RU2238757C1 - Method for treating inhalation lesions - Google Patents

Abstract

FIELD: medicine, anesthesiology, resuscitation.

SUBSTANCE: the present innovation deals with treating inhalation-affected respiratory organs. The method deals with carrying out conventional curative procedures including bronchoalveolar lavage, and at achieving normal values of respiratory function - patient's extubation. Moreover, at oxygenation index value being below 300 mm mercury column lavage should be carried out due to surfactant-BL diluted in physiological solution, then surfactant-BL should be additionally introduced into each main bronchus. Such procedures should be repeated every 12 h for 2-3 d. The method provides high survival rate in patients, rapid restoration of gaseous blood composition and normalizes respiratory function.

EFFECT: higher efficiency of therapy.

1 ex

Description

The invention relates to medicine, more specifically to anesthesiology and intensive care, and can find application in the treatment of injuries of the respiratory tract.

Damage to the respiratory tract (RAP) occurs in people burned as a result of technological disasters, accompanied by explosions and fires in closed rooms of industrial facilities, in transport and in everyday life. During fires in enclosed spaces, toxic products such as phosgene, hydrogen chloride, ammonium, acetaldehyde, formaldehyde, acetic and formic acids, phosphorus oxides and many others that have a damaging effect on the mucous membranes of the respiratory tract are released. Inhaled lesions (PIs) most seriously aggravate the course of a burn disease in victims and are characterized by extremely high mortality among burned patients.

PIs are divided into burns of the upper respiratory tract (from the external nasal passages to the vocal cords) and PDP by combustion products. The latter are mild (single accumulations of soot, moderate hyperemia and edema of the mucosa, a small amount of secretion), moderate (severe edema and hyperemia of the mucosa, multiple accumulations of soot, a large amount of secretion) and severe (total stratification of soot, after which aspiration is visible pale “Dry” mucosa with multiple petechial hemorrhages). The most severe are MPDs, which are noted in 95% of people burned if they were unconscious at the time of the injury or if clothes burned on them and burns are located on the face, neck, front surface of the trunk and upper limbs. Moreover, the general condition of these patients is exacerbated by burns of the skin.

RAP is characterized by high and early mortality of the victims, which, with a mild degree, is up to 20%, with a severe one - up to 80%.

Treatment of IP is carried out at all stages of the evacuation of burned both in peacetime and in the conditions of the medical service of civil defense. First aid is provided in such an amount that is necessary either to save the life of the victim, or to create conditions for his evacuation. At the second stage, all measures are taken that were not carried out during the provision of first aid (administration of droperidol, painkillers, antispasmodics, anti-shock measures). All victims with burns on the face are regarded as victims with RAP. At the 3rd and 4th stages of treatment, specialized burnt care is provided, which includes adequate complex infusion-transfusion and drug therapy, microtracheostomy with auxiliary high-frequency ventilation of the lungs and administration of drugs, and in severe cases, tracheal intubation and artificial ventilation of the lungs (mechanical ventilation) in various modes and all of the above procedures are performed after intubation. If the patient survives within a week, then he still has a chance of a favorable outcome.

Closest to the proposed is a method of treating FE, described in the textbook of the Military Medical Academy. S.M. Kirova [I.F.Shpakov, I.O. Venevitinov, V.A. Sokolov. “Thermochemical lesions of the respiratory tract”, St. Petersburg, 2003, 17 c.], Taken by us as a prototype.

The method consists in the fact that against the background of conventional antishock therapy, therapeutic bronchoscopy is performed, the purpose of which is to restore airway patency, and the drug effect on the pathological process in the trachea and bronchi. Therapeutic bronchoscopy begins with aspiration of the contents of the respiratory tract (DP) with an electric suction pump under local anesthesia in spontaneous respiration or under anesthesia with mechanical ventilation. The distal end of the bronchoscope is brought to the mouths of the bronchi obstructed with soot or thick secretions and 5-10 ml of physiological saline or 0.5% dioxidine solution are installed with subsequent maximum aspiration. In cases of obstruction of the bronchi with casts of viscous secretion, proteolytic enzymes in a single dose are fractionally injected into the bronchi with subsequent evacuation of the injected solution along with mucous plugs in the form of bronchial casts. The frequency of performing therapeutic bronchoscopy is determined by the severity of the affection of the DP with combustion products and the clinical course of the local wound process. Depending on the amount of pathological impurities, 1-2 readjustments are performed daily. The peculiarity of sanitation in patients with acute respiratory infections, who are on mechanical ventilation, is that even with massive obstruction of the bronchi with soot or a thick secret, there is no need to rinse the tracheobronchial tree with large amounts of liquid, but should be limited to 20-30 ml of antiseptic solution. For endobronchial treatment, drugs are used that are divided into groups according to the mechanism of action:

