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In the area of pediatric pneumology (pulmonology), the consults are made in the Ambulatory of SOMEȘAN CLINIC, by Dr. ERICA NECHITA.
BRONCHOPNEUMONIA ( LOBAR PNEUMONIA ) is an acute inflammatory process with microbial origin, anatomapathological defined by bronchoalveolitis systematized lesions, that appears in the form of small, nodular, peribronchial, with lobar or segmentary distribution focuses.
Bronchopneumonia is that clinical form of bacterial pneumonia with multinodular inflammatory processes that affect the bronchi and the alveoli in the same time, in a limited areas, usually lobar, and is clinically defined by the concordance between the functional signs and pulmonary objectives, and the spreading of the pulmonary lesions.
It is a part of the dyspnea pneumonia and is characteristic to to babies and infants.
ETIOLOGY
Bronchopneumonia is anticipated and favored by viral infections, that decrease the protective strength of the organism and exacerbate the saprophyte flora.
1. Determined cause of bronchopneumonia
The cause is a microbial infection, in most of the cases, preceded by a viral infection, the most frequent bacteria that produce the disease are: Klebsiella, H. Influenze, E. Coli, Salmonella, proteus bacilli, staphylococcus, pneumococcus etc.
2. Favoring causes
a. Small age- increased frequency of bronchopneumonia is between the ages of 0-2 years old
b.Premises: dystrophy, premature birth, rachitis, allergic or exudative diathesis, that frequently give the disease a longer and more severe evolution
c. Deficient alimentation, off-balanced, with a low input of vitamin
d. Hygiene conditions of the living environment decrease the resistance of the organism to infections
e. Diseases like: roseola, convulsive cough, flu etc.
PATHOGENY
Pulmonary parenchyma can be affected on three ways:
- aerial
- vascular
- lymphatic
AERIAL WAY
Is the most important because and for it plead:
1. Etiology arguments:
- the cases of aerial contagion;
- the cases of descendent auto-infection (after rheum);
- the role of the diseases where a bronchial desquamation is produced (roseola).
2. Anatomical arguments:
- the bronchial lesions constant;
- the usual disposition of the alveolar lesions around these bronchi.
Two paths unite the bronchiolitis with the alveolitis: the natural path (endobronchial) and the peribronchial path, the most frequent. This way, the peribronchial nodule is made by inflammatory processes of the bronchus wall, and not by invading its lumen .
VASCULAR WAY
It's possible when a distance infection exists: cutaneous, enteric or toxemic.
The bacteria access is made by a hematogenous way, through the arterial ramifications for the pulmonary bronchiolitis.
LYMPHATIC WAY
The infecton is dispersed on a descendent way from the rinopharynx until the alveoli, with a ganglion tumefaction stage, that implies in a unconditional way, the disperse of the infection in a lymphatic way also.
In the case that no sign of infection is found in the respiratory channels, the fact that the infection was made by a hematogenous or lymphatic way is admitted .
CLINICAL SIGNS
The disease is preceded by a few days with signs with viral character (rheum, dry cough, nasal obstruction, spasm cough, moderate fever, agitation, anorexia), just like in a normal infection of the superior respiratory channels.
After this episode, the bronchopneumonia debut is marked by hyperthermia (39º-40°C), agitation, dyspnea, anxiety and also generalized tonic-clonic seizures may appear.
The disease's period is defined by the presence of some functional syndromes: respiratory, cardiovascular, infectious, metabolic.
RESPIRATORY FUNCTIONAL SYNDROME
Is dominated by respiratory insufficiency, that manifests through aspiratory dyspnea or permanent mixt dyspnea and exaggerated at effort (60-80 resp./min.), moderate until severe air thirst.
The respiration is superficial with short, stacatto expiration. The child presents noise and abnormal cavity (substernal, suprasternal and intercostal).
The cough is frequent and dry, spastic, tormenting. Depending on the stage of the respiratory insufficiency and oxigenation, modifications in the tegument and mucosa coloring appear: the face color is pale-leaden, with a shade of palor or cyanotic-gray.
Cyanosis is determined by the hypoxia stage; initially it appears perioral and perionasal, and after it can generalize.
In lung exam hearing modifications appear, that are coordinated with functional syndrome, and vary, from one exam to another, depending on the apparition of new bronchopneumonia focus.
It's defined by the existence of humid subcrepitant rales, with unique or multiple focus, fugitive, appearing and disappearing in short amounts of time.
CARDIOVASCULAR SYNDROME
Is determined by the myocardium lesions, produced through toxin action (bacterial and viral) and through different metabolic disorders; heart decompression is favored by hypoxia and acydosis, these leading to vasoconstriction and hypertension in lung circulation.
Phenomena of right ventricular insufficiency appear (acute pulmonary congestion ):
- tachycardia ( 140- 180 beats/ minute );
- tachypnea ( over 50 resp./ minute );
- hepatomegaly;
- peripheral edema;
- jugular turgescence.
