RU2476885C1 - Method for prediction of length of artificial pulmonary ventilation in patients with severe guillain-barret disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: patient's blood serum is examined for tau protein and glial fibrillary acidic Protein. If the first value is more than 114 pc/ml and the other value is more than 0.2 pc/ml respectively, a long, min. 8-day APV requiring application of tracheostoma is predicted. If the first value is 114 pc/ml or less, and the other value is 0.2 pc/ml or less, APV is predicted for a number of days 2 to 7 requiring no tracheostoma.

EFFECT: method enables fast and accurate diagnosing the length of artificial pulmonary ventilation.

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Description

The invention relates to medicine, in particular to neurology, and can be used to predict the duration of mechanical ventilation (mechanical ventilation) in severe Guillain-Barré syndrome (GBS).

Guillain-Barré syndrome is an acute autoimmune polyneuropathy that progresses within no more than four weeks and leads in severe cases to the development of respiratory failure and bulbar disorders. Severe cases are considered, accompanied by gross paresis of the extremities, respiratory and bulbar disorders. The function of the pharynx, larynx, tongue suffers. Turning off or weakening the function of the respiratory muscles, leading to respiratory failure, in most patients develops after involving the muscles of the arms and legs in the pathological process. The motor function of the respiratory muscles is also disturbed gradually, from 1-2 days to 2-3 weeks. In the event of a significant decrease in vital lung capacity (VC), less than 50% of the proper values, patients need resuscitation measures - artificial lung ventilation (IVL). Mechanical ventilation helps patients survive the critical stage of the disease. To date, in Russia, many patients with severe Guillain-Barré syndrome have severe consequences of untimely resuscitation care due to the lack of prognostic criteria at the early stage of the disease (on the first day), providing a prediction of the development of respiratory and bulbar disorders.

In the treatment of severe forms of the disease, a revolutionary coup occurred in the early 50s with the introduction into clinical practice of methods of mechanical ventilation (mechanical ventilation), which allowed to reduce mortality by 10-15 times. It is important to timely detect the initial signs of respiratory failure so as not to be late with mechanical ventilation. In the stage of increasing paralysis, monitoring of respiratory functions is necessary. With a decrease in vital capacity of the lungs to 50% or less, respiratory resuscitation is mandatory (M. Piradov Guillain-Barre Syndrome. In the book: Neurology. National Guide, Moscow, 2009, pp. 746-754).

The prior art method for predicting the duration of mechanical ventilation and intubation, which is recommended for a rapid decrease in lung capacity (VC), a violation of blood gases or the presence of symptoms such as dyspnea and tachycardia. Moreover, the attachment of axonal damage leads to a longer stay of patients on mechanical ventilation compared with the “pure” demyelinating forms (Newton-John J. Prevention of pulmonary complications in severe Guillain-Barre syndrome by early assisted ventilation., Med. J. Aust., 1985 ; 142: 444-445). This source of information is considered as the closest analogue.

However, a prognosis based on clinical signs does not provide early and accurate identification of long-term mechanical ventilation requiring tracheostomy. Its main drawback was the timing of application from the onset of the disease, whereas according to modern literature the advantages of early detection of the duration of mechanical ventilation requiring the application of a tracheostomy reduces the frequency of infections and pulmonary complications. Thus, the existing prognostic criteria do not allow timely and fully form the idea of the course of the disease and the development of general muscle weakness, which is the main cause of difficulties in stopping mechanical ventilation and indications for tracheostomy.

The technical result of the developed method for predicting the duration of mechanical ventilation in severe Guillain-Barré syndrome is that the biomarkers used to predict the first days of the disease with high sensitivity and specificity can predict the development of both prolonged mechanical ventilation requiring tracheostomy and mechanical ventilation during several days, and not requiring tracheostomy.

The technical result is achieved by the fact that in order to predict the duration of mechanical ventilation in patients with severe Guillain-Barré form, a blood test is performed, and the level of tau protein and gliofibrillar acid protein (GFAP) is determined in the patient’s blood serum by means of an enzyme-linked immunosorbent assay and if the first indicator is more than 114 pc / ml, and the second indicator is more than 0.2 pc / ml, respectively, predict a long, at least 8 days, mechanical ventilation, requiring tracheostomy, and if the first indicator is less than or equal to 114 pc / ml and the second indicator is less than or equal to 0.2 pc / ml; mechanical ventilation is predicted for several days from 2 to 7 and does not require tracheostomy.

