Download Syndrome of breathless

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MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: The syndrome of dyspnea
(Lesson 26)
Prepared by: associate prof.Yunusov I.I.
Tashkent - 2011
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APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
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Exercise: number 26
Subject: The syndrome of dyspnea during acute bacterial degradation of the lungs complicated
by pneumothorax and pneumoempyema. Definition, classification, clinical features, diagnosis
and differential diagnostika.Taktika GPs in the provision of emergency medical care. Indications
for pleural puncture and drainage of the pleural cavity surgery. Rehabilitation of patients.
1. Venue activities and facilities activities.
- Training room
Area surgeon clinic
- Dressing
- X-ray study
- Cabinet bronchoscopy
- Equipment training: Case patients, models, radiographs (bronhogrammy), macro
medications, medical history with data from laboratory studies. OCP, the algorithms of diagnosis
and treatment of syndromes
case studies, test questions, scenarios of interactive teaching methods, algorithms for
implementation of practical skills.
2. The duration of the study subjects - 327 min.
3. Session Purpose:
3.1 Learning Objectives
- Student must know the concept and essence of the syndrome of chest pain, coughing,
wheezing, dif. diagnosis of these syndromes in chest trauma
- Know the classification of acute bacterial degradation of lung
- Be able to supervise patients with these diseases and be able to identify the main symptoms of
the disease.
- Be able to establish a preliminary diagnosis and differentiation. diagnosis
- Know the methods of examination of patients and interpreting laboratory data.
- Know the symptoms of complications of pneumothorax, pneumoempyema and their diagnosis
and be able to provide emergency assistance.
- Know the basic principles of treating patients
3.2 Educational objectives: The study sample of patients with chest trauma and purulent lung
disease
teach students the basics of medical ethics and deontology, the harm of smoking, bring hard
work, consistency, responsibility, perseverance in pursuing the goal to benefit people and the
State to be necessary.
3.3 Develop objectives: In the study subjects and patients, to develop students' independent
thinking clinical interest in the practical and scientific-research work.
3.4. The student should know:
- Methods of evaluating patients of acute bacterial degradation of c light
- The tactics of treatment of patients
- Indications for surgery and choice of method of operation
- Postoperative rehabilitation of patients
3.5.Student should be able to and fulfill:
- To collect complaints and medical history of patients
- Examine the patients - palpation, percussion, auscultation
- Define the limits of light
- To interpret the survey data
- Carry out pleural puncture
- Perform thoracentesis and thoracostomy
4. Motivation:
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By suppurative lung diseases include abscess and lung gang ¬ Rena and they share the term
"acute pulmonary abscesses," "acute infectious destruction," "destructive pneumonitis." They are
among the most severe diseases, often threatening ¬ schim patient's life, characterized by
necrosis and subsequent purulent or putrid decay (degradation) of lung tissue as a result of
exposure to infectious pathogens.
Treatment of purulent-destructive lung disease and its complications, as well as injuries of the
chest, complicated by hemo-pneumothorax is one of the most important problems of modern
medicine, due to the increasing number of patients with this pathology.
Despite improvements in the organization of pulmonology service at the present stage of its
development and widespread use of antibiotics, not a decrease in the number of patients.
Moreover it seems that increasingly began to see chest injuries and lung abscesses syndrome
with dyspnea. Features of these lung diseases are the destruction of vital organs and body
systems, the rapid development of severe functional impairment and complications, and
therefore the need for urgent
adequate care. Any modern doctor must have complex diagnostics, to know the basic principles
of treatment of patients with purulent diseases of the lungs, as well as be able to provide the
necessary assistance in urgent situations.
5. Interdisciplinary and inter-subject communication.
resuscitation, Clinical Pharmacology, Traumatology.
Brief anatomical and physiological data.
Lungs - paired organ has the shape of a truncated cone. Between the lungs is the mediastinum.
Each lung is enclosed in a separate pleural sac formed by the visceral (lung covering) and
parietal flooring inside the chest cavity leaves the pleura. Downward from the root of these two
sheets of pleura combine to form the pulmonary ligament....
Parietal pleura consists of edge-sternum, diaphragm and mediastinal parts, forms the dome of the
pleura, stood at 3-4 cm above the clavicle, between the sheets of pleura formed sinuses
(costophrenic interlobar).
The right lung oblique and horizontal groove is divided into 3 portion (upper, middle, bottom),
and the left lung oblique groove on the 2 lobes (upper, lower).
