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    Тема: Пневмонія

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    24 views23 pages

    Пневмонія - Передерій

    Uploaded by

    Lana Somova
    Тема: Пневмонія

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
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    Posaia 4. Nxesmonia MKX-10: 10 Tpunoaa GpoHxonHeaMonis (npn ineHTucbikopaHomy Bipyci) 12 Bipycia nHesmonin, He Knacncpixosata 8 iMwHx py6puKax J12.0 Agenosipycia nHepmonin J12.1 PecnipatopHio-cimusrtiansHo-sipycua nHeBMonin J12.2 Naparpunosia nHeBmonis ¢ J12.8 Inui sipychi nHeemoni J13 MesmoKoKosa nHesmonin Ji4 Mhesmonia, svxnuKara Haemophilus influenzae Ji5 Baxrepifiva nHeamonia, He kaccixonana B inwnx py6pnKax J15.0 Mheemonia, auknukana Klebsiella pneumonie J15.1 MHesmonis, svknunana Pseudomonas 415.2 Mkeswonis, auxnukata cracbinoKoKom J15.3 Mkeamonin, suknukana crpenroKoxom rpynu B J15.4 Mhesmonin, snkniKata inuumMn cTpenToKoKaMmn 415.5 NMtesmouia, suxnukana Escherichia coli 415.6 Mieamonin, evxnnkara inwnmn aepoOkHMn rpaMHeraTHEHiMn Gaxrepisnan J15.7 Miesmonin, suknnkara mikonnasmane 415.8 Inui Gaxtepilini mHeEMOHiT J17/ Mtesmonii npu xsopoGax, knacncbikosaninx B intuinx pyOpmKax (Gaxtepiniinx, sipychnx, napasurrapHux, mikosax, OpHirosi i iH.) J18 MHeeMonis nput HeytouHeHomy a6yaHuKy Axryaabnicr mpo6aemn Mhesmonis © onHun is Halimoumpeniiunx 3@XBOPIOBAH’ BHYTPILIKix OpraHie, Ha vacTKy NHeBMOHi”i NpHNaAAC He meHWe 10 sincoTKiE ycix rocnitanisauiii. ¥ BennkoSputaxii wopisHo peectpyetbcs Grvanko 750 THCAY xBOPHX NHER- Monin (npH HaceneHHi GnvabKO 60 minkiioHis oriopi), y CUA — He menwe 3-x minsionie 3a Busnayenna i kaacnpixauia Mesmonin — ue roctpe nonierionoriune BorHMujese ittbeKyiiiHo-sananbHe 3axB0- pronaniisi nereni, o6yMoRnene ypaKenHAM pecniparopunx siqginia nerexi 3 posauTKoM SHYTPIWHbOANbEEONAPHO! sananbHoi eKcy- ‘Rauii i eignosiquoro pextrenonoriuHoro ek- sisanetta incbintpatusvoro saTemHeHia pik (npn HaceneHHi GrusbKo 300 minbiionia Yonosik). Y Yxpaiti ujopisHo peecrpyerecs 10 800 THc. nHeBmoHii. flo tenepiwiworo Yacy, Heapaxatown Ha, 3gasarocs 6, npuronomunMEi yenixn 8 ii nikyaanni, nHesMonin sannwacrscr Onnicto 3 HalMacriumx npwsnk cmepti, oco6nn- Bo y HeMonopHx i OcnaGrieHNx xBOpUX Fereti, wo KnIHINHO BHABNACTEEA roCTPMM PO3BUTKOM pecnipatopHoi CHMnToMaTHKH — Haiuacriwe nuxOMaHKoro, Kawnem, saquul- Koto, iHopi — Gonem y rpyax. 3riqho 3 MixHaponHoW KnacnebiKxauiero xeopo6 10 nepernany (MKX-10), nHeBtonis viTko Bigoxpemnena Bin inlunx sananbHMx no- Postin 4. Muesmonist AKOBKEHE NereHesO! TeaHKHH HeiHcbeKuiMHOl apmponn. 13 py6pHKn “nHesMoHii” BHKno¥e- 4i xBOpo6H Nereis, Aki BHHHIKAIOTE B yMOBaX annupy tpisnunnx, ximiviux, aneprivinx Gini owKi8, @ TaKOK OGyMOBNeHHX nopyweHHaNH sDOBOTOKY 8 NereHRX. MHEBMOHii, aki © ONHUM S KriMiNHUX nposBiB incbeKYiiHMX xBOPO6 (Kip, Q-nuxomanka, opHitos, Kopopa Kpackyxa, “yma, HarypanbHa sicna Ta inuil), posrnsaa- ‘STbCA B pamnax incbeKuiiHMx xBopo6. Binzwicts nposigunx nynbmovonorie €epo- nit | Minhiunol Amepunu pifuuna aropys, Wyo 3 npaK- AUHOI TOAKH 30py NOTPIGHO KnacyebikyeaTW NHEB- wOHiIO, SBaKAIOUN Ha ocOGNMBOCTI inbiKyeaHHn 260 yMOBH, NPH KX BHIKNO saxBOplonAHHA 3a pospoGneHol0 Ha UboMy npniuiani Knacncbikaui- 20 pospisHAloTe 4 eugu NHEBMOHiN (TaGN. 4.1). ’ Hezocnimansxa nueemonis (HM) — Hati- U7 ROWMpeHa, BHKMKAE y NauieHTiB nosa weKamw sikaper i rocnitanis, sk npagmno, 8 somauirix ymoBax. ~_focnimansna (C1), a60 Hos0KomianbHa sneemonist— ue incbexuiiine ypakenna nereris, =*€ BHHNKae i posBHBACTECS nig vacnepeGysaHHn *S0p0r0 8 CTaujoHapi 3 npHBOAY iHLuOrO saxXBOpHO- Sanus Yepes 48 i Ginewe ronwl nicns rocniranisa- =) 2a Bilis KOM incbexuiininx saxeopiosaHb/ypa- Hb NereviB, WO NepeGybann @ ikyCauiliHomy »soloni Ha moment rocniranisauii xeoporo. PeHT- SHonoriuHe BUABNeHHE y XBOPOTO «HOBOTO» AGO o7 «xeHOW AUXANbHOI HEAOcTaTHicTIO ilaG0 OsHa- kamn BaxKoro cencncy aGo CenTuMHoro WOKy, XaparrepnayeTsca HECTpMTAMBNK NpOrHOsOM i BHMarae npoBENeHHA iHTeHCMBHO! Tepanii. Pexomexayersca expinsti «mani» i «e- nukio Kpurepii BekKoro nepeGiry nheBMoHi (raGnnys 4.2). Mpo BaxKnit nepe6ir nieBMonil cBiquuTe HampnicTe y XBOPUx Ke MEHLUE ABOX «Manx a60 OfHOFO «BENHKOrOn KPUTepIIO, KOKHI 3 KU iMoBIpHO nigeMuye PHsHK PosBUTKY Te- yanbHoro Hacninky. Y Takwx eunanKax PeKo- menpyerbca HeBinknapHa rocniranisayin xB0- pmx y Biaginenis axecresionorii Ta inTeHCHE- nol Tepanit TaGnius 4.2. «Manin i wweankin kpHrepii saakKoro nepeGiry nHeBMOHi «Mani» xpumepil eaxxozo nepeGiey nHeemonil + Yactora pixar 30 3a 1 x8. i Ginbwe + Mlopywentis ceiaomocti + SaO, menue 90 % (3a paki nynbcoKcnMerpil), napyianbia Hanpyra KUCHIO B aprepiansvi xpoai (nani — PaO,) HvoKwe 60 tM pr. cr; + Cutcronivenit AT Hine 90 mm pr. cr; + BoctopoxHe a6o OGwWHPHE ypaNeHHs nereHis, nopoxtwHH posnany, NnespanbHii BuniT, «Benui» Kpumepii eaxxozo nepeGiey nHeeMonil: + HeoGxianicrs nposezetis wrywHoi seHTvnsuil nereHiB + Wewiake nporpecysania Borinueeo-iMbinsrpaTuBHnx amir y nereriAx — sbinbWweHiA poamipiE incpinerpauil Ginewe HK Ha 50 % nporarom 48 roan + Cenrmuniis Wor aGo HeoBxinHicte yeenentin BasonpecopHiX npenaparie nporarom 4 roain i Ginewe; + Toctpa Huprona HenocraTHicT® (KimexicTe cexi menue 80 in 3a 4 rogwiKh aGo pipet kpeaTuniny 8 cHpoBaTui Kpoe! Ginbive 0,180 mmonb/n, aG0 KORYeHTpaYiA asoTy ceNoBHA nue 7 tamonb/n (as0T cevoBMHN = cevoBuiHa (rmonb/n) / 2,14) sa BincyTHocTi XHH. Icropysio TaKoxk cknaees nopin NHeBMOHiT Ha THnopy i aTunogy. Tunosolo nHe@moniei cri Hasmpatu ihcbexuiiHO-sananbHe SaxBopionaHlin nerenia, axe BKrKAeTECA BciMa incpeKuiHMN 6yAHNKaMM, 22 BAHSTKOM BHYTPILLHBOKnTHH Hux naTorenia (Mycoplasma pneumoniae, Le- gionella pneumophila, Chlamydia pneumoniae et psittaci, penknx pipycie). Haiwactiwe gona