Bronchitis

BRONCHITIS, bronchitis (from bronchos-bronch), inflammatory processes of the mucous membrane of the bronchi; from a clinical point of view, this term often implies inflammation of the entire respiratory tree, between the vocal cords and pulmonary alveoli. Bronchitis is distinguished by course and duration - acute and chronic, by location of the process - bronchitis of large and small bronchi; in addition, primary and secondary bronchitis and, as special forms - putrefactive and fibrinous bronchitis. - Etiology and pathogenesis. -I. The cause of acute bronchitis, most clinicians are inclined to consider, mainly, an infectious factor. Most often in sputum in acute bronchitis, pneumococci of Fränkel, streptococci, staphylococci, bacilli of influenza, pneumobacilli of Friedländer, micrococci of Pfeiffer and others are found. The way of introduction of the infectious agent in primary bronchitis (influenza, measles, whooping cough), apparently, is the inhaled air; in secondary infectious bronchitis (typhoid, sepsis, smallpox, scarlet fever, etc.), microbes or toxins enter the bronchi and trachea through the lymphatic and circulatory systems. However, the pathogenesis of bronchitis in various infectious and other diseases cannot be considered fully elucidated. The question of the cause of acute bronchitis that developed after a cold, after inhaling gases, dust and other irritating substances, which themselves can cause severe hyperemia and increase the secretion of the bronchial mucosa, is controversial. Usually such irritation of the mucosa soon passes and is not accompanied by all the phenomena of acute bronchitis. All these external irritations apparently create favorable soil for the penetration of microbes, which cause the disease with acute bronchitis. In chronic forms of bronchitis, it is also possible to admit an infectious factor at the beginning of the disease, and later constitutional factors, anatomical and histological changes and the influence of external conditions play the main role. -II. Predisposing causes. -1. Cold, or cooling, more often of the body than of the bronchial mucosa, is a predisposing factor. Although the essence of the effect of body cooling on the occurrence of diseases in general and, in particular, catarrhs of the respiratory tract has not been clarified, it must be admitted that sharp fluctuations in temperature are a factor predisposing the body to disease with catarrh of the respiratory tract. Accordingly, frequent bronchitis diseases are observed in those localities and at those times of the year when meteorological conditions are most unfavorable (sharp fluctuations in temperature, cold winds, humidity of the air). 2. Age - children under 5 years and the elderly are most predisposed to bronchitis (due to insufficient resistance in the former and weakened stability in the latter). 3. Sex, apparently, has no significance, although men get sick more often, depending on their occupations and lifestyle. 4. Some general diseases, for example, gout, kidney diseases, chronic alcoholism, syphilis, bronchial asthma, maintain and prolong the course of the disease. 5. Circulatory disorders in the form of venous hyperemia, often observed with heart defects or in the form of collateral hyperemia (for example, with emphysema, pleural exudate, pneumothorax, tumors of the lung and mediastinum, etc.). 6. Inhalation of irritating substances in the form of gases, vapors and dust (vapors of HNO₃, HCl, H₂SO₄, Cl, Br; vegetable, animal, mineral and metallic dust). These bronchitis are most often observed in workers of the corresponding industries and should be considered as a professional disease. 7. Individual predisposition, constitutional and associated with temporary or unfavorable conditions and harmful habits (debilitating diseases, anemia, tobacco smoking, etc.). Pathological anatomy. Anatomical changes in acute bronchitis consist in hyperemia of the mucous membrane, in its swelling (depending on vessel overflow, edema and inflammatory infiltration) and in the change of the secretion in quantitative and qualitative relations. In mild cases, changes are limited only to the mucosa itself; in more severe cases, they involve all layers of the bronchial wall. The mucosa appears loosened, thickened, covered with mucopurulent secretion, the walls of the bronchi are thickened due to inflammatory edema and infiltration. In chronic forms of bronchitis, the mucous membrane is cyanotic or ashen-gray in color; with the predominance of atrophic changes (atrophic chronic bronchitis), the mucosa thins and becomes smooth, shiny; with the predominance of proliferation processes (hypertrophic chronic bronchitis), polypoid thickening of the mucosa is observed, and sometimes thickening of the entire bronchial wall. Subsequently, the development