In 1958, Congress adopted the segmental classification of Anatomists distinguish light 10
segments in the right (3-apical, anterior, posterior in the upper lobe, 2-lateral medial to the
middle lobe, 5 in the lower lobe) and 8 segments in the left lung (4 - in the upper lobe, because
the apical and posterior segments are combined and 4 in the lower lobe).
The structure of the bronchial tree: a cylinder covered with ciliated epithelium, bronchi 1.2.3order term, respir.
Perfusion a.pulmonalis (upper - lobar, descending, mid-lobar), and a bronchialis. Vienna-top,
bottom. Innervation - Mr. vagus and sympathetic.
Lung function - breathing (inhalation - contraction of the diaphragm and m \ p muscles, breathe
out-elastic light reduction), that is, gas exchange, where oxygen is absorbed by red blood cells of
air and produces carbon dioxide. Alveolar area of 100 m2. The pressure in the well. 14-16 mm
Hg pulmonalis
О2
СО2
In the air
22%
less
In the exhaled air
17%
more
Normally involved in respiration 1 \ 5 of the 4 \ 5 remain in a state of physiological atelectasis.
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Gas exchange is due to the partial pressure difference.
Breathing: 1) mechanics of breathing (inhalation, exhalation), the diffusion of gases, blood flow
in the pulmonary capillaries - external respiration (determined spirography), 2) transport function
of blood, and 3) internal (tissue) respiration, gas exchange between blood and tissues.
Methods of examination of patients.
External respiration-spirography study, tidal volume 500 - 800 sm.3, minute volume of
respiration (MOU) = respiratory rate (12-16 per minute.) A stomach. volume., ie 8-10 liters.
VC - 3500-5000 ml residual volume of respiration and reserve - 1500 cm 3, an additional volume
of 2000 cm 3. The total volume of the respiratory tract of 5.5 - 6 liters.
FEV1 - the volume of forced breathing.
FEV 1 - Tiffno sample - must be at least 70%
CRO 2 (coefficient of O) for at least 34-40 (calculate).
HBO - On the absorption% (determined biochemically).
When the question of bilobektomii and pulmonektomii spirography conducted separately, ie
turning off one light on and off blood flow and pressure are measured as well. pulmonalis:
- With increased blood pressure by 30-50% operation involves great risk.
- If the pressure is over 50% of surgery is contraindicated, since develops after surgery right
ventricular failure.
- Analysis of sputum pot. seeding.
- Study of immunologic reactivity.
- With AP-graphy, in the capillary phase of drawing clear at pnevmoskleroze as combined
capillaries.
- BA-graphy.
The structure of the lung studied:
- X-ray (spectroscopy, graphite, Multiaxis, sighting, CT, KT)
- Endoscopic ¬ - bronchoscopy (stenosis, stiffness, redness, bumps, rashes)
- Bronchography.
- Plevrografiya - torokoskopiya.
- Mediastenoskopiya - kavagrafiya.
- Radioisotope scanning xenon.
6. The content of lessons:
6.1. Theoretical part:
Abscess and gangrene LUNG
Abscess and gangrene of the lung - a qualitatively different pathological processes.
If an abscess is a pus-limited destructive process in the lung tissue. Limitation of the
inflammatory focus and transition ichorization to fester show pronounced defensive reactions,
whereas widespread gangrene is the result of progressive necrosis as a result of low reactivity or
complete areactivity body.
Among patients with more men aged 30-35 years, women suffer 6-7 times less frequently, which
connected with the peculiarities of industrial activity of men, more common among them are
alcohol abuse and smoking, leading to a breach of the drainage function of the upper respiratory
tract.
Etiology and pathogenesis: key factors in the development of abscesses and gangrene of the
lung, are ubezvozdushnost lung tissue (due to obstruction bronchus, atelectasis and
inflammation) disorders of blood circulation in her direct impact of toxins on airless lung tissue
with impaired circulation.
Distinguish bronchopulmonary, haematogenously-embolic, lymphogenous and traumatic way of
a pulmonary abscess and gangrene.
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Bronchopulmonary way. One of the most common causes of abscesses and gangrene is a
violation of patency of the segmental bronchi and equity due to their release to the lumen of the
infected material from the oropharynx.
In the unconscious (due to alcohol intoxication, after surgery), for serious infectious diseases of
ciliary function of bronchial epithelium is disturbed, the cough reflex is suppressed and the
infected material (food particles, tartar, saliva) can be recorded in the bronchi as much time as
necessary for the development of atelectasis and inflammation in the corresponding portion of
the lung. Typically, in these cases the abscesses are located in the posterior segments (II, VI) and
more often in the right lung.
