The development of pneumonia in patients with CLL is promoted by acute viral respiratory diseases. In the overwhelming majority of cases, pneumonia begins as focal, less frequently as lobar. However, pneumonic focus tends to spread rapidly. Often, having begun as a one-sided, pneumonia quickly spreads to another light. Pneumonia in CLL may be the first clinical symptom of the disease . Repeated pneumonia occurs in 75% of patients with CLL . The state of health of patients is sharply worsening. A patient with full somatic compensation for several hours turns into an extremely serious patient. Extrapulmonary manifestations of pneumonia predominate – fever, chills, tachycardia. . Dyspnea predominates among pulmonary manifestations. Often the disease makes its debut with a picture of endotoxic shock . Septicemia and septic shock are leading as causes of mortality among hospitalized patients with leukemia and lymphomas . The cause of septicemia can be enterococci, streptococci , or pyocyanic stick . The latent version of pneumonia in patients with chronic lymphoproliferative tumors has to be differentiated with specific tumorous lesions of the lungs .

L. Rome et. al. (2001) identified factors that contribute to the protracted course of community-acquired pneumonia . Among them, CLL patients are characterized by at least 7 factors: elderly age, the presence of a tumor neoplasm, suppression of T-cell activity, a decrease in the level of IgM, prolonged therapy with cytostatics, systemic glucocorticoids, and the presence of concomitant pathology.

Particular attention is paid to the occurrence of hospital pneumonia in patients with CLL. Nosocomial pneumonia develops in 37.1% of hospitalized hemoblastosis patients and in more than 60% of cases is fatal . Hospital pneumonia is distinguished by a large variety of etiological agents, including gram-negative flora (enterobacteria, pseudomonas bacillus, acinetobacter, etc.) and Staphylococcus aureus, which largely accounts for their severe course . Infectious complications in the hematological clinic often have the character of public- acquired infections. In specialized hematology hospitals, where patients with pronounced immunosuppression and new pathogenic pathogen pathogens appear, very often flare up “epidemics” . Therefore, it is considered necessary to hospitalize CLL patients in hospitals only for life reasons .

It should be borne in mind that in CLL, due to the lack of granulocytes in the tissues of pneumonia, a limited inflammatory focus is not always formed, giving a clear physical and X-ray picture even from 2 to 4 days after the onset of pneumonia . According to M.A. Volkova, only in 6% of patients with complicated, especially in the initial period, the course of CLL on radiographs of the lungs showed inflammatory foci. Computer tomography contributes to more accurate diagnostics . It is quite obvious that in CLL, the problem of improving the methods of early diagnosis of inflammatory and leukemic lesions of the bronchopulmonary system, contributing to the most effective treatment of complications, is relevant.

Oikonomou et al. examined radiological manifestations of influenza viral pneumonia in hematological patients. The patients underwent radiographs and high resolution computed tomography (CT). The authors developed pneumonia on the basis of the analysis of X-ray and CT images. Demonstrated new features in the diagnosis of this pathology using CT .

In 60–70 years, Gram-negative, aerobic bacteria were the main causative agents of infection in CLL patients; at present, gram-positive bacteria have become frequent pathogens, and erobic cocci and fungi . According to A. B. Bakirova (1996), among identified microorganisms in lymphoproliferative diseases of microorganisms, 51.9% were gram-negative, 48.1% gram-positive bacteria and yeast-like fungi. At that, 57.7% – streptococci, 22.8% – staphylococcus, 21.9% – Pseudomonas aeruginosa, 19.9% ​​- yeast cells, 13.6% – Klebsiella, 12.7% – Neisseries, 9.6% – Enterobacteria, 14.8% – Proteus, intestinal strand, cytobacteria and serrations. Recently serѐznoy The problems of in hematological patients and are nvazivnye mycoses . In most cases, it is candida and aspergillosis . Less commonly, invasive mycoses can be caused by other micromycetes . G.A. Klyasov et al. (2007) developed an algorithm for the treatment and prevention of candidiasis and aspergillosis in adult patients with leukemias, lymphomas and blood formation depressions .

