhalation and exhalation (calm or forced), the duration of the various phases of the respiratory cycle, the volume of inspiration and expiration, minute volume of respiration, intraalveolar pressure, aerodynamic resistance of the respiratory tract, extensibility (compliance) of L. and chest, respiration. The method is based on the use of inertialess optical and electrical pressure gauges. General plethysmography of the body is usually combined with pneumotachography; measurements of breathing mechanics are carried out in an airtight cabin - plethysmograph of the body. Alveolar pressure, total intrathoracic gas volume, functional residual capacity (FOE), bronchial resistance and other indicators are determined. 6. Research methods of regional ventilation of the lungs. The information obtained with their help allows us to judge the functioning of individual sections of L., which opens up the prospect of identifying violations at an early stage, when the integral parameters of the functioning of L. are not yet substantially changed. The study of regional ventilation is carried out using X-ray methods: densitometry, X-ray diffraction, pulmonography, and also radio pneumography (registration in the process of breathing of the amount of 133 Xe radioactive particles added to the respiratory mixture over various parts of L.).
The presence and severity of diffusion disorders is assessed by the method of determining the diffusion capacity of the lungs (DL). Among the various methods for determining the DL, the most widely accepted method is the steady state using carbon monoxide as an indicator gas.
Pulmonary blood flow is most accurately assessed by catheterization of the heart and blood vessels of the pulmonary circulation. The technique allows you to determine the pressure in the chambers of the right heart and vessels of the small circle and is the basis for calculating other hemodynamic parameters. Indirect methods for diagnosing pulmonary hemodynamics, such as rheography, electrocardiography, electromyography, colorimetry, etc., are gaining more and more importance. Rentgenol and radioisotope research methods provide valuable information on the state of pulmonary circulation.
An extremely important and most vulnerable aspect of external respiration is the matching of ventilation and blood flow. Violation of this correspondence is the most common cause of respiratory failure. The uniformity of the ventilation-perfusion ratio in the lungs is judged by the size of the functional dead space of the lungs (FMF), as well as by the ratio of FMP / DO (DO - tidal volume) and EAV / MOD (EAV - effective alveolar ventilation, MOD - minute breathing volume). FMP is determined using indicator gases - carbon dioxide, oxygen, helium, argon, xenon, etc. They use methods of a single respiratory cycle or return breathing in a closed circuit; for the latter method, it is convenient to use the POOL-1 installation. An assessment of ventilation-perfusion disturbances can be obtained using capnography - a continuous graphical recording of changes in CO2 concentration in exhaled air using an inertialess analyzer - a capnograph. The most widely distributed commercially available capnograph GUM-2.
In assessing the activity of the entire external respiration apparatus, the study of the gas composition of arterial blood and acid-base balance is important.
To identify the remaining reserve capabilities of the body in patients and to study the compensatory possibilities use a test with physical. load on the bicycle ergometer. The most widely accepted dosage load of 50-60-80 watts lasting 5 minutes. or a load of increasing power. External respiration in the load test is examined using a spirograph and other devices.
Instrumental methods. In addition to the instrumental methods used for func- tions, lung studies, a number of highly informative instrumental methods are used to diagnose diseases of the external respiration apparatus: bronchoscopy, using a swarm, in addition to examining the bronchi, a number of instrumental methods of biopsy, mediastinoscopy, thoracoscopy, etc. are performed.
Laboratory methods. 1. General clinical lab. methods for the study of blood, urine, sputum, pleural effusion. The availability, reliability and information content of these studies are very high, they are used in the study of all patients and used in the diagnosis. 2. Cytol, a study of sputum, pleural effusion and material obtained by biopsy, is most effective in recognizing L. tumors and often allows you to establish their histol. form, which is very important when choosing to lay down. tactics and forecasting. 3. Bacteriol., Virusol, and serol, studies allow to establish the etiology of patol, a process that allows for etiotropic treatment. Isolation and identification of the pathogen in pneumonia and other respiratory infections is a very time-consuming process, especially for viral and mycoplasma diseases. Instead, it is often difficult to resolve the issue of etiol, the role of an isolated microorganism in a given disease. In these cases, serodiagnostic studies are necessary. The same can be said about viral and mycoplasma infections. 4. Immunol, studies in pulmonology are carried out to study immunity in diseases inf. nature and allergies in asthma. They also make it possible to monitor the effectiveness of therapy, especially desensitizing, immunosuppressive. 5. Biochemistry, studies of lung diseases are carried out to determine the indicators of various types of metabolism, to identify the nature of the genesis of the disease (inflammatory, allergic, etc.), to assess the condition of other organs and systems, assess the activity of the inflammatory process. 6. Methods for determination of surfactant.
X-ray methods. In the complex diagnosis of most diseases L. rentgenol, the method has an important place. For mass verification examinations and the detection of latent diseases L., including tuberculosis and cancer, fluorography is used. X-ray fluorograms in direct and lateral projections are also performed for all patients visiting the clinic if they have not undergone another fluorographic examination at the place of residence or work during the calendar year. Persons who are suspected of having fluorography patol, changes, cause a special wedge, and rentgenol, a study. The latter begin with the production of x-rays, X-rays or large-frame fluorograms in the front and side projections. If necessary, produce fluoroscopy and resort to special methods - tomography, bronchography, angiopulmonography, etc. Each radiograph is studied according to plan. First of all, the projection of the study and the correct installation of the patient are determined. Then follows a general examination of the shape, size and structure of L. Next, X-ray morphol is produced. and X-ray functions. analysis and synthesis. In the process, they distinguish between "norm" and "pathology", rentgenol, signs of the disease are identified and evaluated. The results of the analysis are compared with the data of other wedges, and instrumental studies, carrying out clinical-rentgenol, analysis and synthesis. Radiodiagnosis is based on the identification of rentgenol, symptoms of diseases L. These symptoms are varied. They reflect changes in the size, shape and shape of the pulmonary fields, changes in the pulmonary pattern (its depletion, strengthening, deformation), various lesions of the bronchial system and individual bronchi, lesions of the lymph and nodes (their hyperplasia, calcification), changes in the transparency of the pulmonary fields. Those areas of L. in which a lot of blood, exudate, connective tissue, tumor cells, etc. are concentrated and, therefore, there is little air, give shadows - blackouts on radiographs. Those places in which there is a lot of air look like light areas - enlightenment. If the interstitial tissue is mainly affected, then the transparency of L. changes little, and the pulmonary pattern is enhanced.
The size and shape of blackouts and enlightenments depend on the extent of the lesion: with lesions of the acini, foci of dia appear. 0.1-0.2 cm; altered lobules produce shadows of up to 1.5–2 cm in size. Even larger blackouts are detected when a segment, lobe or whole L. is damaged. As for cavities in L., cavities up to 1 cm in diameter are called small, medium-sized - from 1 to 2 cm, large - st. 2 cm
Changes in the transparency of L. are often associated with impaired bronchial patency. A small persistent narrowing of the bronchus leads to hypo-ventilation of the corresponding part of L., the edge on the roentgenogram looks slightly darkened, the pattern in it is strengthened due to the convergence of blood vessels and plethora. With valvular stenosis of the bronchus, obstructive emphysema develops: part of L. increases, it seems lighter on the x-ray than the neighboring departments. With complete closure of the lumen of the bronchus, atelectasis occurs. The airless section of L. decreases and gives an intense shadow on radiographs. Atelectases of all lobes and segments have a typical picture.
A radioisotope study of the respiratory system in modern conditions is used to study pulmonary ventilation, blood supply and visualization of the pulmonary parenchyma.
Pulmonary ventilation is examined by inhalation of radioactive inert gases (usually 133Xe). When inhaling, radioactive gas fills all departments of L. on the bronchi, which is recorded by scintillation counters located above them. The procedure is carried out by a seven-channel Xenon radiometer with the recording of activity measurements and obtaining the characteristics of the dynamics of drug excretion from each lobe of L.; using a scan or a computer-scintigraphic system, the use of a swarm allows you to quickly and most informatively obtain data on the distribution of a radioactive preparation in zones L. In both cases, it is possible, when determining the dynamics of the removal of radioactive gas from L., to establish the percentage contribution of each zone to the total amount of excretion. The specified technique allows to give a quantitative assessment of ventilation of various departments of L. in the norm and at various patol, conditions.
The main radioisotope methods for studying pulmonary circulation are static radiometry of L. after intravenous injection of inert gases (133Xe) and scanning L. after perfusion of labeled human serum albumin macroaggregates. With intravenous administration, the rr 133Xe enters the arterial link of the pulmonary circulation and quickly diffuses into the lumen of the alveoli in proportion to the arterial blood flow in this region L. The study is carried out using a Xenon radiometer when sensors are installed above the posterior surface of the chest. For chest injuries and other emergency conditions I. T. Korkulenko et al. (1978) developed a method of anterior spiroradiography. The data obtained is processed by measuring the amplitude of the curves recorded by sensors over all departments of L., followed by determining the percentage contribution of each zone to the total volume of blood flow. Violations of pulmonary blood flow and pulmonary ventilation are pronounced with atelectasis and malignant tumors L.; with hron, inflammatory processes, ventilation and perfusion disorders are less pronounced and are mainly observed in the affected area. The study using 133Xe provides fairly reliable information about the state of the pulmonary blood supply, but does not allow to obtain a picture of the vasculature of L., which is possible when using visualization of the functioning L. parenchyma using radioisotope scanning.
Visualization of a functioning L. parenchyma can be carried out with the intravenous administration of macroaggregates of radioactive compounds; after inhalation of radioactive aerosols, particles of which settle on the mucous membrane of the bronchi and alveoli. The inhalation method of introducing radioactive aerosols is not widespread due to insufficient accuracy. Therefore, the scanning method is often used after intravenous administration of labeled compounds, which allows to identify areas of impaired blood circulation. In certain cases, for example, in the differential diagnosis of areas of prolapse with emphysema L. or embolism of the branches of the pulmonary artery, a sequential scan using inhalation and perfusion methods of administering radioactive drugs is necessary.
The most promising diagnostic combination of radioisotope functions, research methods with scanning. It is optimal to conduct dynamic scintigraphy with the processing of the obtained data on a computer, which allows you to accurately identify and track the dynamics of changes in regional ventilation and blood flow in the lungs. The resulting information on functional morphol. disturbances makes it possible to reliably assess the course of patol, the process.
Lung dystrophy occurs due to the action of exogenous (dust, inf. Pathogens, smoking, high temperature, gases, including excessive oxygen, ozone, nitrous oxide, etc.) and endogenous (hypoxemia, release of biologically active amines in shock, others patol, conditions, exposure to endotoxins, etc.) factors. The most universal response of L. to damage is the hydropic dystrophy of the respiratory alveolocytes, endotheliocytes located on both sides of the fused basal membranes of the alveoli and capillaries. A larger number of pinocytotic vesicles appears in them, compared with the norm, they increase in size, merge with each other, turning into microvesicles diam. 0.06-0.09 microns and vacuoles, the sizes of which are also calculated in micrometers. The formation of vesicles also involves the accumulation of fluid in the cytoplasmic reticulum, edema and swelling of the mitochondria, from which the cristae disappear. The development of the so-called. giant bubbles in the endothelium (dia. 2-4 microns) can be accompanied by a rupture of the cytoplasm and their penetration into the lumen of the capillaries, where they are detected by electron microscopy in the form of clearly defined glycocalyx bubbles containing fine-grained electron-dense masses. If the bubbles break through the posterior surface of the endothelial cells facing the basement membrane, these cells detach from the membrane. Sometimes they remain attached only to the ends of their processes attached to the membrane, and platelets penetrate between the cell body and the basement membrane, which gives impetus to the development of prolonged thrombosis of blood vessels L. The formation of vacuoles in the cells of the airborne barrier is accompanied by swelling of the organelles, some compensatory changes in the form of an increase in the number of ribosomes , a rough cytoplasmic reticulum, mitochondria, which contributes to the restoration of cells. With the predominance of alteration, hydropic dystrophy can turn into diffuse interstitial and intraalveolar edema L. Alveolar cells become electronically optically bright, containing amorphous osmiophilic flakes instead of organelles. If this is accompanied by the death of the nucleus, the cells die and are rejected into the lumen of the alveoli.
Granular dystrophy can accompany hydropic or (less commonly) occur independently (e.g., when exposed to 3-methylindole released from tobacco smoke, with anesthesia, L. denervation). The process is characterized by an increase in the electron density of the cytoplasm, an increase and swelling of mitochondria, an expansion of the cytoplasmic reticulum, and also the appearance of individual myelin-like figures of an abnormal structure in large alveolocytes. The combination of hydropic and granular dystrophy of the respiratory alveolocytes, which turns into cell necrosis, leads to a sharp swelling and increase in size, as a result of which they become visible under light microscopy, which, for example, is characteristic of radiation pulmonitis. Dystrophy of the respiratory alveolocytes, as a rule, leads to the accumulation in the lumen of the alveoli of large alveolocytes, which are the precursors of respiratory alveolocytes. At the same time, the content of myelin-like laminar structures that go to build a surfactant increases in them. Migrating into the lumen of the alveoli, large alveolocytes turn into alveolar macrophages and lie among the eosinophilic masses formed as a result of the release of laminar bodies, their transformation into lattice structures and the decay of previously rejected cells. With light microscopy, such pictures are sometimes incorrectly designated as a manifestation of desquamative pneumonia. Dystrophy of the airborne barrier is expressed not only by the changes in its cells described above, but also by changes in the basal membranes of the alveoli and capillaries, which usually look like a single fused membrane. The latter swells, its electron density changes. With pronounced changes, a thickening of the alveolar septa occurs, which is accompanied by a sharp increase in capillary permeability, edema, and hemorrhages.
The pronounced protein and fatty degeneration of large alveolocytes with the deposition of a significant amount of laminar bodies and drops of lipids inside the alveoli and in their walls characterizes the so-called. alveolar proteinosis.
L. amyloidosis can clinically manifest itself in the form of several forms, but there is also a subclinically occurring amyloidosis, which is increasingly detected by L. biopsy in the form of an accidental find. In 30% of cases, it accompanies primary amyloidosis, as well as amyloidosis associated with myeloma. Amyloid in these cases is detected by electron microscopy in the form of a lattice along the capillaries of the alveoli. The free spaces of the lattice occupy a sufficient area of the inner surface of the alveoli, in connection with which violations of external gas exchange do not occur.
Amyloid-like bodies are not related to amyloid, their electron microscopic picture corresponds to microlithiasis, but, according to Spencer (N. Spencer, 1977), it is characterized by the absence of calcium content.
In addition to hydropic, granular and amyloid dystrophy, hyalineosis of the fibrous layers separating the anatomical units of L. refers to a violation of protein metabolism. It occurs with sharp violations of the lymphatic circulation of L. and is a nonspecific reaction that occurs with circulatory disorders or inflammatory processes of a protracted course.
Fatty degeneration occurs in certain areas of L. and is sometimes incorrectly designated as endogenous lipid pneumonia. It usually occurs with subacute and hron, L. diseases, accompanied by complete and incomplete atelectasis. In areas of aeration disorder (atelectasis), the process of lipid synthesis and hydrolysis changes, to which the largest are the large alveolocytes rich in lipase. In diabetes and hypoxia, the macrophage reaction intensifies, and the lipophages, together with the flocculent masses of freely lying lipids, accumulate in large quantities in the atelectasis zones, which may be accompanied by secondary inflammatory processes in the form of interstitial pneumonia or the development of lipogranulomas.
Dystrophy of collagen and elastic fibers of the respiratory parenchyma can be caused by elastase and other proteases of granulocytes and macrophages, in particular smoker's macrophages, as well as in an experiment under the influence of papain and trypsin. As a result of exposure to proteases, the elasticity of L. decreases, pulmonary emphysema develops. According to Wimster (W. Whimster), with biochemistry, and histochemistry. a study of collagen and elastic fibers revealed violations of the content of neutral and aromatic amino acids of the protein elastin and glycosaminoglycans of the cementing substance. When studying the ultrastructures of these fibers, disorientation and spiral-like arrangement of collagen fibrils and a violation of the tinctorial properties of elastic fibrils were found.
Necrosis. In addition to total necrosis of all components of the lung tissue, limited focal necrosis of the alveolar lining and mucous membrane of the bronchioles is possible in the foci of gangrene and heart attack, which is accompanied by the development of hyaline membranes characteristic of acute respiratory failure in newborns and adults. Hyaline membranes are tissue detritus, among which fragments of organelle cells of the alveolar lining are distinguishable, including osmiophilic laminar bodies of large alveolocytes, impregnated with blood proteins, in particular fibrinogen. Focal necrosis of the bronchial mucosa with subsequent ulceration is characteristic of inf. bronchitis, and may also be the result of a burn of the bronchi.
Pulmonary circulatory disorders are not only the result of hemodynamic disturbances in the pulmonary circulation and the pulmonary circulation, but also the result of disturbances in L. aeration, since the lumen of the capillaries and their orientation in the walls of the alveoli depend on the intra-alveolar air pressure. So, when L. is inflated, his tissue becomes ischemic, pale pink with a clearly identifiable anthracosis on a pale background. In areas of atelectasis, with a decrease in the filling of lung tissue with air, it decreases, becomes cyanotic, plethora of capillaries develops, their bulging into the lumen of the alveoli.
L. ischemia, caused by compression or obstruction of the branches of the pulmonary artery, quickly gives way to plethora, hemorrhage due to the opening of arterio-arterial and arteriovenous anastomoses, i.e., bypass surgery, which is accompanied by the development of atelectasis due to impaired production of surfactant and aggravates anemia. Dystrophic processes develop in L.'s tissue, leading to L. edema. According to G. D. Knyazeva, M. M. Morozov, with prolonged moderate ischemia, for example, with Fallot tetrad, a decrease in the amount of phospholipids occurs, but dystrophy does not develop due to blood flow according to the bronchial system. The combined narrowing of the branches of the pulmonary and bronchial arteries and the development of emphysema due to prolonged obstructive processes in L. lead to ischemia and the so-called. progressive pulmonary dystrophy, and essentially to atrophy of L. parenchyma, thinning and disappearance of alveolar septa.
Acute hyperemia of L. arises in the conditions of strangulation asphyxia, at injuries of L., a brain, at a shock. Anemia is uneven, because it is accompanied by spasms of arterioles, venules, sludge syndrome (wet L. syndrome), hemorrhages in the parenchyma and under the pleura, sometimes with its detachment. Reflex contractile atelectases exacerbate the irregularity of blood supply, which, for example, is characteristic of a "shock lung".
Pulmonary hemorrhages and hemorrhages occur during injuries and ruptures of the vessels of the root of L., explosions, any barotrauma that violates the aeration and blood supply of certain sections of L. Massive hemorrhages in L. also occur when the aneurysm of the descending thoracic aorta breaks, and also complicate pulmonary embolism, which It is associated with increased blood flow in ischemic L. Hemorrhage should be distinguished from blood aspiration during gastric bleeding, bronchial tumors, mediastinum. When aspirated, mucus and foreign particles are mixed into the blood. Hemorrhages in L. seldom bear the features of a hematoma, hemorrhagic infiltration, petechiae that dissolve without scarring with the help of macrophages that turn into siderophages more often develop.
Lymphatic circulation disorders in L. in the form of lymphostasis occur:
- mechanically due to increased pressure in the pulmonary veins with left ventricular failure or compression of the pulmonary veins by a tumor;
- due to dynamic insufficiency of lymphatic circulation with a mismatch between the formation of tissue fluid and its abduction, which is observed in atelectasis zones;
- with resorption insufficiency due to increased permeability of lymph, capillaries and changes in the composition of tissue proteins, for example, with inflammation.
The first mechanism is often accompanied by diffuse lymphostasis, while in the second and third it is usually focal in nature. Lymph, blood vessels at the same time expand sharply, fibrous layers in their circle swell, lymphangiectasia or varicose lymph are noted. vessels. As a result, lymphogenous sclerosis develops and an increase in the number of lymphs, follicles, which are immunocompetent formations. In acute lymphatic insufficiency, pulmonary edema develops. Initially, it is localized in the interstitium of the alveolar septa, which thicken; in cells of L.'s tissue there is a hydropic dystrophy. With the detachment, separation of respiratory alveolocytes, interstitial edema passes into intra-alveolar edema, because, judging by the electron microscopic studies of Schneeberger-Kelly, Karnovsky (F. Schneeberger-Kelley, M. Karnovsky), it is with damage to the respiratory alveolocytes that fluid flows into the inside alveoli. The connections between these cells are normally stronger than between the endotheliocytes, therefore, leaving the capillaries, the fluid first accumulates in the walls of the alveoli, and then breaks inward. If the edema is accompanied by detachment, and not the death of the surfactant, air bubbles are clearly visible in the edematous fluid inside the alveoli.
Compensatory-adaptive processes in L. are carried out by compensatory and regenerative hypertrophy. According to L.K. Romanova, after resection of a part of L., dystrophic changes in the alveolar epithelium develop within a month, and the synthesis of nucleic acid cells decreases. In the subsequent hypertrophy of the damaged and second L. is noted, characterized by activation of synthesis of nucleic to - t cells of walls of alveoli and strengthening of their mitotic activity. Compensatory-reduction processes occur inside the cells: protrusion of the nuclear membrane, increase in the number of pinocytotic vesicles, hypertrophy of the lamellar complex and villi of the respiratory alveolocytes, increase in the size and number of osmiophil bodies of large alveolocytes. The number of alveolar macrophages and alveolocytes of the third type also increases, which is accompanied by activation of surfactant synthesis, detected both at the ultrastructural level and by the method of determining the surface activity of L. swabs. L. hypertrophy is characterized by an increase in the volume of alveoli and their depth, however, unlike emphysema, this the process, according to HX Shamirzaev, is reversible. After L.'s resection, either stabilization of morphofunction occurs. restoration, or its decompensation in the form of the development of emphysema L., which is accompanied by a flattening of the alveoli and sclerosis of their walls. According to L.K. Romanova, when 50% of L. mass is removed in adult animals and humans, decompensation does not develop for 4-15 years. At a resection of 60-65% of L.'s mass the phenomena of hypertrophy prevail over emphysema. With a resection of 70-85%, as a rule, emphysema develops.
Posthumous changes. So-called. acid malignancy of the lungs - autolysis due to casting of gastric juice in L. These are L. brown-yellow sections of flabby consistency with poorly defined cell nuclei. They need to be differentiated with gangrene by the absence of an inflammatory reaction. Special studies of the mass of L., their dry residue in the experiment, according to S. A. Zhanaydarov, revealed the posthumous development of plethora 4 hours after death. It rises by 12 o"clock. and then ceases; plethora depends on the movement of blood from the veins of the head, trunk and abdominal cavity due to rigor mortis in the heart and increased intra-abdominal pressure due to gas in the intestines. It is accompanied by an increase in the permeability of capillaries for liquid and proteins (detected by posthumous penetration of blood proteins labeled before death from capillaries into tissue). Intraalveolar edema after death may decrease due to the transfer of a certain amount of fluid into the pleural cavities.
Classification of diseases of L. presents great difficulties. They are caused by insufficient knowledge of the etiology and pathogenesis of a large number of patoles, processes that affect L., the lack of prevailing ideas about nosol, the independence of a significant part of these processes, and conflicting views on the similarities and differences in the many known diseases, patoles, conditions, and syndromes from the literature, which complicates them Association in certain groups.