Similar conditions occur when blockage of the bronchus tumor, foreign body, narrowing its
lumen scar (obstructive abscesses). Removal of foreign body and restore patency of the bronchus
in these cases often lead to a rapid cure the patient. Metapnevmonicheskie abscesses occur in
1.2-1.5% of patients with pneumonia. Their development is conducive to reducing the reactivity
of the body, pronounced disturbances of ventilation and blood supply to the lung, often caused
by previous lung diseases, the inadequate treatment of pulmonary process.
Haematogenously-embolic way. In this way developing 7 - 9% of lung abscesses.
Of infection in the lungs is due to transport by the blood stream of infected emboli from
extrapulmonary foci of infection in septicopyemic, osteomyelitis, suppurative thrombophlebitis
and other infected emboli occlude vessels of the lungs - pulmonary infarction develops, which is
subject purulent fusion. Abscesses with haematogenously-embolic origin, usually localized in
the lower lobes, and they are numerous.
Lymphogenous way of developing lung abscess and gangrene is rare. Skid infection in the lungs
is possible with angina, mediastinitis, subdiaphragmatic abscess, etc.
Abscesses and gangrene of traumatic origin are the result of closed chest injuries with damage to
lung tissue and penetrating wounds.
Pathological anatomy: at the time of abscess formation in the lung tissue against the
morphological changes characteristic of pneumonia, there is one or more areas of necrosis.
Under the influence of bacterial proteases is purulent fusion of the necrotic masses - a cavity
filled with pus. The destruction of the wall of a bronchus in the zone of necrosis, causes flow of
pus in the bronchial tree. Further morphological changes determined by the state reactivity of the
patient, drainage of abscess and conditions of its size, the course of inflammation in the
surrounding lung tissue. In the single-festering abscess cavity quickly released from the pus, the
walls of her gradually cleared of necrotic masses and covered with granulation, abscess formed
on the spot or scar epithelium lined the narrow cavity. For large poorly draining cavities
prolonged purulent melting of necrotic tissue, the presence of inflammation in the surrounding
parts of the lung cavity on the release of necrotic masses has been slow in the wall of an abscess
is formed by dense scar tissue that prevents healing.
Chronic abscess is formed.
Multiple abscesses are usually preceded by widespread inflammation in the lung. Against this
backdrop, in several sections of lung tissue necrosis. Areas of necrosis are purulent fusion at
various times, the breakthrough of ulcers in the bronchial tree takes place simultaneously.
With multiple abscesses are the outcome of the acute period of the formation of several bubbles
surrounded by a thick membrane of the necrotic and granulation tissue. Lung tissue between the
abscess does not recover its normal structure.
For lung gangrene is characterized by limitations otststvie altered lung tissue from healthy. Plot
mortify tissue without sharp boundaries becomes ramyagchennuyu lung tissue of dark color,
which is also not clear-cut changes in healthy tissue.
Clinic and diagnosis: the typical forms of the disease occurring in the clinical picture can be
separated into two periods: 1) prior to the opening of an abscess in the bronchus, 2) the period
after the opening in the bronchus.
The disease usually begins with symptoms characteristic of pneumonia: increased body
temperature, pain in the flank with a deep breath and cough. Physical examination reveals gap in
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the breath of the chest, the affected parts of the lungs cootvetstvuyuschey, tenderness, here
define the shortening of percussion sound.
The x-ray and CT scan is visible large or smaller dense shade. Following initial treatment,
pneumonia is not permitted and becomes protracted. High temperature is accompanied by chills
and pouring sweat. Sometimes patients say bad breath. In the study reveal high blood
leukocytosis, an abrupt shift formula of white blood left.
The second period begins with the breakthrough of abscess into the bronchial tree. In cases
where it is emptied through a large bronchus, just leaves a large amount of pus, sometimes
mixed with blood. The patient's condition is improving rapidly. However, more often draining
the abscess does not occur directly, through a major bronchus, and bronchial tubes formed by a
winding course that starts at the top of the abscess. Accordingly, the liberation from the pus is
slow, the patient's condition remains serious. Pus, falling into the bronchial tubes, causing
purulent bronchitis development with abundant formation of mucus (up to several hundred
milliliters per day). Sputum in lung abscess has an unpleasant smell, and when standing in the
bank is divided into three layers. The bottom consists of pus, the average - of serous fluid and the
top - frothy. Sometimes the sputum may see small fragments of altered lung tissue (pulmonary
sequestration). A microscopic study of its exhibit a large number of white blood cells, elastic
fibers, a variety of bacteria.
