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48. Pulmonary abscess and gangrene. classification. clinical manifestations. diagnostics.

Methods of treatment.

Surgery and therapy of suppurative diseases of the lungs and pleura have come a long way since ancient times and
is far from being completed today. For many centuries, doctors have tried to find the most appropriate ways to treat
pulmonary suppuration. Hippocrates found out the main clinical manifestations of this pathology and developed
rational methods for their treatment. With empyema of the pleura, he opened the chest cavity with a knife or a red-
hot iron rod, following his principle: ubi pus, ibi incision - where there is pus, there is an incision. After opening the
abscess, he introduced bronze drainage tubes into the pleural cavity. The legacy of Hippocrates was almost
forgotten in the Middle Ages, and the unfortunate patients with pulmonary suppurations were doomed to a slow,
painful death.
Abscess and gangrene of the lungs as separate nosological forms were identified by Laennec in 1819 (“Traite de
lauscultation mediate et des maladies des poumons et du Coeur”). He ismade the first description of lung gangrene
as the most severe form of pulmonary pathology. Sauerbruch proposed to unite these diseases under the general
name "pulmonary suppuration". The first information about the pathogenesis of lung gangrene was published in
1871. L. Traube. G. Sokolsky (1838) in the work “The doctrine of chest diseases, taught in 1837. in the Department
of Medical Sciences of the Imperial Moscow University for students of 3, 4 and 5 courses" gave a detailed clinical
description of lung gangrene. The first report on the surgical treatment of gangrene dates back to 1889, when N.G.
Freiberg described the pneumotomy performed by K.K. rapper. The first generalizing work, which described 26
cases of pneumotomy in patients with lung gangrene, was published in 1894. M.B. Fabrikant. In 1924 at the XVI
Congress of Russian Surgeons I.I.
A gentle minimally invasive technique for draining pathological lung cavities was first used by David in 1783. Then
the method of transthoracic drainage of cavities in tuberculosis was actively used by V. Monaldi (1938). In the USSR,
drainage for gangrene and lung abscesses was first used at the suggestion of I.S. Kolesnikov in 1968.
With the introduction of antibiotics into clinical practice, the prevalence of this pathology has not decreased, but the
results of treatment and prognosis have improved. At the same time, with widespread destruction caused by
associations of microorganisms, unsatisfactory results of treatment and high mortality still persist.
The first successful pneumonectomy for suppuration in the lung was performed by Nissen in 1931; Rienhoff also
processed the elements of the lung root separately (1937). In Russia, a successful pneumonectomy was performed
in 1946 by V.N. Shamov with bronchiectasis and A.N. Bakulev in lung cancer.
A successful definition of destructive pulmonary processes is given in the guide of I.S. Kolesnikov and M.I. Lytkin
(1988).
lung abscess- purulent or putrefactive decay of necrotic areas of the lung tissue, more often within a segment with
the presence of one or more destruction cavities filled with thick or liquid pus and surrounded by perifocal
inflammatory infiltration of the lung tissue. In 10-15% of patients, the process can become chronic, which can be
said no earlier than 2 months from the onset of the disease.
Gangrene of the lung- this is purulent-putrefactive necrosis of a significant area of \u200b\u200bthe lung tissue,
more often a lobe, 2 lobes or the entire lung, without clear signs of demarcation and tending to further spread and
manifesting itself in an extremely severe general condition of the patient (with gangrene of the lung, the cavity
contains sequesters of the lung tissue. With an abscess this is not).
Gangrenous lung abscess- an intermediate form of infectious destruction of the lungs, characterized by less
extensive and more prone to delimitation than gangrene, necrosis of the lung tissue. At the same time, in the process
of lung tissue melting, a cavity with parietal or free-lying tissue sequesters is formed.
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Name of the nosological form of the disease
(code according to ICD-10):
Lung and mediastinal abscess (J85):
gangrene and necrosis of the lung (J85.0);
lung abscess with pneumonia (J85.1);
lung abscess without pneumonia (J85.2);
mediastinal abscess (J85.3).

Epidemiology.
In the domestic literature, there are practically no
reports on the incidence of abscesses and
gangrene, light in relation to the population. Foreign
authors provide such data only selectively. So, in
1944, 10.8% of patients with pulmonary abscesses
per 10,000 admitted were noted in the
Massachusetts hospital. In France, the number of
people hospitalized in pulmonology departments does
not exceed 10 people per year.
The incidence of this pathology has not changed
significantly in recent years. The proportion of patients
with purulent diseases of the lungs and pleura is up to
40% in thoracic surgery (Perelman M.I., 1986,
Gostishchev V.K., 2005). Men make up the majority of
patients with this pathology (67%), more often of
working age (40-50 years). In general, diseases are
common and are accompanied by complications.

Classification of acute pulmonary

suppurations(E.G. Grigoriev and co-authors, 2003, with additions):
I. By etiology:
1. Post-traumatic
2. Hematogenous
3. Suction
4. Post-pneumonic
5. Obstructive

II. According to clinical and morphological characteristics:

1. Acute abscess (mortality 7 -10%):
A) single
B) multiple (unilateral or bilateral)
2. Gangrene of the lung:
A) limited (gangrenous abscess - lethality 10 -15%)
B) common (mortality up to 40%).

Morphological characteristic:
— colliquative necrosis - "wet" gangrene;
— coagulative necrosis - "dry" gangrene;
— coagulation-coagulation necrosis - mixed type.
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III. For complications:

1. Blocked abscess
2. Pleural empyema:
A) with bronchopleural communication
B) without bronchopleural communication
3. Pulmonary bleeding
4. Pulmonary sepsis
5. Aspiration inflammation of the opposite lung.

Classification of suppurative lung diseases (N.V. Putov, 1998):

I. Etiology:
1. Aerobic and/or conditionally anaerobic flora;
2. Obligate anaerobic flora;
3. Mixed anaerobic-aerobic flora;
4. Non-bacterial pathogens (fungi, protozoa).

II. Pathogenesis:
1. Bronchogenic, incl. aspiration, postpneumonic, obstructive;
2. Hematogenous, incl. embolic;
3. traumatic;
4. Associated with the direct transition of suppuration from neighboring organs and tissues.

III. Clinical and morphological form:

1. Abscess is purulent;
2. Abscess gangrenous;
3. Gangrene of the lung.

IV. Location within the lung (in relation to the root of the lung):
1. Peripheral (cortical);
2. Central (radical).
V. The prevalence of the pathological process:
1. Single;
2. Multiple;
3. Unilateral;
4. Bilateral;
5. With the defeat of the segment;
6. With the defeat of the share;
7. More than one lobe affected.

VI. The severity of the flow:

1. Easy current; Abscesses of the lung: a, b - a single
abscess of the lung;
2. Moderate course;
c - multiple abscesseslung
3. Severe course;
4. Extremely severe course.

VII. Presence or absence of complications:

1. Complicated;
2. Uncomplicated:
 Pyopneumothorax(from 10 to 38.5%), pleural empyema;
 Pulmonary bleeding(from 6 to 50%);
 bacteremia shock;
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 Acute respiratory distress - adult syndrome;
 Sepsis;
 Phlegmon of the chest;
 The defeat of the opposite side in the primary unilateral process(from 8 to 12%);
 Other complications.

VIII. The nature of the flow (depending on time criteria):

Acute;
With a subacute course;
Chronic abscesses of the lungs (chronic course of gangrene is impossible).

Etiology and pathogenesis.

Factors predisposing to suppuration of the lungs:
 Unconscious state;
 Coma;
 Alcoholism;
 Addiction;
 Smoking;
 Chronic nonspecific lung diseases (chronic bronchitis);
 Epilepsy;
 Traumatic brain injury;
 Cerebrovascular disorders;
 General anesthesia;
 Overdose of sedatives;
 Stenosing diseases of the esophagus;
 Immunodeficiency states;
 Flu;
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 Antisocial lifestyle (2/3 of patients).
 Inflammatory periodontal disease (contributing factor).

Important:
 inhalation of an aerosol from small particles (protection - mechanical protection, mucociliary transport);
 aspiration (including microaspiration) of oropharyngeal secretion (protection - cough, epiglottic reflex).
Aspiration mechanismdevelopment of destruction of the lung dominates (damage to the posterior segments).
At a symposium held in San Francisco in 1976 on the problems of treating pulmonary suppurations, the following
main body conditions were identified that contribute to the occurrence of aspiration lesions: alcoholism, drug
addiction, epilepsy, head trauma, accompanied by a prolonged unconsciousness. There is a direct relationship
between the incidence of aspiration pulmonary suppuration and the presence of infectious foci in the oral cavity -
carious teeth, periodontal disease, chronic tonsillitis, sinusitis.
Just as with postpneumonic lesions, aspiration pulmonary suppurations develop as a result of bronchogenic
ingestion of an infectious agent into the lung. However, here the pathological process begins with aspiration of the
infected material, its fixation in the small bronchi or bronchioles, and atelectasis. The inflammatory process and all
subsequent stages of its course up to suppuration develops for the second time. In clinical practice, it is often very
difficult to distinguish postpneumonic suppuration from aspiration. The only exceptions are cases of the disease,
where the fact of aspiration is precisely known in the anamnesis. Numerous experimental data have shown that an
aspiration abscess in the lung is formed 8-14 days after aspiration.
The frequency of aspiration abscesses and gangrene of the lungs, according to various authors, ranges from 20 to
75% in the structure of the probable mechanisms of their development. Aspiration abscesses develop much more
often in the right lung, the short and wide main bronchus of which, being, as it were, a continuation of the trachea,
increases the likelihood of aspirated material getting into the posterior segments of the right lung.
The mechanism of development of aspiration abscesses and gangrene of the lung is as follows: aspiration into the
tracheobronchial tree of foreign material, subject to a decrease in the level of consciousness, leads to their fixation
in the small bronchi and the development of atelectasis. Of great importance are also concomitant chronic lung
diseases that change their normal function and contribute to the development of violations of the drainage function
of the bronchi and blood circulation. The inflammatory process that begins in the bronchi further disrupts bronchial
patency and leads to the development of atelectasis of pneumonia. Some authors call this stage pneumonitis. If
timely treatment is not carried out at this stage or it is started late, then the pathological process in the atelectatic
area of the lung progresses. There is necrosis of airless lung tissue due to circulatory disorders due to thrombosis
and compression of blood vessels by an inflammatory infiltrate. Under the influence of microbes and their metabolic
products, purulent or putrefactive decay of dead tissues begins with the formation of multiple cavities of destruction.