1) substances that mechanically clean (physiological saline, Ringer-Locke solution, 0.25% novocaine solution),

2) antiseptic substances (rivanol, 0.5% dioxidine solution, 0.5% metrogil solution),

3) substances that reduce the surface tension and viscosity of bronchial secretions (2% sodium bicarbonate solution, proteolytic enzymes: trypsin, chymotrypsin, mucolytic drugs: acetylcysteine),

4) antibiotics, which occupy a leading place in the treatment of purulent complications of the tracheobronchial tree,

5) bronchospasmolytics (for relief of bronchospasm, 5-10 ml of 2.4% solution of aminophylline is administered),

6) hormonal preparations (for swelling of the mucous membrane, it is irrigated with 125 mg of a suspension of hydrocortisone).

Due to the rapid self-cleaning of the mucous membrane, the number of bronchoscopies in those burned with a mild degree of PI is limited to one diagnostic and one control. Medical bronchoscopy is performed daily for those suffering from severe thermochemical damage, and those on mechanical ventilation with a complete impaired drainage function - twice a day after 8-10 hours. When normal respiratory function is achieved without hardware support, the victim is extubated.

Carrying out such intensive therapy in mildly burned burners takes 4-5 days, a moderate degree - 1-2 weeks, a severe degree - 2-3 weeks, while simultaneously treating burns of the skin. And yet, despite the implementation of intensive care, the survivability of the victims is not high: with mild and moderate degrees, it is 70-80%, with severe - 20%.

The technical result of the present invention is to increase the survival of patients with PI due to the use of surfactant-BL in the treatment regimen.

This result is achieved by the fact that in the known method of treating PI by conducting traditional therapeutic measures, including bronchoalveolar lavage, and when normal respiratory function is achieved without hardware support, the patient is extubated according to the invention with an oxygenation index below 300 mm Hg. lavage is carried out by means of 5-10 mg of surfactant-BL dissolved in 5-10 ml of physiological solution, after which 65-70 mg of surfactant-BL in 4-5 ml of physiological saline is bolus injected into each main bronchus, repeating these procedures every 12 hours within 2-3 days.

Carrying out bronchoalveolar lavage using surfactant-BL ensures the adsorption of toxic substances, soot and secretion (in addition to their mechanical washing off) due to the huge sorption surface area of the particles of the emulsion of this liposome preparation, and its subsequent introduction into the bronchi helps to restore many local functions inherent in native pulmonary surfactant ( restoration of local immunity, protection of the structure and function of the bronchoalveolar epithelium and stimulation of the synthesis of its own surfactant, which is not possible is to provide any other drug), and thus - recovery of bronchoalveolar epithelial respiratory surface structure and lungs. Since exudate accumulates in the alveoli during PI, namely PDP, which increases the barrier between blood and air, as a result of which respiratory function is impaired, the introduction of surfactant-BL, as we have shown, eliminates intraalveolar edema and exudate from the alveoli in almost a few hours, restores the gas composition of the blood and normalizes impaired respiratory function, preventing the development of diffuse atelectasis, pneumonia and adult dystrophy syndrome. This allows you to save the victim independent breathing with minimal hardware support, and when using mechanical ventilation to carry out earlier extubation of the patient.

The use of lavage with surfactant-BL with an oxygenation index value below 300 mm Hg allows you to prevent the development of acute pulmonary injury syndrome and thereby increase the survival of this heavy contingent of patients. The oxygenation index (OI) is the ratio of the pO _2a value (partial pressure of oxygen in arterial blood) to the FiO ₂ value (oxygen concentration in the inhaled air-gas mixture in%), and normally its value is 360-400 mm Hg. and more.

