LECTURE No. 17. Broncho-obstructive syndrome. Clinic, diagnosis, treatment. Respiratory failure. Clinic, diagnosis, treatment

Broncho-obstructive syndrome is a clinical symptom complex observed in patients with generalized obstruction of the bronchial passages; its leading manifestation is expiratory shortness of breath and asthma attacks. Diseases accompanied by airway obstruction.

Major causes of airway obstruction in children.

1. Upper airway obstructions:

1) acquired:

a) allergic rhinitis;

b) nasal polyps;

c) hypertrophy of the tonsils;

d) inflammation of the epiglottis;

e) viral laryngotracheitis;

f) laryngospasm (with spasmophilia);

g) foreign body;

h) congenital stridor;

i) retraction of the tongue in an unconscious state; j) mechanical compression of the trachea and bronchi;

2) congenital:

a) thymomegaly;

b) enlarged lymph nodes;

c) tumor.

2. Obstruction of large intrathoracic airways:

1) narrowing of the lumen (developmental anomaly, tumor, scar, foreign body);

2) compression from the outside (tumor, abnormal vessel);

3) excessive collapse due to weakness of the cartilaginous rings and (or) the membranous part (tracheomalacia). III. Obstruction of the lower respiratory tract:

1) viral bronchiolitis;

2) bronchial asthma;

3) aspiration of vomit;

4) foreign bodies;

5) cystic fibrosis;

6) a₁ - antitrypsin deficiency. Mechanisms of disorders in obstructive syndrome.

1. Reversible:

1) inflammatory edema and mucosal infiltration and submucosal edema;

2) disruption of mucociliary transport, obstruction of the bronchial lumen with viscous secretion;

3) bronchospasm.

2. Irreversible:

1) fibroplastic changes in the walls of the bronchi.

2) stenosis, deformation and obliteration of the bronchial lumen.

3) expiratory collapse of the bronchi, the presence of emphysema.

Protective mechanisms of the respiratory apparatus.

1. Mechanical.

2. Biochemical.

3. Immunological.

Mechanical protective system of the breathing apparatus:

1) aerodynamic mechanism;

2) mucociliary escalator mechanism;

3) kinetic energy of exhaled air;

4) cough push, biochemical protective system of the respiratory apparatus;

5) bronchial secretions of the respiratory apparatus (sialomucins, fucomucins, glycosaminoglycans, etc.);

6) phospholipids of cell membranes of bronchi, alveoli, surfactant;

7) BAS (serotonin, histamine, etc.).

Immunological defense system of the respiratory apparatus.

1. Specific:

1) secretory IgA;

2) plasma IgM, G, E.

2. Non-specific:

1) alveolar macrophages;

2) lysozyme;

3) kallikrein;

4) lactoferrin;

5) interferon;

6) b-lysine.

1. Acute bronchitis

Acute bronchitis is a common disease: there are 1000-200 cases per 250 children in the first years of life.

Etiology. The vast majority of bronchitis are viral diseases. Respiratory syncytial virus - 50%, parainfluenza viruses - 21%, mycoplasma pneumonia - 8,3%, cytomegalovirus - 6,3%, rhinoviruses - 4,2%, coronaviruses - 4,1%, echoviruses I serotypes - 2%, influenza A virus - 2%, adenoviruses - 2% Bacterial agents are among the rare or non-playing factors in the etiology of bronchitis. Bacterial flora is more often found in “non-wheezing” patients than in “wheezing” patients.

Clinic. Clinical symptoms of bronchial obstruction against the background of ARVI in young children:

1) acute onset of the disease;

2) wheezing;

3) variability of dry and wet rales;

4) swelling of the chest;

5) shortness of breath (reaches 60-80 in 1 min);

6) retraction of the jugular fossa and intercostal spaces (hypoxemia);

7) low body temperature. In addition to the main symptoms, there may be:

1) rhinitis;

2) frequent painful cough;

3) swelling of the wings of the nose (hypoxemia);

4) refusal of the breast;

5) loss of appetite;

6) the presence of small crepitant rales, often diffuse;

7) stool disorder;

8) poor sleep;

9) cyanosis (hypoxemia);

10) apnea (hypoxemia).

Laboratory data. Blood test: red blood - without features, accelerated ESR, leukocytosis. X-ray data are characterized by an increase in the transparency of the pulmonary fields, an increase in the anteroposterior diameter of the chest due to the overflow of the lungs with air, emphysema, a high standing dome of the diaphragm, and hilar infiltration. In almost 1/3 of patients, scattered areas of compaction are visible, which can be explained by the development of atelectasis in response to obstruction. In approximately 44% of cases, the x-ray picture remains normal. Culture of discharge from the nose and trachea is a common flora.

