Treatment of severe broncho-obstructive syndrome in children of early age

 

(57) Abstract:

The invention relates to medicine, in particular to Pediatrics. Injected, mikrostruyno nitroglycerin dose of 2 to 6 µg/kg/min with subsequent dose reduction to 1 µg/kg/min, a rate of 2 to 4 days. This method leads to an improvement of the respiratory function of the lungs, reducing pulmonary hypertension, contributes to bronchodilatation, which leads to more rapid relief peribronchiolar and perivascular edema and improve the condition of patients. table 4.

The invention relates to medicine, namely Pediatrics.

According to modern literature, the majority of authors: Raczynski S. C., Tatochenko C. K., Artamonov, R. (respiratory Diseases in children: a guide for physicians.- M. Medicine. -1987-pages 186-194, "Obstructive bronchitis in children. M. 1996-pp. 103-147), Kavalov S. M. ("broncho-Obstructive syndrome in children Novosibirsk. 1992), Tsybulkin E. K. ("Threatening condition in children With P. 1994-pages 74-78), Salonen R. O. (Acta Farmacol. Toxicol.57 Suppi. 3: 1-38; 1985), Wilkie, R. , Bryan, M. , 1987, Denjean A, et al. (J. Pediatr.6. -pages 974-979, 1992) and other major in the treatment of broncho-obstructive syndrome (BOS) in children of early age wide variety of bronchodilatation acting on different pathogenetic zveki, anticholinergics. However, the role of bronchospasm increases in children with recurrent episodes of barefoot. Typically, the age of these children over the age of 1.5 - 2 years.

Violation of respiratory function in children of early age, primarily associated with the development of peribronchial edema (Tatochenko C. K., Artamonov, R., 1987, 1996, respiratory Diseases in children: a guide for physicians.- M : Medicine-1987-pages 186-194; "Obstructive bronchitis in children. M. 1996-pp. 103-147; Kavalov C. M."broncho-Obstructive syndrome in children"- Novosibirsk.- 1992).

Hence low, according to our data, the effectiveness of bronchospasmolytic therapy in infants, although in the modern literature on this controversial information.

The main drug in the treatment of BOS remains aminophylline, which in many clinics in severe biofeedback is used for dosing schemes proposed by the staff of the Department of clinical pharmacology, Smolensk medical Institute (Stratchounski L. S. and others 1993, "Pediatrics" -N 2. in 1993. -S. 67-70).

Along with the positive properties, the drug has many negative properties, which makes it often impossible in practice. Therapeutic dose of aminophylline of blokeish, agitation, muscle tremor, tachycardia, seizures. The drug increases requirement of a myocardium for oxygen (Gusel C. A., Markov, I. C., "Handbook of pediatrician in clinical pharmacology", 1990 - page 177-180; Vidal 1997-page 704). Tatochenko C. K., Artamonov R., ["Obstructive bronchitis in children M. 1996, pp. 104-147] offer in the treatment of severe obstructive bronchitis (ABOUT) to use with decongestants in order glucocorticoids at doses of 6-8 mg/kg short course.

In practical work is used at the same time, usually more than 10 drugs for the treatment of severe ABOUT that is certainly unacceptable, both from an economic and pharmacological point of view.

We have conducted research in Central and peripheral hemodynamics, respiratory disorders, oxygen status, autonomic nervous system, in 80 infants with ABOUT.

In our research we used the impedance pneumography apparatus "SpaceLabs" registered respiratory rate (BH), the relationship tidal volume to body surface (UP/m2), relations minute volume of breath to the body surface (MOD/m2), the ratio of inspiratory time to expiratory time (TVD/Tvydproceed heart rate (HR), cardiac index (MI), stroke index (si), the fraction of the expulsion of the left ventricle (PHI), mean pulmonary artery pressure (p.FOR), pulsoximetry registration saturation of oxygen by the "BCl"; cardiointervalography; Central venous pressure apparatus Waldman; blood pressure monitor ""Hewlett Packard" 78352C; acid-base status (KHS) apparatus "Radiometr" ABL-50 with the study of pH, partial carbon dioxide tension (pCO2), oxygen (pO2), deficit (BE). Identified the following changes.

1) Pulmonary hypertension significantly with increasing severity of disease.

2) the high prevalence of giperdinamicheskim mode of Central hemodynamics. The compensation level of the cardiovascular system also varied with the severity of the disease. In severe form OF sub - and decompensated type hemodynamics.

3) Hyperventilation syndrome (according to the impedance pneumography).

