RU2725213C2 - Method of treating respiratory distress syndrome in patients with acute ischemic stroke - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to neurology. Acute respiratory insufficiency syndrome is treated in the patients with acute ischemic stroke. If observing the hypoxaemia, monitor the following indicators: blood pressure, heart rate, PaO2, PCO2, lactate, ECG, EEG, body temperature and external respiratory function values are ensured by reperfusion therapy. As an effect on respiratory tracts inhalation of the mixture heated to t = 45–60 °C comprising 65–75 % helium (He) and 25–35 % of oxygen (O) is performedInhalation of the mixture is daily 3–5 times a day with a daily increase in the duration of inhalation from 7–10 to 15–20 min taking into account the patient's tolerance for the acute period of the stroke.EFFECT: method provides real acceleration of neurological recovery on the scale of NIHSS and daily mRS function in patients with ischemic stroke and respiratory disorder.1 cl, 6 tbl, 3 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, accompanied by respiratory disorders syndrome.

Cerebral stroke (CI) is one of the leading causes of death and disability worldwide. In the Russian Federation, about 420 thousand new cases of CI are registered annually. An early 30-day mortality rate after a stroke is 34.6%, and about half of those who die within a year. In more than half of cases, the course of QI is complicated by the onset of somatic disorders, among which complications from the pulmonary system occupy one of the leading places in frequency. Up to 35-40% of patients with CI in intensive care units have pneumonia and respiratory failure. There is a connection between the likelihood of developing pneumonia and the severity of a stroke, older age, and the presence of other concomitant diseases. The presence of pneumonia in the acute period of a stroke significantly worsens the 6-month prognosis for survival. The development of respiratory failure enhances cerebral edema, triggers various vicious circles and, as a result, aggravates the patient’s condition and aggravates the prognosis regarding life and the degree of recovery.

Hypoxemia that develops in acute stroke is common, often remains undiagnosed and underestimated. The cause of hypoxemia is, first of all, violations of the ventilation-perfusion relationship and, to a lesser extent, diffusion disorders.

Normally, blood perfusion occurs in those areas of the lungs that are ventilated at this time (von Euler reflex). In these areas, gas is exchanged between the alveolar air and the blood of the pulmonary capillaries. In a healthy person, the ventilation-perfusion ratio (VA / QT) is 0.8-0.83. The areas of the lungs that are not ventilated at the moment are in a state of “physiological atelectasis”, there is no perfusion in them. When these areas begin to be ventilated (for example, during physical exertion), pulmonary blood flow is redistributed, and perfusion captures these areas. In acute ischemic stroke, this rule is violated, and then three zones arise in the lungs. In the first, where gas exchange takes place, there are ventilation and perfusion. In the second, the alveoli are ventilated, but there is no perfusion, and, therefore, there is no gas exchange. This zone is included in the volume of physiological dead space (VD) and significantly increases it. For ventilation, the VD value itself is not so much important as the ratio of the volume of dead space and tidal volume (VT). An even greater danger is the third zone, where there is blood flow, but there is no ventilation and, accordingly, gas exchange. Venous blood flowing into this zone is not oxygenated. Mixing with the blood flowing from the ventilated areas, it creates venous mixing with arterial blood, i.e. increases the shunt from right to left. Normally, this shunt does not exceed 7% of the volume of blood flow. With an increase in shunt, hypoxemia develops, which the body cannot compensate for by increased respiration. An increase in the venoarterial shunt in the lungs leads to an increase in the alveolar-arterial oxygen difference D (Aa) PO ₂ . In a healthy person, when breathing normal, atmospheric air, the alveolar-arterial oxygen difference should not exceed 20 mm Hg, and when breathing 100% oxygen, 100 mm Hg. An increase in DO ₂ leads to a decrease in PaO ₂ . You can increase the latter only by increasing the content of PAO ₂ . However, with a significant increase in D (Aa) PO ₂ , for example, up to 450 mm Hg and more, even breathing 100% oxygen (FiO ₂ = 1.0) does not eliminate hypoxemia.

In the acute period of a stroke, hypoxemia is combined with hypocapnia due to increased ventilation of those areas of the lungs where gas exchange occurs. However, hyperventilation, contributing to enhanced CO ₂ excretion, cannot saturate hemoglobin with oxygen up to more than 100%, and that part of the blood in which SaO ₂ remains low, mixing with blood completely saturated with O ₂ , creates venous mixing.