It is generally accepted that L.'s diseases are divided into acute and chronic according to the predominant type of patol, process, but it is not applicable to all nosol, forms, since some of them, depending on the influence of etiol, factor and reactivity of the patient"s body, can proceed according to -differently (acute, subacute, chronically). In a number of cases, the same disease, beginning acutely, tends to go into hron, form.
More clearly it is possible to separate the disease and patol, L.'s condition according to the following two fundamentally important signs. The first of them is the predominance of damage with a given patol, the process of the respiratory tract or the respiratory department (the so-called parenchyma) L. An example of a disease with a primary lesion of the respiratory tract is bronchitis, bronchiectatic disease, bronchial fistula, bronchogenic cancer, etc. Examples of diseases with a predominant lesion of the respiratory department - pneumonia, L. emphysema, various types of disseminated pneumosclerosis, granulomatosis, etc.
The second important determinant is diffusion or localization (regionality) of the distribution of patol, a process along the bronchopulmonary system. The group of diffuse processes includes, for example, bronchitis, lung sarcoidosis, alveolar microlithiasis, and the group of localized (regional) pneumonia, tumors of L., foreign bodies of the tissue of L. or bronchi, etc.
The grouping of L. diseases according to etiol, the principle, is much more complicated. Such a grouping, almost all known diseases and patol, L.'s conditions are included in the group, is carried out in the table below, developed at the All-Union Scientific Research Institute of Pulmonology M3 of the USSR N.V. Putov, G. B. Fedoseev, H. N. Kanaev. When analyzing it, it should be borne in mind that some of the main rubrics reflect the etiology of diseases only conditionally. So, in one group the anomalies of the development of L. are combined, the causes of which have not been studied, in the other - the tumors of L. Chron, bronchitis and emphysema L., in the etiology of which, in many respects, common, but far from completely established factors are important, are also singled out in a single heading; when isolating them, the extremely important medical and social significance of these nosols, forms, the similarity of the Clinical and physiol, manifestations (obstruction), etc., was taken into account. Allergic diseases of L. are united not so much by a common etiology as by a similar pathogenesis. A large number of predominantly rare diseases of a not completely clear etiology are combined in one section, most of them systemic in nature, in which L. is prevailing or often observed. With patol, L.'s conditions associated with impaired pulmonary circulation, it can be considered as etiol. factor is also conditional and is, in essence, only the main element of the pathogenesis of the corresponding processes in L.
In a special section, diseases and patol, conditions that occur with a predominant lesion of the pleura are highlighted, which to some extent violates the etiol, (pathogenetic) classification principle.
For some practical diseases that are important in practice, the basic elements of the classification within nosol are given. In cases where such a classification is complex, but is officially accepted and approved in the USSR, an appropriate reference is given to this classification (e.g., for pulmonary tuberculosis, bronchial asthma).
Violations of the process of embryogenesis of L. cause the appearance of defects in their development. So, the cessation of the growth of bronchopulmonary kidneys in the early stages (4th week) leads to agenesis of both or one L. The delayed development of bronchopulmonary kidneys at the 5th week. causes hypoplasia of both or one L., and on b - the 7th week — the appearance of agenesis or hypoplasia of L. lobes. There may be a violation of the formation of mesenchymal elements of the main and lobar bronchi, which is accompanied by bronchomegaly and stenosis of the bronchi.
The ideas of various authors about the frequency of malformations of L. are contradictory. It ranges from 2.5 according to A. I. Strukov and I. M. Kodolova (1970) to 20% according to G. L. Feofilov (1976) of all non-specific diseases of L.
Malformations associated with the underdevelopment of the lung, its anatomical, structural and tissue elements. Agenesis and aplasia of L., L. hypoplasia of simple and cystic (polycystic), congenital lobar emphysema, and also tracheobronchomegaly should be attributed to the most frequent of them.
By agenesis is understood the absence of L. along with the absence of the main bronchus. Aplasia - the absence of L. or its part in the presence of a formed or rudimentary main bronchus. At bilateral agenesis and aplasia of L. children are not viable, at unilateral - they can develop normally. Observations of patients with L. agenesis are described, who survived to a very old age. However, with the addition of inflammatory phenomena in a single L., respiratory failure develops faster, and total confluent pneumonia of a single L. can become the main cause of death.
The wedge, a picture of agenesis and aplasia of L. in newborns and older children has some differences. An objective examination in newborns and infants on the side of the absent L. during percussion determines the shortening of percussion sound, and when listening, the complete absence or significant weakening of breathing. In the future, there is a compensatory increase in a single L. The mediastinum is significantly shifted. There is an anterior mediastinal hernia with L. prolapse on the opposite side. In an objective study of a child at an older age, on the side of the absent L., one can listen to normal vesicular from the front, and slightly weakened breathing from the back. The borders of the heart are significantly shifted to the sick side, where heart tones are better heard. The diagnosis of agenesis and aplasia of L. (share) is specified on the basis of bronchoscopic and angiopulmonographic research, a cut is preferable to bronchography. Children with agenesis or aplasia of L. (share) do not need special treatment, but should be under the supervision of a doctor.
Hypoplasia - the underdevelopment of all elements of L. (bronchi, blood vessels, pulmonary parenchyma). There are simple hypoplasia and cystic (polycystic). Moreover, underdevelopment of the entire L., lobe or segment may occur. Hypoplasia can also be unilateral and bilateral.
With an early arrest of development, areas resembling L. embryo arise: among the wide layers of the preserved parenchyma, tubes lined with a cylindrical epithelium are visible. With a late arrest of development, parenchyma tissue resembles foci of congenital atelectasis, hypoplasia can be proved by the morphometric method. There are primary hypoplasia, often combined with a malformation of the kidneys, and secondary, caused by diaphragmatic hernias (usually on the left) or hydroamnion (bilateral). A moderate degree of hypoplasia may be a finding during a routine examination of the child. However, inflammation develops more often in underdeveloped L., a cut, as a rule, takes cron, course, is accompanied by signs of intoxication and respiratory failure. When viewed in cases of lesions of the entire L., asymmetry of the chest is noted with its flattening on the sore side and narrowing of the intercostal spaces. Percussion and auscultatory data depend on the severity of inflammatory changes in this L.
When rentgenol, the study determines the dimming of the pulmonary field or part of it corresponding to the affected section. The mediastinum is more or less shifted towards the lesion, the dome of the diaphragm is usually elevated. With polycystosis, numerous thin-walled cavities with smooth contours, usually not containing fluids, can be detected. When bronchoscopy pathology does not find or show signs of hron, bronchitis. The most demonstrative bronchographic picture. With simple hypoplasia, the bronchial tree pattern is depleted, the diameter of the bronchi is sharply reduced, the peripheral sections are not filled with contrast medium or are not completely filled. At a cystic hypoplasia, besides reduction of L.'s volume, multiple cystic cavities come to light, the segmental and subsegmental bronchial tubes end with. Angiopulmonography shows that with hypoplasia, blood flow in L. is sharply depleted or absent.
The main treatment method is operative (removal of the corresponding departments of L.). With extensive bilateral lesions, only a conservative treatment is possible, consisting in the prevention and relief of exacerbations of the suppurative process.
Congenital lobar emphysema is a malformation of L., characterized by stretching of the parenchyma (usually L.'s lobes). The terms are also used to refer to a disease: "congenital localized emphysema", "lobar emphysema", "obstructive emphysema", "hypertrophic emphysema". The disease is based on a defect in the development of cartilage elements of the bronchi, smooth muscle aplasia of the terminal and respiratory bronchioles. Bend of the bronchus, compression by its vessel, hypertrophy of the mucous membrane are also possible. The valve mechanism arising at the same time leads to sharp bloating of a parenchyma of L., a cut and defines a clinical rentgenol, a picture of defect. The lesion should be differentiated with secondary lobar emphysema of the newborn, due to blockage of the lobar bronchus by the mucous plug.
In accordance with the wedge, the picture distinguishes compensated, subcompensated and decompensated forms of congenital lobar emphysema. The latter has the most pronounced symptoms of respiratory and heart failure due to acute bloating of the pulmonary parenchyma, leading to a collapse of the adjacent sections of L. and displacement of the mediastinal organs. In this case, shortness of breath, general cyanosis, dry cough, asphyxia attacks during feeding can be pronounced. It is necessary to differentiate this form of the defect with strained pneumothorax and a strained solitary cyst L. The diagnosis is specified using x-ray and angiopulmonography. Bronchological research methods can provide some help in differential diagnosis. However, in the presence of stress syndrome, they are quite dangerous, because they can aggravate respiratory failure.
In most cases, with congenital lobar emphysema, surgical treatment is indicated. In case of stress syndrome, it should be carried out on an emergency basis and consist in the removal of the affected lobe.
With a subcompensated and compensated form, a planned operation is performed.
Unilateral congenital emphysema ("light" lung, "translucent" lung, lung hypoplasia with predominant underdevelopment of the pulmonary artery, McLaud"s syndrome) is a group of diseases of L., which has a similar clinical-rentgenol, a picture accompanied by increased transparency of the lung tissue. Information on the etiology and pathogenesis of these diseases is contradictory. Wedge, manifestations depend on the severity of inflammatory changes in the tracheobronchial tree and parenchyma, as well as on the degree of respiratory failure, which determine to lay down. tactics (usually symptomatic therapy).
Defects associated with the presence of excess (additional) dysembryological formations. These include supplementary L., L. sequestration, L. cysts, hamartomas and other congenital tumor formations.
An additional lung (L. share) is a rare defect, with Krom along with normally developed L., but separately from them there is L., usually of small sizes, the main bronchus departs from the trachea, and the vessels have a connection with a small circle blood circulation. Depending on the degree of maturity of the structural and tissue elements in additional L., it can participate in gas exchange. In the absence of interlobar fissures in the complementary L. and the communication of its bronchial system with the main or lobar bronchi of normal L. it is called the extra L. for surgery, bronchography or autopsy. However, additional L. can be hypoplastic, which contributes to the occurrence of inflammatory changes in it or funkts, violations. In such cases, bronchography and angiopulmonography help to clarify the diagnosis. Treatment consists in removal of an additional L. (share).
Pulmonary sequestration - the presence of an additional part of L., communicating or not communicating with the bronchial system of L., but having independent blood circulation due to an abnormally located artery, departing directly from the aorta. The outflow of blood from the sequestered lobe, with rare exceptions, is carried out into the pulmonary veins. So, the lung pulmonary sequestration more often represents a cystic hypoplasia of additional L. (share) with aortic blood supply. When an area with abnormal blood supply is located inside a normally developed L., intra-lobe or intralobar sequestration of L. is said to be. The most frequent localization of such a lesion is the lower lobe of the right L. The location of the additional L. (lobe) with aortic blood supply outside the normally developed L. (in the chest cavity, on the neck, in the abdominal cavity, etc.) are called extra-field pulmonary sequestration. Pulmonary sequestration may not have a wedge, manifestation and may be accidentally detected during life or at autopsy. However, more often this defect is accompanied by a hron clinic, inflammation in a hypoplastic L. On radiographs, a darkening of a round or irregular shape is seen, more often in the lower internal part of the pulmonary field. With the help of aortography, you can detect an additional vessel extending from the aorta and verify the diagnosis. At the establishment of the diagnosis operation is shown, edge consists in removal of the sequestered site L. Surgical intervention should be carried out in the period of remission. During surgery for intra-lobe pulmonary sequestration, it is often necessary to remove, together with sequestration, the normally developed lobe L. As well, remember that there is an abnormal vessel that usually passes in the pulmonary ligament and requires separate dressing and flashing to avoid dangerous bleeding.
Congenital solitary cysts of the lung can be central and peripheral. The first are located in basal zones, occur when the development of large, often segmental, bronchi is delayed and sometimes communicate with other departments of the bronchial tree. In the lumen contain mucus. Their walls are lined with cylindrical epithelium, contain glands, cartilage plates, a little muscle and an abundance of elastic fibers. Peripheral cysts occur when there is a violation of the branching of smaller bronchi, often bronchioles. They are lined with a low cylindrical or cubic epithelium, sometimes the walls are represented by parenchyma tissue. A congenital cyst of L. can be of the type pneumocystocele (when filled with air) and mucocystocele (with, filling with a mucous secretion). The frequency of L. cysts is 2.9-5.3% of the total number of patients with L. diseases in surgical clinics. Wedge, picture - a congenital L. cyst, small in volume, may not manifest itself for a long time. However, over time, most of them are complicated by tension or suppuration. This defines a fundamentally active surgical tactics in relation to the L. cyst. Pneumothorax as a complication of the congenital L. cyst in children is rare. Significant in volume or complicated by tension cysts are characterized by signs of respiratory failure, a pulmonary sound with a box-like tint, weakening of breathing on the side of the cyst, and displacement of the mediastinum in the opposite direction. The diagnosis is clarified using x-ray, tomography and angiopulmonography. Angiopulmonography is more informative than bronchography. In addition, conducting bronchography with severe respiratory failure is dangerous. With an unclear history and fuzzy rentgenol, the picture in the absence of indications for emergency surgery should be observed for a sick child in dynamics for 7-8 months. In the absence of dynamics, the cyst must be removed. In children, a lobectomy is more often performed) together with a cyst located in the lobe, less often a segmentectomy. When suppuration of the cyst of L. surgery is preceded by a thorough conservative treatment, including bronchoscopic debridement, puncture (with confidence in the presence of adhesions in the pleural cavity) or drainage.
The unusual location of the anatomical structures of the lung is not accompanied, as a rule, by impaired function and is an extreme form of variability or anomaly.
Anomalies of pulmonary furrows are an increase or decrease in their number. Additional gaps form, as a rule, between segments. Quite often the 6th, 7th and reed segments are separated, but this does not have a wedge, it does not matter. The absence of an interlobar sulcus can be the cause of technical difficulties during surgery.
"Mirror" lung is a concept that includes an anomaly of the bronchial discharge or the number of pulmonary furrows, when L. on one side is a mirror image of the contralateral L. Anomaly is rare, is not accompanied by functionalities, disorders and is detected by accident during bronchography, surgery or autopsy.
The reverse location of the lungs has a certain practical value, because it is part of the so-called. syndrome (or triad) of the Kartagener.
The proportion of an unpaired vein (lobus v. Azygos) by most authors refers to anomalies associated with the presence of additional pulmonary grooves. The reason for this anomaly is the presence of an additional fissure and cleavage of a portion of the upper lobe of the right L. The additional fissure is a duplicate of the parietal pleura, in which a unusually located unpaired vein passes. A similar anomaly occurs, according to D. S. Lindenbraten and L. D. Lindenbraten (1957), in 0.5 - 1% of all rentgenol, L. Klin studies, this anomaly does not give manifestations and, as a rule, is detected by chance with rentgenol , study. An X-ray in the upper inner part of the right pulmonary field reveals an arched line, convex outward and descending to the root, where it ends with an oval shadow. The latter is an axial or semi-axial section of an unpaired vein. Studies by M.F. Lomov and L. M. Nepomnyashchikh (1971) showed that the share of an unpaired vein in all cases has its own bronchus, communicating with the trachea, bronchus of the upper lobe or bronchus of the apical segment of the right L. with normally formed right L.
When hron occurs, the inflammatory process shows the removal of this lobe.
Anomalies in the development of the bronchial tree are very diverse. An abnormal discharge of the bronchi occurs (e.g., upper lobar tracheal - additional - bronchus), supernumerary bronchi, congenital stenosis of the bronchial trachea, tracheo-bronchial diverticula, tracheo- (bronchial) esophageal fistula.
Malformations of the blood and lymph vessels of the lung. Congenital arteriovenous aneurysms are of the greatest practical importance. The pathoanatomical picture of this disease is quite diverse, which explains the variety of its names (arteriovenous pulmonary fistulas, pulmonary cavernous angioma, varicose vessels L.). Between the branches of the pulmonary artery and veins there can be one or more patol. anastomoses, leading to the discharge of blood from an artery into veins, bypassing the capillary network (bypass). Localization of aneurysms in L. is different, more often they are located in the lower lobe of the right or left L. However, approximately 1/3 of such patients have multiple arteriovenous fistulas, which are often combined with malformation of vessels of other organs, mucous membranes and skin (telangiectasia). Such multiple vascular malformations are described under the name Osler-Randu disease.
Wedge, manifestations depend on the size, location and nature of arteriovenous aneurysms. With an arteriovenous shunt greater than 30%, severe symptoms of oxygen starvation develop. At the same time, patients complain of weakness, fatigue, shortness of breath, aggravated by physical. voltage; often there are headaches, dizziness, tinnitus, less often nausea and vomiting, diplopia, speech impairment, paresis of certain muscle groups, sudden collaptoid states, epileptiform seizures. Polycythemia and polyglobulia are characteristic, although not constant. In some patients, the number of red blood cells reaches 10-12 million in 1 μl of blood, and the hemoglobin content is 155 g / l. Pathognomonic, although not in all patients, the symptom is vascular extracardiac noise, heard over those departments of L. where the lesion is localized. A common symptom of arteriovenous pulmonary aneurysm is hemoptysis. With a localized aneurysm and a small diameter of the shunt wedge, symptoms may be absent, and patol, changes in L. are an accidental finding during rentgenol, research. X-ray and chest x-ray reveal a different shape and size of a homogeneous shadow of aneurysm in L. From it to the root of L. go the shadows of dilated vessels, which are more clearly detected on tomograms. Angiopulmonography allows you to determine not only the location, but also the degree of shunting. Arteriovenous aneurysms of L. require surgical treatment, a cut consists in a resection of the affected area of a lung.
Anomalies of the venous bed. The largest vein is most often determined, carrying blood from the right L. not to the heart, but to the inferior vena cava and causing the appearance on the tomograms of a shadow resembling a curved saber - scimitar syndrome. Congenital varicose veins look different. On radiographs, wide and unusually walking vascular trunks are visible. Sometimes they merge into a ball, giving a rounded shadow with scalloped outlines. Unlike arteriovenous aneurysm, this formation does not pulsate. In addition, with arteriovenous aneurysm, the caliber of the adductor artery is much larger than the veins departing from the aneurysm. In doubtful cases, the distinction is carried out using angiopulmonography.
Malformations of the lymphatic system are rare and do not have much practical significance.
Bronchopulmonary manifestations of genetically determined systemic diseases
Genetically determined systemic diseases with pulmonary manifestations include cystic fibrosis, alpha-1 antitrypsin deficiency, primary immunodeficiency states, Marfan syndrome, Osler-Randu disease, neonatal hyaline membrane disease, hereditary idiopathic pulmonary fibrosis. This group also includes rare pulmonary alveolar microlithiasis, which consists in the deposition of inclusions containing clumps of lime in the alveoli. The cause of the pathology is unknown. Sometimes the disease occurs in relatives, which may indicate a genetic predisposition. L. are pale, have a large mass, rocky density, especially in the lower lobes, where the process is most intense. Morphologically L.'s defeat is characterized by the presence in the alveoli of the psammothous bodies of a spherical shape. The younger of them have a concentric structure, contain calcium, phosphorus, iron, traces of magnesia, lipids, are intensively stained with hematoxylin, PAS-positive; the walls of the alveoli are infiltrated by mononuclear cells, sometimes they contain giant cells of foreign bodies. The disease leads to a violation of microcirculation L., capillary-alveolar block. It occurs at the age of 20-40 years. It can be combined with stenosis of the left atrioventricular opening, pneumosclerosis, hron, bronchitis. It should be differentiated with alveolar petrification of the lung, the edge reflects metastatic calcification and is characterized by the deposition of calcium plates under the basement membranes of the alveoli and bronchioles.
Clinically, the disease is asymptomatic for a long time. Then there is a cough and increasing shortness of breath due to obstruction of the alveoli. In the future, cyanosis, polycythemia, signs of a pulmonary heart occur. Calcifications are sometimes found in sputum. Radiologically projected onto each other, calcareous inclusions cause intense dimming of the pulmonary fields, especially in the lower sections. Pictures with elevated voltage make it possible to detect microliths and distinguish them from the branching calcifications and ossifications observed with branching osteoplastic osteopathy L. The disease gradually progresses and ends with death from pulmonary heart failure. Effective treatments do not exist.
Isolated injuries of L. are rare, ch. arr. with closed chest injuries; lesions of L. are the main component of all damages of a breast, they are followed by such pathophysiol, changes in an organism which are not inherent in a trauma of other localizations (a head, a stomach, extremities).
As a result of a gunshot and closed L. injury, pneumothorax, hemothorax, massive pulmonary hemorrhage, hemoptysis, "shock lung" syndrome, "wet lung" syndrome, subcutaneous emphysema and pneumomediastinum can occur. These patol, conditions underlie acute respiratory and cardiovascular failure, often accompanying a chest injury with damage to L. The mechanism of its development is extremely complex, but four reasons are of primary importance in it.
The first reason is a decrease in the volume of expansion of the chest due to a violation of the integrity of the ribs, scapula, sternum, diaphragm. One of the most severe injuries of the chest bones is double rib fractures (the so-called rib valves, leaflet fractures), in which, especially if they are multiple, chest flotation and paradoxical breathing develop, which leads to a sharp decrease in the volume of inhaled air (up to 200 - 150 ml instead of 500-600 ml with normal inspiration). With combined damage to the bone skeleton of the chest and diaphragm, chest mobility restrictions are even more pronounced. In these cases, the indices of external respiration, including VC, are sharply reduced. It aggravates a decrease in chest mobility and constant pain due to damage to the parietal pleura by fragments of the ribs.
The second reason is associated with the collapse of L. due to positive pressure in the pleural cavity with pneumo-, hemothorax. Collapse of L. is most significant at valve (tense) pneumothorax. The combination of L. collapse and blood loss leads to a decrease in the respiratory surface of L., a decrease in alveolar ventilation and oxygen transportation to tissues (due to a deficiency in the volume of circulating blood).
The third reason is a violation of tracheobronchial patency. Obstruction of the lumen of the trachea and bronchi of blood (including clots), secretion, scraps of L. tissue makes breathing difficult and evacuation of contents from the airways, which can lead to atelectasis, and sometimes to acute pulmonary edema. Often in these cases, the so-called. Kurnan"s vicious circle - ventilation disorders and hypersecretion of the bronchial glands (as a response to tracheobronchial obstruction) cause hypoxia, which in turn supports hypertension in the pulmonary circulation and, on the contrary, hypertension enhances hypersecretion, and consequently ventilation disorders. Extremely fast violations of tracheobronchial patency occur with a combination of mechanical trauma of L. and a burn of the respiratory tract (eg, with gunshot wounds to the chest and napalm burns).
The fourth reason is circulatory disorders. They can develop immediately after damage to the heart or large vessels with severe blood loss (primary acute cardiovascular failure) or as a result of displacement of the mediastinum with pneumo-, hemothorax and difficulty in blood circulation (secondary acute cardiovascular failure).
The result of the influence of this complex of causes creating acute respiratory and cardiovascular failure can be hypoxia, hypercapnia, depression of the respiratory center, asphyxiation, shock.
In accordance with the accepted classification of damage to L. in the absence of a wound of the chest wall is called closed, and in the presence of a wound - open.