BHHNKaE B NosanikapHAHNX yMoBaX i BHKNKA- ereca Streptococcus pneumoniae, Haemophi- lus influenzae, Moraxella catarrhalis, Staphylo- coccus aureus, 2epo6HOIO rpanseraruaHioro ni- Kpodbnopoto. ATHNOBa NHEBMOHIs BHKNMKAETECA smuesragannin tikpoopratismann 3 sHyTpiL HboKniTiMiHnns cnocoBoM ichyBaHHs i, sk npasH- No, Mae AeFKi OcoBNHAOCTI KniKi4HINX NORRIE. SanexHo Bin sipynentHocti a6yaHn- Ka, cTaHy maxpoopraviamy, ocoGnusocren Possin 4: Mueanonis wyHonorisHorO «CTaTycy, NHEBMOHIR MOKE KonoHiayaaTn CTMOTKY, NPOTE HiDKHI QUXANBHI LuNAXH pH Hosoxomiansta nHeEMoHin Tpamverarwani Mikxpoopratiisnan: Pseudomonas aeruginosa Enterobacter aerogenes Klebsiella pneumoniae Escherichia coli Haemophilus influenzae TpamnosuTveHi Mikpoopravismy: Staphylococcus aureus Streptococcus pneumoniae Acoujauii mixpoopraviisnsia ~ Tesmonin npn imynonediynri Untomeranosipyc Pneumocystis carinii Naroreni rpu6n Streptococcus pneumoniae Staphylococcus aureus Pseudomonas aeruginosa Acouiauii mixpoopravisnia ubomy sannuatorber crepuneinmn. Mixpo- acripayis: Bmicty porornorkn — cbisionorivuiii thexomen, wo npyeyrni y 40-70 % snopo- Bmx nioneit nig, 4ac cry. HopmanbHie cbynkui- OnyBaHHA MykoUMniapHoro anapaty Tpaxeo- GponxiansHoro Aepera i Kaunesoro perpnex- cy, Aocratin alruGaxrepianbia aKTMBHicrs anbBeonapHux maKpotbaria i ceKperopHux imyHornoGynivis saGeaneuyiore enimitiayjio inepiKoBaHoro ceKpeTy 3 HIOKHiX AMXaneHHX 10. Yactunia 1. Saxnoprosantia opranis su Ta6nun 4.4. OcHoBHI MexaHismu incbikysaHHs npH NHEBMOHIAx + Acripauia emicty porornorkn + Bawxanna aeposomo, wo micTum naroreliti mixpoopranisht + Temarorerie posnoscionxenin incbexui s nosanereHesoro ocepeaty inbexuil (Hanprknan, cenrisinit TpomBochne6ir Bex Taga, incbeKulizHui eHoKapANT TpUCTyNKoROTO KNanaHa) + Besnocepente posnosciomxenns ikcbexyii a ypaxennx Tkarw npunerrinx opranis (vanpiknan, rHivHMi nepnKapAWT, a6CyeC neNinKn) AGO BHACTIAOK IHcbiKyBAHHA pH poHiniatournx NopaheHHAX rpyfHot Kirk winaxis, Aocsraiow crary Horo nepannHol CrepunbHocri. Mp nopywenHi anuesragaHix SaxvicHuX mexakiswia ao acnipayii BMcoKosi- pyMeHTHHX wixpoopraviawia. y BeNnKMX Kinb~ KOCTAX CTROPIOIOTECA CnpMATNNB! yMOBH ANA POSEHTKy NHEEMOHi, Etionoriuie sHaveHHA acnipayii GararoxpatHo nocunioerbca y oci6 3 NopywekHaMH axTy KOBTAHHA (rocTpi i xpoHi4- Hi posnaan moakoBoro KpoBooGiry, xpoHiMHMit anvoronism), np pantosHx nopyuleHHiAX cBi- Romocti (HanaaH eninencii, Yepeno-MosKOBi Tpaemu), y nicnaonepayivitomy nepioni abao- minansunx xipyprivnux etpyvatits is wnyHKo- 2010 peryprirauicio. {lHranauin aeposomo, wo Mictate naro- Text KoHTariosHi wikpooprakiann, — Mexavism incbikyeanns, skit Haye HalGinbWOr noUM- peHHA y EVHMKYeHHI rocniranLHot arHnosol nHesMoHil (HanpuKnag, iMebikyeaHiiA Legionella Spp., Chlamydia psittaci). Bauxariia aeposonio, ujo mictims cycne#sito mixpoopratismis noaitpa nanam aGo sinnineiia iHreHcHaHoi Tepanii, a TaKOK HEpXORKeHHA NaToreHHOro miKpoopraHio~ My 2 NOTOKOM noBiTpA 3 AMXANLHOTO MeAMYHO- ro yeTarkyBaHiHs nig Wac nposeneHHa wTy4Ho! seHTvnsuii neretie np Hapxosi Ta iKWwilt peani- mauiiiniis Aonomosi € ocHOBHUMM MexaHisMann inthinysantis xeopux npn posemrky rocniranbHol nHeeMoHil, Mpu nepeGysanHi 8 nikapHaHNx na- natax y GinbulocTi siinapKie chovatky KonoHisy- JOTECR FocriTaMbHUMM LTaMaN wikpOopranis- mis BepXHI AMKANbHI WINAXK, @ OTM — HYDKCHL Bennke sHaveHiA mae YuHHHK Yacy — SMM TPH sania rocniranisauis, 11M Ginstua siporighicrs incbiryeanns. ¥ ennanKax wry4no! seHTHnaU Nerevie evcoKoBipyneHtHul natoreHnuit tixpo- opratiam Moke sigpasy qocaram nereHesot TKQHMEM, BMKNINKAIOGM POSBUTOK NHeEMOHi! 3) TematoreHHe posnosciomxentis _incbex- ui’ 3 nosanereHesoro sormMuja HaltuacTiwe aycrpivaerbon np incbexiiiHomy eHpoKap- AuTi y «in‘exyiiiix Hapkomanis (abyqHMK Staphylococcus aureus), a TaKoxk npn abao- mivanbHux onepauiax y xipyprivHilt npaktu- Ui (Haituacriwi s6ypHuKn — Escherichia coli, Pseudomonas aeruginosa). B erionorii nHeeMonilt sinirpaiors Baxniey pont He Tinkxn incpexuimi aByqHimn i ix nato- FeHHicTS, ane 7 UMHHKKH puauKy, nepewcneHi y Ta6nny 4.5, TaGnuis 4.5. YHHHMKM pHaHKy BHHMKHeHHA NHeBMOHIi + Bik (pitw, ocoGnHG0 HeMoBnaTa, mony NoxuNoro Biky) + Manis tiotiony + BxNeaHHs HapKOTUKiB, anoskVBAHHA arkoroneM + Xponivni saxsopionanis nereHis, Cepuys, HMPOK, LUuNyHKOBO-HLLKOBOTO TpaKTy + KoxTakmw 3 Teapvitami, nraxan, rpusyHanan + ImyHonediuutsi crahn (npypomkeHni imyHonedbiywt, CHIL, sTporeHia imyHocynpeci); + NepeoxonoaxeHiin + SaGpynHeHHA armocdbepy | noskinna + Toctpi pecniparophi sipycvi saxeoptosaiHia 4. Muesionin a 3aranbHi natoreHeTviki MexaHiaMu MHeBMOHI! B yMoBaX annuBy ihcheKyiAHHx s6yaHUKia nO- 28ri y raGnuui 4.6. TaGnuus 4.6. OcHosHi naToreHeTHYHI MexGHi3mH MPH NHEBMOHIAXx NowKomkerhA anbsconoKaninapHol MemGpann 3 NopyWeHHSM OcHOBHMK ii cbyHKIit: rasooGmliy, yreopeHHA cypcbakranTy, imybHot bys ykounniapHol HenocraTHocti; AHTMOKCHMAHTHO! CHCTeMMA, Mopyweriia cbyHKyionyeaKHA MykoyWniapHoro anapaty poHxianbHoro Aepewa 3 posaTKOM Mopywenr pishosam mix iHTeHCHBHiCnO nepeKVCHorO OKMCNEHKA niniale | moxKnMBoctAMn BithiikeHHA cHHQpoMy BHYTpIWHEOCyAUHHO! rinepKoarynaull KOEI e Soul SananbHMK SMI Ka ‘Thi HeNOCTaTHOCTI qbiGpUHONiTHUHO! cHCTENM; PoganToK pecniparopkoro nvctpec-culinpomy (NOUKORMeHHA aNbEeoroKaninspHoro Gap'epy 8 peayntrati iHcheruiito-sananbHoro NpoYecy, NOPYWeHHA cypcbaKTAHTHO! cHcTeMM nereHis, PosEHTOK cHAPOMy Eporxiam.Ho! OGCrpyKyil { NPoYeCia WYHTYBAHHA KpoB! B MarOMy Koni Kposoobiry). Kainiuni npospa KniniuHa CumnTomaTHka riHeBMOHiA Hap- seeaiino pisHomavinya. BoHa sanexutb Bin ssrorenHux Bnactusocrelt 36yaHnKal s6yaHH- axeoploeaHHsi, wnaxie i mexabismie incpiny- x5, ocoGnMeocTel imyHHoi eignogigi opra- =2Hy, NovaTKoBOrO CTaHy pishitx Horo opratie i vi, RpagMnbHocTi i caoe¥acHocri novaToro Ha. Mepesaxaiors y KnisivHi”s cimnro- =U) CHHApOMN saranbHO! iNTOKCHKaUl, O- {S[eHOro" YUNINBHEHHA nereHeBo!