With metapneumonic processes, the abscess is localized in the basal pyramid and the middle lobe.
Abscesses or gangrene that develop as a complication of pneumonia are the most common - from 63 to 95%. The
outcome in suppuration in croupous pneumonia is associated with the hyperergic nature of inflammation and a sharp
violation of local blood circulation in the presence of an infectious agent. Among the various types of bacterial
pneumonia, staphylococcal and frindler pneumonias are especially often complicated by purulent-destructive
processes. The main feature of staphylococcal pneumonia is their tendency to early formation of cortical purulent-
necrotic foci in the lungs, often progressing and leading to perforation of suppuration into the pleural cavity. The
frequency of Frindler's pneumonia ranges from 0.5 to 4% in the structure of the causes of pneumonia. A
characteristic feature of such pneumonias is their very frequent complication by widespread necrosis of the lung
tissue. The disease often proceeds with massive sequestration of dead areas of the lung. There are cases when
entire lobes of the lung and even the entire lung were sequestered and separated with pus.
The pathogenesis of postpneumonic abscesses can be represented as follows. Bronchogenic, hematogenous or
lymphogenous infection of the lung tissue causes inflammation of the parenchyma and small bronchi. Violation of
the patency of the small bronchi due to spasm, edema or obstruction with a secret results in atelectasis of the lung.
Infiltration and progressive tissue edema due to inflammation lead to direct compression of small blood vessels and
capillaries by the inflammatory infiltrate, which is accompanied by circulatory disorders in the inflamed airless area
of the lung. Circulatory disorders also depend on the toxic effects of microbial waste products and inflammation on
the walls of capillaries with damage to their structures, on changes in the nervous regulation of blood circulation and
 6
trophism of the lung tissue. With further progression of inflammation in the lung and compression of small vessels
and capillaries, a sharp slowdown in blood circulation occurs, reaching stasis and thrombosis of blood vessels with
the occurrence of necrosis of areas of the lung parenchyma. Invasion into the dead areas of the lung of pathogenic
microflora directly from the obstructed bronchus, from the upper respiratory tract and oral cavity, lymphogenously or
hematogenously leads to the beginning of purulent or putrefactive decay of the areas of the dead lung (stage of
abscessing pneumonia). The predominance of elements of necrosis or purulent fusion predetermines the
development of the disease as an abscess or gangrene of the lung, which largely depends on the state of the
reactivity of the patient's body. reaching stasis and thrombosis of blood vessels with the occurrence of necrosis of
areas of the lung parenchyma. Invasion into the dead areas of the lung of pathogenic microflora directly from the
obstructed bronchus, from the upper respiratory tract and oral cavity, lymphogenously or hematogenously leads to
the beginning of purulent or putrefactive decay of the areas of the dead lung (stage of abscessing pneumonia). The
predominance of elements of necrosis or purulent fusion predetermines the development of the disease as an
abscess or gangrene of the lung, which largely depends on the state of the reactivity of the patient's body. reaching
stasis and thrombosis of blood vessels with the occurrence of necrosis of areas of the lung parenchyma. Invasion
into the dead areas of the lung of pathogenic microflora directly from the obstructed bronchus, from the upper
respiratory tract and oral cavity, lymphogenously or hematogenously leads to the beginning of purulent or
putrefactive decay of the areas of the dead lung (stage of abscessing pneumonia). The predominance of elements
of necrosis or purulent fusion predetermines the development of the disease as an abscess or gangrene of the lung,
which largely depends on the state of the reactivity of the patient's body. lymphogenous or hematogenous leads to
the beginning of purulent or putrefactive decay of areas of the dead lung (stage of abscessing pneumonia). The
predominance of elements of necrosis or purulent fusion predetermines the development of the disease as an
abscess or gangrene of the lung, which largely depends on the state of the reactivity of the patient's body .
lymphogenous or hematogenous leads to the beginning of purulent or putrefactive decay of areas of the dead lung
(stage of abscessing pneumonia). The predominance of elements of necrosis or purulent fusion predetermines the
development of the disease as an abscess or gangrene of the lung, which largely depends on the state of the
reactivity of the patient's body.
Obstructive mechanism of suppuration.
Under obstructive suppuration of the lungs, it is customary to understand a purulent-destructive process caused by
blockage of the bronchus by some foreign body that accidentally got into it, a benign or malignant tumor that
develops from the wall of the bronchus, or a tumor that compresses the bronchus from the outside, as well as
stenosis of the bronchus due to various inflammatory processes. The frequency of obstructive suppuration ranges
from 1.5 to 23%.

Post-traumatic abscessesand gangrene of the lungs can be divided into two groups: after a closed chest injury
(bruises, compression) and after an open injury (gunshot, stab wounds). According to E.A. Wagner, post-traumatic
pulmonary-pleural suppurations account for 10% of purulent diseases of the lungs and pleura.
The frequency of hematogenous-embolic pulmonary suppuration is relatively low and, according to the clinical data
of various authors, ranges from 0.8 to 9%. The most common sources of septic emboli: septic endocarditis, purulent
thrombophlebitis of the veins of the extremities and pelvis, phlebitis after prolonged catheterization of peripheral
veins, abscesses of various localization. Mechanism of development: blockage by a thrombus of small branches of
the pulmonary artery leads to a wedge-shaped hemorrhagic infarction of the lung parenchyma area, followed by its
necrosis. The zone of necrosis undergoes purulent or putrefactive decay due to the seeding of its flora, either along
with a septic embolism, or secondarily bronchogenically.

The respiratory tract has enough local and systemic mechanisms to maintain the sterility of the terminal bronchioles
and lung parenchyma. The pathogen contaminates the lung either by inhalation of an aerosol of fine particles or by
aspiration of oropharyngeal secretions. Mechanical retention at the level of the upper sections, in combination with
mucociliary transport, prevents penetration into the bronchioles of most particles that have entered the bronchial
tree. Aspiration of oropharyngeal contents is prevented by cough and supraglottic reflex. The local presence of
immunoglobulins (especially IgA), complement, glycoproteins (fibronectin) in secret prevents colonization of the
mucous membranes by virulent microorganisms. If the infectious agent reaches the alveolar level, cellular and
humoral mechanisms are activated, designed to eliminate pathogenic microorganisms. These include the specific
 7
antibacterial activity of the surfactant, opsonization by immunoglobulins, direct lysis by complement activation,
phagocytosis by alveolar macrophages, and phagocytosis by recruited polymorphonuclear cells.
The insufficiency of one or another protection factor is associated with the characteristics of inflammatory changes
in the respiratory tract and typical pathogens. For example, impaired consciousness or swallowing disorders alter
the function of the epiglottis and allow excessive aspiration of oropharyngeal secretions into the lower airways.
Intestinal gram-negative bacteria colonize the oropharynx due to the suppression of normal microflora during
massive antibiotic therapy or due to changes in the glycoprotein of the epithelial surface in severe concomitant
diseases. Some microorganisms of this group can secrete proteases that destroy IgA. Myxoviruses, especially the
influenza virus, are able to invade and destroy the ciliary cells of the bronchial tract and disrupt the bactericidal
activity of phagocytes, thus contributing to
For patients with asplenia, hypoglobulinemia or dysglobulinemia of various origins, infections caused by
encapsulated bacteria such as S.pneumoniae, H. influenzae are common. Granulocytopenias lead to a decrease in
the number of polymorphonuclear leukocytes attracted to the infected focus, thereby facilitating the development of
gram-negative bacterial pneumonia. Insufficiency of cell-mediated immune mechanisms in azotemia, cachexia, the
use of glucocorticosteroids, organ transplantation, HIV infection predispose to destructive pneumonia caused by
intracellular pathogens such as Legionella pneumophila, Pneumocystis carnii and endemic mycoses.
Progress in the development of microbiological diagnostics of acute bacterial destruction of the lungs (ABDL) is
associated with the work of J. Bartlett, S. Fingold (1974), S. Nelson (1976). They proved that in the etiology of acute
pulmonary suppurations, undoubtedly, the leading role is played by strict non-spore-forming anaerobic
microorganisms (60-70%). Currently, more than 350 species of pathogens of this group are known that can cause
pulmonary destruction. Bacteroides, Peptostreptococcus, Fusobacterium, Peptococcus are most often isolated from
purulent foci, i.e. flora that usually colonizes the nasopharyngeal region. Only in 32% of patients the pathogen is
isolated in monoculture. In other patients, associations of 2-3 or more microorganisms are observed. In 10% of
cases, sowing turns out to be without growth.

Table. The frequency of inoculation of microorganisms (in%) from the focus of pulmonary suppuration
(E.G.Grigoriev, corresponding member. RAMN)

Clinic and diagnostics

A destructive infectious process in the lungs
can be suspected by the following symptoms
and signs (specificity is low and amounts to
50%):
 weakness, malaise;
 chills;
 subfebrile or hectic body temperature,
accompanied by heavy sweats;
 chest pain associated with breathing;
 difficulty breathing, hemoptysis;
 dyspnea;
 unproductive cough at the onset of the disease or later separation of purulent, profuse, sometimes fetid sputum
up to 200-500 ml per day.
In the elderly and immunocompromised patients, signs of an inflammatory process in the lung may be masked.

With a lung abscess(before a breakthrough in the bronchus) during percussion, there is an intense shortening of
the sound above the lesion, auscultatory - breathing is weakened with a hard tone, sometimes bronchial. The patient
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takes a forced position (more often on the "sick" side). After the breakthrough of the abscess in the bronchus with
good drainage, the patient's well-being improves, the body temperature decreases. With percussion of the lungs
over the lesion, the sound is shortened, less often - a tympanic shade due to the presence of air in the cavity,
auscultatory - fine bubbling rales. Symptoms disappear within 1.5-2 months. With poor drainage, body temperature
remains high, there is a cough with poor separation of fetid sputum, shortness of breath, intoxication, thickening of
the terminal phalanges in the form of "drumsticks" and nails in the form of "watch glasses".
The classic clinical course of an acute lung abscess: before and after emptying the abscess into the bronchial tree,
is observed only in 20-25% of cases. With gangrene, the boundary between these periods is indistinct.
The most severe category is patients with blocked abscesses. They complain of chest pain, which is caused by
increased pressure in the abscess cavity and involvement of the visceral pleura in the inflammatory process. The
cough is usually dry or with the release of a small amount of serous-purulent sputum, due to concomitant bronchitis
or pneumonia. There is a high temperature up to febrile numbers, accompanied by chills and heavy sweats.
Symptoms of endogenous intoxication are expressed: general weakness, loss of appetite, weight loss, fatigue, poor
sleep, shortness of breath, tachycardia. Physical examination reveals symptoms characteristic of an inflammatory
process in the lungs: restriction of respiratory excursion of the chest, muffling of percussion sound over the affected
area, hard, weakened breathing, dry and wet rales of various calibers. Radiologically, a cavity with a pronounced
perifocal infiltration of the lung tissue with multiple cavities of destruction or without visible destruction is determined.

Gangrene of the lungdiffers in a more severe course - hectic

temperature, severe intoxication, weight loss, shortness of breath.
Characterized by pain in the chest on the side of the lesion, aggravated
by coughing. Sputum production with gangrene of the lung is
significant; foul-smelling sputum, with tissue sequesters (a product not
only of the collapse of the lung parenchyma, but also a consequence
of pleural empyema, draining through many bronchopleural fistulas into
the bronchial tree). With percussion over the affected area, a dull sound
and soreness (Kryukov-Sauerbach symptom), with palpation with a
stethoscope on the intercostal space in this area, a cough appears
(Kiessling symptom). With the rapid decay of necrotic tissue, the
blunting zone increases, and areas of higher sound appear against its
background. On auscultation, breathing over the affected area is
weakened or bronchial.

Complications of acute pulmonary suppuration:

The most common complications of pulmonary suppuration are pyopneumothorax and pulmonary hemorrhage.
The frequency of pyopneumothorax after acute abscesses is, according to the literature, from 10.6 to 38.5%.
Gangrene of the lungs is complicated by pyopneumothorax much more often - in 18.7 - 89%.
Symptoms of perforation of lung abscesses into the pleural cavity can be different: from pronounced to erased and
completely invisible, often detected only by X-ray. Pleural empyema in acute abscesses is much less common. In
the clinic of I.S. Kolesnikov, among 170 patients with lung gangrene, pleural empyema was noted in 3 patients.
According to VI Astafiev (1980), out of 132 patients with a complicated course of acute abscess, 39 were diagnosed
with pulmonary hemorrhage (29.6%). Hemoptysis is even more common. VT Egiazaryan (1975) observed
hemoptysis in more than half of patients with gangrene of the lungs. Excretion with sputum of blood more than 50
ml can be considered bleeding, which can be small (up to 100 ml), medium (up to 500 ml) and heavy (more than
500 ml).
A rare but very dangerous complication is the breakthrough of an abscess into the pericardial cavity -
pneumopericarditis. The clinical picture of pneumopericarditis is characterized by a sudden sharp deterioration in
the condition, the appearance of increasing subcutaneous emphysema of the upper half of the trunk, neck, head,
and collapse. By the nature of the resulting hemodynamic disorders, this complication is essentially fatal.
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Diagnostic algorithmin acute bacterial destruction of the lung

(OBDL):
 Main research methods:anamnesis, examination, percussion,
palpation, auscultation;
 Instrumental research methods:
- radiological;
- fibrobronchoscopy;
- CT scan;
- ultrasonography;
- ventilation-perfusion hemoscintigraphy of the
lungs.
 Laboratory diagnostics:bacteriological
examination of sputum, bronchial washings, contents of the purulent
cavity. cytomorphological diagnosis.
 Research in dynamics:dynamic (1-3
times a week) chest x-ray, computed tomography, ultrasound, fibrobronchography + therapeutic measures.

