RU2169592C2 - Method for preventing and treating respiratory disorders - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying electric stimulation of diaphragmal nerves from the moment the patient is admitted in hospital. The treatment characteristics are 10 V voltage, 1.0 ms impulse duration, 1:3 on-off time ratio, 12-24 respiration cycles per 1 min. The sessions are repeated 3-8 times a day. Decompression-stabilization operation is carried out on injured vertebral column segment in urgent mode. Diagnostic bronchoscopy is carried out with endobronchial infrared laser radiation after escaping from anesthesia. Vibratory chest massage, postural draining and respiratory exercises are applied every 2 h. Ultrasonic inhalations with herbal decoctions and antibiotics. Healing bronchoscopy is carried out every day in alternating helium-neon laser radiation and infrared laser with 24 h pause. To prevent respiratory complications, radiation course is composed of from 4-6 procedures. Curative course is at least 6-8 procedures long. Respiratory complication having occurred, UHF-therapy and electrophoresis with euphylline and antibiotics are applied in combination with pathogenetically valid medicamentous therapy. EFFECT: reduced frequency of respiratory complications. 2 tbl

Description

 The invention relates to medicine, namely to neurotraumatology and resuscitation, and can be used for the prevention and treatment of respiratory disorders in patients in the acute period of spinal cord injury (PSMT) of the cervical spine.

 Known methods for treating respiratory disorders in patients in the acute period of PSMT of the cervical region, including: electrical stimulation of the phrenic nerves (ESDN) (Priymak AA "Treatment of respiratory failure in tuberculosis and chronic inflammatory diseases of the respiratory system by electrical stimulation of the phrenic nerves" / Methodical recommendations. - 1989.); rehabilitation bronchoscopy (Carter RE "Respiratory aspects of Spinal Cord injury management" / J. Paraplegia. - 1987. - vol. 25, N 3. - p. 262-266; Churlyaev Yu.A., Korotkevich AG "Prevention and treatment of pneumonia in spinal cord injury "/ Proceedings of the Department of Neurosurgery. Edited by Professor A. A. Lutsik, Novokuznetsk, 1988. - P. 153-156; Kanshina NF, Korotkevich AG" Morphoendoscopic changes bronchial mucosa with severe cranio-vertebral injuries "/ Vertebral and spinal injury (diagnosis, treatment, rehabilitation): Collected scientific papers - Novokuznetsk, 1988. - pp. 78-80); ultrasonic inhalations with a decoction of herbs and antibiotics; chest vibration massage and postural drainage (Malone PR, Infizmary CR, Wales S. "Early prognosis in traumatic quadriplegia" / J. Injury. - 1984. - vol. 16, N 1. - p. 2-5; Cagg MC "Postoperative management and acute rehabilitation of patients with spinal cord injuries "/ J. Ortopedic Clinics of North America. - 1986. - vol. 17. - p. 171-181; Carter RE" Respiratory aspects of Spinal Cord injury management "/ J. Paraplegia . - 1987. - vol. 25, N 3. - p. 262-266; Kolyhan VP "Cerebro-spinal injury in" divers "/ Abstract of dissertation for the degree of candidate of medical sciences, Kiev, 1988) respiratory gymnastics (Kolykhan VP "Cerebro-spinal injury in" divers "/ Abstract of dissertation for the degree of kmn, Kiev, 1988); the use of mechanical ventilation in various modes (Kassil V.L. "Application of high-frequency mechanical ventilation in intensive care" / Anesthesiology and intensive care. - 1983. - N 5. - p. 26-30; Carter RE, Donovan WH "Comparative study of electrophrenic nerve stimulation and mechanical ventilatory support in traumatic spinal cord injury "/ J. Paraplegia. - 1987. - vol. 25, N 2. - p. 86-91; Levite EM, Nemerovsky L.I." The role of acoustic resonance in the implementation of the RF mechanical ventilation effect " / Anesthesiology and intensive care. - 1991.- N 6); pharmacological correction, including antibiotics, angioprotectors, lipid peroxidation inhibitors, glucocorticoids, antioxidants, membrane stabilizers and immunostimulants (Ganssen L., Hansebout R. "Pathogenesis of Spinal Cord Injury and Never Treatments. A review" / J. Spine. - 1989. - vol. 14, N 1. - p. 23-32; Polishchuk HE "Comprehensive treatment of patients with spinal and spinal cord injuries in the acute and early period of trauma" / Damage to the spine and spinal cord. Diagnostic and treatment questions: symposium materials. Ed. Savchenko, April, Novokuznetsk, 1993).