_napenxinu, S=SuuniapHol HenoctarHocTi ¥ Knivivnid) KapTUHi MHEEMOHi! pospisHA- fe= 4a/Ginsws Tunosi cy6'exTHeHi i O6'eKTHBHi SmenvoMM saxeoplosaliis, nonaki y Ta6n. 4.7. 3anexno sig s6ypHMKa, piahi 3a eTiono- THeaMoHli MOXxyT’ MATH AeAKi KNIHIMHE éeeocri, npeacraaneni Hove. MHeemoKoKosi nHeeMoHii. Cxnana- envy YACTHHY THNOBUX HerocnitanbHux S==suonill | © pyntosHunn, Take, LO saxon- Dect» yolo YacTky NereHi (pHcyHoK 4.1). Maro seceSonoriso 8 nepeGiry KpynosHoi nHeeMonit Ser=pientuoro Ha6paxy; 2) cTania oneuinKy- == («eppoHoro» i «ciporo»); 3) crapin pos- aie Nepwa crapia Tpusae Gina 2-x abies i xa- paktepvayeTeca mixpoGHMim Ha6pAKOM TKAHMHM ereki, Lyo NoctynoBo posnoeciomkyeTbCA i 3a- xonmioe ecto YacrKy. Ak npaBuno, y HaOpaKnini pial shaxopurica senvKa kinbKicTs nHeBMo- kokia. MpuGnusHo y 25 % xsopux nHeBMoKoKie Moxta eMneuTh y nepwi roauEN xeopoGu ie kposi. Ha 2-ii ctapii saxsoprosarits, aka sasen- Yai niowMaetbCR Ha 3-1 feHb saxsopiosan- ha i Tpveae 5-7 ni6, sinGyeaerca pianenes epurpourTie i netiounrapHa (Heimpocinua) ingpinerpauia ypaxeHoi jinatiKn nereti (nexine- kox cermenTis, Yactky), a TakOx aNnanaHHA & anbpeonn ciGpury, yHacniqok voro BHyTpi- HboanbeeonapHnit excynat cae winbHvm i Haragye 3a KOHCMCTeHuicO TKAHMHy nediHKH. Tomy wo cragito inoni HasneaioTe crapicio re- narusauii, a6 onevinKyeaHHiA. O60B'RIKOBVM KOMMOHEHTOM Kiel cTaii € cbiGprHosHMit nnes- pit. Ha 3-4 cragii @ peaynerari axtueayit npo- Teonitwunnx chepmettia Heitpodpinia i ci6- PuHoniuuHol cHctemm nerevi sigGysactica Noctynose poscmoKtyeaHH ciGpuiry i ium KOMNOHeHTIS excyaary. Tepmitin uiei cranii pia- Hi 8 cepenHtomy 2-3 Txt Oco6nnpocramm KniKikn KpynosHo! nHeS- i €: TOCTpHi4, 3 NOTpACaIOWMM O2HOGOM, nR Hactunta 1. 3axtopiosainin opratiin annem Ta6nuyp 4.7. CuMntomatnka nHeBMoHii Cy6'extweni cumnromn (ckaprn): + Micyes! cHmnToMM: KaWent cyxnit a6o 3 BHAiNeHHAN MOKPOTUHHA, KpoBOXapKANHA, Gln y Tpyahih KniTUi, noB'AgaHMT 3 aKTOM AuKaHHS! /aGo KaUINeM; + Jaranbui cvmnTOMW: FOCTpHi NeYaTOK 3axBopIOBAHHA, O3HOG, AMKOMAHKA NOHAR 38 °C intoxcnKauin. OG'exruni cumntomn: + ahi xninivnoro nocrimxeHiA, Wo BHAKANAIOTb CHMITTONM NOKANLHOTO ypaKeHHA NereHeBC! napenximn (y Gin-WocTi aunankis soHM sanexart Big THny NHEBMOHIT Npn sornuweniis nHeEMoni — npumynnesins nereHeBoro 3Byky, OcnaGNeHHA ForocoBOrO TPENTIHHA i Gporxocpouii; — ccnaGrieHe sesnKynapHe AMXAaHHA; = Kpenirauin, Bosiori api6Honyxnpyact xpunn, Tipu kpynosniit nresmoni = Tyniii nepKyTOpHHil aeyK, nocHMeHHA ronocoBOro TPeMTiH® | GpoHXocboHil = GponxlanbHe avxaHin; = xpenirauia, sonori apiGHonyxupyacri xpunn, WyM TepTA nineBpH. Pettrenorpacbin: romorenne BaTEMHEHHE BepXNLOT acTkit npaeoi nereHi hile moxporunHn 3 Konodil nHesmoxoKa npyt HeBHOKOKANH Gaxtepiansromy nociei Puc. 4.1, MesmoKoKosa nHeaMonia BeEpXHBO! YacTKH Npanoi AereHi, cTaali onevinkyaanis (3a ©. Herrepom) Desai 4. Mneenonin “oMGTOK saxBoploBaHiin, paHHs Nosea empaxe- sex Bons y rpyanidt «nity i Kawne, pu AKo- wy 9 2-3 216 nownriae Binxonum xapaKrepHe epxane>, a60 Kpos'nHe MoKpoTHHHIA. HepiaKo ~2 novarky saxsopioBanna a'Asnsorbca herpes sesalis et labialis, rinepenia woKn Ha cropoHi yeSKeHHA, BincTaBaHi ypaxeHo! nonosuHu Seanoi eniten 6 arti Quxaria. Mpu cbisvkantHo- c6crexeHHi Ha Nepuiit crapii saxsoploean- 95 BUSHANIOTLGR: yKOpONeHHA MepKyTopHoro sosy | ReAKe NocHNeHHA fonocoBOrO TPEMTIKHA El YpaXeHOIO HaCTKOIN, a TAKOX WyM Tep- “= fineepn i noNaTkopa xpenitauis (crepitatio edux) ~ caccpighe xapaxtepHe norpickyeaxns BUCOTI BAMXY, WYO BMHVKAE BHacigoK pos- “ereliHa anbaeon, Axi nocnapanuea. Npu tanositi nepebiry i anexsatHomy nixy- x1 NHEBMOKOKOBOI MHEBMOHii Ao MovaTKy 2-1 =r2aii cTaH noninuycts¢a, Temnepatypa aHu- bon, disnkanbHHMN BigobpaxeHHaMn uiet sraail ¢ piako nocuneHie ronocose TpemTiHA i wit sByk NH NepKycii, @ TaKoXxk Gporxians- “= avanikn (8 pesynerari supaxeHoro yuline- SSH TKaHMHM NereHi i NopyweHHA quxanbHoi icransrnkw Gporxis) Hag ypaxeHoro pinay nereni. Bonori xpinu I kpeniauia ana ule! |) He xapaKrepHi Ha 3-4 crapii, xonu nowntaerbea pospi- ShnR Excynaty i anbeeonn nownaioTe Haby- 27H noBiTpAHOCTi, sHoBy s'ANAETscA Kpenita- Tek sana crepitatio redux). NapanensHo YBAETLCA SMEHUIEHHA BUpakeHOCTi acix seronorivux cunmnronia, Mixonnasmosa niesmonia, wo avKni- Ch wiKOrINasMoW NHeEMOHi, 3a NoWMpe- 2 sHaxonuTbcr Ha 2-3 wicui cepen ycix Movil, cKMapatoNn GineuicTe Tak 3BaHMX ScwroBuxX niesMoni”. Lett wixpoopranisn, sSsovTuin Eaton i cnieaem. we 8 1944 pou, sipynentHnit i Moke evKniKaTK piaHo- eeerui ypaxentia auxanbHnx unsxie — Bia BupaxeHoro puHocpapwnriry No BAKKO! Seseuonil. Xapaxrepxmmn ocoGnmeoctamn € see2inela TpBanicTs saxsopioBanHa no roc- se aisayil — 1-2 Ten, npotarom aKux xeopi Susprarbca Ha BupaNeHy saranbiy cnabxicrb, ® =20 3in Yacy MoposmTe, cyxnit Kaen, can- === 2a rpyaHnnioto, cyGcpe6punbry Temnepa- “ey ¥ pasi poseurky NHEEMoHiT niganuyeTecA ssereparypa tina i ehtiiKaioTe pisko enpaxe- B Hi cumntomM iKToKCMHaYIi, aki nepeB@KaIoTe Hag nerevesum cvmntowamu. 