Symptoms of pneumonia after a stroke. Pneumonia in bedridden patients - causes, treatment and prevention of the disease. Features of drug therapy

A bedridden patient is a great test for his entire family. It must be passed, giving your elderly relative a chance to live longer. To do this, it is necessary not only to provide for his physiological needs, but also to pay attention to the slightest changes in his condition. Because under any of them, even if it is a “little thing” like constant drowsiness, congestive pneumonia can be hidden - a disease that takes the lives of bedridden patients.

Congestive (hypostatic) pneumonia is an inflammation of the lung tissue that develops initially in those areas where blood and tissue fluid accumulate and cannot circulate normally. These areas become "easy prey" for infection, which of them is able to spread to the rest of the lungs. Bedridden patients suffer from congestive pneumonia most often. The risk of getting sick with it increases in old age, with heart disease and previous surgeries. Masquerading as the symptoms of the underlying disease, hypostatic pneumonia can be recognized late, often leading to death. Only close cooperation of a competent doctor and caring relatives gives chances for the timely start of treatment of pathology.

How the lungs work

In order for oxygen to enter the vessels, it must go a rather long way from the nose to the smallest bronchi, and eventually get into the alveoli - the main structures in which gas exchange takes place. In their structure, the alveoli are similar to "sacs", open on the side where air enters them. The walls of the alveoli are a membrane. On the inside it is filled with air, and on the outside it borders on blood vessel. Oxygen passes through the membrane into the blood, and carbon dioxide enters the “pouch” from the blood, which should be released on exhalation. If the wall of the alveolus thickens or fluid appears between it and the vessel, gas exchange worsens.

But even normally, different parts of the lungs are ventilated, that is, they are supplied with air, unevenly. In an upright position, air best enters the lower sections of the lungs, where the elastic lung tissue is well stretched by the diaphragm, and this is facilitated by movable ribs. If a person lies on his back, intra-abdominal pressure rises. But this not only reduces ventilation in the lower parts of the lungs, but also leads to a decrease in inhaled volumes.

If a person has emphysema, pneumofibrosis, or bronchial asthma, then, even when he is not lying down, breathing in different parts of the lungs becomes more uneven, and this creates conditions for microbes to live in poorly ventilated sections.

But in order for the body to receive a sufficient amount of oxygen, air entering the lungs alone is not enough. You also need to ensure that the lungs are sufficiently supplied with blood.

Blood to the lungs comes from the pulmonary artery. The path from the heart to the smallest pulmonary capillaries is made by blood not under pressure and not because of pushing it by the heart muscle - only along a pressure gradient: it flows from the highest pressure to the lowest. Therefore, blood flow is highly dependent on the position of the body: in a standing position, the lower sections of the lungs are best supplied with blood, and when lying on your back, more blood accumulates in areas closer to the back.

At rest, in a healthy person, blood flows through only half of the pulmonary capillaries. At physical work pressure in the pulmonary arteries increases, and more vessels begin to work. The alveoli that communicate with them must get access to air - then breathing can provide the person's need for oxygen.

When a person is constantly lying down, especially if he does not change position in bed, it is difficult for blood to "get" from the lungs to the heart against gravity. There is stagnation of blood, which leads to the expansion of local capillaries. Expanded and overflowing with blood vessels become heavy and squeeze the alveoli. This is the beginning of congestive pneumonia. If the situation does not change, the liquid part of the blood penetrates from the capillary into the alveoli and the tissue that lies between the alveoli. The infection quickly penetrates here, which can also spread to neighboring parts of the lungs. If the situation is not changed, or only the destruction of the infection is carried out, the affected lung tissue is replaced by connective tissue, and is permanently switched off from breathing.

Causes of congestive pneumonia

As can be seen from the previous section, congestive pneumonia in bedridden patients develops due to their immobile position, causing stagnation in the pulmonary circulation. The disease may develop in early dates(for 2-4 days) after a forced horizontal position, but its appearance can be delayed (for 14 days and later).

The risk of developing congestive pneumonia in the early stages is higher in older people who suffer from:

• angina;
• cardiosclerosis;
• heart defects (especially if it is mitral valve stenosis);
• heart rhythm disturbances: extrasystole, atrial fibrillation;
• arterial hypertension arising from various causes;
• lung diseases: bronchial asthma, bronchiectasis, emphysema;
• diabetes mellitus;
• chronic pyelonephritis;
• diseases of the bone skeleton: kyphosis, scoliosis in the thoracic region, deformities of the ribs,

as well as those people who have recently undergone any operation, which is explained by the fact that the postoperative wound hurts, so the person tries to breathe more shallowly, thereby increasing congestion in the lungs. For these categories of people, it is important to start the prevention of congestive pneumonia as early as possible, and also to call a doctor every time the condition changes and exclude the development of this particular disease in the first place.

In addition to a poor outflow of blood from the pulmonary vessels, congestive pneumonia requires the addition of an infection.

Microbes that cause inflammation of the fluid released from the pulmonary capillaries are usually:

• streptococci, in particular pneumococcus;
• hemophilic bacillus;
• staphylococci.

The favorite localization of congestive inflammation is the lower parts of the right lung, but with a combination of immobility and one of the above diseases, the pathology can become bilateral.

Why is congestive pneumonia dangerous?

The danger of the disease lies in the fact that those parts of the lungs where the fluid has leaked into the alveoli and the tissue between them cease to participate in breathing. In addition, when a person continues to lie against the background of the development of this pathology, it becomes difficult for him to cough up sputum (and the cough reflex does not always occur). As a result, it clogs the bronchi, and an even larger section of the lung ceases to participate in breathing.

Accession of infection leads to poisoning of the body of an elderly person with the waste products of microbes. This is toxic to the heart, aggravating its damage. In addition, intoxication leads to a decrease in appetite, and as a result, a person refuses to receive proteins and vitamins necessary to fight infection and restore lung tissue.

Other dangers of congestive pneumonia in bedridden people are complications such as exudative pleurisy (effusion of inflammatory fluid outside the lungs, into the pleural cavity) and pericardial effusion (effusion of inflammatory fluid into the heart sac). As a result of the first complication, respiratory failure is further exacerbated. Exudative pericarditis, as a result of squeezing the heart with fluid, leads to a deterioration in the work of its muscles.

