RU2326670C1 - Method of complex intensive therapy of children acute stenosing laryngotracheitis - Google Patents

Abstract

FIELD: medicine; pediatry.

SUBSTANCE: treatment staged larynx stenosis compensation is performed. Medicinal agents are introduced through inhalations by means of nebulyser. For this purpose pulmycort, lasolvane and physiological solution of 0.9% sodium chlorides are used. Children with body weight less than 20 kg take inhalations of pulmycort dosed 250 mcg twice within one hour and then dosed 250 mcg every 12 hours. Lasolvan is inhaled in dose 7.5 mg every 8 hours. Physiological solution 0.9% is inhaled in dose of 5.0 ml every 6 hours of therapy course. Then inhalations are taken every 2 hours during first day. Then Inhalations are taken every 3 hours until laryngotracheitis symptoms stop. Children with body weight more than 20 kg are given wit double dose of pulmycort and lasolvan.

EFFECT: This therapy enables to avoid tracheostomy, to stop stenosis of compensation stage and to prevent progress of acute respiratory compromise, to reduce necessity of system glucorticosteroids and to decrease reanimation therapy period.

2 ex.

Description

The invention relates to medicine, in particular to anesthesiology and intensive care, and pediatrics.

Acute stenosing laryngotracheitis in children belongs to the category of life-threatening conditions requiring urgent medical and diagnostic intervention. The peculiarities of acute stenosing laryngotracheitis in children are the polyetiology of this condition, the predominant occurrence at an early age, and a rapid increase in the picture of respiratory failure. Despite many years of research experience in the field of pediatrics, intensive care and resuscitation, the treatment of children with stenotic laryngotracheitis is a complex and far from resolving problem. Mortality among children with acute stenosing laryngotracheitis ranges from 0.4 to 5%, and with the development of the terminal stage of laryngeal stenosis reaches 70%. At the same time, today there is no single approach to the treatment of acute stenosing laryngotracheitis in children, the current Russian literature does not adequately cover the issues and possibilities of inhalation nebulizer therapy of this condition, there is no clear preventive treatment in the stage of stenosis compensation.

A known method of complex intensive care of stenosing laryngotracheitis in children, including inhalation of moistened oxygen, an oxygen-helium mixture, a racemic adrenaline aerosol with a nebulizer and tracheal intubation with worsening condition and decompensation of stenosis [Karpov V.V., Safonenko L.A. Acute and recurrent stenosing laryngotracheitis in children. - Rostov-on-Don. - 1999. - P.19].

The disadvantages of this method are the lack of criteria for the appointment and frequency of use of a particular drug, side effects of activation of the sympathoadrenal system (tachycardia, agitation, arterial hypertension, cardiac arrhythmias) caused by the use of racemic adrenaline, as well as a high degree of likelihood of subsequent tracheostomy during tracheal intubation for resolution stenosis.

A known method of complex intensive care of stenosing laryngotracheitis in children, including vapor-oxygen inhalation, inhalation of a 5% solution of ephedrine, a suspension of hydrocortisone, a 1% solution of diphenhydramine, a 0.5% solution of sodium bicarbonate [Veltishchev Yu.E., Belozerov Yu.M., Kobrinsky B .BUT. and others. Emergency conditions in children (handbook). - M.: Medicine. - 1994. - P.121].

The disadvantages of this method are the pathogenetic unfoundedness of the use of ephedrine and diphenhydramine, side effects of ephedrine, similar to those when using racemic epinephrine, as well as the inability to use the method at the prehospital stage due to the cumbersomeness of the tent for oxygen vapor inhalation.

Closest to the claimed is a method of complex intensive care of stenosing laryngotracheitis in children, including inhalation of moistened oxygen, an oxygen-helium mixture, a racemic adrenaline aerosol using a nebulizer, the introduction of corticosteroid drugs (oral, parenteral and inhalation) [Avdeev S.N. Pulmicort suspension nebulizer therapy: a place in the treatment of respiratory diseases. Toolkit for doctors. - M., 2004. - 32 p.]

The disadvantages of this method are the lack of criteria for the appointment and frequency of use of a drug, depending on the degree of compensation of stenosing laryngotracheitis, as well as side effects of activation of the sympathoadrenal system (tachycardia, agitation, hypertension, cardiac arrhythmias) caused by the use of racemic adrenaline, systemic side effects administered corticosteroids (hyperadrogenemia syndrome, steroid ulcers, thrombocytopenia, hyperaldosteronism).

The objectives of this invention: to optimize the comprehensive intensive care of acute stenosing laryngotracheitis in children, taking into account the pathogenetic mechanisms of the development of the disease, to reduce the severity of side effects from drug therapy (glucocorticosteroids and sympathomimetics), to ensure the availability of treatment at any stage of care, to avoid tracheal intubation and tracheostomy.