of bronchiectasis (see) is possible. Depending on the duration and nature of the pathological process, changes in the nature of the secretion from the mucosa are observed. As outcomes of some forms of bronchitis (for example, with measles, influenza, the effect of suffocating gases), a transition (metaplasia) of the cylindrical epithelium of the bronchi into multilayered flat epithelium can be observed; in addition, in small bronchi, bronchioles (when their epithelial cover is damaged), obliteration of the lumen with connective tissue (so-called bronchiolitis fibrosa obliterans) is possible. Changes in the lungs in acute bronchitis can be observed in the form of atelectasis, peribronchitis and catarrhal bronchopneumonia (when small bronchi are affected); in chronic, long-standing bronchitis, interstitial changes in lung tissue, emphysema are also found. The heart in prolonged and extensive bronchitis, especially the right one, is almost always hypertrophied and dilated. The lymphatic glands of the bronchi and lungs are usually enlarged. Individual forms of bronchitis. -I. Acute catarrh of the larynx and bronchi, bronchitis et tracheo-bronchitis acuta, the most common form of catarrh of the respiratory tract, usually begins with a runny nose, passing into catarrh of the larynx, respiratory tract and then - large and medium bronchi. In mild cases, the manifestation of the disease is limited to a dry moderate cough, which after several days turns into a wet cough with a small amount of mucous and mucopurulent sputum. The disease lasts 1-2 weeks and is not accompanied by severe general phenomena. In some cases, it apparently concerns unclear forms of influenza infection. In severe forms, patients complain of malaise, indisposition, feverish condition, loss of appetite, dry irritating cough, pain in the chest and sometimes moderately difficult breathing. The fever lasts for several days, of an irregular type, usually not exceeding 38-39° and soon gradually decreases to normal. The pulse quickens in accordance with the fever. The cough at the beginning of the disease is dry, frequent, painful, sometimes in the form of attacks, accompanied by a feeling of tickling in the throat. In the first days, a small amount of viscous, mucoid-glassy sputum (sputum crudum) is secreted, the amount of which subsequently increases, the sputum becomes less viscous, easily expectorated and mucopurulent (sputum coctum). On microscopic examination of it, cells of flat, cylindrical and ciliated epithelium, an admixture of leukocytes and bacteria are found. Sometimes an admixture of blood can be detected macroscopically and microscopically, for example, with a tense cough. Shortness of breath is usually observed in a very moderate degree or is absent. On physical examination of the chest, on percussion - normal lung sound, and on auscultation - muffled or harsh vesicular breathing, buzzing rales (ronchi sonori) from swelling of the mucosa of the trachea and large bronchi and wheezing rales (ronchi sibilantes) from swelling of the mucosa of medium bronchi and accumulation of viscous sputum. In the next stage of the disease, when more liquid mucopurulent sputum accumulates in the bronchi, large and medium-bubbling moist rales appear in both lungs - in larger quantity in the posterior lower parts. Unlike moist rales in lung diseases, they are not resonant. Disorders from the digestive system, circulatory system, nervous system and urination are usually insignificant. Recognition, based on the symptoms indicated, does not present difficulties. The prognosis is usually favorable. Only in children, the elderly and debilitated patients, severe acute bronchitis can sometimes lead to death, and in tuberculosis patients, worsen the condition. - Postoperative bronchitis does not differ in course from acute. The causes are not exactly clarified; apparently, a number of factors play a role: the presence of ordinary microorganisms in the upper respiratory tract, weakening of reflexes from the peritoneum (frequent development of bronchitis after abdominal surgery), insufficient ventilation of the lungs with shallow breathing, fixed position of the body (stagnant phenomena in the bronchi) and irritation of the mucosa from inhaling vapors of chloroform and ether during anesthesia. A bronchitis existing before the operation often intensifies. The prognosis, in the absence of complications, is favorable. - Capillary bronchitis, or bronchiolitis, bronchitis capillaris s. bronchiolitis, representing inflammation of the smallest bronchi (bronchioles), in adults rarely develops as an independent disease; it usually joins acute primary, and even more often secondary bronchitis 9v in severe diseases by spreading the process to small bronchi (b. diffusa), easily complicated by catarrhal (lobular) pneumonia.