Microbial strains isolated from patients with tumors are often characterized by multiple resistance to antibiotics . Antibiotics that are effective against gram-negative aerobic microorganisms and, above all, Escherichia coli, Klebsiella pneumonis, Ps, are used as first-line drugs of empirical antibiotic therapy. aeruginosa. This is due to the fact that infections caused by gram-negative aerobic bacteria are the most rapidly developing and dangerous bacterial shock. The mortality caused by these pathogens is 50–70%. . The most commonly used combinations are aminoglycosides II – III generation (tobramycin, sisomycin, amikacin) with cephalosporins III – IV of the generation active against the pseudomonas aeruginosa; a positive result is observed in 70–78% of patients . The combinations of III – IV generation cephalosporins with ureidopenicillin ( mezlocillin, piperacillin) have proven themselves well . Combined therapy with III-IV generation cephalosporins and imipenem is most effective against gram-negative bacteria, including Ps. aeruginoza . In a comparative study of vancomycin and a glyco- peptide antibiotic — tekop lanin, some researchers have come to the conclusion that teikoplanin ef vancomycin is more effective and less nephrotoxic [34]. Inpatients with hemoblastosis during the development of infectious complications , manifested by fever of not clear genesis, many authors of the rivers recommend to start antifungal therapy with amphotericin B, fluconazole as early as possible . In recent years, it proved high, comparable with the results of treatment with amphotericin B, Klinichev eskaya and antimycotic effectiveness ciency and trakonazola fluconazole in the treatment of fungal invariant fektsy Wu Bo lnyh hematological malignancies . G.A. Klyasov developed a protocol for empirical antibiotic therapy in patients with hemoblastosis, which consists of 4 stages, taking into account the chemotherapy and The focus of infection . This treatment protocol is currently used in most hematological clinics in Russia.

Much attention in the modern literature is given left-most cheniyu serѐznogo complications of pneumonia in patients with hemo blastosis – acute respiratory failure spine .

In addition to pneumonia in CLL, on the background of pronounced immunodeficiency, especially under the influence of active cytostatic and hormonal therapy, pulmonary tuberculosis is often diagnosed . Tuberculosis infiltration in the lungs during granulocytopenia is not always radiologically detected, not to mention the ulcer that is not detectable radiographically, ulcerous bronchoadenitis . The greatest diagnostic difficulties are posed by the differential diagnosis of pneumonia of the following forms of pulmonary tuberculosis: infiltrative pulmonary tuberculosis, limited to 1-2 segments (broncholobular infiltration); infiltrative pulmonary tuberculosis, limited to one lobe (rounded, cloud-visible infiltration, pericyssuritis and lobitis); Kaze pneumonia .

In 1991 A.G. Chuchalin described the damaging effect of cytostatic drugs on the lung tissue. According to A.N. Soko lova et al. (2007), such cytostatics used in the treatment of CLL, such as cyclophosphamide, chlorambucil, fludarabine, doxarubicin, and vincristine, have a pulmonary toxicity. V.M. Gorodetsky (1998) indicates the need for differentiation between infectious, specific lesions of the lungs in patients with hemoblastosis and pneumonitis caused by chemotherapy or radiation therapy. Since cyclophosphamide, which is often used in the treatment of CLL, reduces the level of glutathione and thereby reduces the degree of antioxidant protection, a high concentration of oxidants stimulates pulmonary damage . So far, there are no uniform criteria for predicting the pneumotoxic risk of chemotherapeutic drugs; The most informative is considered to be a rapid decrease in the diffusion capacity of the lungs at the initial stages of chemotherapy, even in the absence of significant changes in radiographs and CT scans of the lungs. . The frequency of radiation pneumonitis during irradiation of the chest is 5–15 % . Risk factors for left-of pulmonary damage during radiation exposure are involved a large amount of light (> 10%), the daily dose of radiation (> 2,67 Gy), high cumulative dose of concomitant chemotherapeutic Pius, lung collapse, young age, cancellation of glucocorticoid hormones in radiation therapy time .

One of the most severe manifestations of chronic lymphocytic leukemia is exudative pleurisy. Its nature can be different: a couple or metapneumonic pleurisy with a banal infection, tuberculosis pleurisy, lymphatic infiltration of the pleura, compression or rupture of the thoracic lymphatic duct. Infectious pleurisy is most often a complication of pneumonia . In the exudate, along with lymphocytes, there are many neutrophils . In case of compression or rupture of the thoracic lymphatic duct, the exudate will be lymphatic, but the fluid will contain large amounts of fat a (malignant fluid) .

