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"lead": "Нарушение здоровья, относящееся к группе другие болезни плевры",
"description": "Пневмотораксом называют проникновение воздуха в полость плевры, из-за чего возникает частичный (неполный) или абсолютный коллапс легкого, герметичность которого нарушилась. Патология бывает одно- или двухсторонней, травматичной этиологии или спонтанно возникающая. ",
"etiology": "<p>К причинам развития пневмоторакса относят: </p>\r\n<ul>\r\n<li>закрытая травма грудной клетки: повреждение лёгкого отломками рёбер; </li>\r\n<li>открытая травма грудной клетки: проникающие ранения; </li>\r\n<li>ятрогенные повреждения (осложнение после лечебного или диагностического вмешательства) </li>\r\n<li>неспецифический пневмоторакс: разрыв булл (очаговая буллезная эмфизема), кист, прорыв абсцесса лёгкого в плевральную полость (пиопневмоторакс), спонтанный разрыв пищевода; </li>\r\n<li>туберкулёзный пневмоторакс: разрыв каверны, прорывы казеозных очагов; </li>\r\n<li>искусственный пневмоторакс накладывают с лечебной целью при туберкулёзе лёгких, с диагностической для торакоскопии, для дифференциальной диагностики образований грудной стенки. </li>\r\n</ul>\r\n<p>Причинами первичного спонтанного пневмоторакса могут быть: </p>\r\n<ul>\r\n<li>генетически обусловленная слабость плевры, при которой для её разрыва достаточно смеха, приступа кашля, физического напряжения; </li>\r\n<li>врожденная нехватка фермента альфа-1-антитрипсина, вызывающая патологические процессы в легких; </li>\r\n<li>путешествие на самолете (перепады давления), дайвинг, ныряние. </li>\r\n</ul>\r\n<p>Вторичный спонтанный пневмоторакс развивается в связи с легочной патологией: </p>\r\n<ul>\r\n<li>болезни легких, травмирующие соединительную ткань (саркоидоз, лимфангиолейомиоматоз, идиопатический пневмосклероз, туберозный склероз); </li>\r\n<li>злокачественные новообразования (рак легкого, саркома); </li>\r\n<li>болезни дыхательных путей (муковисцидоз, бронхиальная астма в тяжелой форме, ХОБЛ); </li>\r\n<li>инфекционные болезни легких (абсцесс легкого, туберкулез, пневмония на фоне ВИЧ); </li>\r\n<li>системные болезни соединительной ткани, включающие поражение легких (дерматомиозит, ревматоидный артрит, системная склеродермия, полимиозит, синдром Марфана). </li>\r\n</ul>",
"pathogenesis": "<p>Воздух или газ может попадать в плевральную полость снаружи (при открытом повреждении грудной клетки и сообщении с внешней средой) или из внутренних органов (например, при травматическом разрыве лёгкого при закрытой травме, либо при разрыве эмфизематозных пузырей, «булл», при минимальной травме или кашле, спонтанный пневмоторакс). В норме лёгкое расправлено за счёт того, что в плевральной полости, как правило, давление меньше, чем в самом легком. Поэтому при попадании туда воздуха лёгкое спадается. </p>\r\n<p>Различают открытый, закрытый и клапанный пневмоторакс. При открытом полость плевры сообщается с просветом бронхов, при закрытом дефект в плевре закрывается в результате коллапса легкого, воспаления и выпадения фибрина. При клапанном пневмотораксе воздух входит во время вдоха в плевральную полость, но на выдохе дефект закрывается. В результате нарастает внутриплевральное давление с развитием напряженного пневмоторакса, смещением органов средостения в противоположную сторону, нарастанием дыхательной и сердечной недостаточности. </p>",
"diagnostics": "<p>При анализе газов артериальной крови гипоксемия (снижение парциального давления кислорода крови) наблюдается у 75 % больных с пневмотораксом. </p>\r\n<p>Для подтверждения диагноза необходимо проведение рентгенографии грудной клетки (оптимальная проекция — переднезадняя, при вертикальном положении больного. Для диагностики небольших по размеру пневмотораксов КТ является более надежным методом по сравнению с рентгенографией. </p>",