Closed injuries result from shock, concussion, or compression. They are divided into bruises, or concussions, in which the integrity of the visceral pleura is preserved, and tears, in which it is broken. Internal ruptures of fabric L. without damages of a visceral pleura are observed seldom.
L. injuries, depending on the severity of the injury, are accompanied by small subpleural hemorrhages, hemorrhages in the alveoli with hemorrhagic infiltration or crushing of L. tissue, with damage to the bronchi, large vessels and the formation of cavities in L. filled with air and blood.
L. tissue breaks are single and multiple, and in shape - linear, polygonal, patchwork. In cases of L. damage by the end of a broken rib, the gaps look like a gaping gap or an irregular crater. In cases of especially severe injury, a crush of L. is observed with multiple ruptures of blood vessels and bronchi.
With L. bruises, pneumothorax and hemothorax usually do not happen, and the wedge, the picture is mainly determined by the volume of intrapulmonary hemorrhage. In cases of extensive crushing, the victims are delivered with a picture of severe shock, severe respiratory failure and hemoptysis. Massive hemoptysis and pulmonary hemorrhage are sometimes observed. A physical examination often reveals a shortening of percussion sound, increased voice trembling, attenuation or absence of respiratory sounds. They disappear after 7-10 days.
At L.'s breaks air penetrates into a pleural cavity and blood is poured out. In cases of patchwork ruptures of L., deep wounds with damage to large bronchi and rupture of the mediastinal pleura, valve pneumothorax, proceeding as an internal one, is often complicated by mediastinal emphysema and subcutaneous emphysema.
At breaks of L. traumatic shock often occurs. Hemoptysis or secretion of frothy sputum with an admixture of red blood, cyanosis, subcutaneous emphysema are typical.
Sometimes, with a severe closed chest injury, accompanied by blood loss, a shock lung syndrome occurs. Clinically, a shock lung is manifested by acute respiratory failure with scanty auscultatory data: vesicular breathing, weakened or hard, no wheezing.
A serious complication of a closed injury of L. is also the occurrence of a wet lung syndrome. This syndrome develops hl. arr. with violations of the drainage function of the bronchi and simultaneous hypersecretion of interstitial fluid and sputum, which fill the lumen of the bronchial tree. Wedge, a picture with a wet lung syndrome is quite characteristic. Patients experience a feeling of fear, suffocation, restless. Breathing - up to 40-50 in 1 min., Superficial, intermittent. Tracheal rales are audible in the distance. Over L., weakened vesicular breathing with many wet rales of various sizes is heard. The pulse may be intense, and blood pressure increased due to hypercapnia. With the appearance of circulatory failure, the heart rate increases, blood pressure decreases. In connection with a gas exchange disorder, loss of consciousness sometimes occurs and there is a suspicion of intracranial hemorrhage. After 1-2 days. progressive respiratory failure often leads to death.
Physical research at L.'s breakup is often difficult or even impossible due to the patient's motor excitement, sharp chest pain and development of subcutaneous emphysema. Therefore, the most important method for diagnosing the nature of damage is rentgenol. study.
If L. is damaged, the radiologist must find out which of the organs is damaged, what is the nature of the damage, what phenomena accompany it (hemothorax, pneumothorax, pneumomediastinum), whether there is a violation of the integrity of the chest bones. At a heavy contusion of L. at first the interstitial edema of L. is detected, and after 2-3 hours - alveolar edema, which lasts from 1.5 to 10-12 days. Intrapulmonary hemorrhages on the radiographs cause individual merging shadows, delimited by small bright areas. But a large hematoma may appear, giving a shadow to the dia. 2-4 cm. With multiple ruptures of the pulmonary capillaries (for example, with concussions from the blast wave), scattered small foci are visible against the background of an enhanced pattern and bronchio-emphysema. A rupture of the small bronchus sometimes leads to a pneumatic target - a rounded thin-walled air bubble is revealed in the picture among the darkened part of L. Rentgenol. manifestations of a shock lung - a decrease in the transparency of L., increased pattern due to interstitial edema, small fuzzy focal shadows. Gradually, the size and number of shadows increase. Pleural puncture allows you to confirm or exclude the presence of air and liquid blood in the pleural cavity.
Lech. measures for all closed injuries of L. are carried out but according to the same rules as for other chest injuries. To relieve pain, especially in cases of simultaneous fracture of the ribs, analgesics are prescribed and alcohol-novocaine blockade of the fracture of the ribs is made, as well as vagosympathetic blockade on the corresponding side. In case of multiple fractures of the ribs and "unstable rib cage", the fixation of the central fragment of the double fracture of the ribs and prolonged epidural anesthesia are effective. Disorders of tracheobronchial patency due to poor coughing require transnasal catheterization, microtracheostomy or bronchoscopy with sputum aspiration. In patients with a shock lung, anticoagulant therapy is carried out, and with severe gas exchange disorders, artificial ventilation of the lungs is performed.
With stopped bleeding in the pleural cavity and a small pneumothorax, pleural punctures are indicated. For L.'s expansion in patients with valvular pneumothorax or recurrence of pneumothorax after 2-3 punctures, the pleural cavity is drained with constant aspiration. If within 3-4 days air continues to flow through the drainage and the lung does not straighten, there are indications of thoracotomy and suturing of the lung wound. Urgent thoracotomy is indicated with continued bleeding into the pleural cavity and the absence of a positive effect from drainage and aspiration in cases of valvular pneumothorax. According to E. A. Wagner (1969), with closed injuries of L., the need for thoracotomy arises only in 2-3% of cases. Constantly in the treatment of closed injuries L. exercise therapy is indicated, and with a threat or occurrence of inf. complications - antibiotic therapy.
Open injuries usually occur as a result of stab wounds and gunshot wounds.
With stab wounds, the destruction and hemorrhagic impregnation of L. tissue are usually not extensive and the disorders associated with the development of pneumo- and hemothorax come to the fore.
Gunshot wounds are more severe injuries. The gunshot wound has a complex structure. Distinguish the wound channel containing blood, tissue scraps and foreign bodies, the area of primary traumatic necrosis, and to the periphery from it - the zone of molecular concussion. The last zone occurs under the influence of a side impact force, a wounding projectile (bullet or fragment). The wealth of L. elastic fibers, the laws of aerodynamics lead to amortization of the projectile"s manpower, in connection with which the size of the wound channel, as shown by IV Davydovsky, does not exceed the diameter of the bullet; it is often slit-like and heals with a linear scar.
At small wounds of a chest wall signs of simultaneous damage of L. are allocation of foamy blood from a wound, hemoptysis, hemothorax. A rapidly growing hemothorax indicates an injury to large vessels of L., mediastinum, or chest wall.
At a chest x-ray fresh L. wounds usually are not revealed. Only on tomograms or radiographs at a later date can you see the progress of the wound channel. Therefore, the main purpose of rentgenol, research is to determine the presence of foreign bodies, to determine the presence and amount of air and blood in the pleural cavity and assess the degree of expansion of L.
Treatment of wounds of L. is carried out according to the principles identical for all the getting wounds of a breast. It should strive for the earliest complete straightening of L., restoration of the hermetic integrity of the pleural cavity and its liberation from the accumulation of blood. The detection of air and fluid in the pleural cavity is an indication for pleural puncture. With valve pneumothorax, the introduction of intercostal drainage is indicated. In cases of a large amount of air, indications for the conduct of one or two more drains may occur. With intensive air leakage in the first 12-24 hours, it is better to refrain from aspiration and limit yourself to underwater drainage. Then proceed to constant aspiration with a vacuum of 15-20 cm water column. A stronger dilution is undesirable, since it can interfere with the closure of lung wounds with fibrin. Indications for thorapotomy and suturing of lung wounds with open injuries are as follows: the lack of the full effect of aspiration through drains for 3-4 days; preservation of intense pneumothorax and emphysema of the mediastinum with functioning drains (usually in these cases large wounds of the lung or large bronchi are found); massive or ongoing intrapleural bleeding, determined on the basis of general clinical, rentgenol, data and with puncture of the pleural cavity; coagulated hemothorax, if conservative measures (pleural puncture with irrigation, use of fibrinolytic agents, etc.) were not effective: foreign bodies in the pleural cavity and in L. if they cause a risk of complications (abscess, bleeding, etc.).
The surgical treatment of wounds has some features. Small superficial wounds of L. capture with a clip, under the Crimea apply the usual ligature. Larger wounds are sutured with thin interrupted or U-shaped sutures - synthetic threads on an atraumatic needle. Additional sealing of the seam line can be done with cyanoacrylate adhesive. Deep wounds of L. are sutured with obligatory capture of their bottom in order to avoid the formation of intrapulmonary air cysts and hematomas. Before suturing such wounds, it is advisable to pre-bandage or sheathe damaged vessels and bronchi. In the presence of a torn-bruised or crushed wound of L. non-viable tissues are economically excised or, depending on the extent of the damage, produce atypical L. resection, lobectomy, pulmonectomy.
The duration of treatment of patients with injuries of L. is determined by the severity of injuries and the nature of possible late complications. In uncomplicated cases, the duration of treatment varies from 2 to 3 weeks., Disability is restored after 2 to 3 months. Mortality in peacetime with closed and open injuries L. 2-4%.
Stage treatment in a military field environment and GO conditions for injuries of L. is an integral part of the complex of measures for the staged treatment of all wounds of the chest.
The acquired diseases of L. are extremely diverse. The etiology of a significant part of them is associated with biol, pathogens (bacteria, viruses, fungi, parasites). The etiology of another, no less numerous, group of diseases of L. cannot be reduced to this factor, although biol and pathogens can play a significant role in the pathogenesis of these sufferings and in the development of complications.
In a large group of diseases, the etiology of which is not directly related to inf. or other biol, pathogens, hron, nonspecific diseases of L. are of greatest importance, to hrym include hron, bronchitis, emphysema and bronchial asthma. The role of hron, non-specific diseases of L. in morbidity, disability and mortality of the population of most industrialized countries of the world is growing rapidly; they occupy the third or fourth place after cardiovascular diseases, malignant tumors and injuries.
Non-specific diseases of a bacterial and viral nature
From the so-called. non-specific pathology L. inf. etiology of the greatest importance is pneumonia, as well as pulmonary suppuration associated with the destruction of lung tissue: abscess and gangrene L.
Classification. S. I. Spasokukotsky (1935) considered the abscess and gangrene of L. different stages of pulmonary suppuration. This point of view was widespread for many years and was based on the data of the wedge, and morphological studies on the possibility of the transition of one form to another. However, many clinicians (M. S. Grigoriev, V. I. Struchkov, I. S. Kolesnikov and B. S. Vikhriev and others) and pathologists (A. M. Abrikosov, A. T. Khazanov and V. D. Zinserling and others) consider an abscess and L. gangrene as independent diseases with peculiar wedges, and morphol, signs. However, they do not exclude situations in which a limited purulent fusion of L. (abscess) acquires features characteristic of its localized or even widespread necrosis (gangrene).
Many classifications of abscesses and gangrene of L. are offered, for example. A. A. Opokin, S. I. Spasokukotsky, B. E. Linberg, H. M. Amosov, I. S. Kolesnikov and B. S. Vikhriev, B. P. Fedorov and G. L. Vol-Epstein, F.G. Uglov and V.F. Yeghiazaryan. The most common classification of P. A. Kupriyanov and A. P. Kolesov (1955): acute purulent abscess (single, multiple); gangrenous abscess; common gangrene L.; hron, abscess (single, multiple). In addition, the classification indicates the localization of the process by shares, the etiology of the abscess and gangrene of L. and their complications: pyopneumothorax, the occurrence of an abscess in previously unaffected parts of L., bleeding, brain metastatic abscess, septicopyemia, amyloidosis, etc.
The fundamental difference between the classification of P. A. Kupriyanov and A. P. Kolesov from other classifications is the division of L. lesions, characterized by necrosis of the tissue, into a gangrenous abscess and L. gangrene. This division is advisable primarily because the classical one described in old textbooks and manuals L. gangrene, invariably ending in the death of the patient, is now quite rare.
Etiology. There is no specific causative agent of abscess and gangrene L., and the bacterial flora in them must be characterized as microbial-viral. The microbial flora allocated at patients with an abscess and L. gangrene is more often polymorphic. Of primary importance are the associations of streptococcus and staphylococcus, which are highly resistant to antibiotics. In the lesion focus are white and golden hemolytic staphylococcus, green and hemolytic streptococcus, fusospirochete flora, E. coli, Friedlander's bacillus. The polymorphism of the flora in the area of the purulent-destructive process can be associated with the penetration of saprophytic microbial populations from the oral cavity and nasopharynx. Introducing into the lung tissue, these saprophytic populations immediately acquire the features of pathogenic microorganisms. A relatively small number of microbial populations were detected in M. Ya. Elova, P.E. Lukomsky, and T.V. Stepanova in acute abscesses of L., however, in cases of the transition of the process to a chronic number of microbial forms, it increased significantly.
A significant role is played by the increasing frequency of antibiotic-resistant microbial forms and, first of all, strains of the coccal group. In severe forms of pulmonary suppuration, the microbial flora resistant to basic antibiotics, according to L. M. Nedvedetskaya, is detected in 60 - 70% of cases. According to the materials of B. P. Fedorov and G. L. Vol-Epstein, in patients with abscess and L. gangrene, the microbial flora from the lesion was sensitive to tested antibiotics only in 12-20%.
A number of authors emphasize the role of mycoplasmas ("Eaton's agent") and viruses in the development of acute and chron, forms of pulmonary suppuration and indicate the importance of influenza virus in the process of abscess formation.
Pathogenesis. Abscesses and lung gangrene can have different pathogenesis. They are post-pneumonic, aspiration, hematogenous-embolic, traumatic, lymphogenous. Most often, an abscess and L. gangrene are complications of acute pneumonia. The role of pneumonia in influenza is very significant, which is characterized by destructive changes in the walls of the bronchi, deterioration of their drainage function, impaired microcirculation with thrombosis of small pulmonary vessels, as shown by I.V. Davydovsky, L.S. Bekerman. According to I.S. Kolesnikov and B.S. Vikhriev, in 63.9% of patients with abscess and L. gangrene, the cause of their occurrence was pneumonia, and in 14.1% - the flu. According to the materials of B.P. Fedorov and G.L. Vol-Epstein, in 76.1% of cases the development of abscess and gangrene was directly associated with pneumonia. The widespread use of antibiotics does not prevent abscess formation in acute pneumonia, especially with the late start of antibiotic treatment. As the resistance of pneumonia pathogens to antibiotics increased and the body reactivity changed, the frequency of the development of abscesses and L. gangrene began to increase somewhat. So, according to V.I. Struchkov, in 1952 - 1957. the frequency of purulent-destructive complications of acute pneumonia was 1.8%, and in 1960 - 1966 - 2.23%.
The aspiration path of the development of an abscess and gangrene of L. is associated with infection of the L. site, ventilation of which is disturbed as a result of obstruction of the corresponding bronchus by a foreign body, vomit, blood, mucus. An abscess and gangrene of L. of an aspiration genesis more often develop after a diabetic coma, an epileptic seizure, maxillofacial injuries, heavy alcoholic intoxication, surgical interventions in the larynx and nasopharynx.
A more rare way of developing an abscess and gangrene L. is hematogenous-embolic. At the same time, a septic embolus, having got into one of the branches of the pulmonary artery with a blood stream, causes a heart attack L. In the infected zone of a heart attack, purulent fusion and the formation of an abscess quickly occur. L. embolic abscesses complicate the course of deep vein thrombophlebitis and pelvis, septic endocarditis, osteomyelitis, postpartum sepsis. Surgery on infected tissues can also contribute to the separation of a thrombus and its introduction into L.'s vessels. Almost as often abscesses and L. gangrene develop after a chest injury with a fracture of the ribs and hemorrhages in the lung tissue. The lymphogenic pathway of infection into the lungs is casuistic. However, the anatomical connections of the lymph, L. system, pleura and mediastinum make possible the lymphogenous development of abscesses and L. gangrene with purulent pleurisy or mediastinitis.
In addition to the factors listed above, the development of an abscess and gangrene of L. is promoted by diseases in which bronchial drainage and pulmonary circulation are disturbed for a long time — chron, bronchitis, bronchial asthma, emphysema.
Disorders of the nervous regulation and lymph circulation in L. also play a certain role in the pathogenesis of abscesses and gangrene of L.
In the development of the gangrenous process, an important role is played by an increase in the blood coagulation potential, observed, according to G.I. Lukomsky, with pulmonary suppuration. There is a state of prethrombosis, a cut is exacerbated by progressive dysproteinemia and hypoalbuminemia.
Of great importance in the pathogenesis of abscess and gangrene L. belongs to the nature of changes in the reactivity of the organism. While maintaining the body's defenses, elements of purulent fusion prevail and an acute purulent abscess forms; with a decrease in them, necrotic changes prevail, a gangrenous abscess or widespread L. gangrene occurs
Pathological anatomy. Abscess L. - limited purulent-necrotic lesion of the lung tissue with the presence of one or more cavities, gradually lined with granulation tissue. They rarely have a correctly rounded shape and contribute to the development of bronchiectasis and pneumosclerosis.
Gangrene L. - necrosis of lung tissue with a tendency to progressive spread. Putrid, putrefactive gangrene of L. is characterized by diffuse necrosis with the formation of fuzzily outlined foci of brown-black color, which undergo decay with the formation of cavities. In the central departments of necrosis there is a lot of blood pigment, tissue detritus, crystals of leucine, tyrosine, fatty cells. Bacterioscopy reveals a variety of, mainly anaerobic, pathogens. Aputrid gangrene - necrosis without putrefactive decay, occurs most often in patients with diabetes under the influence of fungi. So-called gangrene should be distinguished from gangrene. acid pneumomalacia under the influence of agonal or cadaveric reflux of the acidic contents of the stomach in the bronchi. These are flabby foci of brown color, in which the structure of L. is poorly detected, but they are not accompanied by any reaction on the periphery.
Pathophysiological and biochemical shifts at an abscess and gangrene L. differ only in severity. Hypoalbuminemia progresses, edge occurs due to the loss of a significant amount of protein with pus and a violation of the protein-forming function of the liver due to intoxication. At the same time, there is an increase in globulin fractions - mainly alpha-1-, alpha-2- and gamma-globulins. Therefore, general hypoproteinemia is usually not observed. Later, with the development of hypoproteinemia, the water-binding function of the protein decreases and edema occurs.
An increasing decrease in albumin contributes to changes in the water-salt and electrolyte balance, which in turn change the acid-base balance. There is a tendency to increase the sodium content in red blood cells and reduce it in blood plasma. In the most severe forms of pulmonary suppuration, metabolic acidosis develops. If an abscess and gangrene occur against a background of emphysema, pneumosclerosis, common bronchiectasis, bronchial asthma, respiratory acidosis can be observed. According to G.I. Lukomsky, M.E. Alekseeva, the volume of circulating blood and its components changes dramatically. From the indicators of the blood coagulation and anticoagulation system, there is an increase in the level of fibrinogen and an increase in plasma tolerance to heparin, i.e., the prevalence of the activity of the coagulation system over the anticoagulation.
All pathophysiol, and biochemistry, changes are closely interconnected, depend on the volume and nature of the lesion of L., on the phase of the process, the degree of intoxication, concomitant diseases. After natural or artificial evacuation of pus from the abscess cavity and reduction of intoxication, these indicators gradually normalize, objectively confirming the effectiveness of therapy.
Clinic and diagnosis. Abscessing with pneumonia usually occurs according to one of the three options described by F. Sauerbruch, O"Shaughnessy, and then L. S. Beckerman. The first option: after 12-20 days from the onset of pneumonia, after the acute phenomena subsided and the apparent recovery, a significant deterioration occurs - the temperature rises, pains in the side reappear, with a cough, profuse purulent sputum begins to stand out. The second option: pneumonia becomes protracted and after 20-30 days from the onset of the disease against the background of a rise in temperature, the amount of purulent sputum increases, and a cavity is revealed radiologically in the zone of inflammatory focus. The third option: against the background of a 1-2-week malaise, low-grade fever, chest pains, body temperature rises to high numbers with subsequent heavy sweats, and after 2-3 days the patient suddenly begins to cough off fetid sputum with a "full mouth" (breakthrough syndrome). With this course of the disease, P. E. Lukomsky, A. Ya. Gubergrits, Decroix and Kurilsky (G. Decroix, R. Kourilsky, S. Kourilsky) wrote about the "primary lung abscess".
An acute abscess of L. is observed hl. arr. in men aged 30-50 years. In the development of an abscess, it is customary to distinguish two phases. The first phase is characterized by acute purulent inflammation and destruction of the lung tissue until the purulent necrotic masses break into the lumen of the bronchial tree. The second phase begins after such a breakthrough, which usually occurs on the 2-3rd week. from the onset of the disease. Good emptying of the cavity is more often observed with abscesses of the upper lobes. In cases of intensive treatment, the purulent cavity usually decreases rapidly and ceases to be detected. Sometimes a thin-walled cavity without signs of inflammation remains in place of the abscess. With poor or insufficient emptying, a cut more often occurs with localization of the abscess in the middle and lower lobes, purulent-necrotic inflammation of the wall of the cavity and surrounding lung tissue does not tend to persistently subside. Repeated exacerbations occur, in the abscess wall there is a progressive development of connective tissue, pneumofibrosis develops in the surrounding L. tissue. 2-3 months later. from the onset of the disease, such an abscess loses its tendency to heal and becomes chronic.
The gangrenous abscess of L. arises as a result of the begun gangrene, edge does not extend to all L., and affects only its greater or lesser part. Such defeat, keeping signs of L. gangrene, at the same time possesses the features characteristic of an abscess. Isolation of gangrenous abscess as an independent form of pulmonary suppuration is justified due to a kind of wedge, and rentgenol. the picture, the severity of the disease and the need for emergency intensive care. L. gangrenous abscess is more often observed in men aged 25–45 years. In the anamnesis, most of them have indications of cron, alcoholism, diabetes, cron, bronchitis, repeated pneumonia. The initial lesion is usually localized in the upper lobe of L., but the process spreads rapidly, leaving most often only the basal sections of the lower lobe intact.
The most characteristic symptoms of a beginning acute L. abscess with any etiology are chest pain, cough with a three-layer purulent sputum, sometimes with a fetid odor, high intermittent fever with chills and sweats, sleep and appetite disorders, headache, shortness of breath. Percussion and auscultation reveal various changes, largely depending on the length, localization, stage of patol, the process, the presence or absence of pleural effusion. With a large volume or with subpleural localization of the lesion and the presence of effusion in the pleural cavity, respiratory excursions of the corresponding half of the chest are limited, percussion sound is shortened, breathing is weakened, and with a massive effusion it is not audible at all; in other departments of L. dry and wet rales of various sizes, caused by concomitant bronchitis, are often heard. ROE reaches high numbers, hemoglobin in the blood decreases, leukocytosis is typical with a shift in the leukocyte formula to the left until the appearance of young forms of neutrophils and toxic granularity in them. Signs of intoxication persist and even increase until the purulent-necrotic contents burst into the bronchus and the patient begins to cough him. The amount of sputum increases sharply, the temperature and other symptoms of intoxication gradually decrease, leukocytosis decreases, and ROE slows down. Auscultatory in the destruction zone, large bubbling rales are heard, with large and gigantic cavities - breathing with an amphoric hue against their background.