The normal oxygen saturation range is 97 ± 2% in young people. In healthy people, the partial pressure of oxygen in the blood decreases with age and in healthy elderly people, slightly below 95%.

With a stroke, blood oxygen saturation decreases. According to Sulter et al. 63% of stroke patients had at least one episode of hypoxia, defined as saturation of less than 96% for more than 5 minutes. In a recent study conducted at the D.D. Pletnev, it was found that more than 90% of patients with acute ischemic stroke have latent hypoxemia, detected by direct oximetry of arterial blood using the laboratory express method.

The consequences of severe and prolonged hypoxemia are obvious. The role of mild and moderate severity of hypoxemia on the course and prognosis of acute ischemic stroke have been considered in a number of studies: Silva et al. Hypoxemia is reported to double the risk of early deterioration in patients with ischemic stroke. These researchers note that the level of night desaturation can contribute to the deterioration of the functional state of patients on the Barthel scale in the first 12 months. Sandberg et al. demonstrated the connection between night desaturation and the development of behavioral changes, decreased mood and quality of life.

In a study by Moroney et al. It was shown that patients with episodes of hypoxemia in the acute period of stroke over the next 5 years of observation had a higher risk of developing heart failure, pneumonia, epileptic seizures, sepsis, myocardial infarction, arrhythmia and crown, compared with patients without episodes of hypoxemia. Although there is no direct evidence of a causal relationship between minor hypoxemia in patients with an acute stroke and a poor outcome, correction of hypoxemia is a reasonable and safe management strategy for these patients. Correction of respiratory failure syndrome in patients with acute ischemic stroke is a difficult task. Drug treatment and oxygen therapy are often ineffective and insufficient to prevent the progression of both the underlying disease and hypoxemia. Despite the use of new high-tech respiratory equipment with various ventilation modes, and the improvement of mechanical respiratory support methods, the problem of managing such patients remains relevant. This is due to the fact that the methods of respiratory support in patients with respiratory failure syndrome in cerebral stroke are still not well developed.

National and international guidelines for the treatment of stroke pay much attention to the correction of hypoxia in acute ischemic stroke using oxygen therapy and mechanical ventilation (non-invasive ventilation and mechanical ventilation).

From the patent literature (see patent RU No. 2645410, class A61M 16/00 (2006.01), publ. 21.02.2018) there is a known method for the correction of respiratory disorders in patients with acute stage of ischemic stroke, including exposure to the respiratory tract with apnea / hypopnea index ≥15 events / hour with drug therapy. Within 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 tissue saturation level of at least 95%, which is controlled using a finger pulse oximeter

The disadvantages of oxygen therapy are improved oxygenation only due to passive diffusion along the increased concentration gradient and the possibility of toxic effects as the dose and duration of oxygen supply increase. In patients with severe disorders of the function of the bronchopulmonary apparatus and cerebral and general hemodynamic disorders, when shunt diffusion disorders of gas exchange predominate, acid therapy is ineffective, and a high oxygen concentration is required to achieve even a moderate effect. In more severe cases, with low efficiency of oxygen therapy, a method of creating a constant, positive airway pressure during spontaneous breathing (CPAP) can be used to improve oxygenation. However, in the acute period of cerebral stroke, this method of mechanical ventilation has limitations due to low patient adherence.

The method of mechanical ventilation for the treatment of respiratory failure syndrome in patients with ischemic stroke is also not widespread in view of the complications arising during its conduct, trauma, and also due to its inexpediency in case of unexpressed respiratory distress syndrome.

The technical problem of the invention is the expansion of pathogenetic methods of treating respiratory failure in ischemic stroke. The technical result consists in improving blood oxygen saturation, reducing hypoxia and hypoxemia, accelerating the clinical and radiological resolution of pneumonia, reducing the intensity of the formation of reactive oxygen species by leukocytes, accelerating the restoration of neurological functions, as well as increasing the adaptive reserve of the body.