X-ray examination remains the main method for confirming the

diagnosis of bacterial destruction of the lungs. Characteristic is
unilateral darkening with fuzzy boundaries, polysegmental, lobar or
total. Sometimes, even before the breakthrough of pus into the
bronchi against the background of a massive infiltrate, there are
multiple enlightenments associated with the accumulation of gas in
the purulent substrate, caused by anaerobic flora. It is often possible
to observe the "sagging" of oblique or horizontal interlobar fissures.

In the second period of the disease, against the background of the

infiltrate, a cavity with a fluid level begins to be determined in the case
of the formation of an acute lung abscess. With gangrene of the lung, as the decay progresses, small cavities merge
with each other, forming larger ones, with fluid levels. Lung abscess often affects segments 2, 6 and 10 of the right
lung.
The last decades are characterized by the active introduction of digital medical imaging methods in the diagnosis of
pulmonary suppuration. Computed tomography (CT), which has high diagnostic characteristics, undoubtedly plays
a leading role in this regard. On the one hand, it provides invaluable assistance in the differential diagnosis of lung
cavity formations. On the other hand, under the control of CT, it is possible to conduct a biopsy of solid lung
formations, drainage of purulent cavities with an intrapulmonary location and a “difficult” trajectory of access to the
formation.
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Much later, ultrasonographic diagnostics took its place in the
diagnostic arsenal of pulmonary surgery. Despite the fact that
air-containing tissues are a medium that conducts ultrasound
poorly, the method is increasingly used in the differential
diagnosis and treatment of purulent-inflammatory diseases of
the chest wall, pleural cavity, mediastinum, and subpleurally
located lung formations. The latest generation devices that use
digital technologies for the formation and processing of an
ultrasonic beam further increase the sensitivity and specificity
of the method in pulmonary pathology. Biopsy of solid
formations of the chest wall, pleura, and drainage of subpleural
cavities under ultrasonographic control was the result of the
introduction of high-frequency transducers with a special
instrumental port into clinical practice.

The list of
mandatory
instrumental studies includes bronchoscopy, which allows to
assess the severity and nature of endobronchitis, exclude the
tumor nature of the process, and collect material for
bacteriological and cytological examination.
In addition to diagnostic tasks, endoscopic methods play an important role in the treatment algorithm. Bronchoscopy
allows performing multiple sanitation of the tracheobronchial tree (TBD), selective microtracheostomy,
transbronchial drainage (deblocking) of the abscess cavity, occlusion of the fistulous bronchus, and endoscopic
arrest of pulmonary hemorrhage.
A very valuable diagnostic method for obdl, especially complicated by the development of pulmonary hemorrhage,
is bronchial arteriography. Catheterization of the bronchial artery and other branches of the aorta is carried out by
transfemoral access according to the Seldinger method. Changes in regional blood flow in pulmonary suppuration
are not of the same type. In acute lung abscess, hypervascularization of the lung tissue develops with a significant
increase in peripheral branches and an intense parenchymal phase of contrast enhancement. Expansion, tortuosity
of bronchial-pulmonary communications are characteristic of a chronic abscess. For gangrene of the lung, a
hypovascular variant of the blood supply to the pathological zone is characteristic.
Diagnostic manipulation in this study can be easily transformed into a therapeutic one. With pulmonary hemorrhage,
endovascular hemostasis is effective in most cases. The irreversible cessation of regional blood flow is achieved by
the introduction of a non-absorbable material - finely porous foam rubber or Teflon velor. Manipulation should be
 11
completed by installing a catheter at the mouth of the bronchial artery for endovascular regional infusion therapy
(ERIT) for up to 6-7 days. In this case, the concentration of drugs in the affected area can increase several times
and, therefore, the effectiveness of drug treatment increases. An important characteristic of the functional state of
the affected lung can be obtained by assessing lung perfusion by intravenous administration of albumin
microspheres, labeled with 99mTc. There is a direct correspondence between the volume of the affected lung tissue
and the zones of reduced accumulation of the radiopharmaceutical.
Bacteriological examination should be carried out, if possible, before starting antibiotic therapy. It is necessary to
give preference to the results obtained by taking the material directly from the purulent focus during puncture and
drainage according to Monaldi or during bronchoalveolar lavage. In the study of sputum, the latter being settled, it
is divided into 3 layers: the lower one consists of a crumbly sediment, representing fragments of lung tissue and
Dietrich plugs, the middle layer, the most pronounced, cloudy, liquid, the upper layer is mucopurulent foamy.
Microscopic examination of sputum reveals elastic fibers, fat droplets, cellular elements and bacteria confirm the
breakdown of lung tissue.Sputum examination for VC and cytology is carried out three times; sputum culture to
determine the microflora and antibiogram. Routine examination of sputum, due to contamination by the microflora
of the oropharynx, may give an incorrect idea of the pathogens of the purulent process in the lung, especially if it is
anaerobic in nature.
Without the use of anaerobic cultivation techniques, there is a high frequency of "sterile" crops masking obligate
anaerobes.

Differential diagnosis.
In addition to purulent - destructive diseases, the formation of intrapulmonary cavities is observed in a number of
other lung diseases, primarily in cavernous pulmonary tuberculosis, actinomycosis, cysts, decaying lung cancer.
Difficulties in differential diagnosis, in addition to radiographic data, are also due to the similarity of clinical
manifestations (chest pain, cough with sputum, fever, shortness of breath). Often there are cases of a combination
of lung cancer and paracarcinogenic secondary abscess in the atelectatic area of the lung; a combination of
tuberculosis and suppurative lung disease.Of decisive importance in the differential diagnosis of cancer and
suppurative diseases of the lung are endoscopic and radiological studies. With central forms of lung
cancer, bronchoscopy with biopsy and cytological examination of the washings of the bronchial tree is
more informative.
With a peripheral form of cancer, a puncture biopsy is preferable. Along with this, computed tomography,
bronchography, and linear tomography can be quite informative. Decaying lung cancer is radiologically characterized
by the presence of a cavity with thick, uneven edges, without a liquid level. Bronchographically in cancer, a symptom
of amputation of the bronchus is more often detected.
In contrast to the tuberculous cavern, with a lung abscess, the symptoms of intoxication are more pronounced.
Sputum with tuberculosis is excreted in a smaller amount and odorless, it can be found Mycobacterium tuberculosis.
Tuberculosis is not characterized by high leukocytosis. Radiographically, with a lung abscess, there are no
tuberculous foci around the cavity and in other parts of the lungs, and often in another lung. For a lung abscess,
localization of the focus of inflammation in the apical and posterior segments is not typical. The detection of
Mycobacterium tuberculosis resolves all doubts in the diagnosis.

lung abscess Cancer Tuberculosis

Often preceded by The presence of tuberculosis in
Anamnesis Long-term smoking
influenza, acute pneumonia the past; contact with TB patients
Minor, with a small amount of
Cough With a lot of mucus Often painful, hacking, with little phlegm
sputum
Mucopurulent, often raspberry jelly; More often mucous; tuberculosis
The nature of sputum Purulent
atypical cells microbacteria
Intoxication Expressed Moderately pronounced Expressed
Variable in intensity, fickle
Chest pain Intense, permanent Often missing
character

Often encysted, often
Pleurisy
purulent
Usually smoothness in the
cavity with a draining Cavity with an area of enlightenment in the
X-ray picture
bronchus in the form of a
path to the root
High neutrophilic
Blood leukocytosis
ESR increase
Antibacterial therapy The effect of antibiotics
12
Often hemorrhagic, atypical cells in Serous-fibrinous; mycobacteria in
exudate exudate
The presence of a cavity with
center with a bumpy inner wall signs of dissemination of foci
Often moderate leukocytosis.
Often lymphocytosis
ESR increase
Inefficient The effect of tuberculostatic drugs

When air and echinococcal cysts of the lung are infected, as a result of the infection entering the cavity of the cysts
through the draining bronchi, patients develop: fever, cough with purulent sputum, intoxication phenomena.
Radiologically determined intrapulmonary cavities with a horizontal level of fluid in them. However, it should be noted
that due to the presence in the cysts of a dense connective tissue membrane that separates them from healthy lung
tissue, the intoxication syndrome is less pronounced than with an abscess. On radiographs, suppurated non-
parasitic cysts have a spherical or oval shape with clear, even, thin walls. The parenchyma surrounding the cyst is
not changed, in contrast to the abscess, in which extensive infiltration is observed. Cysts are often multiple.
Most often, there are difficulties in the differential diagnosis of a lung abscess with an echinococcal cyst in the open
phase after its perforation and suppuration. At the same time, it is necessary to carefully clarify the history of these
patients: living in an endemic zone for echinococcosis, frequent cases of hemoptysis, the beginning of the opening
of an echinococcal cyst from an episode of coughing up a large amount of salty, bitter liquid, the so-called
"echinococcal vomiting". In sputum, fragments of the chitinous membrane are often detected in the form of whitish
pieces. In the blood test, eosinophilia is often expressed, elements of the chitinous membrane, scolex hooks are
found in the sputum. Of great importance is the serological reaction of latex - agglutination, which is positive in more
than 80% of cases. Radiologically, the walls of the cavity due to the fibrous membrane are clear, even, lung tissue
around changed slightly. With a relatively satisfactory condition of the patient, a large cavity with a high level of fluid
is determined radiographically, often with a waviness of the upper line due to floating fragments of the chitinous
membrane.
With actinomycosis of the lungs, intrapulmonary cavities and mycotic abscesses are rarely formed, which are very
difficult to distinguish from an abscess of a nonspecific nature. The final diagnosis of actinomycosis is based only
on the basis of laboratory data, when drusen and mycelium of the fungus are found in the sputum. Often,
actinomycosis also affects other organs with the formation of fistulas.

Treatment
The basis for the successful treatment of the pathology under consideration is the timely elimination of the purulent-
inflammatory process in the lung, the identification and adequate correction of the complications caused by its
course. Undoubtedly, the effective solution of these problems is possible only in a specialized department with
modern equipment and collective experience in the treatment of this category of patients.
Acute abscessin most cases, it is possible to stop conservative and parasurgical measures. With lung gangrene,
conservative treatment is considered as a preoperative preparation, the purpose of which is to maximize the
sanitation of the decay cavities and the pleural cavity with concomitant pleural empyema, the treatment of
pneumogenic sepsis. Also, in all patients without exception with widespread gangrene of the lung, it is necessary to
prevent life-threatening complications - profuse pulmonary bleeding, the spread of the process to the contralateral
lung.
The sequence of therapeutic measures for the pathology under consideration is as follows.
Conservative and parasurgical methods of treatment
1. Infusion therapy, the nature of which is determined by the severity of volemic disorders and intoxication.
2. Antibacterial therapy should be carried out taking into account the isolated pathogens and their sensitivity to
antibacterial drugs. But, given the duration of the bacteriological study, treatment must begin with an empirical
scheme (gold standard). Since OBDL is caused by associations of anaerobic-aerobic microorganisms, the following
antibiotic therapy regimens seem appropriate: amoxiclav or 3rd generation cephalosporins for parenteral
 13
administration and clindamycin. In case of intolerance to penicillin preparations, it is possible to administer
fluoroquinolones in combination with metronidazole or clindamycin. Reserve drugs are carbapenems. It is more
expedient to inject antibacterial drugs into the regional arterial bed.