3a ceoimn ¢hisukanbHumn | pertrevonorivnumuy aaHiaan mikonnasMoea nieeMoHia HacrTineKM Haranye THEBMOKOKOBY NHEEMOHIIO, WYO cnovaTKy nicna BinypuTta Mycoplasma pneumoniae Horo Ha- 3eann pleuropneumonia-like organism, 10610 MikpoopraHigM, UO sviKrinkae saxeopioBaHKA, cxoxKe Ao nNeBponHesNoHil Onticlo 3 Haiieaxux © ctatbinoKoKo- 8a nkesmonia. Ii BiamitHoo ocobnusicnio ¢ WHAM possMToK rHiHWX gecTpyKTHEHUX yeknanHerb, y nepwy vepry — aGcyegyeanna 3 Mlopanbuin yreopeHHan ToHKOCTIHHIX noBiT- PAHWX NopoxkHUH (puc. 4.2). Lle nos'rsaHo 3 THM, WO cracpinoKOKH € exsoTOKCHHNPoDyKy- Jounmn Gaxrepisnn, aki eMpoGNaITS neynTM- Hasy, choctparasy, remoniaiu i Koarynaan, Lo BuKninKaloTe AecTpyKyio NereHeeol TKAHMHN, Ao niiuvis pusiny poaaiTey cracpinoKo- koaol nHesMonii sinHocATicA UyKpoBMit ziaGer, HeujoasHo nepeHeceHuit rpun i nepeGyeanHs ® crauioapi. NepeGir cracbinoxoxoroi nhee- Moni BAKU, HK MHEBMOKOKOEOT NHeBMoHil. Bora nepeGirae 3 eucoKoio nvxoMaHKoI0, 3a- Avuikoto i Gonsmy & rpyanii knirui, suainesHae THiliHOro MoKpoTHHKA, BMPAKEHO!O iHTOKCHKA- Uicio. OisnkanbHi AaHi BignoBiqaioTs BorHMue- sit nHeEMoHi i xapaKrepwayroTEcA AlnAKKaMNA YKOPONEHHA nepKyTopHore Tony, iNoai— Tuna ity, Han AKIN BMCHYXOByIOTECR 3By4H! Boor! Api6Honyxipuacti xpunu. PextreHonorisno 3a- senuaii BnABnAtoTECA pisHoKaniGepxi BorHWe- Bi | SnMBHi savemHeHHR, Ayke Yacto — 3 Bor Huujamy ecrpykuii. Fpn cbopmyearni a6cyecy BUABNAETECA oro XapaKTepHa peHTreHonoriy- Ha O3HaKa — MlopoxkHMHa 3 pisHeM piquHn. IHO- Ai, y pasi poskpurrra aGcyecy # nneeparbiy no- POXKHMHY, BMHMKaE enniema nnespy. Oco6niiso1o taxKKicTIO nepeGiry BiapisHA- eTBCA TaKOK NHEBNOHiA, BHKNYKAHA KNeBCiC- Noto NHEBMOHii (naNH4KOIO Opignernepa). Bova © Tunosclo «nHeaMonicio ocnaGneHioro rocnonapa». li ocoBnusocraMu € HansAMualHo Wace BHAMKHEHHA y ankoronixia i ocnaGneHinx, iMyHoKomnpomerosaHix xsopux, mogen no- xunoro Biky, YaCTe YpaxeHHA BEPXHiX WACTOK, XapaxrepHe Kpos'aHe MoKpOTHHHA (TuNy «Ma- NMHOBOTO KeNe>, Wo NpunuNaE AO NiANEGINHA, 74 A ees eee ae See neooe ‘Cragbinovox i Heimpocbinu y MORpOTMHHi NpH sa6apaneHti 32 Fpanont Yacruna 1. Saxnopiosanne opranin nuxantin Flowatkosa cranist nheeMcHil ‘isn cranii AHeEMOHi 3 abcyecann, Heemoropaxcom Puc, 4.2. YeKaaanena crachinoKoKona aScueayiova nhesmonin (30 ®. HeTrepom) mae sanax ropinoro Mca, 8 AKOMY MOH BH ait rpaMHeraTHeHy KancynoBaHy nanwuKy), pannilt possvToK peCTPYKUil TkaHHHN NereHi 3 possimriom a6cuecie (pic. 4.3). Haiwacriwolo npH4MHo1O BipycHMX nHen- moniti 6 sipyc rpuny. XapakrepHumn oco6nv- BOCTAMM € BUKUKHEHHS ix y nepionH enigemii, TOCTpiiii NowaTOK, CHMATTOMN piskKO EHPAKeHCI intoxcnKauli — cunbHuit ronoBKil Gins, rinep- TepMia, Goni 8 ourWx sOnyKax i M'ngax. Y pasl POSBUTKY NHeBMOHil BoH@ HOCHTS reMoparivHul xapaktep, ToMy OfHMN ia CHMNTOMIB & PAHHA (y nepwy Ao6y) noABa KpoBoxapKania. Nlerevest cutanronn, soKpema ¢pisnmanbii AaKi, Benoni misepxi i samKan BUpaXxeHO MeHWE cHMnToMia inToKcuKayli. XapakTepHow osHaKow rpunoskol niieswonil (ra inLuMx BipycHHx nHeEMOHi) © BiA- cytHicts netikounTosy | niaenuyeHoro LOE, wo Tak xapakTepHo Ana GakTepianbHHx nHEBMOHit Nepebir rpunostici nHeBMoHll sam@xKaN Ganka | Moxe savinwiTiica neTanbHMM HacniaKoM Yepes Auxanty i CepyeBo-cyaMHHy HenocTarHicrs. Ockosii ycknapHents nHeBMmonii noaaHl y raGn. 4.8. Excygaani nnespura — Haiacriwe yoxnapneriin nkeaMonil, AKO NnespaT BHKM- kae y posnani xeopow, sit HasvBacTbCA napan- HeBMOKiYHNM, @ FRO nin KiHeub nHesModil — MetankeeMorisnum. [po nosey nneepuTy sa- seuvait cBiquatb Taki KniMivHi OsHAKK, AK sMiKa npurynineriiaTynicrio, piske ocnaGnenHa pial ts i ronocoBoro TPeMTiHHiA y HiDKHIX CermeHTaX nerevie, shuiiehHa npocTopy Tpay6e npH niko- Giunii noxanisayil npouecy, NoABA TpIKyTHAKa Peszin 4. Tiemonin MpawoctoponHs sepxHbouacrouona kne6cienoea nieemonin (®pinnexpepa) 3 BMAINCHHAN MOKPOTNNA y BHINR! “ManHOBOFO mene”, chopmyBaHHss Kononil Klebsiella, wo evipocr Ha eHnoarapi Peurrenorparan xeoporo 3 weEMOHieN Opinnennepa Puc. 4.8. NHesmonin pianeniaepa y naujeHra 3 aecbexramu imynirery (3a ®. Hertepom) TaGnuys 4.8. OcHosHi yCKAGAHEHHA NHEBMOHIT + Dnespirr (cbiGpmmosiiit aGo eunitHni) ~ y 20% xeopux + Evmniewa nnespu + Incbexuiiina nectpyruin nerevie (a6clenyBania a6o ranrpeHa) * Poctpa quxanbHa HegoctatHicT: + Focrpuit pecniparopHiii anctpec-cimppom (roKcnsHii: HaBpAK nereHie) + Toctpe nerenese cepye + Inchenyimo-roKcumHii wok THii mpouec (Meniactunir, nepuKapauT, MeHiHriT) + Miokapaur + ExnoKapaur «ko — Payxcbyca Ha snoposit cropowi, scye —Bkaayeanoca emule, HeBerwKi KineKocTi BHmo- seratis Cepenoctinna y snoposmi Gik. AK yKe TY (MeHWe 300 mn) npM peHTreHonori4HOMy 76 Aocnipxenki MoxyTb He BusiensTHCA, | To Ala THocTauriMM MeTofiOM BuBopy € ynLTpassyKoBe nocnipxeniin, npu sikoMy ferko HaMiriry ont Manbhy TouKy ANA Nneepan’Ho} MyHKUi. MpGniaHo y 3-4 % xeopHX WacTKOBH- Mu MKEBMOHiAMM, OcoGTHNBO y OCI niTHEOrO i noxunoro Biky, a Tako xBOPHX UYKPOBHM pia6ero i ankoronixis, ayctpivaiorcr rH Hi yeknagHenHa. Hairactiwie a6cyeayiort Yactuna 1. Saxsoprosatin opretis muxann sipyco-Gaxrepiii nesmouli. Yacto a6cuec niarmoctyworb tinbk nica npopuBy 8 6pOHX. BupiNeHHIA CMEpAINOTO THIZIHOFO MOKOTHHHA i nonBH xapaKTepHoro pisHA pisvHn. Doci Hepinko sycrpivaioteca ycKnanHeHHs 3 GoKy cepyeso-cyAUHHO! cucteMM Y BurnAR Konancy, FOcTporo fereHeBoro Cep\yA, FoCTpOFO pecniparopHoro sucrpec-cuHapomy (ToKCH4HO- ro KaBpaxy neretiie), eHOKapAMTY, MioKapauTy. Qliarnocruxa i ziarnocruuni KpuTepii Penmeenozpatbin opeanie epydHoi Knim- ku © HaieaknuMBiWuM IHCTpyMeHTaNbHYM Me- Tonom aiarnoctien nHeaMoHil, Tpn axariai pertrexorpam y npaiilt | Givnit (Ha Goul ypa- >dkeHHA) NPOeKUIAX OUIHIOIOTE xapaKTep, OG'eM, TOMOreHHiCTh YPaKeHHA NereHeBo! TkAHMHM, a TaKox peaxtlilo nnepH. Ha novanositt cranii nHesMonil (y nepuil ropMHN aGo Aelb saxooprOBaHHs) EHsHANAETECA NOCMNeHHA nereHeBoro ManloHKa B ypaxeHux cermentax nereri. FposopicT nereHeeo! Tal Hu We He NopyweHa aGo AeEWYO NoHIOKeKa. Ha- ani npn ywinbHenHi nerevesol TkaHunn (craps ‘epeoxoro i ciporo onesiHKyBaHHA) aysHasaETECA saTeMHeHHA ypaxeHix pinaHok nereniB. 3anex- Ho Big xapartepy \boro saTemHeHHA permeeHo- noziaHo pospisiatork Aba THNM NHEBMOHi — na- penximaroaHi a ikreperuuiansii (raGnnyr 4.9). TaGnuts 4.9, Pextrevoaorivni THnK NHeBMOHIA 1. Mapexximamosni neemoril, pri xapakTepuayl0TLCA NEPEBAKHO eKCYAATHBHMM KOMNOHEHTOM sgananeHia i npn AKMX BinsHaYyeTECA: a) fOMOreHHe 3aTeMHeHHR NeKinbKOX CerMeHTiB AGO Kino YacrkM NereHi (Kpynosha NHeBMoHiA) — pic. 4.4; 6) HanBHicts opHOrO 4 AeKiNbKOX BOTHUIN| AGO incbinsrparie (HeroMOTeHHHX, pisHot senwuntia | bopMy) 8 opi Gn OGox slereHAX (BOrHMU\eBA NHEBMOHis) — pre. 4.4. 