Bronchography is an essential essential radiological method of research, which allows to determine the condition of the bronchi, inaccessible to study with bronchoscopy. Bronchography makes it possible to clarify the nature of changes in the bronchi, localization and prevalence of the process. This method is especially necessary for assessing the functional state of the bronchial system as a whole, as well as of individual segmental and subsegmental bronchi affected by the pathological process. A bronchographic examination is carried out according to the generally accepted technique with a guided catheter inserted after local anesthesia through the nose under X-ray control. Bronchography is performed on an empty stomach. 30 minutes before the intervention, luminal is given – for adults, at a dose of 0.1 g, for adolescents – 0.05 g and for children – 0.03 g. For anesthesia, a mixture is recommended as follows: for adults and adolescents – 5% solution of novocaine and 0.025 g of dicaine , children – 5% solution of novocaine with the addition of 0.005 g of dicaine. To obtain case anesthesia, 6-10 ml is enough when the mixture is injected into the nose, larynx, trachea and bronchi. In order to quickly release the bronchi from the contrast mixture with the help of an electric suction device, sulfoiodol is removed from the bronchi. In recent years, the combination of bronchoscopy with bronchography, both under local anesthesia and under general anesthesia, is considered the most rational in the cases shown, especially in children.

Bronchial tuberculosis is the most common complication of various forms of primary and secondary (mainly bacillary) pulmonary tuberculosis (5-10% of hospitalized patients with pulmonary tuberculosis examined bronchoscopically). The statistics of recent years indicate a decrease in the number of diseases of bronchial tuberculosis, which is associated with a number of general and local causes (a decrease in the number of lung tuberculosis diseases, timely detection, active antibacterial and surgical treatment, etc.). However, the percentage of this complication in fibrocavernous and especially in primary processes remained high. With tuberculosis of the bronchi, the main ways of spreading the infection are as follows. 1. Bronchogenic (intracanalicular) – infection of the bronchi most often occurs through the mucous glands and is the main one with cavernous and destructive forms of pulmonary tuberculosis. 2. Lymphogenic metastasis of the lymphatic and perivascular vessels. This pathway is the main one in primary tuberculosis, tuberculosis of the tracheo-bronchial lymph nodes, especially in children and adolescents. 3.

The direct breakthrough of caseous masses from the affected lymph node (perforation, fistula) or the germination of tuberculous granulations through the walls of the bronchus from the lymph nodes affected by tuberculosis. 4. The hematogenous route of infection is extremely rare. In most patients (98%), bronchial tuberculosis develops gradually. Tuberculosis of the bronchi, especially in the initial forms, can be asymptomatic. Symptoms of the disease depend on the general reactivity of the patient, the form of pulmonary tuberculosis, the clinical onset and course of the process, as well as on the phase. Below are the most common symptoms of bronchial tuberculosis. 1. A loud, persistent, barking, whooping cough, convulsive cough, often with pain in the chest, usually does not subside not only with large doses of drugs, but even with prolonged treatment with modern antibacterial drugs. 2. Persistent and diverse pain behind the sternum, often with a slight cough, especially with wheezing, squeaky or persistent parasternal, paravertebral wheezing and generally voiced and wheezing in a limited area of ​​the lungs. 3. Shortness of breath with slight exertion, not corresponding to the prevalence of pulmonary tuberculosis, often with asthma-like attacks and even cyanosis. 4. Root localization of the process in the lungs or a close relationship of tuberculous changes with the root of the lungs. 5. Atelectasis of the entire lung or its individual lobes and segments, atelectasis after surgery. 6. The presence of blocked, bloated large or giant caverns. 7. Suspicion of the possibility of stenosis of the trachea and bronchi with normal larynx and expiratory dyspnea.

The clinic of bronchial tuberculosis in children has some features compared with the course of this form in adults. Tuberculosis of the trachea and bronchi in children can have a diverse clinical course – from rare severe forms, accompanied by asphyxia, to asymptomatic. In contrast to adults, whose processes usually occur chronically, in childhood, acute forms are possible, although relatively rare with modern TB treatment, when caseosis from the lymph nodes breaks into the bronchus. At the same time, a turbulent clinical picture is observed, simulating in some cases a foreign body. In most cases, the clinic of bronchial tuberculosis in children is poorly expressed or asymptomatic. However, these children have marked changes in the lungs. With tuberculosis of the trachea and bronchi in children, the most characteristic symptoms are those associated with impaired bronchial obstruction in the presence of lobar or segmental atelectasis.