Drugs of choice:amoxicillin/clavulanate,ampicillin/sulbactamorcefoperazone/sulbactamin / in;benzylpenicillinin / in,

thenamoxicillininside (step therapy);benzylpenicillin+metronidazolein / in, thenamoxicillin+metronidazoleinside
(step therapy).

Alternative drugs:lincosamides+aminoglycosides II-III generation;

fluoroquinolones+metronidazole;carbapenems.

Duration of therapydetermined individually.

Doses of antibiotics for the treatment of LRT infections in adults

A drug Dose (for adults)

Benzylpenicillin 1-3 million units IV every 4-6 hours

Oxacillin 2.0 g IV every 4-6 hours

Ampicillin 0.5-1.0 g orally, 1.0-2.0 g IV or IM every 6 hours

Amoxicillin 0.5 g orally every 8 hours

Amoxicillin/clavulanate 0.625 g orally every 6 to 8 hours 1.2 g IV every 6 to 8 hours

Ampicillin/sulbactam 1.5-3.0 g IV, IM every 8-12 hours

Ticarcillin/clavulanate 3.1 g IV every 4-6 hours

Piperacillin/tazobactam 3.375 g IV every 6 hours

Cefazolin 1.0-2.0 g IV, IM every 8-12 hours

Cefuroxime 0.75-1.5 g IV, IM every 8 hours

Cefuroxime axetil 0.5 g orally every 12 hours

Cefotaxime 1.0-2.0 g IV, IM every 4-8 hours

Ceftriaxone 1.0-2.0 g IV, IM every 24 hours

Ceftazidime 2.0 g IV, IM every 8-12 hours

Cefoperazone 1.0-2.0 g IV, IM every 8-12 hours

Cefoperazone/sulbactam 2-4 g IV, IM every 8-12 hours

Cefaclor 0.5 g orally every 8 hours

cefepime 2.0 g IV every 12 hours

Imipenem 0.5 g IV every 6-8 hours

Meropenem 0.5 g IV every 6-8 hours

Aztreonam 2.0 g IV, IM every 8 hours

Erythromycin 0.5 g orally every 6 hours 1.0 g IV every 6 hours

Clarithromycin 0.5 g orally every 12 hours 0.5 g IV every 12 hours

 14

3-day course: 0.5 g orally every 24 hours 5-day course: 0.5 g on the first day, then 0.25 g
Azithromycin every 24 hours

Spiramycin 3 million IU PO every 12 hours 1.5–3.0 million IU IV every 8–12 hours

Midecamycin 0.4 g orally every 8 hours

Gentamicin 4-5 mg/kg/day IV, IM every 24 hours

Tobramycin 5 mg/kg/day IV, IM every 24 hours

Netilmicin 4-6 mg/kg/day IV, IM every 24 hours

Amikacin 15 mg/kg/day IV, IM every 24 hours

Ciprofloxacin 0.5-0.75 g orally every 12 hours 0.4 g IV every 12 hours

Ofloxacin 0.4 g orally and IV every 12 hours

Levofloxacin 0.5 g orally every 24 hours 0.5 g IV every 24 hours

Moxifloxacin 0.4 g orally every 24 hours

Lincomycin 0.5 g orally every 6-8 hours 0.6-1.2 g IV, IM every 12 hours

Clindamycin 0.6-0.9 g IV every 8 hours 0.15-0.6 g orally every 6-8 hours

Vancomycin 1.0 g IV every 12 hours

Rifampicin 0.5 g IV every 12 hours

Doxycycline 0.2 g orally or IV every 24 hours

Metronidazole 0.5 g orally every 8 hours 0.5-1.0 g IV every 8-12 hours

Antiviral treatment.The choice of antiviral therapy regimen should be based on the following assumptions:

 the participation of viruses in the etiopathogenesis of AIDL in a particular patient is highly likely or proven by
one of the methods of etiotropic diagnosis;
 the choice of drug should correspond to the severity of pulmonary suppuration and be made taking into account
the state of interferon status and other indicators of antiviral resistance.

Exogenous leukocyte alpha-interferon "Interlock" is one of the effective and widely available antiviral drugs. It is used
in the form of ultrasonic inhalations of 30,000 IU per 15-20 ml of 0.9% sodium chloride solution 3 times a day.
Immediately before the inhalation of the antiviral drug, in order to increase the resorption capacity of the mucous
membrane of the tracheobronchial tree, a session of its sanitation is necessary. It consists in stimulating cough
activity, spraying terrietin or terridecase in the trachea and bronchi, washing them through a nasotracheal catheter or
through therapeutic bronchoscopy. The total duration of the course of interlocotherapy is 7-10 days, the course dose
of the drug is 420,000 - 900,000, respectively.ME. The drug is well tolerated, there are no side effects.

Cycloferon, a low molecular weight inducer of interferon formation, is used both per os and parenterally. In this case,
endolymphatic administration of the drug is preferable by means of catheterization of the lymph node in the inguinal
region. It is in the lymphatic system that the total protective effect of interferon, which is formed by regional lymph
nodes, is realized. The solution is administered at a rate of 10 ml/hour. The course of endolymphatic administration
consists of 5-7 injections of 10 ml of a 12.5% solution of cycloferon. The maximum clinical effect of interferon formation
inducers and the effect on antiviral resistance is observed in situations where the body's ability to produce
endogenous interferon is initially preserved. With gangrene of the lung, when in most cases the level of endogenous
interferon is low,
 15
3. Anabolic steroids (to combat the consequences of activation of catabolism) retabolil 1 ml of a 5% solution IM 1
time per week, nerobolil 25-50 mg (1-2 ml) IM 1 time per week.
4. Vitamin therapy, especially vitamins C and E, since the latter are blockers of lipid peroxidation.
5. Antienzymatic drugs (inhibition of proteases circulating in the blood).
6. Blood transfusions for the correction of anemia, with protein losses (sputum more than 200 ml / day) - plasma
transfusions are required.Compensation for significant protein losses in the body during a long and severe purulent process is
carried out using parenteral nutrition methods. Patients are usually prescribed amino acid mixtures (polyamine, moriamin) and
protein hydrolysates (aminosteril, alvesin) at the rate of 1-2 g of protein per 1 kg of body weight. Albumin (100 ml 2 times a week),
protein, plasma are also very useful. The amount of parenterally administered protein should cover at least 40-50% of the daily
requirement.
7. Immunotherapy:
• specific (antistaphylococcal gamma globulin, staphylococcal bacteriophage)
• non-specific (interleukin-2, T-activin, etc.)
Immunoreplacement therapy includes the introduction of native, hyperimmune plasma, polyvalent human 5 or 10%
immunoglobulin, leukocyte mass, xenospleen perfusate. As the condition of patients improves, immunostimulating
therapy with thymus preparations (thymalin, splenin, thymogen, etc.), spleen (splenin), lipopolysaccharides
(pyrogenal, prodigiosan, diucifon), interleukins are started. An important role in the correction of the immune system
is played by extracorporeal methods of detoxification (plasmapheresis, plasma sorption, hemosorption,
lymphosorption, etc.), which, by removing toxins from biological fluids, help reduce the toxic-antigenic load on the
body and enable immunocompetent cells to work effectively.
Anti-measles gamma globulin is used for viral and purely bacterial infections, as it neutralizes bacterial toxins and
activates phagocytosis. Gamma globulin is especially indicated with a decrease in IgG (below 5 g / l). Assign 1-2
doses per 1 kg of body weight after 1-2 days, with a higher content of IgG, 3-6 doses are prescribed daily for 3-5
days.
In severe suppurative processes, antistaphylococcal gamma globulin and also immunoglobulins with an increased
content of antibodies to Pseudomonas aeruginosa, Proteus and other gram-negative bacteria are used. The drug is
administered intramuscularly at 3-7 ml daily or every other day (5-7 injections in total).
In extremely severe patients, daily or every other day administration of nonspecific gamma globulin intravenously in
25-50 ml is shown.
Patients with a deficiency of T-lymphocytes, their subpopulations, with a decrease in the level of immunoglobulins
and phagocytosis in an acute infectious process or a tendency to a protracted course, undergo immunomodulatory
therapy.
Sodium nucleinate stimulates the function of almost all parts of cellular and humoral immunity, increases the activity
of phagocytosis and induces the formation of interferon. Sodium nucleinate is administered orally in powders of 0.8-
3.0 g / day in 3 doses for 2-3 weeks (up to 40 g per course). The drug does not give side reactions, there are no
contraindications to it.
Levamisole affects the hormonal response of the immune system, it is used at a dose of 150 mg once orally for a
week or 150 mg for 3 days with a break of 4 days, in total 2-3 courses.
Pentoxyl and methyluracil are prescribed 0.2-0.5 g 3 times a day after meals. The course of treatment for pentoxyl
is 2 weeks, methyluracil - 3. When prescribing these drugs, dyspeptic symptoms may occur. The drugs are
contraindicated in malignant tumors, lymphogranulomatosis and high fever.
T-activin and thymalin contain active substances isolated from the goiter gland of cattle. T-activin is injected s / c at
night once a day, 40 - 100 mcg for 5-7 days. Timalin is administered intramuscularly in a 0.25% solution of novocaine
at a dose of 10-30 mg for 5-20 days.
Topical use of recombinant interleukin-1-betasignificantly increases the adhesive properties of polymorphonuclear
leukocytes in the focus of destruction, the phagocytic activity of neutrophilic granulocytes, their migratory properties
and bactericidal activity. Interleukin-1-beta is applied topically (into the destruction cavity) at the rate of 2-4 ng/kg
body weight three times a week. The introduction should be preceded by sanitation of the destruction cavity, its
transbronchial or transthoracic drainage.
8. Postural drainage with giving the patient such a position in which the lower point of the purulent cavity is the mouth
of the draining bronchus. It is advisable to supplement postural drainage with vibromassage (effleurage on the chest
wall in the projection of the abscess). It should be especially insisted that postural drainage be carried out in the
morning to clear the bronchi of sputum accumulated during the night, and in the evening before bedtime. The number
 16
of procedures is 8-10 times a day, which usually provides a fairly complete independent discharge of purulent sputum. Rational
coughing in a postural, drainage position and vibration massage of the chest wall for some patients is quite effective and ensures the
emptying of the abscess in the lung even with partially impaired patency of the draining bronchus. At the same time, within 1-2
weeks, it is possible to achieve favorable dynamics in the development of changes in the lungs in all cases with well-draining cavities
of destruction and in the majority of those in whom bronchial drainage was not completely preserved.
9. Inhalations of antiseptics, proteolytic enzymes, bronchodilators.
The use of drugs that affect the bronchial mucosa to reduce edema and eliminate bronchospasm (Eufillin -2.4%
solution, 10 ml intravenously 1-2 times a day for 10-12 days, Teofedrin, Bronholitin, etc.). The best way to administer
them is by inhalation. It is advisable to include hormones with a pronounced anti-edematous effect in the composition
of the inhalate. Liquefaction of viscous sputum - expectorants, etc., as well as inhalations with the inclusion of
proteolytic enzymes (Terrilitin, Trypsin, Chymotrypsin, RNase) and Acetylcysteine in a dispersible solution.
10. An effective way to combat hypoxemia is prolonged inhalation of humidified oxygen, which significantly improves
arterial blood oxygenation. For this purpose, paired thin nasopharyngeal catheters lubricated with petroleum jelly
are inserted into the lower nasal passages to a depth of 10-12 cm. The supply of oxygen through them (6-8 l / min)
increases its concentration in the inhaled mixture to 30-50%. This amount of oxygen is quite enough to treat severe
respiratory disorders. At higher concentrations, the toxic effect of oxygen may occur, as well as drying of the mucous
membranes of the respiratory tract with damage to the epithelium.An effective means of combating hypoxia is also
the use of HBO.
Conservative treatment can achieve complete or clinical recovery in almost all patients with acute lung abscesses
with good bronchial drainage. In patients with insufficient drainage, therapy is effective in 80-85% of patients.
Parasurgical measures include drainage of abscess cavities according to Monaldi, drainage of the pleura in case of
parapneumonic empyema of the pleura. Drainage according to Monaldi is subjected to subpleural cavities, and
recently this manipulation is often performed under ultrasound control. For successful drainage of the abscess, the
following conditions are necessary: its subcortical location; at least two weeks from the onset of the disease (the
time required for the development of a mooring that prevents the lung from collapsing); accurate localization of the
abscess with multiple fluoroscopy. Thoracocentesis is performed according to the standard technique. Two-lumen
drainage tubes are widely used for the simultaneous administration of antiseptic solutions and vacuum aspiration.
With peripheral abscesses that do not drain into the bronchus, transthoracic drainage or transbronchial drainage
according to Kuhn
It is advisable for all patients, without exception, to carry out prolonged catheterization of the draining bronchus, in
the form of microconicostomy. Forlavage, carried out 1-3 times per knock, an isotonic solution of sodium chloride is
used with the addition of proteolytic enzymes, bronchodilators, mucolytics and expectorants.