Symptoms

Congestive pneumonia is a very insidious disease for a bedridden patient. Arising against the background of the pathology that chained a person to bed, it disguises itself as its symptoms. So, in a person who has had a stroke, there is a little more inadequacy or lethargy than before, or a person with a hip fracture due to osteoporosis began to complain of pain in the chest. Such symptoms are not always noticeable to relatives who spend most of the day at work, and are not realized by the patient himself.

More obvious signs of congestive pneumonia, which, unfortunately, sometimes appear already in the later stages of the disease, are:

• an increase in body temperature: it can be small, up to 38 ° C, but in some cases (less often) it can exceed 38.5 ° C;
• moist cough. If a person is able to cough up, and not swallow, sputum, then it is clear that it has a mucopurulent character, streaks of blood may come across there;
• weakness;
• nausea;
• lack of appetite;
• sweating.

Congestive pneumonia is accompanied by symptoms from the cardiovascular system: a violation of the heart rhythm, its increase, the appearance of interruptions or pain in the heart. The disease can also be manifested not by coughing or fever, but by nausea and diarrhea.

The fact that a significant part of the lungs has ceased to participate in breathing is evidenced by an increase in breathing of more than 20 breaths per minute at rest (not when a person eats or performs some kind of effort), a feeling of lack of air. If pneumonia is extremely difficult, the person's consciousness is oppressed: he becomes extremely drowsy, may stop waking up, not answering questions, tossing and turning in bed and saying incoherent phrases. In this state, breathing becomes either extremely rare, or arrhythmic, or very frequent. These symptoms indicate that urgent hospitalization is needed, but, unfortunately, the prognosis here may be unfavorable.

Diagnostics

A general practitioner who hears wheezing or crepitus in the lungs (especially in the lower sections) can suspect congestive pneumonia. But the diagnosis is made only on the basis of x-rays. It is performed in multidisciplinary clinics or a polyclinic at the place of residence, where there is an Arman apparatus or a stationary X-ray machine adapted for bedridden patients.

The patient can be taken to the x-ray using any of the paid medical services (or paid " Ambulance""), equipped for the transportation of bedridden patients. Although the best option is hospitalization in a hospital, where an X-ray will be performed, and doctors and qualified personnel will monitor the condition of your relative.

In order to select the necessary antibacterial drugs, the patient must pass sputum tests. Both analyzes are collected in sterile jars: the first is sent to the clinical laboratory, the second to the bacteriological laboratory. With the help of clinical analysis, the nature of inflammation is determined, cancerous or tubercular cells are detected. Bacteriological analysis of sputum makes it possible to establish the type of microbe that caused pneumonia, as well as to select antibiotics that will act specifically on it.

The examination package also includes:

• general blood and urine tests;
• determination of blood gases;
• biochemical blood test;
• Ultrasound of the heart.

Treatment of congestive pneumonia

The disease requires complex therapy, since its development disrupts the activity of many internal organs.

First of all, doctors must determine if the oxygen balance has been affected. If this happens, the patient is hospitalized in the hospital where there is a department intensive care and start treatment:

• if the balance is not strongly disturbed, breathing with humidified oxygen using a mask is prescribed;
• if severe respiratory failure has developed, the patient is put into anesthesia, against which he is transferred to artificial lung ventilation. This is the only way to supply oxygen to the alveoli at the right pressure.

The second direction of therapy is the appointment of antibacterial drugs. Initially, before obtaining the results of a bacteriological study (bacteriological examination) of sputum and blood, broad-spectrum drugs are prescribed. After 5 days, if necessary, change antibiotics, use those to which the sputum microflora turned out to be sensitive. The optimal route of administration of these drugs, at least the first 5-7 days, is intramuscular or intravenous.

In parallel with taking antibiotics, even before the results of bakposev, antifungal agents are prescribed. This is dictated by the fact that, according to statistics, most congestive pneumonia is caused not by bacteria alone, but by a combination of bacteria and fungi.

The next mandatory component of therapy is the appointment of drugs that dilate the bronchi: this way you can facilitate the drainage of sputum and improve airway patency for oxygen. Bronchodilators may be given by inhalation if the person is not on a ventilator. The intravenous route of their administration is also used.

Also, with congestive pneumonia, drugs are prescribed that improve the supply of oxygen to the blood, as well as facilitate the work of the heart. These are diuretics, expectorants, antioxidant and immunomodulating agents, cardiac glycosides.

If the bedridden patient is conscious, he is asked to cough up sputum. If he is on artificial ventilation of the lungs, or his cough reflex is depressed, he is given daily bronchoscopy - cleaning of large and medium bronchi using a special device equipped with optics (that is, the doctor sees what the condition of the bronchi is) and a system for vacuum removal of bronchial discharge .

With congestive pneumonia, the recumbent must necessarily perform vibration massage, turns from side to side, and also, after stabilization of the condition, laying on the stomach (in this position, sputum is better removed).

If complications such as exudative pleurisy or pericarditis have developed, a puncture of the pleura or pericardium is performed in a hospital setting, followed by removal of stagnant fluid.

When the patient is conscious and does not need to be transferred to artificial lung ventilation, he must be prescribed breathing exercises. These are classes on the complexes of Strelnikova, Buteyko, inflating balloons, blowing out the candles, exhale through the tube into the water.

During treatment, it is imperative to provide the patient with a complete and rich in vitamins and proteins. If the patient is conscious, and his swallowing and chewing reflexes are preserved, it is recommended to eat grated meat products, steamed or boiled. If the patient cannot swallow or is on machine breathing, he is fed through a probe - a tube inserted through the nose into the stomach, and enpits, second broths, vegetable broths with streaks of meat are used for nutrition. As a drink, such patients are given fruit drinks, a weak decoction of wild rose, a decoction of thyme, linden tea.

When the patient's condition is stabilized, in addition to active turns in the bed, he will need vibration massage of the chest, back massage, physiotherapy.

