RU2782103C1 - Method for the treatment of respiratory failure after acute respiratory distress syndrome, regardless of etiology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to pulmonology, anesthesiology and resuscitation. Intrapulmonary percussion of the lungs and the introduction of a surfactant through a built-in nebulizer are carried out. In this case, the introduction of natural pulmonary surfactant is carried out simultaneously with intrapulmonary percussion of the lungs. The frequency of respiratory oscillations is 500 per minute against the background of maintaining a constant pressure in the respiratory tract at a level of 16 cm of water. The procedure is performed twice a day for three days.

EFFECT: method makes it possible to ensure rapid relief of the patient's oxygen dependence, to reduce the rehabilitation time after acute respiratory distress syndrome, regardless of etiology, and to improve patient survival rates.

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Description

The invention relates to medicine, namely to pulmonology, anesthesiology and resuscitation, and can be used to treat respiratory failure after acute respiratory distress syndrome, regardless of etiology.

The incidence of acute respiratory distress syndrome (ARDS) is, depending on the region, 1.5–13.5 cases per 100,000 people per year. Among all patients in the ICU receiving respiratory support, 16-18% meet the criteria for ARDS (see Avdeev S.N. Acute respiratory failure: basic approaches to diagnosis and therapy. Pulmonology and Allergology. 2005, No. 4. C 24-29) .

The main pathogenetic method for the treatment of DN of any etiology is respiratory support, including controlled oxygen therapy, non-invasive and invasive ventilation of the lungs (see A. I. Gorelov, S. M. Rudakova, M. F. Balluzek, I. A. Umarova. Modern approaches to Respiratory Therapy of Respiratory Failure in Elderly and Senile Patients with Pneumonia // Bulletin of St. Petersburg State University, Series 11, 2012, Issue 4, pp. 32-41).

Undoubtedly, invasive ventilation methods are often a necessary measure to save the life of the patient, but the complications associated with endotracheal intubation, as well as the high risk of developing ventilator-associated colonization, lead to high mortality and significant costs. Involuntary medical sedation of patients also worsens the prognosis. All of the above, as well as discomfort for the patient, make it advisable to use invasive ventilation only in the most severe forms of DN (PaO2 < 60 mm Hg, SaO2 < 90%, pO2/FiO2 < 200); development of ARDS with FiO2 < 0.21 (see III International Congress on Respiratory Support. Krasnoyarsk, August 25–27, 2009. Materials of the Congress: Recommendations for non-invasive ventilation of the lungs).

Intrapulmonary percussion ventilation of the lungs is a method of hardware respiratory therapy, in which the patient is given percussion, small in volume and pressure, air flows with a high frequency, which is regulated by the doctor during the procedure, into the bronchopulmonary tree. The range of indications is quite wide: chronic obstructive pulmonary disease, bronchial asthma, bronchiectasis of the lungs, cystic fibrosis, demyelinating diseases of the peripheral nervous system, acute respiratory distress syndrome (see Umetov M.A., Urusbambetov D.A. Effect of intrapulmonary percussion ventilation on the quality Life of Patients with Chronic Obstructive Pulmonary Disease, Scientific News, 2016, No. 5, pp. 121-124).

One mode of mechanical ventilation, known as intrapulmonary percussion ventilation (IPVL), has theoretical life-saving properties in patients with refractory acute respiratory distress syndrome who require respiratory assistance. Unfortunately, in the modern scientific literature there is a limited number of publications regarding the practical use of IPVL to improve gas exchange function (see S. L. Babak, M. V. Gorbunova, E. V. Belykh, A. G. Malyavin. Intrapulmonary percussion ventilation lungs in the practice of a specialist in respiratory medicine Doctor. Ru, 2013, No. 8, pp. 62-68).

For the treatment of ARDS, mechanical ventilation is combined with endobronchial administration of bronchodilators or perfluorocarbon.