To perform long-term transbronchial catheterization, radiopaque catheters with an outer diameter of 2.0-2.8 mm are
used (ureteral catheters N5-6 on the Charrier scale, angiocatheters N8-9 are suitable for manipulation). The length
of the catheter should be twice the length of the instrumental channel of the bronchoscope. When using catheters of
shorter length, use mandrin, exceeding the length of the instrumental channel of the bronchoscope twice. Departing
from the distal end of the drainage 2-3 mm, several additional lateral holes are made in it at a distance of 2-3 mm
from each other. The distal end is modeled, giving it a shape convenient for manipulation in the tracheobronchial tree.

30-40 minutes before the drainage, the patient is injected with 1-2 ml of a 2% solution of promedol and 1-2 ml of a
2% diphenhydramine to reduce negative emotions before the intervention and to suppress the cough reflex. The
patient is taken to the X-ray room. Produce local anesthesia of the nasal cavity and pharynx by spraying a 10%
solution of lidocaine. The patient is positioned supine on the X-ray table. Under local anesthesia Sol. Trimecaini 2%-
10.0 perform fibrobronchoscopy. The distal end of the bronchoscope is set in the projection of the alleged segmental
or, if possible, subsegmental bronchus draining the abscess cavity. A catheter is inserted into the selected bronchus
through the instrumental channel of the bronchoscope. Its advancement and position in relation to the destruction
cavity is controlled by polypositional fluoroscopy. To clarify the position of the catheter, several milliliters of a contrast
agent are injected through it. When the drainage is localized intracavitary, the contrast spreads along the walls of the
cavity. When performing abscessography in the patient's standing position, the contrast agent accumulates at the
bottom of the abscess. If the catheter is located outside the abscess cavity, the tracheobronchial tree is contrasted
and the contrast does not penetrate into the cavity. In this case, the tube is removed and re-introduced through
another adjacent subsegmental bronchus. Manipulation is continued until the catheter is inserted into the cavity.
 17
Under fluoroscopic control, the bronchoscope is gradually removed, moving the catheter forward and maintaining the
selected position of the distal end of the catheter in the abscess cavity. The catheter is fixed to the skin of the face
with a plaster bandage.

During the day, the patient should be under the supervision of the medical staff on duty. To stop coughing and
sensation of a foreign body in the larynx, antitussive drugs (codeine, libexin) should be prescribed, re-irrigate the
oropharyngeal mucosa with solutions of local anesthetics (2% trimecaine solution, 10% lidocaine aerosol).

Drainage of the destruction cavity using long-term transbronchial catheterization is carried out in the position of the
patient opposite to the drainage one. The volume of the injected solution should not exceed the volume of the cavity,
so as not to cause aspiration. Washing is carried out until a clear wash solution is obtained from the cavity. If
necessary, solutions of adrenomimetics (0.1-0.2 ml of a 0.1% solution of naphthyzinum or galazolin, 0.1-0.2 ml of 5%
ephedrine) are injected into the destruction cavity, which reduces the swelling of the mucous membrane of the
draining bronchi. During days sanitation is repeated from 2 to 5 times. The multiplicity of the procedure is determined
by the nature and phase of the course of the purulent-destructive process and in the 2-3rd phase is limited to 1-2
procedures.

After the end of the procedure, the tracheobronchial tree is anesthetized through a catheter and the necessary drugs
are administered in the antipostural position: antibiotics, antiseptics, hormones, proteolytic enzymes, depending on
the phase of the purulent-destructive process. The patient is offered to be in the indicated position and not cough up
the solution for 1-2 hours.

The technique allows you to act directly on the pathological focus in the lung the required number of times during the
day. In addition, the technique avoids the complications inherent in transthoracic drainage and transbronchial
catheterization using microtracheostomy access (pyopneumothorax, suppuration and emphysema of the tissues of
the neck and chest wall, injury of neck vessels, pulmonary bleeding).

The main disadvantages of transbronchial drainage of the destruction cavity and possible complications are:
hemoptysis (up to 5%), aspiration of the contents of the destruction cavity into healthy sections of the tracheobronchial
tree (up to 1%), catheter migration from the abscess cavity (up to 10%), laryngospasm (no more than 1% ).

The disadvantage of long-term transbronchial catheterization is the blockage of the drainage tube with thick pus and
lung tissue sequesters, which makes it impossible to aspirate the contents of the abscess through the catheter. This
disadvantage is easily eliminated with the help of proteolytic enzymes and mucolytics.

In some cases, it is advisable to resort to flow-wash drainage of the destruction cavity, which is carried out by
combining transthoracic and transbronchial drainage. The advantages of this technique are especially noticeable with
large (more than 5 cm) sizes of the abscess cavity. The use of lavages should always be preceded by an
abscessography. It allows you to determine the localization of the draining bronchi and choose the position of the
patient's body, in which washing excludes aspiration of the solution into the healthy parts of the tracheobronchial tree.
The essence of local treatment and the arsenal of medications when using this method of sanitation of the destruction
cavity does not differ significantly from those described above.

With bronchopleural fistulas, it is optimal to combine catheterization of the bronchus with its simultaneous
occlusion.Moreover, the distal end of the microconicostomy is wound behind the occluder, which allows irrigation
with drugs directly to the pathological focus. In this case, the effect of “double” drainage of the cavity occurs, on the
one hand, contamination of the contralateral lung is prevented, on the other hand, the fatal consequences of
probable profuse bleeding. The catheter can stay in the abscess cavity for 1-1.5 weeks, which, as a rule, does not
have undesirable consequences. However, frequent x-ray control is necessary for timely detection of catheter
migration. In some cases, it is advisable to flush the abscess cavity through the catheter in a postural position.
 18
The main mechanisms that make up the therapeutic effect of temporary endobronchial occlusion can be reduced to
two main ones: 1) sealing of the tracheobronchial tree; 2) protection of healthy sections of the tracheobronchial tree
from aspiration of pathological contents (blood, sputum, pleural exudate, etc.). Sealing the tracheobronchial tree
allows you to temporarily eliminate broncho-pleural communications and thereby restore negative pressure in the
pleural cavity or destruction cavity, and therefore, at the cost of temporary atelectasis of the affected area of the lung
parenchyma, create conditions for straightening the collapsed lung. Sealing the fistula-bearing bronchus eliminates
the pathological discharge of air from the respiratory tract, the so-called "bronchial discharge" syndrome, which allows
you to restore the aerodynamics of the respiratory tract and improve the conditions of pulmonary ventilation, as well
as create "rest" for central or peripheral bronchial fistulas in the treatment of their failure. Blockade of the bronchus in
combination with external drainage may be the method of choice in providing emergency care to patients with
decompensated tension pneumothorax, tension lung cyst, subcutaneous and mediastinal emphysema.

The protective mechanism of temporary endobronchial occlusion allows it to be used for pulmonary bleeding, for
intraoperative blockade of the affected area of the lung, for protecting a healthy lung from aspiration of purulent
sputum in case of lung gangrene during the preparation of patients for surgical treatment, as well as for creating
favorable conditions for sanitation of intrapulmonary and pleural cavities, communicating with the tracheobronchial
tree.

Thus, the main indications for the use of temporary endobronchial occlusion in patients with purulent-destructive
lesions of the lungs and pleura are:

 acute pyopneumothorax with a limited purulent-destructive process in the lung;

 failure of the stump of the lobar bronchus and lung tissue after partial resections of the lungs;
 acute "giant" abscesses of the lungs, subject to their external transthoracic drainage;
 massive pulmonary bleeding with the threat of asphyxia;
 blockade of the bronchus of the affected area of the lung during surgery;
 blockade of the bronchus, draining the area of the lung, carrying peripheral bronchial fistulas ("lattice" lung) in
combination with muscular plasticity;
 open chronic pleural empyema and pyopneumothorax with widespread lung gangrene to seal the bronchial
tree of the affected lung in preparing patients for surgery.

Contraindications for temporary endobronchial occlusion are:

 the presence of a purulent-destructive process in the lung in the absence of external drainage of the pleural
cavity or a focus of destruction;
 general contraindications for bronchoscopy.
 19
Occlusion of the main or intermediate bronchus is possible only with rigid bronchoscopy. Selective delimitation of
the abscess is carried out using a fibrobronchoscope. A string is inserted into a radiopaque catheter pre-modeled in
shape, facilitating its advancement into the segmental and subsegmental bronchi. With blocked abscesses, the
above technique can be supplemented by bougienage of the corresponding bronchus with a string, along which a
catheter is then introduced into the purulent cavity.
Sanitary bronchoscopy is performed mainly in patients on mechanical ventilation or when it is impossible to install a
conico- or microtracheostomy. Antibacterial drugs, proteolytic enzymes, mucolytics and bronchodilators are used
for sanitation. The number of therapeutic bronchoscopies does not exceed 2 procedures per week and 3-5 per
course of treatment.
Therapeutic bronchoscopy - multiple sanitation of the tracheobronchial tree (especially in patients on mechanical
ventilation), selective microtracheostomy, transbronchial drainage (unblocking) of the abscess cavity, occlusion of
the fistulous bronchus and endoscopic arrest of pulmonary hemorrhage.
Bronchial arteriography is valuable in the development of pulmonary bleeding (endovascular hemostasis). It is
achieved by the introduction of non-absorbable materials - finely porous foam rubber or Teflon velor. The
manipulation ends with the installation of a catheter at the mouth of the bronchial artery for endovascular regional
infusion therapy (ERIT) for up to 6-7 days.

Surgery

Indications for urgent operations:

 pulmonary bleeding;
 hemoptysis, not stopped by complex hemostatic therapy;
 pyopneumothorax, which developed as a result of an abscess rupture into the pleural cavity, accompanied by
elements of tension pneumothorax (total collapse of the lung, progressive subcutaneous emphysema, extracardiac
tamponade of the heart), despite the ongoing complex of conservative measures (early drainage of the pleural cavity,
active vacuum aspiration, temporary endobronchial occlusion).