To the clinical picture of acute bronchitis are added more severe general phenomena, shortness of breath, severe cough, and often a higher and more prolonged fever. Capillary bronchitis in children is of serious significance, representing a severe disease. Capillary bronchitis is also dangerous for the elderly, in whom it easily passes into catarrhal pneumonia. Physical examination of the chest in capillary bronchitis reveals higher and more widespread buzzing and whistling rales and an abundance of small and medium moist rales with a clear percussion sound, which may become dull in case of complications (lobular atelectasis, pneumonia, etc.). At first the sputum is scanty, later it becomes more abundant, in character mucopurulent. Children usually do not expectorate sputum. Complications in the form of bronchopneumonic foci, atelectasis, and acute emphysema of the lungs are common. In children and the elderly, cerebral phenomena are often observed depending on the fever and poisoning by carbon dioxide. In cases where the process passes into bronchiolitis fibrosa obliterans, the disease takes a prolonged course and is expressed in chronic asphyxiation with progressive general exhaustion. Recognition presents no difficulties. It is more difficult to determine the presence of pneumonic foci, which often cannot be determined by percussion and auscultation due to the abundance of rales and emphysematous distension of adjacent areas of lung tissue. The prognosis in healthy adults is favorable. In young children, weak patients, and the elderly, capillary bronchitis always represents a severe disease, often ending in death. Occasionally, bronchitis is complicated by meningitis. II. Chronic catarrh of the respiratory tract and bronchi, bronchitis et tracheo-bronchitis chronica, develops either independently under the influence of prolonged action of harmful factors and the transition of acute bronchitis into a chronic form, or secondarily in various diseases (of the lungs, heart, kidneys), in workers of dusty industries (millers, bakers, masons, coal miners, ore miners, etc.), in chronic alcoholics and smokers. The main symptoms are cough, shortness of breath, and expectoration of sputum, to which in secondary bronchitis are added the symptoms of the underlying disease. In mild forms, cough is usually observed in the morning, with the expectoration of a small amount of mucopurulent sputum. In cold weather the cough intensifies, in summer it is weaker or absent altogether. Shortness of breath is slight - during exertions, there is no fever, the general condition is satisfactory. In severe forms, the cough is constant, at times with severe attacks, shortness of breath is pronounced, there is cyanosis of the face and a number of general disorders. The disease can last for years and give rise to severe secondary phenomena - emphysema, bronchiectasis, etc. Physical examination of the chest gives a clear, loud percussion sound with an increase in the boundaries of the lung; on auscultation - vesicular and harsh breathing with prolonged expiration and scattered dry and moist rales. Most often rales are heard in the lower lobes of the lungs, where the conditions for the accumulation of secretion are most favorable. It is customary to distinguish several forms of chronic bronchitis: 1. Dry chronic bronchitis, bronchitis catarrhalis chr. sicca, catarrhe sec (according to Laennec), is characterized by a tormenting, tense cough and slight expectoration of viscous, mucous sputum, often in the form of sago grains containing few leukocytes and bacteria, but many alveolar epithelial cells and myelin droplets. Severe shortness of breath, frequent asthmatic attacks. On auscultation - dry rales, on percussion - clear, loud sound. The course is prolonged, usually complicated by emphysema and stagnation phenomena. 2. Bronchoblennorrhea, bronchoblennorrhoea, is characterized by abundant mucopurulent sputum, reaching up to 1 liter per day. When standing, it divides into three layers. It usually develops from simple chronic bronchitis under the influence of frequent exacerbations and other harmful causes. On auscultation - moist rales, especially in the lower lobes, decreasing after expectoration of large amounts of sputum. The course is prolonged, often leading to exhaustion. A transition to putrid bronchitis is possible; it is often accompanied by bronchiectasis. It is almost not amenable to cure. 3. Chronic serous bronchitis, bronchorrhoea serosa, catarrhe pituiteux (according to Laennec), is characterized by prolonged attacks of cough, with abundant expectoration of up to 1-2 liters per day of frothy, seromucous sputum containing little protein. Shortness of breath is constant, at times increasing, in the form of asthmatic attacks (asthma humidum). On auscultation - many moist rales. General nutritional disorders occur late. The cause is not clarified. One can assume a change in the secretory function of