RU2443393C1 - Method for conducting bronchoalveolar lavage for treating patients suffering massive bronchial obstruction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely pulmonology, intensive care, and can be used for treating patients suffering massive bronchial obstruction. That is ensured by the 3-staged bronchoalveolar lavage. The 1st stage involves dry aspiration of the tracheobronchial secretions from a trachea and two primary bronchi - left and right, with no lavage medium introduced. The 2nd stage involves dry aspiration of the tracheobronchial secretions from lobar and segmental bronchi, with no lavage medium introduced. At the 3rd stage, a limited amount of the lavage medium is introduced by 10-20 ml per one segmental bronchial system. A total amount of the introduced lavage medium makes 50-100 ml.

EFFECT: method enables the safe bronchoalveolar lavage ensured by eliminating resorptive syndrome due to using a minimum amount of the lavage medium.

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Description

The invention relates to medicine, in particular to pulmonology and phthisiology, and is intended for bronchoalveolar lavage in patients with severe obstruction of the tracheobronchial tree with bronchial secretions.

Bronchoalveolar lavage is a necessary tool for the evacuation of pathologically altered viscous bronchial secretions, which is carried out during bronchoscopy. This is a necessary measure for various lung diseases (bronchial asthma, chronic obstructive pulmonary disease, pneumonia), when the mechanisms of natural drainage of the tracheobronchial tree when coughing are ineffective.

Bronchoalveolar lavage usually involves the introduction into the lumen of the lavage medium during bronchoscopy, necessary to dilute the bronchial secretion and reduce its viscosity. In parallel with the introduction of lavage fluid during bronchological benefits, there is a continuous aspiration of bronchial secretion, which, when diluted, is much easier to evacuate.

However, due to the physiological characteristics of the functioning of the tracheobronchial tree, it is possible to aspirate the introduced lavage fluid only by 70-75%. Accordingly, the more secretion in the bronchial tree (its accumulation can occur in various pathological conditions) or it has the worst rheological properties, i.e. increased viscosity, the lavish medium is usually used in a larger volume. This interferes with the normal gas exchange, contributes to the preservation of the oxygen debt of the body, despite the active evacuation of the secret, and in some cases it may increase.

Another negative point is increased absorption as a result of bronchoalveolar lavage of the contents of the tracheobronchial tree. The bronchial secret cannot be completely removed; it is only partially evacuated. The remaining secret, mixing with the non-removable part of the lavage medium, becomes less viscous, its rheological properties are significantly improved. As a result, absorption of the secretion in the tracheobronchial tree is enhanced. Along with it, various biologically active substances (decay products of pathogenic microorganisms, cells of desquamated bronchial epithelium, segmented white blood cells entering the lumen of the tracheobronchial tree for phagocytic function) enter the bloodstream. As a result, a resorptive syndrome develops, which can have a different degree of severity: from a moderate temperature reaction to severe encephalopathy with loss of consciousness. Moreover, the volume of medium introduced during lavage is approximately proportional to the severity of the resorptive syndrome.

There is a classic method of conducting bronchoalveolar lavage, which involves the simultaneous administration of 1500-2000 ml of lavage medium to thin the bronchial secretion, followed by a single aspiration [1].

The disadvantage of this method is too significant volume of lavage medium. This method was used only when conducting rigid subnestic bronchoscopy against the background of artificial ventilation of the lungs and complete drug-induced depression of consciousness. At present, the main method of bronchoscopy is bronchoscopy with flexible bronchoscopes (fibrobronchoscopy or digital bronchoscopy), performed under local anesthesia. With this variant of bronchoscopy, the use of such doses of the lavage medium is simply incompatible with life.

A known method of conducting bronchoalveolar lavage, designed specifically for bronchoscopy with flexible rather than rigid bronchoscopes. It consists in the sequential washing of each segmental bronchus with 10-20 ml of lavage medium with simultaneous removal of bronchial contents. Moreover, as a rule, lavage is carried out first in the bronchial pools of one lung, and then another. Given that the total number of segments is 19 (10 segments in the right lung and 9 in the left), the total amount of lavage medium ranges from 190 to 380 ml [2-5].

The disadvantages of this method are the development of a pronounced resorptive syndrome, which can be especially dangerous when performing fibrobronchoscopy in patients with encephalopathy, and a rather significant amount of lavage fluid that is not completely aspirated during bronchoalveolar lavage. This can be dangerous for patients with initial respiratory failure, which as a result of fibrobronchoscopy with lavage according to the described option, may increase.

The aim of the present invention is to develop such a method of bronchoalveolar lavage, which would have maximum safety in case of initially massive obstruction of the tracheobronchial tree with bronchial secretions.