 However, all of the above methods are applied in isolation from each other. Moreover, each method affects only one of the many links in the pathogenesis of respiratory disorders, ignoring other factors that are realized in acute PSMT of the cervical spine. In addition, all of the above methods are used for therapeutic purposes, i.e. already with a developed respiratory complication. None of these methods are used to prevent respiratory disorders. All these methods are used without taking into account the degree of damage to the spinal cord.

 Closest to the claimed method relates to electrical stimulation of the phrenic nerves or diaphragm (A.V. Livshits, V.A. Belyaev "Electrostimulation in patients with damage to the cervical and upper thoracic spinal cord," Sat. IV All-Union Congress of Neurosurgeons, M., 1988 , pp. 245-246). The possibility of using this option for providing mechanical ventilation is confirmed by a number of experimental works and clinical observations. In an experiment on dogs, the authors showed the possibility of maintaining adequate ventilation for many hours using ESDS without significant deviations of the basic physiological parameters.

The disadvantages of this method of treatment of respiratory disorders in the acute period of PSMT of the cervical region are:
- the impossibility of conducting ESDN in a continuous mode due to the development of the syndrome of "fatigue" of the diaphragm;
- the inability to remove sputum due to inhibition of the patient's cough mechanism;
- cannot be used as a way to prevent respiratory disorders;
- there is no correction of phagocytosis and correction of violations of local immunity;
- does not affect the main respiratory muscles;
- does not affect the pathogenic microflora of the tracheo-bronchial tree;
- does not have a therapeutic effect in developing respiratory complications;
- cannot be used in patients with oppression of consciousness and during mechanical ventilation.

 The objective of the proposed method is to develop a set of measures for the prevention and treatment of respiratory complications in patients in the acute period of PSMT of the cervical spine, aimed at reducing the frequency of respiratory complications and, as a consequence, reducing mortality.

 The problem is solved due to the fact that the electrical stimulation of the phrenic nerves is carried out from the moment the patient enters the regime - voltage 10 V, pulse duration 1.0 ms, duty cycle 1: 3, respiratory rate 12-24 per minute, multiplicity of sessions 3-8 times per day; perform an emergency decompression-stabilizing operation of the damaged segment of the spine; after exiting anesthesia, diagnostic fibrobronchoscopy with endobronchial irradiation with an infrared laser is performed; every 2 hours they carry out vibration massage of the chest and postural drainage, breathing exercises; conduct ultrasonic inhalations 2 times a day with a decoction of herbs and antibiotics; then daily sanitation fibrobronchoscopy is performed, alternating the irradiation of a helium-neon laser with an infrared laser; for the prevention of respiratory complications, the irradiation course consists of 4-6, and for therapeutic purposes at least 6-8 procedures. In case of developed respiratory complication, an additional UHF-therapy and electrophoresis with aminophylline and antibiotics are carried out daily in combination with components of pathogenetically substantiated drug therapy.

 The solution of this problem allows you to achieve a positive therapeutic effect, which consists in the prevention, treatment of respiratory complications in the heavy population of patients and thereby reduce mortality. In addition, when solving the problem, there is an economic effect, consisting in lowering hospital days in the intensive care unit and the cost of treatment; upon completion of treatment, the degree of disability of the victims decreases. In addition, there is a social effect - the patient’s return to society.

The method is as follows:
The first day after the injury.