4) the Source of sympathetic-hypersympathicotonia, with increasing severity of disease, with prevalence asimptoticheskoi reactivity in severe patients.

5) Expressed human peripheral blood flow, high demand Rowany acidosis with accumulation in the weighting of the condition of carbon dioxide (hypercarbia).

All patients had a combination of respiratory and cardiovascular disorders.

The technical result of the proposed method for the treatment of severe ABOUT is to increase the effectiveness of remedial measures, reducing the number of used medicines that can improve the quality and effectiveness of therapeutic measures, reduces the treatment time ABOUT in children of early age. The above is achieved by intravenous, microfluidic injection of nitroglycerin dose 2-6 mcg/kg/min with subsequent dose reduction to 1 mcg/kg/min, a rate of 2-4 days.

The selected remedy in the treatment of severe biofeedback in children of early age was used in 15 children.

According to literature data (Gusel C. A., Markov, I. C. (Handbook of the pediatrician in clinical pharmacology" 1990 - pages 115-116), Vidal, 1997, pages 393-394, Drummond V., Lock, J.,1989 (In the book "Clinical pharmacology newborn" Markova, I. C., Shabalov, N. P., L. Sothis, 1993)) nitroglycerin is clear vasodilatator reducing the intracellular activity of calcium ions into smooth muscle cells of blood vessels. In small doses over the venous vasodilator action.

The drug reduces pre - and postnagruzku heart, uverito easier for the heart, reduces requirement of a myocardium in oxygen, improves the metabolism in the heart muscle. It is also noted direct myotropic action.

Nitroglycerin is used mainly in adults with left ventricular heart failure, myocardial infarction. About using it for the treatment of severe ABOUT in the available literature data, we did not find.

In modern literature in recent years intensively proceedings on the application of nitric oxide. The latter is increasingly used as vasodilatatore in the treatment of pulmonary hypertension in adults. Consider that the effect of nitroglycerin is associated with the release into the lumen of the vessel of nitric oxide. But nobody uses today nitroglycerin as a bronchodilator (A. P. silber- "Respiratory medicine". -Petrozavodsk.-page-418-422).

All of the above allows us to recommend the use of nitroglycerin in order to relieve respiratory failure in combination with hemodynamic, circulatory disorders, especially in children with severe ABOUT.

In addition, a bronchodilatory effect of nitroglycerin, caused, apparently, by reducing peribronchiolar edema, the transition of the liquid in route of administration: intravenous, mikrostruyno, constantly.

Dose: 2 mcg/kg/min

Maximum dose: 6 mg/kg/min

The gradual elimination of the drug during the day, with the transition to a dose of 1 mcg/kg/min

The average duration of administration: 3 - 4 days.

If necessary transition to oral nitrosospira at a dose of 0.05 - 0.1 mg/kg

Use 1%, 0.1% solution of nitroglycerin bred him up to 20 ml 0.9% sodium chloride solution or 5% glucose solution.

The syringe is charged in the infusion pump and put the prepared solution at a given speed (typically 1-2 ml/h).

Side effects of nitroglycerin, described in detail in various publications, we did not observe. This is due to the low doses of the drug and its pharmacokinetic characteristics (rapid destruction).

In some sources (Herling I. M.(Am. Heart J. 108: 141 - 149,1984)) reported that nitroglycerin is able to connect with polyvinyl chloride, which is used in the system for intravenous infusion, so you should use syringes made of glass or polyethylene (Khan MG, 1988, IN book P. Marino- "Intensive care" -1998-pages 241-244).

Comparative characteristic data KHS, the ECHO-KG, pneumatic is glicerina, are given in table. 1.

Was significantly reduced compared with normal oxygen tension in the blood taken from the pulp of the finger (capillary blood), before the introduction of nitroglycerin and its increase after the introduction of the drug. Other indicators KHS there is no reliable, dynamics, changes that reflect the different compensation mechanisms, tissue homeostasis.

Found the source of arterial hypertension and normalization of parameters of HELL after the appointment of nitroglycerin.

When the ECHO-KG examination revealed giperdinamicheskim mode hemicircular. The degree of hyperdynamic was significantly decreased after treatment with a drug. Increases myocardial contractility, decreased heart rate, decreased significantly pressure in the pulmonary artery. Data received by pneumography, allow us to characterize the source ventilation mode as hyperventilation syndrome, reflecting the compensatory function of the respiratory system aimed at maintaining the oxygen balance. This is achieved through a significant increase in respiration, increase in minute volume of respiration (in many patients there is a decrease in tidal volume, which causes a great time the donkey introduction, reduces the severity of hyperventilation syndrome due to ischemia BH, which undoubtedly translates pulmonary ventilation at a more economical mode of operation. Significantly increased the ratio of inspiratory time to expiratory time (VD/Vyd), decreases in the dynamics of the ratio between the time of exhalation of the breathing cycle (Vyd/R-R).

