A method of treating pulmonary complications in patients with severe traumatic brain injury

 

(57) Abstract:

The invention relates to medicine, namely to resuscitation, and can be used for the treatment of pulmonary complications in severe traumatic brain injury. Patients do artificial lung ventilation with a change of position on his back and stomach every 12 hours Sanitizing the fibrobronchoscopy carried out every 6 h in position of the patient on the back and on the belly. Endotracheal inhalation of broncholytic carried out for 10 min with an interval of 3 hours Treatment continuously for 7-14 days before edema respiratory failure and recovery of consciousness. The method allows to improve the drainage function of the tracheobronchial tree. This reduces the time of treatment of patients with this pathology.

The invention relates to medicine, in particular to the intensive care unit.

Acute respiratory distress syndrome in adults (ARDS) is characterized by rapid increase hydration of the lung tissue with the appearance on radiographs infiltrative changes in the lungs and a sharp increase in hypoxemia. ARDS is considered as polietiologic, but monoatomically process based on a defect in the permeability of the alveolar-capillary echnosti; M, M, 1989: 342-345).

Most often when SBTI there are complications of the lungs (Savvatimsky, L. //Some questions Pato-teratogenesis, traumatic disease in traumatic brain injury. Pathological anatomy of surgical diseases of the nervous system. SPb., 1991: 184 - 195). According to the Traumatic coma Data Bank the level of mortality in the development of pulmonary complications in patients with STBI is 41% (Piek J., Chesnut, R. M., Marshall L. F. et al //Extracranial complications of severe head injury, J. Neurosurg, 1992; 77: 901-907). According to Russian authors attach to brain damage pulmonary complications increases mortality to 65.1% (lenzman Y. C., Ershov A. F., Zanewich M. C. //Pulmonary complications in patients with closed injuries of the skull and brain. The wedge. honey., 1980; 10: 66-70).

The cornerstone of therapy for ARDS at the present time is the use of artificial lung ventilation (ALV) and its various modifications. (Luce, J. M. //Acute lung injury and the acute respiratory distress syndrome Crit Care Med 1998; 26 (2):369-376).

Known methods of treatment of ARDS:

They represent the application of these modes of ventilation, such as ventilation with positive pressure at the end of the expiratory (peep) (Marino P. L. //The ICU Book, second edition, Williams & Wilkins, 1998: 371-387). Peep is used //Prone position can augment the effect relatively low PEEP on oxigenation and attenuate the adverse hemodinamic effect of optimal in a dog ARDS model, Crit Care Med 1998 26(1) (Suppl) (A 105). The disadvantage of this method is the increase in intrapleural pressure and intrathoracic pressure during the creation of peep, which causes certain concerns in mind the possibility of increased intracranial pressure (Hemmer, M.// In: The Integrated Approach to Trauma Care. The First 24 Hours. (Update in Intensive Care and Emergency Medicine. Vol.22) (Editors) Goris R. J. A., Trentz O.; Springer-Verlag Berlin Heidelberg 1995: 52-61), which is not desirable when SBTI.

Mode IVL reverse correlation of phases (ASFV) is also used in patients with ARDS, both in the supine and prone. (Marik, R. E., Iglesias J.//A "prone dependent" patient with severe adult respiratory distress syndrome. Crit Care Med 1997; 25 (6), 1085-1087). Mode ASFV improves the drainage function of the tracheobronchial tree, the oppressed, the traditional modes of mechanical ventilation. The disadvantage of this method is the elongation phase of the breath with the aim of providing short exhalation and thereby prolonged the creation of positive intrathoracic pressure during the time of inhalation phase. It can also lead to an increase in intracranial pressure.

The use of sanitation fibrobronchoscopy (FBS) in patients with STBI (Korotkevich, A. G., Hooks centuries, Curlew Y. A. //Early changes of the bronchial tree and their role in the pathogenesis of pneumonia in acute severe traumatic mongkolchaiarunya secret. This ensures that, as the restoration of the airway and prevents the progression of tracheobronchitis. The disadvantage of this method is low efficiency, even with frequent FBC holding, in adequate removal of sputum in patients with severe tracheobronchitis.