The most frequently encountered specific lymphoproliferative pleurisy as a manifestation of lymphoid pleural infiltration . Diagnostics of lymphoproliferative pleurisy is supported by computed tomography. With CT, it is often possible to detect tumor growth in the pleura, infiltration or sarcoma nodes . The treatment of specific lymphoproliferative pleurisy is complex and long-term, its adherence is an unfavorable prognostic factor for CLL patients. Topical administration of cytostatic preparations is usually not very effective . The best results are given by the general cytostatic therapy according to the schemes COP, CHOP; sometimes it is necessary to resort to irradiation of the pleura (tangentially); with a sharply enlarged spleen, splenectomy can lead to the elimination Pleurisy for many years .

In the literature, there is a small number of works covering the course of chronic obstructive pulmonary disease (COPD) in patients with chronic lymphoproliferative diseases. V.M. Provotorov and A.Yu. Kazabtsov (1997) examined patients with COPD with concomitant lymphoproliferative diseases – CLL, lymphocytic lymphoma, and myeloma. The authors concluded that in patients with COPD on the background of chronic lymphoproliferative tumors, a violation of the tracheobronchial cleansing is more pronounced than in patients with COPD without lymphoproliferation. The course of COPD, when combined with lymphoproliferative diseases, is characterized by slow dynamics of clinical symptoms and a more severe course [204]. A.Yu. Ka- zabtsov (1998) found that in patients with COPD on the background of CLL, a violation of mucociliary transport is more pronounced than in patients with COPD without concomitant lymphoproliferation.

Much attention is paid to immunomodulatory therapy for CLL . It is necessary to conduct therapeutic and recreational activities for all related diseases in patients with CLL in an outpatient setting, as well as the appointment of prophylactic immunostimulating therapy in the autumn-spring period. Timely prevention and treatment of infectious complications in CLLs contributes to the prolongation of life of these patients .

Multiple myeloma (MM) is a lymphoproliferative disease, the morphological substrate of which is plasma cells that produce monoclonal immunoglobulin . MM is known as “elderly disease”, the average age at the time of diagnosis is 61 years . MM has a large variety of forms and options. Each of these options has its own clinical manifestations and requires special therapeutic approaches. Klee Niko-anatomical classification is based on radiological examination of the skeleton, morphological analysis of punctates and bone trepanates. Diffuse-focal (60% of observations), diffuse (24%), multiple-focal (15%), sclerosing (<1%), mostly visceral (<0.5%) forms of MM are distinguished. Immunochemical studies of monoclonal secretion of serum and urine Ig determine the immunochemical variant of MM. Myeloma G is the most common (55–65% of all cases of multiple myeloma), myeloma A is in second place (20–25%), Bens-Jones myeloma is in third place (secretion of light chains only) 12–20%), rare forms of the disease are myeloma D, E, M, non-secreting, diclonal myeloma.Depending on the size of the tumor mass at the time of the study there are three stages of MM; An additional feature of all stages, which determines substage (A or B) is the function of the kidneys . Staging MM by B.Durie and S.Salmon (1975) is generally recognized. MM remains an incurable disease . From 20 to 40% of patients are insensitive to chemotherapy treatment (primary resistance), in all patients sensitive to chemotherapy, secondary resistance to previously administered therapy develops at different times . When MM poly- primary pathological secreting IgA resistance occurs in the pa 2 for more than myeloma G . In recent years, an increase in the incidence of MM has been observed throughout the world, only partly due to the success of diagnostics and Life expectancy . With the introduction of melphalan into medical practice, the average life expectancy of a large MM has reached 36 months . Attempts to increase the life expectancy of patients with the help of various polychemotherapy schemes were not crowned with success . High-dose chemotherapy, followed by transplantation of autologous stem cells, is considered the most effective method for treating MM . The use of autologous transplantation allowed us to increase the median survival of myeloma patients to 54.4 months . However, taking into account the age structure of the patients and the complicated somatic status, this method is not applicable to all . Therefore, for a large cohort of patients with MM, even in economically developed countries, standard therapy remains the method of choice . In our country, the majority of patients receive chemotherapy without subsequent transplantation of stem cells . In addition to pathogenetic patience, the program for treating patients with MM includes: for the prevention and treatment of hypercalcemia, the improvement of the repair of bone destruction bisphosphonates ; in the presence of anemic syndrome, erythropoietin ; with a high content of protein in the serum of Crimea, plasmapheresis , etc.