In adolescence, when there is a significant restructuring of the endocrine and nervous system, primary tuberculosis or incompletely resolved and calcified caseous sites in the lymph nodes are often found. In this regard, adolescents also experience clinical forms of tuberculosis of the trachea and bronchi, which are very similar to similar forms in children. The clinical course of tuberculosis of the trachea and bronchi in children and adolescents with secondary forms of pulmonary tuberculosis does not differ from that in adults.

Changes in bronchi in primary tuberculosis have their own characteristics. The affected lymph nodes can exert simple mechanical pressure on the bronchi, which causes a narrowing of their lumen. Similar changes can be observed in patients of any age suffering from primary tuberculosis. However, this is especially common in children whose bronchial walls are softer and more pliable than in adults.
Clinically and pathologically, bronchial tuberculosis is detected in the form of a predominantly productive and predominantly exudative reaction. These reactive processes are usually observed in two main forms – infiltrative and ulcerative.

A predominantly productive process, usually characterized by a chronic occurrence and course, is observed in about 90% of cases. The mucous membrane of the affected areas is pale pink, swollen, inflammatory changes are absent or slightly pronounced. Infiltrates with a productive nature of the process in most cases are flat, limited, dense, irregular round or elongated. Ulcers are usually superficial, limited, with insignificant inflammatory phenomena in the circle or even without them, often with a smooth or covered with granulation bottom, barely edges.
The predominantly exudative process is characterized by acute or subacute onset, a progressive course, is observed much less frequently (about 10% of cases). The color of the infiltrates during the exudative process is usually bright red, they are swollen, soft, gelatinous, in most cases diffuse and quickly disintegrate. The ulcers are multiple, but can be isolated, quickly merge into continuous deep crater-shaped, often penetrating to the perichondrium and cartilage, with a dirty gray coating, bleeding granulations, and less often whitish-yellow, dense or tiny caseous masses. With a biopsy of the latter, sections of necrosis are found, sometimes in the absence of cellular elements. A special color makes it possible to detect large quantities of Mycobacterium tuberculosis, which clarifies the true nature of the disease.

With the introduction and increasing use of antibacterial therapy in patients with post-primary pulmonary tuberculosis, a marked predominance of tuberculosis of the trachea and bronchial tubes of the infiltrative forms (90.5%) over the ulcer (9.5%). However, with primary
tuberculosis, there is a significant predominance of ulcerative forms (71.1%) over infiltrative forms (28.9).
With clinical treatment of bronchial tuberculosis, 20% of patients have scars, usually in the form of single, superficial,
whitish, sometimes shiny irregular strips. Significantly less likely may be massive concentric scars that almost cover the lumen of the main, intermediate (trunk), lower lobe or mouth of the lobar bronchi. With primary bronchoscopy, scars are detected in 2-3% of patients with pulmonary tuberculosis.

Stenosis occurs not only with the formation of a scar or fibrous tissue, they can be caused by massive infiltrates with ulceration, accompanied by the growth of granulation tissue. There are stenoses of I degree (lumen of the larynx, trachea or bronchi is closed by one third), II degree (captures two thirds of the lumen), III degree (a slight slit-like or oval lumen of the bronchus is visible).

Stenoses of a different nature caused by infiltrates, ulcers, granulations and scars are observed in 5-10% of patients with bronchial tuberculosis. With clinical treatment of bronchial tuberculosis, fibrous and cicatricial stenosis of I, II and III degree are diagnosed in 3-5% of patients.
Fistulas in adult patients with secondary tuberculosis during the breakthrough of caseous masses from the tracheobronchopulmonary lymph nodes occur in about 3% of cases. In primary tuberculosis, tracheo-bronchial lymphatic fistulas are observed in 15.6% of children and 9.6% of adolescents. The formation of fistulas in bronchial tuberculosis is one of the features of bronchial tuberculosis compared with the tuberculosis process of the upper respiratory tract. With tuberculosis of the nose, mouth, pharynx and larynx, fistulas are not formed. Their presence in these organs in patients with pulmonary tuberculosis makes the clinician suspect a non-tuberculosis disease, in particular gum, malignant tumors, abscesses, etc.
In most cases, fistulas form small, sometimes diagnosed only with an optical bronchoscope, proceed with mild clinical manifestations, in some cases asymptomatic. They are characterized by the presence of mycobacterium tuberculosis in sputum, bronchial lavage water in the absence of active tuberculous changes in the lungs, but in the presence of primary tuberculosis, bronchoadenitis. Often, enlarged tracheo-broncho-pulmonary lymph nodes are diagnosed only with the help of special x-rays (tomograms, overexposed, etc.).