the mucous glands of the bronchi. Recognition of chronic bronchitis presents no difficulties (according to anamnestic data, subjective and objective symptoms and the course of the disease), but it is necessary to carefully examine other organs (lungs, heart and kidneys, the disease of which bronchitis may depend on), as well as to apply fluoroscopy and radiography (aneurysm, lung abscess, mediastinal tumors, some forms of tuberculosis, etc.). Prognosis. Chronic bronchitis is a stubborn disease, giving improvement and very rarely - cure. The outcome of secondary bronchitis depends on the nature of the underlying disease. Treatment of bronchitis. First and foremost should be prevention and elimination of all the harmful factors mentioned above (see Etiology). In persons prone to colds, it is appropriate to use reasonable hardening of the body. It is necessary to fight against various constitutional causes (anemia, obesity, gout, scrofula, syphilis, etc.), as well as to promptly treat diseases of the heart, lungs, kidneys, nose and throat. Treatment of acute bronchitis in mild cases is limited to general hygiene regimen: clean air in the room at moderate temperature and rest in bed during fever; warm drinks are beneficial, especially hot milk with alkaline and alkaline-salt waters. In severe forms, dry cups, mustard plasters, compresses and sweating treatment are beneficial. For dry cough - morphine, codeine, dionine, heroin, opium, and for an abundance of moist rales - expectorants (ipecac, senega, apomorphine, etc.). Treatment of bronchitis in the elderly requires serious attention: it is necessary to maintain strength (strengthening diet) and cardiac activity (small doses of strophanthus, strychnine, etc.). Hydrotherapy is rather contraindicated; emetics should be avoided. In the treatment of chronic bronchitis, it is necessary to eliminate all harmful factors. It is beneficial to wear appropriate clothing and to choose a climate (forested areas, seacoast, moderately high places protected from winds, etc.). When choosing a resort for bronchitics, it is necessary to take into account the general condition of the body, accompanying diseases, and the time of year. Of the mineral waters, alkaline and alkaline-salt waters are indicated, as well as other waters, in connection with the presence of accompanying diseases (obesity, gout, scrofula, diseases of the kidneys, liver, etc.). "Pneumatic therapy", consisting in inhaling compressed air, resp. exhaling into rarefied air, with the help of pneumatic cabinets and apparatuses (Waldenburg, etc.), has been little applied in recent times. Pharmacotherapy comes down to the use of expectorants and narcotics, inhalation of resinous, balsamic substances, and inhalation of alkaline solutions. For dry bronchitis, the following are indicated: inhalation of water vapor, 1-2% solution of table salt, soda, alkaline waters, internally iodine preparations and narcotics for severe cough and asthmatic attacks. For bronchoblennorrhea, expectorants, balsamic and resinous substances are used per os and in the form of inhalations (turpentine, terpin hydrate, preparations of guaiacol and creosote, oil of Eucalyptus, etc.). For chronic serous bronchitis, along with the usual therapy, inhalation of astringent agents (tannin, alum, lead acetate, etc.) is recommended to reduce sputum. III. Putrid bronchitis, bronchitis putrida s. foetida. For putrid bronchitis, the characteristic feature is the expectoration of foul-smelling, mucopurulent sputum. It develops in most cases on the basis of long-standing chronic bronchitis and very rarely from acute. The causative agents are putrefactive microorganisms. The course is varied - from milder cases lasting for years with periodic deteriorations to very severe cases with septic phenomena, rapidly leading to death. The sputum in putrid bronchitis is abundant, watery, foul-smelling, and when standing divides into three layers: the upper - frothy, the middle - dirty green in color, seromucous, and the lower - heavy, consisting of purulent parts, with lumps of dirty yellow color, the size of a millet seed and larger - so-called Dietrich's plugs. They consist of needle-shaped crystals of fatty acids, decay of pus cells, detritus, and numerous bacteria. Clusters of twisted Leptothrix threads, resembling elastic fibers, are often encountered. On chemical examination, products of putrefaction, leucine, tyrosine, etc. are found. Complications: bronchiectasis, bronchopneumonia, sometimes passing into abscess or gangrene of the lung, more rarely metastatic abscesses in the brain and meningitis. The general condition and nutrition sooner or later worsen, characteristic thickenings of the nail phalanges of the hands and more rarely of the feet ("drumstick fingers") are often observed. The physical changes are the same as in chronic bronchitis. Recognition. The distinguishing feature of putrid bronchitis is the character of the sputum.