Prevention

To protect a bedridden relative from congestive pneumonia as much as possible, follow these simple rules:

1. Be sure to help him change his body position every 2 hours. Don't forget to put it on your stomach.
2. After laying an elderly bedridden patient on his stomach 3 times a day, take "Camphor alcohol" and rub the areas of the lungs, bypassing the area of ​​​​the spine.
3. In the position on the stomach, conduct a vibration massage of the lungs. To do this, place the palm of one of your hands on the chest of a relative, from the back, and lightly tap on it with the fist of the other hand. The direction of these movements is from the lower sections to the upper ones.
4. Once every 3-4 days, put mustard plasters on the back of the patient or perform cupping massage.
5. Breathing exercises should be carried out daily: according to Buteyko, according to Strelnikova, or prescribed according to the best practices of the attending physician.
6. A bedridden patient should not be supercooled, so he should be dressed warmly enough.
7. It also cannot be overheated.
8. The room in which the patient is located should be ventilated (at the same time, he should not be in a draft) and quartzize 2 times a day. Daily wet cleaning is a must.
9. A bedridden patient should have a complete diet rich in proteins, microelements and vitamins.
10. A lying relative must be periodically examined by a doctor.
11. Every day you need to measure the temperature and monitor the patient's condition: his adequacy, drowsiness, pulse, pressure and the number of breaths per minute. If your condition changes, you need to consult a doctor.

Pneumonia in stroke is the leading cause of death in patients with stroke. Immediately after a stroke, every fourth patient, and within a month, every eighth begins pneumonia. What are the causes, symptoms, prognosis and treatment for this diagnosis?

Reasons for development

Due to a stroke, left without oxygen for a while, certain areas of the brain are affected. Because of this, there may be a violation of the functions of blood flow in the pulmonary circle, dysfunction of the diaphragm and the drainage system of the lungs.

All this, as well as a depressed immune system, allows sputum to accumulate in the lungs and airways, causing inflammation and creating a favorable environment for the reproduction of pathogenic microorganisms.

The position of the patient lying on his back and the absence of a productive cough accelerates the dynamics of the disease, which makes expectoration of sputum almost impossible.

Patients at risk:

These are not all the causes of foci of inflammation in the lungs. Thus, cases of bacterial infection of patients after the use of invasive methods of resuscitation, poor disinfection of air conditioners and humidifiers, and also in the absence of the necessary patient care are not uncommon.

But even in the presence of any of the above factors, timely preventive measures can prevent the development of pneumonia. But it can be difficult to recognize the clinical picture, as well as to make a prognosis of the course of the disease.

Symptoms and diagnosis

It is almost impossible to notice the manifestations of pneumonia in the early form (which occurred in the first 72 hours after a stroke). This is due to such a disturbed general condition after a stroke that the clinical picture of pneumonia is quite blurred and difficult to diagnose.

But there are still some typical symptoms:

• a slight increase in overall body temperature;
• wheezing and nonspecific sounds (gurgling, gurgling) when breathing;
• obvious changes in the tissues of the lungs on x-ray;
• In blood tests, as a rule, there is an increase in the level of leukocytes.

Cough in most cases is absent or mild and ineffective.

But with a late form of pneumonia (the onset occurs on days 14-30), the symptoms are more pronounced:

At the slightest suspicion of the occurrence of pneumonia, the patient is taken a sputum sample to identify the pathogen, and the doctor will also recommend an x-ray examination (computed tomography or traditional plain chest x-ray).

If it is possible to notice signs of pneumonia in the early stages, then timely treatment started gives hope for a positive prognosis.

If the use of x-rays is not possible due to the severe course of the underlying disease, then the diagnosis is established on the basis of general symptoms, as well as available laboratory data. After confirming the diagnosis and prescribing treatment, a blood test is collected daily and a number of other general studies are performed to monitor the dynamics of the disease.

Treatment

The appointment of drug therapy should occur immediately after the diagnosis is confirmed. Antibiotics with a broad spectrum of activity are used at the beginning of treatment, and after the pathogen and its resistance to drugs are accurately established, the prescription of drugs may change.

The most common causes of inflammation are:

• gram-negative microflora;
• fungal infection;
• Pseudomonas aeruginosa;
• anaerobic bacteria.

Depending on the type of pathogenic microflora, treatment can take from 10 to 45 days.

At the same time, they are not limited to the appointment of monotherapy (that is, only one drug). Usually, expectorants, sputum-thinning, diuretic drugs, as well as drugs that excite the cough center (if the patient's condition allows it) are added to the main drug.

If pneumonia was caused by food entering the pulmonary tract, vomiting, or a swallowing reflex is impaired due to a stroke, then food is administered to the patient directly into the stomach through a probe. But at the same time prerequisite is the treatment of the mouth and teeth several times a day with antimicrobial solutions.

In severe cases, with a large amount of accumulated sputum, it may need to be removed invasive methods(using a long needle and syringe) using local anesthesia. This procedure can be repeated several times until the condition improves.

All drugs in the first days are administered mainly intravenously, and then gradually move to oral administration.

Also, along with drug therapy, additional procedures are carried out to increase the effectiveness of coughing and expectoration of secreted mucus:

• special vibration massage by manual or hardware method;
• breathing exercises;
• changing the position of the patient every 2.5-3 hours.

IN modern methods treatment, it is possible to use immunomodulating drugs, as well as agents that promote detoxification.

Supportive procedures also include physiotherapy with the use of bronchodilators.

With adequate and timely treatment, the prognosis is quite favorable. But what older man the less chance of a positive outcome. So, according to statistics, every 10 cases of pneumonia after a stroke in people old age ends with death.

How to avoid pneumonia?

Proper and meticulous care of a stroke patient can reduce the risk of pneumonia.

Performance exercise should begin immediately after the permission of the doctor, so the cough will become more productive, and blood circulation in the small circle will improve significantly. This approach is one of the most effective methods prevention and elimination of congestion after pneumonia.

A stroke in itself is a serious disease that can easily make a bed invalid out of a person. What can I say, when after one "hit" on health follows a second, no less serious - pneumonia. The congestive variant of this disease most often develops, which is a complication of a previous stroke.

According to statistics, the incidence of pneumonia after a stroke is from 35 to 50%. Approximately 15% of cases of complications of pneumonia is the cause of death. It would seem that a person survived after one illness, but could not cope with the second. Any pneumonia with a stroke has its own causes, it makes sense to deal with them in more detail.