The amplitudes of oscillations in the N-range (due to sympathetic effects on smooth muscle cells of arterioles and arterio-venular anastomoses) and in the M-range (characterizing the state of the muscle tone of the pre-capillaries regulating blood flow to the nutritive channel) did not have significant differences with control .

The amplitudes of oscillations in the D-range in patients of the first subgroup did not have significant differences compared with the control indicators; in the second subgroup, there was a decrease in the amplitudes of oscillations in the D-range (P <0.05). The decrease in the amplitudes of the respiratory waves is due to insufficient blood flow into the venules, which may be due to the presence of leucostasis in CLL patients in the later stages of the tumor progression.

The amplitudes of oscillations in the C-band decreased during the tumor progression, in the first subgroup they did not have significant differences compared with the control, in the second subgroup the cardiac wave indices decreased (P <0.01). A decrease in cardiac wave values ​​indicates a decrease in arterial blood flow into the microvasculature, which may be due to the presence of vascular accumulations of lymphocytes, in some cases completely blocking the gaps of small vessels.

Significant inverse correlations were found between the level of leukocytosis in peripheral blood and a decrease in the fluctuations in the D and C ranges (respectively, r = –0.64, P <0.01 and r = –0.68, P <0.01), between duration of illness and a decrease

It can be concluded that in patients with CLL, in the process of tumor progression, the parameters characterizing the passive factors of LDF grams (causing fluctuations in blood flow outside the microcirculation system) —the amplitudes of fluctuations in the heart and respiratory ranges (pulse wave from the arteries and suction action ” respiratory pump “from the veins). These oscillations propagate with the bloodstream into the probed area, since the microvasculature, which is an integral part of the circulatory system, is topographically located between the arteries and the veins. Thus, in patients with CLL in the late stages of tumor progression, the flow of arterial blood into the microvasculature and its outflow to the venules due to the presence of leukostasis decrease.Indicators of active factors controlling microcirculation (directly affecting the microcirculation system — amplitudes of vibration in the EH and M bands), modulating blood flow from the vessel wall and realized through its muscular component, change to a much lesser extent. One of the reasons for this can be the fact that active mechanisms create transverse oscillations of the blood flow as a result of alternation of contraction and relaxation of vascular muscles (alternating episodes of vasoconstriction and vasodilatation); passive factors organize longitudinal blood flow oscillations, expressed in periodic changes in the blood volume in the vessel; in the arterioles, the nature of the volume change is determined by the pulse wave, in the venules the workermodulating blood flow from the vascular wall and implemented through its muscular component, change to a much lesser extent. One of the reasons for this can be the fact that active mechanisms create transverse oscillations of the blood flow as a result of alternation of contraction and relaxation of vascular muscles (alternating episodes of vasoconstriction and vasodilatation); passive factors organize longitudinal blood flow oscillations, expressed in periodic changes in the blood volume in the vessel; in the arterioles, the nature of the volume change is determined by the pulse wave, in the venules the workermodulating blood flow from the vascular wall and implemented through its muscular component, change to a much lesser extent. One of the reasons for this can be the fact that active mechanisms create transverse oscillations of the blood flow as a result of alternation of contraction and relaxation of vascular muscles (alternating episodes of vasoconstriction and vasodilatation); passive factors organize longitudinal blood flow oscillations, expressed in periodic changes in the blood volume in the vessel; in the arterioles, the nature of the volume change is determined by the pulse wave, in the venules the workerthat active mechanisms create transverse blood flow oscillations as a result of alternation of contraction and relaxation of vascular muscles (successive episodes of vasoconstriction and vasodilatation); passive factors organize longitudinal blood flow oscillations, expressed in periodic changes in the blood volume in the vessel; in the arterioles, the nature of the volume change is determined by the pulse wave, in the venules the workerthat active mechanisms create transverse blood flow oscillations as a result of alternation of contraction and relaxation of vascular muscles (successive episodes of vasoconstriction and vasodilatation); passive factors organize longitudinal blood flow oscillations, expressed in periodic changes in the blood volume in the vessel; in the arterioles, the nature of the volume change is determined by the pulse wave, in the venules the worker rhythm of the respiratory pump . Lecostasis in small vessels of the lungs and bronchi present in a significant number of CLL patients to a greater extent impede longitudinal fluctuations in blood flow.