"treatment": "<p>Первая помощь при открыом пневмотораксе - перевести его в закрытый путем наложения стерильной повязки на открытую рану грудной клетки. При наличии клапанного пневмоторакса необходимо срочное проведение плевральной пункции с целью удаления свободного газа, расправления легкого и устранения смещения органов средостения. </p>\r\n<p>Лечение пневмоторакса заключается в его ликвидации путём отсасывания воздуха из плевральной полости и восстановления в ней отрицательного давления. </p>\r\n<p>При закрытом пневмотораксе без действующего сообщения с лёгким достаточно пункционной аспирации газа из плевральной полости при помощи набора для ликвидации пневмоторакса в асептических условиях операционной. Если аспирация иглой оказывается неэффективной, это свидетельствует о поступлении воздуха из ткани лёгкого. В таких случаях выполняют герметичное дренирование плевральной полости («дренаж по Бюлау»), либо создают систему активной аспирации, в том числе с применением электровакуумных приборов. </p>\r\n<p>Открытый пневмоторакс требует первоначальной торакотомии или торакоскопии, ревизии органов плевральной полости, устранения повреждений легочной паренхимы, а затем дренирования плевральной полости и ушивания последней. </p>\r\n<p>При наличии неразорвавшихся булл принимается решение об удалении сегмента или доли легкого и плевродеза (формирование сращений между листками плевры) для недопущения возникновения пневмоторакса. </p>",
"prevention": "<p>Рекомендованная для пневмоторакса профилактика включает в себя: </p>\r\n<ul>\r\n<li>Своевременное лечение заболевания лёгких; </li>\r\n<li>Предотвращение травм грудной клетки; </li>\r\n<li>Профилактика повторных пневмотораксов.</li>\r\n</ul>\r\n<p> </p>",
"clinical_picture": "<p>При возникновении пневмоторакса наблюдается: </p>\r\n<ul>\r\n<li>Резкая, колющего характера, сильно ощутимая болезненность в районе грудной клетки с иррадиацией в брюшину (в область кишечника), шею, плечевой пояс; </li>\r\n<li>Нехватка воздуха;</li>\r\n<li>Неполноценное дыхание, кашель;</li>\r\n<li>Учащение, поверхностность дыхательных движений;</li>\r\n<li>Цианоз кожного покрова;</li>\r\n<li>Бледность лица и верхней части туловища;</li>\r\n<li>Выпирание межреберного пространства над пораженным легким;</li>\r\n<li>Отставание в респираторном акте половины грудной полости со стороны предполагаемой патологии;</li>\r\n<li>Беспокойство, боязнь смерти;</li>\r\n<li>Вынужденное положение тела (на больном боку лежа). </li>\r\n</ul>\r\n<p>Пациент с открытым пневмотораксом принимает вынужденное положение, лежа на поврежденной стороне и плотно зажимая рану. Воздух засасывается в рану с шумом, из раны выделяется пенистая кровь с примесью воздуха, экскурсия грудной клетки асимметрична (пораженная сторона отстает при дыхании). </p>\r\n<p>Спустя несколько часов интенсивность боли и одышки ослабевают: боль беспокоит в момент глубокого вдоха, одышка проявляется при физическом усилии. Возможно развитие подкожной или медиастинальной эмфиземы – выход воздуха в подкожную клетчатку лица, шеи, грудной клетки или средостения, сопровождающийся вздутием и характерным хрустом при пальпации. Аускультативно на стороне пневмоторакса дыхание ослаблено или не выслушивается. </p>",
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"code": "B59",
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"description": "Инфекционное заразное заболевание.",
"etiology": "<p>Возбудитель - Pneumocystis carinii относится к типу простейших, подтип Sporozoa, класс Haplospora. Местом естественного обитания в нормальных условиях являются легкие. Жизненный цикл построен таким образом, что в альвеолярной ткани можно обнаружить 2 основные формы этого микроорганизма: мелкие одноядерные трофозоиты (1-5 мкм) и размножающиеся бинарным делением цисты (10 мкм), имеющие толстую стенку и содержащие от 2 до 8 клеток (1-2 мкм), называющихся спорозоитами. Когда зрелая циста разрывается, спорозоиты либо продолжают цикл развития в альвеолах, превращаясь в трофозоит, либо выходят во внешнюю среду (с капельками слизи при кашле) и, в случае обретения нового хозяина, также включаются в свой цикл развития.Пневмоцисты широко распространены у людей и животных. Передаются воздушно-капельным путем. Известно, что от 1 до 10% здоровых людей являются носителями пневмоцист. </p>",