This goal is achieved by the fact that bronchoalveolar lavage in patients with massive bronchial obstruction is carried out in 3 stages: at the 1st stage, “dry” aspiration is performed without introducing the lavage medium of the tracheobronchial contents from the trachea and 2 main bronchi - right and left; at the 2nd stage, “dry” aspiration is carried out without introducing a lavish environment of the tracheobronchial contents from the lobar and segmental bronchi; at the 3rd stage, a limited amount of lavage medium of 10-20 ml is administered per one lobar bronchial pool (the total amount of introduced lavage medium is 50-100 ml).

The proposed method of bronchoalveolar lavage in patients with massive bronchial obstruction is as follows.

Stage 1 begins with the passage of the flexible bronchoscope through the glottis. At the same time, an electric aspirator is connected, connected by a flexible tube to a bronchoscope. The vacuum circuit is turned on and aspiration of the tracheobronchial contents begins, first from the trachea, then from the main bronchi of the right and left lung. The sequence of removal of the bronchial secretion from the main bronchi is variable: they usually begin with the main bronchus, where a greater accumulation of secretion is visually determined. If the secret blocks the biopsy channel of the bronchoscope through which aspiration is performed, then the bronchoscope is removed and the channel is cleaned outside the tracheobronchial tree. The task of the 1st stage is to restore air flow along the main sections of the lower respiratory tract.

After this, the 2nd stage begins: “dry” aspiration without the introduction of a lavage medium is carried out in the lobar and segmental bronchi, and the lower-lobe bronchial pools are sanitized first, since the bronchial secretion accumulates therein in greater quantity due to natural anatomical features. The task of the 2nd stage is to evacuate the secret from the bronchi of the second and third orders (lobar and segmental). This stage completes the drainage of the proximal lower respiratory tract.

After this, the 3rd stage begins: the bronchoscope is alternately reintroduced into the lobar bronchi (a limited amount of lavage medium of 10-20 ml per one lobar bronchial pool is introduced); at the same time, aspiration of diluted bronchial secretion is carried out. The task of the 3rd stage is the evacuation of bronchial secretion from the distal lower respiratory tract, starting with subsegmental bronchi.

CLINICAL EXAMPLES

1. Patient T-va E.M. For 62 years she was hospitalized in the intensive care unit of the Moscow City Medical University No. 4 Samara City Hospital in an emergency with a diagnosis of Chronic obstructive pulmonary disease of a severe degree, proceeding mainly by the bronchitis type. Exacerbation phase. Severe bronchial asthma, steroid-dependent "Respiratory failure of the III degree. Chronic pulmonary heart in the phase of decompensation." Upon admission, there was an almost complete cessation of natural exposure, shortness of breath (number of respiratory movements - 31 '), severe cyanosis, a decrease in the level of oxygen saturation to 86-87%. Given the patient's clinical signs of increasing obstruction of the tracheobronchial tree with bronchial secretions and rapidly increasing respiratory failure, it was decided to conduct fibrobronchoscopy according to emergency indications. When conducting fibrobronchoscopy, a massive accumulation of purulent creamy secretions was found already in n / 3 of the trachea, the left main bronchus was completely obstructed with a purulent cork, and the right main bronchus was partially obstructed. During the 1st stage of bronchoalveolar lavage, the secret was evacuated from the trachea, then from the left main bronchus (initially it was completely obtuated with a bronchial secret), then from the right main bronchus. During the first stage, the bronchoscope had to be removed twice and mechanically restored to pass the biopsy canal. During the 2nd stage, the lower lobe of the right lung, the lower lobe of the left lung were sequentially drained; middle lobe of the right lung, upper lobe of the right lung and upper lobe of the left lung. As a result, the secret was almost completely evacuated from the trachea, as well as from the main, intermediate, lobar and segmental bronchi. During the 3rd stage of lavage, lavage medium (isotonic sodium chloride solution) with simultaneous aspiration of bronchial contents was introduced into the lobar pools in the following sequence: 20 ml in the lower lobe bronchus of the right lung, 15 ml in the lower lobe bronchus of the left lung, 10 ml in the middle lobe bronchus of the right lung, 15 ml - in the upper lobe bronchus of the right lung and 20 ml - in the upper lobe bronchus of the left lung. The patient felt a significant decrease in shortness of breath already during bronchoscopy. Manifestations of the resorptive syndrome were minimal, limited to a slight increase in temperature to 37.2 ° C 7 hours after bronchoscopy and did not require special medication correction. In a subsequent patient, a series of debridement bronchoscopies with therapeutic bronchoalveolar lavage was performed according to the described technique, which made it possible to stabilize the process and transfer the patient to the general department for further treatment.

