Localized pneumonia in children
From the cardiovascular system there are almost no deviations from the norm: heart tones are clear, the pulse is correct, good filling. The gastrointestinal tract is seldom affected, and only occasionally acute parenteral dyspepsia is associated. This form can be regarded as an indicator of the child's high reactivity. It is more common in children with satisfactory nutrition and breast-fed or mixed-feeding, at an age after 3-4 months of life. The temperature curve with these forms of pneumonia is of different nature, but more often it is of the type of continua. The fall in temperature is usually lytic, but sometimes it is also critical. In the period before the application of sulfonamides, the duration of the disease was determined in 5-7 days. These forms of pneumonia have always yielded an insignificant percentage of deaths. Evidence of good resistance of the organism to localized forms of pneumonia can be considered that, in spite of the isolation from the patient's sputum in a significant percentage of cases of highly virulent pneumococcus, the reaction of the organism was limited only by the local process in the lungs.
Sufficient resistance of the organism is also confirmed by minor violations of tissue respiration and metabolism. With such forms of pneumonia, the level of respiratory enzymes and coenzymes( glutathione, carbon anhydrase, vitamins C and B,) is usually reduced slightly. Blood gases and the value of arteriovenous difference also indicate a very insignificant degree of oxygen deficiency, which is very quickly eliminated. Along with this, with such a seemingly favorably flowing form of pneumonia, a significant depletion of the child's body with ascorbic acid is observed, but with recovery, the content of ascorbic acid in the blood is restored fairly quickly even without its introduction from the outside, which also characterizes the high reactivity of the organism.
This high reactivity is reflected in the nature of the anatomical process in the lungs. Usually it is limited to a radical infiltrate or a more isolated focus( focal pneumonia), mainly in the posterior parts of the lungs and more often to the right.
As mentioned above, there are no sufficient grounds for assigning these pneumonias to bronchopneumonia. On the contrary, the known time interval separating the catarrh of the respiratory tract from the onset of pneumonia, and the extremely frequent radical localization of it, speak of lymphogenous rather than bronchogenic spreading of the process with primary localization, perhaps in the root of the lungs. In children weakened, especially re-ill with pneumonia, the disease is less pronounced. Qatar of the respiratory tract can be prolonged for a longer time, accompanied by a subfebrile condition, and the development of the focus can not give a bright temperature reaction. Such forms are much more difficult to diagnose, because lethargy, blurred dyspnoea and weak coughing can give rise to a suspicion of a specific tuberculous process. Objectively, these forms have few definite signs that prove the change in lung tissue: almost always in the lungs on a background of dry and wet wheezing, percussion sound gives a very slight blunting, only with a slight tympanic tinge, with predominant localization in the paravertebral regions;when you listen, breathing for a long time remains harsh and only gradually takes a bronchial shade with the appearance of bronhophonia. The most evident is the change in the character of wheezing, which in the center of blunting takes on a sonorous, crackling character. With a deep locus of the focus, percussion and auscultation, until the resolution of the process, do not give convincing results, in the presence of dyspnoea and coughing, it makes one suspect that pneumonia, which in most cases is confirmed by X-ray examination.
Response from the blood with a localized form is different. Along with leukocytosis, with a neutrophilic shift of the formula to the left and accelerated ESR, an almost unchanged pattern of blood is found, especially with a sluggish course.
Currently, in connection with the use of sulfonamides, the localized form of pneumonia has changed its course enormously, and the disease sometimes lasts only 2-3 days, provided that the treatment is correct.
Large and small focal pneumonias can be segmental and usually occur more severely than diffuse focal.
The issue of segmental pneumonia is adequately covered in the work of both pathologists and clinicians. The incidence of individual lung segments in pneumonia of early childhood, according to pathologists and clinicians, is not the same. According to the data of the children's clinic of the Moscow Medical Institute, the II, VI, IX and X segments are more often affected in acute pneumonia, less often I, VIII and V. In prolonged and chronic pneumonia, the process is more often localized in the VI, IV and V segments.
In the first months of a child's life, polysegmental pneumonia develops, usually bilateral, and after the first year - both polysegmentary and monosegmentary. Monosegmentary pneumonia in early childhood pass like a croupier pneumonia, sometimes with a rather severe general intoxication and a violation of the cardiovascular system. X-ray in the background of emphysema usually reveals a fairly clear shadow occupying a certain segment.
Polysegmentary pneumonia, ie, a simultaneous lesion from 2 to 4-5 segments, was observed in the majority of children in the first year of life who had pneumonia. The localization of such pneumonia in the II, VI, IX and X segments corresponded to the so-called paravertebral pneumonia( in the former terminology).
According to AI Strukov and IM Kodolova, polysegmental pneumonia mainly indicates the anatomical isolation of segments in children of the first months of life and is explained, obviously, by the functional and anatomical features of segmental bronchi, ie, their level, angle of separationfrom the lobar bronchi and their direction.
Polysegmentary pneumonia, in contrast to monosegmentary, proceeds either as catarrhal or as interstitial. In the latter case, they give an especially severe clinical picture. With polysegmentary pneumonia, there are usually severe respiratory and tissue oxidative processes, and the use of antibiotics and sulfonamides does not give the desired effect and the process is consistently extended to other segments, accompanied by a deterioration in the general condition.
According to E. E. Friedman, with histological examination of segmental lung lesions within one segment, inflammatory exudate is usually homogeneous( the so-called primary segmental pneumonia).However, in some cases, it may be heterogeneous and uneven, with a sequential development of the process by the type of drainage pneumonia by perifocal spread( secondary segmental pneumonia).
Diagnosis of polysegmental pneumonia in early childhood is extremely difficult, and in most cases a diagnosis of paravertebral pneumonia is clinically made. Only with X-ray examination can the true nature of pneumonia be established.
In early childhood, polysegmental pneumonia is very difficult and sometimes fatal.
Under the supervision of the children's clinic of the Moscow Medical Institute were children of the first months of life with extremely severe forms of general candidiasis, fungal sepsis and fungal pneumonia. One child from this number died on admission to the clinic. Clinical diagnosis - sepsis, fungal universal candidamycosis, bilateral paravertebral polysergment pneumonia, mainly interstitial. Anatomical diagnosis confirmed polysegmentary pneumonia and universal candidiasis.
The preferred place of congestive pneumonia is considered to be the VI segment, it often develops chronic pneumonia and bronchiectasis. According to Yu. F. Dombrovskaya, a decrease in the transparency of pulmonary fields and an increase in the bronchoconstrictive pattern after a prolonged pneumonia are observed radiographically mainly in the VI, IV and V segments.
Recognizing the specific clinical significance of the localization of processes in individual segments, it should nevertheless be pointed out that the issues of the etiology and pathogenesis of both monosegmental and polysegmentary pneumonia need further study. Based on observations, they can be attributed to the reaction of the organism to both localized forms and toxic ones.
Read more - Treatment of pneumonia in children