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Respiratory failure



Respiratory (ventilation-pulmonary) insufficiency is characterized by such 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 and 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, usually absent. Cyanosis is perioral, unstable, aggravated by anxiety, disappearing when breathing with 40–50% oxygen; pallor of face Blood pressure is normal, rarely moderately elevated. The ratio of the pulse to the number of breaths is 3.5-2.5: 1; tachycardia. Behavior is restless or not disturbed.

II degree. Restless dyspnea constant, with the participation of auxiliary muscles in the act of breathing, contraction of compliant places of the chest; may be with the predominance of inhalation or exhalation, that is, wheezing, grunting exhalation. Cyanosis of the perioral face, hands constant, does not disappear when breathing 40-50% oxygen, but disappears in the oxygen tent; generalized pallor of skin, sweating, pallor of nail beds. Blood pressure increased. The ratio of the pulse to the number of breaths is 2-1.5: 1, tachycardia. Behavior: lethargy, somnolence, weakness, alternating with short periods of arousal; decreased muscle tone.

III degree. Severe shortness of breath (respiratory rate - more than 150% of normal); shallow breathing, periodic bradypnea, respiration desynchronization, paradoxical breathing. Reduction or absence of respiratory noise during inspiration. Cyanosis generalized; there is cyanosis of the mucous membranes, lips, does not pass when breathing with 100% oxygen; generalized marbling or pallor of the skin with blue; sticky sweat. Blood pressure is reduced. The ratio of the pulse to the number of breaths varies. Behavior: lethargy, somnolence, consciousness and reaction to pain are suppressed; muscle hypotonia, coma; convulsions.

Causes of acute respiratory failure in children.

1. Respiratory - acute bronchiolitis, pneumonia, acute laryngotracheitis, false croup, bronchial asthma, congenital malformations of the lungs.

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

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

4. Injuries, burns, poisonings, surgical interventions on the brain, chest organs, poisoning with hypnotics, narcotic, sedatives.

5. Renal failure.

Differential diagnosis. Acute bronchiolitis in children

The first year of life is carried out with bronchial asthma, obliterating bronchiolitis, congenital malformations of the vascular system and heart, congenital lobar emphysema, bronchopulmonary dysplasia, cystic fibrosis, foreign body, acute pneumonia.

Acute bronchiolitis in older children is performed 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 breathing up to 70 in 1 minute and above; anxiety of the child, changing poses in search of the most convenient; marked exhalation voltage intercostal muscles; the appearance of difficulty in breathing with the engagement of the pliant areas of the chest; central cyanosis (one of the signs - cyanosis of the tongue); reduction of PO2; increase in PCO2.

Treatment. Treatment of obstructive syndrome: a constant supply of oxygen through the nasal catheter or nasal cannulas is necessary, the introduction of b-agonists in an aerosol (2 doses without a spacer, and preferably 4-5 doses through a 0.7-1 l spacer), parenterally or orally: salbutamol ( Ventolin), terbutaline (bricanil), fenoterol (berotek), berodual (fenoterol + ipratropium bromide), ortsiprenalin (alupente, astmopent). Together with the b-agonist, one of the corticosteroid preparations, prednisone (6 mg / kg at the rate of 10-12 mg / kg / day) is injected. In the absence of the effect of the introduction of b-agonists, aminophylline is used together with corticosteroids in / to the drip (after a loading dose of 4-6 mg / kg, constant infusion at a dose of 1 mg / kg / hour). In / in the injection of fluid is carried out only in the presence of signs of dehydration. The effectiveness of therapeutic measures is judged by reducing the frequency of breathing (by 15 or more per 1 minute), a decrease in intercostal tension, and an intensity of expiratory noise.

Indications for mechanical ventilation in obstructive syndrome:

1) the weakening of the respiratory noise during inhalation;

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

3) reduction of pain reactions;

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

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 transcription of RNA) from the 1st year of life, a course of 4-5 days - arbidol (the mechanism of the same + interferon inducer), from the 6-year age - 0.1, older than 12 years - 0.2, course - 3-5 days - amixin is used in children older than 7 years. In adenovirus infection, topical (intranasal, conjunctival) ointments are used: 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, influenza) more active (10 000 units / ml) intranasally, viferon in the form of rectal suppositories.