Any disease, including pneumonia after a stroke, has its own causes and risk factors. Such knowledge will help prevent complication and prevent its occurrence in principle.

Often with inflammation of the lungs after a stroke, elderly and senile people experience. Their normal drainage function of the lungs is disturbed, and after a stroke, sputum separation is practically absent, especially if the disease is severe. The risk of pneumonia increases significantly after a person is 65 years old.

Excess weight itself is a predisposing factor for the development of stroke. In the case of a complication in the form of pneumonia, the chances are much higher. Pneumonia can occur in people who had chronic forms of heart and lung disease before the stroke.

After a stroke, a person can often be in a coma, which contributes to the development of a congestive process in the lungs. The cause of this condition is a violation or complete absence of outflow of sputum. A similar condition occurs with prolonged artificial ventilation of the lungs, which is carried out in the absence of spontaneous breathing. Often a week is enough for pneumonia to develop. Sometimes, even in the mind, the patient is on bed rest, which contributes to stagnant processes in the pulmonary system.

Development mechanism

It is no secret that the prognosis after a stroke is often sad. There are some reasons that trigger the pathological mechanism of the development of the disease. They consist:

• in an oppressed mind for a certain time;
• central respiratory dysfunction;
• lack of active movements;
• violation of the blood supply to the lungs.

The degree of damage depends on the massiveness of the damage to the brain tissue, as well as the place where the hemorrhage or blockage of the vessel occurred. As a result, the function of sputum drainage from the lungs suffers in some patients. Reduces or absent cough reflex or urge to cough, it is he who is protective and promotes sputum discharge. There is a replacement of microorganisms with more aggressive ones that can cause disease. Further, it is just a matter of time and the disease does not take long to wait, the inflammatory process develops rapidly.

Other factors

But not always artificial ventilation of the pulmonary system after a stroke is the cause of the development of the disease. Often an infection joins, which is constantly in the hospital, especially in the intensive care unit. The level of immune protection also decreases, the body is not able to resist infection.

Symptoms of the disease

Diagnosing pneumonia after a stroke, even at the present stage of development of medicine, can be very difficult. The problem remains open for the next generations of doctors. It is difficult diagnosis that is the factor that contributes to human mortality. In general, manifestations can be easily veiled by the primary disease.

Some of the symptoms may turn on:

• the temperature rises moderately;
• breathing is disturbed according to the type of pathological variant of Cheyne-Stokes or Kussmaul;
• as a result of a violation of the cough reflex, there is no sputum separation;
• on auscultation heard wheezing of various calibers.

Features of aspiration pneumonia

This variant develops as a result of food particles entering the respiratory tract. After such a segment of the lung ceases to perform its function normally, and the bacteria that are there are rapidly developing.

With aspiration pneumonia, the manifestations resemble intoxication or poisoning. Initially draws on a cough, which is excruciating. The hilar variant of aspiration pneumonia is difficult to diagnose. joins heat, cough becomes painful. A dangerous option is the situation when a large bronchus is blocked by pieces of food.

Late symptoms

Diagnosis of the late version of the disease is much easier. To make a proper diagnosis, a doctor will need certain symptoms. Among them it is worth noting:

• rapidly developing fever, numbers above 38 degrees;
• in a blood test, an increased number of leukocytes is of interest;
• pus is present in sputum or discharge from the trachea;
• pathological changes in the lung tissue are clearly visible on the x-ray.

Final diagnosis

In addition to the symptoms, there are some standards for instrumental diagnosis of the problem. Initially, it is worth listening to the chest with a phonendoscope, if there is a suspicion of pneumonia, then an X-ray examination of the lungs is prescribed. In the picture, in addition to stagnation, the most intense focus of shading will be clearly visible.

The sputum or washings from the bronchi are subject to research. This analysis will determine the type of pathogen, after which its individual sensitivity to antibacterial drugs is carried out. This analysis will later allow the doctor to prescribe an effective treatment.

Treatment

In case of pneumonia, which could complicate a stroke, measures are aimed at eliminating hypoxia as soon as possible. The tissues should receive more oxygen, this is done with the help of artificial ventilation of the lungs or the use of oxygen pillows. It is necessary to pay attention that pulmonary edema often joins, which is why prevention of this condition is carried out.

In parallel, the treatment of the underlying disease is carried out, which is prescribed by a neuropathologist. After establishing the type of pathogen and its sensitivity to antibiotics, appropriate drugs are used. Prior to this analysis, broad-spectrum antibacterial drugs are indicated. The dose of the antibiotic is selected individually, but, as a rule, they are used in large quantities.

Diuretics are mandatory, they help reduce swelling and prevent pulmonary edema. Cardiac preparations and expectorants are indicated. If there are problems with expectoration due to its viscosity, the doctor may prescribe drugs to thin it.

Additionally

After stabilizing the condition for a stroke, physiotherapy is recommended for a person. Excellent helps to remove sputum electrophoresis with potassium iodide. Exercise therapy is also shown under the guidance of an instructor, it is mainly aimed at restoring breathing.

Even in bed, the doctor may recommend breathing exercises to a person. If the patient is able to breathe on his own, then in bed he is recommended to inflate balloons. Special drainage positions are also used to help expel sputum from the lungs. Massage in the acute period is undesirable, but in a mild form it helps to remove sputum and is carried out by a massage therapist.

Prevent pneumonia

When there is an understanding of the mechanism of the development of the disease, it is possible to prevent the development of the disease. Based on this, certain preventive measures were developed, the observance of which will reduce the risk of developing the disease. An approximate list of them can be presented as follows:

1. It is worth reducing the pathogenic factor, because the risk of developing the disease largely depends on medical workers, the quality of their performance of their duties. In the intensive care unit, in addition to processing instruments and surfaces, sanitation of the bronchial tree is mandatory.
2. It is required to carefully observe the rules of hygiene, including personal. Medical workers it is worth adhering to the rules of asepsis and antisepsis.
3. The tube that is used for ventilation of the lungs must be for individual use and after use it is processed and disposed of. The same applies to the rest of the instruments that can come into contact with the human respiratory system.

Prevention

There are some steps you can take to help prevent the development of pneumonia after a person has had a stroke. Some moments will require efforts from the carer and staff, but then they will fully justify themselves.

