Method for treating acute respiratory distress-syndrome

FIELD: medicine, anesthesiology, resuscitation.

SUBSTANCE: under conditions of artificial pulmonary ventilation at positive pressure at the end of expiration one should set the level of positive pressure at the end of expiration being above against pre-chosen optimal one for 4-8 cm water column. About 10-15 min later one should introduce perfluorocarbon as aerosol with the help of nebulizer for 10-15 min. The innovation enables to introduce perfluorocarbons without depressurization of respiratory contour, decreases damaging impact upon pulmonary parenchyma and, also, reduce invasiveness of the method and decrease expenses of perfluorocarbons.

EFFECT: higher efficiency of therapy.

1 ex

 

The invention relates to medicine, namely anesthesiology and critical care medicine.

In patients with acute respiratory distress syndrome (ARDS) application of even modern methods of respiratory support is not always possible to achieve adequate oxygenation of blood in the lungs. When this artificial lung ventilation (ALV) has a damaging effect on the original intact areas of the lung parenchyma, depriving thus, light of the potential to maintain a residual function, and for subsequent recovery. So currently in intensive care patients with ARDS apply different arespiratory methods of correction of hypoxia and protect the lungs, including intra-lungs using perfluorocarbons.

There is a method of treatment of acute respiratory distress syndrome, including the use of mechanical ventilation with positive pressure at the end of expiration [Tyler D.G. Positive end-expiratory pressure: A review // Crit. Care Med. - 1983. - Vol.11. - P.300-308]. In terms of ventilation positive pressure at the end of the expiratory (peep) is achieved by creating a specific resistance in the circuit exhalation and is measured in centimeters of water column. Modern respirators allow you to adjust the level of peep in a wide range (from 1 to 35 cm of water. article). Positive pressure at the end of exhalation is not ventilation method, but it is used in any method of respiratory support in patients with ARDS improves ventilation-perfusion relationships in the lungs mainly due to involvement in gas exchange damaged (collaborating) of the alveoli. Damaged alveoli are "therapeutic target" application of peep in patients with ARDS. And from that, succeed or not to return them to an active gas exchange, depends not only on the effectiveness of respiratory care, but also forecast the subsequent recovery of lung function [Peruzzi W.T. The current status of PEEP // Resp.Care. - 1996. - Vol.41. - #4. - P.273-274]. The optimal level of peep can reduce the fraction of oxygen in the inhaled gas, to reduce peak airway pressure and the amplitude between the maximum inflation pressure and the pressure in the expiratory phase, and sometimes the magnitude of tidal volume and frequency of the breathing, that is to reduce the damaging effect of mechanical ventilation to the lungs [Suter P.M., Fairley H.B., Izenberg M.D. Optimum end-expiratory pressure in patient with acute pulmonary failure // N.Engl. J.Med. - 1975. - Vol.292. - P.284-289].

Although in the world for more than four decades in the treatment of patients with parenchymal ONE is actively used mechanical ventilation with peep, the ambiguity of the impact of this method on respiratory-circulatory system does not allow to recognize its positive and safe. Mechanical ventilation with positive end expiratory pressure may adversely affect the Central and systemic hemodynamics, compromise renal and hepatic blood flow, vnutricherepnuyu hemo - and liquorodynamics. In addition, when conventional mechanical ventilation with peep is often a reflex depressed myocardial contractility and a delay occurs, the liquid is in the body, disturbed the normal interaction of the ventricles of the heart [Kassil V.L., Zolotokrylin Y.S. Acute respiratory distress syndrome // Moscow. - Medicine. - 2003. - 224 S.].

As the closest analogue is adopted a method of treating acute respiratory distress syndrome through the introduction of intra-lungs perfluorocarbons during the traditional mechanical ventilation [Hirschi R.B., Pranikoff T., P. Gauger et al. Liquid ventilation in adults, children and neonates // Lancet. - 1995. - Vol.346. - P.1201-1202]. Perfluorocarbon compounds (PFOS) have a high solubility for O2and CO2have a low surface tension, Biologicheskie inert. The positive physiological effects of intra-lungs applications of perfluorocarbons due to both biochemical properties PFOS and their biophysical impacts on the mechanics of breathing [Leach C.L., Fuhrman B.P., Morin F.C. et al. Perfluorocarbon-associated gas exchange (partial liquid ventilation) in respiratory distress syndrome: A prospective, randomized, controlled study // Crit. Care Med. - 1993. - Vol.21. - P.1270-1278].