These physical examinations are changed compared to the first period. As the release of the
abscess cavity and pus permission of perifocal inflammation disappears zone shortening
percussion sound. In the presence of a large cavity, free from pus, and above it can be
determined by TIMP-canonical sound more clearly detectable, if the patient opens his mouth
percussion. With significant amounts of abscess listened amforicheskoe breath over the cavity
and mixed wet rales, mainly in the adjacent regions of the lung.
X-ray examination after oporozh equation abscess cavity is determined, sometimes with a fluid
level. At first, she has fuzzy contours due to perifocal inflammation. As the evacuation of
abscess and inflammation subsided around the abscess borders are becoming clearer.
If there is a blockage of the hole leading to the bronchus, the body temperature rises again. With
good drainage condition gradually improves and begins recovery.
More severe the multiple abscesses of the lung. 0bychno they are metapnevmonicheskimi and
appear against a background of inflammatory infiltration of large areas of pulmonary tk.ani. The
breakthrough single from an abscess in the bronchial tree does not lead to a substantial decrease
toxicity and improve the patient's condition, as in the lung tissue are foci of necrosis and purulent
melting. Heavier state developing purulent bronchitis with copious foul-smelling sputum.
Physical examination determines the lag in breathing chest on the affected side, dullness on
percussion, respectively, one or two lobes of the lung; auscultatory - a lot of wheezing different
caliber.
X-ray study reveals the first extensive blackout in the lung, as emptying the contents of pustules
on a background shade become visible cavities with fluid levels. Recovery of the sick, usually
does not occur.
Tion disease progresses. Developing pulmonary heart disease, stasis in the pulmonary
circulation, degenerative changes in parenchymal organs. All this quickly leads to death.
Gangrene is the most severe form of purulent lesions of the lung. Absorption ichorization
products resulting from the gangrene of the lung, and bacterial toxins leads to rezchayshey
intoxication patient. In the early lung gangrene starting gins to separate a large number of foulsmelling frothy sputum, which has the form "meat slops" due to admixture of blood from the
pulmonary vascular arrozirovannyh. The process usually involves the pleura, which leads to the
development of putrid empyema or pneumoempyema. In the study of patient attention is drawn
to severe shortness of breath, anemia, cyanosis, a significant shortening of the zone of percussion
over the affected lung; auscultation rales heard a lot of different calibers. Radiograph reveals
extensive blackout in an easy-to Thoroe increasing every day. Before the advent of antibiotics,
patients with lung gangrene usually died within the first days of illness.
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Treatment: acute purulent lung disease should be treated comprehensively, it is aimed at
strengthening the resilience of the body, improving the drainage of abscess, infection control,
normalization of heart function, the function of internal organs
1. Increased resistance to achieve: a) appropriate hygiene regime, b) enhanced nutrition of
patients with sputum lose large amounts of protein, primarily albumin. Total caloric intake
should be 3500-4000. The diet should be protein, energy payback for a full useful parenteral and
enteral (including tube) feeding.
2. Improving the drainage of the abscess may be achieved: (a) the use of expectorants, (b) the
introduction of the bronchial tree of solutions of proteolytic enzymes, Muko-ligicheskih funds in
the form of an aerosol, by filling the cavity of the abscess through the bronchoscope, the
puncture through the chest wall abscess in the case of subpleural its location, (c) the appointment
of physical therapy in combination with postural drainage (giving the patient a situation in which
the contents of the abscess will be flowing due to gravity).
3. Rational antimicrobial therapy should be tailored sensitivity of flora planted in sputum. In the
absence of data on the sensitivity of flora appropriate to use broad-spectrum antibiotics (aminoglycosides, cephalosporins, etc.) in combination with sulfonamides, metronidazole (trihopol).
Apart from the introduction of antibiotics intravenously, intramuscularly or orally, you must
enter them into the bronchial tree or abscess cavity (in the form of aerosol, through the
bronchoscope in the bronchial skopni in the abscess cavity by puncture of the abscess).
4. Normalization of heart reach the heart of application Niemi.
For detoxification and improve microcirculation to use gemodez, reopoligljukin.
5. Of great importance is Immunocorrecting therapy. Repeated blood transfusions of plasma, the
introduction of IgG (gamma globulin), increase the therapeutic sera reactivity. It is promoted,
and some medications: levamisole, thymosin, prodigiozan etc.
2. When staphylococcal destruction to the introduction of lipofundina or other lipid emulsions
used for parenteral nutrition. Injected into the blood fat linked bacterial enzymes and reduces the
damaging effects on the lung tissue.