The use of burnt surfactant-BL in the treatment regimen for the first time allowed us to save all patients (by now there were 7 of them) with such a severe lesion of DP, with which they had previously died. The treatment regimes we declare (the amount of surfactant-BL, the frequency and timing of its administration) were found by us empirically.

Previously, surfactant-BL was used by us in the treatment of pulmonary tuberculosis (patent 2195313), acute lung injury syndrome with extended surgical interventions (patent 2195958), respiratory failure in critical conditions in children (patent 2149017), adult respiratory distress syndrome (patent 2149016) , postnatal pneumonia in newborns (patent 2149015), acute bronchopneumonia complicated by atelectasis (patent 2149014), in modes specially designed for this. For the treatment of PI, surfactant-BL was proposed by us for the first time and, as shown by its clinical testing, ensured high survival of the burned.

The essence of the proposed method is illustrated by example.

EXAMPLE

By-P., 18 years old (medical history No. 24522) was delivered from the fire site by the ambulance crew to the clinic of thermal injuries of the Military Medical Academy on 13.05.05.09.2002, 1 hour after an injury in shock with burns to the head and trunk and upper limbs II-IIIA degree on an area of 44% of the body surface.

Using direct laryngoscopy, hyperemia of the mucous membrane of the upper respiratory tract and soot on it were detected. General condition was regarded as severe, unstable. The patient was hospitalized in the intensive care unit and intensive care with the diagnosis: “Multifactorial lesion. Burn with a flame of 44% / II-IIIA degree of the face, trunk, upper limbs. Burn of the upper respiratory tract II degree. Thermochemical damage to the respiratory tract by severe combustion products. Burn shock. Carbon monoxide poisoning. ”

According to the results of the examination: general blood test: red blood cells - 3.4 × 10 ¹² / l, hematocrit - 36 l / l, hemoglobin - 120 g / l, white blood cells -12.1 × 10 ⁹ / l, ESR - 23 mm / h ; pH _a = 7.3, pO _2a = 94 mm Hg, pCO _2a (partial pressure of carbon dioxide in arterial blood) = 37.5 mm Hg, HbO _2a (saturation of hemoglobin with arterial oxygen) = 96% , НbСО (carboxyhemoglobin) = 30%, IO - 279 mmHg

According to the integral rheography of the body, the stroke volume of the blood circulation is 42.2 ml, the stroke index is 28.3 ml / m ² , the minute blood volume is 6.2 l / min, the cardiac index is 4.1 l / min × m ² , heart rate (heart rate) - 145 / min, BH (respiration rate) - 20 / min, CDI (coefficient of respiratory changes) - 1.25, CIT (coefficient of integral tonicity) - 74.2.

The patient was intubated with trachea, the superior vena cava was catheterized, and comprehensive anti-shock infusion-transfusion therapy with glucose-salt and native colloid solutions was performed (within 48 hours).

Respiratory therapy was carried out using the apparatus “NELLICOR PURITAN BENNET-760” (USA) in the spontaneous breathing mode with pressure support - 5 cm water column, PEEP (positive pressure at the end of expiration) - 5 cm water column, respiratory volume 350 ml, minute ventilation 6.5 l FiO ₂ - 30%. Tactics of respiratory therapy determined the provision of parameters with the minimum aggressiveness possible to maintain normopnea and gas composition of the blood. Temporary ventilation was performed with inversion of the respiratory cycle (inspiratory / expiratory ratio reached 1.2 / 1).

Given the instability of hemodynamics (low stroke volume, tachycardia), inotropic support of the myocardium with dopamine at a dose of 5 μg / kg / min was started from the first hour of treatment.

Diagnostic fibrobronchoscopy was performed, in which the trachea, main and segmental bronchi were covered with a total mucosal coating with hard to wash soot, while trying to wash it, the whitish bleeding mucous membrane was exposed, and the mosaic of the affected mucosa was determined: areas of the brightly hyperemic and edematous mucous membrane of the trachea and bronchi were significantly dominated areas of healthy mucosa, multiple erosion of the mucous membrane was determined, abundant separation was observed with discord with isolated sputum casts of the small bronchi. All this testified to the severity of the inhalation lesion and the development of severe erosive tracheobronchitis.