The problem is solved, and the technical result is achieved by the fact that the method of treating acute respiratory failure syndrome in patients with acute ischemic stroke in the case of established hypoxemia consists in inhaling a mixture containing 65-75% helium (He) and 25 -35% oxygen (O ₂ ), daily 3-5 times a day with a gradual daily increase in the duration of inhalation from 7-10 to 15-20 minutes, taking into account the tolerability of the procedure by the patient during the acute period of stroke. Inhalation of the He-O ₂ mixture is carried out under monitor control of blood pressure, heart rate, blood saturation, PaO ₂ , PCO ₂ , lactate, ECG, EEG, body temperature and indicators of external respiration functions. Inhalation of the He-O ₂ mixture is carried out against the background of standard drug therapy, including, if indicated, reperfusion therapy.

The gas mixture of helium and oxygen used to support breathing has a density lower than air. Inhalation of this mixture leads to a decrease in resistance in the airways, and, consequently, to a decrease in the load on the respiratory muscles. The therapeutic effect of this gas mixture is based on the special properties of helium. Inert gas helium is an ultra-pure gas and has extremely high penetration (density is almost 7 times lower than that of nitrogen, the main gas of oxygen diluent in air), thermal conductivity (5.8 times higher than that of nitrogen), low solubility in fats and water (4.5 times less than that of nitrogen) and contributes to the rapid elimination of CO ₂ and other toxic and poisonous substances from the body.

Helium does not enter into chemical reactions in the body. It provides an increase in the volumetric velocity of the gas mixture, normalizes the gas composition of the blood and acid-base balance, relaxes and reduces the load on the respiratory muscles and optimizes the activity of the respiratory center. Helium also improves oxygen diffusion through the alveolo-capillary membrane, reduces breathing resistance due to its low density and reduces sputum viscosity. The mechanism of action of a mixture of helium and oxygen (helium oxygen) in pneumonia is associated with the fact that helium easily penetrates into the lungs even through mucous plugs, an inflammatory exudate and improves diffusion through the alveoli - capillary membrane, reduces breathing resistance, relaxes the smooth muscles of bronchioles, reducing the load on them , thereby contributing to the improvement of tissue respiration.

The results of a study conducted at the Department of Internal Medicine of the Faculty of Biology, Federal State Budgetary Educational Establishment of Higher Education “Russian National Research Medical University named after N.I. Pirogov’s Ministry of Health of Russia, in the therapeutic departments of the Central Clinical Hospital of the Russian Academy of Sciences and the hospital of the Russian Academy of Sciences Troitsk, allow us to recommend the use of inhalations of a heated helium-oxygen mixture according to the proposed method in the complex treatment of patients with community-acquired pneumonia to accelerate the clinical and radiological resolution of pneumonia, reduce the intensity of active forms of oxygen by leukocytes, as well as increasing the adaptive reserve of the body.

Clinical example 1.

Patient Ch., A 78-year-old man, was admitted to the neuroresuscitation department with a diagnosis of CVB: cerebral infarction in the left middle cerebral artery pool with hypertension, cerebral atherosclerosis, paroxysmal atrial fibrillation (cardioembolic subtype), right-sided hemiparesis.

The real deterioration is associated with the independent cancellation of oral anticoagulant therapy (xarelto 20 mg) a week before admission to the hospital. Also, the patient constantly takes concor 2.5 mg, enalapril 10 mg x 2 times a day. Allergic history: not burdened.

At the initial examination, the patient's condition is regarded as serious. Consciousness saved. The patient was somewhat tired and preferred a semi-ortopic position. The skin is of normal color. No swelling of the lower extremities. Reduced nutrition (height 190 cm, weight 75 kg). The chest of the usual form. In the lungs, breathing in the lower sections was somewhat weakened, a few dry rales in the lower sections were auscultated, with percussion, the blunting of percussion sound in the lower sections. The borders of the heart were not determined, heart sounds were rhythmic, deaf, heart rate - 115, blood pressure - 150/80 mm Hg. The abdomen on palpation is soft, painless, the liver is not enlarged. The symptom of striking is negative on both sides.

A computed tomography of the brain was performed upon admission. On radiographs of the chest organs in standard projections in a sitting position on the background of diffuse pneumosclerosis, an increase in the pulmonary pattern due to the pronounced vascular component, compaction of the pattern in the basal zone, redistribution of blood flow to the upper sections are determined. The roots of the lungs are densified, their structure is reduced due to the main branches of the pulmonary artery. Pulmonary fields without fresh focal and infiltrative shadows. The high standing of the dome of the diaphragm is determined. On the left, the dome of the diaphragm is deformed by the mooring, the lateral and front sinuses are soldered. On the right, visible sines are free. The shadow of the aortic arch is densified with calcification zones. The heart is widely adjacent to the diaphragm. Bone-destructive changes were not identified.

