Method of acceding respiratory tract to perform forced ventilation of lungs in case of traumas of lower trachea portions and unilateral parenchomatosis damage of lungs

FIELD: pulmonology, intensive care, and reanimation techniques.

SUBSTANCE: two bronchial tubes are used, one being led through translaringal (nasobronchial or orobronchial) way into right or left bronchus and the other tube through trancheostomic hole led into principal bronchus on the opposite side thereby disengaging lungs below trachea bifurcation.

EFFECT: enabled access to respiratory tract of patient with damaged segment of trachea disconnected from respiration act in order to provide most favorable conditions for performing selective pulmonary ventilation.

1 dwg, 2 tbl, 3 ex

 

The invention relates to medicine, the field of intensive care and resuscitation, in particular to methods of artificial ventilation of the lungs with injuries of the lower divisions of the trachea and unilateral parenchymal damage the lungs.

The injury to the membranous portion of the trachea is one of the most serious complications that arise when performing percutaneous dilatational tracheostomy, when changing a tracheostomy tube for rigid conduit[1, 2, 7, 8, 9]. The frequency of this complication, according to the literature, ranges from 1.5 to 12,5% [1, 2, 9]. They are based on perforation of the posterior wall of the trachea. Damage to the trachea during percutaneous tracheostomy may occur at the time of the Explorer obturator wearing on him tracheostomy tube [7], while conducting dilatator [8], the introduction deep in the trachea forceps, especially in the time of disclosure and expansion tracheotomies holes [2]. Therapeutic measures in trauma trachea aims to “give rest” affected area, i.e. endotracheal tube is held in such depth that its cuff was below the area of damage to the trachea. Such manipulation is sufficient to stop the inflow of air into the tissues [7]. However, when trauma lower divisions of the trachea to perform this procedure is not possible, because, if the damage is in the Astok is located near the bifurcation of the trachea, even at the maximum reduction of intubation (tracheostomy) odnoprovodnoi tube it is located below the cuff or cuff that does not stop the inflow of air into the tissue through the defect. Use double barreled endobronchial tube (tube Carlense, white, Robertshaw), and Winternitz tracheostomy tube [3] does not allow to exclude the affected area of the act of breathing, as its installation tracheal cuff is above the level of injury, and through the channel leading to pentaboranes the bronchus, the air-gas mixture is pumped into the damaged area of the trachea. In these cases, if you cannot isolate this area of the trachea, it is necessary to resort to thoracotomy, surgical closure of the defect of the trachea.

Another area of application of the proposed method is selective mechanical ventilation with predominantly unilateral lung involvement. Selective IVL two respirators described long ago in both domestic and foreign literature for the treatment of patients with predominantly unilateral lung involvement [4, 6, 10]. However, in all these works it is proposed to use either a double barreled endotracheal or Winternitz tracheostomy tube [4, 6]. Described the IVL in a patient with atelectasis of the lower lobe of the lung through the tracheal trunk and catheter with obturator sheath, held under the control of the bronchoscope in the proximal bronchus [4, 10]. At the same time, because of the narrow clearance of these tubes is difficult to conduct rehabilitation and diagnostic fibrobronchoscopy that is important in the treatment of these patients.

Thus, currently available methods for mechanical ventilation in trauma lower divisions of the trachea and unilateral lung damage imperfect and either do not allow a conservative to cure the sick, or have some significant drawbacks.