Indications for planned surgical interventions for infectious destructions of the lungs are:

 gangrene of the lung (common and limited after the maximum possible sanitation of the abscess). The
condition for a successful outcome of the operation is the stabilization of the patient's condition, the correction of the
main indicators of homeostasis, the sanitation of the focus of destruction in the preoperative period;
 failure of conservative treatment;
 chronic lung abscess.

Elective surgeries for infectious destruction of the lungs are performed due to the futility of conservative treatment,
but provided that it is carried out in full. This applies to large abscesses, occupying up to 1/3 of the volume of a lung
lobe and not tending to decrease within 4-6 weeks from the start of a full sanitation of the cavity. This period,
according to our observations, is optimal.

Currently, the most recognized for lung gangrene is the implementation of a radical anatomical excision of necrotic
tissue - lobectomy or pneumonectomy, under endotracheal anesthesia with separate bronchial intubation. Drainage
operations, such as pneumotomy or thoracoabscessotomy (Gostishchev V.K. et al., 2001), followed by the formation
of a pleurostomy and prolonged debridement of limited gangrene (gangrenous abscess), also remain in the surgical
arsenal. The optimal term for surgical treatment is 14-21 days from the onset of the development of the destructive
process with stabilization of the general condition of the patient.
These types of operations historically preceded resection methods and are exhaustively described in the classic
manual of Beer A., Brown G. and Kümmel G. (1930).
Widespread gangrene of the lung remains one of the most severe lung diseases, with conservative treatment of
which the mortality rate reaches 100%. The first successful pneumonectomy for suppuration in the lung was
performed in 1931 by Nissen. In 1937, Rienhoff made the first pneumonectomy with separate processing of elements
 20
of the lung root. In Russia, a successful pneumonectomy was performed in 1946 by V.N. Shamov with bronchiectasis
and A.N. Bakulev in lung cancer.
With gangrene of the lung, active surgical tactics, which consists in performing radical operations to remove the
source of infection, does not cause reasonable objections. The optimal timing of surgical treatment is 14-21 days
from the onset of the development of the destructive process in the lung with stabilization of the general condition of
the patient.

Drainage abscess lung

Flow-washing drainage of acute lung abscesses is carried out with two drains introduced using thoracocentesis. A
trocar is used, which is inserted through a small incision in the skin of the chest wall in the corresponding intercostal
space along the shortest path. The puncture point is marked under the X-ray screen in the upper and lower poles of
the abscess. The trocar is passed through the skin incision, advanced through the fascia, muscles, pleura,
penetration into the abscess cavity is determined by overcoming some resistance.
After removal of the stylet, pus begins to flow through the trocar tube. Through the cannula of the trocar, a drainage
tube is inserted into the cavity of the abscess, the tube and cannula are removed. A skin incision is sutured and a
drainage tube is fixed with a thread.
The lower pole is drained with a 6-7 mm tube and connected to a vacuum system (suction OP-1, water-jet suction).
Through the top pole enter a tube with a diameter of 2 — 3 mm. It serves to introduce solutions of antiseptics,
antibiotics, proteolytic enzymes into the abscess cavity. To combat anaerobic flora, the abscess cavity is periodically
purged with air or oxygen. Periodically, the cavity is filled with glycerin to stimulate reparative regeneration.

Thoracoabscessoscopy
Indications for thoracoabscessoscopy are acute lung abscesses with a cavity larger than 5 cm in diameter, an
abscess breakthrough into the pleural cavity with the formation of pyopneumothorax, and the need to determine the
nature of lung tissue destruction.
Under x-ray control with multi-axial transillumination of the chest, a point for puncture of the chest wall is determined.
Under local infiltration anesthesia or intravenous anesthesia, the skin is incised with a scalpel (incision length 1 cm)
and through this incision the chest wall is punctured with a trocar. The latter is carried out through the chest wall and
lung tissue. The trocar stylet is removed, the elastic tip of the aspirator is inserted through the cannula and the
contents of the abscess are removed. Then the thoracoscope tube is inserted through the trocar cannula. With
purulent abscesses, the contents of the abscess have a white, yellow, green color, thick consistency. The inner
surface of the cavity is smooth, regular in shape, covered with fibrin. In the presence of a draining bronchus, its
lumen is determined. A gangrenous abscess is characterized by a liquid discharge with fragments of necrotic tissue,
putrid odor of contents. The cavity of the abscess is irregularly shaped with foci of necrosis of the wall, fibrinous and
dirty greenish necrotic accumulations. Sequestered gray lung tissue lies freely in the abscess cavity or is partially
associated with one of its walls.
If it is necessary to introduce an instrument into the abscess cavity (forceps for crushing sequesters or drainage for
washing the abscess cavity), under visual control through a thoracoscope, an additional puncture of the abscess is
performed with a trocar of a smaller diameter. Then, an instrument or drainage is inserted through its cannula and
manipulations are performed in the abscess cavity. The abscessoscopy is completed by introducing a drainage tube
into the cavity of the abscess through the trocar cannula used to introduce the thoracoscope, or with two drainages
(the second drainage is carried out through an additional puncture). This method of debridement of a lung abscess
is alternative to pneumotomy, but less traumatic.

Pneumotomy
In case of lung abscess, lung tissue sequestration, when bronchopulmonary sanitation, transparietal puncture are
ineffective, and radical surgery (lobectomy, pulmonectomy) is impossible due to the patient's serious condition, the
only method that gives hope for saving the patient's life is opening and draining the abscess. This operation is called
pneumotomy. With gangrene of the lung and sequestration of lung tissue with the formation of a gangrenous
abscess, the operation is performed in an emergency okay.
The position of the patient on the operating table is determined by the location of the abscess. Given the most
frequent localization in the posterolateral sections of the lung, the patient is placed on the stomach or healthy side.
 21
Before the operation, under the X-ray screen, the point of the closest location of the abscess to the chest wall is
marked. With abscesses of the upper lobe, the incision is made in the axillary region, since the scapula behind and
the muscle mass in front do not allow for a good surgical access.
The incision is made along the rib closest to the abscess. The length of the incision is 9-10 cm. A section of one or
two ribs 5-6 cm long is resected subperiosteally. The periosteum is dissected in the region of the rib bed and the
parietal pleura is exposed. If the latter is thickened, the lung tissue does not shine through it, which indicates
obliteration of the pleural fissure, the abscess is punctured with a thick needle. When pus appears or a sensation of
“failure” occurs, the needles are passed through the needle with a scalpel into the abscess cavity, pus is aspirated
by suction and the resulting hole is expanded with an instrument (forceps, Billroth clamp) or a finger, thick pus is
aspirated, sequesters and tissue detritus are removed. Access to the abscess should be chosen so that the
penetration into the abscess cavity is carried out in the shortest way, through the thinnest layer of lung tissue. The
abscess cavity is drained with a tube, which is fixed to the skin with one or two sutures. The edges of the wound are
brought together with sutures to drainage. After the operation, aspiration drainage of the abscess cavity is performed.
Sometimes it is necessary to perform the operation in 2 stages, which is a necessary measure in a situation where,
after resection of the rib and dissection of the periosteum, a thin, transparent sheet of the parietal pleura is revealed
and the movable surface of the lung shines through it. In this case, performing a pneumotomy is risky due to the risk
of infection of the pleural cavity during the opening of the abscess. In this case, the pleura is not dissected, a gauze
swab is brought to it, the wound is sutured. After 8-10 days, when obliteration of the pleural fissure occurs due to
the fusion of the parietal and visceral pleura, the second stage of the operation is performed - opening and drainage
of the abscess. The edges of the lung incision are sutured with separate sutures to the parietal pleura or aponeurosis.
With large abscesses, a thinned area of \u200b\u200blung tissue that makes up the wall of the abscess
wide pneumotomy.The operation is performed with multiple abscesses as forced, when a radical lung resection
operation is impossible due to the severity of the patient's condition. The purpose of the operation is to open and
drain all abscesses, remove existing lung tissue sequesters. To do this, the lung is exposed throughout the lesion,
which is achieved by removing 4-5 ribs, each of which is resected for 8-10 cm. After resection of the ribs, the
intercostal muscles are excised and the parietal pleura is exposed. When obliterating the pleural fissure, the pleura
is dissected, the lung is exposed, punctured and the abscess is opened along the needle. Pus is aspirated. The
cavity of the abscess is opened widely with excision of the thinned lung tissue. Abscesses located in the depths are
opened in a blunt way and everything is connected into one large cavity. The edges of the resulting cavity are sutured
to the pleura, aponeurosis, perform a semblance of marsupialization and fill with a swab with a water-soluble
ointment. The operation leads to the formation of persistent multiple bronchial fistulas (ethmoid lung), which then
requires resection of the lung or special plastic closure of the fistulas. Not being radical, the operation allows you to
bring patients out of a state of severe intoxication, improves their condition.