The wedge, the course of hron, the abscess of L. usually has a cyclical character and is largely determined by the degree of patency of the draining bronchi and the emptying of the purulent cavity. These factors are critical in alternating periods of exacerbation and remission. With good drainage, exacerbations are rare, intoxication is not very pronounced. However, the cough usually persists, especially in the morning and when the body position changes. Sputum remains purulent. Often blood streaks appear in sputum or hemoptysis, a cut threatens to clog the draining bronchi with blood clots. Sometimes pulmonary bleeding occurs, easily leading to the development of aspiration pneumonia. Violation of the drainage function of the bronchi, as a rule, leads to an exacerbation of the process, an increase in intoxication, secondary respiratory and circulatory disorders, an increase in the risk of developing amyloidosis of the internal organs.
Gangrenous abscess from the very beginning is very difficult, accompanied by fever with temperatures up to 40 °, severe intoxication, respiratory and circulatory disorders. Patients complain of chest pain and excruciating cough, initially accompanied by the release of only a relatively small amount of purulent, foul-smelling sputum. The skin is dry, grayish in color. Lips and nail phalanges are cyanotic. Breathing with an amphoric shade and a mass of wet rales is heard over the affected area, hard breathing with dry and single moist rales is over other parts of L. The liver is often enlarged and slightly painful. In the analysis of urine, the appearance of protein is noted. In the blood there is a very high leukocytosis with a shift of the formula to the left, ROE reaches 60-70 mm per hour. Significantly expressed changes in the proteinogram and the volume of circulating blood. After 10-15 days, the melting and rejection of the necrotic masses begins. The amount of sputum increases rapidly and reaches 1-1.5 liters per day. The sputum consistency is thick and even mushy, the color is brown, the smell is putrid (gangrenous). 1/4 patients have hemoptysis, pulmonary hemorrhage. Despite the usually good emptying of gangrenous abscesses, which, as a rule, are drained by several bronchi, intoxication does not decrease, and in some cases even increases due to the lack of a demarcation shaft, the involvement of new areas of L., the presence of large necrotic pulmonary sequestration in the abscess cavity tissue. If the intensive treatment is not started at the right time or if it is ineffective, the patients die of progressive intoxication or complications - pulmonary hemorrhage, breakthrough of the gangrenous abscess in the pleural cavity with rapid development of pyopneumothorax. Under the influence of complex intensive treatment, intoxication gradually decreases, breathing, blood circulation, and metabolism normalize. Sputum becomes more fluid, homogeneous, purulent and loses fetid odor. Hemoptysis occurs less frequently and is less profuse, but the risk of pulmonary hemorrhage remains. The further course is most often favorable. However, in place of a gangrenous abscess, a residual cavity, clearly visible on radiographs, always remains, the value of a swarm slowly decreases. Despite the wedge, well-being, normalization of the hemogram, absence of sputum, the walls of such a residual cavity for a long time, as shown by abscessoscopy, are covered with necrotic plaque.
Gangrene L. is clinically most severe. There is always a pronounced intoxication, severe respiratory, circulatory and metabolic disorders are observed.
Complications Possible complications during pulmonary suppuration are impaired drainage through the bronchus, breakthrough of pus in the pleural cavity, and pulmonary hemorrhage. In such cases, the condition of the patients worsens again, chest pain intensifies, the amount of sputum decreases, the body temperature rises, and leukocytosis in the blood rises. Complications of L. gangrene are similar to complications of an abscess, but develop more often and are more difficult.
X-ray diagnostics. At an abscess of L. at the beginning the radiologist discovers only a shadow of an infiltrate, sometimes roundish, with vague contours. The predominant localization of the abscess is the 1st, 2nd and 6th segments of the right L. Then, as the abscess is emptied through the bronchus, the classic signs of abscess appear: a cavity containing gas and a liquid that forms a horizontal level is visible in the infiltrate. With successful treatment, the cavity decreases, the fluid in it decreases. In place of the abscess, a field of inhomogeneous compaction remains, sometimes with a residual cavity. With putrefactive disintegration (gangrene) of lung tissue in the area of widespread infiltration, irregularly shaped cavities with uneven outlines and shadows of necrotic sequesters emerge. L. root is infiltrated.
Separate (metastatic) abscesses stand out. Their rentgenol. the picture consists of interstitial pneumonia and sections of lobular or confluent infiltration. In the lung, one or more rounded thin-walled cavities of destruction of diam. 0.5 - 1.5 cm, containing gas and almost always free of liquid. The walls of these cavities are even, there is no significant infiltration in the surrounding tissue, the cavities can quickly change in size and, reaching the visceral pleura, lead to spontaneous pneumothorax and empyema of the pleural cavity.
Treatment of abscess L. provides for the suppression of infection, drainage of the abscess and increase the patient's body resistance. Infection is affected by the use of antibiotics, which should be selected taking into account the nature and sensitivity of the microbial flora isolated from sputum. It is advisable to use two or even three drugs at the same time. A very difficult question is the choice of the method of administration and doses of antibiotics, given that L. abscesses in many patients develop against the background of inadequate antibiotic therapy. It is preferable to various special methods to create a higher concentration of antibiotics in the lesion. The most acceptable are intravenous drip of antibiotic solutions and their introduction into the abscess cavity through a transnasal catheter, microtracheostoma, bronchoscope or catheter installed in the abscess cavity by thoracocentesis under conditions of pleural cavity obliteration. All methods of administering antibiotics through catheters and a bronchoscope are combined with measures that improve drainage of the purulent cavity, such as aspiration, washing, and the introduction of proteolytic enzymes.
Antibiotics are drip intravenously in isotonic sodium chloride solution or in 5% glucose solution for 5-7 days or more. The daily dose of penicillin can reach 80,000,000 units, morphocycline - 1,000,000 units, methicillin sodium salt - 10 g.
Infusion of antibiotic solutions into the abscess cavity, if it is well drained through the bronchus, is performed every other day by transnasal catheterization after local anesthesia of the nasal mucosa, pharynx, larynx, trachea and bronchi. A rubber or plastic catheter is used, which is inserted under the control of X-ray television. The technical implementation of catheterization is greatly facilitated by the use of special catheters with a universal control handle. In cases of poor drainage of the abscess, a course is carried out to lay down. bronchoscopies during which they lay down. catheterization of the draining bronchi and, if possible, the abscess cavity. If these methods are ineffective or insufficient, abscess puncture through the chest wall and drainage of the abscess by thoracocentesis are used. Punctures are carried out under local anesthesia and X-ray television control at the point of the chest wall located closest to the abscess. During the puncture, pus is aspirated, the abscess cavity is washed with 1: 5000 r-rum of furatsilin or 3% boric r-rum, and then the antibiotic rr is administered. With puncture of lung abscesses, complications such as pneumothorax, limited empyema of the pleura, and phlegmon of the chest wall can occur. Therefore, sometimes they carry out activities to cause an adhesion process in the pleura. Drainage of abscess L. by thoracocentesis compared with punctures is more effective. Therefore, drainage is indicated in most severe cases, when other therapy does not allow to eliminate purulent intoxication due to persistent violation of patency of the bronchi draining the abscess cavity. The usual period of drainage in the abscess cavity is 2-3 weeks.
A high and stable concentration of antibiotics in the area of abscess L. is also achieved by their fractional or prolonged drip infusion into the corresponding branch of the pulmonary artery or, more effectively, into the bronchial artery. However, these methods are associated with the need for catheterization of the pulmonary artery through the subclavian vein, vein of the shoulder or thigh, and catheterization of the aorta through the femoral artery and therefore are rarely used, mainly in specialized departments.
Common events that contribute to a better evacuation of the contents of the abscess of L. through the bronchi are special breathing exercises, postural drainage, inhalation of alkaline aerosols, and the use of bronchodilators.
Increasing resistance and improving the general condition of patients is achieved by a complete diet with a large number of proteins and vitamins, the use of auto-vaccines, plasma infusions, protein solutions, 1% calcium chloride solution, as well as the introduction of anabolic hormones and nonspecific metabolic stimulants, such as pentoxyl and methyluracil. A significant increase in the reactivity of the body can be achieved by the introduction of staphylococcal toxoid, gamma and polyglobulin, as well as native antistaphylococcal plasma.
Surgical interventions have to be performed in approximately 10% of all patients with hron, L. abscesses. In acute abscesses with necrotic sequestration, pneumotomy remains a rational operation. In all other cases, this operation, which was previously widely used, has lost its significance due to insufficient effectiveness and the frequent need for subsequent thoracoplasty and muscle plasty to close the residual cavities and bronchial fistulas.
In patients with L. gangrene, conservative treatment methods usually fail. Therefore, if the diagnosis is not in doubt, you need to try to save the patient as early as possible, as a rule, by removing the entire affected L., since it is usually not possible to stop the progressive necrosis of the lung tissue. Mortality in such operations and in modern conditions remains very high. The main operations at hron, abscesses of L. are resections of the affected parts of L. - usually a forehead-silt and bilobectomy. In cases of involvement in the process of the upper and lower lobes of L. or with multiple abscesses in different parts of L. pneumonectomy is indicated. In patients with severe pulmonary hemorrhage, urgent indications for L. resection occur.
The prognosis of pulmonary suppuration is largely determined by its form and timely started full-fledged therapy. With the timely and correct use of the described conservative methods of treatment, it is possible to achieve a wedge, recovery in 80% of patients with acute abscesses L. The total mortality rate with conservative and surgical treatment of lung abscesses is 5 - 7%.
In the prevention of abscesses and gangrene L. wide gig are of primary importance. measures aimed at preventing diseases of the bronchi and L., timely started full-fledged treatment of acute pneumonia, prevention of aspiration of foreign bodies into the respiratory tract.
Features of pulmonary suppuration in children
Suppuration of L. in children, as in adults, can be acute and chronic. Features of suppuration of L. in childhood are determined by many factors, among which it is necessary to highlight the relative immaturity of bronchopulmonary structures, continuing their quantitative and qualitative development, as well as the level of infection resistance different in different age groups. In addition to these factors, the frequency and severity of suppuration of L. in newborns and infants is affected directly or indirectly by the complicated course of pregnancy and childbirth (maternal diseases, aspiration, hypoxia during childbirth, etc.), prematurity, hypotrophy, rickets.
Among pathogens of suppuration of L. staphylococcus predominates in children. Most acute pulmonary suppuration occurs due to aerobronchogenic infection, however, in about 20-30% of cases there is a hematogenous pathway in the presence of previous extrapulmonary purulent foci. In the neonatal period and early infancy, hematogenous infection is more common than in older children; such foci are usually omphalitis, pyoderma, soft tissue abscess, otitis media, etc.
A special group is made up of patients in whom the inflammatory process develops against the background of congenital malformations of L. (single and multiple cysts, hypoplasia, sequestration, etc.). Significantly greater proportion, compared with adults, in children is pulmonary suppuration due to aspiration of foreign bodies.
Among acute pulmonary suppuration, two main forms can be distinguished: small focal and large focal abscess formation. The first of these forms is very typical for staphylococcal abscessed pneumonia - the so-called. staphylococcal destruction of L., occupying the first place in the structure of acute pulmonary suppuration in childhood. With small focal abscessing, abscesses are small, they are most often multiple and are located mainly in the peripheral parts of the lung. In this regard, the pleural cavity is quickly involved in the inflammatory process (due to increased exudation in the pleura or by breaking through abscesses). As a result, pulmonary pleural suppuration develops, a cut can be in various forms of pyothorax (cloisonne, delimited, total) or pyopneumothorax (intense, stressless, delimited). It is important to emphasize that the rapid attachment of pleural complications mask rentgenol, signs of abscessing, and signs of an inflammatory process in the pleura come to the fore. The following pattern is characteristic - the younger the child, the more often the tendency to generalization of the inflammatory process in the pleura, which consists in the predominance of severe forms of total pyothorax, intense and unstrained pyopneumothorax. This is especially noticeable in infants and infants.
In children over the age of one year, the tendency to delimit the inflammatory process in the pleura becomes more pronounced, they are more likely to meet along with severe relatively favorable forms such as cloak-like and delimited pyothorax, delimited pyopneumothorax. According to this trend, in newborns and infants are incomparably more often than in older ones, the purulent process is accompanied by the development of signs of sepsis.
Large focal abscessing is observed in children 4-5 times less often than small focal, and can have three main roentgenomorphol. forms: abscess with liquid level, filled abscess and abscessing as a lobite. In these cases, the pleural cavity is usually not involved in the inflammatory process, or the latter is reactive and more pronounced in the area of the abscess. Large-focal abscessing in children is most often one of the forms of staphylococcal destruction of L. However, it can occur with aspiration of foreign bodies and, as a result, "metastasis" from extrapulmonary purulent foci (osteomyelitis, peritonitis, etc.).
One of the most frequent forms of hron, an inflammatory process in L. is bronchiectatic disease. With this disease, suppuration by type hron, abscessing in the parenchyma L. is very rarely observed. Most often there is a more or less pronounced hron, purulent bronchitis with deformity of the bronchi like cylindrical or saccular bronchiectasis. However, with bronchiectasis due to a malformation (the so-called polycystic lung), the wedge, and rentgenol, the picture is very close to hron, pulmonary suppuration. Chron, L. abscesses in childhood are much less common than in adults. Their formation, as a rule, is associated with insufficiently effective treatment in the acute period when complete and early emptying of the cavity and its subsidence are not provided. In some cases, the formation of hron, abscess is associated with the passage of foreign bodies from the lumen of the bronchus into the parenchyma L. With pulmonary pleural forms of acute purulent process, an outcome in hron is possible, suppuration, a cut takes the form of hron, pleural empyema. The latter may be accompanied by irreversible changes in L. (bronchiectasis, formed bronchopleural fistulas). The outcome of acute pulmonary-pleural suppurations in hron, empyema in children is much less common than in adults, and ranges from 0.5-3% of cases. Rare causes of hron, empyema are fistulas of the bronchus stump after resection of L. and foreign bodies of L. and pleura.
All forms of acute pulmonary suppuration are accompanied by symptoms of rapidly developing purulent intoxication (high fever, loss of appetite, hemodynamic and microcirculation disorders, metabolic disorders, etc.). Usually they are accompanied by respiratory disorders, the severity of which depends on the volume of the pulmonary parenchyma involved in the inflammatory process, and the presence of factors that mechanically impede breathing (intrapleural or intrapulmonary tension, obstruction of the respiratory tract with sputum, restriction of respiratory excursions of the diaphragm due to intestinal paresis). They come to shortness of breath, violation of the depth and rhythm of breathing, up to attacks of asphyxiation. The prevalence of manifestations of toxicosis or respiratory disorders depends on the form of suppurative process. Respiratory disturbances usually come to the fore with pulmonary suppuration, accompanied by intrapleural or intrapulmonary exertion. Other things being equal, the signs of toxicosis and respiratory disorders are more pronounced and progress more rapidly in patients of the neonatal and early infancy years. In acute pulmonary suppuration at first, the general symptoms of intoxication in children prevail over clinically detectable signs of a local pulmonary process. In some patients, masking syndromes (pseudo-abdominal, neurotoxic) are observed.
The pulmonary process is often long regarded as ordinary pneumonia, especially if the diagnosis is limited to physical research methods. An important condition for the recognition of various forms of acute pulmonary suppuration is the earlier use of rentgenol, research. On the basis of survey radiographs (in the vertical position of the patient, in two projections), it is very likely to suspect large focal abscess formation. It is more difficult to detect small-focal abscess formation, which is often masked by perifocal infiltration. In these cases the tomography is expedient, edge can reveal cavities in L. of the small sizes. This study is less informative in the presence of pleural complications.
With pulmonary-pleural forms of suppuration, a necessary additional research method is puncture of the pleural cavity. With pulmonary forms of suppuration, diagnostic bronchoscopy is advisable. In the diagnosis of hron, forms of pulmonary suppuration, instrumental methods are widely used - bronchoscopy, thoracoscopy and rentgenol, methods - bronchography, pleurography, angiopulmonography. They allow you to confirm the irreversible nature of the change in L. and pleura and to clarify the localization and extent of the lesion.
In acute pulmonary suppuration, the main principle of treatment is the combination of intensive conservative therapy with instrumental and surgical methods. The choice of the latter is determined by the form of suppurative processes and age-related features of their course. For the treatment of acute abscesses JT. in children, various methods have been proposed. Widespread in the 50-60s. puncture treatment and drainage of the abscess cavity, as well as surgical methods in modern conditions are rarely used. Bronchoscopic drainage is becoming more widespread, the most effective sanitation is ensured in this case through transbronchial catheterization of the abscess. Surgical treatment is indicated only in cases of ineffective bronchoscopic drainage, which often happens in the neonatal period and early infancy. In the treatment of acute pulmonary pleural suppuration, the puncture method is advisable in the presence of relatively favorable pleural complications (cloisonne pyothorax, "delimited forms of pyothorax and pyopneumothorax). In severe forms of total pyothorax, strained and unstressed pyopneumothorax (pneumothorax), pleural cavity drainage with active aspiration is most often used. In order to accelerate the expansion of the lung, sometimes forced inflation is used under anesthesia. A more promising method of spreading L. with pyopneumothorax is the artificial sealing of the bronchial system by temporary occlusion of the bronchus, which carries peripheral fistulas. In a number of specialized institutions, advanced operations on L. and pleura are used (the so-called radical operations) in severe forms of acute pulmonary-pleural suppuration. They consist of simultaneous rehabilitation of the pleural cavity, combined with the removal of the purulent focus in L. Such operations are most justified in children of the neonatal and early infancy, in which there is a tendency to progression of the purulent process, and the effectiveness of the drainage of the pleural cavity is insufficient. The best results, according to Yu. F. Isakov et al. (1978), at this age give early surgical interventions. In case of pulmonary-pleural suppuration in children, a number of surgeons apply surgical treatment at a later date, with stabilization or improvement of the general condition in patients in whom L. remains unrepaired. Treatment of all forms of cron, pulmonary suppuration in children (bronchiectasis, cron, abscess, suppurative cysts , hron, empyema), as a rule, operational. The basic principle is a combination of radicalism and economy of surgical intervention, which provides for the maximum possible preservation of healthy L. sites.
The prognosis for acute pulmonary suppuration depends on many factors: the age of the patients, the one- or two-sided nature of the process, the adequacy of the treatment. The greatest threat is the development of sepsis, which is more often observed in children of the neonatal and early infancy with severe forms of pulmonary pleural suppuration. Long-term results in children undergoing acute pulmonary suppuration are generally favorable. The prognosis for hron, suppuration L. in children depends on the radicalism of surgical treatment.
To specific, mainly chronically current inf. processes in L. concern, first of all, tuberculosis. Syphilis is extremely rare. Congenital syphilis L. is observed in premature, stillborn fetuses or in newborns dying in the first days after birth. L. at the same time diffusely condensed. Microscopically detected pronounced fibrosis of the interstitial tissue, abnormal development of alveoli lined with cuboidal epithelium, and a large number of pale treponemas. Acquired syphilis of L. is characterized by the development of large or small gummas, which, undergoing necrosis and scarring, disfigure L. as pulmo lobatus, especially if gumma develop in the walls of the bronchi and lead to ulceration of the latter with the addition of non-specific sclerosis. Syphilis of the branches of the pulmonary artery manifests itself in the form of endo- or mesovasculitis and in conditions of pulmonary hypertension can, according to Spencer (N. Spencer), cause the development of aneurysm of its branches. Treponemas are detected poorly and more often in the form of atypical forms as opposed to congenital syphilis.
Syphilis L. is radiologically expressed by a combination of interstitial pneumonia and foci or infiltrates (gum) in the parenchyma L. The diagnosis is made on the basis of the detection of suspicious shadows during radiography and positive serol, reactions to syphilis. In unclear cases, a biopsy of L. is appropriate, confirming the specific nature of the lesion. The treatment is the same as with other forms of tertiary syphilis.
Fungal diseases. Fungal flora can be the cause of a number of predominantly chronically current diseases of L., combined into a group of pneumomycoses.
The cause of parasitic diseases of L. are both the simplest unicellular organisms and various helminths.
Protozoan infections of L. include pneumocystic pneumonia caused by Pneumocystis carinii, a cut is characterized by foamy contents of alveoli with the presence of cysts of 2-5 microns in size, well detected by the PAS reaction.
Pulmonary lesions in toxoplasmosis caused by protozoa Toxoplasma gondii consist in the formation of granulomas in the lung tissue, in which the focus of necrosis is surrounded by lymphocytes and plasma cells. In the future, calcification may occur. Toxoplasmosis in adults proceeds as acute interstitial pneumonia; the parasite is found in macrophages. Clinically observed common manifestations of toxoplasmosis. Often there is a cough, wet rales during auscultation. X-ray multiple focal shadows are visible, further foci are calcified. Typically, the same lesions are detected on radiographs of the skull in the brain. Lab diagnosis and treatment, as with other forms of toxoplasmosis.
L. amoebiasis is caused by Entamoeba histolytica, which primarily affects the colon. Of the latter, parasites hematogenously enter the liver, where an abscess forms, secondarily extending to the diaphragm and the lower lobe of the right L. Very rarely, the hematogenous amoebic abscess of L. forms without liver damage. Amoebiasis is characterized by foci of chocolate-colored necrosis due to deposition of blood pigment. With secondary infection, the fields of necrosis undergo purulent fusion with the formation of true abscesses surrounded by a zone of non-specific pneumosclerosis.
Clinically, the patient develops pain in the right half of the chest, high fever with chills, cough with secretion of copious grayish-brown liquid pus, amoeba can be detected in the rum. Radiologically there is a high standing of the right half of the diaphragm, darkening in the lower parts of L. with the subsequent formation of a cavity with a horizontal level, sometimes pleural effusion. Treatment is carried out, as with other forms of amoebiasis. Sometimes drainage of empyema or abscess cavity is necessary. At transition to hron, a form - a resection of L.
Of the parasitic diseases of L. caused by helminths, Echinococcosis is of the greatest importance.
Alveococcosis is much less common in L., with Krom lung tissue, as a rule, is affected secondarily by the hematogenous route or due to the germination of alveococcosis nodes from the liver through the diaphragm.
Paragonimiasis L. (endemic hemoptysis) is caused by pulmonary fluke (Paragonimus westermani). A parasite that enters the patient"s intestines, through the wall of the intestine, peritoneum and diaphragm penetrates into the lung tissue, where it ripens. There is bronchitis, circulatory disorder, in certain areas of L. like heart attacks with subsequent decay and the formation of cavities (cysts) with brown contents. Cysts can be emptied into a bronchial tree and filled with air and calcified. Clinically, the disease is manifested by chest pain, cough with profuse sputum of a rusty color or an admixture of fresh blood. Radiologically at paragonimiasis in L. sites of infiltration which are not having any specific features and reminding focal pneumonia can be found. Subsequently, small cavities appear in them, combining into a cyst surrounded by perifocal inflammation. Cysts exist for many months, are gradually replaced by granulation tissue and are scarred. The diagnosis is specified by the detection of parasite eggs in sputum. Treatment is carried out with emetin, rezohin, potassium iodide.