 After admission, in order to eliminate hypoventilation and hypoxemia, transdermal electrical stimulation of the phrenic nerves (ENDS) begins. During the first stimulation session, the ESDS parameters are individually selected for each: respiratory rate, voltage amplitude, electric pulse duration, ratio of inspiratory time to the duration of the respiratory cycle (duty cycle). The effectiveness of electrical stimulation is determined by the subjective sensations of patients (comfort and the absence of pain with a sufficient reduction of the diaphragm) and objective indicators of the function of external respiration and the gas composition of arterial blood. Typically, ESDS is carried out in the following mode: voltage 10 V, pulse duration 1.0 ms, duty cycle 1: 3, respiratory rate 12-24 per minute, multiplicity of sessions 1-6 times a day.

 In order to prevent obstructive and congestive pulmonary disorders, ESDS is performed from the moment the patient enters the emergency room according to the method described above with sessions lasting 30-45 minutes and up to 3 times a day. With a compromised respiratory function (the presence of a chronic non-specific lung disease or acute inflammatory process in the bronchi and lung tissue), ESDS is performed for up to 60 minutes and up to 8 times a day. Before and after the ESDS session, the gas composition of the blood is controlled.

 Immediately after the ESDS session, chest vibromassage, postural drainage techniques and active sputum aspiration using an electric suction device are performed.

In parallel, they carry out comprehensive anti-shock therapy aimed at correcting hypovolemia, stabilizing systemic hemodynamics, inhibiting free radical processes and correcting secondary ischemic disorders in the injured spinal cord:
- patients are injected with medrol salt at a dose of 30 mg / kg intravenously for 15 minutes. After 45 minutes, the drug is continued to be infused at a dose of 5.4 mg / kg / hour for 23 hours;
- Lasix - 40 mg bolus, then according to indications;
- sermion - 16 mg per day intravenously, drip;
- Cavinton - 10 mg per day intravenously, drip;
- isoptin - 10 mg per day intravenously, drip;
- trental - 100 mg per day intravenously, drip;
- Actovegin - 400 mg per day intravenously, drip;
- trasilol - 200'000 units per day intravenously, drip;
- histodil - 200 mg intravenously after 6 hours;
- ascorbic acid 5% - 30.0 per day, intravenously;
- pyridoxine 5% - 30.0 per day, intravenously;
- alpha-tocopherol 30% - 10 mg / kg per day, intramuscularly;
- broad-spectrum antibiotics.

 In order to stabilize the damaged segment of the spine and eliminate compression of the spinal cord at this level, a decompression-stabilizing operation is urgently performed, which contributes to the early activation of patients and improve their "quality" of life.

 After exiting anesthesia, the patient is diagnosed with fibrobronchoscopy to evacuate sputum and reorganize the tracheobronchial tree.

 Immediately after fibrobronchoscopy, endobronchial laser irradiation through a tracheostomy or laryngeal mask is used to prevent and treat respiratory complications. When choosing a dose of laser radiation are guided by the following provisions. On the first day, endobronchial irradiation is carried out with a semiconductor infrared laser with a wavelength of 830 nm and a radiation power of 0.008 W at the fiber end for 5 minutes. The procedure is repeated at intervals of 48 hours.

 Ultrasound is performed twice a day with a decoction of herbs, bronchial and mucolytics.

 The state of the function of external respiration is monitored: chest x-ray, including inspiratory x-ray to exclude unilateral paralysis of the phrenic nerve at least once a day; spirometry once every three days; study of the function of external respiration (HFD) with the obligatory determination of the vital capacity of the lungs (VC), the residual capacity of the lungs (OEL), the reserve volume of inspiration and expiration every three days for timely diagnosis of a critical decrease in the respiratory system; study of the gas composition of arterial and mixed blood at least twice a day to monitor the respiratory potential of blood.

 The second day after the injury.

 Drug treatment program. Additionally, the treatment regimen includes: - proserin 0.05% - 1.0 after 6 hours to stimulate the function of holding the spinal cord intramuscularly; heparin at a dose of 10,000 units. per day, intravenously, through an infusomat for the prevention of thromboembolism, if there are no contraindications for hypocoagulation.

 Electrical stimulation of the phrenic nerves is performed according to the scheme described above.