The operation of choice for gangrenous abscesses and gangrenes of the lung is thoracoabscessostomy followed by
staged necrosequestrectomy and sanitation of the decay cavity. Thoracoabscessostomy is an improved version of
the draining operation - pneumotomy. The disadvantages of the well-known pneumotomy include the possibility of
arrosive bleeding and persistent bronchothoracic fistulas, requiring complex resection methods of treatment, as well
as severe phlegmon of the chest wall, osteomyelitis and chondritis of the ribs.
The essence of thoracoabscessostomy is as follows. After verification of the cavity (cavities) of decay in the lung
under X-ray control on the eve of the operation, the optimal surgical approach is planned. At the same time, one
should strive to ensure that it is located in the area of the closest fit of the destruction cavity to the chest wall, which
makes it possible to reduce trauma to the lung tissue and avoid infection of the pleural cavity. In some cases,
ultrasound can supplement the data of fluoroscopy. Operations are performed under endotracheal anesthesia with
separate bronchial intubation. The length of the incision should be adequate to the size of the destruction cavity. A
limited thoracotomy is performed through the bed of resected 1-2 ribs and opening of the decay cavity,
necrosequestrectomy - removal of free-lying sequesters. Attention is drawn to the presence of sufficiently large
thrombosed vessels, protruding into the lumen of the destruction cavity. During the operation, multiple areas of lung
tissue decay tend to be transferred into a single cavity. Due to the risk of bleeding, excision of fixed necrotic tissues
is not carried out, and viable lung tissue is also not affected. The draining bronchi that open into the destruction
cavity are sutured with polysorb on an atraumatic needle. Sanitation is carried out using mechanical antiseptics,
massive washing with antiseptic solutions, most often with 0.1% sodium hypochlorite solution.
 22
Thoracoabscessostomy is formed by suturing the parietal pleura and periosteum to the skin with removable sutures,
with careful adaptation of the skin and pleurosubperiosteal flaps, which close the ends of the resected ribs. The
operation is completed with the introduction of tampons with levomikol ointment into the cavity. During the operation,
multiple areas of lung tissue decay tend to be transferred into a single cavity. Due to the risk of bleeding, excision
of fixed necrotic tissues is not carried out, and viable lung tissue is also not affected. The draining bronchi that open
into the destruction cavity are sutured with polysorb on an atraumatic needle. Sanitation is carried out using
mechanical antiseptics, massive washing with antiseptic solutions, most often with 0.1% sodium hypochlorite
solution. Thoracoabscessostomy is formed by suturing the parietal pleura and periosteum to the skin with removable
sutures, with careful adaptation of the skin and pleurosubperiosteal flaps, which close the ends of the resected ribs.
The operation is completed with the introduction of tampons with levomikol ointment into the cavity. During the
operation, multiple areas of lung tissue decay tend to be transferred into a single cavity. Due to the risk of bleeding,
excision of fixed necrotic tissues is not carried out, and viable lung tissue is also not affected. The draining bronchi
that open into the destruction cavity are sutured with polysorb on an atraumatic needle. Sanitation is carried out
using mechanical antiseptics, massive washing with antiseptic solutions, most often with 0.1% sodium hypochlorite
solution. Thoracoabscessostomy is formed by suturing the parietal pleura and periosteum to the skin with removable
sutures, with careful adaptation of the skin and pleurosubperiosteal flaps, which close the ends of the resected ribs.
The operation is completed with the introduction of tampons with levomikol ointment into the cavity. Due to the risk
of bleeding, excision of fixed necrotic tissues is not carried out, and viable lung tissue is also not affected. The
draining bronchi that open into the destruction cavity are sutured with polysorb on an atraumatic needle. Sanitation
is carried out using mechanical antiseptics, massive washing with antiseptic solutions, most often with 0.1% sodium
hypochlorite solution. Thoracoabscessostomy is formed by suturing the parietal pleura and periosteum to the skin
with removable sutures, with careful adaptation of the skin and pleurosubperiosteal flaps, which close the ends of
the resected ribs. The operation is completed with the introduction of tampons with levomikol ointment into the cavity.
Due to the risk of bleeding, excision of fixed necrotic tissues is not carried out, and viable lung tissue is also not
affected. The draining bronchi that open into the destruction cavity are sutured with polysorb on an atraumatic
needle. Sanitation is carried out using mechanical antiseptics, massive washing with antiseptic solutions, most often
with 0.1% sodium hypochlorite solution. Thoracoabscessostomy is formed by suturing the parietal pleura and
periosteum to the skin with removable sutures, with careful adaptation of the skin and pleurosubperiosteal flaps,
which close the ends of the resected ribs. The operation is completed with the introduction of tampons with levomikol
ointment into the cavity. Sanitation is carried out using mechanical antiseptics, massive washing with antiseptic
solutions, most often with 0.1% sodium hypochlorite solution. Thoracoabscessostomy is formed by suturing the
parietal pleura and periosteum to the skin with removable sutures, with careful adaptation of the skin and
pleurosubperiosteal flaps, which close the ends of the resected ribs. The operation is completed with the introduction
of tampons with levomikol ointment into the cavity. Sanitation is carried out using mechanical antiseptics, massive
washing with antiseptic solutions, most often with 0.1% sodium hypochlorite solution. Thoracoabscessostomy is
formed by suturing the parietal pleura and periosteum to the skin with removable sutures, with careful adaptation of
the skin and pleurosubperiosteal flaps, which close the ends of the resected ribs. The operation is completed with
the introduction of tampons with levomikol ointment into the cavity.
Subsequently, staged sanitation of the destruction cavity is carried out, which includes excision of sloughing necrotic
areas of the lung tissue, ultrasonic cavitation, chemical necrectomy, ozonation and treatment of the cavity with
antiseptic solutions (sodium hypochlorite 0.05%). The formed thoracoabscessostomy allows you to visually control
the course of the wound process and actively influence it. Thoracoabscessoscopy using a thoracoscope makes it
possible to more accurately determine the condition of the internal walls of the abscess, evaluate the effectiveness
of the treatment, and also identify small bronchi that open into the abscess cavity, which, if possible, are sutured.
At the beginning, abscess cavities have an irregular shape, their walls are uneven due to necrotic areas of the lung
tissue and fibrin deposits, they contain purulent exudate of a dirty brown color with a putrid odor. As staged
rehabilitations are carried out, the decay cavity is cleared of necrotic tissues and decreases in size due to the
expansion of the lung, the growth of granulation tissue.
Thoracoabscessostomy is the method of choice in the treatment of gangrene of the lung and gangrenous abscesses
with sequesters in the cavity of destructionwhen conservative treatment is futile, and the risk of radical surgery is
extremely high. It should be noted that technically performing thoracoabscessostomy is not so difficult, short in time,
 23
and patients easily tolerate this operation. Thoracoabscessostomy is done for health reasons and most often leads
to clinical recovery.

Peculiarities radical operations at purulent diseases lungs

Operations for purulent-inflammatory diseases of the lungs are characterized by the difficulty of mobilizing the lung
and elements of its root, significant blood loss. This is due to a pronounced adhesive process in the pleural cavity,
the presence of powerful mooring lines, the separation of which is fraught with bleeding. When performing the
operation, there is a risk of opening a lung abscess and infection of the pleural cavity and wounds of the chest wall.
Anterolateral access provides a wide opening of the chest, a good view, opens the anterior surface of the lung root.
Convenient for left side pulmonectomy, upper lobectomy and right side pulmonectomy and upper lobectomy, middle
lobe removal.
The use of an anterolateral approach provides a good approach to the pulmonary vessels. Isolation and ligation of
the pulmonary artery creates a safer environment for ligation of the pulmonary veins.
The patient is on his back, the side is slightly raised, the arm is bent at the elbow and fixed above the patient's head.
The skin incision begins at the sternum, is carried out along the IV rib and ends at the level of the midaxillary line.
The intercostal muscles are dissected, not reaching 1.5-2 cm to the sternum. With this access, it is convenient to
carry out anesthesia, aspiration of the contents of the bronchi during the operation, but hermetic closure of the wound
of the chest wall is difficult.
Side accessapplicable to perform all kinds of operations on the lung. It combines the advantages of anterior and
posterior access.
The operation is performed in the position of the patient on a healthy side. The hand on the side of the operation is
taken up and fixed. The skin incision starts from the posterior axillary line or from the angle of the scapula and is
carried out along the V rib 2-3 cm below the nipple in men or under the mammary gland in women and continues to
the mid-clavicular line. The latissimus dorsi and pectoralis major muscles are partially incised at a distance of 3-4
cm, the serratus muscle is stratified along the fibers. The intercostal muscles, together with the pleura, are dissected,
and then bluntly divided along the ribs. The pleural cavity is opened along the fifth intercostal space.
In chronic purulent-inflammatory diseases, surgical access is usually supplemented by resection of one of the ribs
or the intersection of two adjacent ones, which creates more favorable conditions for mobilizing the lung and
approaching the root of the lung or lobe. Resection of the rib also makes it possible to achieve better tightness of
the chest wall when suturing the surgical wound. The opening of the corresponding intercostal space is determined
by the nature of the proposed resection: with an upper lobectomy, the chest cavity is opened through the fourth
intercostal space, with a pulmonectomy or lower lobectomy, through the fourth or fifth intercostal space.
With posterolateral accessa skin incision is made from the level of the spinous process of the IV thoracic vertebra
and is led downward along the paravertebral line, bordering the angle of the scapula and continuing along the VI rib
to the anterior axillary line. Dissect all the muscles along the skin incision to the ribs. Throughout the incision, a
subperiosteal rib is resected, crossing it as close as possible to the spine. The pleural cavity is opened through the
bed of the removed rib, dissecting the periosteum, intrathoracic fascia and parietal pleura.
After dissection of the parietal pleura, the adhesions along the incision are carefully separated with a finger, so that
the cartilages of adjacent ribs and intercostal muscles can be freely cut. The intersection of the cartilage of the rib is
necessary in the case of adhesions of the lung with the pericardium and diaphragm. Cartilages are crossed at a
distance of 2-3 cm from the edge of the sternum. After separating the adhesions along the edges of the chest wall
incision and along the anterior and lateral surfaces of the lung, the retractor is inserted, its jaws are carefully parted
so as not to break the adhesions and lung tissue. Such a complication can lead to the opening of the abscess and
infection of the pleural cavity and wounds of the chest wall. Gauze pads are placed under the dilator jaws to reduce
the chance of wound infection. The wound dilator is gradually diluted, additionally dissected with a sharp scalpel or
an fusion electroknife. Break tight adhesions, i.e. to separate the adhesions in a blunt way, it is dangerous because
of the rupture of the lung. Dissection of adhesions with scissors, electrocautery should be performed closer to the
lung, retreating from the chest wall, pericardium, mediastinum, diaphragm. With this separation of adhesions,
bleeding is less. For better separation of adhesions, they can be infiltrated with a 0.25-0.5% solution of novocaine
(hydraulic preparation according to Vishnevsky). After the anterior and lateral surfaces of the lung are completely
freed from adhesions, the wound is expanded as much as possible. Next, it is necessary to perform complete
pneumolysis - the release of the lung from adhesions, before proceeding with the isolation and processing of the
 24
elements of the lung root. The most massive attachments are determined more often in the posterior and lower
sections of the pleural cavity. Separation of these adhesions from the anterior approach is difficult, therefore, it
becomes necessary to cross one or two ribs in the lower corner of the wound. Massive cicatricial adhesions can be
difficult to separate under these conditions. In such cases, in order to avoid damage to the lung and opening of the
abscess, it is advisable to separate the lung along with the parietal pleura and intrathoracic fascia. Particular care
must be taken when dissecting the apex of the lung due to the risk of damage to the subclavian vessels.
When separating adhesions, if bleeding occurs, then it is stopped by electrocoagulation, sheathing of bleeding areas
with a purse-string, Z-shaped or mattress suture. For the purpose of hemostasis, a hemostatic sponge is used.
Separation of the adhesions allows the root of the lung to be released so that it can be bypassed from all sides. Due
to pronounced cicatricial changes or inflammatory infiltrate in the region of the lung root, the isolation of vessels is
associated with the risk of damage to them and the development of bleeding. The mobilized root of the lung, due to
its release from adhesions, facilitates manipulations to stop the bleeding that has occurred.
Intrapericardial ligation of the vessels of the root of the lung in purulent-inflammatory diseases is rarely resorted to.
In the presence of gross adhesions or inflammatory infiltrate in the region of the lung root, the isolation and ligation
of vessels are associated with a high risk of vascular damage and bleeding. Of particular difficulty is the isolation of
the posterior wall of the vessels, which is performed blindly, by touch with the help of a dissector, a Fedorov clamp
(in the presence of adhesions, scars, damage to the vessel is possible). If bleeding occurs, you should squeeze the
root of the lung with your fingers, bypassing it, press the bleeding vessel with a tupfer and try to apply a Billroth-type
hemostatic clamp and proceed with intrapericardial isolation and ligation of the vessels. To continue to stop bleeding
from the vessels of the root of the lung in such conditions is a difficult task, associated with significant blood loss. In
the presence of these changes in the root of the lung, one should immediately proceed to intrapericardial ligation of
the vessels. When isolating the vessels of the lung root, P. A. Kupriyanov recommended using a dense gauze ball
clamped in a Mikulich clamp. With such a ball, the pericardium is peeled off from the anterior surface of the
pulmonary artery, which makes it possible to apply a ligature to the vessel. If the pericardium is opened with this
exposure, this opening can be widened with scissors and the vessel ligated intrapericardially. With such a ball, the
pericardium is peeled off from the anterior surface of the pulmonary artery, which makes it possible to apply a ligature
to the vessel. If the pericardium is opened with this exposure, this opening can be widened with scissors and the
vessel ligated intrapericardially. With such a ball, the pericardium is peeled off from the anterior surface of the
pulmonary artery, which makes it possible to apply a ligature to the vessel. If the pericardium is opened with this
exposure, this opening can be widened with scissors and the vessel ligated intrapericardially.
Pericardiotomy is performed with a linear incision parallel to the phrenic nerve, retreating from it posteriorly by 1-1.5
cm. If the phrenic nerve makes it difficult to expand the incision, then it can be crossed. The opened sheets of the
pericardium are bred to the sides and expose the posterior sheet of the pericardium, which covers the vessels. A
solution of novocaine is injected under the posterior leaf of the pericardium on the left, it is notched, it is peeled off
from the pulmonary artery and in a blunt way, using a Fedorov clamp, the posterior surface of the artery is bypassed
and the end of the clamp is brought out above the artery trunk. It is more expedient to hold the ends of the clamp
from the bottom up, insert the clamp between the superior vein and the artery and withdraw it at the upper edge of
the artery, protruding the posterior pericardium. The pericardium is incised above the end of the clamp, the clamp is
removed, the ligature is grasped and the ligature is passed in reverse motion and the artery is ligated.