3. Interferon inducers:

1) cycloferon (methylglucamine acridone acetate), neovir (crisdimod) - low molecular weight substances that contribute to the synthesis of endogenous a-, b-, and y-interferon;

2) Amiksin (tilorone) - ribomunil (in the acute stage of respiratory disease is used according to the scheme (1 bag of 0.75 mg or 3 tablets of 0.25 mg in the morning on an empty stomach for 4 days). Antipyretic drugs in pediatric practice do not

use - amidipirin, antipyrin, phenacetin, acetylsalicylic acid (aspirin). At present, only paracetamol, ibuprofen are used as antipyretic in children, and, when it is necessary to quickly reduce the temperature of the lytic mixture, inject 0.5–1.0 ml of 2.5% aminazine and promethazine (pipolfen ) or, less desirable, analgin (50% solution, 0.1-0.2 ml / 10 kg body weight. Symptomatic therapy: antitussive drugs are indicated only in cases when the disease is accompanied by unproductive, painful, painful cough resulting in sleep disturbance, appetite and general exhaustion of the child. It is used in children of any age for laryngitis, acute bronchitis and other diseases accompanied by a painful, dry, obsessive cough. Preferably non-narcotic antitussive drugs are used. Mucolytic drugs are used for diseases accompanied by productive cough with a thick, viscous, difficult to separate sputum. In acute bronchitis, it is better to use mucoregulators - carbostesin derivatives or mucolytic drugs with expectorant effect. Mucolytic drugs should not be used with antitussive drugs. Expectorant drugs are indicated if the cough is accompanied by the presence of a thick, viscous sputum, but its separation is difficult. Antitussive drugs of central action.

1) narcotic: codeine (0.5 mg / kg 4-6 times a day);

2) non-narcotic: synecod (butamirate), glauvent (glaucine hydrochloride), dry-cough Verdex (also contains paracetamol and vitamin C).

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

Antitussive combined drugs: tussinplus, stoptussin, bronholitin (glaucine, ephedrine, citric acid, basil oil).

Mucolytic drugs.

1. Actually mucolytic drugs:

1) a proteolytic enzyme;

2) dornaza (pulmozyme);

3) acetylcysteine ​​(ACC, mucobene);

4) carbocysteine ​​(Bronkatar, mukodin, mukopront, fluvik).

2. Mucolytic drugs with expectorant effect:

1) Bromhexine (Bizolvon, Broxin, Solvin, Flaminamine, Fulpen);

2) Ambroxol (Ambrobene, Ambrogexal, Ambrolan, Lasolvan, Ambrosan).

3. Expectorant medicines:

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

2) glycers (licorice);

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

4) Coldrex (terpinehydrate, paracetamol, vitamin C).
Bronchodilator drugs are used for obstructive

forms of bronchitis. Preference is given to sympathomimetics in-agonists in the form of an aerosol. B2 adrenomimetics:

1) salbutamol (ventolin);

2) fenoterol (berotek);

3) salmeterol (long acting);

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

In the program "ARI in children: treatment and prevention" (2002), it is said that the use of EUFILLINA is less desirable because of possible side effects. Anti-inflammatory drugs. Inhaled glucocorticosteroids:

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

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

3) flunisolide (ingakort);

4) fluticasone (flixotide).

Non-steroidal anti-inflammatory drugs Erespal (Fenspirid) - 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 ARD is accompanied by the appearance or intensification of allergic manifestations (histamine H1 receptor blockers).

Preparations of the first generation: diazolin, diphenhydramine, pipolfen, suprastin, tavegil, fenistil.

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

Immunotherapy.

1. Ribomunil is a ribosomal immunomodulator, which consists of the ribosomes of the main pathogens of the upper respiratory tract and respiratory organs, which have a vaccinating effect, and membrane proteoglycans that stimulate non-specific resistance of the organism.

2. Bronhomunal, IRS-19 - bacterial lysates, which include bacteria of the main pneumotropic pathogens and have mainly immunomodulatory effects.

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

Indications for appointment Ribomunyl.

1. Inclusion in rehabilitation complexes:

1) recurrent diseases of upper respiratory tract;

2) recurrent respiratory diseases;

3) often ill children.

2. Inclusion in the complex of etiopathogenetic therapy:

1) acute otitis media;

2) acute sinusitis;

3) acute pharyngitis;

4) acute tonsillitis;

5) acute laryngotracheitis;

6) acute tracheobronchitis;

7) acute bronchitis;

8) pneumonia.

