RU2645410C1 - Method for improving early functional neurologic recovery in patients with ischemic stroke and respiratory depression in sleep - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurology. Patient in acute stage of stroke with apnea/hypopnea index ≥ 15 events/hour, against background of drug therapy, for 7 days, during the night sleep from 22.00 to 7.00, raise the head end of the bed by 30 degrees and simultaneously carry out continuous insufflation of oxygen through the nose canula at a rate of 2–4 liters/min. At the same time, the tissue saturation level is maintained at a level of at least 95 %, which is controlled with a finger pulse oximeter.

EFFECT: method allows to increase efficiency of restoring neurological disorders, which is achieved by the above-mentioned methods of the method.

1 cl, 2 tbl, 2 ex

Description

The invention relates to medicine, in particular to neurology, and can be used for early recovery of neurological disorders and daily life of a patient with ischemic stroke and respiratory failure.

Increasing the efficiency and improving the neurorehabilitation system is an urgent task of angioneurology. Early rehabilitation, carried out in the acute period of a stroke (the first 3-4 weeks from the moment of its development), is obliged to create a base that allows achieving the maximum possible result at the next stages of treatment [Gudkova V.V., Stakhovskaya L.V., Kirilchenko T.D. . et al. Early rehabilitation after a stroke. Consilium medicum 2005; 8: 692-696]. The results of the generalized experience show that the recovery rate is highest in the early post-stroke period, which is explained by the beginning of the functioning of neurons reversibly damaged during the primary lesion [Vorlow, Ch. P., Dennis, M., van Gein, J. et al. Stroke. A practical guide for managing patients. St. Petersburg, 1998]. The resumption of the function of nerve cells in this case occurs due to an improvement in their blood supply, restoration of metabolism, and relief of cerebral edema.

-Armengol A., Bonnin М., et al. Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Eur Respir J 2011; 37: 1128-1136].It is known that the rehabilitation process depends on many factors, such as age, severity of stroke, size and location of the ischemic focus, blood pressure level, the presence of anemia, coronary heart disease, atherosclerosis, cardiac arrhythmias, heart and kidney failure, diabetes mellitus, dyslipidemia, as well as severe cognitive impairment and dementia [Saposnik G., Kapral M.K., Liu Y. et al., Investigators of the Registry of the Canadian Stroke Network, Stroke Outcomes Research Canada (SORCan) Working Group SO. Circulation 2011; 123: 739-49]. Recently, patients with stroke began to pay special attention to respiratory failure in a dream. Obstructive sleep apnea syndrome (OSA) is known to occur in 70% of patients with acute stroke [Hermann DM, Bassetti CL Sleep-related breathing and sleep-wake disturbances in ischemic stroke. Neurology 2009; 73: 1313-1322]. It is shown that OSAS can adversely affect the course of the acute period of stroke and the restoration of neurological functions [Parra O.,

-Armengol A., Bonnin M., et al. Early treatment of obstructive apnoea and stroke outcome: a randomized controlled trial. Eur Respir J 2011; 37: 1128-1136].

To date, it is known about the restoration of lost functions in patients in the acute period of ischemic stroke through exposure to dynamic electroneurostimulation (DENS) and reflexology. In this case, the DENS effect is carried out on one of the universal zones of general action: the cervical-collar zone (SHV) or lumbosacral zone (SCZ), speech zones, the second cervical vertebra zone, the correspondence zone SU Jock (RU 2531693 from 10.27.2014) .

It is also known to restore the motor and related functional recovery of post-stroke patients who, along with drug therapy, perform neuromuscular electrical stimulation of paretic extensors of the fingers and wrists, followed by an assessment of motor function. Neuromuscular electrical stimulation of paretic extensors of the fingers and wrists begins from the moment the fact of ischemic stroke is established and continues for 3-4 weeks (RU 2284836 from 10.10.2006).

It is known to restore impaired limb functions and eliminate speech disorders by performing low-power helium-neon intravenous laser therapy, drug therapy: actovegin, glycine, piracetam, tocopherol, cerebrolysin and acupuncture reflexology (RU 2145895 from 02.27.2000). However, all these methods of restoring lost functions to patients with ischemic stroke do not take into account the presence of respiratory disorders and their effect on neurological recovery.

When analyzing respiratory disorders, two main parameters are traditionally distinguished: the apnea / hypopnea index (YAG) and the hypoxemia index (IG). Currently, the definition of YAG is the main way to assess the severity of respiratory disorders. It was found that with an increase in YAG, the worst neurological recovery is noted.