L.'s defeat at a schistosomatosis is connected with a hematogenous skid of eggs of the parasites nesting hl. arr. in the distal colon and urogenital tract, in the pulmonary arterioles, where they cause an inflammatory reaction, destruction of the walls of blood vessels, thrombosis, sometimes the formation of pseudo-aneurysms. Schistosomatosis in L. gives four types of lesions: a) embolism with parasites; b) embolism with eggs of parasites; both forms in the case of death of parasites cause the development of granulomas, similar to tuberculosis; c) allergic arteritis with fibrinoid necrosis and a productive reaction of the inner membrane up to obliteration of the lumen; d) changes characteristic of high hypertension with the development of glomus anastomoses. As a result of impaired patency of a significant part of the arterioles, pulmonary hypertension occurs and a pulmonary heart forms. Clinically, the disease manifests itself with a slight cough, increasing shortness of breath, signs of stagnation in a large circle of blood circulation. X-ray revealed multiple small focal shadows, expansion of the pulmonary artery, an increase in the right heart. In addition, with schistosomatosis as an allergic phenomenon, limited pulmonary edema (volatile eosinophilic infiltrate) may appear. An accurate diagnosis is made by finding parasitic eggs in the urine, feces, less often in sputum. Treatment - according to the general principles of treatment of schistosomatosis.
L.'s defeat at ascaridosis is rare and mainly in childhood. At a hematogenous hit of Ascaris larvae in L., a blockage of arterioles occurs, accompanied by the occurrence of microinfarctions. Clinically, the disease is manifested by fever, cough, shortness of breath, the appearance of eosinophilia in the blood. X-ray revealed transient shallow focal shadows. Ascaridosis treatment is carried out according to general principles. Allergens secreted by parasitic parasites in the intestines are important in the pathogenesis of pulmonary eosinophilia, in particular Leffler's syndrome.
Disease Inhalation Diseases
Professional factors, and above all, dustiness in the air in the area of workplaces, are the cause of a large group of occupational diseases of L. Most of these diseases are associated with the ingestion of the smallest particles of inorganic substances into L. together with inhaled air, which have a more or less specific harmful effect on the lung tissue. These diseases are combined by the term pneumoconiosis. Byssinosis is also referred to the same group of diseases — L.'s disease, associated with inhaling dust from cotton, flax, or hemp.
Allergy-related diseases pathogenetically
The most common disease, the basis of the pathogenesis of to-rogo are allergic mechanisms, is bronchial asthma. A more rare similar pathology of L. is a group of diseases of not always clear etiology, combined by the presence of severe peripheral blood eosinophilia.
Eosinophilic infiltrate. Acute eosinophilic infiltrate L. Hron, eosinophilic infiltrate (syn. Eosinophilic Kartagener infiltrate) is rare and differs from acute in a longer course (from one to several months). The basis of the disease is, apparently, an allergic reaction of the lung tissue. With morphol, the study reveals a focus of well-delimited interstitial pneumonia: the walls of the alveoli are infiltrated by histiocytes, lymphocytes, plasmocytes and eosinophils, but vary greatly in number in different parts of the infiltrate. Usually there is an outcome in focal fibrosis and small cysts with the accumulation of siderophages here. Clinically observed is a prolonged, sometimes rather high fever with a satisfactory general condition of the patient, cough with sputum of sputum containing eosinophils. In a physical study, wet rales in the affected area are often heard. Radiologically determined more or less homogeneous dimming, usually with fuzzy contours, sometimes bilateral. Throughout the disease, the infiltrates can dissolve and be replaced by others, sometimes in the opposite L. The number of blood eosinophils usually exceeds 10%. In the treatment, desensitizing therapy is used, with a pronounced wedge, the picture uses glucocorticoids for 4-6 weeks. The forecast is favorable.
Asthmatic pulmonary eosinophilia - a combination of hron, L. eosinophilic infiltrate with a wedge, manifestations of bronchial asthma.
Exogenous allergic alveolitis. Some occupational diseases of L. are connected with inhalation of organic industrial dust. Most diseases of this group are caused by allergic reactions of lung tissue to antigens contained in dust and is called exogenous allergic alveolitis. Many forms of allergic alveolitis have been described. The most famous among them are the so-called. farmer's lungs caused by an allergy to thermophilic actinomycetes contained in fresh hay; bagassosis associated with the processing of moldy sugarcane; "Lung of tanneries", at Krom the allergy develops to the fungus vegetating on a maple bark used when tanning skin; "Lung of poultry farmers" resulting from inhalation of bird droppings allergens; "The lung of workers who process mushrooms," apparently associated with an allergy to thermophilic actinomycetes, etc. Unlike bronchial asthma, edge can also occur due to an allergy to the production factors mentioned above, with allergic alveolitis, there are no attacks of bronchospasm, and a delayed type reaction, expressed by edema and infiltration of the walls of the alveoli by lymphocytes, plasma cells and neutrophils, the development of bilateral interstitial pneumonia with predominant localization is productive of inflammation in the walls of the bronchioles, their obliteration, observed by Pepys (H. Pepys) in 25% of cases. The lumen of the affected bronchioles can be blocked by inflammatory exudate. With a long course of the disease, nodules form from epithelioid cells surrounded by lymphoid, plasma, and sometimes giant cells. Clinically, the disease can be acute, subacute, less often - chronically. In a typical acute course, after several hours of contact with an allergen (e.g., fresh hay), malaise, fever, cough with sputum, sometimes stained with blood, appear. Crepitious wheezing can be heard in the lungs. Symptoms disappear within 2-3 weeks, but with repeated contacts appear less acutely and last for a longer time. The disease can go into hron, a form with progressive respiratory failure. Radiological changes are absent or the appearance of small focal shadows, more pronounced in the lower parts of L. The diagnosis is made by a combination of these signs, identifying possible contact with allergic production factors, delayed by several hours of reaction to contact with the allergen. Precipitin tests with appropriate allergens sometimes help. Prevention consists in preventing work with refined and overheated organic substances and materials, observing the correct technology for harvesting hay, sugarcane, mushrooms, etc., and ensuring perfect ventilation of the working premises. If an allergy occurs, it is necessary to prevent further contact with the allergen and professional reorientation. Treatment with glucocorticoids in acute and subacute cases has a pronounced effect. Chron, forms are difficult to treat.
Diffuse pneumosclerosis, granulomatosis and lung damage in systemic diseases. Sarcoidosis is a systemic disease with primary localization of patol, changes in L. and lymph, mediastinal nodes; in modern conditions, is increasingly common.
Diffuse fibrosing alveolitis, or Hamman-Rich syndrome, is a very serious, although infrequent, disease.
Alveolar proteinosis is a rare disease described in 1958 by Rosen (S. H. Bosen) et al. Its essence is the accumulation in the alveoli of a relatively dense protein-like substance. The etiology of the disease is unclear.
Alveolar proteinosis is characterized by dystrophy and necrobiosis of large alveolocytes, accumulation in their protoplasm, as well as in the lumens of the alveoli and bronchioles of P AS-positive granules, merging into dense protein masses in the form of a thick eosinophilic fluid. The latter gives a metachromasia reaction with toluidine blue, is not stained with alcian blue, contains lipids. The walls of the alveoli were loosely infiltrated by lymphocytes. L. are enlarged, foci of the type of gray guardianship alternate with fields of atelectasis. The process occurs 3 times more often in men, sometimes initially, but more often described with leukemia, lymphomas, pneumoconiosis. Experimentally, Yu. P. Likhachev (1975) et al. A model of alveolar proteinosis under the influence of silica dust and inhalation of aerosols containing copper was obtained. Sputum is sterile, contains lamellar bodies - desquamated large alveolocytes, which confirms the connection of the process with the death of the lining of the alveoli under the influence of dust.
Clinically, the disease can begin acutely, with a high fever, chest pain, dry or phlegm cough, sometimes hemoptysis. In other cases, the onset is imperceptible, with the gradual onset of weakness, malaise, weight loss, etc. In the future, a cough is added, dry or with sputum. In both cases, the disease flows in waves, with periodic exacerbations and gradually increasing respiratory failure. Physical symptoms from L. are scarce (weakened or hard breathing, sometimes crepitus). X-ray cirrus, fuzzy nodular shadows that resemble a picture of L. edema are found. In the sputum and lavage of the bronchi, a substance with a positive SHIK reaction is sometimes detected. Clarifies the diagnosis of lung biopsy. The treatment consists of inhalation of agents that dilute the patol, the contents of the alveoli (acetylcysteine, bisalvon). The most effective alternate washing of each of L. with isotonic acetylcysteine r-r in anesthesia and artificial ventilation, which gives a long-lasting effect.
Collagen diseases of the lungs
Patol. changes in L., sometimes coming to the fore in a wedge, a picture, are characteristic of most systemic diseases of connective tissue - the so-called. collagenoses. There are primary lesions of L. with collagenoses, caused by changes typical of the underlying disease, and secondary, resulting from stagnation and secondary infection, characteristic of the terminal phase of the disease. Two types of primary lesions of L. are distinguished at collagenoses: so-called. pulmonary vasculitis, with Krom mainly the vascular system is affected, and interstitial pneumonitis, when the connective tissue of the interalveolar and interlobular septa is primarily affected. Both of these processes, as a rule, develop simultaneously, although one of them can prevail, which finds expression in the wedge, and rentgenol, the picture.
Pulmonary manifestations in rheumatism, rheumatoid arthritis, systemic lupus erythematosus, systemic scleroderma, periarteritis nodosa and dermatomyositis are distinguished by a certain peculiarity and at the same time have a number of common features. Rarity of development of emphysema and a pulmonary heart is considered characteristic of defeat of L. at collagenoses. Wegener's granulomatosis, not having a typical rentgenol, semiotics costs close to L.'s defeat at a nodular periarteritis. with it, infiltrates in the pulmonary fields, and reticulonodular restructuring of the pattern, and compaction of whole segments and lobes are observed.
The most typical rentgenol, a picture with scleroderma. In the lower parts of L. a peculiar fine-mesh pattern and small thin-walled cavities are determined. Small foci, disk-shaped atelectases are also noted. It is more difficult to suspect other collagenoses radiologically; here the account of clinical and laboratory data is especially important. With systemic lupus erythematosus, the high position of the diaphragm, a small effusion in the pericardium and pleura, enlargement of the heart, diffuse enhancement of the pulmonary pattern with the appearance of fuzzy delimited areas of infiltration are noteworthy. A similar increase in the pattern is observed with nodular periarteritis; but against this background, nodular formations arise, sometimes up to 2-3 cm in diameter. Decay of intrapulmonary nodes and hyperplasia of lymph nodes in the roots can occur. Of great importance for checking rentgenol, the diagnosis of collagenosis is the observation of L. in the treatment of immunosuppressants and glucocorticoids.
Sjogren's syndrome is, apparently, a variant of the course of rheumatoid arthritis with pulmonary manifestations. The syndrome is considered characteristic: 1) rheumatoid arthritis; 2) dry keratoconjunctivitis; 3) xerostomia. The last two components of the syndrome are caused by rheumatoid lesions and dysfunction of the lacrimal and salivary glands. Pulmonary manifestations are similar to those observed with rheumatoid arthritis. Patients often complain of a dry cough caused by a decrease in secretion and dry mucous membrane in the larynx and trachea. Violation of mucociliary function leads to the development of a secondary infection in the bronchi and lungs. Often, patients die from pneumonia. Radiologically in L. changes characteristic of collagenoses come to light. Sometimes pleural effusion is found. The diagnosis is made on the basis of a combination of manifestations of rheumatoid arthritis, keratoconjunctivitis and xerostomia. Treatment as with rheumatoid arthritis.
Idiopathic hemosiderosis of the lungs is a peculiar diffuse lesion of L. of unknown etiology and is characterized by repeated hemorrhages in L.'s tissue, hemoptysis and secondary iron deficiency anemia.
Goodpasture syndrome has some similarities with idiopathic hemosiderosis. The etiology is unknown. The disease is more common in adults. Changes in Goodpasture syndrome are usually represented by massive intrapulmonary diapedetic bleeding with accumulation in the alveoli, regional lymph, hemosiderin nodes and simultaneously occurring glomerulonephritis. In contrast to idiopathic hemosiderosis, fibrin deposits are more often observed in the alveoli. A wedge, manifestations consist in repeated hemoptysis, a picture of glomerulonephritis, which usually proceeds without severe arterial hypertension and leads to progressive renal failure, from which a majority of patients die. Radiologically, Goodpasture syndrome during remission only increases pulmonary pattern. But during periods of hemoptysis in the basal divisions of L., numerous focal shadows appear, resembling areas of edema.
The diagnosis is made on the basis of a combined lesion of L. and kidneys. Detection of siderophages in sputum, sometimes a renal biopsy, is of some importance. The treatment is not developed enough and comes down mainly to the use of corticosteroid drugs.
Amyloidosis usually occurs as a complication of cron, infectious diseases. Primary amyloidosis of L. is much less common, observed, according to Spencer, in the form of four morphols, forms: a) localized tumor-like; b) small-bronchial lesions; c) nodular; g) diffuse lesions of the respiratory department. In the bronchi, the amyloid is located under the mucous membrane, which leads to atrophy of the glands and cartilage; exposed to resorption by giant cells. Large nodes in the respiratory department are often mistakenly macroscopically mistaken for tumor metastases. Diffuse damage to the respiratory department can also occur with secondary amyloidosis, begins under the capillary endothelium. Amyloid in L. often refers to paraamyloid and may not give typical reactions with Congo and other dyes. More often, men over the age of 50-60 are sick. Clinically and radiologically, the disease is manifested by symptoms of bronchial obstruction, which often leads to incorrect diagnosis of bronchial adenoma or bronchogenic cancer. The diagnosis is established based on the results of a biopsy performed through a bronchoscope. With diffuse lesions of L. parenchyma, progressive shortness of breath may be observed. The disease is often detected accidentally during rentgenol, examination and in the presence of foci are often regarded as cancer metastases. To establish the true nature of patol, the process requires a biopsy. Treatment for localized lesions of the large bronchi consists in the removal of foci of amyloidosis operatively or endoscopically. With diffuse damage, the treatment is symptomatic.
Ossification of the lungs manifests itself in two forms. 1. Osteoplastic bronchopathy, characterized by the development of rings and plates of bone tissue in the process of metaplasia of fibrous and cartilaginous tissue of the bronchi. The glands of the bronchi atrophy, the mucous membrane, while remaining intact, rises above the bony plates penetrating the muscle layer. It occurs more often in men after 50 years; not associated with inflammation or changes in blood calcium. 2. Diffuse parenchymal ossification of L. occurs with mitral heart disease, in the walls of caverns, rarely in intact L. Islets of bone tissue are first localized in the peribronchial or perivascular tissue, and then can capture the whole lobe. Bone marrow is visible inside the plates.
In diseases of accumulation, lung lesions can also be observed. In Nimann-Peak disease, sphingomyelin is deposited in macrophages, mainly in the alveolar, which gives L. a rubber consistency. Girke's disease is characterized by the fact that glycogen is deposited not only in macrophages, but also in cartilage, glands, and integumentary epithelium of the bronchi. In Fanconi's disease, cystine crystals are found in the walls of the alveoli, in the peribronchial and perivascular tissue.
Pathological conditions associated with impaired pulmonary circulation can be acute and chronic. Acute circulatory disorders are associated with blockage of the pulmonary artery or its branches with emboli, the sources of which may be pathology of the veins of the pulmonary circulation — thrombophlebitis, phlebothrombosis, or the cavity of the right heart — endocarditis. Obstruction of the embolism of the trunk of the pulmonary artery or its large branches can immediately end in death or cause a complex of severe disorders of vital functions. At a thromboembolism of a large artery its shadow on roentgenograms and tomograms breaks off, and part of L. fed by it becomes more transparent.
Pulmonary infarction. Under certain conditions, thromboembolism of the branches of the pulmonary artery of medium caliber (eg, 1-4th order) can cause a heart attack L. The cause of the heart attack, apparently, may be thrombosis of the branch of the pulmonary artery due to vasculitis, more often observed with rheumatism. Thrombosis is promoted by cardiogenic congestion in the pulmonary circulation, characteristic of heart failure, decreased blood rheological properties, hypercoagulation and a number of other factors.
At the heart of L. infarction lies the necrosis of a portion of lung tissue due to the cessation of blood flow through the pulmonary artery. The dead area is imbibed with blood penetrating into it from the system of bronchial vessels, as a result of which the heart attack becomes hemorrhagic. Bronchi in the infarction zone usually remain viable, because they have autonomous arterial blood supply. Most often, a heart attack develops in the peripheral layer of the lower and middle sections of L. and is often accompanied by fibrinous or serous-hemorrhagic effusion. Macroscopically revealed conical foci of red color, swelling above the cut surface, leaving under the inflamed pleura. On the first day, a hemorrhage and edema are determined in the infarction zone, then there are signs of necrosis of the walls of the alveoli, siderophages accumulate. Fibrous layers of L. and walls of large vessels can be a source of the subsequent organization of heart attacks which occasionally heal with a cellular scar. The ischemic infarctions meeting at L.'s collagenoses are caused by closing of a gleam of bronchial arteries and in view of complexity of the architectonics of the last do not have a wedge-shaped form. When an area of necrosis is infected and suppurates, an abscess of L. can form. Clinically, L. infarction is manifested by chest pain when breathing and hemoptysis in patients with peripheral vein thrombosis or with heart disease. The temperature is often subfebrile. Tachycardia is noted. Physical symptoms are scarce. Radiologically, myocardial infarction L. gives a limited uniform dimming, which coincides in position, shape, and size with a segment or part thereof. Cardiogenic heart attacks always occur against the background of general plethora in L., phlebogenic heart attacks - without stagnation. A heart attack can be complicated by the development of pneumonia and pleurisy. With thromboembolism of small vessels, multiple small focal shadows occur. With a favorable course in 1-2 weeks. chest pains and hemoptysis cease, and radiologically homogeneous darkening is gradually replaced by a focus of fibrosis. In cases of suppuration of a heart attack, profuse purulent or purulent-bloody sputum appears, the temperature rises significantly, leukocytosis increases. X-ray in the dimming zone reveals a cavity with a horizontal level. When establishing a diagnosis of heart attack L. the patient is shown anticoagulant therapy: heparin for 2 days. with the subsequent transition to drugs of indirect action. Antibiotics are used to prevent suppuration. With significant pleural pain, analgesics may be required. Prevention of heart attack L. reduces primarily to the prevention and treatment of conditions that are a source of thromboembolism and pulmonary thrombosis (thrombophlebitis, phlebothrombosis, endocarditis, heart failure).
"Shock" lung. Multiple hemorrhages accompany sludge syndrome and disseminated intravascular thrombosis with shocks of various origins, which are characterized by multiple hemorrhagic atelectases, which become persistent due to the secondary destruction of surfactant in conditions of impaired blood circulation. This is the so-called. shock lung, or the syndrome of acute respiratory failure in adults, sometimes resembling a hyaline membrane disease of newborns. Acute pulmonary circulation disorders associated with impaired pulmonary vein outflow (e.g., with acute weakness of the left ventricle of the heart or mitral stenosis) can lead to pulmonary edema, with an intense darkening of the pulmonary fields visible on the radiograph.
Other disorders of pulmonary circulation. Chron, pulmonary circulation disorders associated with impaired patency of the small branches of the pulmonary artery, are observed in pulmonary arterial hypertension, both primary and secondary.
With hron, pulmonary circulation disorders associated with difficulty in outflow, for example, with the left ventricular type of heart failure, the so-called. congestive lung, in essence not representing an independent nosol, form. Its typical manifestations are shortness of breath with physical. load or at rest, sometimes cyanosis, cough with "rusty" sputum, in which red blood cells and siderophages are microscopically detected. There is a tendency to repeated pneumonia. Crepitious wheezing is auscultated, mainly in the posterior departments of L. Radiological enhancement of the venous, and in many cases arterial, components of the vascular pattern of L. is observed. Treatment is carried out according to the general principles of the treatment of heart failure.
Tumors of L. represent a group of benign and malignant neoplasms of various histogenesis of primary and secondary nature.
According to a wedge, a course the majority of primary tumors of L. can be divided into benign and malignant.
A benign tumor of L. was first described by A. Muller in 1882. At the Cancer Research Center of the Academy of Medical Sciences of the USSR, patients with benign tumors of L. in relation to all operated on for tumors of L. made up 10.8%.
Pathological anatomy. Among benign tumors of L. distinguish epithelial tumors (adenomas), tumors of mesenchymal origin (myxomas, lipomas, plasmacytomas, fibromas, etc.), hamartomas (teratomas). According to A. I. Rozhdestvenskaya (1964), among benign tumors, adenomas have the largest specific gravity (30–40%), hamartomas are somewhat less common, and 20–30% are accounted for by other, less common tumors.
Bronchial adenomas are a group of tumors that are most diverse in histogenesis and clinical manifestations. OK. 80% of adenomas are carcinoid tumors. They have a characteristic histological structure that differs from the structure of the bronchial wall. They come from neurosecretory cells of the duct duct of the bronchial mucous glands and may contain endocrine and exocrine secretory elements. In 2-7% of cases, tumor tissue can secrete serotonin and some vasoactive polypeptides, less often ACTH.
There are bronchial carcinoids at any age, but more often in 40 - 45 years old, somewhat less often in men. In 70% of cases, large-caliber bronchi are affected. If the size of the tumor exceeds 3 cm, metastasis along the lymph pathways is sometimes found.
Pathologically, bronchial carcinoids are characterized by alveolar, tubular, or acinar structures. Under electron microscopy, tumor cells have a polygonal shape and a significant number of pseudopodia; clearly defined secretory granules are determined in the cytoplasm.
To the bronchial adenomas is also a cylindroma emanating from the bronchial glands. It occurs only in large bronchi, is located in the deep layers of the mucous membrane, has a slow infiltrating growth along the nerves, and often metastases.
A very rare form of bronchial adenoma are benign mucoepidermoid tumors.
According to modern views, the cylinder is a special form of slowly growing cancer (adenoid cystic cancer). Carcinoid tumors occupy an intermediate position between benign and malignant neoplasms. Carcinoids and cylindromes have the potential for infiltrating growth, recurrence (especially cylindrome), and metastasis. It is not possible to predict the degree of their aggressiveness on the basis of microscopic data. Mucoepidermoid tumors do not malign.
Adenomas develop mainly in large bronchi and grow endobronchial, gradually closing the lumen of the bronchus. In some cases, adenomas grow toward the pulmonary parenchyma extrabronchially. This often happens with adenomas developing from the walls of the small bronchus.
Among benign tumors of mesenchymal origin, there are chondroma, osteoma, hemangioma, myoma, fibroma, neuroma, etc. All these tumors are quite rare. In some cases, chondroma is mistaken for hyperplasia of the cartilage of the bronchus. Chondromas are associated with the wall of the bronchus and grow from the cartilaginous elements of the bronchus. Plasmocytomas can be in the form of separate distinct formations in the lungs or in the form of infiltrates spreading along the bronchus wall without clear boundaries. The tumor nature of vascular tumors - hemangiomas, is not recognized by everyone, considering them malformations of the vessels of the lung. Tumors from muscle tissue in L. are rare and can have the structure of striated and smooth muscle. They often have a connection with the bronchi.