Immunoglobulins for on / in the introduction, registered and approved for use in the Russian Federation.

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

1) normal human immunoglobulin for iv 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) V. I. Biaven (Pharma Biajini S. p. A, Italy);

8) Whigam liquid (Bio Products Laboratory, UK);

9) Whigam C (Bio Products Laboratory, UK).

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

Non-drug treatments.

1. LFK.

2. Electro procedures (UHF, UHF, diathermy) are indicated for sinusitis, lymphadenitis; with diseases of the chest, their effectiveness is not proven, including electrophoresis of drugs.

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

States that are not indications for the use of antibiotics for SARS.

1. General disorders: body temperature less than 38 С or more than 38 С less than 3 days, febrile convulsions, loss of appetite, headache, myalgia, herpetic eruptions.

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 probable bacterial infection: body temperature above 38 ° C from 3 days or more, asymmetry of wheezing during auscultation, chest retraction, severe toxicosis, leukocytosis more than 15,000 and / or more than 5% of juvenile forms of the core, accelerated ESR more than 20 mm / h, sore throat and raids (streptococcal angina is possible), earache (acute otitis media), nasal congestion for 2 weeks or more (sinusitis), lymph node enlargement (lymphadenitis), shortness of breath without obstruction (pneumonia). (See table. 1, 2)

Table Selection of the starting drug for community-acquired pneumonia

Age form Etiology Starting preparation Replacement for inefficiency
1-6 months. Typical (febrile with infiltrative shadow) E. coli, other enterobacteria, staphylococcus, less commonly pneumococcus and H. influenzae type b Inside, in / in: amoxicillin / clavulanate in / in, in / m: ampicillin + oxacillin, or cefazolin + aminoglycoside In / in, in / m: cefuroxime, ceftriaxone, cefotaxime, lincomycin, vancomycin, carbapenem
6 months —6 years, typical uncomplicated (homogeneous) Pneumococcus (+ H.influenzae non-capsule, less often - type b) Inside: amoxicillin, smallpox, azithromycin, macrolide (with lactam intolerance). V / m: penicillin Inside: amoxicillin / clavulanate, cefuroxime-aksetil. In / in, in / m: penicillin, lincomycin, cefazolin, cefuroxime
6–15 years old, atypical (inhomogeneous) M. pneumoniae, C. pneumoniae Inside: azithromycin, macrolide Inside: other macrolide, doxycycline (> 12 years)
Table Selection of the starting antibiotic for intrahill pneumonia

Age form Etiology Starting preparation Replacement for inefficiency
6–15 years complicated by pleurisy or destruction Pneumococcus, H. influenzae type b, rarely - streptococcus In / in, in / m: penicillin, ampicillin, cefuroxime, amoxicillin / clavulanate In / in, in / m: cephalosporin I — III generation, chloramphenicol + aminoglycoside
Therapy before pneumonia Probable pathogen Recommended drugs
Not conducted As a hospitalspneumonia The choice of drug, as the hospital infectious
Penicillin, ampicillin Staphylococcioplasma In / in, in / m: oxacillin, lincomycin, cefazolin, vancomycin Inside: macrolide
Generation cephalosporin I, oxacillin, lincomycin E.Coli, another gram-negative flora, resistant staphylococcus Inside, in / in: protected penicillins. In / in, in / m: aminoglycoside, cephalosporin 2-3 generations, vancomycin
Therapy before pneumonia Probable pathogen Recommended drugs
Aminoglycoside Pneumococcus or Gram-resistant flora, resistant staphylococcus In / in, in / m: penicillin, ampicillin, in the absence of effect: ceftriaxone, carbapenem, vancomycin, ureidopenicillins, rifampicin, for vital reasons - aminoglycoside in high doses (gentamicin 15 mg / kg / day; amikacin - 30-50 mg / kg / day).
Aminoglycoside + cephalosporin II — III generation Pseudomonas, serration, other gram-negative flora-resistant staphylococcus Parenteral: carbapenem, timentin, aztreonam, for vital reasons - aminoglycoside in high doses (gentamicin 15 mg / kg / day; amikacin - 30-50 mg / kg / day). Vancomycin, rifampicin
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Respiratory failure

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