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0FEATURES OF THE COURSE OF SEVERE PNEUMONIA IN CHILDREN UNDER ONE YEAR OF AGE AGAINST THE BACKGROUND OF INFECTIOUS TOXICOSIS
1Kuziev D.B., 2Aliev A.L., 3Zokirova A.M.
1,2,3Tashkent Pediatric Medical Institute. Tashkent https://doi. org/10.5281/zenodo. 12684902
Abstract. Altogether 101 children under 3 years old with acute pneumonia due to infectious toxicities were examined for the clinical, roentgen-morphological and anamnestic aspects of the given condition. The clinical aspects were delineated on the basis of the universal status covered by the formalized case report. Methods included gathering anamnesis, clinical observation, x-ray studies. In the result, it is determined that the course of severe pneumonia in children of early age complicated with infectious-toxicosis conducted with adverse anamnesis of mothers, premorbid background, artificial feeding and age of children.
Keywords: clinical and anamnestic features of the course of severe pneumonia, young children, infectious toxicities.
Relevance. Respiratory diseases occupy a leading place in the structure of general morbidity of children, every two out of three children whose parents visit a pediatrician have respiratory diseases.
Out-of-hospital pneumonia is a special problem in the world and is an urgent problem of modern pulmonology. According to the World Health Organization (WHO) the incidence of pneumonia in children of the first 5 years exceeds 10-20%, and the specific weight in the structure of causes of child mortality is 25% and WHO declared pneumonia the main cause of child morbidity and mortality and adopted a 'global action plan for the prevention and control of pneumonia. To date, the increasing incidence, insufficient study of pathogenetic mechanisms, the peculiarities of clinical course, the emergence of severe complications of community-acquired pneumonia require research on this nosology. Among the most significant factors of unfavorable outcome are untimely (late) medical attention, incorrect assessment of the condition and prognosis of patients, as well as inadequate initial antibiotic therapy. The severity of pneumonia is determined by the presence and severity of syndromes complicating its course: respiratory failure, toxic syndrome, cardiovascular failure, acid-base disorders, lung destruction, development of pleurisy, etc. The severity of pneumonia is determined by the presence and severity of syndromes complicating its course.
Extra nasal pneumonia (EP) is a part of general diseases, the development of which is among the urgent tasks of modern medicine. This is due to the severity of the pathology, the reasons for the low effectiveness of therapy are systemic lesions in the organization of sick children, as well as increased resistance of pathogens to modern antibiotics (1,3,6).
Emergency conditions in young children. Despite certain successes achieved in recent years in studying the features of pathogenesis, their clinical manifestations, methods of therapy and rehabilitation of patients, continue to retain their relevance. This is, first of all, due to the significant frequency of formation of critical conditions in children at the age requiring the use of
a complex of intensive measures. Among the syndromes causing the formation of morning conditions in infants, the leading place is given to infectious toxicosis (2,5,3).
According to modern concepts, shock is an acute progressive decrease in tissue perfusion with insufficient oxygen supply and metabolic disorders of various organs. Endotoxic Gramnegative bacteria (mucopolysaccharide A), Exotoxic cause excessive release of interleukins 1 and 6 tumour-narcotising factor, damage the vascular endothelium, activate glycolysis, causing lactate acidosis (the first earliest sign of toxic shock), activate glycolysis, causing lactate acidosis (the first earliest sign of toxic shock), activate adhesion receptors on endothelium (E-selective), leukocytes and platelets and further the complement procoagulant system. Activation of neutrophils and platelets leads to a decrease in the 'fluidity' of intravascular blood coagulation.
Clinical manifestations of shock in young children include tachycardia (more than 160 per minute), tachypnoea, pallor and decreased skin temperature. Diuresis is absent or sharply reduced. An important value in the diagnosis of shock in young children is the value of blood pressure.
Thus, the initial link of infectious shock is the lesion of the microcirculatory channel. Further, due to activation of the sympathoadrenal system, thyroid gland and cortical layer of the adrenal glands there is centralization of blood flow - hyperdicomic counter regulation.