X-ray against the background of diffuse pneumosclerosis picture of congestion in the lungs. Pleurophrenic commissural process on the left.

On the ECG - sinus bradycardia, ventricular extrasystole. The position of the EOS is a pronounced deviation to the left. Blockade of the anterior branch of LDL. AB - blockade of 1 degree. LVH. LV myocardial insufficiency. In the presence of an anamnesis of scars in the lower wall of the LV.

Upon admission, the patient began to complain of shortness of breath, palpitations, fever to febrile numbers, a sharp decrease in appetite. On examination, a sharp decrease in saturation to 80% in air was noteworthy. Chest x-ray was recommended, and CT angiopulmonography was used to rule out relapse of pulmonary embolism.

Radiography: Upon repeated examination of the chest organs against the background of an enriched vascular pattern, the phenomena of pneumosclerosis and pneumofibrosis, lung tissue infiltration of the lower lobe of the right lung is noted. The root of the right lung is compacted, heavy, not structural in the tail. The root of the left lung is not expanded, compacted, heavy. The diaphragm is flattened. In the right pleural cavity, the excreted fluid in the outer and anterior sinuses cannot be excluded. Left - sinuses are free. Heart with enlarged left ventricle. The aorta is sealed. Right-sided lower lobar pneumonia. Emphysema. Diffuse pneumosclerosis. Local pneumofibrosis. Bronchiectasis cannot be ruled out.

CT angiopulmonography: no data on pulmonary embolism. The trunk of the pulmonary artery is 3.1 cm wide, branches up to 2.0 cm. The shape of the chest is normal. Lung volume saved; pulmonary fields are symmetrical. In the upper, middle and lower lobes of the right lung and lower lobe of the left lung, the areas of broncho-pleuropneumonic infiltration of lung tissue are determined. The mediastinum is structural, not displaced. Trachea - without features. Bronchi 1-3 order passable, the walls of the segmental bronchi are compacted, moderately expanded. The heart is usually located; its configuration is not changed. The heart chambers are not expanded. The thoracic aorta is not changed. The diaphragm is usually located, its contours are even, clear. Pleural cavities without features. Paratracheal, retrocaval, para- and aortic lymph nodes, up to 0.5 cm in size, are determined. Soft tissues, bone structures of the chest are not changed. CT picture of bilateral polysegmental pneumonia.

Based on clinical and instrumental data, a clinical diagnosis was established: CVB. A cerebral infarction in the pool of the left middle cerebral artery from 04/04/18. against the background of hypertension, cerebral atherosclerosis, a constant form of atrial fibrillation (cardioembolic subtype) right-sided hemiparesis up to 2.5 points, dysarthria. The total score on the modified Rankin scale (mRS) is 4, on the NIHHS scale - 8, on the Rivermead scale - 2. IHD: Post-infarction cardiosclerosis. Angina pectoris FC 2. GB 3. AH 3. Risk 4. NK 2. Gastrectomy for gastric disease (2017). Cachexia. Bilateral polysegmental pneumonia. Due to the presence of pneumonia, drug therapy has been started: Amoxiclav 1200 mg every 12 hours by intravenous drip, reamberin solution 500 ml iv drip. In addition, Mexidol 10 ml was administered intravenously, bisoprolol 2.5 mg / day enteral, enalapril 5 mg 2 times a day, enteral (via an established nasogastric tube).

Given the severity of the patient's condition (pO2 - 60 mm Hg, pCO2 - 45 mm Hg), the complicated course of the disease, despite oxygen therapy (3.5 l / min) on the first day, it was decided to prescribe inhalations of heated heliox using the apparatus Heliox Extreme. The therapy was carried out daily and included inhalation of a mixture containing 65-75% helium (He) and 25-35% oxygen (O ₂ ) heated to 45-60 ° С 4-5 times a day, with a gradual daily increase in the duration of inhalation from 10 to 20 min, taking into account the tolerability of the procedure by the patient. Inhalation of the He-O ₂ mixture was carried out against the background of standard drug therapy under monitor control of blood pressure, heart rate, blood saturation, PaO ₂ , PCO ₂ , lactate, ECG, body temperature and indicators of external respiration functions.