Confusion with bronchiectasis, gangrene, lung abscess, or ruptured empyema is possible, in which the physical signs are not always clearly expressed. Detailed anamnestic data, fluoroscopy, and radiography sometimes help to clarify the confusing picture of the disease. It is important to exclude putrefactive processes in the nose, pharynx, and oral cavity. The prognosis is always uncertain, as even in cases with favorable outcomes, deterioration with a fatal outcome is possible. Treatment. All means used in the treatment of chronic bronchitis are indicated. Pneumotherapy is contraindicated. Inhalation of resinous and balsamic substances and carbolic acid are especially recommended. Prolonged use of iodine preparations is beneficial. Good results are sometimes obtained from intravenous infusions of neosalvarsan. IV. Fibrinous Bronchitis, bronchitis fibrinosa s. pseudomembranacea, is a rather rare form characterized by the formation of casts in the bronchial lumen, which are coughed up as bronchial casts. These casts, 2-4 to 10 cm long and 2-5 mm thick, consist of fibrin; microscopic examination also reveals mucus, epithelial cells, often erythrocytes, leukocytes, numerous bacteria, and sometimes Charcot-Leyden crystals and spirals. The etiology is not clarified. Fibrinous bronchitis occurs as a primary disease and as a secondary condition—after inhaling irritating gases, in certain skin diseases (pemphigus, etc.), during or after certain infectious diseases (typhoid fever, tuberculosis, lobar pneumonia, influenza, diphtheria), and in chronic heart diseases. Primary idiopathic bronchitis manifests in acute and chronic forms. The acute form is accompanied by high fever, cough, and severe shortness of breath. Initially, a small amount of sticky, mucous sputum is sometimes bloody. Soon, with severe coughing, casts are expectorated, and the patient's condition improves. These attacks may recur several times and last for several weeks. Hemoptysis is often observed. On auscultation, dry and moist rales are heard in places, and breathing is diminished in some areas (due to bronchial obstruction). Percussion reveals signs of acute emphysema. The chronic form is more common and usually develops from simple chronic bronchitis, lasts for years, and is accompanied by periodic attacks with expectoration of fibrinous casts. The course is afebrile or with slight fever. The general condition is satisfactory. Emphysema, cardiac weakness, and congestion often develop. Diagnosis is based on the clinical picture and, mainly, on the presence of bronchial casts in the sputum. The prognosis in acute cases is serious: 25-50% mortality. The course of chronic cases is more favorable. Treatment is the same as for ordinary bronchitis. To dissolve and expectorate the casts, inhalations of a 2-5% solution of soda or lime water mixed with water, iodine preparations internally, expectorants, and in exceptional cases, emetics are recommended.

A. Arutunov. Bronchitis in children, a very common disease, especially in infancy. Predisposing causes are: poor hygienic conditions (overcrowding, lack of light and air, etc.), nutritional disorders after illnesses or on the basis of constitutional anomalies, certain developmental and constitutional anomalies (asthenia, lymphatic, especially exudative diatheses), as well as rickets; in some cases, cooling cannot be disregarded, especially in weak or pampered children. Infants get sick more often and more easily than older children. Bronchitis often accompanies catarrhs of the upper respiratory tract, grouped under the general name 'influenza,' but can accompany any illness, especially acute infections (measles, whooping cough in the first place).- General symptomatology. In the clinical picture of the disease, cough and feverish state predominate. The cough varies in intensity: dry at the beginning of the illness, later becoming wet. Small children do not expectorate sputum but swallow it (the appearance of sputum on the lips of an infant after a cough raises suspicion of whooping cough). In weak and small children, bronchitis sometimes occurs without a cough. The fever is of an irregular type, with low temperature (37.5-38.5°C, sometimes up to 39°C); often there is no fever at all (in mild cases of bronchitis and in very weak children). Among the general symptoms, pallor, malaise, lethargy or, conversely, excitement (in neuropaths) are observed; in infants at the beginning of the illness and in neuropaths, vomiting may appear; in diffuse bronchitis, there is shortness breath of varying intensity. The typical signs of pneumonia (especially in early childhood)-bulging of the chest wall (vo lumen pulmonum auctum) and flattening of the epigastric angle, short breathing, retraction of the intercostal spaces, if observed (in severe bronchitis), are to a slight degree. Cyanosis, however, especially in diffuse bronchitis in small children, is common. The findings of physical examination are, in general, the same as in adults, but they are often much less pronounced than the corresponding anatomical changes. When auscultating small children, it must be borne in mind that, due to the acoustic peculiarities of their chest, the rales characteristic