A known method of functional neurological recovery in patients with moderate and severe sleep disturbances in the sleep (VAT) in the early stages of ischemic stroke by applying the CPAP method (therapy with constant positive airway pressure - from the English. Continuous Positive Airway Pressure). [Parra O., Sanchez-Armengol A., Bonnin M. et al. Early treatment of obstructive apnoea and stroke outcome: a randomized controlled trial. Eue Respir J 2011; 37: 1128-1136;]. Unfortunately, adherence to CPAP among stroke patients was low and ranged from 15 to 30%. In addition, the work was mainly research and an algorithm for the treatment of such patients was not developed. This source of information is taken as the closest analogue.

Given the possible mechanisms of the effect of respiratory disturbances in sleep on cerebral metabolism, we hypothesized that a decrease in hypoxic load in the acute stage of stroke may be effective in relation to the transformation of the ischemic penumbra zone and the course of the disease. The use of oxygen therapy seems promising in this regard.

The technical result of the claimed method is to increase the recovery of neurological disorders and daily life of the patient in the acute period of ischemic stroke with respiratory failure in a dream.

The technical result is achieved in that the improvement of early functional neurological recovery in patients with ischemic stroke and respiratory failure in sleep (VAT) is that patients with moderate and severe VAT are treated with medication, while in patients with moderate and severe VAT with an apnea / hypopnea index ≥15 events / hour, along with drug therapy for 7 days during a night sleep from 22.00 to 7.00, the head end of the bed is raised by 30 degrees and at the same time continuous insuff oxygen oxygen through the nasal cannula at a rate of 2-4 l / min while maintaining a tissue saturation level of at least 95%, controlled with a finger pulse oximeter.

The method is as follows.

All patients with 1-2 days of ischemic stroke undergo daily cardiorespiratory monitoring with an assessment of YAG and assess the severity of neurological disorders and daily functioning. Patients with ischemic stroke and moderate and severe VAT, when YAG ≥15 events / hour in the acute period of the disease, along with drug therapy for 7 days during night sleep from 22.00 to 7.00 give the patient an elevated head position (raising the head end of the bed by 30 °) and at the same time conduct continuous insufflation of oxygen through the nasal cannula at a speed of 2-4 l / min while maintaining the level of tissue saturation of at least 95%. In this case, tissue saturation is monitored using a finger pulse oximeter.

The study included patients who were sequentially admitted to the department of acute cerebrovascular accidents at the Federal State Budgetary Institution of Oncology. Inclusion criteria: men and women, age 18 years and older; ischemic stroke, confirmed by neuroimaging data, 1-2 days from the onset of the disease; moderate and severe VAT, signed informed consent to participate in the study.

For the patients to be examined for daily cardiorespiratory monitoring (CT-04-3P (M), Inkart, St. Petersburg), the presence and structure of respiratory disorders in a dream was studied. The study was carried out on 1-2 days from the debut of the disease. The analysis of respiratory disorders was carried out automatically and supplemented by a visual expert assessment of each fragment. The apnea-hypopnea index was recorded - the number of apnea / hypopnea per hour [Tsara V, Amfilochiou A., Papagrigorakis J.M., et al. Guidelines for Diagnosing and Treating Sleep related Breathing Disorders in Adults and Children. Hippokratia. 2009, 13, 3: 187-191]. The criterion for the diagnosis of moderate and severe VAT was the value of YAG ≥15. Patients with this characteristic were included in the study.

The severity of neurological deficits was evaluated by the National Institutes of Health Stroke Scale (NIHSS), in which a score of 0 corresponds to the absence of neurological impairment, and 25 points to their maximum severity. Assessment of the functional state of the patient was carried out using a modified Rankin scale (mRS) [Vorlow C.P., Dennis M.S., van Hein J. et al. Stroke. A practical guide for managing patients. St. Petersburg, 1998]. The absence of symptoms was rated at 0 points; minimal symptoms that do not limit daily activity - 1 point; some violations requiring limited assistance in some cases, but self-service is possible in full - 2 points; moderate decrease in activity, requiring outside help, but the patient can walk - 3 points; marked decrease in activity, requiring outside assistance - 4 points; the patient is bedridden, constant assistance is required - 5 points. The assessment was performed initially (during hospitalization of the patient, for 1-3 days), as well as after 2-3 weeks against the background of rehabilitation measures.

Statistical processing of the obtained data was performed using the program Statistica 10 (StatSoft, USA). The methods of nonparametric analysis are used. The results are presented as median, interquartile range [Me (25%; 75%)]. The Wilcoxon test was used to analyze data in related groups. Comparison of two independent groups was performed using the Mann-Whitney U test. The result was considered statistically significant at p <0.05 [Rebrova O.Yu. Statistical analysis of medical data. M., Media Sphere, 2002].

The study protocol was approved by the local ethics committee of the FSBI NCH.

A total of 46 patients with ischemic stroke and moderate to severe VAT were included in the observation; Of these, 33 (72%) are men and 13 (28%) are women. The age of patients at the time of inclusion in the study was 62.7 (57; 71) years.