The most important was the dynamics of the gas composition of arterial blood during inhalation treatment of a heated helium-oxygen mixture, is shown in table 1, which shows the dynamics by day: on the 1st day, on the 3rd day, on the 6th day, 10th day, where the effectiveness of the mixture is shown and it is clear that already on the 3rd day the partial pressure of oxygen approaches normal (78.8 mm Hg, N - 82 - 107 mm Hg), the blood pH normalizes - a gradual slight shift (N - 7 , 35-7.45), elimination of carbon dioxide to normal figures 36.7 in 10 days without the use of other methods of respiratory support, increased oxygen saturation by 3 days to 88%, by 10 days to 98%, we also see a decrease in lactate , its normalization by the 3rd day of treatment, which indicates an improvement in metabolism in the body, an increase in blood hemoglobin was noted.

In the tables, the pH-pH of arterial blood, pO2 - partial pressure of oxygen in arterial blood, mm Hg, pCO2 - partial pressure of carbon dioxide in arterial blood, НСО3-bicarbonate in arterial blood, BE (В) - basic excess of arterial blood, Hct - hematocrit of arterial blood, Нb - hemoglobin of arterial blood, Glu - glucose of arterial blood, Lac - arterial blood lactate.

Oxygen saturation also occurred in venous blood, the dynamics of the gas composition of venous blood are shown in Table 2, where the dynamics are shown by day: on the 1st day, on the 3rd day, on the 6th day, and 10th day, where similar changes: normalization of pH from 7.283 to 7.35 by 10 days (venous blood pH N - 7.32-7.42), increase in oxygen content in venous blood, elimination of carbon dioxide, decrease in lactate, increase in hemoglobin, oxygen saturation.

The improvement of arterial and venous blood gas indicators was clinically expressed in an objective improvement in the patient's condition: resolving the symptoms of pneumonia (cough, fever, shortness of breath).

The patient tolerated the therapy satisfactorily. No side effects. The patient's condition improved significantly during the therapy: subjectively, the patient felt better. An increase in blood oxygenation was noted; the elimination of carbon dioxide and the strength of the respiratory muscles increased. A control computed tomography of the lungs was performed on the 7th day of the disease: the chest shape was normal, the pulmonary fields were symmetrical. Bronchi of the III-IV order are moderately expanded, deformed, the walls are thickened. Pulmonary tissue with areas of pneumosclerosis, local pneumopleurofibrosis, mainly in the lower lobes of both lungs. The mediastinum is structural, not displaced. Trachea and main bronchi passable, not deformed. The branches of the pulmonary artery are moderately expanded to 2.4 cm, the trunk is 3.3 cm. The heart is usually located; its configuration is not changed. The increase in the left ventricle is determined. Thoracic aorta, coronary arteries with calcification sites. The diaphragm is usually located, its contours are clear, even. Pleural cavities without features. Critical lymphadenopathy was not detected. Soft tissues, calcified node in the lower pole of the left lobe of the thyroid gland, bone structures of the chest are not changed. The nasogastric tube is positioned correctly.

Complete clinical and radiological resolution of pneumonia was noted, the patient's condition improved on the 10th day, neurological symptoms decreased significantly (right-sided hemiparesis to 2.5 points in the arm and leg to 3.5 points, NIHHS - 6 points), swallowing improved, patient independently moves around the ward with the help of “walkers” (Rivermead 7 points), on the 10th day the patient was discharged for outpatient monitoring.

Clinical example 2

Patient A., 36 years old, was admitted to the intensive care unit with a diagnosis of “Ischemic acute cerebrovascular accident in the vertebrobasilar basin of the system from 10.02.18 g” on the first day after the development of symptoms: headache, dizziness, swallowing, weakness and numbness in the left limbs, paresthesia in the right half of the body. From the anamnesis it is known that the patient works as a software analyst, the work is associated with physical and emotional overload. Past diseases: Prolapse of the mitral valve of the I degree, dorsopathy of the cervical spine. BMI - 22, height 184 cm. Bad habits: no. Allergic history: skin reactions to insect bites. The patient's condition of moderate severity: conscious, skin and mucous membranes hyperemic, clean, no skin rashes. Subcutaneous tissue is developed normally. The thyroid gland is of normal size and shape. Lymph nodes are not enlarged, painless on palpation. The musculoskeletal system without features. Height 184 cm, Weight 82 kg, Temperature 36.6 ° C. Mental state: Consciousness: clear. Memory and intelligence are not reduced. Consciousness: clear, oriented, contact. Speech: slurred (dysarthria). Meningeal s-us: no. FMN: No.I. The olfactory nerve - no change. No. II. Optic nerve - no visual field disturbances. No. III. Oculomotor nerve: Strabismus no. The size and shape of the pupils: medium size, regular shape. Convergence: Saved. The photoreaction is live. Eyeball condition: no features.

