Diseases of the lungs occupy one of the leadingplaces among all causes of the pediatricmorbidity and mortality. The most frequentpulmonary disease is a pneumonia. The majorityof the patients with pneumonia are treated bypediatrics, but sometimes the course ofpneumonia are followed withcomplications, required the surgicalinterventions. This is a bacterial destructivepneumonia.
Route of infection: 1. Primary – by an aerogenous route through the bronchi 2. Secondary - by hematogenous route from other purulent focus.Infecting agent: 1. Gram-negative. 2. Gram-positive. 3. Mixed flora.
1. Pulmonary: a) abscess, b) blebs (residual cavities).2. Pleural: a) exudative pleuratis, b) pyothorax – local and total, c) pneumothorax – tension and non- tension, d) pyopneumothorax – tension and non- tension. 3. Emphysema of mediastinum.
Microbes, reaching thepulmonary tissue, begin toproduce the different toxins(one of them – necrotoxin) andproteolytic ferments, whichcause the tissue necrosis andformations of the purulentcavities. These cavities join andform the pulmonary abscess.
The clinical course of the abscesshas two stages. The first one(formation of abscess orundrained abscess) is followedwith severe clinical symptoms ofthe respiratory insufficiency andintoxication: shortness ofbreath, tachypnea, cyanosis, tachycardia, high temperature, raisedwhite blood cells (WBC) level anderythrocyte sedimentation rate(ESR).
The X-ray shows the roundshadow, that occupies a fewsegments or entire pulmonarylobe. If conservative treatment(antibiotherapy, disintoxication) isineffective, the puncture of theundrained abscess is indicated.
The second stage of theabscess is a drained abscess.Usually the abscess drains intothe bronchi, what is followedwith the violent cough with pus,decreased temperature andimprovement of the patientcondition.
If the bronchial fistula within thebronchus and abscess cavity iswide and the pus leaves the cavityrapidly the conservative treatmentis used. This includes theantibiotherapy, bronchioliticinhalation, expectorants, posturaldrainage. Adequate drainage ofthe lung abscess often is achievedthrough postural drainage andchest physiotherapy. The use ofbronchoscopy to drain an abscessis controversial.
After the successfultreatment of the pulmonaryabscesses the residual air-filled cavities (blebs) arepresent into the lung. Thesecavities need no specialtreatment and usuallydisappear in 3 – 4 months.
The pneumonia almost alwaysis followed with a serousexudate accumulation inpleural cavity. In case of thedestructive pneumonia thesuppuration of the exudatehappens and it becomespurulent. This is a pyothorax(the pus accumulation in thepleural cavity).
The pyothorax is most frequentcomplication of the bacterialdestructive pneumonia. Ifauscultating a child with severepneumonia (respiratoryinsufficiency, fever, intoxication)you found the weak or absentbreath sounds and donthear the moist rales, this usuallymeans a presence of the pusinto pleural cavity.
At the roentrenograms the lung field shadow (local or total) is visible. This shadow closes the pleural sinus and has an oblique upper line. In case of the total pyothorax the upper line reaches the pleural top.
To confirm the diagnosis thepleural puncture at the 6th or 7thintercostal space by linia axillarismedia or posterior should bedone. Presence of the pus in thepleural cavity confirms thediagnosis of pyothorax, whatindicates a necessity for thepleural tube insertion (drainage ofthe pleural cavity).
Sometimes the abscess cavityempties into the pleural cavitywith formation of the bronchialfistula between the bronchus andpleural cavity. This situation leadsto pus and air accumulation intothe pleural condition. Thiscomplication is known aspyopneumothorax. This iscomplication is more severe thanthe pyothorax.
In this case the severe condition of thepatient with pneumonia deterioratessignificantly and may be life-threatening. Thedyspnea increases, cyanosis andapprehension appear, the accessory musclehelp to breathe. The auscultation reveal theabsence of breath sounds, although a fewhours before the moist rales and coarsebreath sounds were heard. During thepercussion the tympanic sound, whichindicates presence of the air, is found. Thetension pyopneumothrax is followed withprogressive air accumulation in the pleuralcavity, what causes the mediastinum andheart shift to the opposite side.
The tension pyopneumothrax is followedwith progressive air accumulation in thepleural cavity, what causes themediastinum and heart shift to theopposite side. The tensionpyopneumothorax is life-threateningcondition, causing the acute cardiacand respiratory insufficiency. The X-rayshows the the air and pus presence intothe pleural cavity with a clear horizontalline between them. The lung iscompressed.
In the case of the tensionpyopneumothorax the shift ofthe mediastinum and heart tothe healthy side is visible. Thetreatment in this case isemergency and includes thepleural tube insertion. Thesystem of the passive aspirationshould be applied.
In case of the pneumothorax theair accumulates it the pleuralcavity. Like the pyopneumothoraxit may be tension and non-tensionand requires the puncture of thepleural cavity to remove the air.The puncture is done at the 2nd or3rd intercostal space by liniasubclavia media. Sometimes a fewpuncture should be done.