Surgical intervention is indicated in gangrene of the lung (pneumonitis or lobectomy), acute
abscess resort to it when there are large pockets of destruction of lung tissue in a satisfactory
drainage ogsutstvii these patients performed simultaneously (in the presence of adhesions
between the visceral and parietal pleura leaves) or Two of the moment (no adhesions)
pneumonopathy.
In recent years, these operations are performed less often, as good drainage of abscess can be
achieved with the use vanii puncture through his chest wall abscess cavity in the introduction of
drainage with the trocar (Figure 16 and b) The subsequent aspiration of pus and schaya
introduction of proteolytic enzymes and antibiotics are usually given good effect.
Conservative baking futile in abscesses with a diameter of 6 cm thick capsule abscess is detected
by the X-ray examination of intoxication is not inferior to) complete the treatment in these cases
we can recommend resection of the lung in the acute period.
Outcomes of acute lung abscess 1) full recovery from which, along with the disappearance of
clinical symptoms and radiographic symptoms disappear lung abscess, 2) clinical improvement
which is characterized by the complete disappearance of clinical manifestations of disease but
the X in the lung revealed genologicheski dry cavity 3) clinical improvement to discharge the
patient remains subfebrialnaya body temperature of a patient selects a small number of spruce
zisto purulent sputum radiologically detected cavity with infiltration of lung tissue in her circle
of 4) with no improvement in these patients without any acute form of disease remission Bani
become chronic intoxication increases rapidly developing pulmonary heart failure dystrophy guy
himatoznyh of 5 ) death.
The most severe complications in the acute stage often cause the death are: a) break the abscess
into the pleural cavity with the development of tension pneumothorax b) bleeding into the
bronchial tree as a result of which can occur Jet asphyxia c) aspiration of pus in the unaffected
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parts of the bronchial tree and the development of new abscesses d) formation ulcers in distant
organs most often in the brain.
Remedial measures determined by the nature of complications and) the development of stress
pneumothorax is urgently needed thoracostomy b) for bleeding in the bronchi Alno tree as
emergency measures shown urgent the Nye intubation tube dvuhprosvetnoi that helps prevent
blood numb in the unaffected lung bronchi. In the future held hemostatic therapy. If the
conditions are suitable endovascular surgery - embolism zatsiya bronchial arteries of the affected
lung arrosion which most often results in bleeding into the airways), the newly formed abscesses
in the lung is treated in correspondence with the above principles of therapy lung abscess d)
metastatic abscesses are treated by the conventional scheme (early opening of the abscess
rational antibiotic therapy immunotherapy, etc.)
2. Clinic and diagnosis of complications of lung abscess
Pneumoempyema developing lung abscess in breaking into the pleural cavity and is
characterized by shortness of breath, tachycardia, cyanosis of the skin and mucous membranes,
chest pain (sometimes shocking), a high temperature. Percussion dullness is noted in the lower
and upper parts of tympanitis in the affected side of the chest, the X-ray obscuring the lower
parts of the chest with a horizontal level and the absence of broncho-vascular pattern in the upper
part, the collapse of the lung.
Clinic aspiration lesions and lung abscess, the opposite is the same as in acute lung abscess.
Pulmonary hemorrhage is characterized by hemoptysis scarlet frothy blood in the aspiration the phenomena of respiratory distress, cyanosis, tachycardia, physical rales. For the diagnosis of
prime importance are bronchoscopy and bronchial arteriography.
The transition to the chronic form of lung abscess is observed in giant and multiple abscesses,
if not properly treated bolnyhz, as well as when the abscess bursts into the bronchus in the upper
pole (the transition to the chronic form after 2 months of onset). The x-ray of light is determined
by the circular shadow with a horizontal level, pyogenic capsule is thick, irregular in shape.
3. The differential diagnosis of acute lung abscess is taken from a peripheral lung cancer and
cysts, tuberculous cavities and gangrene of the lung.
Peripheral lung cancer has a jagged border, the path to the root of the lungs, pneumonia
kantseroznuyu gives the decay of the cavity cancer has a thick irregular wall, a biopsy finding
abnormal cells.
Cyst of the lungs (uncomplicated) has a clear-wall boundary, with echinococcosis are positive
reactions of latex-and hemagglutination, eosinophilia. In the festering cysts - to distinguish them
from acute abscess is virtually impossible.
Gangrene different light weight general condition of patients, acrocyanosis expressed
intoxication, X-ray dimming 01.02 shares of lung without clear demarcation from surrounding
healthy tissue, pockets of destruction. Sputum color of meat slops ihoroznym smell, with
sequestration of lung tissue.