of bronchitis can be confused with 'conducted' rales (from the trachea). Forms of bronchitis-Acute bronchitis can be localized and then proceeds without severe symptoms (if the child is not too weakened), giving the picture described above; if bronchitis becomes diffuse and involves the entire lungs, the picture can become severe: severe shortness of breath, cyanosis, restlessness, high temperature, and a number of nervous phenomena (due to disturbances in cerebral circulation or toxic nature). Bronchitis is often prone to frequent recurrences, creating the impression that the child is almost constantly ill with bronchitis. This form is characteristic mainly of children with pathological constitution (exudative diathesis, lymphatism), as well as pampered children. In some cases, this form is a transitional stage to chronic bronchitis. The tendency to chronic bronchitis is created, besides the above-mentioned factors, by tuberculous infection, prolonged disturbances of pulmonary circulation, for example, in heart defects, bronchiectasis, etc. Chronic bronchitis often occurs without shortness of breath and temperature, giving periodic exacerbations.-Capillary bronchitis deserves special attention-a severe disease that develops more often in infancy. It is characterized by an acute onset, sometimes without an inflammatory process in the upper respiratory tract, and a severe general picture (cyanosis, shortness of breath, cough, emphysema, nervous phenomena); at the same time, physical examination in the first days often reveals nothing, and typical physical symptoms appear later. The clinical and pathological-anatomical changes in the bronchi are, in general, similar to those in adults.-Special forms of bronchitis: stertorous tracheobronchitis (according to Finkelstein's terminology), with a chronic course, accompanied by noise, stertorous breathing and occurs in rachitic children aged 1-2 years; spasmodic bronchitis (Finkelstein)-a rare form, occurring almost exclusively in children in the first 4 months of life and distinguished by rapidly developing attacks of severe shortness of breath and cough with cyanosis and signs of bronchitis; the inspiration is short, and the expiration is lengthened and has a characteristic sound. It apparently has only some similarity in the picture with tetany and asthma, but there is no connection. However, there are no data on the pathological-anatomical picture of this form of bronchitis; one can doubt the independence of this form. - Bronchitis asthmatica-see Bronchial asthma. The course of bronchitis depends on the form and the general condition of the child. Acute bronchitis in a healthy child lasts 1-2 weeks, with little disturbance of the general condition; in weak and artificially fed children, bronchitis can be more prolonged and severe. The outcome is usually due to complications.-Complications. Most often-bronchopneumonia, especially after capillary bronchitis and in small children; in addition, complications related to decreased immunity are common: otitis, pyelitis, pyodermias, etc. In infants, gastrointestinal disorders may appear. Chronic bronchitis is also complicated by bronchiectasis, atelectasis, and signs of putrid bronchitis, and it is necessary to consider the possibility of tuberculosis.-The prognosis depends on the same factors as the course.-Prevention is not easy. First and foremost-eliminating predisposing factors, proper hardening, and protection from contact with infections.-Treatment. The importance of the hygienic environment and appropriate care and nutrition must be emphasized. In some cases, this alone is sufficient; this especially applies to chronic bronchitis. Bed rest is indicated in acute and severe bronchitis; however, small and weak children should be picked up more often and turned in bed to prevent hypostasis. The use of compresses (water, oil) is mainly used in older children with acute bronchitis; in small and weak children, hot baths, sometimes with mustard added, and mustard wraps are preferable. In some cases of acute bronchitis in older children, diaphoretic treatment may be useful. Cautious use of fresh air, as well as sun baths, can be recommended in most cases not only of chronic but also of acute bronchitis. Drug treatment for bronchitis should not be given first place. In small children with acute bronchitis, expectorants or narcotics are usually not prescribed. In older children, these drugs can be used for the same indications as in adults. Cardiac remedies are often necessary. In cases of spasmodic bronchitis, atropine, belladonna, bromides, chloral hydrate are prescribed. Diet in acute bronchitis remains normal, except in cases accompanied by intestinal phenomena; concentrated food, recommended to limit bronchial secretion, has apparently not justified itself. As for chronic bronchitis, attention is paid to eliminating the soil on which bronchitis appeared (see above) and general hygienic measures. First and foremost-extensive use of fresh air, sun (natural and artificial) and physical culture. From medicines, those that improve the general condition of the child are used mainly; then, besides expectorants, also disinfectants (internally and by inhalation).