Initially, it is worth ensuring a constant supply of fresh air. This can be done by ventilating the room, but with certain precautions to prevent hypothermia. A person should be covered with a blanket, and in the cold season with several.

Oral hygiene is mandatory, when a person is unable to cope with it himself, those who care for him help him. To prevent stagnation, the position in bed changes every two hours. In the normal state of the patient, he is given a semi-recumbent position at an angle of 45 degrees.

Additionally, breathing exercises are shown, which is carried out no earlier than one and a half hours after the last meal. It is useful to inflate baby balloons. Additionally, a special massage is performed for about three sessions throughout the day.

As the symptoms of a stroke regress, a person must be activated, first in bed, and then within the ward. This approach will prevent the accumulation of sputum and prevent congestion.

For citation: Piradov M.A., Ryabinkina Yu.V., Gnedovskaya E.V. Pneumonia in patients with severe stroke // BC. 2008. No. 26. S. 1718

Pneumonia is the most common and dangerous infectious complication of severe stroke. It occurs in half of patients and in 14% of cases is the main cause of death.

The high incidence of pneumonia in severe forms of stroke is due to deep depression of consciousness that appears almost from the first day, central respiratory and swallowing disorders, and hemodynamic changes in blood flow in the lungs. The vast majority of patients with severe forms of stroke in the intensive care unit (ICU) develop "hospital" or so-called nosocomial pneumonia. This term refers to pneumonia that developed 48 or more hours after the patient was admitted to the hospital, with the exclusion of infectious diseases with lung damage, which could be in the incubation period at the time of hospitalization.
Highly virulent flora with rapidly increasing resistance to traditional antibacterial medicines leads to the development of severe forms of pneumonia with high mortality rates. An additional factor there is a need for prolonged mechanical ventilation, while the incidence of pneumonia increases by 6-20 times. The risk of ventilator-associated pneumonia, the so-called ventilator-associated pneumonia (VAP), increases significantly with increasing ventilator time. The occurrence of pneumonia in severe stroke increases the length of stay of patients in neuro intensive care units by an average of 10 days.
Etiology and pathogenesis
The main cause of pneumonia in severe stroke is a bacterial infection, the causative agents of which are characterized by severe pneumotropism. The main pathogens are Pseudomonas aeruginosa, Enterobacter, Klebsiella, Escherichia coli, Proteus. Often there are also Staphylococcus aureus, streptococcus pneumoniae, less often anaerobic flora.
According to our data, up to 20% of pneumonias that develop in patients with severe stroke almost immediately after hospitalization (early pneumonia) are caused by gram-negative flora. Pneumonia that occurs after 3 days in the ICU - late pneumonia - in more than 50% of patients is also caused by gram-negative strains.
There are some differences in the pathogenesis of early and late pneumonia. In the development of early pneumonia, violations of corticovisceral regulation are of decisive importance. The rapid development of early pneumonia in stroke, its predominant occurrence in patients with localization of the focus in the area of ​​​​the location of higher vegetative centers or with a secondary effect on the hypothalamus and stem structures, the presence in the lungs of patients with signs of circulatory disorders in the form of plethora, hemorrhages and edema confirm the role of central disorders in the origin of this complication. In the development of late pneumonia, the hypostasis factor plays a decisive role.
With the development of VAP in terms of less than 7 days from the start of mechanical ventilation, the causative agents of pneumonia are pneumococci, Haemophilus influenzae, Staphylococcus aureus and anaerobic bacteria. With the development of VAP in more late dates after the start of IVL greater value acquire drug-resistant strains of enterobacteria, Pseudomonas aeruginosa, Acinetobacner spp. and methicillin-resistant strains of Staphylococcus aureus (MRSA). Sudden outbreaks of pneumonia caused by Legionella pn. are primarily associated with infection of humidifiers, inhalers, tracheostomy tubes, tap water, and air conditioners. In patients receiving long-term antibiotics or glucocorticoids, pneumonia may be due to fungi (eg, Aspergillius spp.).
Risk factors for the development of pneumonia in severe stroke are: the level of consciousness on the Glasgow Coma Scale less than 9 points, dysphagia, tracheal intubation, mechanical ventilation for more than 7 days, prolonged hospitalization, age over 65 years, the presence of chronic pulmonary and heart diseases, the use of H2-histamine blockers receptors, smoking, obesity, hyperglycemia, unbalanced diet, uremia.
The main route of entry of microorganisms into the respiratory tract in patients with severe stroke is the bronchogenic route. It is associated with microaspiration of the contents of the nasopharynx and stomach due to bulbar disorders, inhibition of the cough reflex and the reflex that provides reflex spasm of the glottis.
Extensive brain damage (more than any other critical condition) is accompanied by damage to the nonspecific defense mechanisms of the body, including local cellular and humoral immunity, which also facilitates the bronchogenic penetration of microorganisms into the respiratory sections of the lungs. The change in the composition of the normal microflora of the upper respiratory tract to a highly virulent and very often resistant to traditional antibiotics microflora contributes to the rapid infection of the lungs.
Of great importance is the violation of the drainage function of the respiratory tract: a decrease in the rate of mucociliary transport, which develops from the first hours of a stroke, which is often accompanied by increased production of tracheobronchial secretions. In addition, infection through ventilators and during the necessary invasive procedures (sanitation of the tracheobronchial tree, fibrobronchoscopy), infection of the tracheostomy wound (or wound infection of the tracheostomy) increase the risk of invasion of microorganisms. It should be remembered that in each specific case, the features of the pathogenesis and clinical course are determined by the properties of the pathogen, the initial state of the patient and various body systems involved in inflammation, and the body's response to infection.
Clinic and diagnostics
Clinical diagnosis of pneumonia in severe stroke is still a challenge and continues to be developed. Difficulties in establishing a diagnosis are associated with both overdiagnosis and underdiagnosis, and late diagnosis is one of the reasons for the development of complications and death.
In patients with severe stroke, the clinical signs of pneumonia are masked by symptoms of the underlying disease. Diagnosis of early pneumonia is especially difficult, since its clinical manifestations are hidden behind the severity of cerebral and focal neurological symptoms. Diagnosis of late pneumonia against the background of an improving neurological condition of the patient is less difficult. Complicates the examination process and the severity of the underlying disease, as well as the need for prolonged use of mechanical ventilation.