Our proposed method of access to the airway allows you to isolate the damaged section of the trachea and thereby avoid the need for surgical intervention. The method can also be used to separate bronchial intubation with the purpose of selective lung ventilation (ALV) with two respirators when unilateral parenchymal damage the lungs. In these cases, the parameters for ventilation of each lung are selected depending on the severity of his defeat in accordance with accepted standards [4, 6]. In this situation, the proposed method has the advantage before intubation Winternitz orotracheal tube and Winternitz a tracheostomy. Unlike the first method, when used in the proposed method, n is sobrancelhas tube allows better sanitize the cavity and oropharynx. In addition, when using endotracheal Winternitz tubes lacks the ability to perform a full rehabilitation of the tracheobronchial tree, perform diagnostic fibrobronchoscopy because of the narrow gaps Winternitz tube. Used in the proposed method, two bronchial tubes with an inner diameter of 7-7,5 mm allows you to safely produce not only a reorganization of the bronchial tree on each side, but also to perform rehabilitation and diagnostic bronchoscopy, in particular bronchoalveolar lavage.

The aim of the invention is the provision of access to the airway of the patient when the damage to the trachea and unilateral lung damage thus to turn off the damaged area of the trachea from the act of breathing and provide the most favorable conditions for selective ventilation of the lungs.

The respiratory tract starts from your mouth, and external nasal passages and ends at the entrance to the alveoli. The primary function of the larynx - respiratory protection against penetration of foreign bodies. the Most narrow section of the larynx in adults - the glottis. The trachea begins at the mouth and ends at the level of TIVwhere is divided into two main bronchus. The width of the trachea varies from 17 to 19 mm [5]. The left main bronchus is longer and thinner than the right, its length is around is about 5 cm Wide and short right main bronchus at a distance of approximately 2.5 cm from the bifurcation of the trachea is divided into intermediate and upper lobe bronchi [5]. Narrow glottis limits the size Winternitz tubes for translaryngeal intubation. Usually men use tube size 39F (inner diameter of 6.5 mm) and for women - 37F (inner diameter 6 mm) [3]. Obviously limited in size and tracheostomy hole. At the same time, the inner diameter of the trachea (17-19 mm) allows to pass through it simultaneously two tubes of sufficiently large diameter (for example, 7-8 mm), but with different inlets. It is on this principle and based our method.

Our proposed method differs in that for providing access to the airway of the patient in contrast to prototype in one patient used two odnoproletny bronchial tubes having different inlet openings, and for the right main bronchus is used, the tube having a slit in the bronchial cuff with hole for ventilation of the right upper lobe bronchus (see drawing).

In conditions of General anesthesia, surgeons patient tracheostomy was performed, and then into the lumen of the trachea was introduced endotracheal tube for oranisational intubation inner diameter of 7.5 mm, or if the tracheostomy wiebel made earlier replacing the tracheostomy tube on the above tube. Using fibrobronchoscopy tube was held in the left main bronchus, then swelled its cuff in the lumen of the bronchus. The tube was recorded using a special zavertevshayasya nuts provided for tracheostomy tubes company “Rusch”, and ties were fixed around the neck. Then also fibrobronchoscopy through the nose or oropendula in the right main bronchus was performed tube onelegacy intubation of the right bronchus (firm “Rusch”). This tube has a short cuff and placket in the bronchial cuff with hole for ventilation of the right upper lobe bronchus. Under the control of fibrobronchoscopy tube was installed so that the hole for the upper lobe bronchus was opposite the mouth of the bronchus (see drawing). Installation Oro - or nasotracheal tube it is in the right, not the left main bronchus was determined by the fact that it is easier to fix than the tube is drawn through the tracheostomy opening, which is very important to prevent dislocation exactly in the right bronchus, where a high risk of displacement of the tube relative to the proximal bronchus. After fixing the tube began artificial respiration or by using one fan at the same lungs, or with the help of two fans is in the lungs, expressed in different degrees.

Examples of the method of access to the airway by using the two bronchial tubes.