The palpebral fissure on the left is already right due to slight ptosis. The fundus without visible pathology. Pharyngeal reflex: inhibited. Right nasolabial fold is smoothed. Motor sphere. Range of active movements: limited in the left hand. Decreased strength in the left hand. Pace of movements: slowed down. Passive movements: not limited. Muscle tone: not changed. Muscular atrophy: no. Fasciculation, fibrillation: no. Postural reflexes: staggering upright. Gait: shaky. Sensitivity: reduced pain in the right arm and leg. Reflex sphere: moderate reflexes from the arms and legs. Coordination tests: Pose of Rum berg: staggering. Palatine, heel tests: with intention, - D = S. Dysmetry: negative test. CM backward push: positive. Intentional tremor: from 2 sides; test for adiadhokinesis: positive. Vertebral symptoms: Forced posture: no. Defense: no. Movement in the spine: not limited. Percussion and palpation of the spine: painless. Antalgic curvature: not detected. C-we tension: Lasseg, Matskevich, Neri, Bonnet, Turin, Wasserman, Degerin, Vilenkin - negative.

Функция тазовых органов: не нарушена. Трофические нарушения: нет. Органы дыхания: В легких везикулярное дыхание проводится во все отделы. Хрипов, крепитации и шума трения плевры нет. ЧД: 18 движ./мин. Система кровообращения: Сердечные тоны ясные. Ритм правильный. Пульс хорошего наполнения. АД: 140/80 мм рт.ст, ЧСС: 80 уд./мин, Пульс: 88 уд/мин. Система пищеварения: Язык чистый, влажный. Живот при пальпации мягкий, безболезненный, участвует в дыхании всеми отделами. Перитонеальных симптомов нет. Стул не нарушен. Печень не пальпируется, безболезненная. Селезенка не увеличена, безболезненная. Мочеполовая система: Область почек не изменена, при пальпации безболезненная. Симптом Пастернацкого отрицательный. Мочеиспускание свободное, безболезненное. Оценка по шкале NIHSS составила 7 баллов, ШКГ 15 баллов, Ривермид 13. Подход к лечению был проблемно-ориентирован, согласно его актуальным проблемам:

Pelvic function: not impaired. Trophic disorders: no. Respiratory: In the lungs, vesicular breathing is performed in all departments. There are no rales, crepitus, and pleural friction noise. BH: 18 engine / min. Circulatory system: Heart tones are clear. The rhythm is right. The pulse is good. Blood pressure: 140/80 mmHg, heart rate: 80 beats / min, pulse: 88 beats / min. Digestive system: Tongue clean, moist. The abdomen on palpation is soft, painless, participates in breathing by all departments. There are no peritoneal symptoms. The chair is not broken. The liver is not palpable, painless. The spleen is not enlarged, painless. Genitourinary system: The area of the kidneys is not changed, painless on palpation. Pasternatsky’s symptom is negative. Urination is free, painless. The NIHSS score was 7 points, GCS 15 points, Rivermead 13. The approach to treatment was problem-oriented, according to its current problems:

Нарушение глотания (нутритивная поддержка до 3500 ккал/сут через назогастральный зонд);

Violation of swallowing (nutritional support up to 3500 kcal / day through a nasogastric tube);

Гипоксемия 65 мм рт ст (нормальный диапазон 82-107 мм рт ст); коррекция проводилась термической гелийкислородной смесью 70%/30% температуре 45 градусов. Терапия начиналась с 7 минут 3 раза в сутки, на второй день увеличилась продолжительность ингаляции до 15 минут. В последующие дни ингаляции проводились по 15 минут 3-4 раза в сутки при температуре от 45 градусов до 60 градусов, на протяжении 10 дней.