Closest to the claimed method is mechanical ventilation in the prone (WPI), combined with the percussive massage and FBS with bronchoalveolar lavage. (Stiletto R., Bruck E., G. Bittner //Low cost prone positioning of critically ill ARDS patients with the MPS (modular prone positioning system). Crit Care 1998, 2 (Suppl 1): P121) the Disadvantage of this method is the use of bronchoalveolar lavage, the essence of which consists in the introduction into the lumen of the tracheobronchial tree to a large volume of solution with subsequent aspiration. Against the background of existing microtelecom with ARDS this may increase their number and to exacerbate hypoxemia.

The present invention is to increase the effectiveness of treatment of pulmonary complications in patients with STBI.

The task is achieved by the fact that during the development of pulmonary complications in patients with STBI do artificial lung ventilation in position on the abdomen using fibrobronchoscopy, wherein implementing the alternation of the aces in the prone and supine on the background of constant endotracheal inhalation of broncholytic for 10 minutes with an interval of 3 hours in the prone and supine constantly for 7 14 days to edema respiratory failure and recovery of consciousness.

The novelty of the method of alternating the position of the patient on his back with his stomach every 12 hours over several days can reduce the degree of hydration of the dorsal parts of the lungs and thereby reduce the degree of both General and cerebral hypoxemia. Position the patient on his stomach during ventilation improves the drainage function of the tracheobronchial tree, compared with the traditional position of the patient. The use of active fibrobronchoscopy tactics in the position of the patient on his stomach and back during mechanical ventilation allows you to more effectively remove the tracheobronchial secret compared to the traditional situation of patients. This is poignantly aspiration of tracheobronchial secretions under visual control without additional introduction of the solution. This ensures that, as the restoration of the airway and prevents the progression and tracheobronchitis. Additional application broncholytic, e.g. of aminophylline, in the form of endotracheal inhalation reduces the phenomena of bronchospasm, improves the rheological properties of sputum, and normalizes the production of shacklette research and proven by the absoluteness of these parameters.

A method of treating pulmonary complications are as follows: decrease in paO2/FiO2up to 300, increase hydration in dorsal lungs to computer tomography (CT) in patients with STBI against the backdrop of ongoing mechanical ventilation was considered an indication for inclusion in the complex therapy of mechanical ventilation with the use of VPI and active fibrobronchoscopy tactics on the background of constant inhalation of broncholytic. Mechanical ventilation with the use of VPI consisted in the alternation of the patient's position on the abdomen and on the back every 12 hours during the whole time of mechanical ventilation. Used a special device that facilitates the lifting and rotation of the patient 180oin the horizontal plane. Ventilation parameters and FiO2when changing position has not changed. When the patient is in position on the abdomen under the rib cage, the crests of the iliac bones, the feet were placed pneumatic rollers. The head was fixed on a special stand, with emphasis in the area of forehead and chin. From the first day of mechanical ventilation with the use of ITI conducted FBS periodically every 6 hours as in the prone and supine during the whole time of mechanical ventilation with the use of WPI. Inhalation solution broncholytic (is not throughout the time of mechanical ventilation with the use of VPI nebulizers, placed "on the breath" breathing circuit of the ventilator.