 Remediation bronchoscopy is performed through a laryngeal mask or in the case of mechanical ventilation through an endotracheal tube with the introduction of solutions of antiseptics, antibiotics and mucolytics for the rehabilitation of the tracheobronchial tree. The multiplicity of bronchoscopy is determined by the clinical situation. Before and after bronchoscopy, chest x-ray is performed.

 From the second day, endobronchial irradiation is carried out with a helium-neon laser with a wavelength of 632 nm, a radiation power at the end of the fiber of 0.008 W for 5 min to stimulate the chain of respiratory enzymes and the antioxidant system of blood. The procedure is repeated with an interval of 48 hours. For the prevention of respiratory complications, the multiplicity of laser irradiation sessions is 4-6, and for therapeutic purposes at least 6-8.

 Ultrasonic inhalations are prescribed according to the above scheme using decoctions of herbs, bronchial and mucolytics after 8 hours.

 With decompensation, the function of external respiration is imposed by a tracheostomy.

 The third day after the injury.

 Additionally, immunocorrectors are included in the treatment regimen based on the results of the immunogram and the state of immunity for the treatment of secondary immunodeficiency.

 Electrical stimulation of the phrenic nerves is performed according to the scheme described above with an increase in the duration of sessions up to 60 minutes and an interval of 2 hours

 Fibrobronchoscopy is performed according to the clinical situation.

 Endobronchial laser therapy is carried out according to the above procedure.

 Ultrasonic inhalations are performed using decoctions of herbs, bronchial and mucolytics after 8 hours.

 When the first symptoms of pneumonia appear, UHF therapy is added to the treatment complex according to the standard procedure for up to five sessions.

 If prosthetic function is required, external respiration is preferred by high-frequency mechanical ventilation (HF ventilation).

 The fourth day after the injury.

 Continue sessions of electrical stimulation of the phrenic nerves according to the scheme.

 Fibrobronchoscopy is performed according to indications.

 Endobronchial laser therapy is carried out according to the scheme. Ultrasonic inhalations are continued using decoctions of herbs, bronchial and mucolytics after 8 hours.

 Fifth to seventh day after injury.

 The drug program is carried out according to indications.

 Continue sessions of electrical stimulation of the phrenic nerves.

 Fibrobronchoscopy is performed according to indications.

 Endobronchial laser therapy is carried out according to the scheme. The eighth to tenth day after the injury.

 Continue sessions of electrical stimulation of the phrenic nerves and endobronchial laser therapy.

 Ultrasonic inhalations are performed using decoctions of herbs, bronchial and mucolytics after 8 hours.

 UHF therapy is replaced by electrophoresis with aminophylline and broad-spectrum antibiotics.

 An example of a specific implementation.

 Patient S.V. O. V., 22 years old, case history No. 475, was admitted to the center of the spinal cord injury of the Novosibirsk Research Institute of Automotive Engineering on March 18, 1996, 12 hours after the injury. The circumstances of the injury: falling from a height of the 5th floor. Upon receipt of a complaint about the lack of movement and sensitivity in the lower extremities, weakness in the upper limbs, impaired function of the pelvic organs, such as urinary and fecal retention, pain in the cervical spine. Delivered by ambulance from the site of the injury to the NIITO emergency room.

Upon admission, the condition is serious, due to the nature of the injury, gross neurological deficit (upper paraparesis, lower paraplegia, impaired PTO), spinal shock, water-electrolyte, metabolic disorders. Blood pressure 100/60 mm RT. Art., pulse 52 beats per minute, respiratory rate 16 per minute, body temperature 34.5 ^o C.

 Immediately started stimulation of the phrenic nerves in the mode - voltage 10 V, pulse duration 1.0 ms, duty cycle 1: 3, respiratory rate 20 per minute for 30 minutes. At the same time, anti-shock therapy was started, including the introduction of salt-medrol according to the scheme, infusion-transfusion media in combination with membrane stabilizers, rheological drugs, protease inhibitors and lipid peroxidation.

 After a clinical and radiological examination, including an NMR study, the diagnosis is made: Closed complicated explosive fracture of the body of the C7 vertebra. Spinal cord compression at C7 level. Frenkel A. Lower paraplegia. Upper distal paraparesis. Violation of the PTO. Spinal shock.