Intrapericardial ligation of vessels of the right lung. 1 - allotted sheets of the

pericardium; 2-phrenic nerve.

After the injection of novocaine, Fedorov's clamp is brought

under the upper edge of the superior vein, bypasses its back
surface and protrudes the pericardium (its posterior leaf) with the
tip of the clamp, incised. The reverse stroke of the clamp is
carried out with a ligature and the vein is tied up. Do the same
with the inferior vein (Fig. 1). However, in the pericardial cavity,
the upper and lower veins may have a common trunk, the
ligation of which both pulmonary veins are ligated. This
anatomical variant of the vessels should be remembered, and in
 25
order to be convinced of this, one should carefully examine their position. Inward abduction of the heart may reveal
a fold that indicates an additional vein that needs to be ligated.

Techniques for intrapericardial ligation of the vessels of the right lung are similar to those for ligation of vessels on
the left. Inconvenience for the selection of vessels on the right is created by the inferior and superior vena cava. To
facilitate access to the vessels, the superior vena cava is retracted medially and anteriorly. In a situation where the
intrapericardial ligation of the vessels of the right lung is difficult due to the applied clamp on the vessel during
bleeding that occurred during the exposure of the vessels of the lung root, the vessels are isolated and ligated
 26
medially from the superior vena cava. To do this, the superior vena cava is retracted carefully outward and the artery
is exposed, which is well accessible for ligation here, since it is located in the pericardial cavity on 3/4 of its
circumference. Distally from the superimposed ligature, a second ligature is applied with the vessel stitched.

Crossing the vessels of the hilum of the lung. Vessel chipping

1—pulmonary artery; 2-bronchial stump; 1-stump of a bandaged vessel
3—superior pulmonary vein; 4—lower pulmonary vein; 2-purse suture on the lung parenchyma around
5 — a line of a cut-off of a lung; 6 - easy. peripheral end of the transected vessel

During pulmonectomy, lobectomy, and lung mobilization, care must be taken near the abscess to avoid opening it
and infecting the pleural cavity. To cross the adhesions, the lung is displaced in the opposite direction or taken out
into the wound, as if pulling the adhesions. To isolate the vessels of the root of the lung, the latter is taken outwards
from the root or removed from the wound, fixing the lung with a terminal clamp, the branches of which are covered
with a gauze napkin so as not to damage the lung. When highlighting the vessels of the root of the lung, the back
wall of them is isolated with a finger. If it is difficult to separate the posterior wall of the vessel with a finger, you can
use the Fedorov clamp, but then you should release the posterior wall at a distance of 1.5-2.0 cm with your finger
so that you can tie the vessel proximally. Distal to the applied ligature, the vessel is tied with a ligature with the
vessel stitched, the third ligature is applied as much as possible at the gate of the lung, even capturing the lung
tissue in the ligature, if the vessels are isolated at a short distance. Two ligatures are left at the proximal end of the
vessel (one of them with vessel stitching). The bronchus is stitched with the UKL-40, UO or manually.
Separation of the lobe is performed after pinching or crossing and flashing the vessels. The lobe is r emoved after
inflation with an anestheticapparatus of the remaining share. This allows you to clearly define the boundary of the
shares - the fallen one is removed and the remaining one is inflated. The pleura is incised in the region of the
interlobar fissure and the interlobar fissure is stratified with a tight tupfer or a napkin, the removed lobe is separated.
Suturing the wound of the chest wall with access through the bed of the removed rib is performed as follows. First,
separate catgut sutures are placed on the periosteum and parietal pleura, then sutures are placed on the dentate
and rhomboid muscles, a number of sutures are placed on the fascia.
With access made through the intercostal space, catgut sutures are placed on the intercostal muscles and
pleura and do not tie them. Then the ribs are brought together with a costal retractor. Separate sutures are
applied from thick catgut, bypassing the ribs, and tied. After that, the sutures placed on the intercostal muscles
are tied. Muscles, fascia, skin are sutured in layers.
 27

Flashing of the bronchus with the UKL apparatus.

on the proximal end of the bronchus superimposed branches of the apparatus;

Stages of suturing the bronchus stump.

I—the stump is stitched with separate seams; II - the seams are tightened; III—the bronchus stump is pleurisy.

Failure of the stump of the main bronchus after pneumonectomy for gangrene of the lung
Mortality after radical surgical treatment of lung gangrene, unfortunately, remains high not only due to multiple organ
dysfunction in conditions of pleuropulmonary sepsis, but also local, difficult to correct complications, among which
bronchus stump failure and bronchial fistulas occupy a special place. The incidence of bronchus stump failure (BCL)
can reach 50-65%, and mortality in the event of this life-threatening complication is 56-70%.
Depending on the size of the fistula, E. A. Wagner et al. (1993) divide the NCH into three degrees: I - fistula diameter
up to 0.4 cm, II - up to 1 cm, III - more than 1 cm and complete divergence of the bronchial walls. Failure of the
bronchus stump occurs as a result of violations of the conditions necessary for wound healing by primary intention
- this is crushing the bronchus with the branches of the stapler, poor-quality stitching of the stump with individual
tantalum brackets, additional imposition of frequent sutures on the damaged area, causing a violation of the blood
supply to the bronchus stump and provoking repeated failure. The blood supply to the tissues of the stump is
disturbed when the bronchus is isolated from the fiber of the root; conducting sutures through the mucous
membranes and the lumen of the bronchus contributes to the infection of the wound tissues, the formation of ligature
bronchopleural messages;
The above causes of NKB are universal for surgical interventions performed for any pulmonary pathology. In the
case of widespread gangrene of the lung, another important factor is added - these are the phenomena of necrotic
panbronchitis. Histological studies of the edges of the transected bronchus demonstrated a deep involvement in the
destructive inflammatory process of all its layers, including cartilaginous tissue.
 28
The above factors led to the formation of a new direction - intraluminal formation of the stump of the main bronchus.
As a plastic material, both muscle tissue (the latissimus dorsi muscle) and the greater omentum were used. The
essence of the method of intraluminal closure of the incompetence of the stump of the bronchus and bronchial fistula
using a muscle flap with preserved axial blood supply is as follows.
Myobronchoplasty for failure of the stump of the main bronchus

An autograft was mobilized from the latissimus dorsi muscle by crossing

three fixation points - from the iliac crest, spinous processes of the
vertebrae, and lower ribs. A large and mobile muscle flap was formed
from it. Next, three strands were formed from the distal end of the muscle
graft. The middle strand was adapted to the size of the lumen of the
bronchus stump and was inserted to the carina of the trachea under the
control of a fiberoptic bronchoscope. The outer strands were placed
peribronchially and circularly fixed with separate sutures. Thus, effective
occlusion of the fistula was achieved. In cases of violation of the axial
blood supply to the latissimus dorsi muscle or its atrophy, it is advisable
to perform intraluminal omentobronchoplasty.

Omentobronchoplasty in bronchial fistula of the stump of the main bronchus

(scheme)

It is carried out according to the following method: after mobilization

of the bronchus stump and sanitation of the pleural cavity, an upper
median laparotomy is performed, the greater omentum is
mobilized. Preservation of the blood supply to the graft is carried
out by the branches of the left gastroepiploic artery. The graft is
passed into the chest cavity through a window in the diaphragm in
the region of the costophrenic sinus. And then, by analogy with a
muscle graft, intraluminal bronchoplasty is performed.
Experience in the treatment of patients with NCD shows the
advantage of plastic methods of shelter during primary and secondary operations for lung gangrene. Fistula
recurrences occur in 9.2% of cases, postoperative mortality decreased from 79.4% to 15.6%.

Pulmonary bleeding
Pulmonary haemorrhage (PCH) is a life-threatening OPD. Its frequency reaches 12-27% and is not directly
dependent on the massiveness of lung tissue damage. As for the source of bleeding, it is now generally accepted
that both the branches of the pulmonary artery and the bronchial arteries (mainly), when they are involved in the
pathological process, can cause hemorrhages of varying intensity.
Classification:
I degree (hemoptysis)
I a - 50 ml per day;
I b - from 50 to 200 ml per day;
I in - from 200 to 500 ml per day.
II degree (massive bleeding)
IIa - from 30 to 200 ml per hour;
II b - from 200 to 500 ml per hour.
III degree (profuse bleeding)
III a - 100 ml or more at once. Accompanied by severe violations of ventilation of the lungs;
III b - acute obstruction of the tracheobronchial tree and asphyxia, regardless of the amount of blood loss.
The algorithm includes endoscopic bronchus occlusion and endovascular occlusion of bronchial arteries as the main
interventions.
 29
As an endoscopic aid in the first degree of pulmonary hemorrhage, preference is given to selective occlusion of
segmental and subsegmental bronchi using a fibrobronchoscope. In case of pulmonary hemorrhage of IIB, III
degrees, it is advisable to transport the patient to the laboratory of endovascular surgery (bypassing other
departments), where endoscopic and intravascular interventions are performed simultaneously. With profuse
bleeding, resuscitation begins immediately at the bedside of the ball room, and the main component is tracheal
intubation with constant aspiration of blood until rigid tracheobronchoscopy with occlusion of the main or lobar
bronchus is performed. The organization of work in a specialized institution should include the possibility of
performing resuscitation tracheobronchoscopy at all stages of providing care to patients with massive and profuse
bleeding. Based on many years of experience in the treatment of patients with obdl, it is considered appropriate to
carry out prophylactic EOB if abscess or pleuroscopy with endoscopic necrosequestrectomy is expected, in which
massive pulmonary hemorrhage is likely to occur.

Эндоскопический
Эндоскопический гемостаз
гемостаз при
при легочном
легочном
кровотечении
кровотечении

Ригидная
бронхоскопия –
установка
бронхообтуратора
 30

Эндоскопический
Эндоскопический гемостаз
гемостаз при
при
легочном
легочном кровотечении
кровотечении

Схема
установки
обтуратора Saw

Обтуратор Saw

Способы
Способы эмболизации
эмболизации легочных
легочных сосудов
сосудов Хирургические
Хирургические методы
методы при
при
легочном
легочном кровотечении
кровотечении
Операции

Радикальные Паллиативные

TornadoTM, COOK
Всегда
анатомическая Различные
Неуправляемые FlipperTM, COOK
резекция легкого и, варианты перевязки
чаще всего - сосудов и окклюзии
пневмонэктомия бронхов

Операции на высоте легочного кровотечения

характеризуются летальностью от 35 до 100 % !!!
Гидрогель (ПолиГЕМ) Управляемые
 31
Паллиативные
Паллиативные операции
операции при
при легочном
легочном
Паллиативные
Паллиативные операции
операции при
при легочном
легочном кровотечении
кровотечении
кровотечении
кровотечении
Трансстренальная окклюзия легочной
артерии и главного бронха

Перевязка легочной артерии Лигирование бронхиальных артерий

Перевязка
легочной артерии
Прошивание Мини-инвазивная парастренальная перевязка легочной артерии
главного бронха

Conclusion
Despite the success of pulmonary surgery, mortality among patients with acute abscesses and, especially, lung
gangrene remains high. The introduction of antibiotic therapy into clinical practice, progress in resuscitation,
improvement of the technique of surgical interventions have made it possible to reduce the lethality of abscesses to
2-8%. With widespread gangrene of the lung, it remains at the level of 15-25%. The most common causes of death
are pneumogenic sepsis and multiple organ failure (about 30-45%), pulmonary hemorrhage (up to 10%). with timely
prevention of pulmonary suppuration, improvement of resuscitation and anesthetic aid,

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in diagnosis and tactics. - L .: Medicine, 1984. - 284 p.
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1962. - S. 5-36
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85
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