From patent sources, a method is known for the treatment of pulmonary complications in severe traumatic brain injury, which consists in the fact that patients are artificially ventilated with a change in position on the back and abdomen every 12 hours. . Endotracheal inhalation of a bronchodilator is carried out for 10 minutes with an interval of 3 hours. The treatment is carried out continuously for 7-14 days until the relief of respiratory failure and recovery of consciousness (see Patent RU 2153890 C1, publ. 10.08.2000, Bull. No. 22. )

A known method for the treatment of acute respiratory distress syndrome, which consists in the fact that under conditions of mechanical ventilation with positive end-expiratory pressure, the level of positive end-expiratory pressure is set higher than the pre-selected optimal one by 4-8 cm of water. Art. After 10-15 minutes, perfluorocarbon is introduced in the form of an aerosol. The introduction is carried out using a nebulizer sprayer for 10-15 minutes (see Patent RU 2265434 C2, publ. 10.12.2005, Bull. No. 34).

However, the methods described above did not lead to a significant improvement in patient survival, since the administered drugs had no pathogenetic significance in the treatment of respiratory distress syndrome.

Currently, there are a large number of methods for the treatment of respiratory failure after acute respiratory distress syndrome, which are based on various methods of administering natural surfactant, which prevents the adhesion of previously opened alveoli.

A known method for the prevention of pneumonia and adult respiratory distress syndrome during aspiration of gastric contents, which consists in the fact that the patient is intubated, transferred to mechanical ventilation, sanitation bronchoscopy is performed, glucocorticoids and antibiotics are administered, and no later than 12 hours - pulmonary surfactant in the form of the drug "Surfactant-BL ”, sessions for 4-6 hours for 2-3 days daily or constantly at a daily dose of 750-1000 mg (see Patent RU 2149018 C1, publ. 20.05.2000, Bull. No. 14).

A known method for the treatment of respiratory failure in critical conditions in children, which consists in mechanical ventilation with additional endobronchial administration of the drug pulmonary surfactant "Surfactant-BL" or "Surfactant-HL". The surfactant is administered from the first hours of the development of respiratory failure, first as a bolus at a dose of 300-400 mg/m ² , and then as an aerosol continuously for 1-3 days in an amount of 20-30 mg/h, after which the patient is extubated (see Patent RU 2149017 C1, published May 20, 2000, Bulletin No. 14).

A known method for the treatment of adult respiratory distress syndrome, which consists in the use of adequate modes of mechanical ventilation with additional endobronchial administration of pulmonary surfactant, and surfactant-BL is administered from the first hours of development of respiratory failure in the amount of 700-1000 mg bolus or microstream, and then after 30- 60 minutes in the form of an aerosol constantly, for 15-60 hours in the amount of 30-60 mg/h, after which the patient is extruded (see Patent RU 2149016 C1, publ. 20.05.2000, Bull. No. 14).

The above methods have a significant drawback, since the introduction of the surfactant is carried out against the background of collapsed alveoli, which does not allow to obtain a significant clinical effect.

The technical result of the present invention is the development of a method that allows to effectively treat respiratory failure after acute respiratory distress syndrome, regardless of etiology, by administering a natural surfactant against the background of open alveoli using intrapulmonary percussion of the lungs.

The technical result is achieved by the fact that the introduction of natural pulmonary surfactant is carried out simultaneously with intrapulmonary percussion of the lungs with a respiratory rate of 500 per minute. against the background of maintaining a constant pressure in the airways at the level of 16 cm of water column, the procedure is performed twice a day for three days.

The application of the method allows to effectively treat respiratory failure in respiratory distress syndrome.

To solve this problem, the method includes the introduction of natural pulmonary surfactant, which is carried out simultaneously with intrapulmonary percussion of the lungs with a respiratory rate of 500 per minute. against the background of maintaining a constant pressure in the respiratory tract at a level of 16 cm of water. Art., the procedure is performed twice a day for three days.

The developed method allows to increase the effectiveness of the treatment of respiratory failure in respiratory distress syndrome.

The method is performed as follows.