Right ventricular insufficiency appears, more frequently, in eutrophic and diathesis babies, making a particular form of bronchopneumonia, called "red form".
During bronchopneumonia, peripheral circulatory insufficiency may appear, peripheral collapse is installed, manifested through: marked pallor, cold extremities, drop of arterial tension, imperceptible or filiform pulse (infectious collapse). These symptoms dominate the clinical picture of the "white or gray form" of bronchopneumonia .
INFECTIOUS SYNDROME
Is determined by toxic touch of the nervous system.
Is manifested by inordinate hypertermia (39°-41°C), with big fluctuations, that correspond to the apparition of new bronchopneumonia focuses. Altered general condition, in which case the baby is agitated, has seizures, signs of meningitis rash.
The seizures that appear in the debut of the disease and do not repeat have a good prognosis (fever seizures). The gravity of the seizures is higher if they repeat during the evolution of the affection, in which situation, the problem of an encephalitic complication appears.
Frequently, in babies, we see abdominal meteorism, that can go until paralystic ileus. Digestive symptoms can be seen: vomit, anorexia, diarrhea. Also, oliguria can be installed, with discrete albuminuria and microscopic hematuria.
METABOLIC SYNDROME
Because of the bronchial and bronchiolitis lesions, and of the limitation and blockage of alveolo capilar gas diffusion in the lobar condensation areas, the oxygen saturation drops in the arterial blood (hypoxemia), disorders in eliminating CO2 appear, representing hypercapnia with respiratory acydosis .
The paraclinical picture will be completed by lab tests, imaging investigations and necessary investigations for evaluating pulmonary function.
COMPLICATIONS
Local complications are represented by the evolution towards abcedation, leading to:
1. purulent pleurisy;
2. mediastinitis;
3. pulmonary gangrene.
Distance complications include:
1. purulent otitis media ;
2. latent chronic otitis;
3. mastoiditis;
4. meningitis;
5. seizure;
6. sepsis.
BRONCHOPNEUMONIA PROPHYLAXIS
The most important determinant and favoring factors of bronchopneumonia must be taken in regard.
1. FIGHTING THE DETERMINANT BRONCHOPNEUMONIA FACTORS
The respiratory infections, with microbial causes and virosis, are hard to prevent. The greatest importance in this area is owned by protecting the baby from contact with sick persons, with infection sources, both inside the family and in collectivity.
Microbial respiratory infection prophylaxis, most important than anything, implies respecting and assuring the hygiene conditions in hospitals, especially in maternity, newborns department, pediatric department and other institutions and children collectivities.
The hygiene and asepsis measures must replace the prophylaxis practice through antibiotics, to avoid the selection of the so called hospital flora with increased virulence and antibiotics resistance.
In the newborn, premature and distrophics departments, from children hospitals and clinics, the disinfection and sterilization of water containers , oxygen therapy apparatus, reanimation materials (probe, gloves, catheter) and also incubators, must be observed closely.
Specific prophylaxis of virosis is made through vaccine: flu vaccine and vaccine against infections with adenovirus.
2. FIGHTING THE AGGRAVATING AND FAVORING FACTORS OF BRONCHOPNEUMONIA
Has in sight:
a) rachitis prophylaxis, through conditioning the organism and administration of Ca and vitamin D3, and in case of disease installation-correct treatment ;
b) dystrophy prophylaxis, through a correct alimentation, quantity and quality;
c) prematurity prophylaxis, through preventing measures of premature births, and medical recovery in premature hospital units ;
d) fighting risk factors, included in the notion of "difficult life and environmental conditions", where the medical activity might have a role only in sanitary education and periodic observation (at home and dispensary).
EVOLUTION OF BRONCHOPNEUMONIA
The treatment usually lasts for 7-14 days. The evolution is favorable, except: babies with severe bronchopneumonia, and those who were presented to the doctor very late, and have a tardy treatment.
Two elements are striking in the evolution of bronchopneumonia: symptoms variability, that change daily, in report with the resorption of an infiltrate and the apparition of another, and the discrepancy between the severe general condition of the patient and the absence or discretion of the signs, especially objective-physic signs.
The disease's evolution is variable, because it's conditioned by many factors. It depends, first of all, by the nature of the causing agent, and the possibility to control it with medication.
The clinical form of bronchopneumonia and complex disorders that can be determined by it, also have an important role, as an early complex treatment has, treatment thet must mply a correction of all the physiopathological and biologic disorders that might have been caused. .
PROGNOSIS
- the prognosis is reserved for brain complications, hypernatremic dehydration, for babies with biologic handicap, in forms with important leukopenia.
The mortality is increased in biological risk babies categories, when it could arrive up to 10-15% of cases.
- is influenced by:
- age;
- base;
- complications;
- germ virulence.
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