2. lumepemuujaneni MHeeMOHil, Ki XapakTePMayIOTLCA NepeBaxHo yUjINHEHHAM TPOMOKHOT TKAHWHH NereHi | BUFIENAOTECA NOCHNeHHIM NeTeHEBHM MAMHOHKOM 38 PaxyHOK nepu€porxianbHol i nepueackynapsol ininerpauit. Taxi pexTrevonoriuni osHaKi WacTiWe syCTpi¥aiorbcn np arunoeHx i eipycHo-GakrepiansHyx nHeBMoHinx. Binbwicte nkeemonia cynposopyiots- cA sananbHumu aMinamn nepucbepustol Kpo- Bi. Ak npasuno, HaiivacTiwe sycrpiyactecA neiKouTos, Sennunta AKoro eiqnoBinae imy- Honoriuni Biqnosini opravismy Ha mixpo6Hy arpecito. Kinbxicte neiouwris KonuBaetécA 8 Mexax 9-20 x 10%. Ha nouarky iB pos- nani saxsopioBaliHa cnocTepiraeTecA sHayHe 3GinbWeHHA HeliTpodinis, BupaKeHMi scys neiikounrapHci cbopmynn anipo, ark no Mieno- unTib. [py ubomy KinbkicTs anWuKoRAepHX Heittpocpinie wacto nepesmuyye 10 %. ¥ nepi- Of posnany saxBopionalii 4aCTO SHMKaIOTE eosnnocinn, sHinkyeTeca KinbKicTe mimcpo- umtie i tpomBountie, npuckoproerbor WOE. 3 HacrakHsm pospilleHHR saxBoploBaHHA skazani naronoriMHi amin noctynoso Hopma- nisytorbes. Mpore y pani sunanris, ocoGnuso y BISl- iMcpikosanix nayieHtia, Ha Thi ATPoreHHO! imy- Hocynpecii (y onKonorivAiix i remaronorisHnx xeopux, nicna Tpakonnarayii eHyTpiwrix 4, Tienmsoniin Puc. 4.4, Peitrenonorista KaptHHa npx KpynosHiii (Ha Aisomy sHinKy) isorHmuesin (Ha npasomy sHiAKy) NHEBMOHiT ravi8) NHEBMOHIA Moke nepeGiraTH 3 neliKo- siiet, aBContoTHoW i BigHOCHOIO nimeponeHi- Helponevielo. Ocrans © noranum npo- OCTHMHMM KpuTepiem. MixpoSionorivHe pocnimKeniA Gionoriv- vo mavepiany (Hamwactine MoKpOTMHHA) & 2608'R3KOBMM AlarHOCTMYHMIM MeTOAOM, LO AO- Ss0NRe NPOBECTH KopeKtiio aNTHGaKTepianbHo- nikyeanns nig ¥ac Horo npopenenia. Hessa- i Ha TpyaHoUi 8 erionoriuHilt Bepuchixaui “seMmonil, He cnig sigmosnatncn Big nesHoi mecnigostocri allt np npopepeHHi mixpoGiono- Horo oBcTexeHHs xBoporo (TaGNMLiA 4.10), Diarioctwyiio sHayyumm © Taxwii pe- zymstat mikpo6ionoriuoro —pocni@xentis MOXPOTHHHA, B AKOMY KOHUeHTpauiA NoTeH- =AHoro s6yaHnKa cxnanae 106 i Ginkwe ecfovicyTaoptoiodux onunMyb (KYO) 6 1 wn woxpotunia. Octatouny iKTepnperayiio pe- aynbraris excnpec-Sakrepiockonit i nociay MoKpOTHHHA chin nposoaNT 3 ypaxyeaHHam wniviunux gaHnx. Bpaxosyiown snKnagere, cnig spo6uTw BUCHOBOK, WO OCHOBHKMM AiarHocTu4HHM kpmtepiem nesmonii © eoeHuwese a60 in- dhinempamuene samennenna (incbinsmpayis) Ne2eHeEo! MKAHUMU, SKE BHSENAETECA PeHTTE- Honoriunun gocniaxentan (raGnvys 4.11). 3a sincytHocti aGo HemoxnMeocti oTpH MaHHA peHtreHonorivuora nigrsepaxeHHA PorHMUyeso! NHeEBMoHil pianos HerocniTanbHoi MHEEMOHi BBaXAETECH HETOWHWM (HeBUaHa- vennm). Fp ybomy pianos actaHoanioeTica 3 ypaxysaknan AaHux enigavamHesy, ckapr i shasneHnx dbisnkanbHinx osHak. Crig saanaNn Tu, wo 8 TaKi” cuTyauii aiarHos HerocnitanbHol THEEMOHii OTpuMye peHTreHonorisHe niareep- pxenuia Tinbx 8 22 % punanrie. TaGnuus 4.10, Nocaiaosticts mikpoGionori4HHXx cxaniais np nemo + Mixpocxonis (Gaxrepiocxonia) maakis, saGapsnerim sa Tpamom, ANA nucbeperuiauil rpannosuTueHo! I rpamHerarHeHol twixpocpriop (opienTosHuit excnpec-meron) Tocis matepiany (Garrepionorivinli meron) Ha xvEnnbHe CepenoenUye ANS aNRiNEHHA i inenrvepixauil s6yqHvKa, BusHA4EHHS toro YyTAMBOCTi fo anTHGloruKis (ana sepucbixayi atunoeoi nHeemonil) Mixpockonin maskie 3a Liinem — Hinscetiom (Gaxtepiocxonin miko6axtepiii tyGepxynbosy) Bishavenna cneuncbivnix aktutin i arTurenie y cupoearyl xposi ceponorivunu meron 78 ectune |. 3exaopiosanta opranis auxantin Ta6nuya 4.11. AiarHoctw4ni kputepii HerocnitaabHoi NHeEBMOH Afaevos nheemonil € eusHaveHuM / ecmaroeneHUM 2a Has‘eHocmi y xeopoe0 Ha permeeticepansl eo2nutyesd-incpinempamuenozo 2amemHeHHA y NOeOHAHH 3 Gena i Ginbwe Aodamkoeumu kniviutumu Kpumepiemu: + Toctpwis novatox saxeoprosanHs 3 ninenieHHsm Temnepatypy Tina Ginbwe 38 °C + Kawent 3 enqineniam MoKpoTiiHi + Dani oS'exTnenoro KniniuHOro HOCHIWKEHHS, LUO CBIAYATE NPO NOKANDHE YU\INbHEKHA NereHesoi TKAKUAM (npuTyNNeHviA aGo TynMl NepKyTOpHViA aayk, GpouxianbHe aGo ocnaGneHe BeavnyrpHe AvxXaHHA, cbokye ApiGHOnyxupYactux xprinis ifaGo Kpeniraui); + flevmousToa (Gintwe 10 x 10%/n) ifa60 NanvaKORAEpHHH acye (Ginbwe 10 %) y KpOBi xBoporo. BuckoBoK npo HaseHicTs y xBoporo Heroc- nitanbHoi nHeeMonil manosiporiaMui y xBoporo 3 NNXOMAHKOIO, CkapraMM Ha KAWENb, saqMUUKy, Binginena MoKpoTHHHA i/a60 Gin 8 rpyaHiin knliTui 3a BincytHocti cismKanbHMx OoHaK | HE- Moxnine0cti BKOHAHHA perTreHonoriuHoro o6- ati i Ginbwe nicna rocniranisayil y nocaHaHni 3 KMiMINHOIO CHMITTOMATHKOIO, Aka NigraepmKye ix inehexuimy npupony (HoBA xBVNA NUXOMAH- kM, Mie MoKpoTHHKS, MeAKOUUTOS | iH.), Np BVKNIONEHHI incbexuir, ki nepeByeann & iHKy- Gauiiiomy nepioni Ha MoMeHT HapxomKeHHA CTexeHH nereniB. Hosoxomianbna (rocnitantiia) nHeeMmo- Hin — saxBoploBaHHA, WO XapaKTepuayeTbCA MORBOW Ha PeHTreHOrpaMmi HOBYX BorHiLyeBO- incbintrparueHux ami y nereHax Yepes 48 ro- xpoporo fo Crauionapy. SanexnHo sia Yacy poseyTKy saxeopioBalt- a, HamBHocTi a6o sincyTHocti wMHHKi8 praiiky Oro BHHMKHEHHA, BugiNAOTb 2 BYgM rocniTanb- Hol nHeeMOHii— paniio i nistio (raGn. 4.12) Tabnnus 4.12. Baan rocnitaabHoi nHesMoHii + Pantin rocniransia nHesMonin —siHiiKac npoTAroM nepluix 5 Ais 3 monenTy rocniranisauil, oGymoBnevas6yqHuKan, aki Gynny xBOporo Wye NO KARXOPKeHHAB CTaLioHap (S. pneumoniae, H. influenzae, metnumninosy tment S. aureus Ta iHwi npenCTaBHNHY HOpMaNHO! mixpocbnopH RopoxKKiNKM poTornokH. Haliuactiuie Ui S6yAHMKH YYTTMG! Ao TPARMUIHMK aHTHGioTHKiB i nkeeMoHin Mae CnpuATTMBILN NporHOS. + Mista rocniransta neamonin — possueacrica He pablwe 6 ata rocnivanisaull i o6yMos- seHa BriacHe rocniTanbHoI wikpornopo!o 3 BML PYBHKOM HARBHOCTI BMCOKOBIpyneHTHHX i nonipesncrexrHux wramie, taxux sk P. aeruginosa, Acinefobacter spp., npepctasHuK clveiicra Enterobacteriaceae, metmumniopesvcreHTHuit S. aureus. Xapaktepvayerbon MeHU CNPMATTMBMM NporHOsoM. 