RU2089901C1 - Method for differential diagnostics of respiratory distress-syndrome in neonatals - Google Patents

Abstract

FIELD: medicine, pulmonology, diagnostics, reviviscence. SUBSTANCE: method deals with studying the relation of alveolar macrophages in neonatals with conditionally pathogenic microorganisms. Index of phagocytosis completeness is estimated, at its value lower +0.5 respiratory distress-syndrome is predicted caused by intrauterine infection in neonatals. EFFECT: higher accuracy of differential diagnostics for earlier pathogenetic therapy and decreased number of purulent and septic complications.

Description

 The invention relates to medicine, namely to neonatology, and can be used for differential and rapid diagnosis of respiratory distress syndrome (RDS) in a newborn.

 The fact of using the concept of RDS as a diagnosis indicates that at present there are no reliable differential diagnostic criteria to identify the pathological conditions that determine this syndrome.

 A.V. Tsinserling (1991) notes the high likelihood of a connection between pneumopathy and intrauterine infection (IUI) in children who died in the early neonatal period. Pneumopathy is considered as one of the appearance of respiratory distress syndrome, characterized by a decrease in gas exchange in the lungs after birth.

 IUI is often the cause of the entire spectrum of antenatal pathology: stillbirths, prematurity, intrauterine growth retardation. In addition, a significant part of these diseases, unfortunately, is not recognized either during life or after the death of a newborn child. Statically, they are taken into account as respiratory distress syndrome, asphyxia, perinatal encephalopathy, intrauterine hypotrophy, and a deep degree of prematurity. (G.V.Shastina, A.V. Tsinserling, 1991, N.I. Ermolenko, 1992, N.I. Kudashov, 1990, A.V. Tsinserling, N.P. Shabalov, 1992).

 In the development of symptoms and signs of progressive respiratory failure, various diseases of the mother, immaturity of the lungs, as well as the brain, endocrine system and infectious damage to the fetus play a role (G.V.Shastina, A.V. Tsinserling, 1991, Hallman M. at al. 1981 ) Despite the success in studying the causes of IUI as a trigger for the development of RDS, many domestic and foreign authors note the lack of reliable laboratory tests of IUI, and together with the non-specificity of clinical symptoms, note the complexity of the early diagnosis of this serious pathology.

 There is as yet no description of a clear RDS clinic that would help differentiate it from similar states of the neonatal period (Avery M. Fletcher B. at al. 1981, Studenikin M.Ya. 1984). For practice, it is very important to find out the causes of the development of pneumopathies, including the role, in their occurrence of IUI. Therefore, early detection of the infectious genesis of respiratory failure and early detection of the infectious genesis of respiratory failure in a newborn are of great importance. It is clear that there is a huge difference in the approaches to the treatment of children suffering from respiratory distress syndrome, without participating in the pathogenesis of the disease of the infectious agent and the condition caused by the infectious lesion of the fetus, when intensive, controlled and adequate antibiotic therapy is required in sufficient doses and for a long time to achieve bacteriostatic and bactericidal effect (Ostrovsky A.D. Vorobiev A.S. 1985).

 Currently, clinicians mainly use indirect methods for the diagnosis of IUI, such as microscopy of cord smears (neutrophilic cord infiltration, Bakulev L.P. Nesterova A.A. Surskaya O.A. 1985), microscopy of the gastric and pharyngotracheal apparatus (increased number of leukocytes in the field vision compared with control, Levitskaya S.K. 1991, Afonina L.G. 1990). The bacteriological method of nasopharyngeal aspirates, the contents of the stomach, blood, urine, and cerebrospinal fluid requires too long analysis, while if there is a suspicion of an IUI, urgent intensive and appropriate therapy is necessary (Kudashov N.I. 1990).

 The closest prototype of the invention is a method for the diagnosis of acute bronchopneumonia described in the article Shelest, M. Frakov, T. Lada, A. Pete, published in the journal "Pediatrics", 1990, -N11, pp. 94-95. The essence of this method is that with the help of a bronchofibroscope they intubate the child, a physiological solution of sodium chloride with a temperature of 37 ° C in a volume of 3 x 20 ml is introduced into the canal of the fiber microscope. Each dose is immediately aspirated with a syringe, while the 4th sample is used for microbiological examination. The first three samples (all together) are centrifuged (1200-1600 rpm) for 10 minutes. From the obtained sediment after staining according to May-Grunwald-Giemsa, cell dissociation (CD) is determined: alveolar macrophages (AM), lymphocytes (LI), polynuclear leukocytes (PNL), eosinophils (EO). With a value of (c) AM-3.0, LI-2.5, PNL-94.5, EO-0, acute bronchopneumonia in a child is diagnosed.

However, this test has the following disadvantages:
1. This method can be attributed to indirect, non-specific diagnostic methods.

 2. The method allows you to diagnose a far-reaching infectious process with signs of suppuration in the lungs, which makes it impossible to conduct a quick differential diagnosis of the genesis of respiratory disorders in newborns, makes it difficult to choose the right tactics of patient management and treatment.