Example 1. The patient Was, 21 years old, was admitted to the intensive care unit due to acute respiratory failure caused after delivery due to amniotic fluid embolism. Due to severe respiratory failure in the first hours after birth were initiated mechanical ventilation through nasotracheal tube. On the 3rd day after admission, given the prevailing ONE and planned long-term mechanical ventilation was performed tracheostomy according to the method of Gregs [1] (sets for dilatational tracheostomy firm “Portex”). Established tracheostomy tube with an inner diameter of 8 mm is Made fibrobronchoscopy, in which damage to the trachea is not revealed. On the 2nd day after installation tracheostomy changed tracheostomy tube on the rigid conductor. A few hours later occurrence of subcutaneous emphysema on chest, in the neck. When the x-ray detected pneumomediastinum. When the control bronchoscopy revealed damage to the membranous portion of the trachea, which was located 1.5 cm above the bifurcation of the trachea, which penetrated into the anterior mediastinum. Isolate the affected area of the trachea by the reduction of the maximum low above the bifurcation of the trachea intubation or Tr is kostomiksha tube, by installing double barreled endotracheal tube, Robertshaw was not possible, because the mucosal defect was either at the level of the cuff, or below the level of the cuff. Subcutaneous emphysema continued to progressively increase. Under the control of fibrobronchoscopy made bronchus intubation the two tubes. Transnasal routine endotracheal tube for onelegacy ventilation with a diameter of 7.5 cm, which has on its end a special extra hole for ventilation upper lobe bronchus at the level of the cuff. In the left bronchus through a tracheostomy hole opened conventional endotracheal tube for ora and nasotracheal intubation. This action was achieved off their act of breathing damaged area of the trachea, continue artificial ventilation of the lungs. In addition, separate intubation of the two main bronchi allowed safe conduct of rehabilitation and diagnostic fibrobronchoscopy, bronchoalveolar lavage in turn through each of the endobronchial tube. Because the patient was the heterogeneity of the lungs, changes in the left lung were more pronounced than in the right, separate bronchus intubation was also given the opportunity to provide ventilation at the same time two respirators. Selection of parameters of the artificial lung ventilation to each lung was conducted according to claim what inatum principles depending on the severity of the lesions [4, 6].

Mechanical ventilation through two endotracheal tube lasted the patient for 10 days. During this time, were completely resolved subcutaneous emphysema and pneumomediastinum. The next fibrobronchoscopy found that the defect in the membranous portion of the trachea is completely closed. After 10 days both bronchial tubes were removed, installed conventional tracheostomy tube with a diameter of 8 mm. Continued mechanical ventilation. After 32 days after the start of mechanical ventilation the patient was decanulation and in satisfactory condition discharged home.

Example 2. Patient C., 57 years. Diagnosis: multiple myeloma, bilateral pneumonia, acute respiratory failure, chronic heart failure, chronic renal failure treated with hemodialysis program.

The patient was admitted to the intensive care unit due to acute respiratory failure on the background of bilateral pneumonia. In the first day due to severe hypoxemia, it was decided to put the patient on a ventilator. Was made orotracheal intubation, started the IVL managed pressure (PL. 1). Radiography has attracted the attention of the predominant lesion in the right lung. For monitoring of hemodynamics and oxygen transport installed catheter Swan-Gans in the pulmonary artery. On the third day a ventilator patient was within the and tracheostomy. In connection with the irregularity of the lungs, it was decided to perform separate bronchus intubation and conduct IVL simultaneously two respirators. Under control bronchoscopy was installed nasobronchial tube into the right main bronchus, and through a tracheostomy hole held endotracheal tube with a diameter of 8 mm in the left main bronchus. Started IVL two respirators mode with a controlled pressure, but with different parameters for each light (PL. 1). As can be seen from the table. 1 and 2, the ventilation through two respirators helped to reduce the likelihood of barotrauma (lower peak airway pressure), increase respiratory quotient PaO2/FiO2to reduce pulmonary vascular resistance without a significant change in the other parameters of Central hemodynamics, to improve x-ray picture.