3 ypaxyeaHHam TaxkocTi nepeGiry, cep- HosHocti mporHozy i ocoGnweocTe BeAeHHA peavimauilinyx XBOpHx, BUpINAIOTe TaKOK Tak 3eaHy BeHTUNSTOP-AacoLiioBaHy NHEBMoHitO, ska posBunynaca Nepes 48 ronwH sig nowaTKy nporeneHis IBN sa eigcytHocti osHak nere- Hepol iHpexuil Ha MomeHT ikty6auil. Heseaxka- foun Ha saranbHOBiqoMi OGMexeHHE, KniKiNHe OGcTexCHHA sanuuacTecR «BinNpaBHoW TO kolo» iarHocTuRN rocriTanbHux nHeEBMoHil, @ navi iHuinx MeTonis Rocni@KeHHR TinbKM iHTep- Nperylo 3 ypaxysaHiAM KniviMHO! KApTMHIt xeopo6n. Oopmanisorani jiarnocruusi xpuTepil rocnitantHoi nHeswonii nonaxi y abn. 4.13, Poania 4. Mxesmonin 79 TaSnuuya 4.13. AiarhocTH4ni kpHtepii rocniranHoi nHeEBMOHi Tosiea Ha pexmeevoepami Hoaux eo2HuLe6o-iHcbintmpamuahuX tai y nezersx y nocdHaHHi 3 Oeoma is HagedeHUx O3aK: 1) Tewneparypa tina enuya 38,3° C; 2) Gporxxianbia rinepcexpevin, 3) PaO,/FIO, (FiO, — cbpaxuin weHto 8 nosiTpi, Wo BupMKacTECA, %) menue 240; 4) Kawenb, Taxinvoe, NoKxarbHa Kpenitayia, Bonon xpuinn, GpoxxianbHe ”MxaHHA; 5) KinuxicTe nevKouTie Kosi MeHUe 4,0 x 109in aGo Ginbwe 12,0 x 109/n, nanuuKonnepnHit acys Binewe 10 %; 6) mite moKpOTHKHA / 6porxlansHut cexper (Gintwe 25 nonimopcbHonnephnx neviKOUMTIB y noni sopy npH Mixpockonil 3 Manun abintweHHsn, x 100). Anpepenuiaabna aiarnoctuKa Y ra6nuui 4.14 npeactasneni ockoeHi sexBoploBalita, 3 aKHM cnig nposopMTH AM: Seperuianbuuit alarioa npn nheeMoninx. Flomuinkosa piarkoctka samicrs nHeBMonil rpiny Ta iHwinx FP3 cnocrepiractbca aocuTe «acto, ocoBnueo 8 nepiozy eninemii rpuny TaGnvun 4.14, 3axBoprosaHua AerexiB, Uko BAMaraioTb AMcPepeHUiaAbHo} AjarHocTHKH 3 NHEBMOHIAMH Ha panix etanax nonikniniunoro cnocrepe- >xeHHA (0 50 % yeix evnaaKis). Mpw rpuni ra inwnx FPBI cumnronn inToKcHKayil nepeBa- >kaloTb HAA pecnipatopHimn, cbisnKanbunx i peHTreHonoriuHUX osHaK NHeBMOHii HeMae, xapaktepa Nnelikonexia. + [pun ta iwi PPS + Foctpuii Gporxir + Xpokisnuit Cponxir © ExcygaTuexwii nnespur + Arenexras + Ty6epryntos nereni + HosoyreoperHa nereHi + Bponxoexranmna xeopoGa + [HeemotopaKc Toctpnit Gporxit © pocrarHbo macosmea sxeoplopakiam, wjo Horo NuToMa Bara Cepen, eMcpiuHMx saxeopiosakb nerexis y opoc- mex aocrrae 55%. Bid sagenvan sMHuKas nicns ~speneceHoro [PS (Haliwactiwe pecripatopHo- SeeulrTianbHa Bipycra inipekuia) aGo onHONAC- 3 Hum, MposinHow ckaprow nph roctpomy Saxiri € HananonopiGHuit Kawenb, cnovarky yx, a notim —3 sigainenism crusncToro a60 cnvancto-rHivHoro =MOKpoTMHHA. NMiasvieHHa Tennepatypn Tina npu rocTpomy 6porxiti sa3Bu- aii KopoTKoNacHe (2-3 ari) a60 BoHa sanmuLa- Tea HopmanbHoto. Mepxytophnii sayk Hag ne reneenMn nonawn, sk npasHno, He MinReTHCR, Y XBOpUK NPOCNyXOByETECA NocHNeHe BESMKYNAD- He (kopcTKe) AMXaHHA, a TaKox cyxi a6o Bonori 80. xpunu (pintue). KaniGp xpunie sanexuTe ein pis- HA ypaxeHiA Gpouxie: np sananenHi xpynHnx Sponxie sazsiual eucnyxoayiorecn cyxi 6acosi i Bonori epynkonyxnpyacti xpunn, a npu nepe- Baxtomy sananeHHi ApiGHix Gporxie — ANCKaH- Tosi i mpi6Ho- 1 Cepenrtonyxnpyacri. Bypb-ski amin neKounTapHo! cbopmynn i WOE sasan- vai sincytHi. PettrenonoriuHo ausensieraca Nocuneliin nereHesoro manioHKa B pesynbrati NepnOporxianbHoro HaGpaky 6e3 incbinstparHe- Hux Tite. Tpupanicy kninisivx nporsia npn rocrpomy 6pouxiri sHavo mera — Bin 7 no 14 Avis 3 nopansuum onykaHHAM, Npv npoeenenki aucbeperyiantHoi aia- THOCTHKH nHeBMoHil i xpoHivHoro GpoHxity sycTpivaioreca 2 snqu nowmnok, Nepuie — ye ti- NopiardoctuKa neBMoHi y xsopux xpoHiusviM Spokxirow, Kann KaptuHy posenHytor nies MOKiT XUEHO TpaKTyIOTS 8K sarocTpeHHA xpo- kiutoro 6pouxity. Apyre — ye rinogiansocrnKa XpoHivHoro GponxiTy y xpopux nHeEMoHiero, Jo ocoGnineo sacTo cnoctepiraeTses y Kypuie. Uactuia 1. Saxwopionanes opranie auxantin NpoGnema sigHoweHHis Gpouxity i nHeeMoHit AocuTS cknanHa. Binomul crapuii upunanuii BupAS: «ABKAM BAKO NOCTORIPHO BUILTH, ne KinuaeTocA Gporxit i nownaeTecR nHeBMa- Hin» aBconioTHo aKTyANbAiit i 8 Hawi Ati Y nanwi vac, oco6nveo 8 Hawiih wpaini, ne sexbopioganicn Ha Ty6epKynbos HaGyna xa Pakrepy eninemii, ma6yr», y nepwy vepry cnig Aucbeperuilosatn neaMorito came 3 uM 3a- xeoplopaHHa. Lie nocuT cxnankul npoyec, WO FpyHTYETECA Ha peTenbHomy atianisi naHux alawmesy (baxnsi skasisKu po HaRBHicTs Ty- Geprynbosy a60 Gauwnoxocifictsa y xeoporo G0 8 cim'), KninisHoT KapTHHu (KnacuMHNA BL pas: «npit TyGepkynbosi Gararo BupHO i Mano 4yTH, @ mph nKeEMoHil, HaBnaKn, GaraTo uyrn i mano eupHon), akanisy eposi (anA nteBMonil Ginsu xapaxtepni HeitporpinsHi netiKowToS, eosuHonenis, nineboyntoneria i ninemuyernis UIOE) i perrenanorivtoro o6cremertis. OcHoB- Hi pettTreHionoriuti siawinocti ty6epKynbosto- To Npouecy i nHeEMOHiT nopani y TaBN. 4.15 Tabnuus 4.15. OchosHi pentrenoaorisni BiAMIHHOCTI FHeBMOHiI i Ty6epKyAbOay incbinerpar Tepesakva noxanisauis, Bepxta vactka ‘opia Oxpyrna Inrenenpiicn’ Tisl Bupaxena Koutypit Yin Bornujesicre Aye xapakrepra Borintia o6cimeninns no nepubepil a6o siaganevo 3mina nereHeBoro ManioHKA He xapaxrepya Alopbkka a0 kopens: Xapakrepa 3GinWeHHs KopeHis nerenis —_BigcyHe Duviavixa poscmoxrysaiia Go posnaa Dyke xapaxtepsi y surnagi CRDKUX MARU THEM 6-9 wicruie i Ginbwe AHeBMonil Hupkiia vacTea Henpasinena CnaGxa Posturi BigeyTHs, onHopiana Tint BincymHi XaparrepHa (nocunerHs ereHesoro MarioHKa) Bigcynin a6o cna6o enpaxena Xapaktepne, yacto ABOCTOpOHHE 1-3 Toki Posaia 4. Muernonin Kpim Toro, nesHe sHaveHHs wae BuBYEH- a TyBepkyninoeol sytnusocti (npoBa Marty), xova cnig nam'staTu, wo rinepeprivi ty6epKy- rikoBi npobH MoxyTb crocrepiratvcs iy 20 % xBOpux NHEBMOHiCIO. Y ckTanHuX piarHocTIM- “vx BunapKax