The clinical picture of pneumonia consists of signs of local pulmonary inflammation, extrapulmonary manifestations of pneumonia, laboratory and radiological changes. Diagnosis of pneumonia is usually based on the following clinical and laboratory signs (Table 1). It should be remembered that in conditions of severe stroke, each of these criteria is non-specific.
Diagnosis of pneumonia is made only in the presence of 4 of the listed criteria, and the presence of 3 of them makes the diagnosis of pneumonia likely.
Treatment
Comprehensive treatment of pneumonia should be aimed at suppressing the infection, restoring pulmonary and general resistance, improving the drainage function of the bronchi, and eliminating the complications of the disease.
Antibacterial drugs are the mainstay of treatment for pneumonia. The choice of the most effective one depends on many factors, including:
. accurate identification of the pathogen
. determination of its sensitivity to antibiotics
. early initiation of adequate antibiotic therapy
Nevertheless, even with a well-equipped microbiological laboratory, the etiology of pneumonia can only be established in 50-60% of cases. Moreover, it takes at least 24-48 hours to obtain the results of microbiological analysis, while antibiotic therapy should be prescribed as soon as the diagnosis of pneumonia is established.
The diversity of the etiology of nosocomial pneumonia, the simultaneous detection of several pathogens in one patient, and the lack of methods for express diagnostics of the sensitivity of microorganisms to antibacterial drugs make it difficult to plan therapy. Under these conditions, there is a need for the use of empirical antibiotic therapy, which ensures the study of drugs with the widest possible spectrum of activity. Choice medicinal product is based on an analysis of a specific clinical and epidemiological situation in which a given patient developed pneumonia, and taking into account factors that increase the risk of infection with a particular pathogen.
For nosocomial pneumonia in severe forms of stroke, the weight of gram-negative microflora, staphylococcus and anaerobic bacteria is the highest. Therefore, cephalosporins of the I-III generation (in combination with aminoglycosides) or fluoroquinolones are most often used as initial therapy.
The following combinations and monotherapy regimens may be effective:
. Combination of ceftazidime with "respiratory" fluoroquinolones
. Combination of “protected” antipseudomonal ureidopenicillins (ticarcillin/clavulanic acid, piperacillin/tazobactam) with amikacin
. Monotherapy with IV generation cephalosporin (cefepime)
. Monotherapy with carbapenems (imipenem, meropenem)
. Combination of ceftazidime or cefepime or meropenem or imopenem with second-generation fluoroquinolones (ciprofloxacin) and modern macrolides
The course of the pneumonia resolution process is assessed using clinical or microbiological studies. Clinical indicators are: a decrease in the amount of purulent sputum, a decrease in leukocytosis, a decrease in body temperature, signs of resolution of the inflammatory process in the lungs according to radiography or computed tomography. It is believed that during the first 72-2 hours of empiric therapy, the selected treatment regimen should not be changed.
With a progressive increase in inflammatory infiltration, it is necessary to adjust antibiotic therapy. It is recommended, if possible, to identify the microorganism and prescribe targeted (etiotropic) antimicrobial therapy. The subsequent change of antibiotic therapy should be carried out according to the results of only a microbiological examination of sputum.
Considering the type of causative agent of pneumonia, the proposed pathogenetic mechanism for the development of pneumonia and the time of its development from the onset of a stroke, the recommendations given in Table 2 can be followed.
The average duration of antibiotic therapy in patients with pneumonia is presented in Table 3. In most cases, with an adequate choice of antibiotics, 7-10 days of its use is sufficient. With atypical pneumonia, staphylococcal infection, the duration of treatment increases. Treatment of pneumonia caused by gram-negative enterobacteria or Pseudomonas aeruginosa should be at least 21-42 days.
One of essential conditions successful treatment of pneumonia is to improve the drainage function of the bronchi. For this purpose, expectorant, mucolytic and mucoregulatory agents are used, chest massage (percussion, vibration, vacuum), breathing exercises are used. Bronchodilators are prescribed for severe pneumonia and in persons prone to bronchospastic syndrome. In the ICU, it is preferable to prescribe intravenous infusions of a 2.4% solution of aminophylline, less often inhaled forms of b2-adrenergic stimulators, M-anticholinergics.
In severe forms of pneumonia, infusions of native and / or fresh frozen plasma are carried out. Currently, the issue of the need for immunocorrective and immunoreplacement therapy with immunoglobulins and hyperimmune plasma is being considered. Patients with severe forms of pneumonia also undergo detoxification therapy, taking into account cerebral edema and concomitant pathology of the heart and heart failure.
Prevention
Prevention of pneumonia in severe stroke is based on three main approaches.
1. Elevated position of the upper half of the patient's body at an angle of 450, frequent sanitation of the nasopharynx and physiotherapy of the chest. These simple methods allow to reduce the flow of secretions from the upper respiratory tract to the trachea and bronchi, i.e. microaspiration.
2. Personal hygiene of personnel (elementary frequent washing hands with a disinfectant solution), careful observance of the rules of asepsis and antisepsis, strict adherence to the protocols for changing and cleaning tracheostomy tubes, reservoirs of humidifiers and inhalers reduces the growth rate and the addition of additional microflora.
3. The use of a certain type of tracheostomy tube (with supracuff aspiration) and its correct location, timely aspiration of secretions accumulating above the cuff, orotracheal intubation, insertion of a tube for enteral nutrition through the oral cavity reduce the risk of infection of the lower respiratory tract with nasopharyngeal flora. In addition, it helps to reduce the risk of developing sinusitis.
Until now, a unified view on the prophylactic prescription of antibiotics has not been formed all over the world. In our opinion, this approach definitely does not solve the problem of preventing pneumonia in stroke, especially VAP. It must be remembered that pneumonia is a process characterized by certain features of the course associated with the initial state of the patient and his reaction to the infection, and the role of antibiotics is limited only to the suppression of the infectious agent. In addition, with the prophylactic administration of antibiotics, the development of superinfection caused by antibiotic-resistant strains of microorganisms is possible.
Conclusion
Our data and analysis of the literature suggest that the occurrence of pneumonia in patients with severe stroke worsens the condition of patients. In patients who have survived a period of neurological complications, pneumonia often causes death. Preventive measures should be started already from the first hours of a stroke, and rational therapy of pneumonia should be started immediately after its diagnosis.