Tuberculous cavity is distinguished from an abscess on the basis of history,
rentgen.issledovany over time (usually 2-3 weeks there are signs of dissemination), the
identification of Mycobacterium tuberculosis in sputum (+) tuberculin tests.
Questions of tactics and treatment of GPs OIDL, osl.piopnevmotoraksom dismantled by parsing
algorithms and treatment decision situational problems.
1. When patients with lung abscess should be sent to the Thoracic Department for further
investigation and treatment.
Treatment components:
-Balanced diet, rich in proteins, fats and vitamins
-Antibacterial treatment by tracheal administration of antibiotics and proteolytic enzymes.
Remedial-therapeutic bronchoscopy, postural drainage.
-Transfusion
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Extracorporeal detoxification-I / v infusion 33% r-ra ethyl alcohol and calcium supplementation
-Immunocorrection.
Used in this lesson, the new educational technology: A method of "round table" method of
"doctor" and "expert".
Using the "round table":
1. Embarks on a circle with a piece of paper assignments. Each student writes his answer sheet
and passes the other. Responses should not be repeated. All write down their answers, followed
by discussion: crossed out the wrong answers on the number of right - assessing students'
knowledge.
Examples:
and. Essence syndromes: chest pain, shortness of breath, cough, hemoptysis.
b. The severity of these syndromes in suppurative diseases of the lungs and chest injuries
at. Diagnosis and differentiation. Diagnosis OIDL osl. pneumothorax and pneumoempyema.
Tactics, the treatment of patients, indications for surgery.
d. Complications OIDL and emergency care for them.
2. The group divided into subgroups of 2 people. In each subgroup shall be appointed "doctor"
and "expert." Teacher offers a "doctor" technique on patients. "Expert" tribute to the "doctor" in
3 section that has been done correctly? That wrong? How should they do? Conclusion teacher
makes
Discussion regarding AT ADMISSION OF PATIENTS:
1. Clinic and diagnosis of lung abscess
2. Clinics and diagnoschtika complications of abscess of the lungs.
3. Dif.diagnoz acute lung abscess.
6.2. Analytical part:
1. The patient 45 years after supercooling temperature rose to 39 C, appeared in the left side of
chest, worse when breathing, coughing. Sputum is almost there. The temperature was 8 days,
despite intensive anti-inflammatory therapy. Under the right shoulder blade dullness of
percussion sound, easing breathing.
What disease patient?
1. Acute abscess of the right lung
2. ARI
3. Acute pleurisy
4. Bronchopneumonia
5. Typhoid
What additional methods of investigation should be carried out?
1. Chest x-ray
2. X-ray light
3. Total blood and urine
4. Bacterial blood cultures
5. Scatology
X-ray semiotics of lung abscess to break into the bronchus
1. circular darkening of light in the II and VI segments with perifocal inflammatory infiltration
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2.okrugloe shadow with a horizontal fluid level
3.okrugloe shadow without clear boundaries with the path to the root of the lungs, increasing the
tracheobronchial limfauzlov
Where the patient should be treated?
1. in thoracic surgery ward offices
2. in the therapeutic department
3. Infectious Diseases Hospital in
4. outpatient
5. home
6. in a specialized thoracic department
2. The patient 45 years after supercooling temperature rose to 39C, there were pains in the right
side of chest, worse when breathing. Cough and phlegm almost was not. The temperature was 8
days, despite intensive anti-inflammatory therapy. Then, the patient appeared cough with
purulent sputum with foul-smelling, mouth full, became separated and 200 ml of purulent
sputum for a day. Temperature returned to normal, the condition improved, it was satisfactory.
Under the right shoulder blade back is determined by the shortening of the percussion sound,
impaired breathing, and large bubbling rale amforicheskoe breath.
What disease you suspect a patient?
1. acute abscess of the right lung, after a breakthrough in the bronchus
2. acute lung abscess with a breakthrough in the pleural cavity
3. Acute gangrene of the lung
4. ARI
5. Tifo-paratyphoid infection
What additional research is needed to clarify the diagnosis for?
1. X-ray light in the two projections
2. general analysis of sputum
3. bronchoscopy
4. blood tests and urine
5. Widal reaction
What is your medical tactics?
1. the patient should be treated in the department of thoracic
2. patient treated at home under the supervision of
3. patient treated in the therapeutic department
Complex treatment include?
1. Nutrition and immunokorretsiya
2. therapeutic bronchoscopy
3. antibiotics broad-spectrum antibiotics in / or / m
4. endotracheal fill broad-spectrum antibiotics
5. i / v infusion of fat emulsions, blood, 33% alcohol, calcium chloride, etc.