The method is as follows.

Upon receipt of a patient with complaints of difficulty breathing and swallowing, weakness in the arms and legs, muscles of the face, neck and torso, inability to turn in bed from side to side, they are examined. Clinically, palpation reveals soreness of the nerve trunks, a positive symptom of Laseg. In some cases, the patient is particularly affected by proprioceptive sensitivity, which is manifested by sensitive ataxia. Tendon reflexes are reduced or completely extinguished; the cranial nerves and most often the facial nerve from one or two sides are involved in the pathological process. These signs indicate that the patient has severe Guillain-Barré syndrome. In this regard, at the time of admission, the patient is sampled and the serum is determined for the content of tau protein and gliofibrillar acid protein using the ELISA method (Enzyme-Linked Immunosorbent Assay) using R&D Systems reagents (USA, Canada) and BioVender (Greece).

The principle of the technology for determining tau protein is based on the use of the "Sandwich" method of enzyme-linked immunosorbent assay. Polyclonal chicken antibodies specific for anti-tau are adsorbed in the wells of the microplate. Standards and controls with known concentration and samples are added to the wells of the microplate. During the first incubation (60 min), the antigen binds to immobilized antibodies in the wells (“exciting”). After washing, tau-specific rabbit antibodies are added to the wells. During the second incubation, these antibodies serve as detecting antibodies, binding to immobilized (due to binding to "capture" antibodies during the first incubation) tau. After removing the excess of detecting antibodies, anti-rabbit antibodies conjugated to horseradish peroxidase are added to the wells. They bind to detecting antibodies with the formation of a sandwich complex of 4 components. After the third incubation and washing, excess antibody is removed, after which a substrate solution is added, which interacts with the enzyme to form a color complex. The color intensity of the solution is directly proportional to the concentration of human tau present in the sample. The measurement was carried out on an immunoenzyme microplate reader Victor 2 from PerkinElmer (USA) at a wavelength of 450 nm.

The principle of the GFAP determination method is based on the use of the "Sandwich" enzyme-linked immunosorbent assay (ELISE). Standards and controls with known concentrations, as well as samples, are incubated (120 min) in microplate cells coated with polyclonal antibodies specific for anti-GFAP. During the first incubation, antibodies sorbed on the wells of the microplate capture GFAP. Unbound material present in the sample is removed during washing. Next, biotin-conjugated anti-GFAP antibodies are introduced into the cells, incubated for 60 minutes, then washed. Horseradish peroxidase-conjugated streptavidin (streptavadin-peroxidase), which specifically reacts with biotinylated antibodies bound to the captured during the first incubation of GFAP, is introduced into the cells. Excess streptavadin peroxidase is removed by washing and a substrate (tetramethylbenzidine) is added to the wells. Color develops in proportion to the amount of GFAP in the sample. The enzymatic reaction is stopped by adding citric acid. Then using a microplate reader measure the absorption at a wavelength of 450 nm.

If the level of tau protein in the patient's blood serum is higher than 114 pc / ml and gliofibrillar acid protein is higher than 0.2 pc / ml, a prolonged, at least 8 days, mechanical ventilation is required, requiring tracheostomy. If the tau protein level is less than or equal to 114 pc / ml and gliofibrillar acidic protein is less than or equal to 0.2 pc / ml, mechanical ventilation is predicted for several days from 2 to 7 and does not require tracheostomy.

Clinical examples illustrating the possibility of applying the definition of tau protein and gliofibrillar acid protein to predict the duration of mechanical ventilation in severe Guillain-Barré syndrome.