 3. This method does not allow timely diagnosis of the onset of an infectious process, when the number of macrophages in the contents of BAL has not yet changed significantly, but there is already a decrease in the functional activity of AM due to a decrease in specific and non-specific immunity factors in infected children (S.K. Levitskaya, 1991 )

 These shortcomings can be overcome in our solution.

 The objective of the invention is to increase the accuracy of differential diagnosis, timeliness and reliability of a method for diagnosing respiratory distress syndrome due to intrauterine infection of a newborn, to ensure the earliest pathogenetic therapy and reduce the number of purulent-septic complications.

 To do this, the interaction of AM of a newborn baby with conditionally pathogenic microorganisms is studied, the index of completion of phagocytosis (IFF) is determined, and if the value of IFF <+0.5, RDS caused by intrauterine infection of the newborn is diagnosed.

 Otherwise, IFP values above +0.5 indicate a non-infectious genesis of RDS, which requires completely different approaches to the management and treatment of such children.

 Phagocytosis is the first stage of a specific immunological rearrangement, since the process of antibody formation requires the presence of antigen, not in carpuscular, but in dissolved form. A.D. Ostrovsky, 1985).

 Research Results Christian P. Speer. at al. 1988. show that monocytes of newborns and adults have the same degree of maturity, which is demonstrated in a long-cultivated culture. In addition, neonatal macrophages have full-fledged phagocytic activity compared to adult macrophages. However, the development of an infectious inflammatory process in a child leads to a decrease in specific and non-specific defense factors, including a decrease in the functional activity of macrophages (E.V. Pavlova, 1987, R.S. Cherkasskaya et al. 1990).

 The method is as follows. Alveolar macrophages are obtained by administering to a baby who enters the ward on the first three days after birth with signs of respiratory distress syndrome and is under mechanical ventilation, 0.5 ml of physiological saline solution through an endotracheal tube, followed by aspiration. Such a manipulation is performed three times within 1 hour. The contents of the washings are pooled and filtered through a nylon filter, centrifuged for 10 minutes at 1000 rpm. The supernatant was aspirated and the pellet was resuspended in 1 ml of N199 medium with 10% cattle serum and the absolute number of cells was counted in a Goryaev chamber.

Subsequently, a suspension of macrophages (200,000 cells / ml) is mixed with a microbial suspension of Staphylococcus epididermidis in a ratio of 1:10, respectively. Put on a coverslip and placed for 1 h at 37 ^o C in a C0 ₂ incubator (content of CO ₂ up to 5%). Intact macrophages are used as a control. After incubation, the coverslips are washed in serum-free medium 199 to remove non-phagocytized microbes, some of the glasses are dried, fixed at 96 ^° C with ethanol and stained according to Romanovsky-Giemsa. The remaining glasses after washing in culture medium 199 with 10% serum of cattle are placed in a CO ₂ incubator for 3 hours at 37 ^° C. After cultivation, the glasses are processed as described above.

 Rating. The intensity of phagocytosis was evaluated by the following indicators: the percentage of active phagocytes (% AmF), the number of macrophages containing microbial cells from 100 counted, the phagocytic index (FI1 and FI3) and the index of completion of phagocytosis (IPF).

ФИ1 фагоцитарный индекс (отношение количества бактерий, захваченных макрофагами, к числу сосчитанных фагоцитов), определяемый через 1 ч, ФИ3 это фагоцитарный индекс, подсчитанный через 3 ч.IFF calculated by the formula:

FI1 phagocytic index (ratio of the number of bacteria captured by macrophages to the number of phagocytes counted), determined after 1 h, FI3 is a phagocytic index counted after 3 h.

 IFP makes it possible to assess the ability of macrophages to digest microorganisms and allows to quantitatively characterize the most important final stage of phagocytosis.

 Positive values of IFF characterize the degree of completion of phagocytosis, while IFF = + 1.0 corresponds to fully completed phagocytosis. The lower the value of isf, the incomplete phagocytosis, i.e. the more intensive the multiplication of microorganisms inside the macrophage, the higher the likelihood that the infection of the newborn is intrauterine, which was the reason for the development of a respiratory distress syndrome in the child.

 We give specific examples illustrating the information content of the proposed test for the differential diagnosis of RDS in the newborn.

 Example 1. Child R-s, the medical history N 3091 was born on 05/12/94 from the 1st pregnancy of 38 weeks, proceeding in gestosis of the 1st half, SARS at 28-29 weeks, with symptoms of intrauterine malnutrition, body weight 2,480.0 g, body length 50 cm, with a rating on the Apgar scale of 4-6 points. The condition at birth is severe, the cry is weak, pronounced perioral and acrocyanosis, retraction of the sternum, jugular fossa, pronounced retraction of the intercostal space. In the lungs, percussion shortening of sound from two sides. Auscultation very hard breathing, weakened in the lower parts of the lungs. Heart sounds are muffled, rhythmic. In neurological status: the head is rounded (head circumference 35 cm, chest 33 cm). Large fontanel 0.8 x 0.6 cm, at the level of the bones of the skull, finely spread tremor of the extremities, unstable low-amplitude nystagmus on both sides, decreased diffuse hypotension; tendon reflexes are slightly reduced, D = S. Reflexes of oral and spinal automatism are reduced.