Virological examination using immunofluorescence method, increasing the antibody titer in the blood.

2. Respiratory failure

Respiratory (ventilation-pulmonary) failure is characterized by disorders in which pulmonary gas exchange is impaired or occurs at the cost of excessive energy costs.

Types of respiratory failure:

1) ventilation;

2) distribution-diffusion (shunt-diffusion, hypoxemic);

3) mechanical.

Clinic.

I degree. Shortness of breath varies without the participation of auxiliary muscles in the act of breathing; at rest, as a rule, absent. Perioral cyanosis, unstable, worsening with anxiety, disappearing when breathing 40-50% oxygen; paleness of the face. Blood pressure is normal, less often moderately elevated. The ratio of pulse to number of respirations is 3,5-2,5: 1; tachycardia. Behavior is restless or not disturbed.

II degree. Dyspnea at rest is constant, with the participation of auxiliary muscles in the act of breathing, retraction of the compliant areas of the chest; It may also be with a predominance of inhalation or exhalation, i.e. wheezing, grunting exhalation. Perioral cyanosis of the face and hands is constant, does not disappear when breathing 40-50% oxygen, but disappears in an oxygen tent; generalized pallor of the skin, sweating, pallor of the nail beds. Blood pressure is increased. The ratio of the pulse to the number of respirations is 2-1,5: 1, tachycardia. Behavior: lethargy, doubtfulness, adynamia, followed by short periods of excitement; decreased muscle tone.

III degree. Severe shortness of breath (respiratory rate - more than 150% of normal); shallow breathing, periodic bradypnea, respiratory desynchronization, paradoxical breathing. Decreased or absent breath sounds during inspiration. Generalized cyanosis; there is cyanosis of the mucous membranes and lips, which does not go away when breathing 100% oxygen; generalized marbling or pallor of the skin with a bluish tint; sticky sweat. Blood pressure is reduced. The ratio of pulse to number of respirations varies. Behavior: lethargy, doubtfulness, consciousness and reaction to pain are suppressed; muscle hypotension, coma; convulsions. Causes of acute respiratory failure in children.

1. Respiratory - acute bronchiolitis, pneumonia, acute laryngotracheitis, false croup, bronchial asthma, congenital lung malformations.

2. Cardiovascular - congenital heart diseases, heart failure, pulmonary edema, peripheral dyscirculatory disorders.

3. Neuromuscular - encephalitis, intracranial hypertension, depressive states, poliomyelitis, tetanus, status epilepticus.

4. Injuries, burns, poisoning, surgical interventions on the brain, chest organs, poisoning with sleeping pills, narcotics, sedatives.

5. Renal failure.

Differential diagnosis. Acute bronchiolitis in children 1 year of life is carried out with bronchial asthma, bronchiolitis obliterans, congenital defects of the vascular system and heart, congenital lobar emphysema, bronchopulmonary dysplasia, cystic fibrosis, foreign body, acute pneumonia.

Acute bronchiolitis in older children is carried out with allergic alveolitis, aspiration of foreign bodies, with bronchial asthma, gastroesophageal reflux and aspiration of food into the respiratory tract, parasitic pneumonia. Obstructive syndrome is manifested by increased respiration rate up to 70 per minute and above; restlessness of the child, changing positions in search of the most comfortable one; noticeable tension in the intercostal muscles during exhalation; the appearance of difficulty in inhaling with retraction of the compliant areas of the chest; central cyanosis (one of the signs is cyanosis of the tongue); decrease in PO1; an increase in PCO2.

Treatment. Treatment of obstructive syndrome: a constant supply of oxygen is required through a nasal catheter or nasal cannulas, administration of β-agonists in an aerosol (2 doses without a spacer, and preferably 4-5 doses through a spacer with a capacity of 0,7-1 l), parenterally or orally: salbutamol ( ventolin), terbutaline (bricanil), fenoterol (Berotec), berodual (fenoterol + ipratropium bromide), orciprenaline (alupent, asthmapent). Together with the β-agonist, one of the corticosteroid drugs - prednisolone (6 mg/kg - at the rate of 10-12 mg/kg/day) is administered intramuscularly. If there is no effect from the administration of β-agonists, aminophylline is used together with corticosteroids intravenously (after a loading dose of 4-6 mg/kg, continuous infusion at a dose of 1 mg/kg/hour). IV fluid infusion is carried out only if there are signs of dehydration. The effectiveness of therapeutic measures is judged by a decrease in respiratory rate (by 15 or more per minute), a decrease in intercostal retractions and the intensity of expiratory noises.