Literature
1. Vilensky B.S. Somatic complications of stroke // Neurological journal. - No. 3. - 2003. - pp. 4-10.
2. Koltover A.N., Lyudkovskaya I.G., Vavilova T.I., Viktorova N.D., Gulevskaya T.S., Levina G.Ya., Lozhnikova S.M., Morgunov V.A., Chaikovskaya R.P. The role of the pathology of internal organs in the pathogenesis, course and outcome of strokes. // Materials of the Plenum of the Board of the Society of Neurologists and Psychiatrists "Violations nervous system and mental activity in somatic diseases. - Naberezhnye Chelny. - 1979. - S.198-201.
3. Krylov V.V., Tsarenko S.V., Petrikov S.S. Diagnosis, prevention and treatment of nosocomial pneumonia in critically ill patients with intracranial hemorrhages. // Neurosurgery. - 2003. - No. 4. - S. 45-48.
4. Martynov Yu.S., Kevdina O.N., Shuvakhina N.A., Sokolov E.L., Medvedeva M.S., Borisova N.F. Pneumonia in stroke. // Neurological journal. - 1998. - No. 3. - S. 18-21.
5. Addington W.R., Stephens R.E., Gilliland K.A. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. // Stroke. - 1999. - 30. - 6. - R.1203-1207.
6 Chastre J. and J.-Y. Fagon Ventilator-associated pneumonia .//Am. J. Respir. Crit. Care Med., April 1.-2002.-165(7). - R.867 - 903.
7. Collard H. R., S. Saint, and M. A. Matthay Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review Ann Intern Med. //March 18. - 2003. - 138(6). - R.494 - 501.

Editor

Doctor, forensic expert

Inflammation of the lungs or pneumonia is a popular disease for people of all ages. The manifestation of symptoms does not depend on gender, and the lesions can be quite extensive.

At risk of an infectious disease are people with a weak immune system: (children from birth to a year), and patients,. People with limited motor function often have hypostatic (congestive) pneumonia. It appears due to the lack of normal circulation of fluid in the lung tissues.

general information

Pneumonia in a bedridden patient can manifest due to a decrease in the activity of organ systems, tissue damage. In 70% of cases, inflammation of the lungs is affected by chronic processes that occur in the human body. The appearance of the clinical picture of the disease is the result of hypodynamia, which causes blood stasis. A bedridden patient may develop swelling and bedsores. The decrease in blood flow is indicated by the necrosis of soft tissues in the upper body.

Important! A person who looks after a patient with pneumonia who is lying down should be attentive and constantly monitor changes in his condition and complaints. Since neglect increases the risk of death in pneumonia. Detection of the disease in the early stages makes it possible to save the life of the patient.

Inflammation of the lungs: classification

Inflammation of the lungs is divided into types depending on the place of occurrence:

1. - appears at home or two days after visiting the hospital, clinic. Death from this disease occurs in about 11% of cases.
2. - symptoms of pneumonia appear 2 days after admission to the hospital or within 90 days after discharge from the hospital. The clinical picture is more pronounced and death occurs in 40% of cases.

In bedridden patients are classified as follows:

1. - characteristic of people with loss of consciousness. During fainting, a violation of protective pharyngeal reflexes occurs, which leads to the onset of the disease. In addition, hydrochloric acid from the stomach can enter other organs, causing burns.
2. . A popular form among bedridden patients. Symptoms of the disease manifest as a result of impaired blood supply and the appearance of stagnant processes.
3. Pneumonia against the background of IDS(with hypoplasia of the thymus gland, oncological diseases,).

Why does the disease develop in long-term patients?

In addition, the development of pneumonia can be influenced allergy, infectious lesions organ systems, blood flow disorder in the small circle of the circulatory system, ingestion of hydrochloric acid from the stomach into the lungs during vomiting.

The main factor influencing the appearance of pneumonia is the course of chronic processes. They reduce immunity by involving all the forces of the body in the fight against other diseases. In case of violations of the immune system, the cause of the disease is most often Streptococcus, Staphylococcus, anaerobic infection. These microorganisms are found in the normal microflora of the body, but with inflammatory or chronic processes, they begin to actively multiply, causing pneumonia.

For bedridden patients, inflammation of the lungs is characteristic, which appeared as a result of a deviation in the blood flow of the pulmonary circle. Full chest breathing promotes full blood supply to the lungs, and in bedridden patients, this blood circulation is impaired. The weakened body of a lying person is simply not able to carry out a full inhalation and exhalation. The deviation of the blood flow leads to a change in blood pressure, which adversely affects the lungs.

During exhalation, the body removes:

• carbon dioxide;
• slime;
• microbes;
• dust;
• dirt.

In a lying patient, these particles are not removed from the lungs, since there is a violation of the blood supply and the respiratory organs do not have enough strength to remove the excess. Over time, dirt and other debris builds up, causing pneumonia.

Risk group

Patients who are bedridden after surgery are at additional risk of developing the disease. The postoperative period increases the chance of the onset of the disease, as breathing worsens, and the diaphragm cannot function normally. Being chained to a bed does not allow a person to serve himself on his own. The patient sometimes cannot even get up on the bed. The lack of movement (physical inactivity) leads to the fact that an excess of pathological microorganisms accumulate in the body, and fluid stagnation occurs in the lungs, which creates an ideal environment for the reproduction of pathogenic flora.

Symptoms are more pronounced in bedridden patients, especially in the elderly, who have long lost their motor function. This is due to the fact that it is easier for bacteria to develop in an immobilized organism with a reduced activity of the immune system than in a completely healthy one.

The risk group for the progression of pneumonia are people with:

1. Post-stroke state.
2. Damage to the lower extremities, back, skull, brain, meninges, blood vessels and cranial nerves.
3. Oncological diseases.

For patients with oncology increased risk is a general depletion of the body. Chemotherapy, weakening the symptoms of malignant formation, reduces the work of all organ systems, including the immune system. In addition, the treatment affects blood circulation in the small circle, the removal of excess substances from the lungs (self-regulation). So the respiratory organs lose some functions, which also affects the reproduction of pathogenic flora in the lung tissues.