The method consists in the fact that the patient in terms of ventilation through the bronchoscope through a biopsy channel in the bronchi of I-III procedure enter the perfluorocarbon emulsion in the amount of 200-400 ml of Getting into the alveoli, the perfluorocarbon emulsion prevents them collaborating and improves the diffusion of oxygen and carbon dioxide across the alveolar-capillary membrane.

However, when using the known spacebefore perftoruglerodnaya connection goes only in ventilated areas of the lung, unevenly distributed in the parenchyma of the lungs, resulting in collaborating damaged alveoli does not improve gas exchange. In this way, the introduction of PFC in the lungs may develop regional ventilation-perfusion abnormalities and deterioration of gas exchange in the lungs as a whole.

In addition, vnutrikletochnoe introduction of perfluorocarbon through the bronchoscope under conditions of mechanical ventilation is accompanied by depressurization system respirator-patient, leading to hypoventilation, collaborating previously expanded alveoli and further deterioration of gas exchange in the lungs. This method requires the involvement of medical endoscopists and the use of additional expensive equipment - optic bronchoscope. Endoscopic manipulation in the tracheobronchial tree are vysokointensivnogo procedure, which can lead to complications such as trauma to the epithelium of the trachea and bronchi, the reflex laryngo and bronhiolospazm, iatrogenic infection, reflex disturbances of heart rhythm and hemodynamics, increased average and peak airway pressure, a decrease in minute volume of ventilation, etc. So the negative effects of intra-lungs injection of perfluorocarbon in the conditions of mechanical ventilation in patients with ARDS and severe disorders of gas exchange often p is evohot positive effects of this method.

The objective of the invention is the creation of highly effective and safe treatment for acute respiratory distress syndrome.

The invention consists in that in the method of treating acute respiratory distress syndrome, comprising the introduction into the respiratory tract of the patient perfluorocarbons during mechanical ventilation with positive pressure at the end of expiration, set the level of positive pressure at the end of expiration is above the pre-selected optimal for 4-8 cm water. century, after 10-15 minutes of keeping impose perfluorocarbons - Perftoran in the form of an aerosol using a nebulizer the nebulizer.

The use of the invention allows to obtain the following technical result. The method is highly effective. It can significantly improve gas exchange in the lungs, especially in previously unventilated damaged areas of the lungs. Improving gas exchange in the lungs leads to increased oxygen content in the blood and decrease in blood carbon dioxide, normalization of acid-base status of blood and oxygen balance of the body. It improves the functional status of the lungs, reducing the risk of septic complications and multiple organ failure, reduce the duration of mechanical ventilation and reduced mortality bol is different with ARDS.

Introduction perfluorocarbons proposed method is safe for the patient and does not require bronchoscopy. This allows the introduction of PFC in the lungs of the patient without depressurization of the respiratory circuit and violations of options held by IVL. When this is achieved the maximum contact inhalation of the drug in the damaged areas of the lungs, decreases the invasiveness of the method, reduces the consumption quantity of used emulsions of perfluorocarbons, time and material costs. The application of this method allows not only effectively improve gas exchange in the lungs, and reduce the damaging effect of mechanical ventilation on pulmonary parenchyma.

The technical result is reached due to the fact that inhalation introduction of perfluorocarbon into the lungs of the patient is carried out under conditions of controlled ventilation and involvement in gas exchange previously collaborating alveoli of the lung parenchyma by exceeding the optimal level installation peep. The authors first proposed the use of short-term excess of the optimal level of peep to improve the distribution of inhalation of perfluorocarbons in the damaged areas of the lungs.

The authors proceed from the fact that the use of the nebulizer-nebulizer-integrated circuit inhalation respirator, lets spend the procedure without depressurization system respirator-patient and violations of optimally chosen parameters of mechanical ventilation. This avoids deterioration of gas exchange in the lungs, which is especially important in patients with ARDS and critical hypoxemia. Synchronized with the phase of the hardware breath inclusion of spray-nebulizer increases the efficiency of delivery of inhalation of perftoran the alveoli. The stabilizing effect of perfluorocarbons on the wall of the alveoli prevents their collaboraie while reducing installation peep to source the optimum level after inhalation. This improves the diffusion of oxygen and carbon dioxide across the alveolar-casillero membrane, especially in the damaged areas of the lungs. The perfluorocarbons also has anti-inflammatory action in the damaged areas of the lung parenchyma.