All patients who underwent diffuse endobronchitis during PBS underwent therapeutic measures: active aspiration of the bronchial contents, selective / partial lavage with dioxidine solution, local administration of antibiotics, etc. Two to three weeks after the start of treatment, endobronchial LDF was re-performed in these patients. Changes in the microcirculatory blood flow in the mucous membrane of the proximal bronchi in CLL patients, after normalization of the bronchoscopic picture, were preserved, which is explained by the morphological changes in the microvasculature vessels in CLL patients.

Disruption of microhemocirculation leads to the development of tissue hypoxia, metabolic disturbances in the mucous membrane cells of the bronchi and, along with marked secondary immunodeficiency, contribute to the occurrence of the inflammatory process in the bronchi. Violation of microhemocirculation supports the inflammatory reaction in the bronchi, contributes to its recurrent course, the development of disturbances in gas exchange and the ineffectiveness of antibacterial therapy. In 60% of patients with a progressive course of CLL (40% of the total number of patients with CLL), with PBS, an inflammatory process in the bronchi has been diagnosed with no pronounced clinical manifestations. However, the presence of a chronic focus of infection may contribute to the development of pneumonia in patients with a progressive course of CLL. Considering the above, patients with a progressive course of CLL,in the absence of contraindications, diagnostic bronchoscopy is recommended, and in the presence of an inflammatory process in the bronchi, the appointment of therapeutic measures.

The presence of the inflammatory process in the bronchi, along with their leukemic infiltration, contributes to an increase in bronchial resistance in patients with CLL group III.

Violation of microhemocirculation indices is registered earlier than the clinical manifestations of the bronchopulmonary system lesions appear. Thus, the study of endobronchial microcirculation can help predict the occurrence of inflammatory diseases of the bronchopulmonary system in patients with CLL.

In the study of the functional ability of the right from the heart of the business in patients of group I, a decrease in the ratio E / A TC was observed . In group II, a further decrease in the E / A TC ratio was diagnosed . In group III, a significant increase in KDR, KDO and RV CSR was diagnosed. In patients with group III, the cardiac index (SI) of the pancreas was increased, which is associated with an increase in heart rate in the later stages of hemoblastosis, due to anemia and intoxication. A decrease in the maximum blood flow velocity in the early diastole (E TC ), an increase in the maximum blood flow velocity in the late filling phase of the pancreas (A TC ) and a decrease in the E / A ratio were detected. Increase A TC in the process of tumor progression in CLL can be explained by an increase in heart rate in these patients. E TC depends on the difference in pressure gradient in the cavities of the right heart and is not related to the heart rate, therefore, this indicator does not change in groups I and II. A decrease in E TC was diagnosed only in patients of group III, where dilatation of the pancreatic cavity takes place. Thus, early signs of diastolic dysfunction of the pancreas were detected in patients with CLL I group; in the II and III groups, disturbance of the diastolic function of the pancreas progressed. A significant decrease in the fraction of the prostate ejection was diagnosed only in patients of group III. The index of TMPS PZHDincreased in patients in groups II and III .

In group I patients with CLL, there was an increase in TMZS LC , in groups II and III, it continues to increase. In patients with groups II and III, the thickness of the interventricular septum increases. An increase in the A MC and reduction ratio E / A is diagnosed at the early stages of tumor progression (I group), which is evidenced by the presence of left ventricular diastolic dysfunction. In the process of tumor development, disorders of LV diastolic function are progressing: A MKincreases, reaching maximum values ​​in group III, and, accordingly, the ratio E / A MK significantly decreases . Due to an increase in heart rate, an increase in the LV LV and LV LV . Only in group III there was a significant increase in KDR, KSR, KDO, KS O and a decrease in LV EF .

The revealed changes can be explained by tumor intoxication, cardiotoxic effects of cytostatics, rheological disorders in the coronary vessels in patients with high leukocytosis, anemia, and in some cases lymphoid infiltration of the myocardium. Dilatation of the cavities of both ventricles, an increase in their size and corresponding volumes, a decrease in the ejection fraction were diagnosed only in CLL patients in stage C (with the presence of anemic syndrome). Patients with CLL are people, in the overwhelming majority of cases, elderly, many of them had coronary heart disease, which also contributed to the violation of the LV myocardium and the development of circulatory failure.