Hypoxemia 65 mm Hg (normal range 82-107 mm Hg); correction was carried out with a thermal helium-oxygen mixture of 70% / 30% at a temperature of 45 degrees. Therapy began from 7 minutes 3 times a day, on the second day, the duration of inhalation increased to 15 minutes. In the following days, inhalations were carried out for 15 minutes 3-4 times a day at a temperature of 45 degrees to 60 degrees, for 10 days.

Повышенное АД до 150/80 мм рт ст, коррекция проводилась периндо-прилом 10 мг в сутки.

Increased blood pressure up to 150/80 mm Hg, correction was carried out by perindo-prilom 10 mg per day.

Речевые нарушения

Speech Disorders

Правосторонний гемипарез до 3 баллов.

Right hemiparesis up to 3 points.

Тонус в конечностях D>S

Tone in the extremities D> S

The effectiveness of the therapy was evidenced by the normalization of the arterial blood gas composition during the treatment of the heated helium-oxygen mixture, the dynamics are shown in table 3, on the 1st, 3rd, 6th, 10th day: a rapid increase in the partial pressure of oxygen to 3- m days, elimination of CO ₂ , increased saturation, decreased lactate, increased hemoglobin.

Table 4 shows the dynamics of the gas composition of venous blood during treatment on the 1st, 3rd, 6th, 10th day, the content of oxygen, hemoglobin increased, the content of carbon dioxide, lactate, and normalization of pH decreased.

According to the tables, the partial oxygen tension already on the 2nd day of treatment was adjusted to normal numbers, which was clinically expressed in a decrease in the severity of neurological disorders: swallowing improved on the 3rd day, the nasogastric tube was removed, sanitation measures of the oropharyngeal area were carried out, sensitivity and movements in the right arm and leg, dysphonia and speech disorders regressed.

Upon admission to MRI, it was noted: In the left half of the medulla oblongata, a plot of hypointensitive on T1VI and hyperintensive on T2VI signals of 0.7 × 0.7 cm in size is determined. Ischemic infarction of the left half of the medulla oblongata. Cyst of the maxillary sinus.

With repeated MRI, a positive trend was observed after 10 days and 30 days a positive trend was observed in a decrease in the size and intensity of the foci.

On an MRI scan done after 3 months there were no focal changes indicating a previous ischemic stroke.

The patient was discharged in satisfactory condition with a slight violation of sensitivity in the right hand. According to the rating scales, the state can be estimated as

NIHSS 1 point, Rivermead 15 points.

Clinical example 3

Patient M, 69 years old, was admitted to ICU on the 2nd day of acute cerebrovascular accident according to ischemic type in the pool of the right middle cerebral artery against the background of hypertension, cerebral atherosclerosis. With complaints of increased blood pressure to 200/100 mm Hg, asymmetry of the face, speech impairment, weakness in the left arm and leg, memory loss. Upon admission to the ICU, the patient’s condition of moderate severity, conscious, pO2 - 70 mm Hg (norm 82-107 mm Hg), SpO2 - 90% in air, MHC15 points, central paresis of the VII pair on the left, hemiparesis 2 points, phenomena cerebral edema. The NIHSS score was 7 points. Rankin 1. Rivemid 12. In the history of the presence of arterial hypertension for a long time, takes Lorista N, the absence of cardiac arrhythmias, acute brain disorders, myocardial infarction, and diabetes mellitus. The patient received respiratory support with a thermal helium-oxygen mixture (30% / 70%) sessions from 10 to 20 minutes, the temperature of the mixture from 45 degrees to 60 degrees, and she underwent drug correction of blood pressure, cardiac activity, the main parameters of homeostasis. Before inhalations, the temperature of the gas mixture is established as the patient is tolerated, if it is more comfortable than 45 degrees, then they stop at this temperature, if the patient tolerates the temperature of 60 degrees equally well, then a higher temperature is preferred, at which the diffusion properties increase. From the 2nd and all subsequent days, the duration of inhalation was increased to 15-20 minutes 3 times a day. Upon admission to CT: In the right parietal region, a section of reduced density (22 units N) of dimensions 3.1 × 1.5 cm is determined, with uneven contours. Mixed hydrocephalus.