Example 1. Patient X., 42 years old, was admitted to the FSBI "NTSN" RAMS with complaints of weakness in the arms and legs, double vision, respiratory failure and swallowing. Upon admission in neurological status, oculomotor disorders, weakness of the facial muscles, flaccid, gross tetraparesis, mainly of the proximal type, tendon reflection, disturbances of superficial and deep sensitivity of the polyneuritic type were noted. Vital lung capacity reduced to 50%. Based on the clinical and neurophysiological examination, the diagnosis was made: "Guillain-Barré syndrome of severe form." The patient is on mechanical ventilation. On the first day of admission, the patient's blood serum was examined for the presence of the tau protein level and the level of gliofibrillar acid protein in it, which amounted to tau protein 67 pg / ml (<114 pg / ml), gliofibrillar acid protein - 0.190 pg / ml (<0.2 pc / ml). This involves holding mechanical ventilation for several days without tracheostomy. During the course of treatment and finding the patient on mechanical ventilation, there was no need for a tracheostomy. Program plasmapheresis was performed, resulting in a regression of neurological symptoms: oculomotor disturbances and sensory ataxia regressed, walking improved, tendon reflexes came to life. On the 7th day of mechanical ventilation in connection with the restoration of the strength of the respiratory muscles, the patient was transferred to independent breathing and on the 8th day was extubated.

Example 2. Patient Z., 70 years old, was admitted to the ICU "NCH" RAMS ICU with complaints of weakness in the arms and legs, inability to turn in bed from side to side. In neurological status, flaccid tetraplegia, tendon areflexia, weakness of the facial muscles, neck and trunk muscles were noted. Vital lung capacity at admission 70%. Based on the clinical and neurophysiological examination, the diagnosis was made: "Guillain-Barré syndrome of severe form." On the first day of admission, the patient's blood serum was examined for the presence of the tau protein level and the level of gliofibrillar acid protein in it, which amounted to 167 pg / ml tau protein (> 114 pg / ml), gliofibrillar acid protein - 0.340 pg / ml (> 0.2 pc / ml). This suggests prolonged mechanical ventilation and tracheostomy. Against the background of the treatment, a gradual decrease in lung vital capacity to 43% was noted, trachea was intubated, mechanical ventilation was started. On the 9th day of mechanical ventilation, an operation was performed on the upper median tracheostomy. The duration of mechanical ventilation in this patient was 86 days.

Using the example of 10 patients with severe GBS, it was shown that biomarkers of tau protein and gliofibrillar acid protein allow predicting the duration of mechanical ventilation and indications for tracheostomy in the early days of the disease with high sensitivity and specificity.

Blood samples were taken from all patients included in the study, which were frozen for 2 hours at -56 ° C in Eppendorf type tubes. Patients were divided into groups in accordance with the presence of clinical manifestations of GBS of interest (respiratory failure and mechanical ventilation, requiring tracheostomy or without it).

The first group included patients whose ventilation was short (from 2 to 7 days), tracheostomy was not required, and respiratory failure regressed within a few days after plasmapheresis. The second group included patients whose respiratory muscle strength was restored extremely slowly, which required the application of a tracheostomy and a long mechanical ventilation (from 8 days or more). In all patients of the second group, the level of tau protein in the blood serum was 114 pc / ml and higher, and the level of gliofibrillar acid protein was 0.2 pc / ml and higher in comparison with the first group - short mechanical ventilation. The level of tau protein in the blood serum of the first group was less than 114 pc / ml, and the level of gliofibrillar acid protein was less than 0.2 pc / ml.

Thus, the determination of biomarkers of tau protein and gliofibrillar acidic protein in the blood serum of patients with severe GBS allows predicting the duration of mechanical ventilation and indications for tracheostomy in the first days of the disease with high reliability (p = 0.0002).

The introduction of the indicated method into routine practice will make it possible to predict with confidence the course of GBS and plan tactics for the management of severe patients. Rationally planned tactics of managing patients with respiratory musculature disorders will avoid many complications and reduce treatment costs.

Claims (1)

A method for predicting the duration of artificial lung ventilation (IVL) in patients with severe Guillain-Barré, including a blood test, characterized in that the level of tau protein and gliofibrillar acid protein is determined in the patient’s blood serum using an enzyme-linked immunosorbent assay and when the value of the first indicator is more 114 pc / ml and a second indicator of more than 0.2 pc / ml, respectively, predict a prolonged, at least 8 days, mechanical ventilation, requiring the application of a tracheostomy, and with the value of the first indicator its equal to 114 pc / ml and the second - less than or equal to 0.2 pc / ml predict the conduct of mechanical ventilation for several days from 2 to 7 and does not require tracheostomy.