The bronchoscopic picture of the bronchial fistula with active tuberculosis of the tracheo-broncho-pulmonary lymph nodes at different stages of their formation and course can be very different. At first, only a protrusion of the bronchial wall into the lumen with hyperemia of the mucous membrane above this area is visible. Subsequently, the infiltration increases and takes the form of a boil, either with a sharp tip, or with a more rounded one. When the contents of the lymph node break through, a white dot appears on the top of the boil, gradually increasing in size – caseous masses. With formed fistulas , a boil-like infiltrate with a crater-like depression in the center, where there is a fistula opening, is clearly visible. Gradually, the perforation edges lower and their contours are smoothed out. With long-existing broncho-lymphatic fistulas, granulations develop around the opening up to the formation of lush vegetations resembling an endobronchial tumor. When these granulations are removed for therapeutic or diagnostic purposes, a chronic inflammatory process without specific signs is often morphologically detected. With further biting of granulations or removal of the discovered caseous masses, it is possible to detect a characteristic picture of the tuberculous process. Fistulas are most often localized in the area of ​​bifurcation, on the inner walls of the main bronchi and in the mouths of the middle lobe and upper lobe bronchi, especially on the right.

When diagnosing bronchial tuberculosis, the medical history, complaints of the patient, data from a general and special study are taken into account. In some cases, it is necessary to examine mucus, bronchial lavage water for mycobacterium tuberculosis during bronchoscopy, and also to perform biopsies.

It should be remembered that in patients with pulmonary tuberculosis, non-specific endobronchitis is observed: catarrhal, hypertrophic and atrophic. For catarrhal endobronchitis, more often chronic and less often acute, a uniform diffuse lesion of a significant part of the bronchial mucosa with a large amount of mucus, sputum is characteristic. The mucous membrane of the bronchi is swollen, its surface is often shagreen, folded, and the contour of the cartilaginous rings is also smoothed. With hypertrophic endobronchitis, the mucous membrane is thickened, rough folds form in places, and inflammatory phenomena are significantly pronounced. The formation of granulations and polyps is possible. Atrophic endobronchitis is bronchoscopically characterized by the absence of inflammatory changes, atrophy of the mucous membrane, fibrotic thickening.

All types of benign tumors are found in the bronchi: papillomas, fibromas, lipomas, enchondromas, adenomas, polyps, etc. All types of these tumors are characterized by a tumor-like, mostly limited infiltrate, most often sitting on a leg, less often on a broad base. Usually the mucous membrane is pinkish, without disturbing the integrity of the epithelium. With angiomas and with adenomas, the surface is uneven, sometimes lobed, reddish-cyan in color.

The bronchoscopic picture usually gives reason to suspect clinically one or another type of benign tumor, but the final diagnosis is established on the basis of a biopsy. Of infectious granulomas, scleroma is rare, which is recognized on the basis of dense, whitish-yellow tuberous infiltrates. Confirmation of the positive Borde-Zhang reaction, biopsy, and detection of the Volkovich-Frisch stick in mucus and scleroma tissue is necessary.
In recent years, bronchial cancer often has to be differentiated from the tuberculosis process. Cancer is characterized in typical cases by a tumor-like granular bleeding infiltrate of a fleshy or reddish color, causing rigidity and immobility of the walls of the bronchi. The diagnosis is usually confirmed by biopsy or cytologically. These studies in endobronchial cancer give a positive result in approximately 80% of cases. The study on tumor cells of bronchial lavage water helps, especially with suction.
Sarcoma usually appears in the form of tumor masses resembling a ball of earthworms, in color similar to fish meat. A final diagnosis requires a biopsy.

Bronchial mycoses are characterized by pronounced inflammation, hyperemia, swelling and thickening of the mucous membrane, as well as thick membranous fungal deposits of white, whitish-yellowish or white-gray color.

Sarcoidosis is manifested by changes in blood vessels running across the cartilage rings, in the form of parallel bundles, sometimes located in a vortex-like manner, as well as the formation of plaques and papillae on the bronchial mucosa.

Syphilis of the bronchi is characterized by the presence of single or multiple tumor-like gum, with a high tendency to decay. Gummy ulcers usually have sharply limited edges, covered with greasy plaque. A positive Wasserman reaction, the absence of pulmonary tuberculosis, the effectiveness of specific therapy usually help to diagnose syphilis.
If aortic aneurysm, intravascular goiter, intrathoracic or spinal abscess is suspected, it is necessary, first of all, to conduct a thorough general and local examination before bronchoscopy in order to avoid unpleasant consequences.

The course, outcome and prognosis depend on the general condition of the patient, phase, form and prevalence of pulmonary and bronchial tuberculosis. Modern anti-TB drugs with complex general and local application depending on the above factors lead to the clinical cure of bronchial tuberculosis in 99% of patients.

local_offerevent_note December 4, 2019

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