2. Patient Mr. G.T., 49 years old, was hospitalized in the I-th pulmonology department of the Moscow City Medical University “Samara City Hospital No. 4” in an emergency with a diagnosis of severe bilateral lobar non-community-acquired pneumonia. Chronic obstructive pulmonary disease severe, proceeding mainly by the bronchitis type. Exacerbation phase. Respiratory failure of the III degree. Chronic pulmonary heart in the decompensation phase. Chronic alcoholism. Discirculatory encephalopathy. " Saturation of oxygen at rest and without oxygen supply did not exceed 85-86%; during auscultation, there was a sharp weakening of breathing, isolated wet rales. The patient was in a soporous state, contact with him was difficult. Given the patient's clinical signs of increasing obstruction of the tracheobronchial tree with bronchial secretions and rapidly growing respiratory failure, a decision was made to conduct fibrobronchoscopy according to emergency indications. When conducting fibrobronchoscopy, a massive accumulation of purulent-hemorrhagic secretion obstructing the n / 3 trachea, left and right main bronchi was found. During the 1st stage of bronchoalveolar lavage, the secret was evacuated from the trachea, then from the right main bronchus (the secret in the right main bronchus was more viscous), then from the left main bronchus. During the first stage, the bronchoscope had to be removed and mechanically restored to pass the biopsy canal three times. During the 2nd stage, the lower lobe of the right lung, the lower lobe of the left lung, the middle lobe of the right lung, the upper lobe of the right lung and the upper lobe of the left lung were sequentially drained. As a result, the secret was almost completely evacuated from the trachea, as well as the main, intermediate, lobar and segmental bronchi. During the 3rd stage of lavage, lavage medium (0.08% sodium hypochlorite) with simultaneous aspiration of bronchial contents was introduced into the lobar pools in the following sequence: 20 ml in the lower lobe bronchus of the right lung, 20 ml in the lower lobe bronchus of the left lung , 20 ml - in the middle lobe bronchus of the right lung, 20 ml - in the upper lobe bronchus of the right lung and 20 ml - in the upper lobe bronchus of the left lung. Within 7 hours after fibrobronchoscopy, the phenomena of discirculatory encephalopathy regressed: verbal contact with the patient became possible; he freely orientated in space, in time, in his own personality. Manifestations of a resorptive syndrome were practically absent. Subsequently, the patient underwent a series of debridement bronchoscopies with therapeutic bronchoalveolar lavage according to the described technique, which made it possible to stabilize the process, reduce shortness of breath, and restore self-exposure. The patient was transferred to the general department for further treatment.

Using the proposed method allows to level out such well-known negative effects of bronchoalveolar lavage as resorptive syndrome of various severity and impaired gas exchange due to the impossibility of complete aspiration of the introduced lavage medium [6, 7].

This option of bronchoalveolar lavage allows wider use of rehabilitation fibrobronchoscopy among patients with massive obstruction with bronchial secretion against various pulmonary pathologies.

The invention is possible and appropriate to apply in pulmonary departments, departments of thoracic surgery, as well as intensive care and intensive care units.

INFORMATION SOURCES

1. Thompson H.T., Prior W.J. Bronchial lavage in the treatment of obstructive lung disease. // Lancet. - 1964. - Vol.2, No. 7349. - P.8-10.

2. Chernekhovskaya N.E., Andreev V.G., Povalyaev A.V. Therapeutic bronchoscopy in the complex treatment of respiratory diseases. - MEDpress-inform. - 2008 .-- 128 s.

3. Clinical guidelines and indications for bronchoalveolar lavage: Report of the European Society of Pneumology Task Group on BAL. // Eup. Respir J. - 1990 - Vol. 3 - P.374-377.

4. Technical Recommendation and Guidelines for Bronchoalveolar Lavage. // Ibid. - 1989 .-- Vol. 3. - P.561-585.

5. Wiggins J. Bronchoalveolar lavage. Methodology and application. // Pulmonology. - 1991. - No. 3. - S. 43-46.

6. Luisetti M., Meloni F., Ballabio P., Leo G. Role of bronchial and bronchoalveolar lavage in chronic obstructive lung disease. // Monaldi Arch. Chest Dis. - 1993. - Vol. 48. - P.54-57.

7. Prakash U.B. Bronchoscopy. (In: Mason R.J., Broaddus V.C., Murray J.F., Nadel J.A., eds. Murray and Nadel's textbook respiratory medicine). 4-th ed. - Philadelphia: Elsevier Saunders. - 2005 .-- P.1617-1650.

Claims (1)

A method of conducting bronchoalveolar lavage for patients with massive obstruction with bronchial secretion, characterized in that the lavage is performed in 3 stages: at the 1st stage, “dry” aspiration is performed without introducing the lavage medium of the tracheobronchial contents from the trachea and 2 main bronchi - right and left; at the 2nd stage, “dry” aspiration is carried out without introducing a lavish environment of the tracheobronchial contents from the lobar and segmental bronchi; at the 3rd stage, a limited amount of lavage medium of 10-20 ml is administered per one lobar bronchial pool (the total amount of introduced lavage medium is 50-100 ml).