An apparatus for intrapulmonary percussion of the lungs with a built-in nebulizer is prepared, the pressure of incoming oxygen is adjusted at a level of 2 to 3 bar. The parameters PEEP (positive final expiratory pressure), INSP FLOW (inspiratory flow), INSP TIME (inspiratory time), FRECUENCY (indicator characterizing the elasticity of the lungs, i.e. the ability of the lungs to restore their shape and volume) are selected. The average pressure is set at 16 cm of water column, the inspiratory flow is selected individually for the patient, the inspiratory time is 1:1, the percussion frequency is set at 500 per minute. Prepare the surfactant for the nebulizer. If "Surfactant-BL" (Instruction for medical use RU No. LSR-010019/08) 75 mg in a vial is used, then 2 vials are used to prepare one dose of the active solution. The drug is diluted to 10 ml with saline warmed to a temperature of 37 degrees with gentle stirring of the solution until a homogeneous suspension is obtained. In the case of the use of the drug "Curosurf" (CHIESI FARMACEUTICI, S.p.A. (Italy), reg. No.: P N015827 / 01 dated 05/14/09, re-registration date: 08/02/17) 120 mg. diluted in a vial in 5 milliliters of saline warmed to a temperature of 37 degrees. Fill the glass of the nebulizer with the prepared solution. Using an anesthetic mask, the patient is connected to an intrapulmonary percussionist and percussion ventilation of the lungs is carried out for 10 minutes, for which the nebulizer toggle switch is turned on and the prepared solution is completely inhaled. After turning off the nebulizer, the procedure is continued for 5 minutes in order to maintain the average pressure in the bronchi at the level of 16 cm of water. Art. After the procedure, the patient is put on an oxygen mask with the initial flow of oxygen. The option of performing the procedure on the background of non-invasive lung ventilation has the following features: NIV CPAP ventilation mode (assisted ventilation mode carried out by a non-invasive lung ventilation apparatus using special nasal cannulas) PEEP 6 cm of water column. PC (ventilation mode - pressure control) 0-10 cm of water. Art. FiO2 (percentage of oxygen in the inhaled mixture) 40-50%; the device for intrapulmonary percussion is connected through a T-shaped adapter to the circuit for non-invasive ventilation of the lungs.

We give a clinical example of the application of the method.

Example 1

Patient P, born in 1975, was treated in the infectious diseases hospital from 10/10/2021 to 12/03/2021 with a diagnosis of COVID-19 coronavirus infection (confirmed), severe form. Bilateral polysegmental pneumonia CT-4. RDS. DN3

Upon admission, the temp. 38.3, RR30, SpO2 90% in air, on oxygen insufflation 15 L/min Sat 93%, on non-invasive mechanical ventilation (NIVL) CPAP 5-6 cm. Sat 98%, CT scan from 10/15/2021 The volume of lung tissue damage is 72%, numerous foci of interstitial ground-glass changes and consolidation.

The patient was in intensive care on DRAGER EVITA 500 NIV in MMV (ventilation mode - forced minute volume), APRV (pressure ventilation control mode), CPAP (assisted ventilation mode), with FiO2 parameters 80-100%, PEEP 8-9 see aq. Art. PC 10-15 cm aq. Art. for 2 weeks, one more week on AirVO 50 l. FiO2 0.7. In the next 10 days, the patient was on oxygen insufflation at 15 L/min through a face mask, SpO2 95%, without oxygen, desaturation up to Sat80%, CT scan dated 10/26/2021. The volume of lung tissue damage is 96% according to the ground glass type and consolidation.

Given the lack of dynamics in reducing oxygen dependence, it was decided to conduct inhalation therapy of surfactant using an intrapulmonary percussionist with the creation of positive pressure in the tracheobronchial tree in order to eliminate microatelectasis of the alveoli and increase the area of ventilated alveoli.

By the end of the first day after the surfactant injection procedure, a decrease in the oxygen flow rate to 7 l.min was noted. at Sat 95% The patient subjectively notes an improvement in well-being. On the second and third days, the procedure is repeated with 120 mg of surfactant (Curosurf 120 mg. Chiesi). The patient's condition is positive. CT scan from 02.12.2021 shows a decrease in the volume of lung tissue damage against the background of reticular changes, the volume of involvement of the lung parenchyma is 64%.