Despite the ongoing complex of treatment measures by the second day, the condition of the victim progressively worsened. The amount of sputum was large enough, but it was viscous and difficult to separate with a lot of soot. The stroke volume of blood circulation according to the integral rheography of the body is 31.1 ml, the stroke index is 18.3 ml / m ² , the minute blood volume is 3.8 l / min, the cardiac index is 2.23 l / min × m ² , heart rate - 122 / min, BH - 20 / min, CDI - 12.25, CIT - 76.6. When breathing a mixture with FiO ₂ = 40%, the blood gases were: pO _2a = 86.0, pCO _2a = 31.0, HbO _2a = 95.4%, against the background of respiratory support: pressure - 12-16 cm water ., PDKV - up to 12 cm Hg, IO - 215 mm Hg. The severity of the condition of the victim was determined by the increasing effects of respiratory failure on the background of subtotal damage to the respiratory tract by combustion products.

In this regard, rehabilitation fibrobronchoscopy was performed and lavage with surfactant-BL was performed, for which each of 2 bottles with 75 mg was dissolved in 5 ml of physiological saline and 0.6 ml (9 mg) was diluted with 10 ml of saline and used solutions for the rehabilitation of the bronchi. The remaining 4.4 ml of dissolved surfactant-BL (66 mg of drug) remaining in each vial was bolus injected into both main bronchi, using 150 mg of surfactant-BL for the procedure.

After this procedure, performed on the second day, it was possible to reduce the pressure support to 2 cm aq. and PEEP - up to 1 cm aq, and FiO ₂ - up to 35%. In this case, pO _2a rose to 105, and HbO _2a to 98.5, pCO _2a - 33.9, IO - 300 mm Hg.

However, the patient's condition remained unstable, which was manifested by periodic aggravation of the phenomena of respiratory failure.

After 12 hours, lavage with surfactant-BL was repeated, using 6 mg of the drug from each vial for this, after which 69 mg in 5 ml of physiological saline was injected into each main bronchus (150 mg of surfactant in total). A total of 5 injections of the drug were performed (in three days the patient received 750 mg), each after 12 hours. As a result of this persistent improvement in the patient's condition (stabilization of the blood gas composition and normalization of cardiac activity), it was possible to achieve by the seventh day, after which the trachea was extubated. 15 days after admission, the patient was transferred to the general department, and 33 days after the final epithelization of burn wounds, she was discharged from the clinic of thermal lesions.

Conclusion: only due to the use of surfactant-BL in the treatment regimen it was possible to save the patient, to restore respiratory function on the third day, which made it possible to perform tracheal extubation on the seventh day.

To date, the proposed method has treated 7 injured in fires of persons brought to the Department of Thermal Damage of the Military Medical Academy named after S.M. Kirova (St. Petersburg) in critical condition, and everyone was saved, while previously such patients died.

Compared with the known methods of treating IP, we have a number of significant advantages.

1. Ensures high survival - so far we have managed to save the lives of all victims with an extremely severe degree of damage, which we could not help earlier. According to well-known sources, the survival rate of such patients is no more than 20%.

2. Significantly reduces the time of treatment - the restoration of respiratory function occurs within 2-3 days in the most severe patients, who during this time, as a rule, died. Of the 20% of survivors with standard therapy, such a positive therapeutic effect can be achieved only within 2-3 weeks.

3. In almost a few hours, it ensures the restoration of the gas composition of the blood and the normalization of respiratory function, while in the prototype method this result is achieved within a few days. A persistent improvement occurs within 7-10 days, in the prototype it takes 2-3 weeks.

4. Allows you to maintain independent breathing of the patient with minimal hardware support, while conventional therapy requires mechanical ventilation, and in patients on mechanical ventilation, earlier extubation is achieved.

The method is developed in the department of anesthesiology, intensive care and intensive care of the department of thermal lesions of the Military Medical Academy. S.M. Kirova, together with TsNIRRI, underwent clinical testing in 7 patients with a positive result.

Claims (1)

A method for the treatment of inhalation lesions through traditional therapeutic measures, including bronchoalveolar lavage, and when normal respiratory function is achieved without hardware support, the patient is extubated, characterized in that when the oxygenation index value is below 300 mm Hg lavage is carried out by means of 5-10 mg of surfactant-BL dissolved in 5-10 ml of physiological solution, after which 65-70 mg of surfactant-BL in 4-5 ml of physiological saline is bolus injected into each main bronchus, repeating these procedures every 12 hours within 2-3 days.