When pulse oximetry revealed initially reduced the saturation of oxygen in capillary blood, reflecting tissue hypoxia, is associated mainly with impaired hemodynamics, microcirculation status. When assigning nitroglycerin observed a significant increase saturation, oxygen tension in capillary blood, which is characterized by improving tissue perfusion.

In table. 2 provides a comparative summary of indicators KHS, the ECHO-KG, pneumography, pulse oximetry in patients receiving and not receiving nitroglycerin in the subacute period (when exiting obstructive syndrome).

Indicators KHS, Central hemodynamics, the pressure in the pulmonary artery was not significantly different in the groups.

However, when pneumographic study experienced a statistically significant difference in the degree of g is ventilation syndrome, that was characterized by a decrease in BH, and respiratory minute volume of respiration in relation to the body surface. Significantly reduced length of stay in the intensive care unit and intensive care.

Use of nitroglycerin allows you to renounce the use of aminophylline, cardiotonics, because when using it achieved bronchodilatory effect, stabilization of the blood vessels disorders, improves the supply of oxygen to tissues, making it possible to reduce the number of medications, reduces length of stay of patients in the ICU with severe ABOUT.

Example. Busygin Artem 6 months, was in the neonatal intensive care unit OKB, Ivanovo diagnosed with:

"Adenovirus infection. Obstructive bronchitis. DN z. NC 2A. Perinatal encephalopathy, late recovery period, the syndrome of musculoskeletal disorders".

When entering a serious condition. Gravity is caused by the phenomena pulmonary-cardiac insufficiency, respiratory failure obstructive type. Excited. Pale skin, clean, sufficient humidity. Central cyanosis. Eyelid swelling. Redness of the throat. Cough dry, frequent. Percussion sound Korhogo corresponding hyperthermia. Muffled heart sounds. HR 180 in 1 min. Liver + 3 see Spleen + 1 see Urinating enough.

The child assigned nitroglycerin dose of 2 mcg/kg/min Data on the initial condition, laboratory and instrumental methods of investigation are presented in table. 3 and 4.

According to KHS for admission was respiratory alkalosis. There was a high oxygen content in arterial and significantly reduced in the capillary and venous blood. There was a high demand for tissue oxygen. With the introduction of nitroglycerin improved indicators of blood flow, cardiac activity, respiratory system, reflected in KHS: normalized capillary blood pH, voltage and the oxygen saturation.

If kardiointervalografii noted the original hypersympathicotonia when asimptoticheskoi reactivity. With the introduction of nitroglycerin decreases the degree of sympathicotonia, autonomic reactivity becomes Hyper sympathicotonic.

When the ECHO-KG - in the dynamics, after administration of nitroglycerin decreases the severity of hyperdynamic, decreases HR, SI, increases the TOU. Reduced pressure in the pulmonary artery. Reduced right ventricular dimensions that svidetelstvo is urografii increases the ratio of inspiratory time to expiratory time, that talks about the improvement of bronchial obstruction; reduces the severity of hyperventilation syndrome (reduced BH, MOD). Increases blood oxygenation.

Despite the decrease, compared with the normal CVP, with a standard infusion therapy introduction nitroglycerin does not lead to further worsening hypovolemia, and Vice versa, in hypoxic conditions, energy-dynamic cardiac drug contributes to a reduction of preload and improving blood circulation in cardiomyocytes.

Thus, according to our research, in the treatment of severe forms ABOUT in children of early age with nitroglycerin dose 2-6 mcg/kg/min, administered intravenously, mikrostruyno infusion pump, with a gradual reduction of the dose by 1 mcg/kg/min, a rate of 2-4 days, a proven beneficial effect on hemodynamics, ventilation-perfusion relationships; in addition, a bronchodilatory effect of the drug in children, which makes possible the use of the drug in these patients.

The drug allows pathogenetically grounded biofeedback therapy in children of early age the minimum quantity of drug prepaymania economic effect.

Treatment of severe broncho-obstructive syndrome in young children, including medication, characterized in that the applied intravenously, microstrain introduction of nitroglycerin dose of 2 to 6 mcg/kg/min with subsequent dose reduction to 1 mcg/kg/min, a rate of 2 to 4 days.

 

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