Diagnosis of pulmonary tuberculosis
For the study of bronchi use: 1) tracheobronchoscopy 2) x-ray method. Diagnostic examination of the bronchi and bronchoscopy for therapeutic purposes in a wide range of tuberculosis patients is carried out under local anesthesia. For the production of tracheobronchoscopy under local anesthesia, bronchoesophagoscopes are used according to Brunings (model 401) and Mezrin (model No. 453) using an optical bronchoscope (model No. 451) and an optical tube for direct examination during bronchoscopy (model 494). These bronchoscopes are produced by the Krasnogvardeets plant. Each device is equipped with detailed instructions for its operation and practical use.
Before bronchoscopy, it is necessary to conduct a clinical and radiological examination of the patient. A prerequisite for preparing the patient for tracheobronchoscopy is a psychoprophylactic conversation with the attending physician. Tracheobronchoscopy is performed in the morning on an empty stomach. When bronchoscopy under local anesthesia, 20 minutes before the start, the patient is injected with 1 ml of a 1-2% solution of promedol or 1 ml of a 1-2% solution of pantopon and 0.1% atropine. Teenagers are given half doses of these drugs. For children, instead of promedol, half an hour before bronchoscopy, they are given luminal, corresponding to age, and a 0.1% solution of atropine, 4-6 drops inward per sugar piece.
Local anesthesia is performed as follows: 10% cocaine solution or 2% dicaine solution lubricate the tip and root of the tongue, pear-shaped fossa and larynx; 3% cocaine solution or 1% dicaine solution conduct anesthesia of the trachea and bronchi with a laryngeal syringe with an appropriate incline of the patient with one hand down in one direction or another. Children are anesthetized with 5% and 3% cocaine solution. Each drug solution is consumed no more than 3 ml with the addition of an adrenaline solution at the rate of 1 drop per 1 ml of anesthetic solution.
In the absence of cocaine in adolescents, a solution of dicain – 1% and 0.5% is used for anesthesia of the trachea and bronchi – 3 ml of each solution or dicain – 0.025 g in 10 ml of 5% novocaine solution. Children can be anesthetized with the following composition: dicain – 0.005 ml and novocaine 5% – 10 ml, not more than 6-10 ml for anesthesia. In case of idiosyncrasy or intolerance to cocaine, dicain, you can use 5-10% solutions of novocaine in an amount of 10-15 ml.
At the first signs of intoxication with cocaine, dicain (agitation, blanching, shortness of breath, palpitations), the patient should be given a smell of ammonia, ether, amyl nitrite (1-2 drops), rinse the mucous membranes with saline, inject 10 ml of 10% calcium chloride solution , glucose, injections of caffeine, atropine under the skin, and also provide abundant access to fresh air, inhaling oxygen or introducing it under the skin, heating pad to the legs, mustard on the heart and stomach, massage of the extremities with seizures.
At the end of anesthesia, the patient is seated on a special chair for bronchoesophagoscopy or a low stool (bronchoscopy can be performed in a horizontal position of the patient on his back, side, stomach). Behind the patient should be a nurse who fixes the patient’s head, while at the same time supporting his back. The outer tube is inserted through the mouth with the tongue extended, focusing on the epiglottis, which is pressed with the beak of the bronchoscopic tube from its inner surface to the root of the tongue. Then the tube is installed in the vertical direction (installation on the vocal cords); sometimes, with a narrow glottis, carefully in the lateral position of the tube, with a deep breath and calm breathing of the patient, the respiratory cleft passes without any violence. Insert the inner tube and, focusing on the bifurcation of the trachea, direct the tube with an appropriate incline of the patient with his arm down (in one direction or another) to the right or left main bronchus. Thus, it is possible to directly examine the trachea, the main ones, the stem (intermediate), lobar, and with the help of a domestic optical bronchoscope inserted through the inner tube, and segmental bronchi. With lower bronchoscopy, the bronchoscope tube is inserted after the tracheotomy into the tracheotomy opening after anesthesia of the trachea, bifurcation and bronchi with solutions of cocaine (3%) or dicain (1%).
Bronchoscopy is contraindicated in diseases of the cardiovascular system, aortic aneurysm, decompensated heart disease, recent (up to 1 year) myocardial infarction, severe (III degree) hypertension, atherosclerosis, cardiosclerosis, general serious condition of the patient, active upper respiratory tract tuberculosis, especially with a tendency to stenosis and with Cicatricial changes, with acute, subacute diseases of the upper respiratory tract, intestines, kidneys, liver (especially with anesthesia), amyloidosis, with severe forms of base ovizma, myxedema, diabetes, after recently suffering a pulmonary bleeding during menstruation, and in the second half of pregnancy, when stiffness and curvature of the cervical spine and habitual dislocation of the mandible.
Tracheobronchoscopy is indicated in the presence of symptoms of tuberculosis of the trachea and bronchi, as well as a control study of the condition of the trachea and bronchi before surgery and after surgery to revise the postoperative stump of the bronchus, before bronchography, when coughing up broncholands, with unclear hemoptysis, atelectasis, local emphysema, radiological data (unevenness, tortuosity, stenosis of the bronchi and especially deformities, etc.), as a therapeutic method for postoperative atelectasis, with abscesses and bronchiectasis x, complicating pulmonary tuberculosis, to monitor the dynamics of the process and the production of medical interventions when detecting bronchial tuberculosis, with suspected tumor, foreign body and other diseases of the lungs and bronchi (Beck sarcoidosis, silicotuberculosis, echinococcus, scleroma, pneumosclerosis of unknown etiology, etc. .).
Currently, taking into account the increased asymptomatic tuberculosis of the trachea and bronchi under the influence of chemotherapy, as well as the safety of methods of bronchoscopic studies, bronchoscopy should be performed regardless of the symptoms of the primary tuberculosis complex, tuberculosis of the tracheo-bronchial nodes (bronchoadenitis), fibro-cavernous, cavernous, hematogenous disseminated, focal, infiltrative-pneumonic and other forms of pulmonary tuberculosis, in the phase of infiltration and decay, bacilli in the absence of a wedge co-radiological changes in the chest cavity and in the presence of pulmonary tuberculosis in the phases of compaction, scarring, calcification.