Neurogenic tumors of L. - a neurofibroma, a neurinoma are rather dense, more often strictly round, their malignant variant is sometimes observed.
Hamartoma is an abnormality of development; in L. chondrohamartomas are most often observed, which in frequency take second place after adenomas. Chondrohamartomas are not true tumors, but in some cases they acquire invasive growth and can become malignant. Much less often in L. one can meet vascular, fatty hamartomas, etc. Chondrohamartomas are located more often under the pleura and in the lower lobes of L. Their sizes are different, but more often small, up to several centimeters in diameter. They consist, as it were, of compressed lobules of cartilage, are dense, often with fine-polycyclic clear contours and calcifications.
The clinical picture is very scarce. A tumor emanating from the wall of the large bronchus can cause symptoms of impaired bronchial obstruction: cough with purulent sputum, recurrent pneumonia, asthma dyspnea; hemoptysis is occasionally noted. With carcinoid tumors secreting serotonin and corticosteroids, carcinoid syndrome, less commonly Cushing's syndrome, can be observed. Along with this, benign tumors of large bronchi may not disturb patients and are detected only during bronchoscopic examination as random findings. Benign tumors developing in L. parenchyma far from large bronchi, as a rule, are asymptomatic and are detected with preventive rentgenol. surveys.
Diagnosis. When rentgenol, research, a variety of benign tumors (adenoma, hemangioma, neurinoma, fibroma, etc.) give similar symptoms: a single round intense homogeneous darkening with sharp contours is determined, especially on tomograms. The tumor spreads the vessels and bronchi and does not cause an increase in intrathoracic lymph nodes. Most hamarts differ from this picture, because it contains randomly scattered inclusions of lime or ossification. Teratoma causes intense dimming with uneven contours. Lime deposits, bone elements, and even tooth shadows can stand out against its background. With the intrabronchial development of a benign tumor, which is especially characteristic of an adenoma, hypoventilation, bloating or atelectasis of the part of L. ventilated by this bronchus is detected. On tomograms or bronchography in the lumen of the bronchus, a spherical formation with a convex convex in the proximal direction is found.
In the diagnosis of benign tumors localized in the lumen of the large bronchus, bronchoscopic examination and biopsy are of great importance. Benign tumors developing in the small bronchi and in the L. parenchyma, in most cases cannot be morphologically verified. Therefore, in case of doubt about the benignness of the tumor and the absence of contraindications to the patient's thoracotomy, it is necessary to operate on the operating table and, after clarifying the diagnosis (biopsy, puncture with cytol, examination), determine the necessary volume of resection L. Long-term monitoring of a patient with spherical L. formation is dangerous: you need to remember that peripheral cancer of L. can exist for many months and even years without visible rentgenol, dynamics.
Treatment. Extrabronchial tumors are removed by conventional husking with suturing the bed. If the tumor causes a violation of the patency of the bronchus and irreversible changes develop in the pulmonary parenchyma, resection of the corresponding segments, lobes, and sometimes all of L. is necessary. For benign tumors of large bronchi without signs of atelectasis, more benign operations consisting in circular resection of the bronchus and the application of an interbronchial anastomosis have spread.
Long-term results of surgical treatment of patients with benign tumors of L. are good.
Malignant lung tumors
The initial elements of tumor growth can be the integumentary epithelium of the bronchial mucosa and the epithelium of the bronchial mucous glands. The development of cancer from the epithelium of the pulmonary alveoli has not been proven.
Cancer L. among other malignant tumors of the internal organs occupies a special place. These features are determined, on the one hand, by a rapid increase in morbidity, a tendency to even more accelerate the growth rate of morbidity, and, on the other hand, by the peculiarities of the development and course of a tumor in an organ with rich blood supply, which early gives lymphogenous and hematogenous metastases.
L. cancer should be looked at as a collective concept. There are several wedges, forms of the disease, depending not only on the location of the tumor in the lung, but also on its histol, structure.
Statistics and epidemiology. Cancer L. is one of the most pressing problems of wedge, oncology. Since the beginning of the 20th century the incidence of L. cancer has increased several dozen times. In many industrialized countries (England, Belgium, Holland, Japan, Germany, the USA, etc.), this disease in the structure of oncol and diseases takes first place among the male population. Men are ill with cancer of L. much more often than women (in a ratio of 4: 1).
Etiology. The rapid increase in the incidence of L. cancer is explained by the fact that most modern people living in big cities lead a sedentary lifestyle and constantly inhale various harmful ingredients found in the surrounding air. Mechanization, transport and features dignity. conditions of large cities, undoubtedly affect the concentration and composition of inhaled carcinogens. They are present in the dust of tarmac roads and exhaust gases of internal combustion engines, especially diesel ones. An increase in the concentration of carcinogens in the atmosphere of cities was proved in the works of L. M. Shabad. The life of the city is closely connected with industrial enterprises that emit a large amount of metal dust, compounds of nickel, arsenic, asbestos, chromium, etc., which have a carcinogenic effect on lung tissue. Cancer models of L. were experimentally caused by prolonged inhalation by animals of air saturated with dust with a chemical adsorbed on it. carcinogens and radioactive substances.
It has been firmly established that the risk of L. cancer is high in those who are in professional contact with radioactive substances. So, L. cancer is an occupational disease among miners of uranium mines. An analysis of the incidence of L. cancer in the Japanese after the atomic bomb explosion was carried out. In persons who received a total dose of more than 90 rad, mortality from this disease significantly exceeded the average level. With the improvement of technol, processes, a decrease in the influence of prof. factors on the incidence of cancer L.
The frequency of cancer of L. is in direct proportion to the duration and intensity of tobacco consumption. Based on a large amount of material, it was found that the risk of developing L. cancer in smokers is more than two packs of cigarettes a day is 20 times higher than in non-smokers. Numerous studies, in particular L. M. Shabad, have shown that inhaled tobacco smoke contains carcinogens that can cause a malignant tumor in animals.
Many researchers point to an increase in the incidence among women. Although this is mainly due to the prevalence of smoking habits of young women, the effects of endocrine shifts associated with increased consumption of hormonal drugs cannot be ruled out.
The literature has repeatedly pointed out the relationship between tuberculous lesions of lung tissue and cancer L. A tumor often develops in the area of post-tuberculous scars in the pulmonary parenchyma or in foci of specific fibrosis. But with approximately the same frequency, cancer develops in the opposite healthy L.
Pathogenesis. The mechanism of influence of carcinogenic factors of the environment and the internal environment is still not fully understood. During the aging process, there is a progressive sclerosis of the bronchial walls, a disruption in the relationship in the epithelial system - connective tissue, a disruption in the normal course of bronchial epithelium regeneration. The same changes are recorded with cron, inflammation of any nature. The cylindrical epithelium of the bronchi under the action of external stimuli undergoes desquamation, often turns into a basal, extremely polymorphic. A significant accumulation of DNA in the epithelial cells indicates its high potential for growth. With prolonged contact of the mucous membrane with carcinogenic substances that penetrate the lumen of the bronchial tree with dust, the self-cleaning of the mucous membrane associated with peristaltic movements of the bronchi, the activity of the ciliated movements of the cilia of the respiratory epithelium and the work of the mucous glands are disrupted. This contributes to the long-term retention of dust with carcinogens, radioactive substances adsorbed on dust particles and their penetration into the pulmonary parenchyma.
In the lobar and segmental bronchi, areas of the desquamated epithelium appear, where granulation tissue sometimes grows with polypous outgrowths. The mucous glands expand cystically, their cells change shape, their atypia and proliferation occur. These processes are always accompanied by changes in the basement membrane and underlying tissues. Regeneration is accompanied by metaplasia of the cylindrical epithelium into a flat one, which further impairs the function of self-cleaning of the bronchi and supports chronic inflammation.
Gradually, among the sites of proliferation and epidermoid metaplasia, cells with a changed polarity and irregular mitoses appear. They are located within the mucous membrane or penetrate beyond it, located in the form of strands or chains. So begins the infiltrating growth of cancer. Lymphoid infiltrates with an admixture of plasma cells appear under the epithelium, which is regarded as a manifestation of an immune response to antigenic changes in tissue proteins during carcinogenesis.
Hyperplasia and metaplasia against the background of foci of pneumonia and pulmonary fibrosis can also occur in flattened epithelial cells of the alveoli and end bronchioles. Morphologists distinguish three types of proliferation of epithelium of bronchioles: acinar, squamous and carcinoid; these changes are always combined with focal or diffuse fibrosis. Carcinoid proliferation of neurosecretory cells is accompanied by the formation of micro-tumors. Of these, undifferentiated cancer can subsequently develop.
So, L. cancer is preceded by changes in the inflammatory nature or scar process: tuberculosis, fibrosis, pneumonia, bronchiectasis, hron, abscesses, healed L. infarctions. These changes should be considered optional precancerous conditions, if they are accompanied by epithelial metaplasia with the appearance of atypism. Under certain conditions, they are available for diagnosis using modern endoscopic and cytol methods.
Pathological anatomy. According to the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, cancer occurs in 56% of cases in right L., in 44% in left. Mostly the upper lobes are affected. Clinical and anatomical L. cancer is divided into two groups: central cancer, affecting the main, lobar and segmental bronchi, and peripheral cancer, growing from the epithelium of small bronchi on the periphery of L. It is difficult to determine the frequency of lesions of different caliber bronchi. These data depend on the material on which they are obtained. At autopsy, when the prevalence of the tumor process is usually high, it is difficult to find out where the primary focus of cancer originated. I. L. Tager (1951) believes that cancer in the small bronchi occurs more often, but with growth, the tumor can acquire the features of central cancer.
In the direction of growth, exophytic (endobronchial) cancer is isolated when the tumor grows in the lumen of the bronchus, and endophytic cancer, when the tumor grows mainly in the direction of the pulmonary parenchyma. The wedge, the picture of the disease, depends on the nature of the spread of the tumor.
L. Cancer often proceeds with secondary inflammatory changes, caused in most cases by compression or obstruction of the bronchus with impaired ventilation of the segment, lobe, and sometimes the whole L. Stagnation of the contents of the bronchi leads to the development of infection in the atelectasis zone. Insufficient blood supply to the growing tumor creates the conditions for the breakdown of its tissue with the destruction of the walls of blood vessels, sometimes large ones. The peripheral cancer proceeding with decay can remind abscess of L. Concomitant cancer secondary inflammatory changes in L. lead to hyperplasia and an increase in the size of lymph, L. root nodes and mediastinum.
Histol, the structure of the tumor is very diverse. N. A. Kraevsky (1976) developed histol, a classification of L. cancer, the most simple and convenient for use in the clinic (it is not opposed to the WHO classification).
I. Squamous cell carcinoma:
- with keratinization (highly differentiated);
- without keratinization (moderately differentiated);
- poorly differentiated.
- acinous and papillary (highly differentiated);
- glandular-solid (moderately differentiated).
III. Low-grade cancer:
- small cell-lymphocyte-like;
- large cell.
The most commonly occurring are highly and moderately differentiated forms of cancer L. Undifferentiated cancer is detected more often in people younger than 40 years old, it is more malignant with a poor prognosis. Among the operated patients, Squamous cell carcinoma was observed in 60.6% of cases at the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, undifferentiated cancer - in 31.6%, adenocarcinoma - in 7.8%.
Bronchioloalveolar cancer in the past had many synonyms: L. adenomatosis, alveolar cell cancer, bronchiolar cancer, etc. The term "bronchioloalveolar cancer" itself reflects uncertainty about the cells from which the tumor arises.
The multicentric form of bronchioalveolar cancer was first described by Malassa (L. Ch. Malassez) in 1876. According to modern beliefs, this tumor is considered to be a highly differentiated adenocarcinoma. Primary foci of growth occur most likely in the bronchioles with subsequent spread to the alveoli. Bronchioloalveolar cancer is approx. 2.5% of all observations of cancer L. Distinguish between nodular, multicentric and diffuse (pneumonia-like) form of growth of this tumor. More common growth is in the form of solitary peripheral nodes. Substantial assistance in the recognition of bronchioalveolar cancer can be provided by electron microscopy. For this, histol. type lamellar inclusions in a cytoplasm are characteristic.
L. Cancer metastasizes on lymph, ways and hematogenously. According to V.I. Lyaschenko (1977), with squamous cell carcinoma, metastases to distant organs at autopsy were detected in 13.3% of cases, in lymph, mediastinal nodes - in 17.7%. With glandular cancer, metastases to distant organs occurred in 34.5% of cases, in lymph. nodes - in 25.3%. With undifferentiated cancer, these figures were 30.9 and 25.4%, respectively. Lymphogenic metastasis occurs predominantly along the pathways of lymph outflow. Hematogenous metastases are most often found in the liver, brain and bones.
Classification. Domestic classification of lung cancer by stages was developed in the Moscow P. A. Herzen and approved in 1956. Stage I is a small limited tumor of the large bronchus with an endo- and peribronchial form of growth, as well as a small tumor of the small and smallest bronchi without germination of the pleura and signs of metastasis. Stage II - the same tumor as in stage I, or of large sizes, but also without germination of the pleural leaves, with the presence of single metastases in the nearest regional lymph nodes. Stage III - a tumor that went beyond L., growing into one of the neighboring organs (pericardium, chest wall, diaphragm), with the presence of multiple metastases in regional lymph nodes. Stage IV - a tumor with extensive spread to the chest wall, mediastinum, diaphragm, with dissemination along the pleura and extensive regional or distant metastases.
TNM classification was proposed in 1978 and approved by the International Cancer Union.
Primary tumor - T: T0 - the primary tumor is not determined; TX - the presence of a tumor is proved by the presence of cancer cells in the sputum, with an x-ray and endoscopic examination, the tumor is not detected; TIS - pre-invasive cancer (cancer in situ); T1 - a tumor up to 3 cm in diameter, not sprouting the lobar bronchus (with bronchoscopy); T2 - a tumor larger than 3 cm in diameter or a tumor of any size with atelectasis or obstructive pneumonitis spreading to the root zone of L., with bronchoscopy, the proximal spread of the visible tumor should be at least 2 cm distal to the keel of the trachea; TK - a tumor of any size, spreading to neighboring structures (mediastinum, chest, diaphragm), a tumor spreading during bronchoscopy closer than 2 cm to the keel of the trachea, the tumor is combined with atelectasis, or obstructive pneumonitis of the whole L., or pleural effusion.
Regional lymph nodes - N: N0 - in regional lymph nodes, there are no metastases; N1 - metastases in lymph, L. root nodes on the affected side, including the direct spread of the primary tumor; N2 - metastases in lymph, mediastinal nodes.
Distant metastases - M: MO - there are no distant metastases; Ml - distant metastases, including lymph, nodes of the preclavicular, cervical, supraclavicular, opposite L. root and metastases to other organs; M1a - pleural effusion with the presence of cancer cells in it; M1b - metastases in the cervical, preclavicular and supraclavicular lymph nodes; M1c - other distant metastases; MX - the minimum set of examination methods for identifying distant metastases cannot be performed.
Based on the TNM classification, three stages of cancer L are clinically distinguished. The first stage includes TISN0M0 (cancer in situ), T1 tumors without signs of metastasis (T1N0M0), with lymph metastases only, nodes of the peribronchial and (or) ipsalateral root zone (T1N1M0), as well as T2 tumors without signs of metastasis (T2N0M0). The diagnosis of TxN1M0 and T0N1M0 is theoretically possible, but it is extremely difficult to make. If such a diagnosis is nevertheless established, then the tumor should be referred to the first stage.
The second stage is a T2 tumor with metastases only to the lymph, nodes of the peribronchial or ipsalateral zone (T2N1M0).
The third stage includes: all tumors larger than T2 (T3 with any combination of N or M), tumors with metastases to the lymph, mediastinal nodes (N2 with any combination of T or M), tumors with distant metastases (M1 with any combination of T or N).
Such a separation at the stage is important for all morpholas, types of cancer of L., except for undifferentiated small-cell (oat-cell) carcinoma, with a cut there are no significant differences between the stages according to the main indicator - survival.
The clinical picture depends on the type of growth of cancer L., its clinical anatomical and histol, the form, the rate of metastasis, concomitant (secondary) inflammatory changes. Distinguish between local symptoms caused by changes in the bronchi and lung tissue, and general symptoms caused by the effects of the tumor on the body or intoxication due to secondary inflammation.
Tumor tissue in cancer L. can secrete a wide range of biologically active substances, by the action of the body resembling the action of normal hormones, tissue antigens or toxins. Clinically, this is manifested by Cushing's syndrome, hyponatremia, hypercalcemia, gynecomastia, polycythemia, hypoglycemia, myasthenia, osteoarthropathy, neuritis, dermatomyositis, vascular thrombosis, fever and exhaustion. Similar manifestations are often observed with small tumors and disappear after the patient is cured.
Local symptoms depend on the location and form of tumor growth.
A frequent sign of central cancer of L. is a cough, sometimes constant coughing due to irritation caused by a tumor growing in the wall of the bronchus and accumulation of mucus in its lumen.
With infiltrating tumor growth, when the lumen of the bronchus remains free due to its spread along the wall of the bronchus, a cough may appear late or be completely absent (with some peripherally located tumors).
Of great diagnostic importance are various impurities in sputum. For cancer of L. a small amount of sputum is more characteristic. The further the tumor spreads, the more impurities appear in the sputum. At first, mucopurulent sputum in appearance differs little from ordinary sputum of an elderly and smoking person, but hemoptysis may appear with the decay of the endobronchial tumor. According to the observations of A. I. Savitsky (1967), in 67.1% of patients there is pain in the chest, more often on the affected side, less often on the opposite side and even less often spilled. Sometimes patients cannot characterize their sensations as pain and speak of an unpleasant feeling of heaviness, tingling, etc. This symptom, as a rule, happens with a significant tumor size.
An increase in body temperature may be the first sign of cancer L. This symptom is noted in 50-60% of cases and depends on the secondary inflammatory processes that accompany cancer L. Cancer pneumonitis can develop around the tumor focus or more often in the atelectasis zone. Repeated pneumonia in an elderly person should be regarded as a possible manifestation of cancer L.
An objective examination of the patient may reveal a number of additional symptoms, although in the early stages of the disease there are no objective signs of the disease. In the later stages, on the side of the atelectasis, the chest wall is retracted, it lags behind when breathing, the intercostal spaces are retracted and the ribs come closer together. Auscultation reveals signs of damage to the pulmonary parenchyma and bronchi - pneumonia, pleurisy, bronchitis, etc. In the atelectasis zone, breathing is not heard. With obstructive emphysema, when inhaling air enters through the narrowed bronchus, and when exhaling with difficulty exits, coarse wheezing is heard. Percussion above the swelling zone is determined by the box sound, and dullness above the atelectasis sites. With atelectasis, a high standing of the diaphragm and a limitation of its respiratory excursion are noted. With peripheral tumors adjacent to the parietal pleura, it is also possible to determine the boundaries of blunting of pulmonary sound.
The wedge, the course and timing of the onset of certain symptoms depend on the location and nature of the tumor growth. Exophytic (endobronchial growth early leads to obstruction of the bronchus, the development of atelectasis and pneumonitis and wedges, manifestations of the disease. Tumors spreading along the wall of the bronchus with endophytoperibronchial growth do not disturb its patency for a long time, and the symptoms of the disease occur only with a far advanced process.
A wedge, symptoms of peripheral cancer of L. appears at a germination of a tumor of the next anatomical formations, an obstruction of bronchi and decay of a tumor. In the early stages, peripheral cancer is often completely asymptomatic.
Cancer of the apex L. (synonym: Pancost tumor) is a special kind of peripheral cancer of L., which already in the early stages infiltrates the anatomical structures of the chest wall located in the region of the upper thoracic aperture. This clinical and anatomical form is manifested by the syndrome described by Pankost (N.K. Pancoast) in 1932: radiating pain in the upper shoulder girdle, Bernard-Horner syndrome and rentgenol, signs of an apex tumor L. Often destruction of the upper ribs and vertebrae is observed.
In the late stages of L. cancer, the patient's complaints are numerous and varied. The defeat of the pleura is accompanied by symptoms of exudative pleurisy, and punctate often has a characteristic hemorrhagic appearance. With extensive metastases in the mediastinum, symptoms of compression of the large vessels, trachea, bronchi and esophagus develop: syndrome of compression of the superior vena cava, shortness of breath, dysphagia. The defeat of the recurrent nerve leads to hoarseness, the germination of the sympathetic trunk, vagus and phrenic nerves - to the corresponding nevrol, symptoms.
Atypical clinical and anatomical forms of cancer of L. meet relatively rarely. They are characterized by the small size and localization features of the primary tumor focus, which sometimes cannot be detected not only clinically, but also at autopsy. Symptoms due to metastases come to the fore.
The mediastinal form of cancer of L. is manifested by multiple metastases in the lymph, mediastinal nodes, while the primary tumor in L. by all available wedges cannot be detected by methods.
Miliary carcinomatosis is characterized by multiple focal metastases in L., when the primary cancer node is not known. At a brain form of cancer of L. on the first place symptoms of defeat of c are put forward. n S .: headaches, mental disorders, etc., with a bone form - signs of metastatic lesions of the bones of the skeleton, with cardiovascular - heart rhythm disturbances, effusion in the pericardium, circulatory failure, with glands. form - disorders of the digestive tract, with the liver form - signs of tumor damage to the liver.
Diagnosis. The main problem in the diagnosis of cancer of L. is the search for the possibility of identifying the disease in doclin. stage. Methods suitable for mass use among a practically healthy population are fluorography, preventive rentgenol, examination and cytol, sputum examination. To implement the doclin. Diagnosis of cancer of L. it is necessary to identify among the population a "high-risk group", the edge includes people older than 50 years, especially many smokers, burdened by heredity, prone to diseases of the upper respiratory tract or suffering from hron, pneumonia, etc. Usually this group is identified questionnaire way and medical examination. Routine examinations are carried out annually. An X-ray examination of the "high-risk group" is mandatory. The best results are obtained by a combination of rentgenol, and cytol, research methods. A comparative analysis of two groups of patients identified by the method of prophylactic rentgenol, examination (first group) and turned to lay down. the institution independently (the second group), performed at the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, showed that the resectability of L. cancer in the first group was significantly higher (90.7%) than in the second (78.6%).
Of great importance in the timely diagnosis of L. cancer is the correct assessment of the wedge, symptoms. Repeated short-term rises in temperature, cough, chest pain and hemoptysis are always suspicious of L. cancer. Difficulties in recognition can occur even in the late stages of the disease, when complications (pneumonia, pleurisy, abscess, metastases to distant organs, etc.) mask its true nature.
The diagnosis of cancer of L. is specified on the basis of a comprehensive examination: clinical, radiological, bronchological, radiological, morphological and surgical.
A wedge, symptoms, anamnesis and examination data only allow to suspect cancer L. A lab is of auxiliary value. survey methods. Due to the fact that L.'s cancer often proceeds with severe inflammatory phenomena in L., a shift of the leukocyte formula to the left, leukocytosis, acceleration of ROE, etc. can be observed on the blood side. Biochemistry, blood tests have a certain value in determining the prevalence of the tumor process. determination of hormone levels may indicate hormonal activity of the tumor. However, these shifts must always be evaluated in conjunction with other research methods.