The problem is achieved by the method of complex intensive therapy of acute stenosing laryngotracheitis in children, including the inhalation of medications with a nebulizer. The treatment is carried out in the stage of compensation of stenosis of the larynx, pulmicort, lazolvan, physiological solution of sodium chloride 0.9% are used as drugs. In this case, children with a body weight of up to 20 kg are inhaled with a pulmicort of 250 micrograms twice a hour, then 250 micrograms every 12 hours. Lazolvan is inhaled 7.5 mg every 8 hours. A 0.9% saline solution is inhaled with 5.0 ml hourly in the first 6 hours of therapy, then every 2 hours during the first day, then every 3 hours until the symptoms of laryngotracheitis are stopped. For children weighing more than 20 kg, the dose of pulmicort and lazolvan is doubled.

The novelty of the method:

1. Treatment is carried out in the stage of compensation of laryngeal stenosis, that is, therapy is prophylactic in order to prevent decompensation of acute respiratory failure and the transition to more aggressive therapy (intubation of the trachea and tracheostomy).

2. Pulmicort (budesonide), lazolvan (ambroxol), and physiological saline sodium chloride 0.9% are used as drugs. This set of drugs is used in the stage of compensation for tracheal stenosis, since in the sum of their actions they have the effect of treating and preventing subsequent decompensation of stenosis, which avoids tracheal intubation and tracheostomy. At the same time, a three-component system of drugs allows you to achieve: a pulmonary cortex reduces mucosal edema due to its membrane-stabilizing effect and corrects a spasm of smooth muscles of the upper respiratory tract, which reduces their aerodynamic resistance; lazolvan is a mucolytic drug, that is, it improves the rheology of the secretion of the upper respiratory tract and the process of discharge in the process of coughing; saline solution can improve the hydration of the saline layer of the secretion of the tracheobronchial tree, which helps to thin the sputum and improves its discharge. The three-component system of drugs provides a comprehensive effect on the following links of the disease: swelling of the mucous membrane, impaired sputum discharge with a deterioration in its rheology (fluidity), smooth muscle spasm. The drugs have potentiating effects, that is, the effect of mutual enhancement of action.

3. At the same time, children with a body weight of up to 20 kg are inhaled with a pulmicort of 250 micrograms twice a hour, then 250 micrograms every 12 hours. This action reduces the swelling of the mucosa due to its membrane-stabilizing effect and corrects the spasm of the smooth muscles of the upper respiratory tract, which reduces their aerodynamic resistance and eliminates obstructive respiratory failure.

4. Children weighing up to 20 kg are inhaled with 7.5 mg lazolvan every 8 hours. Lazolvan is a mucolytic drug, that is, it improves the rheology of the secretion of the upper respiratory tract and the process of discharge in the process of coughing.

5. Inhalation of 0.9% saline in 5.0 ml hourly in the first 6 hours of therapy, then every 2 hours during the first day, then every 3 hours until the symptoms of laryngotracheitis are stopped. They improve hydration of the saline layer of the secretion of the tracheobronchial tree, which helps to thin the sputum and improve its discharge.

6. For children weighing more than 20 kg, the dose of pulmicort and lazolvan is increased by 2 times, taking into account the age dosage of the drugs.

The method is as follows. Upon admission to the intensive care unit, the patient is weighed to determine the dosage of the drug and infusion therapy. The degree of compensation for stenosis and acute respiratory failure is determined by the following criteria: respiratory rate per minute, shortness of breath with difficulty breathing in and out, participation in the work of auxiliary respiratory muscles (nose wings, shoulder muscles), skin color, heart rate, oxygen saturation of hemoglobin , level of consciousness. In the case of ascertaining the stage of compensation for acute stenosing laryngotracheitis (the frequency does not go beyond the age norm at 10 breaths per minute, there is no work of auxiliary muscles, cyanosis of the nasolabial triangle, there are signs of difficulty breathing in - stridor breathing, hemoglobin oxygen saturation within 95%) for children with mass body up to 20 kg, a pulmicort of 250 mcg is prescribed twice a hour, then 250 mcg every 12 hours until the stenosis of the larynx is stopped in the form of nebulizer therapy. Use a nebulizer inhaler (Omron, Monsoon) without an ultrasonic atomization source in order to avoid disturbance in the formation of aerosol particles. Lazolvan is administered at 7.5 mg every 8 hours until the symptoms of laryngotracheitis are relieved. Inhalation of 0.9% saline solution in 5.0 ml is carried out hourly in the first 6 hours of therapy, then every 2 hours during the first day, then every 3 hours until the symptoms of laryngotracheitis are stopped, that is, until the respiratory rate decreases, the severity of tachycardia, normalization of quality inhalation and exhalation, relief of stridor breath, increase hemoglobin oxygen saturation up to 99%.