 A preliminary clinical diagnosis was made: respiratory distress syndrome, pneumopathy, partial lung atelectasis. Hypotrophy of the 1st degree.

 On the first day after birth, he entered the intensive care unit, where he underwent a full laboratory and clinical examination. In a general blood test, a slight leukocytosis with a shift in the leukogram to the left, a coagulogram, and biochemical blood parameters without deviations from the norm were revealed. IFV of the alveolar macrophages of the child had a value of + 0.2, which indicated incomplete phagocytosis and deep damage to the functional activity of these cells. In addition, intracellularly located microorganisms, clearly visible in the smear of a monolayer of macrophages, indicated infection of the fetus, manifested in intrauterine malnutrition and the development of symptoms of respiratory distress syndrome. Intensive respiratory therapy (IVL), antibiotic therapy (amikazit, longacef), infusion therapy (10% glucose with components, albumin solution), antihemorrhagic therapy (vikasol, heparin) were administered to the child in the department, and single-dose plasma was administered to the child for passive immunization blood, intravenous human gamma globulin at a dose of 500 mg / kg per day, parenteral nutrition was prescribed by the introduction of solutions of amino acid preparations and fat emulsions. Intensive antibiotic therapy and respiratory therapy were given to the child for 24 days. After 30 days of treatment in the intensive care unit, the child was transferred to the neonatal pathology department for further treatment.

 So, in this case, the timely differential diagnosis of the causes of respiratory failure in the child made it possible to quickly and effectively carry out intensive pathogenetic, including antibacterial, therapy, which made it possible to cope with a whole complex of disorders that led to severe suffering for the newborn child.

 Example 2. The child M-yang, a medical history N 3995, was born on June 26 from IV pregnancy, which was proceeding with gestosis of the second half in a woman of 28 years who was somatically healthy. Childbirth II, urgent, rapid. The boy was born with a body weight of 3250 g. 51 cm long with an Apgar score of 6-7 points. With direct laryngoscopy, a small amount of sputum mucosa is aspirated. Rhythmic breathing, there was a slight mixed shortness of breath up to 40 breaths per min. Minor acrocyanosis. Percussion of the lungs without features. Auscultatory weakened breathing in the lower parts of both lungs, creaking rales on both sides. In neurological status lethargy, adynamia, hyporeflexia were noted. The frog pose, the newborn’s reflexes are inhibited.

 A general blood test revealed leukocytosis, a shift in the ligram to the left, signs of anemia. The clinical diagnosis was made in the department of pathology of newborns of the maternity hospital: perinatal hypoxic-traumatic encephalopathy, acute period, severe course, oppression syndrome, respiratory distress syndrome, pneumopathy, lung atelectasis. The treatment with the introduction of piracetam, etimizole, gentamicin, vitamins, cocarboxylase had no effect. The child's condition worsened, respiratory failure, anemia, hypotension, and lack of exercise increased. Signs of cardiovascular failure appeared.

 June 28, The child was transferred to Rostov NIIAP in an extremely serious condition. Upon admission, the child noted severe respiratory distress, tachycardia, and enlarged liver. IZF on the third day after birth + 0.7.

 In the department, the child underwent respiratory therapy (IVL), antioxidant therapy, infusion therapy (albumin and glucose solutions with components), vitamins, cardiac glycosides, native plasma, and fresh citrated blood were introduced. From antibiotics, the child received gentamicin. The child was on full parenteral nutrition.

 However, the child’s condition did not improve, three days after admission to the ward, symptoms of acute cardiovascular failure appeared and biological death occurred on July 3, 94. Pathological and anatomical diagnosis: natal injury of the cervical spine.

 Thus, the respiratory distress syndrome was caused in a child by a trauma of the central nervous system, the values of isoforms sharply differed from those in the first example, and this fact confirms the non-infectious genesis of R DS. It is completely obvious that the IFF indicator can be used for the differential diagnosis of causes, the development of respiratory distress syndrome in newborns.

The proposed method for the diagnosis of RDS in newborns has several advantages over the chosen one as a prototype:
1. High reliability and accuracy of the differential diagnosis of respiratory distress syndrome, which allows pediatricians and resuscitators to choose the right tactics and treatment in a timely manner, thereby reducing the percentage of purulent-septic complications in newborns during mechanical ventilation.

 2. Differential diagnosis of RDS by the proposed method is carried out in a short period of time, which is important for rapid diagnosis of the causes of respiratory failure.

 3. The method is simple, and therefore can be widely used in intensive care and pediatric hospitals.

Claims (1)

 A method for differential diagnosis of respiratory distress syndrome of a newborn by determining the content of alveolar macrophages in the contents of bronchoalveolar lavage, characterized in that the interaction of alveolar macrophages of a newborn baby with conditionally pathogenic microorganisms is studied, the index of completion of phagocytosis is determined, and when the value of the completeness index of phagocytosis is less than 0.5 diagnosis syndrome due to intrauterine infection of the newborn.