Indications for mechanical ventilation in obstructive syndrome:

1) weakening of respiratory sounds on inspiration;

2) preservation of cyanosis during breathing with 40% oxygen;

3) decrease in pain reaction;

4) PaO2 drop below 60 mm Hg. Art.;

5) an increase in PaCO2 above 55 mm Hg. Art.

Etiotropic therapy begins with the appointment of antiviral agents.

1. Chemotherapy - rimantadine (inhibits the specific reproduction of the virus at an early stage after penetration into the cell and before the start of RNA transcription) from the 1st year of life, course 4-5 days - arbidol (the same mechanism + interferon inducer), from the 6th year age - 0,1, over 12 years - 0,2, course - 3-5 days - amiksin is used in children over 7 years old. For adenovirus infection, ointments are used topically (intranasally, on the conjunctiva): oxolinic ointment 1-2%, florenal 0,5%, bonafton 0,05%.

2. Interferons - native leukocyte interferon (1000 units/ml) 4-6 times a day in the nose - recombinant a-interferon (reoferon, gripferon) more active (10 units/ml) intranasally, viferon in the form of rectal suppositories.

3. Interferon inducers:

1) cycloferon (methylglucamine acridone acetate), neovir (kridanimod) - low molecular weight substances that promote the synthesis of endogenous b-, b-, and g-interferons;

2) amixin (tiloron) - ribomunil (in the acute stage of a respiratory disease, it is used according to the scheme (1 sachet of 0,75 mg or 3 tablets of 0,25 mg in the morning on an empty stomach for 4 days). Antipyretic drugs are not used in pediatric practice - amidipyrine, antipyrine , phenacetin, acetylsalicylic acid (aspirin).Currently, only paracetamol, ibuprofen are used as antipyretics in children, and also, when it is necessary to quickly reduce the temperature, the lytic mixture is administered intramuscularly at 0,5-1,0 ml 2,5, 50% solutions of aminazine and promethazine (pipolfen) or, less preferably, analgin (0,1% solution, 0,2-10 ml/XNUMX kg body weight. Symptomatic therapy: antitussive drugs are indicated only in cases when the disease is accompanied by an unproductive, painful, painful cough, leading to disturbances in sleep, appetite and general exhaustion of the child. Used in children of any age for laryngitis, acute bronchitis and other diseases accompanied by a painful, dry, obsessive cough. It is preferable to use non-narcotic antitussives. Mucolytic drugs are used for diseases accompanied by a productive cough with thick, viscous, difficult to separate sputum. To improve its evacuation in acute bronchitis, it is better to use muco-regulators - carbocesteine ​​derivatives or mucolytic drugs with an expectorant effect. Mucolytic drugs cannot be used with antitussive drugs. Expectorants are indicated if the cough is accompanied by the presence of thick, viscous sputum, but its separation is difficult. Centrally acting antitussives.

1) narcotic: codeine (0,5 mg/kg 4-6 times a day);

2) non-narcotic: Sinecode (butamirate), Glauvent (glaucine hydrochloride), Fervex for dry cough (also contains paracetamol and vitamin C).

Non-narcotic antitussive drugs of peripheral action: libexin (prenoxdiazine hydrochloride) levopront (levodropropizine).

Antitussive combination drugs: tussin-plus, stoptussin, broncholitin (glaucine, ephedrine, citric acid, basil oil).

mucolytic agents.

1. Actually mucolytic drugs:

1) proteolytic enzyme;

2) dornase (pulmozyme);

3) acetylcysteine ​​(ACC, mucobene);

4) carbocysteine ​​(bronkatar, mucodin, mucopront, fluvik).

2. Mucolytic drugs with expectorant effect:

1) bromhexine (bisolvon, broxin, solvin, phlegamine, fullpen);

2) ambroxol (ambrobene, ambrohexal, ambrolan, lazolvan, ambrosan).

3. Expectorant drugs:

1) broncholithin (glaucine, ephedrine, citric acid, basil oil);

2) glyceram (licorice);

3) Dr. MOM (licorice, basil, elecampane, aloe);

4) Coldrex (terpene hydrate, paracetamol, vitamin C). Bronchodilators are used for obstructive

forms of bronchitis. Preference is given to sympathomimetic β-agonists in aerosol form. B2-adrenergic agonists:

1) salbutamol (ventolin);

2) fenoterol (berotek);

3) salmeterol (long-acting);

4) formoterol (action begins quickly and lasts a long time).