Table 1

Parameters of mechanical ventilation one and two respirators
IndicatorsVentilation through orotracheal tube one respiratorDifferentiated two ventilation respirators (2 h)
The right lungThe left lung
BEFORE ml72028760
MOD, lthe 10.1613
The level of the controlled pressure 1302030
Peak pressure on the inhale, see aq. Art.353334
Peep, cm aq. Art.4124
FiO2,%505050
1:E1:11:1,21:1,3
Compliance (ml/cm aq. Art.381630
Notes. TO - tidal volume, MOD - respiratory minute volume, FiO2the fraction of inhaled oxygen, I:E - ratio of inhale/exhale.

The presence of two pipes of sufficient diameter was allowed to perform regular patient rehabilitation and diagnostic fibrobronchoscopy.

Table 2

Indicators of oxygen transport during mechanical ventilation one and two respirators
IndicatorsTraditional IVL one respiratorIVL two respirators for 2 hours
Sao2, ml/DL7,58,0
CvO2ml/DL 2,82,2
DO2I, (ml/min)/m2370395
VO2I, (ml/min)/m2231288
Qs/Qt%12,38
PaO2/FiO2240300
Cardiac index, l/min/m243,848,2
Shock index, ml/m4,904,96
IOPS, (Dyne /cm5)/m29951193
ILS, (Dyne /cm5)/m2310258
HR, 1 min113108
HELL cf., mm Hg7789
Notes. HR - heart rate, Map. - mean HELL, IPSS index, total peripheral vascular resistance, ILSS - index pulmonary vascular resistance, Sao2- the content of oxygen in arterial blood, v2the oxygen content in the venous blood, DO2I - the index of oxygen delivery, VO2I - the index of oxygen consumption, Qs/Qt - shunt.

Our proposed method in contrast to the prototype makes it easy to implement these procedures as are used incubatio the main tube of sufficient diameter to conduct through them fibrobronchoscopy.

Literature

1. Berdikyan A.S. Percutaneous dilatational tracheostomy. Bulletin of intensive. therapy. 1999; No. 1: 63-67.

2. Galstyan G.M. Septic shock and acute respiratory failure in the Hematology clinic. Diss...., M., 2003.

3. Morgan Je, Magid S.M. Clinical anesthesiology, book 2-I. - Lane. from English. - M - SPb.: Publishing house of the BINOMIAL Nevsky Dialect, 2000. - 366 S.

4. Nikolaenko AM, Lazarev BS, Volkova M.I. Selectively adjustable mechanical ventilation in intensive care. Anestesiol. Reanimator. 1984, No. 1, S. 10-14.

5. Chernyakhovsky N.E., Yarema IV Chronic obstructive pulmonary disease. M, Ross. the honey. Academy of postgraduate education. 1998. - 148 C.

6. Cinnella g, Dambrosio m, Brienza n, et al. Independent lung ventilation in patients with unilateral pulmonary contusion. Monitoring compliance with and EtCO2. Intensive Care Med. 2001; 27: 1860-1867.

7. Fish W.H., Boheimer N.O., Cadle D.R., Sinclair D.G. A life-threatening complication following percutaneous tracheostomy. Clin. Intensive Care. 1996; 7: 206-208.

8. Hinerman R., Alvarez F., C.A. Keller Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med. 2000; 26: 1850-1856.

9. Trottier, S., P. Hazard, Sakabu S., et al. Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention. Chest. 1999; 115: 1383-1389.

10. Widermann K., E. Fleisher, Dressier P. Separation of the airways: historical aspects. Anasthesiol. Intensivmed. Notfallmed. Schmerzther. 2002; 37: 8-15.

The method of access to the airway for artificial lung ventilation with injuries of the lower divisions of the trachea and one is of multilateral parenchymatous lung damage, characterized in that use two bronchial tubes, one of which spend translaryngeal (nasobronchial or oropendulas) access right or the left main bronchus, and the other tracheostomy tube through the hole is carried out in the main bronchus of the opposite side, rasamma thereby light below the bifurcation of the trachea.



 

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