Ultrasonic examination of the diaphragm in patients of group I showed no significant changes compared to controls. The thickness of the diaphragm (TD) did not differ from that in the control group. The position, shape, echogenicity of the diaphragm also did not change. Excursion of the diaphragm with calm (EDS) and forced (EDF) breathing did not differ from control. In patients with group II, the thickness of the diaphragm did not change. But the echo structure of the diaphragm became non-uniform, flattening of its dome was noted. The excursion of the diaphragm during calm and forced breathing decreased significantly. In group III, the largest morphological changes in the diaphragm were revealed. The dome was not clear. Its echostructure became non-uniform. Significantly decreased excursion of the diaphragm with calm and forced breathing.Violation of the excursion of the diaphragm and its morphological reorganization, in case of CLL, contributes to severe hepato- and splenomegaly, which occur in the majority of patients of groups II and III. Compression of the diaphragmatic muscle with enlarged liver and spleen significantly reduces its mobility and is one of the causes of the onset of severe and prolonged bronchopulmonary pathology in CLL. Another cause of dysfunction of the diaphragm in CLL is its specific leukemic lesion.Another cause of dysfunction of the diaphragm in CLL is its specific leukemic lesion.Another cause of dysfunction of the diaphragm in CLL is its specific leukemic lesion.

A correlation analysis was performed between indicators of pulmonary and intracardiac hemodynamics, the functional state of the diaphragm, respiratory function and blood gas composition in CLL patients at different stages of tumor progression. Patients of groups II and III showed a significant correlation between a decrease in the excursion of the diaphragm with a quiet and forced breathing and a decrease in the MOR of the lower and middle zones of the lungs. In the second group, the correlation coefficient between the decrease in the EDF and the decrease in the MOR of the lower zones was 0.87 (P <0.001); between a decrease in EDF and a decrease in the MOB of the middle zones of 0.68 (P <0.01). The correlation coefficient between the decrease in the EDS and the decrease in the MOR of the lower zones was 0.72 (P <0.01); between a decrease in the EDS and a decrease in the MOB of the middle zones of 0.64 (P <0.05). In group III, a clear correlation was also diagnosed between a decrease in EDF and a decrease in the MOBR of the lower (0.66; P <0.05) and medium (0.65; P <0.05) zones of the lungs. The correlation coefficient between the decrease in the value of the EDS and the decrease in the MOR of the lower zones was 0.64 (P <0.05), the middle zones 0.62 (P <0.05). No significant correlation was found between the EDF, EDS and MOBP indices of the upper zones of the lungs in patients with CLL. Correlation analysis confirms the assumption of the important role of a violation of the excursion of the diaphragm in CLL patients in reducing the ventilation capacity of the lower and middle zones of the lungs and the redistribution of ventilation in the upper zones.

A reliable average inverse correlation was established between a decrease in the excursion of the diaphragm during forced and quiet breathing and an increase in AHDLA in patients II (r = –0.59; P <0.05 and -0.51; P <0.05) and III (r = – 0.66; P <0.01 and – 0.61; P <0.05) groups. A strong positive correlation was found between a decrease in the MOVP of the sum and a decrease in the pO 2 of blood in patients of the II (0.86; P <0.001) and III (0.9; P <0.001) groups. The inverse correlation relationship between the decrease in blood pO 2 and the increase in SrDLA in patients of the II (r = –0.65; P <0.01) and III (r = –0.9; P <0.001) groups was diagnosed. Smaller correlation coefficient and reliability in group II is explained by insignificant changes in pO 2 indices in these patients. and SrDLA. It can be concluded that a violation of the functional capacity of the diaphragm leads to impaired ventilation of the middle and lower zones of the lungs, as a result of which hypoxemia and PH develop.