The program “ARI in children: treatment and prevention” (2002) states that the use of EUPHYLLIN is less desirable due to possible side effects. Anti-inflammatory drugs. Inhaled glucocorticosteroids:

1) beclomethasone (aldecine, becotide, etc.);

2) budesonide (budesonide mite and forte, pulmicort);

3) flunisolide (ingacort);

4) fluticasone (flixotide).

Non-steroidal anti-inflammatory drugs Erespal (fenspiride) - counteracts bronchoconstriction and has an anti-inflammatory effect in the bronchi.

Indications: treatment of functional symptoms (cough and sputum) accompanying bronchopulmonary diseases. Antihistamines are prescribed when acute respiratory infections are accompanied by the appearance or intensification of allergic manifestations (histamine H1 receptor blockers).

First generation drugs: diazolin, diphenhydramine, pipolfen, suprastin, tavegil, fenistil.

II generation drugs: zyrtec, claritin, semprex, telfast, erius.

Immunotherapy.

1. Ribomunil is a ribosomal immunomodulator, which includes ribosomes of the main pathogens of infections of the ENT and respiratory organs, which have a vaccinating effect, and membrane proteoglycans, which stimulate nonspecific resistance of the body.

2. Bronchomunal, IRS-19 - bacterial lysates, including bacteria of the main pneumotropic pathogens and having mainly an immunomodulatory effect.

3. Lykopid - membrane fractions of the main bacteria that cause respiratory infections stimulate the body's nonspecific resistance, but do not contribute to the development of specific immunity against pathogens.

Indications for the appointment of ribomunil.

1. Inclusion in rehabilitation complexes:

1) recurrent diseases of ENT organs;

2) recurrent respiratory diseases;

3) frequently ill children.

2. Inclusion in the complex of etiopathogenetic therapy:

1) acute otitis;

2) acute sinusitis;

3) acute pharyngitis;

4) acute tonsillitis;

5) acute laryngotracheitis;

6) acute tracheobronchitis;

7) acute bronchitis;

8) pneumonia.

Immunoglobulins for intravenous administration, registered and approved for use in the Russian Federation.

1. Human immunoglobulins are normal (standard) for intravenous administration:

1) normal human immunoglobulin for intravenous administration (Imbio, Russia);

2) immunoglobulin (Biochemie GmbH, Austria);

3) intraglobin (Biotest Pharma GmbH, Germany);

4) octagam (Oktapharma AG, Switzerland);

5) sandoglobulin (Novartis Pharma services, Switzerland);

6) endobulin (Immuno AG, Austria);

7) Biaven V. I. (Pharma Biajini S. p. A, Italy);

8) wigam-liquid (Bio Products Laboratory, UK);

9) wigam-C (Bio Products Laboratory, UK).

2. Immunoglobulins for intravenous administration, enriched with IgM class antibodies - pentaglobin (Biotest Pharma GmbH, Germany).

Non-drug methods of treatment.

1. Exercise therapy.

2. Electrical procedures (UHF, microwave, diathermy) are indicated for sinusitis, lymphadenitis; for diseases of the chest organs, their effectiveness has not been proven, including electrophoresis of drugs.

3. Thermal and irritating procedures. Dry heat for sinusitis, lymphadenitis, wet compress for otitis media (subjective relief). Rubbing with fat is not effective and should not be used. Mustard plasters, cups, burning patches and rubbing are painful, fraught with burns and allergic reactions.

Conditions that are not indications for the use of antibiotics in ARVI.

1. General disorders: body temperature less than 38 °C or more than 38 °C for less than 3 days, febrile convulsions, loss of appetite, headache, myalgia, herpetic rashes.

2. Syndromes: rhinitis, nasopharyngitis, tonsillitis, laryngitis, bronchitis, tracheitis, conjunctivitis.

3. Respiratory syndromes: cough, hyperemia of the pharynx, hoarseness, scattered wheezing, airway obstruction, difficulty breathing.

Signs of a probable bacterial infection: body temperature above 38 °C from day 3 or more, asymmetry of wheezing on auscultation, chest indrawing, severe toxicosis, leukocytosis more than 15 and / or more than 000% of young forms of stabs, accelerated ESR more than 5 mm /h, sore throat and plaque (possible streptococcal sore throat), ear pain (acute otitis media), nasal congestion for 20 weeks or more (sinusitis), enlarged lymph nodes (lymphadenitis), shortness of breath without obstruction (pneumonia). (See Table 2, 1)

Table 1

The choice of starting drug for community-acquired pneumonia

Table 2

Choice of starting antibiotic for nosocomial pneumonia

Author: Pavlova N.V.

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