The application of peep above the optimal level is accompanied by opening of the earlier collaborating alveoli and hyperextension already ventilated alveoli. It is known that patients with ARDS range of optimal values peep lies within the boundaries of 6-14 cm water. Art. and negative effects of positive end expiratory pressure in these patients begin to show when it is above 16 cm water. Art. [Slutsky A.S. Mechanical ventilation // Intensive Care Med. - 1994. - Vol.20. - P.64-79]. Therefore, the excess of the optimal peep at 4-8 cm water. Art. is safe for the patient.

In patients with ARDS in terms IVL involvement in gas exchange collaborating alveoli when edit the Institute of peep level takes 10-20 min [Gattioni L., Pelosi P., S. Crotti, F. Valenza Effect of positive end-expiratory pressure on regional distribution of tidal volume and recruitment in adult respiritory distress syndrome // Am.J.Respir.Crit.Care Med. - 1995. - Vol.151. - P.1807-1814].

The inhalation method of introduction into the lungs of drugs distribution in ventilated areas of the lung occurs in 10-15 min [Grippy M.A. Pathophysiology of light // - Moscow. - Medicine. - 1997. - 344 C.], whereby the inhalation of medication by nebulizer-nebulizer manufacturers recommended during this time.

The method is as follows. Before inhalation of perftoran carry out reorganization of the tracheobronchial tree of the patient, make the correction parameters IVL, optimization level installation peep and relationships inhale/exhale. When selecting the optimal peep sequentially, the steps for 30-40 minutes, increase the level of installation peep, starting with the lowest values (4-5 cm of water. century), and at each stage of the control parameters of oxygenation of arterial and mixed venous blood, the biomechanical characteristics of light, characteristics of the Central and pulmonary hemodynamics.

Optimal is the peep level at which the observed maximum oxygenation of arterial blood and no adverse hemodynamic changes (decrease SI, SI, increased heart rate), i.e. the transport of oxygen to the tissues of the maximum.

After optimizing the parameters of respiratory support for a short period (10-15 minutes) set the level of peep above optimally selected for 4-8 cm water. Art.

Given the ambiguous effect of peep on respiratory-circulatory system, the selection of the optimal level of peep and inhalation of perftoran in peep beyond the optimum level, it is advisable to carry out the integrated respiratory and hemodynamic monitoring (including invasive, using a catheter, Swan-Ganz).

For inhalation use a standard emulsion of Perftoran. Procedure inhalation is produced by spray-nebulizer-integrated circuit inhalation respirator. The outline of the respirator is connected with the airway of the patient via Oro-/nasotracheally intentional tube or tracheostomy cannula. Inhalation of Perftoran is carried out under conditions of controlled ventilation.

Modern ventilators with built-in circuit unit nozzles-nebulizers, working from the gas stream and synchronized with the hardware inhalation phase. Due to the high flow of compressed gas in the path of the spray-nebulizer inhalation drugs into the aerosol, and the inclusion of nebulizer in phase hardware breath contributes to a more efficient allocation of inhalation of the substance in the tracheobronchial tree of a patient, down to the alveoli.

Capacity standard spray the I-nebulizer 50 ml. In the nebulizer-nebulizer put 50 ml of the emulsion of Perftoran. Sprayed particles of the emulsion of Perftoran get into the flow of injected gas into the lungs and transported to the alveoli, where sprayed emulsion of Perftoran increases their stability, has a local anti-inflammatory effect and improves gas exchange in the lungs, including the damaged areas. After inhalation, which lasts 10-15 minutes, level installation peep reduces to the original optimal value. Nebulizer-a nebulizer off, and IVL continue in the previously set mode. If necessary the procedure is repeated after 2-4 hours, from 2 to 8 times per day depending on the specific clinical situation and the obtained effect. The number of perfluorocarbons is 100-400 ml per day.

Example:

Patient M 27 years old was admitted to the intensive care unit of the maternity hospital after the first term labor, complicated by the development of atonic uterine bleeding, massive hemorrhage, hemorrhagic shock, consumptive coagulopathy. Conducted intensive infusion-transfusion conservative hemostatic therapy without effect, and therefore the patient was performed by laparotomy, revision of the abdominal cavity and small pelvis, hysterectomy with appendages. Continued clinical and laboratory is attornye signs of continuing intra-abdominal bleeding, about what was done relaparotomy with ligation of the iliac arteries on both sides. Against the backdrop of ongoing intensive therapy, including infusion-transfusion, hemostatic, combined antibacterial and symptomatic therapy, mechanical ventilation, the patient's condition has stabilized somewhat.