HepinKO BAaIOTECA AO BpoHKo- ckonil 3 Gioncieto i yTomopcponorivHnn Aocni- “okenniam marepiany. Mpore cnig sanaw'sratu, wo eAnHo AO- STOBIpHitM, MaTOTHOMOHINHWI QOKASOM Ty Sepkynbosiici erionorii saxpopionaHHa € surBnenta miko6aktepii TyGepkynbosy 6 MoKpoTunHi, LO6 nigkpecnuTn TpyAHoU! Alt cbepenuianbHol piarHoctuKn nHeaMouii i Ty- piynboay, engaTHIh kniviyucr P. Xernist 28aqaB, WYO Chis BCTAHOBMTH NpABHINO: KOKEH nerenesuh npoyec axaxatn TyGepKynbosHiM Tv, NOKM He Byfe TOYHO eMABNeHA Hanex- iets Fioro no iMwoi rpyni saxBoploeals, & na yboro Bnepro i Hanonernmeo ecima pO- yum chocoBaMn wyKaT miKoGaKTepit =yGepkynbosy 8 MOKPOTHHH, NPOMMBHHX BO- sax Ta inuux cy6ctparax. Excyaarneni nnespurn Hepinko Ha pat x eTanax piarocTuKn npHiimaioms sa nes- \oHilo, OCkiNEKY BOHKA MatoTe GaraTo saranbiinx eninivnux oaHak (CuNbHi Boni 8 TpYAKI KniTUi, 2AQMILKa, yKOPONEHHA nepkyTOpHOrO TOHy, acnaGneHHs AXAHHA, saTeMHeHHA B HUDKHIX sinainax nerevi). Hesennky kinbkicr pigwnn y nnespansti nopoxHuHi Hepinko GyBae AyKe Aesiauia ‘paxel anieo Aesiauis cepya i nepxiskoaoro nourosxy arise 81 BAXKKO BHABUTH peHTreHONoriNHo. ¥ TaKHX BH nankex YIPYANEHHE Nero eMpituye ynbTpasey- kobe pocnipxenns nerevie, ake susiansie Hare ict @xe 150-200 mn eunoty y nnespanbiilt nopoxnuni, Kpim Toro, gna excynaTuBHoro nnespury He xapakrepHuit Kaiten 3 aunines= Ham chwaucro-THinHOro MOKpOTHHHA. ¥ BCix nip capinux BunagKax, oco6nuBo npv HepocTaTHilt signosiai Ha nposepeHin aHTHGioTHKOTepanil i s6epexenni saquuuikn, chin nposopnuTn nostop- He pentrenonorivte RocnimKeHHA, nicnA Yor sypiuiyeaTu nuTakHA npo AOuinLHicTS npoBe- AGH nneBpansHoi NyHKUTt Y anepenuiansaid piariocrayi nHes- Moni i paky nereni crig epaxceysatn xapan- Tepii ANA OcTaHHSOrO TpHBAnKin avaMmHes, kypiliH, KposoxapkaHin, cHligpoMm «mannx o3tiakn (cxygHeHHA, Heamorneopaia onaGictb, shvoKenHia aneTumTy), [yxnnta Moxe o6typyea- Tu 6ponx i npusaect no atenekrasy nereHi, LIO TaKOK MOKE ATH CXOKI 3 NHEBMOHIE! CHMATO- au, sokpema peHTreHonorivHi, Jo arenexrasy MOKYTs TaKOX npvissectn sGinbweHi ninco- Bysnvt KopeHA ere, TyYGepkynboa, YyxopiAHi tina 6poxxie, acneprinsos Ta in. Bupiuianvue SHEMeHHA HagaeTbcR Maku peHTreHonori4vHo- ro i ToMorpacbisHoro pocnimKeHHs (soKpeMa ~ konn'torepici Tomorpatbii), a TaKoxK GpoHxo- cxonii 2 Gioncieio. Tp eeniwomy atenexrasi nere#i xapaKrepHim € acys cepenoctintia y Bik yparkenia (puc. 4.5). Puc. 4.5. Ateaexras aisoi aeretHi Np cnoviraHnomy neeMoropaxei iniogi NOMMTKOBS Moxa NoCTasuTH pianos Kpynos- Hol nhesMonil, Cxoxvau cHmantomanu 6ynyT Goni @ rpynnidy kniTul npw auxaini, sanmuiKa, ocnaGneHiin AuxaHHiA Ha ypaxeHilt cropoxi. Ha KOpMcTs NHeBMoTOpakcy ceiavuTS panToBHi NowaToK, ochaGneHHA a6o noBHa sincyrHicTe AuxehHA y NoeAHaHHi 3 THMnaKiMewM nepKy- TOpHiNM 3ByKOM Ha ypaxeHil? CTOpoHi, faHi PelTreHiocKonil nerevi (pic, 4.6). Cin samKan naM'sTaTv npo BaxnneicTs cBocHacHal piarHoC- TURK NHEBMOTOpaKCy, OCKINEKH B TaKAX BuNAp- kax 22KAN HeOBxiqHa KoHcynbrayia TopaKank- Horo xipypra i chetianiaosaria ponomora, Oxpim — saxsopiosas nerevis, chin faw'atarH i npo ihuli saxeopropanne, nipw six “acto chocrepiraerics ringniarHoctuKa nies moni, Y nepwy Yepry, ue saxeoprosaHna cepyero-cyauHHoi cHcTeMm, ocoGniBO y HemonopHx xBopux. HepiaKo y TaKmx xeopux KniiKiMHMi CraH posuinioeTeca aK incbapKT Mio- Kapaa, rineproniviia xeopo6a a6o kapniockne- P08 3 xpoHiivHoIo HenocTaTHicTio KpoBOObiry, @ Hachpasni y xeoporo Kpynostia nieBMonin Besymosno, y Takmx eunagkax EKT i pentreHo- Tpacbito nerenis chin nposonum™ napanensio. Tpom6oemGonia nerenesoi aprep (TEMA) ~ rpiste ycknapienis pishix saxeo- PlOBaHb, UO sycTpivaeTecA pocHTE YacTo, fae no 30 % cmeprHocti, npuiomy piartos 3a 2XUITTA BCTAHOBMIOETECA TiNbKH y KOXHOFO Tpe- TbOrO xBoporo. Ninospy Ha TENA samKau no- BMHHA BUKNMKAaTH NoABa focTporo NereHeBoro: YPaxXeHHA XBOPOrO, WO cTpaxqae TpomGo- chneGiToM HiMKHix KiKLIBOK | Manoro Taga, xBO- PHX 3 nlopoKamn cepus, rineproHiuHoto xBopo- Goro, cepyesot Henoctatiictio 2-3 crynets, Aixysania mesmoniit Ockony cbapmakorepanil nxeBmonit ckna- Rae pauiovanbia aumuGaKmepianbHa mepa- rnin, #ka 8 Ineani noeuiiia GaayeaTuce Ha paHux MixpoBionoristoro AocnigxeHtA MOKpOTHMNHS! 1 NowHaTcA AKoMora padi. Mpore saromicTe, boro AOCKinKeHHA CTpHMyeTeCA neBHMN TPYAKOUWAMM, NpencTasneHuMn y TaGn. 4.16. Uactisia 1. Saxnopionanns opranin nuxasin Y 0ci6 8 nicnsonepauiviiomy nepiogi, nicna Honorie, npw Tpaamax, ocaGnMBO HUDKHIX Kitt UulBok, y XBOpuX 3 HOBOyTROPeHHAMN. FpaMunx Aucbepenuianbo-piarhocrunux oshak TENA i nHesMoni Hema. Cnig nam'atatu, wo np NHeBMoHil Nepesaxatons iMebeKuIiHO-TOKCYHE cummromn, Toni aK npM TENA — Kaprina woKy i sanyxa. Takomy knacuunomy cumntomy TENA, ak KpoBoxapKanits, OCTaHHiM Yacon HanatoTs mene aHaveHHA, Ta i sycTpivaeTs- csi Gin pinko. Y pasi poapuTey incbapxry nereni aHaveHHiA mae peHTreHonoriuHe AOCniaxKeHHA, Tp AKOMY MOKHa BUSBLITH POSLIMPEHHE KO- peHA nerexi 3 aucbystnm sGinHeHHAM nepu- Gepwurioro MantonKa, mHoKUHHicTE, cboxycie i Hanphicte sacriiHoro cbouy y nereHiax pu kapniorenninx incbapkrax, ix nignnespansne i nepucyncypanie postawysaHHs. LiHHoI0 o3Hakolo Ha KopucTe TESA © EKT-peecrpauia TocTpo BHHMKNOrO NepesaHTaxeHHA npaBux Binginie cepur, Wo BvifenAeTscA KOMnneKca- Mu Tuny SQ, a60 S,,,, HeraTHeHim sy6yem T Y NpaBux rpypHux ainsenennax, Orpim saxeopiogat cepyero-cyninHol cucteMm, nnesponiesMonin (saseMali Kpy- Nastia) MOKe CHMynioBaTu KATHY «rocrporo: aporap i chyryeaTn npueosom ana HenoTpi6- Horo cnepatveHoro eTpyvanHA. Haiuacriuie ApHuniia Takoro pony NoMunok KpueTBCA Y HE- NoBHoTi C6cTexeHHs, nepenycim — penTreHo- NorivHoro. Mipknli nocsin Gararbox noKonitie ni- kapie eumarac, w06 KoKeH xBopHii 3 osHaKaNn «rOcTporo xwBOTA® nignaras o6oB'asKoBOMy ornay He Tineki xipypra, ane ii Tepanesra, skuit i NpMiAMae piteHiHs| po O60B'AsKORe NpC- BeNeHHA peHTreHonorivHoro ObcTexKeHHs (npn HeoBxinHocti — B 2-x npoexuiax). 