 Two hours after admission, the operation was performed: 1) application of skeletal traction over the parietal tubercles; 2) anterior open decompression of the spinal cord by total removal of the C7 body. Anterior spinal fusion with an implant made of porous titanium nickelide and auto-crumb.

 Total intravenous anesthesia with mechanical ventilation was used. The duration of general anesthesia is 4 hours. After the operation, a diagnostic bronchoscopy was performed, followed by irradiation of the tracheobronchial tree with an IR laser with a power of 0.008 W for 5 minutes. After that, elements of consciousness appeared, but spontaneous breathing was inadequate. To conduct mechanical ventilation and further therapy, the patient was transferred to the intensive care unit under conditions of mechanical ventilation.

Two hours after surgery, against the background of a restored consciousness, adequate spontaneous breathing, extubation was performed. When analyzing the gas composition of the blood, moderate arterial hypoxemia was observed: PaO ₂ 65 mm Hg, PaCO ₂ 36.7 mm Hg, SaO ₂ 91%, pH 7.43. A treatment regimen has begun, aimed at the prevention of respiratory complications: electrical stimulation of the phrenic nerves 3 times a day for 40 minutes; daily sanitation bronchoscopy sessions with endobronchial helium-neon laser irradiation, alternating with laser therapy of the infrared spectrum; every two hours, chest vibro massage and postural drainage, breathing exercises were performed; 2 times a day, ultrasonic inhalations with decoction of herbs and antibiotics were performed.

 There were no respiratory complications. On the sixth day, the patient was transferred to the department.

 The dynamics of the gas composition of arterial blood in a patient With-howling O.V. the days of stay in intensive care are presented in table. 1.

 Dynamics of the function of external respiration in a patient With-howling O.V. the days of stay in intensive care are presented in table. 2.

 The patient was discharged from the clinic after three months. Neurological deficit partially regressed (Frenkel B).

An analysis of all the data made it possible to isolate and substantiate the following conclusions that the proposed method for the prevention and treatment of respiratory disorders in patients in the acute period of PSMT of the cervical spine provides:
- the continuity of the process of prevention and treatment of respiratory complications;
- full evacuation of sputum;
- maximum correction of phagocytosis and correction of violations of local immunity;
- effects on the main respiratory muscles;
- impact on the pathogenic microflora of the tracheobronchial tree;
- adequate treatment of the developed respiratory complication;
- prevention and treatment of respiratory complications in patients with depression of consciousness and during mechanical ventilation;
- reduction in the percentage of respiratory complications in patients with acute spinal cord injury (PSMT) of the cervical spine;
- reduction of bed days in intensive care;
- improving the "quality" of life of the victims;
- reduction in mortality.

Claims (2)

 1. A method for the prevention and treatment of respiratory complications in the acute period of spinal cord injury of the cervical spine, including percutaneous electrical stimulation of the phrenic nerves (ESDS), characterized in that the electrical stimulation of the phrenic nerves is carried out from the moment the patient enters the mode - voltage 10 W, pulse duration 1.0 m / s, duty cycle 1: 3 breathing rate 12-24 per minute, multiplicity of sessions 3-8 times a day, in an emergency order perform decompression-stabilizing operation of the damaged segment and the spine, after exiting anesthesia, perform diagnostic fibrobronchoscopy with endobronchial irradiation with an infrared laser; every 2 hours they perform chest vibration massage and postural drainage, breathing exercises, conduct ultrasonic inhalations 2 times a day with decoction of herbs and antibiotics, then perform daily fibrobronchoscopy, alternating irradiation of a helium-neon laser with an infrared laser, to prevent respiratory complications, the course of radiation consists of out of 4 - 6, and for therapeutic purposes at least 6 - 8 procedures.  2. The method according to claim 1, characterized in that with the development of a respiratory complication, an additional UHF therapy and electrophoresis with eufelin and antibiotics are additionally carried out daily in combination with components of pathogenetically substantiated drug therapy.

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