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3. Patient 50 years old enrolled in the thoracic outlet in a serious condition with complaints of
pain in the right lung, marked shortness of breath, acrocyanosis, cough with fetid sputum color
meat slops, severe intoxication, fever, drop in hemodynamic parameters and red blood cells.
On chest radiograph the right notes with no clear boundaries with a lot of heavy shading and soft
lightening of fluid in the pleural cavity.
Your diagnosis?
1. Gangrene of the right lung
2. Abscessed pneumonia
3. Peripheral lung cancer with carcinogenic pnevomniey
4. Bronhoektoticheskaya disease, III stage
5. Abscess of the right lung, a complication pneumoempyema
Your medical tactics?
1. Comprehensive pre-operative intensive care for 5-7 days (broad-spectrum antibiotics, blood
transfusion, hemosorbtion, cardiac, infusion-therapy disintoxication)
2. Pulmonectomy right
3. Therapeutic bronchoscopy remediation
4. pleural puncture and pleural lavage
5. Immunotherapy
4. The patient after 40 years of pneumonia in the remission stage suddenly rose sharply body
temperature, chills, chest pain, cough. On the 7th day from the beginning of the deterioration of
the patient regular cough is accompanied by purulent sputum mouth full. One day was allocated
to 300.0 ml of purulent sputum, decreased toxicity and body temperature. But on the third day
another cough is accompanied by bright red frothy sputum.
Your diagnosis? What research is needed to clarify the diagnosis?
1. Lung abscess, II stage, complicated by bleeding, chest x-ray.
2. OBDL or ulcerative gastric bleeding, EGDFS.
3. Gangrene of the lung, DIC, coagulogram.
4.Bronhoektaticheskaya disease bronchography.
What complication occurred?
1. Lung abscess, complicated by bleeding.
2. Erosive gastro complicated by bleeding.
3. Cirrhosis of the liver, complicated by bleeding from variceal.
4. Rupture of an aortic aneurysm.
The first medical care:
• bronchoscopic sealing a bleeding segment bronchus, haemostatics.
• Separate intubation bronchial haemostatics.
• Bronchial arteriography with embolization of bleeding vessels, haemostatics.
Therapeutic tactics:
1. After stopping, pulmonary hemorrhage and conducted a full survey of the complex
antibacterial, hemostatic, symptomatic therapy, therapeutic bronchoscopy, during the transition
to the chronic form - the operation.
2. Emergency surgery.
6.3. Practical part:
Pleural puncture
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1. Uses: pleural puncture performed for diagnostic and therapeutic purposes in exudative
pleurisy, hemothorax, pyothorax, empyema, spontaneous pneumothorax and stress
2. The necessary tools - 0.5% solution of novocaine, syringes, needle-type Dufour.
3. Student job - Specify the indications and technique of the pleural puncture.
4.Informatsiya examiner to: identify the knowledge and skills of the student and evaluate
separately for each of the items listed below
№
Max.ball Min.ball No
answer
1
Pleural puncture is performed in the second intercostal 10
5
0
space on the line sredneklyuchichnoy (pneumothorax) or
in the eighth intercostal space on the middle axillary line
(if there is fluid in the pleural cavity)
2
Position the patient sitting
10
5
0
3
Treatment surgeon's hands and the surgical field
10
5
0
4
Conduct local infiltration anesthesia of 0.5% solution of 10
5
0
novocaine
5
Puncture of the pleural cavity with a thick needle type 10
5
0
Dufour
6
Suctioning of air or fluid from the pleural cavity using a 10
5
0
syringe
7
To prevent suction of air from the atmosphere through a 10
5
0
needle into the pleural cavity using insertion of rubber
tubing between the needle and syringe
8
Detach the syringe from the tube filled with necessary 10
5
0
after overlaying the clamp on the rubber tube.