However, on the second day, the patient appeared and became acute parenchymal respiratory failure: worsening hypoxemia resistant to increasing the fraction of oxygen in the breathing mix, hypercapnia on the background of the large minute ventilation; on the frontal chest x - ray shows characteristic diffuse "cloud" infiltrative changes in the lung fields on two sides, an index of lung injury on a scale of Murray - 3 points, i.e. a picture of ARDS. For maintaining gas exchange in the lungs was used "aggressive" settings IVL: UP - 0,55 l, BH - 22 min, DOM - 13,2 l/min, peep of 8 cm of water. Art., Rcrec. - 28,4 cm water. article, RTRS - 14.2 cm water. Art., F. - 60 l/min, I/E=1/1, FiO2to 0.8. Despite aggressive settings used mechanical ventilation, the patient remained severe hypoxemia (PaO2/FiO2- 0,68), increased hypercapnia (PaCO2- 56 mm RT. Art.), progressively decreased thoracopulmonary compliance (CStat. - 22 ml/cm of water. Art.), on a frontal radiograph of the chest is a total red eye reduction is the transparency of the lung fields "snow storm", index of lung injury on a scale of Murray - 3.5 points. Thus, the patient clinical, laboratory and instrumental signs of ARDS severe. This required the transfer of a patient on a ventilator with a controlled pressure, an in-depth medical sedation with the use of muscle relaxants, constant correction parameters IVL: increase MOB to 15.6 l/min, peep 12 cm of water. Art., FiO2to 1, inverting the relationship inhale/exhale to 1/1,5. It was noted dangerous Baro - and volutrauma of airway pressure: Rcrec. - 38 cm water. Art., RTRS,4 cm of water. Art. To control indices of Central and systemic hemodynamics, correction of infusion therapy and parameters of mechanical ventilation was performed intubation pulmonary artery catheter Swan-Gans. Pulmonary hypertension (Dlasr. - 32 mm RT. Art.), increasing the preload of the right ventricle (CVP - 17 mm RT. Art.) without signs of overload of the left ventricle (ZLC - 13 mm RT. Art.). That also confirmed the presence of the patient severe ARDS.

On the background of a complex of intensive therapy, the patient began to hold sessions inhalation of Perftoran on the above methodology. Within 1 hour after the first treatment there was a reliable increase oxygenation of arterial blood, reducing the PaCO2growth thoracopulmonary compliance. The following procedure in which ASCII of perftoran was performed after 2 hours and was also accompanied by an increase of blood oxygenation in the lungs and thoracopulmonary pliability, the decrease in PaCO2that helped to reduce the fraction of oxygen in the inhaled gas mixture, to reduce the installation peep and pressure in the Airways. Over the next 72 hours the patient was performed 24 procedures inhalation of Perftoran on the described method. Against this background, it was noted positive dynamics, the patient's condition stabilized. Subsequent inhalation of Perftoran was also accompanied by an improvement of gas exchange in the lungs. In the future this procedure held 4-6 times a day to transfer the patient to spontaneous breathing. During the 13 days of mechanical ventilation was performed 64 procedures inhalation of Perftoran. On the background of therapy the patient's condition improved. After 15 days of stay in the ICU, the patient was transferred to spontaneous breathing, and after 20 days in a satisfactory condition was transferred to the gynecology Department, where at 28 days was discharged home.

A method of treating acute respiratory distress syndrome, comprising the introduction into the respiratory tract of the patient perfluorocarbons in conditions of artificial lung ventilation with positive pressure at the end of exhalation, wherein the set level positive pressure at the end of expiration is above the pre-selected optimal for 4-8 cm water. century, after 10-15 minutes of keeping the lead perfluorocarbons in the form of an aerosol using a nebulizer the nebulizer for 10-15 minutes



 

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FIELD: infectious diseases and surgery.

SUBSTANCE: wound surface is covered with perfluorane porcine spleen perfusate. Application is repeated daily over a period of 4-12 days depending on the wound surface area and virulence of causative agent. Perfluorane porcine spleen perfusate is prepared by passing perfluorane through spleen vessels at velocity 20-40 ml/min and total volume up to 1 L. Perfusate is used in amount 0.5-0.7 ml per 1 cm2 wound surface area.

EFFECT: activated local immunity and tissue oxygenation.

2 ex

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