A significant increase in the liver and spleen, which occurs in many patients with a progressive course of CLL and in the terminal stage of the disease, contributes to a high standing of the diaphragm case and disruption of its excursion. The diaphragm is the main respiratory muscle, which, under physiological conditions, provides 2/3 of the vital capacity of the lungs, and 70–80% of inspiration with forced respiration [208]. So, according to J.L. Shika and V.I. Sobolev, as a result of the movement of the diaphragm, the lower and 40-50% of the ventilation volume of the upper lobes of the lungs is fully ventilated. Violation of the excursion of the diaphragm, the main respiratory muscle, is an important factor in the violation of respiratory function in the late stages of tumor progression in patients with CLL. Compression of the lower parts of the lungs with enlarged liver and spleen is an important factorreducing respiratory volume lower zones and redistribution of ventilation in the upper zones of the lungs. It can be argued that mechanical compression of the diaphragm with enlarged liver and spleen and its specific leukemic lesion contribute to impaired contractility of the diaphragm, which is one of the reasons for the development of hypoxemia and PH in patients with CLL II group without an associated broncho-obstructive process. This group included a greater number of patients with the splenic CLL.

Other causes of hypoxemia and PH in patients with CLL in stage B are a decrease in microhemocirculation and a severe, prolonged course of infections of the bronchopulmonary system, accompanied by impaired ventilation and hemodynamics of the pulmonary circulation.

During the 13-year study period, a fatal outcome was found in 95 CLL patients. The mortality of patients with CLL was analyzed and morphological changes in the lungs, bronchi, and pleura in these patients were studied according to autopsy data. The terminal stage of CLL is more often manifested by the transformation into a large cell lymphosarcoma, the development of cachexia. Prolymphocytic crisis was observed in only two patients. Blast crisis CLL in our study is not registered. The immediate causes of death of patients with CLL are given.

Histological examination of autopsy material showed lymphoid infiltration of the lungs and bronchi in 43 patients (45%). However, only 5 patients had massive leukemic infiltration, which was radiologically detected in the form of focal or infiltrative shadows, and then the diagnosis was made after long-term follow-up of the disease and exclusion of other local processes in the lungs. In the same patients, lymphoid infiltration was diagnosed macroscopically at autopsy. Histological examination of the lungs in these situations revealed a total monomorphic leukemic infiltration along the interalveolar septa, filling the lumen of the alveoli and vessels with lymphocytes . In all other cases, lymphoid infiltration was detected only with microscopic Optical research . Lymphoid infiltration in the lungs was predominantly interstitial. Often, in the stage of malignant transformation, there was a total infiltration of the interstitial lung tissue. Lei goat infiltration was very pronounced along the bronchi, small vessels and in the interalveolar septa, often it was of a confluent nature. Hemorrhages were observed in the interstitial and respiratory tissue with a perivascular edema. Foci of leukemic infiltration in respiratory structures were less frequently observed.

Histological examination in the lungs showed an expansion and congestion of blood vessels, the lumens of many vessels were filled with lymphocytes (leukostasis) . Leukostasis was especially frequently detected in small-caliber vessels. The accumulations of lymphocytes in these situations completely blocked the gaps of small vessels, causing a significant disruption of microcirculation . In some patients, infiltration of the walls of the pulmonary vessels with tumor cells and multiple perivascular arteries of lymphoid cells were noted.

Peribronchial, perivascular, interstitial sclerosis was revealed in many patients. Multiple atelectasis of the lung tissue alternated with areas of emphysematous dilatation of the alveoli, as well as edema and sclerosis of the interalveolar septa . In patients with CLL, it is possible to express an assumption about the compensatory nature of the localized pulmonary emphysema. In some areas, in the presence of diffuse lymphoid infiltration of the pulmonary tissue and an increase in bronchopulmonary lymph nodes, alveoli are excluded from ventilation due to atelectasis. A decrease in the area and ventilation capacity of other alveoli due to edema, sclerosis of the interalveolar septa, lymphoid infiltration of the interalveolar septa, desquamation of the alveolar epithelium is noted. In the remaining parts of the lung, the expansion of the alveoli occurs compensatory. These changes are more pronounced in CLL patients in the later stages of the tumor progression. Speaking of emphysema in patients with CLL, it is also necessary to take into account the elderly age of most patients,in this case, senile emphysema may occur.

Morphometric studies were conducted in patients who died in the presence of CLL. When performing a morphometric study of the bronchi and alveoli, a comparative analysis was carried out with similar indicators of 30 absolutely healthy people, equal in age and sex, who died from injuries incompatible with life and who did not have a history of hemoblastosis and bronchopulmonary pathology (control group).