Example. Patient A. , 34, was admitted to the Department of resuscitation and intensive therapy 16.10.1998 with a diagnosis of severe closed traumatic brain injury. Severe brain contusion with compression of the right hemisphere of acute subdural hematoma. Brain edema, dislocation syndrome. The patient received surgery decompressive craniotomy, removal of subdural haematoma, drainage of the anterior horn of the left lateral ventricle on the Lease. Upon admission to the intensive care unit and intensive care level of human consciousness on a scale Glasgow VI score, the scores on the scale of ARACNE III was 91 with probability vnutrigospitalina mortality of 72%. On the 2nd day of the postoperative period, against the background of the IVL device "EVITA" (firm "Drager, Germany) in mode IPPV (FiO2- 0,4) decreased paO2/FiO2to 286, the control CT of the lungs marked increase hydration in the dorsal divisions of the lower lobes. The total scores for the scale ARACNE III was 126 with a fatality rate of 100%. In the neurological status was observed deepening coma (IV score on the scale of Glasgow), increased ICP to 31 mm Hg, with a stable performance CPP (60 mm Hg). Was n the tick of aminophylline. Monitored ECG, AP (invasive), CVP, CO, ICP, CPP, SpO2(SpaceLabs). Mechanical ventilation with the use of VPI consisted in the alternation of the patient's position on the abdomen and on the back every 12 hours during the whole time of mechanical ventilation. Used a special device that facilitates the lifting and rotation of the patient 180oin the horizontal plane. When the patient is in position on the abdomen beneath the rib cage, the crests of the iliac bones, the foot was placed pneumatic rollers. The head was fixed on a special stand, with emphasis in the area of forehead and chin, preventing pressure on the eyeballs and adapted for discharge of the probes and tubing of the ventilator. FBC (fibrobronchoscopy company Olympus, Japan) was performed with a frequency of every 6 hours as in the prone and supine during the whole time of mechanical ventilation with the use of WPI. FBS was performed immediately and 6 hours after changing the patient's position (on 2 times in the position of the patient on the back, and 2 times in position on the abdomen). The inhalation solution of aminophylline (2,4%) was performed for 10 minutes with an interval of 3 hours during the entire time of mechanical ventilation with the use of VPI nebulizer (firm "Dreger", Germany), placed on the breath" breathing the ASS="ptx2">

Ventilation parameters and the fraction of oxygen in the air we breathe remained constant throughout the time of mechanical ventilation with the use of WPI (IPPV; PEEP - 0 mbar; Ve - 10 l/min; RMH - 30 mbar; FiO2to 0.4). After the first translation into position on the patient's abdomen was not observed changes in ICP and CPP, which remained at the level of 30 and 60 mm Hg, respectively. Indicators of systemic hemodynamics remained stable. The marked increase in the level of oxygenation index - paO2/FiO2to 326. After returning the patient back (12 hours) again marked decrease in paO2/FiO2to the initial level. However, when the patient is on his back, it was necessary to carry out diagnostic and therapeutic measures, reducing edema of soft tissues of the face. When you put the patient on his stomach also had elevated levels of oxygenation index - paO2/FiO2in relation to the original. On the 2nd day when returning the patient back a decrease in oxygenation is not marked. With 3 days of mechanical ventilation with the use of WPI with active fibrobronchoscopy tactics on the background of constant inhalation of broncholytic on control CT scan of the lungs marked reduction in the degree of hydration of the dorsal divisions. is on the back. There was a positive trend in the neurological status. (IX score of Glasgow). The total scores for the scale ARACNE III was 71 with a fatality rate of 51%. Indicators of systemic hemodynamics remained stable, there was a decrease ICP to 16 mm Hg, CPP - 75 mm Hg. On the 7th day of therapy the amount of points on the scale of ARACNE III was 63 with a fatality rate of 38%, the total scores for the scale Glasgow - IX, noted the absence of signs expressed tracheobronchitis. On the 8th day of mechanical ventilation with the use of VPI and active fibrobronchoscopy tactics against inhalation therapy using broncholytics terminated. The patient was transferred to an independent breathing with the support of the ASB (10 - 20 mbar) and was weaned from the respirator and exuberan 10 days after the injury and later transferred to the relevant Department.

A method of treating pulmonary complications in patients with STBI, using mechanical ventilation with the use of VPI and active fibrobronchoscopy tactics against inhalation therapy using broncholytics used in 14 patients in the intensive care unit and intensive care GNCC ASS.

A method of treating pulmonary complications in severe traumatic brain injury consists in prisa fact, what does the alternation of the patient's position on the abdomen and on the back every 12 hours, in doing so, a sanitizing the fibrobronchoscopy with an interval of 6 h in position on the belly and on his back on the background of constant endotracheal inhalation of broncholytic for 10 min with an interval of 3 h in position on the abdomen and back position continuously for 7 to 14 days before edema respiratory failure and recovery of consciousness.

 

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