3 ypaxysantinm euknageroro, y 90-x pp. Muiynoro cronitrs nigxopn po alTMBaKrepi- anbHoro nikyeaniin MHeEMOHiN Bynu neperns- hyti. Y TaGnnyi 4.17 npencrasnexi cyyacni ocHosHI npuHYWiNH aHTHEaKTepianbHol Tepanit neaMonii, Posnin 4. Meamoxis 83 HANPYKEHMM NHEBMOTOPAKC: NATOOISIONONA Tlonirps HanxogitTe y nnespanbiy NOpOxHMHY 3 HagipsaHol nereHi, Brytpiwtonnespanbyiii THoK ka chapacrece, a cepeqocrinnn —-»-POCTAE, Sakpueaiown Knananiiit OTBIp amiuyetber y NPOTHNEKHHI i nepewxorxaiown Bvxogy NoeiTpA. ix, anaamoiown apyry nereHio Ia kon ROUXOM THICK NPOTPECHEHO Inocimooun aixanby pocTae. StiuiennA Cepenocrinksn HenocTarHicr’: abinauiyerson. Kynonn Alacpparwn onyexatorbcn KNIHINHI NPORBA oka sapnuKa Ljarios = Plesiauln taxi Bip y rpyanx Konanc nerebi np nigo6ivHomy nkeMoropaxci. Cepenocrinin i tpaxes aMiuieki npasopys, Kynon Alacbparaut Onyulenitit, sbxpeSepHi npoMiKe BHTITHaIOTECR Diarrocriaia nynnyis: wanosHeniens wnPHLIOM, Ropuerte exurosxyerece is- 38 nigsvujeHioro THeKy Kineup apenay — onycxator y BORY Excrpene noHueHKn TonaKocrowin y 3-my wioxpeber BRYTPIWHBONAeEpANLHOTO THCKY ApeHyBakiia nnespansHo! nopoxxHk unsxon nyHKT Puc. 4.6. Narocbisionoria Ta KaiNiwi npossM HanpyxeHoro nesmoropaxcy (30 ®. Herrepom) 84 ikyBaHHA HerocniranbHHx nHeBMOHiti, Bpaxosyiou Bigomi OGmexeHHA Tpapnuiinx meronia. etionorivHo! piarHoctua Herocri- Tamehix nesmoniit (HI), AOYINsHO nopinuTH NavjieHTis Ha OKpemti pyr, BIAHOCHO KOKHOI 3 FKIX Moka NepeaBauuTH HaaGinbW Biporin- Hux s6ynHiuKie i ix uytnneicTh 20 aHTHGioTHKiB. Y ab'naky 3 YM sanponoHoBaHo acix popocnnx nauieiis 3 HerocnitanernMn nHepworiamn no- pinuru Ha 4 rpynu (raGnuus 4.18), Y xpopyx HP | rpyn aneknarHuis Kni- HiNnMit ecbexT Moxxnueuit np nepopansHomy npiiiomi atTuGaxrepiantHoro npenapary (Mo- Yecrnna 1. Saxsopionanus oprattie auxaunn Horepanis!). Aix npenapar avGopy pekomeray- foTb amoKcnutniti a6 MaKponin (aauTpoMinHH, KnapvTpoMiyin, MigeKamiuun, cnipaniynn). Npw Hemoxnieocti npuiiomy xeopum npena- paty BuGopy npusHavaiors ansrepHaTnBHuit npenapar — pecnipatoprmi cbropxinonon Ill IV noxoninia. Y sunagKax Heedextnaxocti amoKcnynnivy 4epes 48-72 ronnnu nikyeaHtin aK npenapat Apyroro papy npyatayaioTs ma- kponin a60 poKcnynnnin, Le o6ymoanexo ix BUCOKOIO aKTHMBHICTIO BinHOCHO aTHnoeUx s6yn- HuKie, Aki Moxy 6yTH HaliGinbu! BiporiaHoi NpMMNHOIO HeBRaNoro nikyBaHHA aMOKCHUANi- TaGnuus 4.18. [pynv xBopHx HerocnitaabHo1o NHEBMOHIEIO i nrremineerne RY OREN wrtenetsyrmm ey XapaxtepneruKa Syne Komerrapi \ Xeopi HM a Heras 'S. pneumoniae, Y 30-50 % sunaanis s6ynHm fepeGirom Ges cynyTHLo! fnatonorii Ta iMux M. pneumoniae, C. pneumoniae, 2arani He BYRENSETECS, Focnivanisauii He Mogncbinyrownnx unHKiE H. influenzae (Ak npasyno, _norpeGytore. y Kypule) i pecniparopri ‘Bipyon " Xeopi HN s Hesantanna S. pneumoniae, | Pyrata wixpo6ionoriutia nepeGirom is cynyTib010 H. influenzae, S. aureus, | piartocruxa naronorieio (XO3N, M. catarrhalis, Manoicbopmaruana, cepiesa i HMpkoBa pinwe ciueicteo BnisbKo 20 % xeopinx Henocratiicts, Enterobacteriaceae (E. coli, | evmaraiote rocniranigaui 3 uepe6posackynspri Klebsiella spp.), oco6niiso y _ornspy Ha HeecbexTveHicTe xBOpO6H, nyxnMHit, Hemononux am6ynatopHoro nikyeaknn. uyKposiit niaGer, XPoHivHi XBOpOGU NeuinKit, ankoronism, novxi4ti posnapy) i unm moguepikyosrian Muetincann i Xsopi HN a nesancan S. pneumoniae, Tocniranisauia y nepesirom., ane H. influenzae, anmnoei Tepanestvune Binainenna HeonpHRTTBM NporHosoM — | sGynHMN, rpaMMeraTEN! ga MeZWMHVON errTopoGaxepit nokagaHHsa. Vv Xeopi HM 3 barexin nepeGirom | Focniranisauis y BAIT | . H. influenzae, tpanieraTwesti elTepoGaxrepii, S. aureus, M. pneumoniae, P. aeruginosa Posnia 4. Tnexnonin Hom. ¥ Bunapkax Heedexruplocti crapToso1o anTubioruKoTepanii makponigom npenapatom Apyroro pany moxe GyTH aMoKcMMni a6o chropxinonon Iit-IV nokoninns Y xpopyx HM II rpynu Buparxennit Knivive unit ecbext TakOx MOKNWBMIA Np Nepopanb- Homy npiiomi axTuGiorHKa. Mpote, ocKinku a6inbwyeTecs BiporiguicTs erionori4Hoi poni fpamHeraTueHoi Mikpocbnopy, ak npenapat su6opy cri sacroconysamn saxnueHiii ami- HoneHiyunit (amoKcuyunin | KnapynaHoBa xncnota) a60 yecbanccnopi Il noKoninna (uedypoxcumy akcetun). AnsTepHaTieHoio repanieio Moxe 6yTH sacrocyeanHs cbropxi- konony IIHV nokoninia. Mpy Hemoxneoc- Ti nepopanbHoro npuviomy npenapaty a6o HngbKOrO KOMMN@CHCY NPMSHavatoT NapeHTe- panbinii yechanocnopuvoanit axTHGioTHK II noxoninHs (Kpawye YecbTpiakcoH B/M). Ha Apy- romy erani attTuGioTukoTepanii cnig AonasaTu taxponig, B-nakramy 260 samicT Takoi KON SiMopanot Tepanii npusHayarn moHoTepaniio rocritanisauli. Yacrima 1. Sexsoposastn oprania aiskanun Y nayjentie 3 Heeaxxkun nepeGirom HM ar Tu6aktepiansiva Tepania woxe OyTH saKinuena nicna QOCArHeHHA HopMansko! Temnepatypn Tina nporsrom 3-5 pris. Y Taknx eunankax TpwBanict nikyeanns cknanae, sk npaauno, 7-10 atiis. Y pasi mikonnasmosoi a6o xna- miniinoi etionorii HM, Tpupanicth nixysaniin cunanae 8 cepentbomy 10-14 pris. AKO B ui Tepminn pocarkytai nosutuBHii echer, sania avTuBiotnka HegouinsHa, Mpa ctacbi- HokoKoBIA erionori’ HM aituGicruKoTepanito pexomenayeTsca nponomxyeatu (14-21 pene), pit neriovenboakit etionorii nikysariia npono- BXYETBOA He MeHNe 21 Hs Tlixysanna rocniransiinx nesMonii. Ait TuBaxrepianbHy Tepanito xeopum rocritansHoro NesMoHie! chia npnavavarn HeBinKnanHo, Binpasy nicns! ecravoaneHHa piarHosy, ocKinbKn BIACTPONEHHR npusHavenHa aHTuGioTiKie Hasire Ha 4 ron ZOcTORIpHO nizsMuye pusHK CMEpTi TaKnx nayicutie. Haii6inttu srinpaeaaHoio emnipHunoro atri- GiotrKorepanieio xeopix IT] € nikysannn sanex- Ho Bin Tepmitiie BMHVKHEHHA NHEEMOHII («

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