There are 3 stages of infectious toxic shock:1st stage - hyperdynamic ('warm shock', 'warm hypertension'), characterized by: decrease in arteriovenous difference in oxygen content (a consequence of decreased ability of tissues to utilize oxygen, centralization of blood circulation, shunting); increase in pulse pressure, with some decrease in diastolic pressure (with normal and even slightly increased values of systolic pressure), tachycardia, metabolic lactate acidosis, dyspnea, sharply expressed hyperthermia, emotional and motor restlessness of the patient (although periodic depression is possible).
2-stage - transient ('cold hypotension') is characterized by its sharp pallor, cyanosis of mucous membranes, acrocyanosis, pulse weak filling, decreased blood pressure (systolic pressure is not lower than 60% of normal), low pulse pressure, increasing dyspnea and tachycardia; appearance of sub- or compensatory DIC, oliguria, lethargy of the patient, decreased temperature of the peripheral parts of the body ('shell').
Stage 3 - polyorgan failure, characterized by the transition to irreversible shock: coma, sharply reduced diastolic pressure below 60% of normal. Tachycardia exceeds 15% of normal, 'shock lung', various types of pathological respiration, decompensated DIC - syndrome with increased bleeding, anuria, renal and hepatic failure, decreased circulating blood volume with tissue edema, the reaction to drugs can be perverted. Then comes the agonal stage.
In this case, the leading factors determining the high frequency and prevalence of infectious toxicosis in young children are severe acute pneumonia (2).
The above data dictate the need to study the clinical features and manifestations of severe acute pneumonia against the background of infectious toxicosis in hot climates.
Purpose of the study. To analyze the peculiarities of clinical course of acute severe pneumonia in infants against the background of infectious toxicosis.
Materials and methods. The clinical features of 101 young children with severe pneumonia were analyzed in the present study. Pneumonia patients were represented into two groups: the main group (56 patients) acute severe pneumonia complicated by infectious toxicosis and the comparison group (45 patients) acute severe pneumonia without complication. The diagnosis of
pneumonia was based on anamnesis, clinical and radiological findings. ICD-10 classification (International Classification 2010) was used in the work.
All research results were statistically processed on a personal computer using Microsoft office Excel-2019 software. Methods of variation parametric and nonparametric statistics were used with calculation of arithmetic mean (M), standard error of mean (M), correlation coefficient (2). Statistical significance of changes in comparisons of mean values was calculated by Student's criterion(t).
The study was carried out in dynamics, instrumental and general laboratory - before and after treatment.
Result and Discussion. The age of children in both groups was between one month to 3 years. Among the observed patients, there were 28 (0.62) boys and 17(0.37) girls in the comparison group and 36 (0.64) and 20 (0.35) in the main group respectively. The condition of all patients on admission to the intensive care units was assessed as severe. Signs of toxicosis were used as the basis of severity. Children were admitted to the intensive care unit in different terms from the onset of the disease. Thus, the patients of the main group with toxicosis of the I degree were admitted on average on the 12th day from the beginning of the pathological process, and with toxicosis of the II degree on the 7th and toxicosis of the III degree on the 5th day of the disease. The majority of children had febrile or sub febrile temperature at admission, with an average value of 38,5°C. In most cases of III degree toxicosis, the temperature was sub febrile. When examining patients, pale skin coloration was found in 46 patients, 40 patients had grey skin coloration, marble pattern as manifestations of vegetovascular dystonia was observed in 15 children. Semiotics of respiratory organs affection was manifested, first of all, in dyspnea of mixed character in all patients, as well as increased resistance of respiratory tract on exhalation in 28 children. In 17 patients the exhalation was especially difficult and prolonged, i.e. there was a pronounced obstructive syndrome. Disturbance of external respiratory function was manifested by bloating of the nasal wings in 32 patients, recession of pliable places of the thorax - in 43 patients. At admission to the intensive care unit all patients had dry or wet cough. At percussion over the foci of lung lesions there was a shortening of percussion sound, at auscultation there was a weakening of respiration, presence of moist rales on exhalation and in some patients on inhalation. In 62 patients, along with percussion sound shortening, a boxy character of the lung sound was diagnosed. The frequency of separate toxic, aggravating pneumonia syndromes in the main group was as follows: obstructive 23 (0.25), cardiorespiratory 30 (0.33) neurotoxic 17 (0.18), cardiovascular 6 (0.06), discirculatory 9 (0.1), DIC-syndrome 3 (0.03), exsiccosis 2 (0.02). In the comparison group these syndromes had a different frequency of severity: obstructive 17 (0.23), cardiorespiratory 24 (0.32), neurotoxic 18 (0.24), cardiovascular 4 (0.04), circulatory 7 (0.035), DIC syndrome 3 (0.04). Bronchial obstruction syndrome was clinically manifested by expiratory, in children of the first months of life mixed dyspnea. Distant wheezing was diagnosed. Exhalation was carried out with the children who were restless, had chest ballooning, weakened breathing, bronchophony in some places, and percussion with a boxy sound.