On the ECG: Sinus rhythm. HR 62 in min;

Интервал P-Q=0,16 (норма до 0,18);

Interval PQ = 0.16 (normal to 0.18);

Интервал QRS=0,08 (норма до 0,09);

QRS interval = 0.08 (normal to 0.09);

Продолжительность систолы QRST=0,40

Duration of systole QRST = 0.40

Одиночная наджелудочковая экстрасистола

Single supraventricular extrasystole

ЭОС - отклонение влево.

EOS - deviation to the left.

Гипертрофия левого желудочка

Left ventricular hypertrophy

Недостаточность питания миокарда в нижней стенке ЛЖ

Myocardial malnutrition in the lower wall of the LV

Ишемия миокарда в переднеперегородочной области ЛЖ

Myocardial ischemia in the anterior septal area of the left ventricle

Рубцовые изменения в передней стенке ЛЖ.

Cicatricial changes in the anterior wall of the LV.

Laboratory indicators:

Total protein - 74 g / l

Мочевина - 8,30 (норм 2,50-6,50 ммоль/л)

Urea - 8.30 (norm 2.50-6.50 mmol / L)

Креатинин - 137 (0-97 мкмоль/л)

Creatinine - 137 (0-97 μmol / L)

Холестерин общий - 5,5 ммоль/л

Total cholesterol - 5.5 mmol / l

Триглицериды 1,58 ммоль/л

Triglycerides 1.58 mmol / L

Хс-ЛПНП - 3,37 ммоль/л

Chs-LDL - 3.37 mmol / L

Билирубин общий - 23,1 мкмоль/л

Total bilirubin - 23.1 μmol / l

Билирубин прямой - 6,1 мкмоль/л

Direct bilirubin - 6.1 μmol / l

Билирубин непрямой - 17,0 мкмоль/л

Indirect bilirubin - 17.0 μmol / L

АЛТ- 17,0 Ед/л

ALT - 17.0 Units / L

Глюкоза - 7,80 ммоль/л

Glucose - 7.80 mmol / L

The effectiveness of the therapy was evidenced by the normalization of the arterial blood gas composition during the treatment of the heated helium-oxygen mixture, the dynamics are shown in table 5, on the 1st, 3rd, 6th, 10th day: a rapid increase in the partial pressure of oxygen to 3- m days, elimination of CO ₂ , increased saturation, decreased lactate, increased hemoglobin. Table 6 shows the dynamics of the gas composition of venous blood during treatment on the 1st, 3rd, 6th, 10th day, the content of oxygen, hemoglobin increased, the content of carbon dioxide, lactate, and normalization of pH decreased.

Against the background of drug therapy in the amount of:

1) Cytoflavin 10 ml / day

2) Carnitine 10 mg / day

3) Cardicet 20 mg / day

6) Bisoprolol 2.5 mg / day

7) Coplavix 100 mg + 75 mg / day

8) Omeprazole 20 mg / day

9) Diabeton 60 mg / day

- as well as inhalations of thermal helium-oxygen mixture for 15 minutes 3 times a day, rehabilitation measures started (physical therapy, massage, magnetotherapy), the patient's condition improved, which was manifested in the patient's early clinical recovery: cerebral and focal symptoms regressed:

- complete regression of speech disorders;

- regression paresis of 7-12 pairs of FMN left

- fully restored strength in the leg

- lung monoparesis of the left hand is preserved up to 4.5b.

Repeated MRI shows a positive trend in the form of a decrease in ischemic foci on the 10th day of treatment. On MRI performed on day 30, the focus of ischemia in the right parietal region is described as a zone of vascular leuko-areosis (there are no signs of acute cerebrovascular accident).

Claims (1)

A method of treating acute respiratory failure syndrome in patients with acute ischemic stroke, including exposure to the respiratory tract, characterized in that when hypoxemia is established, monitor indicators are performed: blood pressure, heart rate, PaO2, PCO2, lactate, ECG, EEG, body temperature and indicators of external functions respiration, carry out reperfusion therapy, and as an effect on the respiratory tract, inhale a mixture containing 65-75% helium (He) and 25-35% oxygen (O ₂ ) heated to t = 45-60 ° C, while inhaling the mixture carried out daily 3-5 times a day with a daily increase in the duration of inhalation from 7-10 to 15-20 minutes, taking into account the tolerability of the procedure by the patient during the acute period of stroke.