Contribute inflammatory process may be necrosis of soft tissues, which appeared as a result of constant bed rest and swelling.

For people in the above risk group characteristic. So, bedridden patients have constant pressure on the lower back, where fluid stagnation occurs during squeezing, and mixed species of microorganisms become the causative agent of the disease. Because the microflora is favorable for both bacteria and viruses. The clinical picture does not have bright symptoms for the elderly and bedridden patients. This is the difficulty in diagnosing and differentiating the disease. Since the symptoms appear only after a while, the prognosis with conservative treatment can be disappointing.

In other patients with pneumonia, the bilateral form manifests itself due to Streptococcus pneumoniae (Pneumococcus).

Clinical picture

Although the signs of pneumonia are not pronounced in the early stages, they are characterized by some features. So symptoms inflammation of the lungs can be divided into pulmonary And extrapulmonary.

The first can be attributed violation of the frequency and depth of breathing, accompanied by a feeling of lack of air, as well as a slight cough. Such manifestations of the disease are observed in people in a post-stroke state or in senile dementia of the Alzheimer's type.

Extrapulmonary symptoms are characterized inhibition of all processes in the body including the perception of the patient. There are deviations in the activity, functioning of the central nervous system. These manifestations are accompanied by emotional instability, involuntary excretion of urine, and a protracted stressful state.

Popular symptoms of aspiration pneumonia:

The clinical picture of congestive pneumonia in the initial stages is characterized by:

• lack of sputum;
• asthenia;
• mild cough;
• shortness of breath;
• general weakness of the body;
• dysfunction of the respiratory system.

Common signs include the fact that listening to the lungs shows the presence of dry rales. Body temperature does not rise high or reaches insignificant values.

Diagnostics

To diagnose inflammation, you need to use a phonendoscope. Special attention given to the lower back. In addition to wheezing, crepitus can be heard. To confirm the alleged diagnosis, the patient is prescribed at the point where there is a special apparatus designed for bedridden patients.

If necessary, transportation to the point of the procedure is carried out with the help of paid services that have equipment for the hospitalization of patients with impaired motor function.

Severe cases lead to direct admission to the hospital, where they will conduct a complete examination, including x-rays.

Comprehensive examination consists of the following studies:

• blood chemistry;
• general urinalysis (OAM);
• general blood test;
• electrocardiography;
• ultrasound diagnosis of the heart.

To prescribe pharmaceuticals designed to get rid of the pathogen, it is necessary to pass a sputum test. It is collected in two containers and given to the clinical and bacteriological laboratories, one copy each. The study of the material helps to find the cause of the disease, the onset or.

Treatment

Getting rid of the symptoms of the disease in bedridden patients is problematic due to the impact of the disease on other organ systems. In addition, the disease, with a decrease in the activity of the immune system, can quickly turn from unilateral to bilateral. For such cases, in addition to treatment aimed at eliminating the pathogen, pharmacological agents are used to get rid of multiple secondary pathologies.

Forecast

The prognosis for pneumonia in a bedridden patient depends on the general condition, the type of pneumonia, the pathogen, and the response to antibacterial drugs. An important role is played by the fact how the treatment was started. In the early stages, the prognosis is much more favorable..

In addition, a person's life is affected by:

1. The immune system.
2. Chronic diseases in other organs.
3. Deviations of a different type.
4. Complications (purulent inflammation of the tissues of the lungs with their melting and the formation of a purulent cavity).

If the defeat of the respiratory organs by pathological microflora was found at the beginning of the progression of signs, then in almost all cases the prognosis is positive. And within a month, a person completely gets rid of the symptoms of pneumonia.

It is important to consult a doctor in the early stages of the disease for optimal treatment. Since resistance to antibiotics may appear due to bacterial damage. If complications begin, then avoid negative consequences it will be hard.

Therefore, patients are mainly prescribed broad-spectrum pharmaceuticals. This step helps prevent the body from becoming addicted to drugs if the cause of pneumonia lies in the pathological microflora. The downside is that if the patient is bedridden and, moreover, in old age, then severe intoxication begins, which reduces the action of the immune system. Lack of treatment can cause bilateral inflammation. And even cause death.

In the elderly, an insufficient amount of alveolar macrophages is produced, which are responsible for cleansing the body of inhaled foreign particles of various nature. Over time, the disease spreads its effect to the lymph nodes and rarely, when everything is limited to a one-sided form. Therefore, for the elderly who cannot walk, prevention and care is very important. As well as strict supervision of a doctor before a positive trend is monitored.

Prevention

There are a number of actions that help prevent pneumonia in bedridden patients. Prevention includes:

1. Maintain muscle tone through physical activity.
2. Regular follow up procedures physiotherapy exercises aimed at the respiratory system.
3. Watching indoor humidity. In addition to the usual ventilation, you can use special humidifiers. It is important to ensure that the humidity is moderate, too solid air adversely affects the health of the patient. This step is necessary, since dry air is a source of infectious diseases.
4. . It is done with careful movements, even tapping. In this case, you can not touch the spine.
5. For normalization of breathing can be given to the patient Balloons. Inflating balloons helps to remove the “garbage” that cannot normally exit the body due to inadequate lung function.

Physical exercises for bedridden patients:

• assistance in changing the lying position to a sitting position;
• rolling from side to side, at least several times a day;
• for the respiratory organs, raising the upper limbs up and down - this helps to improve blood flow and normalize breathing.

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Conclusion

Bedridden patients are the people who are most at risk of various infectious and viral diseases. Especially old people who have lost the possibility of normal functioning of the motor system or people after a stroke.

To restrict relatives from negative impact environment, it is necessary to monitor the well-being of a person, adhere to the prevention of bedsores and pneumonia. All drugs should be used only as directed by a doctor, as self-medication can cost lives.

If it already happened that somewhere they didn’t watch or didn’t attach importance to cough until the symptoms worsened (fever, confusion), then in such situations need to urgently hospitalize the patient. This the only chance to save a life and prevent the transition of pneumonia to . Therefore, be careful and sound the alarm if there are the slightest deviations.