In our hot climate, the intestinal syndrome developed from the onset of illness or 2-3 days after admission, and was predominant throughout the period.
At X-ray examination focal pneumonia was diagnosed in 28 children, focal-mucous - in 33 patients, bilateral polisegmental - in 40. X-ray reveals predominantly bilateral lung lesions with the presence of a reaction on the side of their roots (dilation, thickening), strengthening of the
pulmonary pattern in the surrounding areas. Clinical variants of the disease are possible: moderate or mild course.
In diseases of the respiratory system the following is carried out:
1) microscopic study of sputum and determination of sensitivity of pathogens to antibacterial drugs. Sputum, uniform discharge of sputum in inflammatory processes or bronchoalveolar system in the absence of pathological cavities (bronchitis, pneumonia). In the presence of cavities, sputum is expectorated in large quantities ("full mouth"), in particular, with the breakthrough of an abscess into the bronchus. By its nature, sputum can be mucous, mucous-purulent. Mucous and mucopurulent sputum is usually noted in bronchitis, pneumonia with a pronounced endobronchial component. Purulent sputum is observed in destructive processes in the lungs. If the sputum is dominated by mucus, it has a whitish or yellowish-grey colour; purulent sputum is greenish-yellow or green. The consistency of sputum can be liquid, thick or viscous, depending on its mucin content. Sputum may be odorless or have a faint unpleasant odour. In cases where sputum decomposes directly in the lungs (abscess), it acquires a sharp putrid odour. In a number of cases, when the sputum lags behind, a layered appearance is formed. Thus, with a lung abscess, two-layered sputum is observed. The character of sputum reflects the peculiarities of the pathological process in the bronchoalveolar system. Sputum in pneumonia contains a significant number of leukocytes, fibrin, epitheliocytes of alveoli. In complicated course of staphylococcal pneumonia (abscessation), elastic fibers appear in sputum, which indicates destruction of lung tissue.
2) blood examination includes determination of the content of its protein spectrum, the level of sialic acids, glucoproteins, C-reactive protein, total lipids and their fractions, acid-base state, electrolyte content. Determination of the content of different classes of immunoglobulins (IgG, IgM IgE IgD), T and B-lymphocytes and their properties gives an opportunity to get an idea of the state of immunological reactivity.
3) study of pleural contents, when pleurisy occurs, pleural contents are examined to clarify the nature of the pathological process. In serous exudate of streptococcal origin, neutrophilic granulocytes, single lymphocytes and mesotheliocytes are found. In purulent exudate the effusion is turbid, thick, greenish-yellow or brownish in colour, contains a large number of neutrophilic granulocytes.
Bacteriological examination of sputum and pharyngeal smear revealed Staphylococcus aureus in 5 children, Staphylococcus pneumoniae in 4 children, Streptococcus pyogenes in 3 children, Hemophilus influenza, mixed microflora, Staphylococcus epidermis, Escherichia coli in 2 children. No microflora was detected in the remaining patients.
Conclusions. Thus, our data indicate that the leading factor determining the high frequency and prevalence of infectious toxicosis in infants is severe pneumonia. Treatment of this group of patients is associated with special difficulties. It requires the participation of specialists of high qualification, consistency and being complex.
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