To clarify the diagnosis of a tumor of L., mandatory auxiliary methods are used.
Rentgenol, the method refers to the mandatory examination methods. It allows you to determine the prevalence of a tumor in L. and beyond, to find out the localization of metastases, etc. It includes fluoroscopy of the lungs, radiography (at least in direct and lateral projection) and tomography. In each case, perform an individual complex of additional methods rentgenol, examination.
Rentgenol, a picture of the central cancer of L. is diverse. A cancer tumor developing in one of the large bronchi (central cancer L.), causes a violation of its patency. As a rule, endobronchial growing cancer is radiologically detected in the phase when it causes hypo-ventilation, obstructive emphysema or atelectasis of a segment, lobe or all of L.
If the tumor does not completely cover the lumen of the bronchus, then on the tomograms and bronchograms, a filling defect with uneven contours is visible. At the initial changes (i.e., the infiltration of the bronchial wall is still flat), the filling defect is small with a barely noticeable wall usuration. With obstructive cancer, a picture of the stump or amputation of the bronchus is revealed.
If cancer grows hl. arr. peribronchial, then on roentgenograms and tomograms basal infiltration is defined, in a swarm narrowed and uneven gaps of bronchial tubes appear. With both endobronchial and peribronchial tumors, metastases in the intrathoracic lymph nodes are noted early.
Difficulties in the diagnosis are largely dependent on secondary inflammatory changes in the area of atelectasis and pleural effusion. Pleurisy can be associated with seeding or germination of a tumor in the pleura, the transition to the pleura of the concomitant inflammatory process, or compression of the lymphatic outflow tract. Diagnostic errors in cancer localization in the lower lobes are especially frequent, when their reduction and concomitant effusion are associated entirely with pleurisy.
The cancer that develops inside the lobe (peripheral cancer) initially looks like a local thickening of the picture, a small focus or a small cavity with uneven walls. The focus itself can be clearly identified on the tomograms. The volume of the focus doubles in about six months. Its shadow becomes more intense, uniform, the contours are clear, but hilly. In the event of decay, a cavity with uneven outlines is detected in the node. At least in one place, its wall is thickened, and tumor tissue extends into the lumen of the cavity.
Apical cancer (Pankost's tumor) is radiologically manifested by darkening of the apex of D., a cut often resembles periapical pleurisy. The greatest difficulties in differential diagnosis arise with tuberculosis. Apical cancer, sprouting ribs, causes the destruction of mainly the posterior regions, the neck and head regions of the ribs, and sometimes the transverse processes of the upper thoracic vertebrae.
Clinical data is made by tomography. In difficult cases of diagnosis, when it is impossible to decide whether the tumor node is located in L. or outside it, diagnostic pneumothorax should be used.
Mediastinal cancer with rentgenol, the study is manifested by the expansion of the shadow of the mediastinum, mainly the vascular bundle, due to enlarged lymph nodes, protruding in the right and left pulmonary field. The increase in nodes can be asymmetric, and sometimes one-sided. The contours of the mediastinum are usually polycyclic. However, in some cases, the lymph nodes, increasing, move away the mediastinal pleura and give a picture of the expanded, straightened mediastinum, which has lost its normal shape. At the same time in L. no changes can be detected, and often even in the section it is not possible to find the primary tumor node.
Miliary carcinomatosis is essentially a manifestation of hematogenous metastasis of a cancerous tumor. Given that in very rare cases a similar picture can be observed with primary cancer of L., this form is considered among others with bronchogenic cancer. In such cases, additional research methods (tomography and bronchography) do not provide any characteristic information. For a final judgment on the primacy of the pulmonary process, it is necessary to examine other organs, and only negative data will allow us to argue that we are talking about primary cancer of L. with extensive metastasis.
Morphol. research methods in confirming the diagnosis of cancer L. are crucial. These include histol, a study of biopsy material and cytol, a study of sputum, swabs from a bronchial tree, scrapings and punctate.
Cytol, a study of sputum allows you to obtain confirmation of the diagnosis in the simplest way. In some cases, this makes it possible to diagnose L. cancer in the absence of a wedge, manifestations and flimsy rentgenol, signs. However, cytol, a study for L. cancer, in no way can replace a full-fledged histol, research. For the correct choice of the treatment method, it is necessary not only to confirm the diagnosis, but also often complete morphol, a characteristic of the tumor, which cannot always be accurately determined cytologically.
Bronchoscopy for cancer L. - a mandatory diagnostic method. It allows not only to examine the tumor, to determine the boundaries of its distribution, to diagnose concomitant endobronchitis, but also to perform a biopsy of the tumor for histol, and cytol, research. If there are only indirect bronchoscopic signs of the tumor, the material for the study can be obtained by scraping or flushing from the bronchial tree or transbronchial puncture patol, focus. Transbronchial puncture is used to confirm metastatic lesions of enlarged lymph, L. root nodes and mediastinum. In peripheral cancer, during a bronchological examination under X-ray, a special brush or catheter is carried out in the corresponding bronchus, which allows obtaining material for cytol, research.
In peripheral cancer, located near the chest wall, transthoracic diagnostic puncture of the tumor with cytol, punctate examination is widely used. This method can give complications such as pneumothorax, bleeding, etc. Pneumothorax occurs more often, the deeper the tumor is located in the pulmonary parenchyma.
Surgical diagnostic methods are used as the final stage of the examination of the patient, when it is not possible to finally confirm the diagnosis or determine the prevalence of the tumor process by other methods. This includes various types of biopsies, including a red-hot biopsy, as well as mediastinoscopy, mediastinotomy and diagnostic thoracotomy.
Mediastinoscopy is indicated in cases of suspected metastatic damage to the lymph, mediastinal nodes, its use in the preoperative period allows to reduce the number of trial thoracotomies. Sometimes this study is performed in peripheral cancer with metastases in the lymph nodes of the mediastinum for morphol. confirming the diagnosis and choosing a treatment method.
Anterior diagnostic mediastinotomy is used for the same indications as mediastinoscopy. This surgery is performed under general anesthesia. A small incision of the skin of the anterior chest wall is carried out over the cartilage of the second rib from the side where the pathology in the mediastinum is more pronounced. After resection of the cartilage of the II rib and ligation of the internal thoracic artery and vein, the structures of the mediastinum are visually and palpated, a biopsy or cytol is performed, puncture of the enlarged lymph, nodes or primary tumor is performed. If necessary, you can open the mediastinal pleura and take the material for morphol, research directly from the lung tissue. With the location of enlarged lymph nodes in the aortic window on the left, mediastinotomy can provide more information than mediastinoscopy.
Diagnostic thoracotomy should be resorted to when a suspicion of L. cancer is clinically justified, but there is no direct morphol, evidence of a diagnosis. This is especially common with small asymptomatic spherical foci in L. So focal pneumosclerosis, benign tumors, tuberculoma and peripheral cancer are manifested. Long-term dynamic observation in doubtful cases is impractical. Diagnostic thoracotomy is less dangerous than the threat of missing L. Morphol cancer; confirmation of the diagnosis is usually obtained with a total biopsy of patol, lesion (planar or wedge-shaped resection of L.), if diagnostic cytol, puncture during surgery does not give positive results. After morpholum, confirming the diagnosis of cancer of L. perform radical resection of L. in the required volume, or the intervention ends with a trial thoracotomy.
Differential diagnosis of cancer of L. is often difficult because this disease often develops against the background of previous patol, processes: pneumonia, tuberculosis, a benign tumor with a similar wedge, and rentgenol, symptoms.
In differential diagnosis, first of all, it is necessary to determine whether the patol is located, the formation in the L. or mediastinum, is it related to the chest wall or to the diaphragm. Next, you need to find out whether the disease is a tumor process or not. If you get the impression of a tumor disease, you need to decide whether it is benign or malignant, and if the tumor is malignant, then it is primary or metastatic. In determining the pulmonary or extrapulmonary localization of the detected changes, rentgenol is crucial, a study in conditions of artificial pneumothorax. To answer the remaining questions, methods of additional examination are strictly individualized.
L. cancer most often has to be differentiated from hron, nonspecific pneumonia, hron, suppurative processes, tuberculosis, benign tumors and parasitic cysts L. Difficulties in the differential diagnosis of central and peripheral cancer make it possible to more widely recommend morphol, and surgical research methods, up to diagnostic thorapotomy. The sequence of application of diagnostic examination methods should be planned from the simplest to the most complex. A correctly drawn up individual examination plan can save the patient from unnecessary painful and dangerous procedures.
Treatment. For the correct choice of treatment method and prognosis, determining the degree of prevalence of the tumor process is of great importance. The real prospects for a complete cure for cancer L. has only the surgical method. Radiation therapy does not give hope for a complete cure, however, it allows the use of treatment to a wider range of patients and sometimes can significantly extend life. Chemotherapy of cancer of L. achieved certain successes.
L. Graham performed the first successful radical pulmonectomy for cancer L. in 1933. After 23 years, the patient was in good condition. Since then, cancer surgery L. continuously improved.
The surgical method of treating L. cancer is the method of choice, however, it is necessary to determine contraindications for surgery, which, unfortunately, are many.
The first group includes contraindications for cancer, order. The operation is meaningless with distant metastases to various organs, the opposite of L. or pleural seeding, with histologically confirmed lymph metastases, mediastinal nodes, mediastinal organ compression syndrome (superior vena cava, paresis of the recurrent nerve), with extensive tumor growth in neighboring organs (heart , main vessels, trachea, chest wall).
The second group of contraindications is associated with an assessment of the individual degree of risk of surgery. Operations on L. are associated with increased funct, load on the body and primarily on the cardiopulmonary system. Therefore, when deciding on the operation, it is necessary to strictly assess the general condition of the patient, his functions, and compensatory capabilities, the state of a healthy L., cardiovascular system, the presence of concomitant diseases, the patient's age, and the volume of the planned operation. An incorrect assessment of the compensatory abilities of the patient"s body can cause serious complications in the postoperative period and, conversely, an unreasonable refusal from the operation can deprive the patient of prospects for recovery.
The poor condition of the patient is not always a contraindication for surgery. For example, concomitant inflammatory changes in L., extensive atelectases can cause a serious condition of the patient, accompanying a small operable tumor that clogged the large bronchus. Such patients can be radically operated on with a good long-term result.
With sufficient preparation of the patient and the correct choice of the volume of the operation, patients with L. emphysema, coronary insufficiency, and even a history of myocardial infarction tolerate it.
Pneumonectomy is an operation that requires greater adaptive capabilities from the patient"s body than a lobectomy. Patients over 60 years of age can hardly tolerate L.'s removal and much better - removal of one or two of its lobes.
The most common postoperative complication due to an incorrect assessment of the function and condition of the cardiopulmonary system before surgery is respiratory failure.
In deciding on the indications for surgery and its volume, separate broncho-spirometry is of great importance. Trial shutdown of patient L. allows you to study the funct, the state of the remaining L. This method, among others, makes it possible to establish indications for pulmonectomy and assess the risk of surgery. Studies conducted by Yu. Ya. Agapov (1970), revealed 5 options funkts, the state of the respiratory system in cancer L. This scheme is convenient to use when deciding on the indications for surgery. The first option - the affected L. is practically turned off from the breath; in such patients, pneumonectomy does not threaten respiratory failure. This is the most favorable option for the postoperative period. This condition most often occurs with central cancer of L., when extensive atelectasis develops, the main vessels are compressed or germinate by a tumor, lymph is affected, the paths and lymphostasis develops. The second option is an equivalent function, the state of both L. The alternate shutdown of the patient and healthy L. keeps breathing at a normal level. This indicates a high funktsion, the ability of the remaining L. and is more common in young patients with small peripheral tumors. Pneumonectomy in such cases is not a risk. The third option is quite common. Both L. take an active part in ventilation and gas exchange, however switching off from. patient L.'s breathing leads to a certain decrease in respiratory function, but after a few minutes the ventilation of a healthy lung increases, shortness of breath does not occur. Removal of L. in such patients in most cases also does not present a risk, but requires a certain amount of preoperative preparation (respiratory gymnastics, oxygen therapy, etc.), and in the postoperative period, rigorous measures to prevent respiratory failure (lay down. Tracheostomy, sometimes assisted breathing). Such patients tolerate a lobectomy well. The fourth option - the affected L. is more actively involved in breathing than healthy. Therefore, when you turn off patient L. there is a significant decrease in the level of oxygenation of arterial blood. Such character of respiration usually meets at a peripheral tumor of L. and depends on funkts, features of L. and a cardiovascular system. Solving the issue of indications for pulmonectomy is extremely difficult. The operation is fraught with great risk, because the remaining L. is functionally inferior. Lobectomy is associated with less risk. In some cases, it is possible to increase the function of the remaining inferior L. by appropriate preoperative preparation, after which it is advisable to repeat separate bronchospirometry. As a preoperative preparation, the imposition of pneumothorax is permissible. If the patient suffers a collapse of the affected L. satisfactorily, then the question of its removal can be more reasonably posed. The fifth option is extremely low funkts, indicators of the remaining healthy L. Patients practically cannot stand the shutdown of the affected L. and the operation is contraindicated.
Evaluate the data of separate bronchospirometry should be combined with a wedge, and rentgenol, indicators.
Early dissemination and severity of surgery for L. cancer lead to low operability. The percentage of operability and resectability given by different authors is very different - from 60 to 30%. The true possibilities to apply surgical treatment determine the operability in the group of initially registered patients. So, according to the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, lobectomy and pulmonectomy are performed in 10-12% of cases among newly diagnosed patients with cancer L. The remaining patients are inoperable by the time of diagnosis by oncol, and funkts, indicators. Some patients refuse surgery. In general, patients with small asymptomatic cancer L. refuse surgical treatment.
The choice of surgery - pneumonectomy or lobectomy - depends on the nature of the patol, the process and location of the tumor. Central cancer of L. with metastases in bronchopulmonary lymph nodes, causes the need for pneumonectomy. Pneumonectomy is the main operation for cancer of L., with a cut, the affected organ is removed along with regional lymph nodes, including bifurcation nodes - an important lymph, a collector collecting lymph from both L. and often affected by metastases.
Lobectomy is indicated for peripheral cancer of L., less often for cancer of the mouth of the segmental bronchus, when there are no metastases in the bronchopulmonary (and especially bifurcation) lymph nodes. A palliative lobectomy is also possible, if possible, to remove metastatic lymph nodes in patients with low functions. Lobectomy performed according to strict indications gives no worse long-term results than pneumonectomy.
When planning operations, it is necessary to take into account the peculiarities of lymphatic drainage. An upper lobectomy in cancer should be accompanied by the obligatory removal of tracheobronchial lymph, nodes, because the lymph outflow from the upper lobe of L. is carried out mainly in the paratracheal lymph, nodes, bypassing the root L. With lower lobectomy, it is necessary to remove bifurcation lymph, nodes, because lymph outflow from the lower lobe of the left L., from the lower and middle lobes of the right L., as shown by D. A. Zhdanov (1952), M. A. Gladkova (1966), occurs through tracheobronchial lymph nodes on the right, including the bifurcation node according to the group of right paratracheal nodes. The radicalism of the planned lobectomy should be checked by urgent histol, examination of bronchopulmonary and tracheobronchial lymph nodes. If metastases are detected in them, it is necessary to assess the possibility of pulmonectomy.
Segmental resections in cancer of L. are not justified from oncol, a position requiring the removal of regional lymph nodes. They can be performed in exceptional cases. If you are unsure of the diagnosis of cancer, first remove the tumor segment for urgent histol, studies and, if necessary, switch to a forehead or pulmonectomy. During the operation, it is necessary to produce an urgent histol, examination of lymph, nodes suspicious of metastases. A negative answer does not prove the absence of metastases in other lymph nodes of the mediastinum, but a positive response can change the plan of operation.
The use of radiation therapy for malignant tumors of L. is based on the destructive or damaging effect of radiation on tumor cells and tissues. Principles of radiation therapy for tumors
L. are the timeliness of application and the choice of the most rational technique that provides for irradiation of the tumor and regional metastasis in a dose that causes the complete destruction of malignant cells with minimal damage to healthy tissues. Radiation treatment should be combined with therapy with an oxygen-vitamin complex and symptomatic agents. Radiation therapy can be more effective when in the early stages a small tumor is irradiated at a dose of at least 6000 rad. Palliative radiation therapy in a total dose of up to 4000 rad is used in common processes in patients with a satisfactory general condition.
Radiation therapy is indicated for operable forms of central and peripheral cancer in patients with func, contraindications to surgical treatment or who have refused surgery; with inoperable tumors, but a relatively satisfactory general condition; in tumors of high malignancy, prone to rapid metastasis, in operable patients in combination with chemotherapy before and after surgery. Radiation therapy is contraindicated in tumor decay, metastatic exudative pleurisy, specific lymphangitis, distant metastases, active forms of tuberculosis, in the first year after myocardial infarction, as well as in the general serious condition of the patient (cachexia, suppression of blood formation, severe cardiopulmonary insufficiency).
Radiation therapy is carried out by static and mobile methods on the remote gamma installations AGAT-S, AGAT-R, LUCH, ROCUS. There are great prospects for high energy sources - betatrons and linear accelerators that generate bremsstrahlung and electron radiation of energies from 4 to 35 MeV. The most important condition for radiation therapy is the determination of the optimal volume of irradiated tissues and the choice of a technique that provides the necessary dose to the tumor. All methods for determining the topography of the tumor, the orientation of the radiation fields and centering are associated with rentgenol, research. In centrally located and peripheral tumors, irradiation is carried out from three fields: two oncoming fields - paravertebral and parasternal, as well as supraclavicular or lateral depending on the location of the tumor with the direction of the radiation beam through the center of the tumor to the mediastinum. The total dose is adjusted to 6,000 rad per tumor and 3,500 to 4,500 rad per mediastinal region. In modern conditions, there are several methodological options for radiation therapy of the tumor L. The most common is small-fraction, when the tumor is irradiated daily at a dose of 200-250 rad, along with regional metastasis. The technique of large fractionation is that a single dose of 400-450 rad is brought to the tumor two to three times a week. An intensely concentrated version of the irradiation consists in summing up a total dose of 2000 rad for 5 daily fractions, which, according to biogram nomograms, of isoeffects is equivalent to a dose of 3400 rad given for 3.5 weeks. in conditions of fine fractionation. Radiation therapy can be used in two stages: at the first, they give half the planned dose; on the second, after a 2-3-week break, - the rest. At any localization of a tumor of L. use radiation through a lead lattice. Smaller volumes of healthy tissue falling into the irradiation zone expand the possibilities of this method.
A combined method is being studied that combines surgery and radiation. Preoperative irradiation of the tumor and regions of regional metastasis reduces the mitotic activity of malignant cells, leads to their necrobiosis, and also reduces inflammatory infiltration around the tumor. The elimination of inflammation and the reduction of the size of the tumor create favorable conditions for the operation, and in some cases, unresectable tumors become resectable. The most rational with the combined method of treatment seems to be an intensely concentrated version, with a rum, the interval between the end of irradiation and the operation should not exceed 5 days.
Postoperative irradiation is indicated when viable tumor cells are found in remote regional nodes after a non-radically removed tumor or test thorapotomy. It is usually carried out in the mode of fine fractionation to a total dose of 4000-5000 rad.
Indications for drug treatment are put in those cases when there are contraindications for surgical and radiation methods. It is carried out in patients with distant metastases of cancer of L. and at its small-cell form. Contraindications: sharply weakened general condition of the patient, cachexia, leukopenia, thrombocytopenia, impaired liver and kidney function, severe hemoptysis due to tumor decay.
According to the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, of all those developed by the end of the 70s. chemotherapeutic agents, the most active in L. cancer are cyclophosphamide and nitrosomethylurea (HMM), methotrexate, CCNU and adriamycin.
Objective improvement - a decrease in the size of a tumor of L. or metastases - can be obtained by metastasizing cancer into lymph, root nodes, mediastinum, peripheral lymph, nodes, another L., with subcutaneous dissemination. Chemotherapy is usually not effective for metastases in the bone, liver, and brain. The effectiveness of chemotherapy for cancer of L. depends mainly on histol, the structure of the primary tumor. Small cell cancer of L. is most sensitive to chemotherapy, an adenocarcinoma is least. In squamous cell carcinoma, the effectiveness of chemotherapy, expressed in direct reduction of the tumor, is low and varies from 6 to 26% depending on the drugs used, in small cell carcinoma - from 17 to 48%, in case of adenocarcinoma and large cell carcinoma - from 10 to 20%.
At undifferentiated small-cell tumors of L. it is advisable to apply complex treatment, i.e., combine radiation therapy with the introduction of chemotherapeutic drugs.
The combination of gamma-ray remote therapy at a dose of 5000 rad and chemotherapy with cyclophosphamide, methotrexate and HMM (or CCNU) according to a special program made it possible to obtain a good direct effect in 90% of patients with small cell carcinoma of stage III-IV, and the life expectancy of patients increased by 2-3 times compared with those patients who underwent single radiation or chemotherapy, and reached an average of 30 months.
Combination chemotherapy (polychemotherapy) of L. cancer is widely used. Thus, with the combination of cyclophosphamide and HMM, the effect can be obtained in 27% of patients with squamous cell carcinoma of L. and in 70% of patients with small cell cancer. The effect can be obtained with a combination of other chemotherapy drugs, however, in all cases, remissions are usually short-term and do not exceed 2 months.
With effusion in the pleural cavity, intrapleural administration of thiophosphamide at a dose of 30-40 mg per administration or delagil (hingamine) of 250 mg (4-5 administrations) daily or every other day can be used. Repeated courses of treatment can be carried out as exudate accumulates.
The practical use of a combination of different treatment methods can be recommended for small cell carcinoma (radiation and drug therapy) and after surgery with dubious radicalism. In this case, after surgery for squamous cell carcinoma, it is sometimes advisable to irradiate the mediastinum.
At relapses of cancer of L. indications to radiation are defined by the general condition of the patient, time of occurrence of a relapse of a tumor and its histological structure. Most often it is necessary to be limited to a smaller total focal dose.
Patients in whom a relapse of the tumor appeared after 1-1.5 years or more, in some cases, you can re-irradiate with a total focal dose of 6000 rad. The irradiation technique is selected taking into account the concomitant post-radiation pneumosclerosis. A combination of radiation therapy and chemotherapy is advisable.
A significant number of patients with L. cancer needs symptomatic therapy. Antibiotics reduce the incidence and severity of the course of inf. complications. Coughing, often with pain, should be suppressed by the administration of dionine, codeine, and morphine. With a tendency to hemoptysis, hemostatic agents and a blood transfusion are indicated. Tumors that grow into the chest wall cause severe pain, which helps alcohol-novocaine blockade and drugs.
The prognosis for L. cancer is always serious. According to L.E. Denisov (1975), patients from the moment the first symptoms of the disease appear, live without treatment for an average of 12.8 months, and from the moment a L. cancer diagnosis is made - 8.7 months. Patients with squamous cell carcinoma L. lived on average 15.1 months. since the onset of the first symptoms of the disease and 8.2 months - from the moment of diagnosis. For patients with adenocarcinoma, these periods are 11.6 and 5 months, respectively, with undifferentiated cancer - 7.6 and 3.8 months.