When a stroke was included in the study on day 1-2, the severity of neurological deficit, as measured by the NIHSS scale (stroke scale of the US National Institutes of Health), ranged from 2 to 18 points, the median was 6 (4; 10) points. Assessment of the functional state of the patient (mRS) ranged from 1 to 5, the median - 3 (2; 5).

All patients were divided into 2 groups: group 1 - without treatment by the claimed method (n = 30), group 2 - with treatment by the claimed method (n = 16). The groups were comparable in all main characteristics, including gender, age, chronic cardiovascular pathology, severity of neurological disorders, and YAG (Table 1).

Patients of the 2nd group in the acute period of a stroke along with drug therapy for 7 days during a night sleep from 22.00 to 7.00 hours were given an elevated position of the head, that is, the head end of the bed was elevated by 30 ° and at the same time continuous oxygen was insufflated through the nasal cannula at a rate of 2-4 l / min while maintaining the level of tissue saturation of at least 95%. Tissue saturation was monitored using a finger pulse oximeter.

After 3 weeks, the severity of neurological disorders (NIHSS) and daily functioning (mRS) were re-evaluated (see Fig. 1 and Table 2).

Note. * - p <0.05 - compared with the initial value in the group.

The NIHSS score in group 1 decreased by 2 (1; 4) points, and in group 2 by 4.5 (2; 5.5) points (p = 0.03). The mRS score decreased in 1 group by 1 (0; 1) point, and in group 2 by 2 (0.5; 2) points (p = 0.018). This dynamics of the severity of neurological disorders is shown in Figure 1, which shows the change (decrement) in the NIHSS and mRS scores during treatment in patients of groups 1 and 2. At the same time, an asterisk indicates: * - p <0.05 - when compared with the indicator in the 1st group.

Thus, the obtained data support the positive effect of the positioning of the patient with a raised head end and the simultaneous oxygen insufflation at night on the restoration of neurological functions in patients with ischemic stroke.

Method implementation examples

Example 1

Patient M., 67 years old, suffered an ischemic stroke with the formation of a cerebral infarction in the pool of the right middle cerebral artery. At admission, there was a pronounced limitation of daily activity and a moderately pronounced neurological deficit (mRS 5 points, NIHSS 7 points). According to cardiorespiratory monitoring performed on the second day of a stroke, during a night's sleep, YAG amounted to 22 events / hour, which testified to the presence of a severe degree of VAT in the patient. Conducted comprehensive standard medical therapy, including antihypertensive, antithrombotic, lipid-lowering and neuroprotective agents. A complex of active rehabilitation measures was carried out. After 3 weeks, a slight restoration of functional independence and an improvement in neurological functions was noted: mRS was 4 points (decrement - 1 point), NIHSS 5 points (decrement - 2 points).

Example 2

Patient S., 69 years old, suffered an ischemic stroke with the formation of a cerebral infarction in the pool of the right middle cerebral artery. On admission, there was a pronounced limitation of daily activity and a moderately pronounced neurological deficit (mRS 5 points, NIHSS 8 points). According to cardiorespiratory monitoring performed on the second day of a stroke, during a night's sleep, the YAG amounted to 24 events / hour, which testified to the presence of a severe degree of VAT in the patient. Conducted comprehensive standard medical therapy, including antihypertensive, antithrombotic, lipid-lowering and neuroprotective agents. Along with drug therapy, the patient was given an elevated position for the head during the next 7 days during the night's sleep from 22.00 to 7.00. That is, the head end of the bed was raised by 30 ° and at the same time continuous oxygen insufflation was carried out through the nasal cannula at a rate of 2-4 l / min while maintaining a tissue saturation level of at least 95%. Tissue saturation was monitored using a finger pulse oximeter. After 3 weeks, a good restoration of functional independence and improvement of neurological functions was noted: mRS was 2 points (decrement - 3 points), NIHSS 3 points (decrement - 5 points).

Thus, the claimed method provides a real increase in functional neurological recovery (neurological disorders (NIHSS) and daily functioning (mRS)) in patients with ischemic stroke and respiratory failure in a dream in the early period of its manifestation.

Claims (1)

A method for correcting respiratory disturbances during sleep (VAT) in patients with ischemic stroke, including exposure to the respiratory tract, characterized in that a patient in the acute stage of a stroke with an apnea / hypopnea index ≥ 15 events / hour, during drug therapy, during 7 days, during the night’s sleep from 22.00 to 7.00, the head end of the bed is raised by 30 degrees and at the same time, oxygen is continuously insufflated through the nasal cannula at a rate of 2-4 l / min while maintaining a level of tissue saturation of at least 95%, which is controlled comfort with a finger pulse oximeter.

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