9
The introduction of antibiotics into the pleural cavity, if 10
5
0
necessary
10
Removal of needles and aseptic dressing superimposition 10
5
0
The maximum score for the station
100
50
0
Pleural puncture
7. Forms of control knowledge, skills and abilities:
- verbally
- writing
- OKP
- Case studies
- OSKE
Innovative techniques used in class:
game "lottery"
3 step interview
- Algorithms for diagnosis and treatment of syndromes
- Case studies
algorithms for Action (OSKE)
8. Criteria for evaluating the current control:
Performance in
№
Mark
The level of the student's knowledge
(%) and scores
14
1
96-100
2
91-95
Very well “5”
3
86-90
4
81-85
5
76-80
Well “4”
6
71-75
Summarizes and makes decisions
Creative thinking
Independently analyzed
Into practice
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solves the case studies with full
justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Creative thinking
Independently analyzed
Into practice
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solves the case studies with full
justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Independently analyzed
Into practice
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solves the case studies with full
justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Into practice
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solve situational problems, but not
sufficiently justify the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solve situational problems, the answer is
not complete study
Understands the subject matter
Knows, says confident
Has a faithful representation
Correctly solve situational problems, the answer is
not complete study
Understands the subject matter
Knows, says confident
Has a faithful representation
15
7
66-70
8
61-65
9
55-60
10
54 and below
Satisfactory “3”
Unsatisfactory
“2”
Understands the subject matter
Correctly solve situational problems, but can not
justify a response
Knows, says confident
Has a faithful representation of some issues topic
Mistakes in solving situational problems
Knows, says uncertainly
Has a faithful representation of some issues topic
Knows, says uncertainly
Has a partial view
It does not accurately represent
Do not know
9. Chronological map of classes
№
1
2
3
4
5
6
Stages of training
Opening remarks of the
teacher. Justification of topics.
Determining the initial level of
knowledge of students.
Interactive game "lottery" with
the use of slides, radiographs, a
standard protocol ..
Form class
15'
The survey, discussion,
standard protocol, the X-ray
Programme, Annex № 1
Conclusion
Explain how to conduct the
practical part of training.
Acceptance of case patients in
the clinic for a three-step
method of interactive
interviews. The study of the
diagnosis and differentiation.
diagnosis.
The study of the practical part
of work under the guidance of
the teacher. Analysis of
diagnosis and tactics of GPs
and emergency trauma care and
thoracic OIDL,
pneumoempyema complication
with treatment algorithms and
solving situational problems
Improvement of practical skills,
analysis and
interpretation of survey data,
laboratory and radiological
investigations. Questions
dif.diagnoza, treatment and
rehabilitation. Implementation
of practical skills. OSKE.
Length classes
minutes)
60'
20'
RECEPTION propagation, visit
the sick, and! B, results of tests
under the supervision of a
teacher according to the method
of three-stage interview with
Annex № 2
Medical history, clinical case
studies, algorithms syndromes
and actions. Appendix № 3
Interpretation of data: blood,
urine and sputum, X-rays.
Implementation of practical
skills in algorithms of actions.
50'
60'
57'
(270
16
7
8
9
Analysis and assessment of
theoretical knowledge and
practical skills of students on
the topic, to build knowledge
and skills in algorithms for
Action (OSKE) Assessment of
the groups to implement the
objectives of this lesson.
Conclusion for the teacher
training, evaluation and
announcement of each student
on a 100 ballnoy system.
Distribution of targets for
training and self-CDS
Self-study student in the library
Poll-discussion, the decision of
situational challenges. Analysis
and interpretation of
radiographs. To consolidate and
assess the practical skills in
algorithms of diagnosis,
treatment, and actions.
Appendix № 4
Information teacher, Ad rating
of each student. Classy
magazine, the list of CDS,
methodical development of
EMC.
45'
20'
45
10. Control questions:
- The concept of an abscess, gangrene of the lungs.
- Chest injuries, a complication of hemo-pneumothorax and apnea syndrome
- Symptoms of abscesses, gangrene of the lungs, gemopnevmotoraksa
- Methods of examination of patients and their results
- Principles of treatment, the definition of indications for pleural puncture and drainage
operations
- Methods of operation and postoperative management of patients
- Complications of injuries of the chest and lung abscess, emergency care
- Definitions of abscess and gangrene of the lungs.
- Etiopathogenesis abscess and gangrene of the lungs. Classification of lung abscess.
- The frequency of lung abscesses in origin
- Methods of diagnosis of lung abscess and thoracic trauma.
11. References:
Main1. SH.I. Karimov "Surgical Diseases" T1994
2. MI Kuzin "Surgical Diseases" M1987
3. Clinical Surgery, edited by JM Pantsyreva M1998
4. VI Pods "Purulent diseases of the lungs and pleura," L1967
5. OKP on purulent diseases of the lungs and pleura. T1997
6. Standard protocols on the subject. T1997
7. John Murtha "Handbook of the general practitioner," translated from English. M1998
8. Surgery. Guide for physicians and students. Edited by VS Saveliev M1998
More9. Algorithms for diagnosis and treatment of major syndromes for training GPs. T2003
10. Algorithms for diagnosis and treatment of surgical. T2003,
11. Algorithms for diagnosis and treatment of major surgical syndromes. Athalia Authors AE,
Yunusov, I., Madaminov RM, Arifzhanova Z.Sh. T.2006g.