For children weighing more than 20 kg with acute stenosing laryngotracheitis in the stage of compensation and incomplete compensation, a single dose of pulmicort increases to 500 mcg; a single dose of lazolvan increases to 15 mg; single dose of 0.9% saline 5.0 ml; the frequency of administration is similar to that in children weighing up to 20 kg. Signs of relief of acute stenosing laryngotracheitis and the end of the procedure are described above.

Example 1. Patient G., No. East. bol. 71, 3 years (body weight 15 kg) was admitted to the Children's Clinical Hospital No. 1 of Kemerovo, intensive care unit 12/30/05 with a diagnosis of SARS. Recurrent laryngotracheitis, option II, continuous course. Laryngeal stenosis in the stage of compensation. The condition at admission is serious due to acute respiratory failure of the II degree (shortness of breath per minute 30, cyanosis of the nasolabial triangle, tachycardia to 120 per minute, decrease in hemoglobin oxygen saturation to 95%), intoxication syndrome (hyperthermia to 38 ° C, tachycardia, leukocytosis). Complex inhalation nebulizer therapy was carried out: pulmicort 250 mcg twice per hour, then every 12 hours for 2 days, lazolvan 7.5 mg every 8 hours for 4 days, 0.9% saline solution - 5.0 ml hourly during the first 6 hours, then every 2 hours during the first day, then every 3 hours for 2.5 days. Syndromes of laryngotracheitis are stopped. Oral rehydration was performed in the amount of 1.5 liters per day. Laryngeal stenosis is completely stopped by the end of 2 days. On day 3, the patient was transferred to the department of older childhood. Discharged home in satisfactory condition on the 4th day.

Example 2. Patient N., no. bol. 332, 4 years (body weight 23 kg) was admitted to the Children's Clinical Hospital No. 1 of Kemerovo, intensive care unit 01/21/06 with a diagnosis of SARS. Recurrent laryngotracheitis, option II, continuous course. Laryngeal stenosis in the stage of compensation. The condition at admission is serious due to acute respiratory failure of the first degree (shortness of breath 28 min, tachycardia up to 110 min, stridor breathing), intoxication syndrome (hyperthermia up to 38.8 ° C). A comprehensive inhalation nebulizer therapy was carried out: pulmicort 500 mcg twice per hour, then every 12 hours during the day, 15 mg of lazolvan every 8 hours for 4 days, 0.9% saline - 5.0 ml hourly during the first 6- hours, then every 2 hours during the first day, then every 3 hours for 3 days. Syndromes of laryngotracheitis are stopped. Oral rehydration was performed in the amount of 1.7 liters per day. Laryngeal stenosis is completely stopped by the end of 1 day. On day 2, the patient was transferred to the department of older childhood. Discharged home in satisfactory condition on the 7th day.

With this method, more than 200 patients with various body weights were treated in children's clinical hospitals in Kemerovo. The cause of acute stenosing laryngotracheitis in 90% of cases was acute respiratory viral infections.

The use of other types of treatment in 50% of cases led to the transition of acute stenosing laryngotracheitis from the stage of compensation to the stage of incomplete compensation (64%) or decompensation (36%). Decompensation of stenosis of the larynx and trachea led to the need to use: systemic corticosteroids intravenously and intramuscularly in 41% of cases, and in 12% - to tracheal intubation and subsequent tracheostomy.

The use of a new method of complex intensive therapy of acute stenosing laryngotracheitis in children made it possible to completely avoid tracheostomy, in 80% of treated children to stop stenosis at the compensation stage and to avoid the progression of acute respiratory failure. In addition, the method has reduced the need for the introduction of systemic glucorticoids by 35% of the original. The length of stay in the intensive care unit decreased to 12-24 hours compared with 3 days, no fatal outcomes were noted.

The application of the method allowed to reduce the need for the use of systemic glucocorticosteroids (by 35% from previously used), to reduce the duration of intensive therapy of acute stenosing laryngotracheitis (by 1 day), to shorten the patient’s hospital stay (up to 3 days) and in the intensive care unit (up to 12 24 hours compared with 2-3 days when using old treatment regimens).

Claims (1)

A method of complex intensive therapy of acute stenosing laryngotracheitis in children, including inhalation of medications with a nebulizer, characterized in that the treatment is carried out in the stage of compensation of laryngeal stenosis, using pulmicort, lazolvan and physiological sodium chloride solution 0.9%, while children with a body weight of up to 20 kg, a pulmicort of 250 mcg is inhaled twice a hour, then 250 mcg every 12 hours, lazolvan is 7.5 mg every 8 hours, 0.9% saline solution is 5.0 ml hourly in the first 6 h t rapii, then every 2 hours during the first day, then every 3 hours until laryngotracheitis relief of symptoms for children weighing more than 20 kg dose pulmicort Mucosolvan and increased 2 times.