"pathogenesis": "<p>Заболевания развиваются только у лиц с первичными или приобретенными нарушениями иммунитета. Ведущую роль играют нарушения механизмов клеточного иммунитета. У больных пневмоцистозом отмечается местная и системная продукция антител, не обладающих, однако, протективным действием. Не встречая противодействия со стороны клеточных элементов защиты (в первую очередь альвеолярных макрофагов), пневмоцисты постепенно заполняют всю полость альвеол. При гистологическом исследовании обнаруживают типичный пенистый вакуолизированный альвеолярный <a title=\"Перейти на страницу симптома Выпот\" href=\"../../../symptom/vypot/\">экссудат</a>, содержащий микроорганизмы, белки сыворотки крови и остатки органических веществ. Отмечается выраженная дистрофия альвеолоцитов I типа, репаративная гипертрофия альвеолоцитов II типа. Указанные изменения постепенно приводят к нарушению газообменной функции альвеолярного эпителия и, соответственно, тяжелой (при отсутствии лечения фатальной) дыхательной недостаточности.</p>\r\n<full></full>\r\n<p>Отягощающим моментом является образование участков ателектаза, что усугубляет нарушения вентиляции и газообмена. У ослабленных детей можно обнаружить интенсивный инфильтрат из плазматичеких клеток, что и легло в основу прежнего названия болезни - интерстициальная плазмоклеточная пневмония. Вне ткани легких пневмоцисты практически не обнаруживаются.</p>",
"diagnostics": "<p align=\"justify\">Клинические, физикальные и рентгенологические данные при пневмоцистозе не являются патогномоничными, что затрудняет своевременную диагностику заболевания. Между тем, пневмоцистную пневмонию всегда следует исключать у иммунокомпрометированных пациентов. С целью верификации пневмоцистоза проводится комплекс лабораторных и инструментальных исследований.</p>\r\n<full></full>\r\n<p align=\"justify\">На рентгенограммах и КТ легких в типичных случаях определяется облаковидное понижение прозрачности легочных полей, получившее название «хлопьев снега» или «ватного легкого». Иногда рентгенологические изменения отсутствуют или имеют атипичную картину. С помощью ФВД обнаруживаются признаки дыхательной недостаточности по рестриктивному типу; исследование газового состава крови свидетельствует о гипоксемии.</p>\r\n<p align=\"justify\">Для подтверждения диагноза пневмоцистоза выполняется бронхоскопия с забором бронхиального секрета, трансбронхиальная биопсия легкого, сцинтиграфия легких с галлием-67. Для лабораторной детекции P.carinii микроскопически исследуются окрашенные мазки мокроты, бронхиальный и трахеальный аспират; выполняется гистологическое исследование биоптатов, исследование мокроты методом ПЦР. Проводится иммунологическая диагностика: определение титра противопневмоцистных IgG и IgM в сыворотке крови с помощью РИФ и ИФА.</p>",
"treatment": "<p>Лечение пневмоцистоза проводится в стационаре. Лица с иммунодефицитом и недоношенные дети должны быть помещены в отдельные стерильные палаты с ламинарным воздушным потоком. В большинстве случаев для проведения специфической фармакотерапии пневмоцистоза используется ко-тримоксазол (триметоприм, септрин, бактрим), пентамидин, триметрексат, триметоприм+дапсон, эфлорнитин, атоваквон в течение 2-3 недель. Для устранения побочных эффектов терапии назначают фолиевую кислоту, глюкокортикоиды. Проводится инфузионная терапия (введение гамма-глобулина, гемодеза, глюкозы, плазмы крови, альбумина и др.), кислородотерапия. У больных ВИЧ-инфекцией этиотропная терапия пневмоцистной пневмонии сочетается с высокоактивной антиретровирусной терапией.</p>",