Two days after the last procedure, with a decrease in flow to 3 l/min and SpO2 96%, without oxygen, SpO2 93-94%, the patient was discharged home for further rehabilitation using an oxygen concentrator. After 1 week, complete recovery of breathing and weaning from the oxygen concentrator. The hospital treatment time was 54 days, 49 days before inhaled surfactant and 5 days after the start of its use.

Example 2

Patient S., 52 years old. She was treated in the thoracic department with a diagnosis of peripheral centralized cancer of the middle lobe of the right lung T3N1M0 condition after combined bilobectomy. Community-acquired left-sided lower lobe pneumonia. DN3 st. For 43 days she was on respiratory support with NIV through various face masks, for 3 days she was on a ventilator. After transfer to the specialized department, she was on oxygen support for 7 days through a face mask with a reservoir bag of 10 l per minute. oxygen, without a tendency to decrease the flow of oxygen. The council decided to perform the procedure of inhalation administration of surfactant with the help of a ventilator in the NIV CPAP PEEP mode of 6 cm of water column for the purpose of respiratory rehabilitation. and an apparatus for intrapulmonary percussion of the lungs with a built-in nebulizer, with an average airway pressure of 14 cm of water. and percussion frequency 480-500v min. Surfactant 100 mg was used by inhalation. (Survanta 100 mg. abbvie) per inhalation. On the first day, inhalation was performed once, the procedure was well tolerated by the patient. After the first procedure, positive dynamics is noted during the day, the oxygen flow decreased to 5 l min. The surfactant administration procedure was performed twice a day for three days. With positive dynamics and a decrease in the need for oxygen support, the patient at 3 liters per minute. oxygen was transferred to aftercare at the place of residence.

Example 3

Patient A., 68 years old, was treated in the surgical department from October 27, 2021 to December 19, 2021. She was diagnosed with T3N1M1 sigmoid colon cancer (single liver metastasis). Bilateral polysegmental pneumonia CT 2. DN2-3 st. SD type 2. PICS 2014. Arterial hypertension.

The patient was on NIV for 5 weeks, given the lack of dynamics of respiratory therapy, a stable condition, a decision was made to introduce a surfactant. Inhalation was carried out according to the developed technique against the background of CPAP therapy with the BMC-30T device in the CPAP mode 7 cm of water. FiO2 50% Sat 96%. The patient underwent the procedure for the introduction of inhalation administration of surfactant BL 75 mg. twice a day for 3 days. Positive dynamics is noted, the patient was switched to respiratory support VPO AirVo 50L, FiO2 70%, then to oxygen insufflation through a face mask with a reserve bag of 10 L min.

12/05/2021 Condition with negative dynamics, the addition of a fungal infection. For another week, the patient needed NIV or HPE. After a course of antifungal therapy with echinocandida, it was decided to re-administer the surfactant according to the accepted method. The inhalation procedure was carried out once a day for 4 days. There is a decrease in the patient's oxygen dependence, Sat 94% per 5 liters of oxygen through a mask, without oxygen, a decrease to Sat 88-89%. The patient was discharged home for rehabilitation using an oxygen concentrator.

The technical and economic efficiency of the method consists in providing a quick relief of the patient's oxygen dependence and reducing the rehabilitation time after acute respiratory distress syndrome, regardless of etiology, due to the opening of atelectatic alveoli. As a result, patient survival rates are improved.

Claims (1)

A method for the treatment of respiratory failure after acute respiratory distress syndrome, regardless of etiology, including intrapulmonary percussion of the lungs and the introduction of a surfactant through a built-in nebulizer, characterized in that the introduction of natural pulmonary surfactant is carried out simultaneously with intrapulmonary percussion of the lungs with a respiratory rate of 500 per minute against the background maintaining a constant pressure in the airways at a level of 16 cm of water column, the procedure is performed twice a day for three days.