The emphysema of mediastinum is arare complication of the bacterialdestructive pneumonia. The presenceof the air in the mediastinum is alwaysfollowed with its spread to neck, wherethe subcutaneous emphysema isvisible. This symptom and X-ray, whichshows the presence of air in themediastinum, allow to make a correctdiagnosis. The local treatment of theemphysema is a suprajugularmediastinotomy and drainage of themediastinum.
X-raysymptom, whichshows thepresence of airin themediastinum
All these complication of the pneumoniarequire a general treatment as well, asmentioned above local treatment. Thegeneral treatment includes theantibiotherapy, infusion therapy,symptomatic therapy. The antibiotherapyis begun with wide-spread antibiotics,then this therapy is adjusted due to resultsof the microbial sensitivity. Theintravenous route for antibiotherapy ispreferable. Quite often the children withbacterial destructive pneumonia needthe oxygen. The nasal cannulas or oxygentent are used for this purpose. The severecases may require the ventilator support.
Pleural effusion, a collection offluid in the pleural space, is rarelya primary disease process but isusually secondary to otherdiseases. Normally, the pleuralspace may contain a smallamount of fluid (5 to 15 ml) actingas a lubricant that allows thevisceral and parietal surfaces tomove without friction.
In certain intrathoracic andsystemic diseases, fluid mayaccumulate in the pleural spaceto a point where it becomesclinically evident, and it is almostalways of pathologic significance.The effusion can be a relativelyclear fluid, which may be atransudate or an exudate, or itcan be blood, pus, or chyle.
The secondary pneumoniadevelops as a complication ofother purulent diseases. The mostcommon among these diseases isan osteomyelitis. Usually thebacterias reach the lungs throughthe hematogenous route. Suchpneumonia have a double-sidelocalization and may be followedwith any above-mentionedcomplication(pyothorax, pyopneumothorax)
A transudate (filtrates of plasma thatmove across intact capillary walls)occurs when factors influencingformation and reabsorption ofpleural fluid are altered, usually byimbalances in hydrostatic or oncoticpressures. A transudate indicatesthat a condition such as ascites or asystemic disease such as congestiveheart failure or renal failure underliesthe fluid accumulation.
An exudate (extravasation of fluidinto tissues/ cavity) usually resultsfrom inflammation by bacterialproducts or tumors involving thepleural surfaces.
Pleural effusion may be acomplication oftuberculosis, pneumonia, congestive heart failure, pulmonary viralinfections, and neoplastic tumors.Bronchogenic carcinoma is themost common malignancyassociated with a pleural effusion.
Usually the clinical manifestations are thosecaused by the underlying disease, pneumoniawill cause fever, chills, and pleuritic chestpain, whereas malignant effusion may result indyspnea and coughing. A large quantity ofpleural effusion will cause shortness of breadwith dullness or flatness to percussion overareas of fluid with minimal or absence ofbreath sounds.
Egophony will be presentabove the effusion. Trachealdeviation away from theaffected side may occur withsignificant accumulation ofpleural fluid.
The presence of fluid is confirmedby chest X-ray, ultrasound,physical examination, andthoracentesis. Pleural fluid isanalyzed by bacterial cultures,Gram stain, acid-fast bacillus stain(for tuberculosis), red and whiteblood сell counts, bloodchemistry studies (glucose,amylase, lactic dehydrogenase,protein), and pH.
The objectives of treatment are todiscover the underlying cause toprevent fluid collection fromrecurring, and to relievediscomfort and dyspnea. Specifictreatment is directed to theunderlying cause.
Thoracentesis is performed to removefluid, to collect a specimen for analysis, andto relieve dyspnea. If the underlying causeis a malignancy, however, the effusion mayrecur within a few days or weeks. Repeatedthoracenteses result in pain, depletion ofprotein and electrolytes, and sometimespneumothorax. In this event the patientmay be treated with chest tube drainageconnected to a water-seal drainage systemor suction to evacuate the pleural spaceand re-expand the lung. Sometimestetracycline, radioactive isotopes, orcytotoxic or other chemically irritating drugsare instilled in the pleural space toobliterate the pleural space and preventfurther accumulation of fluid.
After drug instillation, the chest tube isclamped and the patient is assisted toassume various positions to ensure uniformdrug distribution and to maximize drugcontact with the pleural surfaces. The tube isunclamped chest drainage is usuallycontinued several days longer to preventaccumulation of fluid and to facilitateobliteration of the pleural space by formationof adhesions between the visceral andparietal pleurae. Other modalities oftreatment for malignant pleural effusionsinclude radiation of the chest wall, surgicalpleurectomy, and diuretic therapy. If thepleural fluid is an exudate, more extensivediagnostic procedures are performed todetermine the cause.
The secondary pneumonia developsas a complication of other purulentdiseases. The most common amongthese diseases is an osteomyelitis.Usually the bacterias reach the lungsthrough the hematogenous route.Such pneumonia have a double-sidelocalization and may be followed withany above-mentioned complication(pyothorax, pyopneumothorax).