The use of surgical treatment methods makes it possible to completely cure the patient or extend his life. Among radically operated patients of 5 years and more live apprx. 30 - 35%, however, high postoperative mortality significantly worsens the results of surgical treatment. Mortality is especially high after pneumonectomies, which, according to the Oncological Scientific Center of the Academy of Medical Sciences of the USSR, is 12-15%. The main causes of death are cardiac, pulmonary and septic complications.
The long-term results of surgical treatment of cancer of L. depend primarily on the stage of the disease and histol, the structure of the tumor. Low-grade cancer gives poor long-term results. Particularly poor results are observed with small cell cancer.
According to the summary data of seventeen foreign and domestic surgeons most actively involved in the surgical treatment of cancer of L., five-year favorable outcomes after pneumonectomies in 1960-1975. amounted to 24.1%, and after 2486 lobectomy - 31.5%.
Radiation and chemotherapeutic methods of treatment can delay the progression of the process for some time.
Prevention The main causes of cancer L. are not yet disclosed. But the accumulated facts allow the implementation of preventive measures for malignant tumors of the bronchi. The main ways:
- technical - the organization of production and construction, taking into account the elimination of human contact with carcinogens;
- sanitary-hygienic - the fight against air pollution and smoking;
- medical - treatment and registration of patients with precancerous diseases L.
The allocation of precancerous diseases as a separate group is very important in practical terms, since it contributes to cancer, the general doctors" alertness to lay down. network in relation to a wide range of neonkol. L. diseases. This installation allows systematic mass prophylactic examinations of the population and the most rational allocation of "high-risk groups". The success of L. cancer prevention largely depends on the effectiveness of the fight against smoking, with inf. and viral diseases of the respiratory tract, with hron, non-specific pneumonia and bronchitis.
Primary sarcoma of L. - an extremely rare disease. A tumor develops from the interstitial tissue of L. In some rare cases, individual forms of cancer of L. can differentiate into carcinosarcoma, and then the structure of sarcoma and cancer is found in different parts of the tumor. More often in L. there are solitary metastases of sarcoma that preserve the structure of the primary tumor. Primary sarcomas can have the structure of spindle-shaped cell, polymorphic cell and less often fibrosarcoma. Angiosarcoma and reticulosarcoma are also found.
Sarcomas are localized on the periphery of L., often in the upper lobes, grow rapidly, have a rounded and polycyclic shape, sometimes with daughter (metastatic) nodes in L. Men and women get sick equally often.
Wedge, and rentgenol, a picture of L.'s primary sarcoma almost does not differ from a picture of peripheral cancer. Sarcoma can be suspected on the basis of a rapidly developing wedge, a picture of a tumor of L. or with histol, a study of lymph, mediastinal nodes taken with mediastinoscopy. Usually L. sarcoma is an unexpected finding with histol, a tumor study.
Surgery is the only treatment for sarcoma, but radical surgery is rarely feasible due to early metastasis to distant organs.
The prognosis is poor. Long-term results of treatment are unsatisfactory, although in some rare cases, good long-term results were observed after surgery.
All operations on L. belong to large surgical interventions and often require careful preoperative preparation.
Preoperative preparation is necessary in approximately half of patients with purulent diseases of L. (with exacerbation of the inflammatory process and associated purulent intoxication). The risk of surgery and postoperative complications is much less if surgery on L. is performed in a phase of sufficient stabilization of the inflammatory process and with a small amount of sputum. Postural drainage and bronchoscopic sanitation with a thorough toilet of the bronchial tree, catheterization of purulent cavities, suction of pus, washing, administration of proteolytic enzymes and antibiotics are of primary importance to relieve the outbreak of the inflammatory process and combat purulent intoxication. In some cases at an obliterated pleural cavity I.S. Kolesnikov, B.S. Vikhriev (1973) recommend abscesses in L. to puncture and sanitize through a chest wall. Additional measures that can have a beneficial effect on removing purulent intoxication and improving the general condition of the patient are inhalation of aerosols of proteolytic enzymes and antibiotics, intravenous drip infusion of 1% calcium chloride solution 500 ml 2-3 times a week, blood and plasma transfusion , protein preparations, as well as good nutrition with enough protein and vitamins, breathing exercises. Usually vigorous treatment allows you to prepare the patient for surgery within 2-3 weeks. If a significant improvement does not occur, the purulent cavities in L. need to be drained operatively or undertaken, despite the increased risk, radical surgery.
In patients with L. tuberculosis before surgery, specific anti-tuberculosis treatment is necessary to eliminate the outbreak, the maximum possible stabilization and delimitation of the tuberculosis process. Depending on the general condition of the patient, the form of the tuberculosis process, the phase of the disease and the effectiveness of the therapy, the methods and duration of such treatment vary widely. On average, it lasts 2-3 months. and it is usually carried out not in a surgical, but in a TB hospital.
Features of general anesthesia
The vast majority of operations on L. and bronchi are performed under conditions of operational pneumothorax. In the course of operations, the need may arise for a long and wide opening or complete intersection of the bronchi, while methods of combined general anesthesia under conditions of total myoplegia and mechanical ventilation are widely used. Of particular importance during operations on the L. and bronchi are the methods of mechanical ventilation (ALV) and intubation.
The danger of leakage of pus, sputum, blood from the affected parts of L. into healthy ones is especially great with large and multiple cavities in L. (abscesses, caverns, suppurating cysts), bronchiectasis, pleural empyema with bronchopleural fistulas. In such patients, preoperative bronchoscopy with a toilet of the bronchial tree, an abdominal position with a downward inclination of the head end of the operating table, frequent suction through the endotracheal tube may not be sufficient to maintain airway obstruction and prevent infection of healthy parts of L. During operations during pulmonary hemorrhage, coagulation is possible blood in the respiratory tract with the threat of fatal asphyxiation.
Specific requirements for general anesthesia during operations on the L. and bronchi are the prevention of paradoxical breathing and mediastinal flotation, measures to prevent the ingestion of pus, blood, sputum in the healthy sections of L. and maintaining free airway patency, ensuring adequate ventilation during opening and crossing bronchi. To this end, during the intervention, mechanical ventilation with endotracheal or endobronchial intubation is performed. Induction anesthesia is carried out by the intravenous administration of barbiturates or by the use of combined induction methods. After the introduction of muscle relaxants, intubation of the trachea, bronchus or separate intubation of the bronchi is performed. A thick probe is inserted into the stomach to prevent regurgitation of its contents and to facilitate anatomical orientation in the position of the esophagus. As insufflated general anesthetics at the stage of maintaining anesthesia, fluorotan, an azeotropic mixture, methoxyflurane and nitrous oxide in an oxygen stream are used. General anesthesia is performed using antipsychotics. Mechanical ventilation is carried out by devices. In some cases (with significant resistance in the inspiratory phase and when the airway lumen is opened, when the surgeon periodically closes the hole in them with a tuffer or finger), they switch to manual ventilation L. During general anesthesia and surgery, sputum from the respiratory tract is periodically aspirated by a catheter as necessary which is introduced through an endotracheal tube. This technique provides the majority of operations on L.
To prevent the ingress of liquid masses from the affected sections of L. into healthy ones, intubation of the main bronchus ("one-lung anesthesia"), separate intubation of the bronchi, drainage and blockage of the bronchus are used.
Intubation of the bronchus of a healthy L. prevents the flow of liquid masses from the affected to healthy L. Moreover, the affected L. does not participate in respiration and decreases in volume, which facilitates the resection. For intubation of the bronchus, a sufficiently long endotracheal tube with a short inflatable cuff is used. The right main bronchus is conveniently intubated with a Gordon-Green tube with a special side hole for the right upper lobar bronchus. The position of the tube and the degree of separation of L. before the start of the operation is controlled by auscultation, and after opening the pleural cavity - by palpation and observation of the state of L. and the movements of the mediastinum, respectively, inhale and exhale.
For separate intubation of the bronchi, the Carlens double-lumen tube is most often used. The end of this tube is installed in the left main bronchus, advancing the tube until the fixation of its right-sided spurs on the bifurcation of the trachea.
The advantage of using double-lumen tubes over the intubation method of the bronchus on the healthy side is the possibility of aspiration of liquid mass from the bronchus of the removed L., and the disadvantage is the relative narrowness of the gaps and the impossibility of use in patients of early and young childhood.
With partial resections of L., the use of separate intubation of the bronchi using double-lumen tubes helps prevent leakage of liquid masses into the bronchi on the healthy side and at the right time stop the ventilation of L. on the side of the surgical intervention. The latter is especially important for bronchopleural fistulas that allow large volumes of gas-narcotic mixture to pass and make it difficult to conduct effective mechanical ventilation. To facilitate surgical manipulations, you can connect the channels of the double-lumen tube with two different anesthesia devices or connect a connector with an adjustable clearance to the channel of the operated side and ventilate L. on the side of the operation with a smaller volume of the narcotic drug mixture, the so-called. controlled collapse of the lung, proposed by G.I. Lukomsky and M.A. Vishnevskaya (1964). Before processing the main bronchus, the tube is tightened or replaced with the usual single-lumen.
Drainage of the bronchus is carried out by preliminary, prior to the start of general anesthesia, the introduction of a guided catheter into the bronchus, draining the cavity in L. Then the trachea is intubated and anesthesia is continued. Through the catheter, the contents of the purulent cavities are continuously aspirated without stopping mechanical ventilation; this technique was proposed by M. B. Dribinsky et al. (1959).
The bronchial blockade of the removed L. is carried out by a catheter with an inflatable balloon (bronchial blocker) or gauze tamponade with bronchoscopy. Both of these methods are rarely used, because they are not very reliable and can be accompanied by dangerous ventilation problems in cases of displacement of the balloon or tampon.
For all operations on L., regardless of the method of intubation, the toilet of the trachea and bronchi is important during the operation, by suctioning the liquid contents from the trachea and bronchi. The suction catheter should have an end and several side openings. Through a tee with one open elbow, the catheter is connected to a sufficiently strong suction device. During catheter insertion, an open elbow prevents the creation of a vacuum. After the catheter is sufficiently deep, the open elbow of the tee is closed with a finger and the catheter is slowly removed from the tube. Such a technique reduces trauma to the mucous membrane of the respiratory tract, the edge always occurs to a certain extent when aspirated through a catheter. The suction procedure, usually associated with the termination of ventilation L., should not last more than 1 - 1.5 minutes. It is believed that the suction should not last longer than the time that the anesthetist can hold his own breath.
During the operation, it may periodically be necessary to inflate L. with an increase in airway pressure up to 30-40 cm of water. Art. An increase in pressure is especially important for determining intersegmental boundaries, checking bronchial patency, detecting lung tissue damage, monitoring the tightness of the bronchus stump and bronchial anastomosis, as well as for straightening atelectasized areas of L. at the end of the operation.
During operations on the bronchi, the best conditions for gas exchange and intervention are created by intubation of the main bronchus of the opposite side.
On the bronchi of the right side, it is more convenient to operate during intubation with a Carlens tube, Macintosh-Literdel tube or a single-lumen tube, the end of which can be moved from the trachea to the left main bronchus and vice versa. In operations on the bronchial tubes of the left side, the usual single-lumen tube or Gordon-Green tube is inserted into the right bronchus.
In patients with wide bronchopleural fistulas, and primarily with fistulas of the main bronchi, after a pulmonectomy, prior to the start of general anesthesia, it is necessary to well plug the residual pleural cavity to prevent the discharge of the narcotic mixture through the fistula. The use of bronchial blockers for closing fistulas is impractical. With wide bronchopleural fistulas, especially on the right, intubation of the left main bronchus is sometimes associated with significant technical difficulties. The trachea in such patients is usually curved and shifted to the right, the left bronchus moves away at a large angle, and the tube is easily inserted only into the fistula. In such cases, dense and elastic single-lumen tubes with a large bend are required. The patient"s head is taken to the right, the tube is turned by a bend to the left and slowly advanced so that its section slides along the left wall of the trachea.
In patients with fistula of the stump of the left main bronchus, when accessing the bifurcation of the trachea by right-sided thoracotomy, the only right L. has to be squeezed. In these cases, it is necessary for 5-7 minutes to maintain adequate gas exchange. carry out intensive hyperventilation, and then switch to surface manual ventilation.
The difficulty of conducting general anesthesia and the inevitable interruptions in mechanical ventilation during a number of operations on the L. and bronchi make it necessary electrocardioscopic monitoring and periodic examination of the acid-base state and blood gases. In more dangerous situations, electroencephalographic control is also indicated.
After operations on the L. and bronchi, it is necessary to quickly restore consciousness, adequate independent breathing and a cough reflex. These factors are essential for the favorable course of the immediate postoperative period.
Features of anesthesia in children
Conducting general anesthesia in children has a number of features. At operations on L. they are defined by hl. arr. anatomical physiol. characteristics of the respiratory system. The respiratory tract in children is narrow, and their patency is easily impaired by copious salivation, sputum from L., especially purulent. The narrowness of the larynx and trachea does not allow the use of double-lumen Carlens intubation tubes and other special tubes for separate intubation of the bronchi and their separation. Therefore, tracheal intubation in children is performed, as a rule, with the usual smooth, semi-curved single-lumen tube. At the age of children under 7-10 years old, the use of tubes with inflatable cuffs is contraindicated, which injure the vocal folds during intubation and contribute to the occurrence of edema of the larynx and trachea after anesthesia, especially prolonged. Of the methods for separating the bronchi, it is rational to apply only one - intubation of the bronchus of a healthy L. by promoting a single-lumen tube with a short cut into it. It should be borne in mind that in young children, the bronchi move away from the trachea at almost the same angle, and it is technically easier to hold the tube into the left main bronchus than in adults. At the same time, the short length of the main bronchi makes it easy to move the tube up and down, which either disrupts the separation of the bronchi, or leads to the overlap of the mouth of the upper lobar bronchus and the upper lobe L. being excluded from breathing. In this regard, during bronchus intubation and during surgery systematic monitoring is required, chap. arr. auscultatory, for ventilation of the upper lobe of L. on the non-operated side.
During general anesthesia, dead space should be minimized. Mechanical ventilation is carried out so that tidal volumes exceed their value during spontaneous breathing. In cases of obstructive pathology, the pressure under the Crimea is fed a gas-narcotic mixture, sometimes it is necessary to significantly increase it - up to 50-60 cm of water. Art.
Complications of general anesthesia during operations on the L. and bronchi can be leakage of liquid masses into the bronchi of healthy sections and gas exchange disorders in the presence of bronchopleural fistulas and wide opening of the bronchi. A thorough toilet of the tracheobronchial tree through an endotracheal tube, intubation of a healthy L. bronchus, and separate intubation of the bronchi with double-lumen tubes minimize the likelihood of these complications.
At the development of the phenomena of pulmonary insufficiency after extensive interventions on L. (pulmonectomy, lobectomy) in the near postoperative period, there may be a need for prolonged mechanical ventilation.
For successful operations on L. a number of conditions are necessary. Operating rooms should be equipped with automatic respirators for anesthesia, equipped with aspirators, have a surgical diathermy for electric knife incisions and coagulation of bleeding vessels. Of the instruments, expanders of the chest wall wounds, saws for cutting the sternum (wire, vibration, circular, ultrasound), deep hard and soft mirrors for diaphragm, L. and heart abduction, forceps for grasping L. and pleura, long forceps, scissors, clamps are important and needle holders, dissectors, staplers UO and US with tantalum brackets, tweezers with an atraumatic notch, atraumatic needles of various sizes. We also need tools for resection of the ribs, including box-shaped forceps, spacers and Sauerbruch rib forceps for the 1st rib.
Puncture of the lung is performed with a diagnostic or lay down. purpose. The main indication for diagnostic puncture is the need to obtain material from patol. foci for cytol, and histol, studies. Contraindications to diagnostic puncture are localization of patol, a lesion in the root L., emphysema L., the presence of a single functioning L., suspected intrapulmonary aneurysm or echinococcal cyst. Transthoracic puncture is done under local infiltration anesthesia and X-ray television control. You can use a regular injection needle with a length of 140-150 mm with an outer diameter. 0.9-1.1 mm, a needle with a serrated or split end of Silverman. L. puncture after opening the pleural cavity is done with a normal injection needle. During transthoracic to lay down. puncture of the abscess or cavity through a needle or trocar, you can insert a thin catheter into the purulent cavity, which is fixed to the skin and is used for the systematic sanitation of the abscess or cavity by aspiration, washing and administration of drugs.
Standard operative access for operations on L. is a fairly wide intercostal incision. Depending on the position of the patient on the operating table and the localization of the incision, it is customary to distinguish between anterior, lateral and posterior surgical access. Thoracotomy is performed in the IV, V or VI intercostal space. A number of surgeons use the intersection of the ribs and their resection only with posterior access or when it is necessary to expand the surgical field. At operations on elements of a root of L. or simultaneous bilateral interventions on L. median sternotomy is sometimes used for access.
The most common operations on L. are pneumonectomy, pleuropneumonectomy, lobectomy, segmentectomy and atypical lung resection, lung decortication. More rare operations are the removal of non-parasitic and parasitic cysts of L. (cystectomy, echinococcectomy), removal of a foreign body and opening of the abscess - pneumotomy, opening of the cavity - cavernotomy, drainage of the abscess or cavity through the chest wall (abscessostomy, cavernostomy).
A special technique is used to remove echinococcal cysts L. Usually echinococcectomy is performed after suctioning the contents of the cyst. For this, the cyst is first punctured with a thick needle connected to the suction system. All liquid is sucked off. Lung tissue above the cyst is dissected with an electro-knife. The fibrous capsule is widely opened, the cuticular membrane with its contents is removed, the bronchial fistulas and the cavity of the fibrous capsule are sutured. To reduce the risk of secondary invasion in case of accidental ingestion of echinococcal fluid, immediately after suctioning a small amount of fluid, 1-2% formalin solution can be injected into the cyst for several minutes, and a 2% formalin solution should be lubricated in the cavity of the fibrous capsule after suturing of the bronchial fistula in glycerin. Suturing of large cavities formed by a fibrous capsule in L. presents considerable difficulties and often leads to wrinkling and gross deformation of L. To avoid these negative aspects, A. A. Vishnevsky (1956) proposed a method for treating a fibrous capsule. The essence of the method lies in the fact that the edges of the wide open fibrous capsule are partially dissected and cut off in order to turn the deep cavity into the most flattened one. Then, the edges of the capsule and wounds of L. are sheathed around the circumference with a catgut suture. After this, the inner surface of the fibrous capsule becomes as if part of the outer surface of L. The bronchial fistula is sutured. Echinococcectomy according to the described method is especially indicated for large cysts. In cases of smaller cysts, the "ideal" echinococcectomy is rational, that is, removal of a cyst with an intact cuticular membrane. Lung tissue is dissected above the cyst with an electric knife. Then, the fibrous capsule is very carefully dissected with a scalpel without damaging the cuticular membrane. With a slight increase in pressure in the anesthesia system, an unopened echinococcal cyst is squeezed through an incision in a fibrous capsule. You can also successfully remove the cyst without increasing, but lowering, the pulmonary pressure. The cavity of the fibrous capsule is sutured, paying particular attention to the closure of bronchial fistulas.
With the ever-earlier production of operations for L. echinococcosis and the improvement of surgical technique, "ideal" echinococcectomy with small and medium-sized cysts is becoming more common. Echinococcectomy together with the fibrous capsule is not practical, since the reproduction of the parasite occurs only in the cavity of the cuticular membrane, and the fibrous capsule of the pathogen does not contain. Removal of a share of L., and even more than two shares or even all of L. in patients with echinococcosis, has very limited indications: secondary suppurative processes around the cyst, pulmonary bleeding, suppuration of multiple cysts located in one lobe or in one L.
At patients with several echinococcal cysts in one L. the simultaneous echinococcectomy is shown - "ideal" or with preliminary suction of the contents of cysts. Perhaps a combination of these two methods in the process of removing various cysts. With bilateral cysts, sequential operations are performed to remove cysts from one and then the second L. The usual interval between operations is 2-3 months. The simultaneous removal of cysts from both L. is not recommended because of the greater operational risk.
True relapses of L. echinococcosis after surgery develop in less than 1% of patients. False relapses are occasionally observed - cases where small cysts that were present during the operation were not detected and removed. The average mortality after operations for L. echinococcosis is about 3%, but in a number of clinics it has been significantly reduced in recent years and is in the range of 0.5-1%.
Patients within 2-4 days after surgery should be in the intensive care unit, equipped with control and diagnostic equipment, devices for long-term mechanical ventilation, systems for the constant supply of oxygen through nasal catheters. The presence of vacuum systems for dosed suction of air and liquid through the drains introduced into the chest cavity is very important. In addition to specially designed systems and regulators, a simple system of two bottles with a pressure tube in one of them is also widely used for dispensing vacuum. The department should have a round-the-clock opportunity to study the gas composition of blood, rentgenol, monitor the state of the organs of the chest cavity, transnasal catheterization of the trachea and bronchi, bronchoscopy.
In the first day after the operation, it is necessary to provide sufficient pain relief. The most effective is long-term epidural anesthesia with trimecaine.
After all operations on L. it is very important to ensure a good expectoration of sputum, and after resections of L. - a quick spread of its remaining part. To achieve these goals, the main preventive and lay down. measures include chest massage, respiratory gymnastics, early rising (1-2 days after the operation), transnasal catheterization of the trachea and bronchi, constant suction of fluid and air from the pleural cavity through the drainage. According to indications, specialized coughing machines are used in specialized institutions.
With low functions, indicators and a tendency to increased secretion of bronchial mucus, microtracheostomy is used. To do this, during the operation or on the first day after it, the trachea is punctured just below the cricoid cartilage, a thin vinyl chloride tube is inserted into its lumen, edge, irritating the mucous membrane of the trachea, causes a cough reflex, and also serves to inject drugs that dilute sputum, and antibiotics. An effective means for aspirating sputum and blood clots that can enter the bronchi during surgery is transnasal bronchofibroscopy. In the development of acute pulmonary failure, tracheostomy and artificial respiration are indicated.
Drainage introduced into the pleural cavity after a lobectomy is removed on the 2nd to 4th day. When the lung is completely discharged and there is no liquid or gas left in the pleural cavity. Punctate the pleural cavity to remove accumulating exudate after pneumonectomy is necessary only according to the indications: in case of patient complaints of tightness in the chest and shortness of breath, displacement of the mediastinum to the healthy side, with excessive accumulation of exudate. It is not advisable to remove fluid from the pleural cavity without indications, since this contributes to its further accumulation. At the same time, the patient loses a lot of protein, salts and fluids. The fluid accumulating in the pleural cavity after pneumonectomy is a necessary substrate for its obliteration.
In the postoperative period, much attention needs to be paid to the prevention of pulmonary, pleural and cardiovascular complications. It is necessary to fight with paresis zhel.-kish. tract and acute expansion of the stomach (often observed when the vagus nerve is damaged), because the high standing of the diaphragm significantly complicates breathing and cardiac activity. Thromboembolic complications, quite frequent in the postoperative period, make it necessary to carefully monitor the condition of the coagulation and anticoagulation system of blood, especially in obese and elderly patients with a history of cardiovascular diseases. Serious complications after operations on L. are bronchial fistulas and empyema of the pleural cavity.
By: Eric Teller, MD