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"clinical_picture": "<p>Пневмоцистоз у детей развивается обычно на 4-6-м месяце жизни (недоношенные, больные рахитом, гипотрофией, поражениями ЦНС) и в более старших возрастных группах (при гемобластозе, злокачественных новообразованиях, СПИДе). Заболевание начинается постепенно - у ребенка снижается аппетит, прекращается нарастание массы тела, появляются бледность и <a title=\"Перейти на страницу симптома Цианоз\" href=\"../../../symptom/cianoz/\">цианоз</a> носогубного треугольника, легкое покашливание. Нормальная в начале заболевания температура сменяется субфебрильной с подъемами до фебрильной. В легких появляются непостоянные мелко- и среднепузырчатые <a title=\"Перейти на страницу симптома Хрипы\" href=\"../../../symptom/hripy/\">хрипы</a>. Появляются <a title=\"Перейти на страницу симптома Одышка\" href=\"../../../symptom/odyshka/\">одышка</a> (до 50-70 в 1 мин), <a title=\"Перейти на страницу симптома Цианоз\" href=\"../../../symptom/cianoz/\">цианоз</a>, <a title=\"Перейти на страницу симптома Кашель\" href=\"../../../symptom/kashel/\">кашель</a> коклюшеобразного характера. Нередко <a title=\"Перейти на страницу симптома Кашель\" href=\"../../../symptom/kashel/\">кашель</a> сопровождается выделением пенистой мокроты, в которой могут обнаруживаться пневмоцисты. Рентгенологически регистрируются очаговые тени разной величины и плотности, дающие картину \"облаковидного\" легкого. В крови обнаруживается лейкоцитоз, умеренная эозинофилия и увеличение СОЭ.</p>\r\n<full></full>\r\n<p>Иногда пневмоцистоз у детей протекает под маской острого ларингита, обструктивного бронхита или бронхиолита. В ряде случаев наступает летальный исход при клинической картине отека легких.</p>\r\n<p>У взрослых пневмоцистоз развивается у лиц, получающих иммуносупрессивную терапию (обычно - кортикостероиды), и у больных СПИДом. При медикаментозной иммуносупрессии заболевание часто манифестируется на фоне снижения дозы кортикостероидов. Продромальный период длится обычно 1-2 нед, а у больных СПИДом он достигает 10 нед. Постепенно появляется субфебрилитет, умеренная <a title=\"Перейти на страницу симптома Одышка\" href=\"../../../symptom/odyshka/\">одышка</a> при физической нагрузке, сухой <a title=\"Перейти на страницу симптома Кашель\" href=\"../../../symptom/kashel/\">кашель</a>, боли в грудной клетке. Через 1-2 нед могут появиться <a title=\"Перейти на страницу симптома Высокая температура 38-42° \" href=\"../../../symptom/vysokaya_temperatura_38-42/\">лихорадка</a>, <a title=\"Перейти на страницу симптома Одышка\" href=\"../../../symptom/odyshka/\">одышка</a> в покое, усиливается сухой <a title=\"Перейти на страницу симптома Кашель\" href=\"../../../symptom/kashel/\">кашель</a> (продуктивный <a title=\"Перейти на страницу симптома Кашель\" href=\"../../../symptom/kashel/\">кашель</a> отмечается редко). При осмотре обнаруживается тахипноэ, <a title=\"Перейти на страницу симптома Тахикардия\" href=\"../../../symptom/tahikardiya/\">тахикардия</a>, <a title=\"Перейти на страницу симптома Цианоз\" href=\"../../../symptom/cianoz/\">цианоз</a>. В легких часто выслушиваются сухие, реже - влажные <a title=\"Перейти на страницу симптома Хрипы\" href=\"../../../symptom/hripy/\">хрипы</a>. Количество лейкоцитов обычно зависит от фонового заболевания. При газовом анализе крови обнаруживают прогрессирующую гипоксемию, повышение альвеолярно-артериального кислородного градиента и респираторный алкалоз.</p>\r\n<p>Пневмоцистная пневмония при СПИДе обычно характеризуется вялым хроническим течением. Первоначально аускультативная симптоматика не выявляется, рентгенологическая картина тоже может оставаться без патологических изменений. По мере прогрессирования заболевания появляются двухсторонние прикорневые инфильтраты, трансформирующиеся затем либо в фокусные, либо интерстициальные изменения. Изредка обнаруживаются солитарные узелки, которые могут кавернизироваться с образованием обширной центральной полости. Причиной абсцедирования, вероятно, является присоединение бактериальных и микозных инфекций.</p>",
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